MOUNTAIN VISTA HEALTH CENTER

A survey prompted by complaint #CO37416, #CO38185, #CO38252 AND Incident #38167 was conducted on 11/20/24. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of 10 sample residents was free from neglect. Resident #1 suffered an injury of unknown origin to the left forehead, a hematoma (a localized swelling of pooled blood due to injury or trauma), on 4/3/24 following a shower provided by hospice certified nurse aide (CNA) #1. The resident's son was notified of the forehead hematoma at 3:06 p.m., but the staff did not conduct a full skin assessment on the resident afterward to determine if other injuries were present. Resident #1 sustained a fall three days later, on 4/6/24. No injuries were reported.-However, the staff did not conduct a full skin assessment to determine if other injuries were present. On 4/8/24, a progress note revealed that the resident had a faded yellow bruise to the left shoulder, hip, and a yellow, faded bruise to the left eye. On 4/12/24, a weekly skin assessment was conducted following a shower. It revealed a green/yellow bruise to the left side of the face, shoulder and breast. An abnormal protrusion to the clavicle (collarbone) was noted. -However, since there were no weekly skin assessments conducted since the original incident on 4/3/24, the date and origin of the clavicle injury were not identified. Due to the facility's failure to ensure a complete assessment after identifying an injury of unknown origin on 4/3/24, Resident #1 experienced a delay in care for her clavicle injury which was not discovered until an x-ray was performed on 4/13/24 and revealed a fracture. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/20/24, resulting in the deficiency being cited as past noncompliance with a correction date of 7/31/24. I. Incident and injuries of unknown origin between 4/3/24 and 4/12/24Resident #1 sustained an injury of unknown origin on 4/3/24 and a fall on 4/6/24. A full skin assessment documenting the resident's injuries was not performed until 4/12/24 (nine days later). Due to the facility's failure, the resident's injuries between 4/3/24 and 4/12/24 were not identified and treated immediately. Resident #1 experienced a delay in care which resulted in increased pain. -On 4/6/24, hospice increased the resident's pain medication.-On 4/12/24 an x-ray was ordered, which, on 4/13/24, revealed a clavicle fracture. II. Facility's plan of correctionThe corrective action plan implemented by the facility in response to Resident #1's unknown incident investigation failure between 4/3/24 and 4/12/24 was provided by the nursing home administrator (NHA) on 11/21/24 at 12:16 p.m. The plan revealed the following: A. Corrective actionThe facility notified the hospice company that the hospice CNA (CNA #1) and the hospice social worker were suspended from entering the facility pending the investigation. The investigation revealed hospice notes documented Resident #1 had a fall on 4/3/24, but the facility was never notified. On 4/22/24, the facility terminated their contract with the hospice company due to their lack of communication with the facility and lack of cooperation with the investigation. Education was provided to 23 staff members on 5/16/24 and included the following:-After a resident fall, call the physician and power of attorney (POA);-Complete neurological checks, fall assessment, post-fall evaluation, skin evaluation and risk management form; and,-Obtain witness statements if applicable. On 7/30/24 and 7/31/24, the remaining care staff obtained fall prevention education at the skills fair. Fall binders were created and placed at every nurses station as a reference for the staff and discussed by the unit manager. On 4/13/24, the facility began an investigation of Resident #1's injuries between 4/3/24 and 4/12/24. The facility interviewed all staff on duty who were involved in care for the resident on the day of the fall on 4/6/24 and a few days prior to the fall. The interviews with the facility staff were noted to be consistent with facility documentation. Facility and hospice documentation was reviewed for dates 4/3/24 to 4/12/24. On 4/3/24, Resident #1 had a bruise on the left forehead that was reported by CNA #1 after she gave the resident a shower. No other injuries were noted at that time. Facility staff reported that the bruise was not seen before the shower. CNA #1 denied any incident while in the shower. The facility's director of nursing (DON) notified the hospice DON of the bruise after the DON and registered nurse (RN) #1 saw the resident's hematoma and noted that it was visibly growing.-Hospice documentation stated there was a fall on 4/3/24. The facility was not notified of the fall. The fall documentation was found after the facility requested hospice documentation and began the investigation on 4/13/24. On 4/6/24, the staff reported that Resident #1 sustained a fall. She was found sitting in her room on the floor. Interventions were to review the resident's medications and check her neurological status every 15 minutes for 72 hours. Hospice staff increased her pain medication. On 4/8/24, Resident #1 had bruising to the left shoulder, hip and a yellow, faded bruise to the left eye. The injuries were being attributed to the fall on 4/6/24. On 4/9/24, a nurse practitioner note (NP) stated the resident had bruising to the left shoulder.