CHERRELYN HEALTHCARE CENTER

A complaint survey, prompted by #CO37880 and #CO38079 was conducted on 10/28/24. No deficiencies were cited.

A complaint survey, prompted by #CO37328 was conducted on 9/4/24. No deficiencies were cited.

A complaint survey, prompted by #CO34982 , #CO36686, #CO36699 and Incident #34953 was conducted on 8/26/24. No deficiencies were cited.

A complaint survey, prompted by #CO34976 and #CO35215 was conducted on 3/4/24 to 3/6/24. No deficeincies were cited.

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

A revisit survey was completed on 11/21/23 for all previous deficiencies cited on 8/16/23. The facility is in compliance with all regulations surveyed.

INITIAL COMMENTS (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 a two-story, Type II (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as fully sprinklered. The facility is licensed for 190 beds. This re-certification survey conducted on September 06, 2023, was for compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (2012 edition) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012 edition); and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected. The deficiencies cited were discussed with the Maintenance Director and Administrator during the exit conference conducted at the end on-site survey.

Based on observation and staff interview, 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 (Exits not readily visible during the day and night) Exit light wing 3, wing 6 corridor entrance and by dining room need to new batteries Exit signs by beauty shop and lobby need to flip for proper exit direction 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 has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director and Administrator 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, Hood suppression inspection report listed two bottles overdue hydro as of 2018Hood cleaning report states there are inaccessible areas. NFPA 96, 11.2.1 Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months.stalled in accordance with the connector and appliance manufacturer installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartemnt. Deficient items were discussed with the Administrator 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 Section 9.6 and NFPA 72. Fire Alarm Report listed multiple deficiencies with no repair reports or invoices availableNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

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 101Fire Sprinkler Report listed multiple deficiencies with no repair reports or invoices available Report showed one fire backflow failed there was no repair report or invoice available Sprinkler head loaded (dirty) across from room 419NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101. Wing 1 smoke door needs adjusted door did not latch Kitchen door propped open (Fire Barrier door not aloud to be propped open without mag lock that drops on fire alarm) Fire barrier doors by dining room doors did not latch properly Resident Room 213 does not closeNFPA 101, 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 and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

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. Fire barrier by wing 2, wing 4 have penetrations above ceiling Ceiling tiles need to be repaired/replaced in kitchen NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director and Administrator at the exit conference.

Based on record review, it was determined that the facility failed to maintain documentation for all required elements of the fire safety plan in accordance with the Life Safety Code, Section 19.7.2 and 19.7.2.2. No records or documentation for a Fire Safety/Evacuation Plan that contains the elements of the; Response to Alarms, Isolation of Fire and Fire Extinguishment availible for surveyorNFPA 101, Section 19.7.2.2 requires that; a written health care occupancy fire safety plan shall provide for the following:(1)Use of Alarms(2)Transmission of alarm to the fire department(3)Response to alarms(4)Isolation of fire(5)Evacuation of immediate area(6)Evacuation of smoke compartment(7)Preparation of floors and buildings for evacuation(8)Extinguishment of fire These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

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: No generator battery conductance test records available at time of inspection. Generator Monthly report states panel did not light up and transfer time more than 10 secondsGenerator Monthly reports only go back through March 2023Generator Annual fuel test report not available at time of inspection8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director and Administrator at the exit conference.

A recertification survey with complaints #CO33100, #CO33148 and #CO33152 was completed on 8/9/23 to 8/16/23. Ten deficienies were cited.

An Emergency Preparedness survey was conducted from 8/9/23 to 8/16/23. One deficiency was cited.

Based on record review and interview, the facility failed to develop and maintain an up to date emergency preparedness training program that aligns with the facility's specific individualized emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures, as well as the facility's communication plan, that was delivered to all staff upon hire and annually thereafter. Additionally, the facility will extend training to volunteers and contracted providers who provide care and services in the facility environment. Specifically, the facility failed to:-Provide staff initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role;-Provide emergency preparedness training at least annually;-Maintain documentation of all emergency preparedness training; and, -Demonstrate staff knowledge of emergency procedures. Findings include: I. Facility plan The facility's emergency preparedness (EP) program was provided by the nursing home administrator (NHA) on 8/14/23 at 11:30 a.m. The EP program read in pertinent part: "The training and testing program will be reviewed and updated at least annually. All staff, including individuals providing onsite services under arrangement and volunteers consistent with their expected roles, will be provided initial training in the Emergency Preparedness Program, specifically the Emergency Operations Plan. The facility will test staff competence in their knowledge of the Emergency Preparedness Program through the use of post training quizzes and evaluations during drills and exercises." The Disaster Training policy, revised April 2019, was provided by the NHA on1/16/23 at 3:46 p.m. It read in pertinent part: "This facility has established training and education programs that provide specific guidance and instruction on the proper handling of a crisis or disaster situation. "Policy interpretation and implementation-Staff members, contract employees, and volunteers are trained upon hire and at least annually on the community's emergency preparedness and response plan and procedures.-Exercises, drills, and simulations are conducted on all levels of management within the organization and not just confined to routine fire or evacuation drills. "The main objectives for the training are ...to help ensure that proper planning, response, and recovery programs are in place and are appropriate for the facility. "Training topics presented to facility staff on a regular basis include the following subjects:a. Discovering/reporting an emergency; b. Sounding the alarm/initiating emergency procedures; c. Using, maintaining, and operating emergency equipment; d. Emergency code system; e. Fire control and extinguishment; f. Implementing evacuation, shelter-in -place and relocation procedures; g. Containing or limiting the spread of infectious disease during outbreaks, including proper isolation precautions and the use of personal protective equipment; h. Accessing emergency medical information, equipment, and medications for residents; i. Transfer trauma; j. Evacuation carries and maneuvers; k. Locating and shutting off utilities; l. Severe weather awareness and procedures; m. Sheltering-in-place principles and procedures; n. Emergency response /succession of command; o. General principles of the National Incident Management System (NIMS) and the Incident Command System (ICS); and p. Utilizing community support services." II. Training records The facility had a total of 200 staff listed on the staffing roster and were unable to provide proof that all staff were provided training on the facility's specific emergency preparedness policy and EP program. The facility was able to provide proof of fire drill training and simulation drills. The facility provided evidence that 17 of the 69 housekeeping and maintenance staff received some training on basic housekeeping and maintenance expectation in an emergency; however, the training did not include training on the facility's emergency preparedness policies or on the training topic as listed in the facility's disaster training policy (see above). III. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 8/15/23 at 1:50 p.m. LPN #4 said the facility provided fire drill training and some basic training on emergency preparedness upon hire. LPN #4 was able to explain fire evacuation measures, but did not know what was expected in the event or other types of emergency and disaster situation. LPN #4 said if an emergency occurred there would likely be a supervisor in the building who would give staff direction on how to proceed. LPN #4 was not able to explain procedures for preparing a resident for off site evacuation. Registered nurse (RN) #3 was interviewed on 8/15/23 at 2:00 p.m. RN #3 said she received basic emergency preparedness training upon hire but was unclear of what was expected in the event of a true emergency. RN #3 was unable to give examples of situations when a resident might need to be evacuated from the building or situations where the resident could be sheltered in place or what would be her role in the emergency response process. LPN #2 was interviewed on 8/15/23 at 2:20 p.m. LPN #2 was able to describe the color codes alerts and had basic information on how to manage residents when sheltering in place, but was unclear of procedure how to handle generator failure if the maintenance staff was not in the building or procedures for evacuation of residents to a different physical location. The maintenance director (MTD) was interviewed on 8/15/23 at 2:33 p.m. The MTD said the facility was using a computerized emergency training program that provided standardized industry based training that provided staff with basic skill to respond to emergency events in long-term care. The facility, however, did not provide staff and contracted employee's specific training on the facility's emergency preparedness policies, emergency preparedness plan and communication plan as relevant to the needs of the facility and resident population. The MTD director said he and the corporate consultants were working on developing a more specific training to be offered in the next couple of months. The NHA was interviewed on 8/16/23 at 9:30 a.m. The NHA said that the facility provided regular fire safety in services and drills and provided basic emergency preparedness training; however, the facility was not currently providing all staff training to the facility's policies on emergency preparedness.

Based on observations and staff interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to:-Ensure residents were provided independence and dignity while dining by avoiding the use of disposable cutlery and dishware; and,-Ensure ensure meals were delivered to residents in a timely manner. Findings include:I. Disposable cutleryA. Facility policyThe Residents Rights policy, revised February 2021, was provided by the nursing home administrator (NHA) on 8/17/23 at approximately 3:30 p.m. It read in pertinent part, "Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness and dignity; privacy and confidentiality. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our resident's rights."B. Resident interviews and observationsResident #7 was interviewed on 8/10/23 at 9:00 a.m. Resident #7 said he continued to get plastic utensils at meal time, he did not like plastic utensils and wanted regular silverware. He said because of his multiple sclerosis his hands were increasingly numb and tingly and he was unable to properly grip the flimsy plastic spoon with his hands so the food would fall off the spoon and onto his meal tray, lap or bed. Resident #7 was interviewed on 8/14/23 at 8:45 a.m. Resident #7 said he received a plastic knife with his breakfast meal and it was hard to cut and eat the meal with plastic utensils. Plastic utensils were observed on the resident's meal tray. Resident #7 said he was sent a plastic spoon for a meal on either 8/12/23 or 8/13/23 but remembered it was hard to eat the meal with the plastic utensil. During a meal observation on 8/14/23 at 11:54 a.m. a plastic four compartment cutlery bin in the kitchen that held silverware contained plastic forks. At 1:10 p.m. dietary aide (DA) #1 said she was out of silverware to put on meal trays for unit 400. She asked the cook to stop assembly of resident meal trays for unit 400 because she did not have enough silverware. The dietary manager (DM) held meal services and asked staff to wash more silverware. The clean silverware that was just washed was brought to DA #1 at 1:12 p.m. This caused a delay in getting lunch served to residents on time. A sample meal tray for a regular diet was evaluated by five surveyors on 8/14/23 at 1:30 p.m. after the last resident had been served lunch. The test tray contained an apple curry chicken entree served as a whole chicken breast. The apple curry chicken recipe provided by the nursing home administrator (NHA) at 8:00 a.m. 8/14/23 documented cut up boneless, skinless chicken thighs were to be used instead of chicken breasts. The chicken breast was difficult to cut with plastic utensils as the plastic utensils bended under the pressure needed to cut through the chicken breast and did not cut through or pierce the chicken easily. During a group interview on 8/15/23 at 3:00 p.m. with nine residents (#114, #27, #29, #153, #359, #2, #93, #94 and #111) said they received plastic silverware with their meals on numerous occasions. Resident #29 said if there was not a regular spoon available it was replaced with a plastic spoon and plastic utensils did not cut anything; "plastic utensils were useless."Resident #111 said "we were not at a picnic, we needed regular silverware." Resident #93 said she had her family bring in regular silverware for her to use at meals and keeps that set in her room for occasions when the facility provided plastic silverware in place of regular stainless steel silverware. C. Staff interviewsThe DM and NHA were interviewed on 8/17/23 at 9:25 a.m. The DM said she had residents that liked to keep the facility's metal silverware in their rooms after a meal and that caused a shortage of silverware. The DM said the facility had run out of clean silverware during lunch on 8/14/23. While she tried to keep as much silverware as possible in house, she did not stock a specific inventory amount of silverware. The DM said she was coordinating with the housekeeping department to check for silverware in the residents' rooms to restore the facility's silverware stock for resident meal service. The NHA said the housekeeping and nursing department would assist with checking residents' rooms for silverware that could be returned to the kitchen. The NHA said residents had not expressed their unhappiness with the plastic utensils. D. Facility follow-upOn 8/17/23 at 9:30 a.m. the DM said she ordered 120 forks, spoons and knives for resident meals to increase the silverware inventory. II. Meals delivered timelyA. Resident interviews Resident #11 was interviewed on 8/9/23 at 12:05 p.m. He said some days he and his wife's (who was his roommate) meals come 30 minutes apart. He said he asked to have their meals sent at the same time so he and his wife could eat at the same time but it did not always happen. Resident #7 was interviewed on 8/10/23 at 10:28 a.m. He said his lunch meals were delivered late and he never knew what time the meals would be delivered and delivery times were 12:30 p.m, 1:30 p.m. or 1:45 p.m. During a group interview on 8/15/23 at 3:00 p.m. Resident #2 said the dining room meal was very late on 8/14/23 and room tray meals were late a lot, depending on how many cooks worked that day. B. Record reviewTwo separate grievances completed on 5/5/23 documented room tray service took a long time and when the residents received their food the food was cold. Lunch service times were listed as 11:00 a.m. to 1:00 p.m located in a binder provided during the survey. C. ObservationsMeal service was observed on 8/14/23 from 11:00 a.m. to 1:24 p.m. At 11:21 a.m. cook (CK) #1 said she was waiting for the chicken entree for lunch to cook to the correct temperature before removing it from the oven. At 11:31 a.m. resident meal assembly began for residents seated in the dining room.-However, this was 31 minutes after the post meal time. At 12:11 p.m. resident meal tray assembly for the first of four room tray carts began. At 12:17 p.m. resident meal tray assembly was stopped when the DM asked an unidentified dietary staff member to remove a pan of the one-half inch diced chicken from the steam table and grind it smaller. The dietary staff member ground the chicken and placed the pan in the steam table which caused a delay in meal service. At 12:24 p.m. the DM asked the dietary staff to stop assembling meal trays and asked dietary staff to modify the apple crisp to size listed in the recipe which caused a delay in meal service. At 1:07 p.m. resident meal tray assembly for the last of four room tray carts began. At 1:24 p.m. room trays were delivered to the 400 hall. Staff began passing out room trays to residents and room tray delivery was completed at 1:30 p.m.-However, this was 24 minutes past the posted meal times that ranged from 11:00 to 1:00 p.m. D. Staff interviewsDietary aide (DA) #1 was interviewed on 8/14/23 at 1:11 p.m. She said she did not know how often meals were delivered late due to delays with the dietary staff. The DM was interviewed on 8/14/23 at 1:13 p.m. She said meals tray assembly was usually completed by 12:30 p.m. but two dietary staff members called in that day. The nursing home administrator (NHA) was interviewed on 8/15/23 at 2:30 p.m. He said two dietary staff members called in and did not report to work that day which caused the dietary staff to serve breakfast late. He because breakfast was served late that morning and the dietary staff were unable to catch up and serve lunch on time.

Based on observations, interviews and record review the facility failed to ensure the residents had access to the results of the facility's most recent survey conducted by Federal or State surveyors over the past three years of survey, to include survey findings and any plan of correction, in a place readily accessible to residents, family members and legal representatives of residents. Specifically, the facility failed to make accessible survey results of the previous recertification survey of 6/15/22, and the complaint survey findings for the past three years. Findings include:I. Resident group interviewOn 8/15/23 at 3:30 p.m., a group interview was conducted with nine (#2, #27, #29, #93, #94, #111, #114, #153 and #359) alert and oriented residents. None of the residents knew the location of the results from previous annual and complaint survey findings. Resident #93 said she did not know she could see the results of past surveys. II. ObservationsOn 8/16/23 at 10:44 a.m. the survey findings book was located at the reception desk on a bookcase. The findings book was missing the previous annual survey findings completed 6/15/22 and all complaint surveys for the past three years 2023, 2022 and 2021. III. InterviewsThe nursing home administrator (NHA) was interviewed on 8/16/23 at 11:59 a.m. The NHA said he was responsible for updating the survey findings binder. The NHA said that he pulled out the annual survey for 2022 in June or July for his quality assurance performance improvement (QAPI) meeting. The NHA said he only puts the annual survey results into the binder not the complaint survey results. The NHA said he reviewed the survey results with the residents during a resident council meeting.

Based on observations and staff interviews, the facility failed to ensure that residents were provided privacy during personal care for one (#151) resident out of 56 sample residents. Specifically, the facility failed to provide Resident #151's personal privacy while using the toilet. Findings include:I. Facility policyThe Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, "Residents are treated with dignity and respect at all times. Staff promote, maintain and protect resident ' s, privacy, including bodily privacy during assistance with personal care, and during treatment procedures. demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents." II. Resident statusResident #151, age 70, was admitted on 5/22/23. According to the August 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance. According to the 5/29/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for a mental status score of three out of 15. The resident required extensive assistance of one person with toileting, bed mobility, dressing, transferring and personal hygiene. III. ObservationsOn 8/10/23 at 1:56 p.m. certified nurse aide (CNA) #1 assisted Resident #151 to her room in order to change her soiled brief and pants leaving the main door open. CNA #1 brought the resident into the bathroom. The CNA did not tell the resident what he was about to do or speak to the resident while providing care during the entire care procedure. CNA #1 helped Resident #151 pulled down her pants and sat the resident on the toilet. When the resident was done going to the bathroom the staff cleaned her peri area. The resident was naked from the waist down and exposed to anyone walking by her room. Two unknown staff members walked by and did not offer to close the door. CNA#1 left the bathroom door and the door to the hall open so anyone walking by had a clear view into the resident ' s bathroom; the resident sitting on the toilet and the peri care that was being provided could be viewed. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said when staff assisted residents with toileting or incontinent care the staff should always shut the door or pull a curtain to maintain privacy for a resident. LPN #1 said they should do this regardless of cognitive functioning. The director of nursing (DON) was interviewed on 8/16/23 at 11:03 a.m. The DON said staff should always close the door or use curtains when helping a resident toilet, changing them or while performing incontinent care. The DON said it did not matter the cognitive functioning of the resident, the staff should still provide privacy for the resident. The DON said when staff did not provide the resident with privacy, staff were not treating the resident with dignity of respect. V. Facility follow-upThe DON provided additional documentation that facility staff had been provided an inservice on 8/16/23 at 3:09 p.m. to provide all residents privacy while using the toilet.