-No reported abnormality to the clavicle was noted.-Hospice documentation did not report any abnormality with the resident's clavicle until after the facility documented it on 4/12/24. On 4/15/24, the facility requested interviews with hospice staff and they were never received. The facility was unable to identify the cause of the clavicle fracture after camera footage was obtained. The facility attributed it to either the alleged fall on 4/3/24 that was reported by CNA #1 (but not reported to the facility) or the documented fall on 4/6/24. All documentation and facility staff interviews indicated that if the fracture was sustained on 4/3/24 or 4/6/24, it was not known to the facility or hospice staff until it was displaced and noticed on 4/12/24 (when the skin assessment was performed). B. Identification of othersThe facility terminated their contract with the hospice company on 4/22/24 and there had been no additional residents using that company. The facility made an update to their post-fall management procedures, which included documentation in a root cause analysis form which helped identify causes and potential preventive measures for future falls. C. Systemic changesThe NHA sent an email on 11/21/24 at 12:16 p.m. that documented that all risk management (incident reports) were reviewed daily in the interdisciplinary team meetings. He said that completion of all required assessments after a fall were part of the review process. D. MonitoringThe incident was brought to the facility quality assurance and process improvement (QAPI) meeting on 4/25/24 and involved discussion of the investigation, the findings and actions taken. Falls were reviewed monthly at QAPI and ongoing review of all risk management/incident reports was conducted. III. Facility policy and procedureThe Integrated Fall Management policy, undated, was provided by the DON on 11/20/24 at approximately 5:36 p.m. It read in pertinent part, "Purpose: fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls."Post Fall Procedure: When a resident falls the licensed nurse is notified. The nurse completes an assessment of the resident's condition including an interview, if possible, completion of vital signs and a body assessment."The environment of the fall is evaluated for possible contributing factors and addressed."The interdisciplinary team reviews the fall and care plan changes and may, if needed, implement additional interventions."Documentation of the above items is completed."IV. Resident #1A. Resident statusResident #1, age 76, was admitted to the facility on 4/7/23 and expired on 5/6/24. According to the May 2024 computerized physician orders (CPO), diagnoses included bladder cancer and Alzheimer's disease. The 4/2/24 staff assessment for mental status revealed the resident had short term and long term memory deficits and was severely impaired in making daily decisions. Resident #1 did not use any assistive devices for walking. The resident required partial/moderate assistance with dressing and personal hygiene, supervision or touch assist with shower transfers, and set-up/clean-up assistance for bathing and showering. The MDS assessment indicated she had had one fall with no injury since the last assessment. assessment. B. Record reviewOn 3/29/24 (before the unknown incident), a weekly skin assessment documented that Resident #1 had no skin issues. On 4/4/24 a progress note revealed that the bruise to the resident's head was reviewed in the interdisciplinary team (IDT) meeting and that the facility continued to monitor the resident's neurological status. The note indicated a skin evaluation was still to be done. -However, a review of the resident's electronic medical record (EMR) did not include documentation indicating how the bruise to the resident's head occurred. On 4/6/24 at 3:47 p.m. a post-fall assessment revealed the resident had an old bruise on the left forehead that was fading. On 4/6/24 at 5:45 p.m. a weekly skin assessment revealed there were no skin issues.-However, this documentation conflicted with the earlier assessment on 4/6/24. On 4/8/24 a progress note revealed that the resident had a faded yellow bruising to the left shoulder, hip and a yellow, faded bruise to the left eye. -However, a review of the resident's EMR did not include documentation indicating how the bruise to the resident's shoulder, hip or left eye occurred. On 4/12/24 at 11:27 a.m. a weekly skin assessment revealed a green/yellow bruise to the left side of the resident's face, shoulder and breast. An abnormality to the clavicle was noted. The assessment documented the resident's clavicle abnormality was not reported from the previous nurse. The resident's unwitnessed fall last week was reported. Resident #1's social services care plan, initiated 4/7/23, revealed the resident was a vulnerable adult due to loss of independence and cognition, visual impairment, depression and anxiety, was hard of hearing, received hospice services, had poor impulse control, wandered and was difficult to redirect at times and frequently refused medication. Interventions included administering medications as ordered, providing ancillary services as needed, monitoring and reporting any new changes to the provider and utilizing approaches that maximize her involvement in daily decision making and activity. The fall risk care plan, initiated 4/19/23, revealed the resident was at risk for falls. Interventions included anticipating and meeting the resident's needs and following facility fall protocol. Care plan revisions on 10/19/23 included reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes, altering or removing any potential causes if possible, and educating the resident/family/caregivers/IDT as to the causes of the fall. Revisions on 11/1/23 included offering a chair when leaning or fatigued to avoid potential falls.