Based on observations record review and interviews the facility failed to ensure that the resident environments remained free from accidents hazards as was possible and that each resident had adequate supervision to prevent accidents for for one resident (#151) of one reviewed for medications left unsecured in a common area, two residents (#86 and #23) reviewed for medications at bedside and one (#151) of four residents reviewed for falls out of 56 sampled residents. Specifically, the facility failed to:-Ensure medications were not left unattended for Resident #151's access, who had severely impaired cognition related to dementia and a tendency to wander and pick up items along the way; -Ensure Resident #86 and Resident #23 did not have medications at bedside when not assessed; -Ensure Resident #151 was provide sufficient monitoring, non-slip footwear and other fall interventions the resident was assessed to need in order to prevent multiple falls; and,-Ensure that Resident #151 was assessed by a registered nurse after an unwitnessed fall. I. Unsecured medicionA. Facility policy and procedureThe Medication Labeling and Storage policy, revised last February 2023, received from the nursing home administrator (NHA) on 8/12/23 at 2:50 p.m. It revealed in pertinent part "nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner."Items were not left unattended if open or otherwise potentially available to others."B. Resident #1511. Resident statusResident #151, age 70 was admitted on 5/22/23. According to the August 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance. According to the 5/29/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired with a brief interview for a mental status score of three out of 15. She required extensive assistance of one person with toileting, bed mobility, dressing, transferring and personal hygiene. The behavior assessment failed to assess the residents' wandering behavior. 2. Record reviewThe 5/23/23 comprehensive care plan documented that Resident #151 had behaviors of wandering and eating and drinking anything she finds. Interventions documented were to anticipate and meet the residents needs, provide positive reinforcement/praise any indication of the resident's progress/improvement/control in behavior.-The care planned interventions failed to have an intervention to for staff monitor the resident when wandering to ensure the resident did not get ahold of potentially dangerous and hazardous items. 3. Observation On 8/10/23 at 9:58 a.m. licensed practical nurse (LPN) #1 was observed leaving her medication cart unattended with loose pills in a medication cup on top of the cart. Resident #151 walked up to the medication cart and was grabbing items off the medication cart. As Resident #151 reached for the loose pills in the medication cup a hand was placed over the medication cup containing the loose pills to prevent Resident #151 from picking up the medication cup until nursing staff returned to the area and could be alerted to the situation. At 10:01 a.m. LPN #1 and the director of nursing (DON) were observed walking down the hallway towards the medication cart. The DON redirected Resident #151 towards the nursing station and removed an open pudding cup from Resident #151's hands that the resident had picked up off the medication cart. LPN #1 disposed of the loose medication. 3. Staff interview LPN #1 was interviewed on 8/10/23 at 10:03 a.m. LPN #1 said she left medications unattended and identified the unattended medication as claritin (allergy medication). She stated medications were not to be left unattended because residents who wandered may pick them up. LPN #1 said residents who take medication not ordered for them could cause them to have an allergic reaction or affect them adversely. The DON was interviewed on 8/16/23 at 11:00 a.m. The DON said medications were not to be left unattended because the medication could be given to the wrong person or found and taken by a resident for whom the pill was not prescribed. A resident can have a reaction to a medication if it was not ordered for them. 4. Facility follow upOn 8/16/23 at 11:00 a.m. the DON said the LPN involved with leaving the medication unattended was provided education for medication safety and suspended pending further review. II. Medications at bedsideA. Facility policy The Administering Medications policy and procedure, revised April 2019, received from the Nursing home administrator (NHA) on 8/11/23 at 4:34 p.m. revealed in pertinent part, "Medications were administered in a safe and timely manner and as prescribed. "Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely." B. Resident #861. Resident statusResident #86, under 65, admitted on 1/6/23. According to the August 2023 CPO diagnosis include malignant neoplasm of the colon (colon cancer), type two diabetes (abnormal insulin levels), chronic kidney disease (decreased kidney function) and hypertension (high blood pressure). The 5/25/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required one person assistance for bed mobility, transfers, dressing, toileting and personal hygiene. 2. Resident observations and interviewOn 8/9/23 at 12:16 p.m. a tube of diclofenac cream (topical pain cream), a Flonase (allergy nasal spray) and Peridex (prescription antiseptic mouthwash) were observed on the resident's bed side table. Resident #86 was interviewed on 8/10/23 at 11:53 a.m. Resident #86 said she used these medications regularly and kept them on her bedside table to keep them within reach. Resident #86 was unable to recall if the facility had assessed her for self administration and she said she did not have a lock box in her room to safely store the medications. Diclofenac, flonase and peridex were on her bedside table during the interview. 3. Staff interviewLicensed practical nurse (LPN) #2 was interviewed on 8/1/23 at 4:16 p.m. LPN #2 reviewed Resident #86's room and found the following medications on the bedside table and night stand; triamcinolone acetonide 0.5% cream (cream for skin irritation), Peridex 0.12 % liquid, Flonase 50 micrograms (mcg)/actuation (act), lidocaine 5% prilocaine 2.5% cream (topical pain relief, diclofenac sodium 1%, and nystatin 100000 units per milliliter (ml) suspension (antifungal). All medications were removed from the resident's bedside pending further assessment. LPN #2 said if a resident was able to self administer medications they would have a locked box in their room to keep medications safe from other residents who should not have access the medicions LPN #2 said the facility nursing needed to complete an evaluation to determine if the resident was able to administer medication independently. LPN #2 said there were not any residents in the 200 hall that were able to self administer medications and no residents should have medications in their rooms to self administer without a physician order. LPN #2 reviewed Resident #86's medication list on 8/10/23 at 4:20 p.m. LPN #2 said that Resident #86 only had orders for three of the six medications (see record review below) removed from Resident #86's room. LPN#2 did not say the physician would be notified about self administration of medications of medications nor if the physician would be informed of the medications Resident #86 was taken without physician orders. 4. Record reviewReview of Resident #86 electronic medical records revealed there was no physician order for self administration of medications. Review of Resident #86's medical record failed to reveal if the resident had been assessed for self administration of medications. The August 2023 CPO documented the following orders:Triamcinolone acetonide 1 percent cream; Flonase nasal suspension 50 mcg/act; and,Peridex solution 0.12 percent. -There were no orders for lidocaine 5 percent prilocaine 2.5 percent cream, diclofenac sodium 1 percent cream, and the Nystatin 100000 units/ml suspension. 5. Other staff interviewThe director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said in order for a resident to self administer medications they would need to be assessed to ensure that they were cognitively able to safely administer the medications, have physician approval/orders, and a lock box would be provided for the residents room to safely store the medications away form the reach of other residents not approved ot have access to the medications. The DON said even if the resident was assessed to have the ability to self administer a medication the nurses would still need to monitor medication to ensure they were taken properly. The DON said there was a risk a resident would take too much or too little and residents who wander to encounter medication if not secured appropriately. 6. Facility follow up A health status note dated 8/10/23 at 5:34 p.m. documented "the resident willingly turned over her medications to the nurse as she could not self administer her medications due to the lack of a safe place to store them." C. Resident #23 1. Resident statusResident #23, age 75, was admitted on 7/22/22. According to the August 2023 CPO, the diagnoses included dementia, anxiety, chronic respiratory failure, and mild intermittent asthma. The 7/19/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required extensive assistance from one person for bed mobility, locomotion on and off the unit, dressing, toilet use, personal hygiene, bathing, and needed supervision and one person assistance for eating. 2. Observations and resident interviewResident #23 was interviewed on 8/9/23 at 12:05 p.m. A bottle of vitamin B12 gummies that was one-third full was observed unsecured on a bedside table next to Resident #23's bed. Resident #23 said the B12 vitamins were hers. She said other residents wandered into her room and items were picked up from her bedside table. Resident #23 said she kept candy bars on her table and thought it was possible some candy bars were missing and taken by a resident who frequently wandered into her room and picked things up without permission. Resident #23 was interviewed on 8/17/23 at 10:00 a.m. The B12 vitamins were observed unsecured on Resident #23's bedside table. Resident #23 said her daughter brought the vitamin B12 gummies in and she might not take them anymore after she finished the vitamins in the bottle. 3. Record reviewA review of the August 2023 CPO on 8/17/23 at 10:30 a.m. revealed Resident #23 did not have a physician's order for vitamin B12 and there was no record of the resident being assessed to be competent to self-administer any medications including the vitamin B12.4. Facility follow-upThe director of nursing was interviewed on 8/17/23 at 11:30 a.m. She said the vitamin B12 gummies were removed from Resident #23's bedside table. III. Resident fallA. Facility policyThe Fall policy, revised March 2018, was provided by the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, "Based on previous evaluation's and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. "According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming, external force. An episode, where a resident lost his/her balance, and would have fallen if not for another person, or if he, or she had not caught him/herself is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, the fall is considered to have occurred. "If falling reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of nature, or category of falling until falling is reduced or stopped, or until the reason for the continuation of the is identified or unavoidable. "The staff will monitor and document each resident response to interventions intended to reduce falling or the risk of falling. If the resident continues to fall, staff will reevaluate the situation, and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified."-The policy failed to document steps for a registered nurse to assess a resident for injuries following a fall. B. Resident #1511. ObservationsOn 8/10/23 at 9:44 a.m. Resident #151 was observed on the floor. The resident was alone in the room barefoot on her hands and knees crawling across the floor in front of the privacy curtain dividing side A from side B. There were no fall mats on the floor. At 9:47 a.m. CNA #1 entered the resident's room and lifted the resident from the floor, by reaching under the resident's arms and lifting her off the floor and assisted the resident to sit on the bed. The CNA assisted the resident to put on non-slip socks with rubber grippers. After doing so the CNA left the resident alone in the room. -None of the nurses on duty provided the resident a post fall exam to assess for injury to include an assessment of mobility or neurological assessment in case the resident hit her head or attempted to determine the cause of the resident coming to be on the floor. At 9:54 a.m. the resident left her room to walk the hallway grabbing items in the common area. The resident was off balance and was unsteady on her feet. Staff did not intervene or provide interventions as care planned. On 8/10/23 at 1:00 p.m. Resident #151 was observed walking down the hall, barefoot without non-slip footwear. A CNA approached and assisted the resident to use the bathroom, but did not assist the resident to put on any non-slip footwear. At 2:45 p.m. the resident continued to walk through the halls without barefoot non-slip footwear on her feet. On 8/14/23 at 8:47 a.m. Resident #151 was observed sitting on her bed. Staff assisted her from her bed to a chair the resident did not have shoes or socks on and staff did not assist her to put on any footwear. At 9:49 a.m. the resident continued to sit in a chair without socks or shoes on. Staff did not go into the residents room or encourage the resident to put footwear on. At 10:18 a.m. the housekeeper mopped the resident room and placed a wet floor sign outside the resident's room. The floor was visibly wet and the resident was in the room sitting in a chair and she was completely bent over falling asleep with her head touching the floor. The resident continued to not have footwear on. At 10:56 a.m. the resident was still sitting on the chair slumped over sleeping in her chair without non-slip footwear. The medication nurse brought the resident her medications. The nurse did not offer to assist the resident to lay down or put on non-slip footwear. At 10:54 a.m. the resident was observed barefoot standing on one foot and scraping the other foot on the door jam; then she started to wander the hallways. The resident gait was off balanced. Two staff members passed the resident but did not offer to help the resident with footwear. At 10:57 a.m. a CNA walked up to the resident while she was wandering the hall and said "no socks for you?" The CNA kept walking and did not help the resident put on any non-slip socks. The resident did not respond and continued to walk down the hallway. At 11:12 a.m. a CNA walked her into the common area and the resident remained barefoot. At 11:45 a.m. the resident was sitting in the common area near the nurse station without non-slip socks or shoes on. Two unknown staff walked by the resident and did not offer footwear. On 8/14/23 at 3:06 p.m. the resident was observed in the hallway walking with one non-slip sock on and one sock off. An unknown staff member walked by the resident and did not assist the resident to put on appropriate non-slip footwear. 2. Record reviewAccording to the 5/29/23 MDS assessment, the residents' balance was not steady, but able to stabilize with human assistance. The assessment documented the resident had not fallen in the prior three months. The resident's comprehensive care plan had a care focus for fall prevention, revised on 5/31/23. The care focus documented the resident was at risk for falling, due to memory loss, and a need for frequent redirection and cueing. Additionally, it documented the resident had impaired balance and safety awareness. Care plan interventions included: Encourage the resident to lay down in her bed when tired. Provide frequent rounding, anticipate resident's needs. Follow fall protocol. Keep the resident bed in the lowest position. Ensure the resident was wearing appropriately fitting footwear and clothing. Provide an environment free of clutter and remind the resident to use the call device light for assistance. A post fall investigation dated 6/24/23 documented the resident had witnessed fall. The resident was sleeping in a chair and slipped out of the chair onto the floor. The investigation documented that the resident had balance problems, and a history of prior falls having had more than three falls in the last 90 days. A post fall investigation dated 7/28/23 documented the resident had an unwitnessed fall and was found on the floor in her room just outside of the bathroom. The investigation documented that the resident had an unsteady gait and had balance problems.-The facility was not able to produce a post all investigation report investigating the unwitnessed fall on 8/10/23 when CNA #1 was observed picking Resident #151 up off the floor in her room (see the DON interview below). 3. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said staff should assume the resident fell if they find them on the floor. LPN #1 said residents who were found on the floor need to be assessed by a registered nurse and put on neurological checks to assess for a potential head injury. LPN#1 said Resident #151 was a fall risk. LPN#1 said interventions were in place and should be followed. LPN #4 said if staff saw the resident sleeping in a chair they should suggest she be laid down in her bed to prevent a fall. CNA #4 was interviewed on 8/16/23 at 10:00 a.m. CNA #4 said when a resident was found on the ground the CNAs should immediately get the nurse so they could assess the resident before moving the resident. CNA #4 said Resident #151 was at risk for falling and she should always have gripped socks or non-slip shoes on. CNA #4 said Resident #151 had a history of slipping out of her chair. The DON was interviewed on 8/16/23 at 11:05 a.m. The DON said staff should assume a resident fell if the staff found the resident on the floor. The DON said if a resident was found on the floor an RN assessment and neurological checks should happen before picking up a resident off of the floor. The DON said staff should follow the interventions put into place to prevent individuals from falling. The DON said the staff did not report that Resident #151 had a fall on 8/10/23. The DON said Resident #151 did slip out of her chair when she was tired and if that happened the staff should have helped the resident to her bed before she fell. If staff found Resident #151 sleeping in a chair staff should offer to assist her to lay downfor a nap. The resident's bed should always be in the low position with a fall mattress on the floor next to her bed. The DON said the facility did not have a post fall investigation for the resident falling on 8/10/23.