-Resident #1's fall care plan was revised on 4/15/24 after a fall. New interventions included a pain management patch, 15-minute checks for 72 hours to better capture her personal and physical needs, staff maintaining heightened awareness for the resident and offering assistance as needed and for hospice staff to perform a medication review. Resident #1's hospice care plan, initiated 12/28/23, indicated the resident was on hospice services with terminal diagnoses of bladder cancer and dementia. Interventions included establishing and coordinating the plan of care and services between the facility and the hospice team, maintaining communication and informing of changes, hospice staff documented provisions of care for the facility staff, updated and reviewed as changes occurred. V. Staff interviewsThe DON was interviewed on 11/20/24 at 5:28 p.m. The DON said she was new at the time of the incident on 4/3/24 and was on vacation when it happened. She said the SBAR (situation, background, assessment and recommendation) assessment was the standard nursing assessment documented after a fall and included questions about the resident's range of motion, pain level, and neurological status. She said it was not a full head-to-toe assessment. She said when Resident #1's forehead hematoma was first noted by facility staff, a full skin assessment should have been done. RN #1 was interviewed on 11/20/24 at 5:36 p.m. RN #1 said she was a unit manager. RN #1 said Resident #1 had a big lump on her head after a shower with CNA #1 on 4/3/24. RN #1 said she was not sure if the resident fell or if she hit her head while being combative. She said the resident had a history of being combative during care. She said she saw the resident the morning of 4/3/24 before the shower and she did not see any injury to her forehead. The DON and RN #1 were interviewed together on 11/20/24 5:36 p.m. RN #1 said that a few processes had changed since the incident. RN #1 said the facility developed a root cause analysis form. RN #1 said a fall binder was developed as a reference for the nurses and supervisors and RN#1 said she had conversations with the nurses about the new binder. She said the facility did more audits and checklists now. RN #1 said she saw the resident after the incident and the hematoma was the size of an egg, growing, and looked new. RN #1 said she, the previous DON and the nursing home administrator (NHA) assessed Resident #1. RN #1 said neurological checks were started at 7:00 p.m. that night (4/3/24) because nobody was sure how she got the injury to her head. RN #1 revealed part of the facility's procedures after a fall included leaving the resident where they were found and having a RN assess the resident before moving them. She said the resident's provider and family would be notified of the fall, and a post-fall evaluation and RN assessment would be documented. She said RN assessments were documented under risk management. She said neurological checks were conducted on the resident for three days, even if no injuries were noted or the fall was unwitnessed. RN #1 said huddles were conducted with the CNAs so they could discuss the fall and future prevention methods. RN #1 said the hospice company would not let the facility talk to CNA #1 who gave Resident #1 the shower and had originally reported the hematoma. RN #1 said that because of the confusion and uncertainty, and because they could not get timely information from the hospice company, the facility implemented cares in pairs for the resident's safety. She said normally staff would have done a full skin check after noticing the hematoma on the resident's head, but the resident would not let anyone perform a skin assessment. RN #1 said the resident resisted a lot of care. She said if staff had done a full skin assessment, at least on 4/6/24 after the resident's other fall, it would have helped them determine the timeline of the resident's injuries, but the resident refused to let staff do full skin assessments. She said as a standard, skin checks were done weekly. RN #1 said it was the facility's mistake that they did not chart the resident's history of refusals of care. RN #1 said the facility received hospice notes well after the incident but did not receive CNA notes, and that the facility did not know if the documentation was in real-time or post-dated. She said they still did not know for sure how Resident #1 sustained a clavicle injury.