Based on observations, interviews and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#101 and #111) of two residents reviewed for catheter care of 56 sample residents. Specifically, the facility failed to:-Ensure Resident #101's catheter bag was positioned below the bladder; and. -Ensure Resident #111's physician orders were followed. Findings include:I. Facility policy and procedureThe Catheter policy, revised in August 2022, was provided by the nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, "The purpose of this procedure is to prevent urinary catheter - associated complications, including urinary tract infections. Review the residents care plan to assess for any special needs of the resident."Catheter evaluation: review and document the clinical indications for catheter use prior to inserting. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use. Remove the catheter as soon as it is no longer needed. "Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. If the catheter material contributes to obstruction, notify the physician and change the catheter, if instructed to do so. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstructions. Change catheter and drainage bags based on clinical indication, such as infection, obstruction, or when the closed system is compromised. Residents who form encrustations that can quickly lead to an obstruction need more frequent catheter changes at intervals specific to the individual resident. The catheter should be changed before blockage is likely to occur."II. Resident #101A. Resident statusResident #101, age 68, was admitted on 12/27/21. According to the August 2023 computerized physician orders (CPO), diagnoses included Parkinson's, neuromuscular dysfunction of the bladder and anxiety disorder. According to the 6/30/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. She required extensive assistance of one person with toileting, bed mobility, dressing, transferring, locomotion eating and personal hygiene. The resident had an indwelling catheter. B. ObservationsOn 8/9/23 at 12:20 p.m. the resident was in the bathroom emptying her own catheter. An unidentified certified nurse aide (CNA) went into the bathroom to help the resident with her catheter. After assisting the resident with emptying the catheter, the CNA took the bag and stuffed it behind the resident's back so the catheter bag was resting on the resident's seat and was between the wheelchair and the resident's back which was above her bladder..Observations 8/14/23 -At 10:30 a.m. the resident's catheter was placed on the resident's seat behind her back between the resident and the back of the chair. CNA #5 interacted with the resident, however, did not move the catheter below her bladder. -At 12:36 p.m. the resident went to the bathroom. CNA #5 said she put the catheter on the resident's seat behind her due to her messing with the catheter bag. CNA #5 put the catheter bag on the wheelchair behind her so the resident was leaning against the catheter. -At 3:16 p.m. the resident's catheter remained in the same position placed on the resident's seat between her and the back of the seat. The resident was in a common area and several staff walked by her and no staff attempted to lower the catheter bag to below her bladder. C. Record review According to the August 2023 CPO the resident had a Foley catheter since 1/66/22 with the associated diagnosis of neuromuscular dysfunction of the bladder. According to the catheter care plan revised 6/7/23 documented the resident had a catheter. The resident perseverates over the Foley bag. Staff should implement the following interventions: Staff should reassure the resident the Foley bag was emptied. The resident needed to be reminded to not pull on the Foley tubing. Staff should check tubing for kinks. Nurse should provide catheter care as ordered. D. InterviewsLicensed practical nurse (LPN) #1 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said catheter bags should be covered and placed under the wheelchair. LPN #1 said the catheter needed to be placed below the bladder to prevent blockage which could cause a urinary tract infection (UTI). LPN #1 said that Resident #101 would put the catheter bag on her seat behind her so the bag was between the resident and the back of the wheelchair. LPN #1 said staff should redirect the resident and encourage the resident to place the catheter under her chair. CNA #4 was interviewed on 8/16/23 at 10:00 a.m. CNA #4 said catheter bags should be covered and placed under the wheelchair. CNA #4 said the catheter needs to be placed below the bladder to prevent blockage which could cause a UTI. CNA #4 said the resident liked to empty the catheter without help. CNA #4 said staff should place the catheter bag under the resident's wheelchair. The director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said the Foley catheter bag needed to be placed below the bladder. The DON said if the bag was placed above the bladder it could cause the urine to go back into the bladder and could cause a urinary tract infection. The DON said because of behavioral issues Resident #101 was concerned about her Foley bag. The DON said staff should redirect and attempt to put Resident #101's Foley bag below her bladder. The DON said the refusal to keep the catheter bag below the bladder should be careplanned due to the risks. III. Resident #111A. Resident statusResident #111, age 74, was admitted on 9/30/22. According to the August 2023 CPO, the diagnoses included obstructive and reflux uropathy (obstructed urinary flow), benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms and chronic respiratory failure. According to the 6/30/23 MDS assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. He required extensive assistance of one person with toileting, bed mobility, dressing, locomotion eating and personal hygiene. He required extensive assistance of two people with transfers. The resident has an indwelling catheter. B. Resident interview and observationsResident #111 was interviewed on 8/9/23 at 3:37 p.m. the resident was in bed and had a green chux (a protective pad) bunched up around his waist. The resident said his catheter had been leaking on and off for months. The resident said the chux was there to catch the urine and he was wearing a brief because it leaked so bad. The resident said the leaking stopped after the catheter was flushed but the catheter had started to leak continuously again for three or four days. Resident #111 was interviewed on 8/16/23 at 3:38 p.m. The resident had a brief on and said his catheter continued to leak. He said he did not get daily flushes. He said the nurses might flush his catheter once a month. He said when they flush the catheter it no longer leaked. He said he had to ask nurse staff to flush his catheter otherwise the staff would not do it. He said he did not understand why he had a catheter if he had to continue to wear a brief. He said he worried about developing wounds because of urinating and sitting in a wet brief. C. Record reviewThe catheter care plan revised 4/13/23 identified the resident had a catheter. Pertinent interventions included: observe and report signs of infection provide catheter care twice per shit and as needed, position catheter bag below level of bladder and encourage fluids. The August 2023 CPO documented catheter care according to protocol should be done daily. Staff should document output daily. Change Foley bag and tubing every Sunday. The June 2023 medication administration record (MAR) and treatment administration record (TAR) had no documentation of changing the Foley bag and tubing every Sunday. The July 2023 MAR and TAR there was no documentation of changing the Foley bag and tubing every Sunday. The August 2023 MAR and TAR there was no documentation of changing the Foley bag and tubing every Sunday. According to the progress notes:The 6/17/23 progress note documented the nurse changed Foley catheter. The 7/1/23 progress note documented the nurse flushed the catheter with normal saline so urine can drain from the bladder. The 7/19/23 progress note documented the nurse changed Foley as needed for leaking per order. The 5/4/23 urology physician visit documented the resident had urine retention. The order for treatment was the following: -Encourage increased fluid intake;-Daily catheter flushes with normal saline or sterilized water;-Catheter exchanged every two to three weeks; and,-Do not treat UTIs unless the resident was symptomatic. According to 5/5/23 healthcare practitioner notes documented the resident went to a urology appointment recommendations are encouraging increased fluid intake. Daily catheter flushes with normal saline or sterilized water. Catheter exchanged every two to three weeks. Do not treat UTIs unless the patient was symptomatic. -The order for daily catheter flushes were not indicated in the physician's orders. According to the 8/2/23 physician progress note documented the facility needs to follow up with 5/3/23 urology orders. -The medical record failed to show the facility followed up with the urologist. D. Staff interviewsLPN#1 was interviewed on 8/16/23 at 9:45 a.m. LPN #1 said when a catheter was leaking the nurses notified the physician. LPN #1 said it could be a sign of blockage. LPN# 1 said blockage could cause UTIs. LPN #1 said any orders for the catheter would be in the resident's MAR or TAR. LPN #1 confirmed there was no orders to flush or change Resident #111's catheter as ordered by the urologist. The director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said when a catheter leaked they would likely change the bag. The DON said catheter care orders did not include flushing or changing the catheter. The DON said Resident #111 had an urology appointment because his catheter was leaking. The DON acknowledged the urologist ordered daily flushes and catheter changes every two to three weeks. The DON said the nurse practitioner (NP) got the recommendations from the urologist. The DON said if the NP wanted to follow the orders from the urologist he would have put them in. The DON said the NP sometimes gave verbal orders to the nurses. The DON said it was the NP's responsibility and the NP would let a nurse at the facility know if the NP wanted orders to be put in. -However, according to the practitioner note on 5/5/23 it was documented for the orders to be followed from the urologist (see above).

Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#92 and #411) of four residents reviewed for supplemental oxygen use out of 56 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Residents #92 and #411. Findings include: I. Facility policy The Oxygen Administration policy, revised October 2010, was provided on 8/16/23 at 5:00 p.m. by the director of nursing (DON). It read in pertinent part, "The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure and review the physician orders or the facility protocol for oxygen administration." II. Resident #92 A. Resident status Resident #92, over age 65, was admitted on 2/1/22. According to the August 2023 computerized physician orders (CPO), diagnoses included chronic diastolic congestive heart failure, generalized anxiety, and depressive disorder. According to the 5/9/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required extensive assistance for bed mobility, grooming, toileting, and two-person total assistance with transfers. The resident received oxygen therapy. B. Record review The care plan initiated on 2/2/22 and revised on 4/12/23 identified that the resident had an increased risk for a potentially ineffective respiratory pattern. Interventions included oxygen as ordered by the physician. Monitor for signs and symptoms of respiratory distress. The August 2023 CPO included an order dated 2/2/22 for oxygen therapy at four (4) liters per minute (LPM) continuously via nasal cannula every shift. C. Observation On 8/10/23 at 9:27 a.m. Resident #92 was lying down in bed with her oxygen nasal cannula in her nostril. The resident's oxygen concentrator was set to 2 LPM. On 8/14/23 at 2:44 p.m., Resident #92 was sleeping in her bed with her cannula on. The concentrator was set at 2 LPM. On 8/15/23 at 2:15 p.m., Resident #92 was awake in bed with her oxygen cannula in her nostril. The concentrator was set at 2 LPM. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 8/15/23 at 3:15 p.m. LPN #3 said oxygen was considered a medication and needed to be administered according to the physician's orders. The LPN said the resident was receiving oxygen at 2 LPM and then adjusted Resident #92's oxygen to 4 LPM to be given per the physician's order. The LPN said a possible negative outcome of the resident not receiving oxygen therapy at the rate of LPM as per the physician's could be the resident's organs and tissues would not be receiving sufficient oxygenation to keep functioning properly which could be fatal. The director of nursing (DON) was interviewed on 8/16/23 at 1:13 p.m. The DON said oxygen therapy required a physician's order in order to be administered. The DON said Resident #92's oxygen should have been administered as the provider ordered it. The DON said a negative outcome from not following the physician's order could have resulted in respiratory distress for resident #92. III. Resident #411 A. Resident status Resident #411, age 78, was admitted on 11/21/16 and readmitted on 4/13/21. According to the August 2023 CPO, diagnoses included idiopathic epilepsy, seizures, systolic and diastolic congestive heart failure, dementia and Parkinson's disease. According to the 6/6/23 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and total staff assistance with toilet use. The resident received oxygen therapy. B. Rec

Based on record review and resident and staff interviews, 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) of two residents reviewed for psychosocial well-being out of 56 sample residents. Specifically, the facility failed to coordinate timely mental health services for Resident #20. Findings include:I. Facility policy The Behavioral Health Services policy revised February 2019, was provided by the Nursing home administrator (NHA) on 8/16/23. It revealed in pertinent part, "The facility will provide residents behavioral health services as needed to attain or maintain the highest, practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. "Behavioral health services are provided to residents as needed as part of the interdisciplinary, person centered approach to care. Residents who exhibit signs of emotional and psychosocial distress receive services and support that address their individual needs and goals for care. Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial, adjustment, substance abuse or post-traumatic stress disorder will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavailable. Staff must promote dignity, autonomy, privacy, socialization, and safety, as appropriate for each resident and are trained in ways to support residents in distress."II. Resident #20A. Resident statusResident #20, age 70, was admitted on 9/18/22. According to the August 2023 computerized physician orders (CPO), the diagnoses included Parkinson's disease and dementia and depressive episodes. According to the 7/7/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. He required extensive assistance of one person with toileting, bed mobility, dressing, locomotion, eating, transfers and personal hygiene. Psychology therapy was administered zero days and psychological therapy was administered for at least fifteen minutes in the last seven days. B. Resident interviewResident #20 was interviewed on 8/10/23 at 2:13 p.m. The resident said he wanted to see a therapist/counselor and the facility did not provide him with one. He said he feels paranoid and thinks staff were tricking him, tracking him and keeping him in the facility against his wishes. He said that he needed to talk to someone to help him work through these feelings. C. Record reviewAccording to the care plan initiated on 4/11/23 documented the resident meets criteria for a preadmission screening and resident review (PASSAR) II due to schizoaffective disorder and bipolar. Interventions included: The resident will receive appropriate specialized services to attain or maintain their highest practicable psychological, physical, functional, and psychosocial well-being. The resident will be educated on the benefits of counseling. Resident #20 was to be scheduled to receive counseling services. According to the trauma informed care plan revised on 4/10/23 the resident has a history of trauma. Interventions included the following; Behavioral health consults. Explain and collaborate care with the resident. Encourage the resident to express their feelings. According to the PASSAR II evaluation Resident #20 had a diagnosis of major depressive disorder. The treatment included psychiatric case consultation, psychosocial rehabilitation services and individual therapy. According to the 6/12/23 diagnostic assessment the resident's PHQ-9 (depression assessment) score revealed the resident had severe depression with a score of 16 out of 19. Recommendations were individual therapy four times a month with a review on 10/12/23. -A request was made to the facility for therapy notes from 6/12/23 to 8/16/23; the facility was only able to present verification of one subsequent psychiatric visit for consultation on a gradual dose reduction (GDR) assessment related to psychotropic medication taken by the resident, but no actual documented therapy session. According to the 7/28/23 psychiatric GDR assessment the resident was seen for a pharmacy request for gradual drug reduction and not therapy counseling services. -There was no other documentation of individual psychological therapy for Resident #20. Additional documentation was presented by the director of nursing (DON) on 8/17/23 at 12:42 p.m. revealed that the facility called the therapy provider to see why there was a delay in providing Resident #20 with the recommended psychiatric services The community provider told the facility that there was a change in psychologists causing a shortage of available psychologists to provide community services. The newly assigned psychologist had not seen Resident #20 yet. The new assigned psychologist was in the facility on 8/9/23 and was in the building seeing other residents. The psychologist did not go see Resident #20. D. Staff interview The social service assistant (SSA) was interviewed on 8/16/23 at 9:00 a.m. The SSA said when a resident had a PASSAR II recommendations the facility would follow those recommendations. The SSA said the resident had a PASSAR II and was recommended individual therapy four times a month. The SSA said Resident #20 did receive behavioral health services including individual therapy. The SSA said Resident #20 had confusion but he was receiving individual therapy.-The SSA was not able to provide documentation of individual therapy notes. Licensed practical nurse (LPN)#1 was interviewed on 8/16/23 at 9:45 a.m. LPN #4 said Resident #20 was paranoid and thought the nurses were tracking him. LPN #4 said the resident saw a behavioral therapist but did not know how often or where the documentation was. The DON was interviewed on 8/16/23 at 11:00 a.m. The DON said the facility followed all PASSAR II recommendations. The DON said Resident #20 was getting individual therapy four times a month, but the resident refused services. The DON said the documents provided for psychiatric services dated for 6/12/23 and 7/28/23 were the only documents the facility had to show dates of services related to provision of behavioral therapy for Resident #20.

Based on observations and interviews the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for two of three medications carts reviewed for storage and labeling. Specifically the facility failed to:-Ensure Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; and, -Ensure medication carts were maintained clean and free of loose pills. Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy and procedure, revised February 2023, received from the nursing home administrator (NHA) on 8/11/23 at 4:34 p.m. It revealed in pertinent part "Nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. "Multi-dose vials that have been opened or accessed needle puncture were dated and discarded within 28 days."Medications were stored in an orderly manner in cabinets, drawers, and carts to prevent the possibility of mixing medications of several residents."-Insulin which is used for diabetes is considered a multi-dose vial. II. ObservationsOn 8/10/23 at 1:43 p.m. the 300 hall medication cart was reviewed. One glargine insulin (used to treat abnormal glucose levels) injection pen 100 units/milli litter (ml) with no open date. One open Insulin glargine vial with no open date. Once alerted that the vial was not labeled registered nurse (RN) #1 discarded the insulin vial and injection pen into the sharps container on the medication cart. On 8/10/23 at 1:57 p.m. the 600 hall medication cart was reviewed. One Degludec injection flex touch insulin pen 100 units per ml had no open date. The cart had six whole tablets and five half tables loose in the cart. III. Staff interviewsRN #1 was interviewed on 8/10/23 at 1:43 p.m. RN #1 said the vial and insulin pen had no open dates and they need to be dated when they were opened to ensure they were not used past the one month window as they could not be as efficient in the residents management of diabetes. RN #1 said she put the medications into the sharps container to dispose of them in order to make sure it was not used. RN #2 was interviewed on 8/10/23 at 1:57 p.m. RN #2 said the insulin pen did not have an open date and needed to have one since it needs to be used within 30 days of being opened. RN #2 said she was unsure by who or when the medication carts were cleaned and medications should not be loose in the medication cart. RN #2 did not know how to dispose of the insulin pen and left it in the cart to call the assistant director of nursing (ADON) for further directions. The ADON was interviewed on 8/10/23 at 2:27 p.m. The ADON said the insulin pen did not have an open date and pens were only good for 30 days once opened/accessed. The ADON said medications that were discontinued or no longer can be used were placed in the medication room in containers for the night shift supervisor to dispose of them in the appropriate containers per pharmacy directions. The director of nursing (DON) was interviewed on 8/16/23 at 11:00 a.m. The DON said insulin pens or vials should be dated with the date of opening to ensure they were not used past the 28 day period of use. The DON said expired medications including insulin were to be placed into the medications room for destruction and never be put into the sharps container due to state regulations. The DON said medications carts were cleaned every night during night shift but they did not have a sign off sheet to ensure the task was completed. The DON said it was important to keep the carts clean and free from debris to prevent contamination and infection control purposes.

Based on record review and observations, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the resident's care plan. Specifically, the facility failed to:-Ensure meals were provided to Resident #103 according to the prescribed diet order; and,-Ensure three residents had food prepared according to their diet orders of mechanical soft-ground texture as indicated on their meal tray cards. Findings include:I. Facility policy and procedureThe Food and Nutrition Services Staff policy, revised October 2017, was provided by the nursing home administrator (NHA) on 8/17/23 at approximately 3:00 p.m. It read in pertinent part, "The food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competencies to carry out functions of the department. The food and nutrition services staff under the supervision of the dietitian and/or food and nutrition services manager will safely and effectively carry out the functions of the food and nutrition services department. The department will maintain staffing levels to meet resident nutrition needs and preferences taking into consideration the acuity and diagnoses of the residents as well as individual assessments and plans of care. Food will be palatable, attractive and served in a timely manager at proper temperatures. Meals and nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident ' s medication requirements."The Therapeutic Diets policy, revised October 2017, was provided by the nursing home administrator (NHA) on 8/17/23 at 2:00 p.m. It read in pertinent part, "Therapeutic diets are prescribed by the attending physician to support the resident ' s treatment and plan of care and in accordance with his or her goals and preferences. The diet order should match the terminology used by the food and nutrition services department. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. The dietitian and nursing staff will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. The attending physician may liberalize the diet at the request of the IDT (interdisciplinary team) if the resident is not eating well, or the resident. If the resident or the resident ' s representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives."II, Resident #103A. Resident statusResident #103, age 84, was admitted on 8/8/23. According to the August 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, bipolar disorder, dysphagia (difficulty swallowing) and falls. The 8/9/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required extensive assistance from one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and hygiene. She needed supervision and set-up assistance for eating. The MDS assessment documented Resident #103 had coughing or choking during meals or when swallowing medications and she was on a mechanically altered diet. B. Resident interview and observationResident #103 ' s representative was interviewed on 8/9/23 at 1:58 p.m. The representative said Resident #103 had difficulty swallowing and food that was too dry caused Resident #103 to choke and not eat. The representative said Resident #103 ' s diet texture was not served correctly in the past and her meal was not cut up as small as usual. The representative said she reported her concern to staff who removed Resident #103 ' s meal tray and returned with her food cut smaller. The representative said Resident #103 loved tomato soup and grilled cheese sandwiches. On 8/14/23 at 12:41 p.m., Resident #103 ' s meal tray was observed with a grilled cheese sandwich that was only cut in half with the crusts cut off. Resident #103 ' s meal ticket was observed on her meal tray and documented the texture as mechanical soft-ground.-The grilled cheese recipe for a mechanical soft diet modification was provided by the dietary manager (DM) on 8/14/23 at 8:00 a.m. The recipe documented the mechanical soft-ground modification for a grilled cheese sandwich as, "If SLP (speech language pathologist) allows bread, shred the cheese and moisten with condiments. Moisten the bread and cut into pieces no larger than one eighth of an inch."C. Record reviewA review of Resident #103 ' s August 2023 CPO documented a diet order for a mechanical soft texture diet, ordered on 10/24/22. Resident #103 ' s annual dietary profile dated 8/9/23 documented Resident #103 ' s diet required mechanical soft texture and that Resident #103 enjoyed grilled cheese sandwiches.-Neither the physician ' s diet order or annual dietary profile documented if the ordered mechanical soft texture diet was supposed to be mechanical soft-ground or mechanical soft-chopped. II. Mechanical soft food preparation A. Meal service observation, record review and staff interviewMeal service was observed on 8/14/23 from 11:00 a.m. to 1:24 p.m. The posted menu documented the lunch meal as apple curry chicken, parmesan potatoes, green beans, apple crisp and dinner roll. Two pans of one-half inch size diced chicken pieces were observed in the hot food holding/steam table. Cook (CK) #2 said the two pans of one-half inch diced chicken were prepared for the residents who were prescribed mechanical soft textures diets. -According to the dietary manual (see below) the mechanic chopped and mechanical soft ground were two different consistencies but the facility had one consistency of diced chicken to serve residents on both textured diets. There was no differentiation consideration given to the resident on chopped versus a ground textured consistency.-The recipes for the 8/14/23 lunch meal were provided by the dietary manager (DM) on 8/14/23 at 8:00 a.m., The recipes documented mechanical soft-ground and mechanical soft-chopped textures were offered; the recipe modification for apple curry chicken for mechanical soft-chopped was specified as one-half in size diced chicken as observed in the steam table; the recipe modification for mechanical soft-ground texture was specified as diced to one-eight of an inch and was not observed in the steam table prior to meal service starting.-At 12:16 p.m., a resident ' s lunch plate was assembled by CK#2 with one half inch diced chicken. The meal ticket on the tray documented a mechanical soft-ground texture. The meat was not chopped to the one-eight inch size as was the instruction on the recipe modification for a mechanical soft-ground texture. The DM said the mechanically altered chicken on the plate was the incorrect size for a mechanical soft-ground texture, which the resident for whom the meal was prepared for was prescribed. Once alerted to the concern the DM asked CK#2 to stop plate assembly and then asked an unidentified dietary staff member to remove a pan of the one-half inch diced chicken from the steam table and grind it smaller for a mechanically soft-ground textured diet. The dietary staff member ground the chicken to the appropriate size of one-eighth inch and placed the pan in the steam table. The DM was interviewed on 8/14/23 at 12:17 p.m. The DM said the mechanical soft-ground chicken should have been diced smaller than the one-half inch size chicken pieces that were observed in the steam table.. CK #2 was interviewed on 8/14/23 at 12:19 p.m. CK #2 said she thought the one-half inch diced chicken was fine to be served as bite size and told the DM she was sorry for the error.-At 12:23 p.m. a clear plastic dessert dish of apple crisp contained apples sliced one inch in length and was placed on a resident ' s meal tray. The meal ticket on the tray documented that the resident was on a mechanical soft-ground texture. The meal tray was placed in the serving window. DA #1 and the DM were alerted that the size of the apples in the apple crisp was incorrect for the residents on a mechanical soft-ground texture.-At 12:24 p.m. the DM asked staff to stop assembling meal trays and she removed the apple crisp from the meal tray in the serving window. -At 12:26 p.m. CK #2 said she grabbed the wrong apple crisp and placed it on the trays of the residents on a mechanical soft ground diet by mistake. The recipes provided by the DM documented both mechanical soft-chopped and mechanical soft-ground apple crisp were offered; the recipe modification for mechanical soft-chopped apple crisp was apples diced to one-half of an inch; the recipe modification for mechanical soft-ground apple crisp was apples diced to one-eight of an inchThe DM was interviewed at 12:27 p.m. The DM said the mechanical soft dessert modifications for ground or chopped diet textures had not been prepared for the lunch meal; only the puree and regular texture desserts were prepared. The DM told the cook the apples should have been chopped for the dessert. The DM stopped meal assembly and asked dietary staff to modify the apple crisp to the size listed in the recipe. B Other record review The facility ' s diet manual dated 2022 was provided by the nursing home administrator (NHA) on 8/14/23 at 8:00 a.m. The diet manual documented the mechanical soft-chopped consistency as meats and other foods diced to one-half of an inch and the mechanical soft-ground consistency as meats and other foods diced to one-eighth of an inch. III. Other staff interviewsThe speech language pathologist (SLP) was interviewed on 8/16/23 at 8:30 a.m. The SLP said that she performed a comprehensive assessment of a resident including their plan of care before she upgraded food items listed as restricted on a modified texture diet. The SLP said she had not assessed Resident #103; however Resident #103 was scheduled for a nutrition evaluation per the therapy schedule. The SLP said there was a risk assessment and education provided to a resident regarding the risks of choking associated with consuming food items not part of the resident ' s prescribed diet order. The DM and NHA were interviewed on 8/15/23 at 2:30 p.m. The DM said the mechanical soft textures offered were ground and chopped and staff should have followed the recipes to modify textures correctly. The DM said the facility started a new menu program in May 2023 and the texture modifications were on individual recipes whereas a spreadsheet of modifications was used in the previous menu program. The DM said the dietary department tried to adjust to the new menu program quickly and use new menu program recipes for staff education, but did not use the diet manual. The DM said due to time constraints sliced bread was used at lunch on 8/14/23 instead of dinner rolls, and was supposed to be moistened for mechanical soft texture modification. Resident #23 was able to have a grilled cheese sandwich because the crust was cut off the sandwich; however, the DM could not verify the bread was moistened. The DM said the dietary staff did remove the one-half inch size diced chicken from the steam table and ground the chicken to a smaller size. She said the one-half inch sized chicken in the steam table was a product she ordered that was pre-cooked and pre-cut to one-half inch in size. The NHA said the facility should have done more staff education on the new menu program when it was implemented and the education that was done was not enough. The NHA said if a resident requested a menu item that was restricted on their diet, the facility staff would educate theresident the first time the request was made and then provide the menu item to the resident as it was the resident ' s right.-Education for Resident #103 regarding consumption of menu items listed as not allowed on her modified texture diet was requested and not provided. The DM was interviewed on 8/17/23 at 9:17 a.m. The DM said a paper diet communication form was provided for each resident with a diet change and upon admission. The facility kept the paper diet order for 30 days and then the document was destroyed. The DM said she clarified a diet order if she received written diet communication that said mechanical soft and did not include ground or chopped. F. Facility follow upOn 8/16/23 at 10: 30 a.m. the regional clinical support (RCS) provided a Liberalized Diets for Older Adults policy. She said she contacted the facility ' s corporate dining support team and they said the facility followed the liberalized diet orders listed on the policy. The policy read in pertinent part, "Soft, dental soft, dysphagia (difficulty swallowing) mechanical soft may not be liberalized unless any improvement in chewing or swallowing was approved by the speech therapist."

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, in two of two dining rooms and with resident room trays. Specifically, the facility failed to:-Ensure cold food holding equipment and ready to eat perishable food were kept at the appropriate holding temperature in two of two walk-in refrigerators; -Ensure proper unit refrigerator temperatures were maintained in one one of three resident snack refrigerators that contained ready to eat perishable food;-Ensure the high temp dish washing machine functioned at the proper temperatures;-Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in the first floor dining room; and,-Ensure residents were offered hand hygiene before eating their meals in two of two dining rooms and in resident rooms with meal trays. Findings include:I. Cold food holding of ready to eat food and unit refrigeratorsA. Professional referenceThe Colorado Retail Food Regulations, effective 1/1/19 and retrieved 8/23/23 from https://cdphe.colorado.gov/environment/food-regulations read in pertinent part, "Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified."The FDA (Food and Drug Administration) food code reviewed 3/27/23 and retrieved 8/23/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 read in pertinent part, "Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. B. Facility policyThe Food Receiving and Storage policy, revised November 2022, was provided by the nursing home administrator (NHA) on 8/14/23 at approximately 10:00 a.m. It read in pertinent part, "Danger zone means temperatures above 41 degrees F and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially hazardous foods (PHF) or time and temperature control for safety (TCS) foods held in the danger zone for more than four hours (if being prepared from ingredients at ambient temperature) may cause a foodborne illness outbreak if consumed. Food services, or other designated staff, maintain clean and temperature/humidity appropriate food storage areas at all times. PHF/TCS foods are stored at or below 41 degrees F, unless otherwise specified by law. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements."Food and snacks kept on nursing units: All food items to be kept at or below 41 degrees F are placed in the refrigerator located at the nurses' station and labeled with a 'use by' date. Refrigerators must have working thermometers and are monitored for temperature according to state- specific guidelines."C. Kitchen observations, record review and interviewsThe following observations were made on 8/9/23:At 9:13 a.m. during the initial kitchen walk through, walk-in refrigerator #1's digital thermometer revealed the refrigerator's internal temperature was 46 degrees F; five degrees above acceptable temperatures to ensure food safety (see professional reference above). Walk-in refrigerator #2's digital thermometer revealed the refrigerator's internal temperature was 43 degrees F; two degrees above acceptable temperature to ensure food safety. Walk-in refrigerator #1's temperature log was posted on a clipboard outside the walk-in door, staff documented the walk-in refrigerator temperature as 46 degrees F on 8/8/23; five degrees above acceptable temperature to ensure food safety . Staff documented the temperature of walk-in refrigerator #2's as 41 degrees F on 8/9/23 as 43 degrees F; two degrees over acceptable food temperatures to ensure food safety. -Neither temperature logs had reference temperature ranges to alert staff to acceptable temperature ranges. Walk in refrigerator #1 contained several perishable food items including six cases of four ounce yogurt containers, three containers of sour cream, two containers of soy milk, three-five pound logs of sliced american cheese, one six to eight pound ham, approximately eight ounces of sliced deli ham, approximately three pounds of tuna salad, and a case of two six to eight pound turkey breasts. At 9:15 a.m. the dietary manager (DM) was alerted to the observed walk-in refrigerators temperatures being out of range (see above). The DM was interviewed at 9:16 a.m. The DM said the dietary staff called her on 8/8/23 in the evening and informed her walk-in refrigerator #1 was running at a higher temperature than appropriate. The DM said she instructed staff to take temperatures of the individual food inside walk-in refrigerator #1; the food items tempt within correct temperature ranges (41 degrees F and under), so the food was not discarded. The DM said there was no adjustments made to walk-in refrigerator #1 and no additional monitoring of the food temperatures to see how long the temperature of walk-in refrigerator #1 remained above acceptable temperature of range or to ensure the food in the refrigerator remained within safe range. The DM said she was not aware that the second walk-in refrigerator's temperature was also temping higher than acceptable range. The DM said both walk-in refrigerators were new and just installed on 8/6/23 and both were cooled to appropriate refrigerated temperatures (40 degrees F or below) before staff placed food into each of the walk-in refrigerators. The dietary staff then checked the walk-in temperatures at 5:00 a.m. the following day (8/7/23) and again first thing the next morning after the door had been closed and left unopened all night; staff responded that the refrigerator had maintained appropriate temperatures until the evening of 8/8/23 when staff reported high temperatures. At 9:22 a.m. walk-in refrigerator #1's digital thermometer documented the internal refrigerated temperature was 42 degrees F and walk-in refrigerator #2's digital thermometer documented the internal refrigerator temperature was 45 degrees F.At 9:30 a.m. temperatures of perishable food items in walk-in refrigerator #1 were taken and observed to be greater than 41 degrees F.-Sour cream (unopened and unused) was 45 degrees F.-Sliced deli ham was 45 degrees F. -Silk soy milk was 45 degrees F.-Tuna salad was 43 degrees F. At 11:13 a.m. walk-in refrigerator #1 was 37 degrees F and walk-in refrigerator #2 was was 43 degrees F. The tuna salad in walk-in refrigerator #1 was not discarded and observed to have some product scooped out. The other food items that had temped above acceptable temperatures had been discarded. -Because the time of day temperature logs only documented two temperatures per day it could not be determined how long the temperature for walk-in refrigerator #1 was out of range. The DM was interviewed at 11:15 a.m. The DM said she had not yet taken temperatures of any of the additional perishable items that were observed to be in the walk-in refrigerators when the refrigerators were observed to be above safe food holding temperatures (see above). The perishable items observed still in walk-in refrigerator #1 included six cases of four ounce yogurt containers, three containers of sour cream, one container of soy milk, three-five pound logs of sliced american cheese, one six to eight pound ham and a case of two six to eight pound turkey breasts.-The safety of the food items (see above), that had not been tested immediately when it was discovered they had been in the walk-in refrigerator for an undetermined amount of time when the refrigerator's internal temperature was above acceptable range, could not be verified to be safe for resident consumption because it was unknown if the food items maintained safe food temperatures and it could not be verified how long the food might have temped at unsafe temperature ranges. D. Unit refrigerator observationsOn 8/10/23 at 12:59 p.m., the 300 and 400 units shared resident snack refrigerator temperatures were observed. The thermometer inside the shared unit snack refrigerator had a high out of range temperature reading of 42 degrees F. The refrigerator temperature log contained a.m. and p.m. columns for recording refrigerator temperatures; the refrigerator temperatures were not consistently recorded. The recorded temperatures for August 2023 were as follows:-On 8/2/23, the morning temperature was 50 degrees F;-On 8/3/23, the morning temperature was48 degrees F;-On 8/4/23, there were no recorded temperatures; -On 8/5/23, the morning temperature was 48 degrees F;-On 8/6/23, the morning temperature was 48 degrees F;-On 87/23, there were no recorded temperatures;-On 8/8/23, the morning temperature was 46 degrees F;-On 8/9/23, the morning temperature was 42 degrees F; and,-On 8/10/23 there was no temperature.-The refrigerator temperature log did not contain a reference range for appropriate refrigerator temperatures, nor was there documentation of a corrective action for temperatures recorded out of range over the temperature of 40 degrees F. Each of the unit refrigerators contained 10 four ounce yogurt containers. D. Staff interviewsRegistered nurse (RN) #1 was interviewed on 8/10/23 at 12:59 p.m. RN #1 said she was unsure who was responsible for checking and recording the temperatures of the snack refrigerators. Assistant director of nursing (ADON) #2 was interviewed on 8/9/23 at 1:04 p.m. a ADON #2 said the overnight staff were responsible for checking the temperatures of the unit snack refrigerators. ADON #2 was interviewed on 8/9/23 at 2:00 p.m. ADON #2 said the recorded temperatures in the 300 and 400 unit refrigerator were unacceptable and too high to ensure food safety. The director of nursing (DON) was interviewed on 8/17/23 at 11:00 a.m. The DON said the overnight staff checked the unit refrigerator temperatures. She said a new log was put in place that included a temperature range for reference and staff were instructed to check temperatures in the morning and evening. E. Facility follow-upThe DM was interviewed on 8/15/23 at 2:30 p.m. The DM said a plan was created and staff were trained that if walk-in refrigerator or freezer temperatures were higher than the acceptable temperature range, staff were to record the temperatures and alert the dietary manager. This included a refrigerator temperature over 41 degrees F. The DM said if the temperature of the walk-in refrigerator was higher than the acceptable range for more than 15 minutes without the refrigerator door opened then the internal food temperature of the food inside the walk-in refrigerator needed to be taken and monitored. If the food temperature was over 41 degrees F the food needed to be discarded. IV. Proper high temperatures dish machine temperaturesA. Professional referenceThe Colorado Retail Food Regulations, effective 1/1/2019 were retrieved 8/21/23 from https://cdphe.colorado.gov/environment/food-regulations. It read in pertinent part, for "Mechanical warewashing equipment and hot water sanitization temperatures in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold (dish compartment space) may not be less than 180 degrees F."B. Facility policy and procedureThe Sanitization policy, revised November 2022, was provided by the dietary manager (DM) on 8/14/23 at 3:35 p.m. It read in pertinent part, "General recommendations for heat sanitization is High temperature dishwasher (heat sanitization) wash temperature 150-165 degrees F and rinse temperature 180 degrees F; and 160 degrees F at the rack level/dish surface reflects 180 degrees F at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured."C. ObservationsOn 8/14/23 at 10:50 a.m. the high temperature dish machine was observed during a wash and rinse cycle. The wash temperature was observed at 152 degrees F and the rinse temperature was observed at 181 degrees F. The dish machine log was observed on a clipboard in the dish room, and dish machine temperatures were not recorded for 8/13/23 dinner and 8/14/23 breakfast. The DM asked the dietary staff member why there was no dish machine temperature recorded for breakfast. The dietary staff member said she forgot and asked if she could write in the dish machine temperatures she observed earlier that morning. The DM was interviewed at 10:51 a.m. The DM said a new associate who was observed working in the dish room was being trained on 8/14/23 by another dietary staff member observed working in the dish room. The DM said the rinse temperature of the dish machine needed to be 180 degrees F to sanitize the dishes properly. D. Record reviewThe high temperature dish machine temperature logs were provided by the DM on 8/14/23 at approximately 3:00 p.m. The temperature logs documented that the minimum wash temperature reference was 150 degrees F and the minimum rinse temperature was 180 degrees F. -A review of the August 2023 dish machine logs revealed that 14 of the 39 recorded rinse temperatures were below 180 degrees F with no documentation of corrective action. A review of the July 2023 dish machine logs revealed that 57 of the 93 recorded rinse temperatures were below 180 degrees F with no documentation of corrective action. E. Staff interviewsThe DM and NHA were interviewed on 8/15/23 at 2:30 p.m. The DM said the dietary supervisor (DS) was to take a nightly kitchen walk through checking for irregularities including checking the dishwasher temperature log. If the DS found any concerns the DM would hold a briefing to educate staff on proper procedure with staff the next morning. The DM said if the dishwashing machine was not working correctly she would contact the vendor/company who provided their dish machine for a technician to service the machine. The NHA said the company who provided the dishwashing machine service the unit monthly to ensure the machine was working correctly. The NHA said the dietary staff needed to tighten up on their temperature monitoring. The DM and NHA were interviewed on 8/17/23 at 9:30 a.m.. The DM said the dietary associates were trained on to properly check the dishwashers wash and rinse cycle temperatures and how to respond properly if the temperature were not adequate to ensure proper dish ware sanitation. The DS's were trained to check the dishwasher temperature log and how to respond to irregularities. IV. Hand washingA. Professional referenceThe Colorado Retail Food Regulations, effective 1/1/2019 were retrieved 8/21/23 from https://cdphe.colorado.gov/environment/food-regulations. It read in pertinent part, "Food employees shall keep their hands and exposed portions of their arms clean. Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. "Food employees shall clean their hands and exposed portions of their arms as specified under immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; 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; after engaging in other activities that contaminate the hands."B. Facility policyThe Handwashing/Hand Hygiene policy, revised August 2019, was provided by the Dietary Manager (DM) on 8/14/23 at 3:35 p.m. It read in pertinent part, "This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Wash hands with soap (antimicrobial or non-antimicrobial) and water when hands are visibly soiled. Use an alcohol based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty, before and after direct contact with residents, before donning (putting on) sterile gloves; after contact with a resident's intact skin; after removing gloves, before and after eating or handling food; before and after assisting a resident with meals; and after personal use of the toilet or conducting your personal hygiene. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections."When applying and removing gloves:1. Perform hand hygiene before applying non-sterile gloves. 2. Apply/ remove one glove from the dispensing box touching only the top of the cuff."C. ObservationsOn 8/9/23 at 11:55 a.m., lunch service was observed in the first floor dining room. The meal was brought to the dining room from the main kitchen, placing the hot foods in the preheated stem table, and placed the cold food on ice on a table beside the steam table. The main server, cook (CK) #1, started the meal service by washing his hands with soap and water and applying disposable plastic gloves, but failed to perform proper hand hygiene while serving residents their meals. Meal tickets were delivered to CK #1 and left on the counter at the steam table. CK #1 plated a hamburger and side dish options, as ordered, and walked the plate to the resident's table. While at the table CK #1 Touched several surfaces including the back of a resident's chair and the dining table then returned to the steam table to palate another hamburger. CK #1 did not change gloves or perform hand hygiene before reaching into the bread bag and grabbing a roll for the next resident's meal. This method of serving continued through the meal service. While plating on resident meal CK #1 scooped up a serving of ground hamburger to serve a resident and packed it onto a roll with the same gloved unwashed hands that previously touched unsanitary surfaces such as counters, cupboards, the refrigerator doors, the microwave meal tickets handled by residents and other staff. CK #1 only change gloves and performed hand hygiene once during the entirety of serving resident meals. However, after performing hand hygiene and changing gloves CK #1 cleared a used place setting from a resident's table, handled the plate and used napkin, scraped the plate into the trash. CK#1 removed the dirty gloves while touching the dirty surface of the gloves but did not perform hand hygiene prior to putting on new gloves then continued to serve other resident meals handling the rolls and meat with contaminated gloves and unwashed hands. D. Staff interviewsDietary aide (DA) #1 was interviewed on 8/17/32 at 4:32 p.m. DA #1 said staff should wash their hands after each task and remove their gloves, changing the gloves in between each task. DA #1 said staff should wash their hands after performing a service for a resident and also before putting on new gloves, after using a broom, after taking a break, after using the restroom, after taking out the trash and after working with a resident. DA #1 said staff could not touch a ready to eat food like a sandwich with their bare hands or touch a utensil and then a ready to eat food with the same gloves. Staff should wash their hands for 20 seconds and sing happy birthday twice while washing your hands before moving from one resident task to another..The DM was interviewed on 8/17/23 at 4:45 p.m. The DM said she educated CK #1 on proper food handling; CK #1 was able to correctly demonstrate proper food handling and handwashing procedure. The DM planned to educate the entire dietary team. IV. Failed to ensure residents were provided with an opportunity to participate in hand hygiene before and after meals. A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 8/21/23 from:https://www.cdc.gov/handwashing/when-how-handwashing.html revealed in part, "Handwashing is one of the best ways to protect yourself and your family from getting sick. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surface to person when you prepare or eat food and drinks with unwashed hands. Stay healthy by washing your hands often."Washing hands with soap and water is the best way to get rid of germs in most situations. If soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. You can tell if the sanitizer contains at least 60% alcohol by looking at the product label." B. Facility policy The Hand Hygiene policy, revised in August 2019, was provided by the dietary manager (DM) on 8/14/23 at 3:25 p.m. It read in pertinent part, "The facility considers hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation included,1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the hand washing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 3. Residents, family members, and visitors will be encouraged to practice hand hygiene."C. Observations On 8/9/23 at 11:25 a.m., lunch service was observed in the main dining room on the second floor. The staff passed lunch trays without offering any of the residents in the dining room the opportunity to perform hand hygiene before and after eating their lunch. The residents were served hotdogs and hamburgers and most ate the sandwiches with their hands. On 8/9/23 at 11:55 a.m., lunch service was observed in the first floor dining room. Resident hand hygiene opportunities were not offered or encouraged to any resident in the dining room. Residents entered the dining room with staff assistance and on their own propelling their wheelchairs by handling the large wheels and rolling forward. None of the residents entering for the meal were offered an opportunity for hand hygiene prior to eating the meal. Lunch that day consisted of hamburgers and hotdogs which residents ate with their hands. On 8/10/23 at 12:30 p.m., the delivery of a room tray for lunch service was observed on hall 300. Staff delivered the resident meal and helped the resident set up their food. Staff entered eight shared resident rooms serving approximately 10 residents on hall 300 their lunch and did not offer any of the residents an opportunity to perform hand hygiene with hand sanitizers or sanitizing wipes for the residents occupying those rooms. Most of the residents had ordered grilled cheese sandwiches and other finger foods which they ate with their hands. On 8/15/23 at 5:15 p.m., dinner service was observed on hall 300. Staff started passing room trays to resident rooms without offering or encouraging any of the residents the opportunity to perform hand hygiene. The residents in rooms #306B and #307A used their fingers to pick up and ate the food items from their plates and were not offered an opportunity to perform hand hygiene. D. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 8/15/23 at 6:25 p.m. The CNA said there were no sanitizing wipes on the resident's room trays, but they had paper towels on the resident trays. She said if a resident requested hand sanitizer she would deliver it to the resident. The CNA said hand hygiene was important to prevent the transmission of infectious diseases. The director of nursing (DON) and assistant director of nursing (ADON) #1 were interviewed on 8/16/23 at 1:30 p.m. The DON said staff members should provide hand hygiene opportunities to residents before and after meals. ADON #1 said hand hygiene was important to prevent infections and the spread of diseases. The DON said she would provide education for staff and residents about the importance of hand hygiene.

A complaint survey, prompted by #CO32155 was conducted on 5/18/23 to 5/22/23. No deficiencies were cited.

A revisit survey was completed on 4/28/23 for all previous deficiencies cited on 2/13/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 4/28/23 for all previous deficiencies cited on 2/13/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO30621, #CO30679, #CO30682, #CO30696 and #CO30789 was conducted on 1/31/23 to 2/13/23. One deficiency was cited.

Based on observations, record review, and interviews, the facility failed to provide a comfortable and homelike environment for residents on three of six halls in the facility. Specifically, the facility failed to ensure that staff provided clean washcloths and hand towels to residents in their rooms on two of six halls. Findings include:I. Facility policy and procedureThe facility was unable to provide a policy regarding the provision of clean washcloths and towels for the residents. II. Resident interviewsResident #60 was interviewed on 2/2/23 at 11:03 a.m. Resident #60 said he frequently did not have washcloths or hand towels in his room. He said he often had to ask the staff to bring him some. Resident #72 was interviewed on 2/2/23 at 11:31 a.m. Resident #72 said he did not have hand towels and washcloths in his bathroom very often. III. ObservationsOn 2/2/23, the following double occupancy room observations were made:-At 11:31 a.m., Room #319 had no hand towels or washcloths in the bathroom;-At 11:45 a.m., Room #313 had no hand towels or washcloths in the bathroom;-At 11:59 a.m., Room #109 had no hand towels or washcloths in the bathroom;-At 12:03 p.m., Room #112 had no hand towels or washcloths in the bathroom;-At 12:07 p.m., Room #116 had no hand towels or washcloths in the bathroom; and,-At 12:10 p.m., Room #215 had no hand towels or washcloths in the bathroom. On 2/7/23, the following double occupancy room observations were made:-At 9:49 a.m., Room #319 had no hand towels or washcloths in the bathroom;-At 9:53 a.m., Room #313 had no hand towels or washcloths in the bathroom;-At 10:02 a.m., Room #215 had one hand towel and no washcloths in the bathroom;-At 10:07 a.m., Room #109 had no hand towels or washcloths in the bathroom; and,-At 10:10 a.m.; Room #112 had one washcloth and no hand towels in the bathroom. On 2/9/23, the following double occupancy room observations were made:-At 10:44 a.m., Room #319 had no hand towels or washcloths in the bathroom;-At 10:47 a.m., Room #313 had one washcloth and no hand towels in the bathroom;-At 10:51 a.m., Room #215 had one hand towel and no washcloths in the bathroom; and,-At 10:55 a.m., Room #112 had no hand towels or washcloths in the bathroom. On 2/9/23 at 3:09 p.m., the linen carts on the 300/400 halls were observed to contain a stock of hand towels and washcloths. On 2/9/23 at 3:12 p.m., the linen closet on the 100/200 halls was observed to contain a stock of hand towels and washcloths. On 2/13/23, the following double occupancy room observations were made:-At 12:15 p.m., Room #112 had one washcloth and no hand towels in the bathroom;-At 12:18 p.m., Room #116 had no hand towels or washcloths in the bathroom; and,-At 12:24 p.m., Room #215 had no hand towels or washcloths in the bathroom. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/9/23 at 3:04 p.m. CNA #1 said the residents were provided with one washcloth and one hand towel which were stocked in the bathrooms by the night shift CNAs. She said the day shift CNAs used the linens when providing morning personal care with the residents. She said the hand towels and washcloths were put in the soiled utility cart when the CNAs were finished providing care. CNA #1 said if the rooms did not have washcloths or hand towels that meant the linens had already been used for the morning care of residents. She said the linens would be stocked again on the night shift, however, she said if a resident needed another towel or washcloth during the day, the resident could ask a CNA to get them. CNA #2 was interviewed on 2/9/23 at 3:11 p.m. CNA #2 said the night shift CNAs were responsible for providing each resident with a hand towel and washcloth. She said if the linens were used for morning care and put in the laundry, the CNAs should go to the linen cart or linen closet and obtain a fresh hand towel and washcloth for the residents to use throughout the day. CNA #3 was interviewed on 2/13/23 at 12:26 p.m. CNA #3 said the CNAs were responsible for stocking hand towels and washcloths in resident bathrooms. She said that was part of the night shift duties, however, she said CNAs on the day shift should replace the linens when they had used them with a resident. CNA #4 was interviewed on 2/13/23 at 12:30 p.m. CNA #4 said the night shift CNAs were responsible for stocking each resident's bathroom with fresh hand towels and washcloths every night. She said the linens should be restocked when needed. The director of nursing (DON) was interviewed on 2/13/23 at 12:35 p.m. The DON said CNAs were responsible for putting washcloths and hand towels in the resident rooms. She said stocking the linens was part of the night shift CNAs routine duties. The DON said every resident in each room should be supplied with one hand towel and one washcloth. She said once the day shift CNAs had used the linens for morning care with the residents, the CNAs put the hand towels and washcloths in the dirty laundry. She said if a resident needed another hand towel or washcloth during the day, CNAs could go and get the supplies out of the linen closet or the linen carts located at the end of each hall. The DON said residents also had paper towel dispensers in their bathrooms if they did not have a hand towel to use.

A complaint survey prompted by complaint #CO29726 was completed on 1/31/23 to 2/13/23. One deficiency was cited.

Based on interviews and record review, the facility failed to permit one (#12) of three out of 20 sample residents to return to the facility following a facility initiated transfer. Specifically, the facility failed to re-admit Resident #12 to the facility, following a facility initiated transfer. The facility failed to provide the resident with an involuntary discharge notice prior to or after the transfer and did not permit the resident to be readmitted to the facility. Findings include:I. Facility policy and proceduresA. The Transfer or Discharge policy, revised March 2021, was provided by the nursing home administrator (NHA) on 2/13/22 at 2:22 p.m. It read in pertinent part, "Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty days prior to a transfer or discharge.-Residents are permitted to stay in the facility and not be transferred or discharged unless:a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility.b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility .c. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facilityd. The facility ceases to operate.-Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility.-Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge:a. The safety of individuals in the facility would be endangered;b. The health of individuals in the facility would be endangered;c. The resident's health improves sufficiently to allow a more immediate transfer or discharge;d. An immediate transfer or discharge is required by the resident's urgent medical needs; and/ore. The resident has not resided in the facility for thirty (30) days.-The resident and representative are notified in writing of the following information:a. The specific reason for the transfer or discharge;b. The effective date of the transfer or discharge;c. The location to which the resident is being transferred or discharged."B. The Bed Holds and Returns policy, revised March 2022, was provided by the NHA on 2/13/22 at 2:22 p.m. It read in pertinent part, "Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer (in the admission packet), and at the time of transfer (or, if the transfer was an emergency, within 24 hours). The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available."II. Resident statusResident #12, age younger than 70, was admitted on 3/16/22 and discharged to the hospital on 6/19/22. According to the June 2022 computerized physician's orders, diagnoses included anxiety disorder, depression, and unspecified psychosis not due to a substance or known physiological condition. The 6/19/22 comprehensive facility assessment revealed that the resident's memory was intact. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She did not exhibit hallucinations or delusions, however she exhibited verbal and other behavioral symptoms directed toward others on four to six days during the seven day look back assessment period. III. Hospital record reviewReview of the hospital case manager's notes revealed the following notes documented in pertinent part:6/19/22 at 5:10 p.m: "Patient resides in a long term care facility. Both the emergency department (ED) physician and case manager (CM) were unable to contact the facility to coordinate the patient's return. Message left requesting nurse call back. Attempts to contact daughter were also unsuccessful. CM to follow to coordinate return to the long term care facility."6/20/22 at 5:23 p.m: "Patient lives at (name of facility). She has been there for approximately three months. She was sent to the ED with complaints of trouble swallowing and diffuse body pain. Patient was seen in the ED yesterday and staff were unable to talk with staff at the facility or patient's daughter. Pt was placed in observation overnight. CM called the facility this morning and spoke with the patient's nurse. CM gave report that the patient is being treated for a urinary tract infection (UTI) here and is cleared medically to return. CM then had a conference call with registered nurse (RN) #1, the facility's NHA, the patient's physician's assistant at the facility, and the facility's admissions person. The facility at this time will not accept the patient back, they tell CM that she has called 911 service 125 times in one month, one day alone she called 17 times. CM was told that if the patient did not make the calls to 911 that they would be okay with her returning as she does not have any other behaviors. At this time the administration of the facility is willing to accept the fine of not accepting patient back into the facility. Per NHA, they had not given any notices of intent to discharge. CM will make appropriate referrals and follow."Review of the hospital physician's notes revealed the following notes documented in pertinent part:6/19/22 at 1:40 p.m: "(Age of resident) year-old woman with history of dementia presented by emergency medical services (EMS) for complaint of trouble swallowing over about the last week, diffuse body pain. She has a significant cognitive disorder, as yet not yet fully defined, however her overall clinical presentation is consistent with Parkinson's-like dementia. She has normal range vital signs here, is occasionally agitated, and has diffuse tremor, tongue rolling, and muscular rigidity, which appear chronic. Diagnostics are undertaken, to evaluate for possible infection, with urinalysis indicative of UTI, urine culture is pending, and she will be treated with a dose of intravenous (IV) antibiotics. She has symptomatic improvement with IV fluids, and will also receive a dose of Tylenol. She repeatedly requests that she be able to stay in the hospital, however there does not appear to be a reason for admission at this time. Despite multiple attempts for telephone contact to her sending facility, I was unable to speak to a sending nurse staff."6/20/22 at 11:32 a.m: "Will need placement but will be a very challenging disposition. The current facility will not take patient back. She has behavioral issues and also is calling EMS over 100 times per month."IV. Facility record reviewReview of Resident #12's electronic medical record (EMR) revealed the following progress notes, documented in pertinent part:4/20/22 at 6:49 a.m: "Resident calling out this morning. This nurse assessed the resident, no complaints of pain. The resident stated she is 'nervous' and this nurse explained that staff is here to help if she needs anything. Resident confirmed understanding. This nurse assured resident she is safe and encouraged use of call light if anything is needed."4/20/22 at 7:34 a.m: "Resident continues to yell out. This nurse along with a certified nurse assistant (CNA) transferred the resident to her wheelchair per her request. Seroquel (antipsychotic medication) per physician's assistant (PA). Notified daughter of increase and resident's daughter in agreement. Also asked daughter if there was anything that this nurse should know to assist resident with anxiety. The resident's daughter gave suggestions."4/20/22 at 10:09 a.m: "Resident continues to yell out this shift. Resident claims to be seeing a dark presence and forces in the room. Per PA, send to hospital for altered mental status, delusions, dementia with psychosis, severe anxiety. Called for transport to hospital."4/20/22 at 10:52 a.m: "Resident refused to go to the hospital."4/20/22 at 1:06 p.m: "Resident continues to yell out. This nurse reassured the resident she is safe and encouraged the use of call light. The resident continues to refuse to go to the hospital."4/28/22 at 1:37 p.m: "This resident was having a very difficult morning. She was calling 911 when this nurse first went into the room before 7:00 a.m. She was redirected and was helped out of bed by CNA's. She proceeded to scream out after many attempts to help her. She was given morning medications. 911 was called several times during the morning and they did show up one time. She has anxiety and the paramedics suggested talking to the physician about an increase in medications. Her Risperdal (antipsychotic medication) was increased as well as her Ativan (anti anxiety medication). She did call 911 one more time. She seemed to start to calm down around 12:30 p.m. after extra medications were given. She seems to want someone with her at all times. She is not complaining of pain, just anxiety."4/28/22 at 5:54 p.m.: "Resident was calling 911. 911 here at the facility at which time the resident told the officer that she was having chest pain but not at the time and she wanted to go to hospital. The writer notified the director of nursing (DON) and the resident is being sent to the hospital for evaluation and treatment."4/28/22 at 10:00 p.m: "Resident returned from the hospital with no new orders noted. In bed resting at this time. Will continue to monitor."4/29/22 at 1:10 p.m: "Resident is being monitored for behaviors. Medicines have been increased. She is alert and reminded to use call light. She has called 911 several times today. She was brought out to the nurses station to sit and screamed so then returned to her room. Chest x-ray and a urinalysis have been ordered."4/29/22 at 6:16 p.m: "Resident continues to call 911, she has called 17 times today. Police officer out to talk to her to inform her she needs to use her call light and have staff assist her instead of using 911. The resident has called due to being cold, being hot, she needed to be changed, she wanted water, she wanted more Ativan, she wanted to go outside. Resident states she is scared of being alone and wants someone to sit with her."5/4/22 at 5:42 a.m: "Resident called 911 services, said her chest and legs hurt. 911 showed up to the facility, electrocardiogram (EKG) done and per paramedic, EKG was perfect. Resident in bed at baseline. Received Ativan earlier than scheduled time."5/9/22 at 5:22 p.m: "Conversation with resident regarding utilizing 911 services for true emergencies and not for anything else. The resident agrees."5/25/22 at 6:31 p.m: "Resident called 911, complained of chest pain, legs hurting, not able to swallow or drink and having suicidal ideations, with no noted plan. Police arrived at the facility, the resident told the officer about her complaints, and the officer said the resident wanted to go to the hospital. Physician gave a new order to send to the hospital. Paramedics arrived at the facility, spoke with resident and assessed. Resident then changed her mind, said she was not having chest pain or suicidal ideations, so paramedics decided not to take resident to hospital."6/6/22 at 12:15 p.m: "Resident continues to call 911. DON and this writer spoke to the fire chief, and going forward, when the resident calls 911, the dispatcher will reach out to nurse at the facility and ask that resident be assessed. If further assistance is needed they are to notify the dispatcher, if no further assistance is needed, fire and EMS will not arrive at the facility."6/19/22 at 1:55 p.m: "Resident called 911 to facility and stated she was dying multiple times despite staff monitoring vitals, reassuring, and offering medication. The resident refused medication and requested to go to the hospital. Vital signs within normal limits. Paramedics and the fire department spoke with the daughter who agreed to send the resident out, and the resident was transferred to the hospital via ambulance."-Review of the progress notes did not reveal documentation of referrals made to other long term care facilities in an attempt to find a facility better equipped to meet the resident's needs (see interviews below). Review of Resident #12's EMR further revealed the resident had been seen by an outside psychiatrist on 5/16/22 and 6/8/22. Per the psychiatric assessment documentation on 5/16/22, the resident called 911 while the clinician was in the room with her and stated she had fallen and was on the floor, despite being seated in her wheelchair. The psychiatrist recommended medication changes, including starting the resident on Celexa (an antidepressant medication).-The resident was never started on the Celexa. Review of the 6/8/22 psychiatric documentation, the psychiatrist again recommended starting the resident on Celexa.-The resident was never started on the Celexa. Review of an email thread provided by the social services director (SSD) revealed the facility had secured placement for the resident at another long term care facility. Per the last email, dated 6/7/22, the transfer of the resident was to take place on 6/8/22. -According to the SSD, the accepting facility denied acceptance of the resident on the day she was to transfer (see SSD interview below).-The SSD did not provide documentation which detailed the accepting facility's denial of acceptance on 6/8/22.-Review of Resident #12's comprehensive care plan revealed the resident did not have a care plan or interventions for the resident's behaviors or for her continuous calls placed to 911.-Review of Resident #12's EMR did not reveal an involuntary notice of discharge or a bed hold agreement. V. InterviewsThe medical director (MD) was interviewed on 2/9/23 at 9:51 a.m. The MD said she was not involved in the decision not to accept the Resident #12 back to the facility, so she was not able to speak to what occurred on 6/19/22. She said the resident had cognitive impairment and some behaviors. The MD said Resident #12 had a significant history of calling 911 multiple times from her cell phone during her stay at the facility. She said emergency medical services (EMS) would come and there was often not a reason to transport her to the hospital or the resident would then refuse to go to the hospital. The MD said EMS was very frustrated with the facility and wanted them to take her cell phone away from her, but the facility could not do that because it was against resident rights. She said the resident would call 911 multiple times and then state that she had not called 911. She said the resident had seen psychiatric services and the facility put her on the medications that were suggested by the psychiatrist. She said the resident was inconsistent with taking her medications though, so it was difficult to reach a consistent level of the medication which would provide benefits with her behaviors. She said the resident's behaviors improved and she would stop calling 911 as frequently as long as she was taking her medications. The MD said she thought the facility had made referrals to other facilities that could provide increased psychiatric and behavioral services for the resident. She said the resident was supposed to go to one facility that accepted her but that had fallen through. The MD said the facility tried interventions such as distraction with activities but that did not always work with the resident. Registered nurse (RN) #1 was interviewed on 2/9/23 at 11:28 a.m. RN #1 said Resident #12 constantly called 911. He said EMS was frustrated with the facility because of all the 911 calls. He said EMS and the facility made an agreement that whenever they received a call from the resident, the dispatcher would call him. He said he would go assess the resident while the dispatcher was on the phone, and if there was not a need for EMS to come to the facility, he would tell the dispatcher emergency services were not needed. He said he did not document every time that he assessed the resident when the dispatcher called him. RN #1 said he thought he had documented some of the occasions. He said he did not recall having a telephone conference with the case manager at the hospital on 6/20/22 (see hospital case manager notes above). RN #1 said he did not recall that anyone in the facility had told the hospital that the facility would not accept the resident back. The NHA was interviewed on 2/9/23 at 1:15 p.m. The NHA said Resident #12 had only resided at the facility for three months. He said the resident had a cell phone and would constantly call 911. He said EMS would frequently respond to the calls, however there was often not a reason to transport the resident to the hospital. He said EMS became very frustrated with the facility and wanted the facility to take away the resident's phone. He said the facility could not take away the phone because it was the resident's right to have the phone. The NHA said the 911 calls the resident made were considered a behavioral issue. He said the facility did provide the resident with psychiatric services but that did not resolve the issue. He said the facility tried multiple interventions with the resident, including one-on-one interactions, activity distraction, and medication management. He said the resident would continue to call 911 even if someone was sitting with her. The NHA said the facility felt like they could not meet the resident's psychosocial needs and looked for another facility to transfer her to that could better meet her needs. He said the SSD sent out several referrals but only one facility would accept the resident. He said the accepting facility backed out of the transfer at the last minute. The NHA said the facility did not refuse to take Resident #12 back on 6/19/22. He said he told the case manager that the hospital and the facility needed to work together to find a solution so the 911 calls did not occur anymore. He said he told the case manager the facility would take her back when the solution had been found. He said the hospital never called the facility back to make a referral when the resident was ready to return to the facility. The NHA said the facility did not give an involuntary discharge notice to the resident. He said the resident's bed hold agreement should be in her EMR.-The facility did not provide a copy of a signed bed hold agreement for Resident #12 during the survey. The SSD was interviewed on 2/9/23 at 2:42 p.m. The SSD said he sent referrals for Resident #12 to other facilities. He said the facility wanted to get the resident to a facility that had an appropriate program that could better meet her needs. He said a facility had accepted the resident, but then they had an administration change and the new administrator decided on the day she was to transfer to them that they would not accept her after all. He said most of the facilities he sent referrals to denied the resident due to her level of acuity and the inability to take away her cell phone without violating her rights.-The SSD did not provide copies of the other referrals he sent, nor was there documentation regarding the referrals in Resident #12's EMR (see record review above).

A revisit survey was completed on 1/11/23 for all previous deficiencies cited on 11/4/22. The facility is in compliance with all regulations surveyed.