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

A complaint survey, prompted by #CO36252 was conducted from 6/17/24 to 6/18/24. No deficiencies were cited.

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

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

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/08/2024 and 04/14/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on April 11, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This facility consists of two structures of different construction types that are separated by a common wall having a two-hour fire rating. This structure is a one (1) story with a partial basement and is approximately 45% Type II (000) and was built in 1963. 55% of the structure is Type V (111) (VA) construction. There is a partial basement that has no resident access. The facility is licensed for 168 beds and the census on the date of the survey was 108. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. The wet-pipe system protects the main level. There is an anti-freeze loop sprinkler system that protects the main entrance canopy. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Plant Operations Director during the exit conference conducted on April 11, 2024

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. 1. Memory care switch for door | All control need to be at door for egress/light switch should be disable from this use 2. Exit door by room 214 scrubbing at bottom when trying to open 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:(1)Locks complying with 19.2.2.2.5 shall be permitted.(2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.(3)Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted. NFPA 101: 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows:(1) The opening forces for interior side-hinged or pivoted-swinging door leaves without closers shall not exceed 5 lbf (22 N).(2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.(3) The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided in Chapters 22 and 23.(4) The opening forces for power-operated door leaves shall be as provided in 7.2.1.9. The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows:(1) The opening forces for interior side-hinged or pivoted-swinging door leaves without closers shall not exceed 5 lbf (22 N).(2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with Maintenance personnel at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code NFPA 101. This deficient practice could affect all residents, staff and visitors throughout the facility if an immediate exit cannot be identified during an emergency. 1. Exit signage needed at east//west nurses station | Exit signs need to be added at cross sectionsNFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with Maintenance personnel at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101.1. Beauty shop fire rated | Facility need to provide verification that fire glass is rated for 1 hour | shop is in egress corridor 2. Path for egress needs to cleared throughout record storage roomNFPA 18.3.2.1. The areas shall be enclosed with a 1-hour fire-rated barrier, with a ¾ hour fire-rated door without windows (in accordance with 8.7.1.1). Doors shall be selfclosing or automatic-closing in accordance with 7.2.1.8. Hazardous areas are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and 8.4. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with Maintenance personnel at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Fire Sprinkler | Missing previous semi annual, quarterly reports 2. Quick response used as sidewall sprinklers | Standard response sprinkler in corridors - Only one type should be used within any smoke compartment 3. Sprinkler head in kitchen storage needs to be fixed NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 13 8.3.3.2 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with Maintenance personnel at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire Drills | document review revealed that the fire alarm system was not used during multiple fire drillsNFPA 101, 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with Maintenance personnel at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1. No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with Maintenance personnel at the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. Oxygen transfer room | Ventilation needed within 12 inches of floor like other rooms/Container need to labeled and separated by empty and Full | All combustible items need to be removed from rooms | Posters can be treated with flame retardantNFPA 99: 11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa (50 psi) shall include the following:(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures. NFPA 163.2.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. [55:6.15.7.2]NFPA 99: 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:(1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hourNFPA 99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with Maintenance personnel at the exit conference.

A licensure survey was completed on 3/13/24 to 3/20/24. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to two (#87 and #92) of three residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 34 sample residents. Resident #87 was admitted on 1/12/23. Her admission weight was 113.8 pounds (lbs). The resident maintained a weight between 113 lbs and 118 lbs between January 2023 and January 2024. The resident lost 12.3 pounds between 1/4/24 and 2/15/24. The facility did not weigh the resident monthly despite a physician's order for monthly weights. The registered dietitian (RD) recommended weekly weights and weights were not consistently obtained on a weekly basis. The resident had poor meal intake and refused meals. There were no preventative measures implemented to address her eating patterns to ensure her intake was adequate. Due to the facility's failure to implement nutritional interventions, Resident #87 sustained a severe weight loss of 10% or 11.7 pounds in six months. Resident #92 was admitted on 5/12/24. Her admission weight was 152 lbs. The resident maintained a weight between 147.3 lbs and 153.2 lbs between 5/12/23 and 2/6/24. Weekly weights and weights were not consistently obtained on a weekly basis. There were no nutritional interventions implemented between 2/6/24 and 3/3/24 when she sustained a 15.1 lbs weight loss. Due to the facility's failure to implement nutritional interventions, Resident #92 sustained a severe weight loss of 17.36% or 26.6 pounds in six months. Findings include: I. Facility policy The Nutritional Assessment policy, revised October 2017, was received by the nursing home administrator (NHA) on 3/20/24 at 12:42 p.m. It read in pertinent part, "The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition.""Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences."The Weight Assessment policy, revised March 2022, was received by the NHA on 3/20/24 at 12:42 p.m. It read in pertinent part, "Resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss."II. Resident #87 A. Resident status Resident #87, age 87 years old, was admitted on 1/12/23. According to the March 2024 computerized physician orders (CPO), diagnoses included prediabetes, osteoporosis, abnormal weight loss, major depressive order, vascular dementia with behavioral disturbance, atherosclerosis of native artery, chronic obstructive pulmonary disease and gastro-esophageal reflux disease (GERD). The 1/17/24 facility assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required set up assistance for eating. She required substantial assistance with oral hygiene, personal hygiene, toileting and showering. The assessment documented the resident required set up assistance with eating and the resident had not experienced weight loss. Her height was 4 feet 11 inches and she weighed 116 pounds. Her diet was a mechanically altered diet. B. Observations and interviewThe resident was in the dining area of the secured unit on 3/13/24 from 12:11 p.m until 12:46 p.m. She required complete assistance withher meal. She consumed less than 25% of her meal. On 3/18/24 the resident was in her room due to contact isolation measures. The nurse brought the resident lunch at 12:41 p.m. The nurse left the room at 1:09 p.m. The nurse said the resident ate about 25 percent of her meal. The nurse said the resident did well with a nutritional supplement shake and liquids but not the actual meal. The meal intake record documented she consumed less than 25% of her meal. C. Record reviewResident #87's weight loss history revealed significant weight loss as follows: -On 10/5/23, the resident weighed 116.3 pounds; -On 11/6/23, the resident weighed 118.3 pounds; -On 12/2/23, the resident weighed 117.8 pounds; -On 1/4/24, the resident weighed 116.3 pounds; -On 2/15/24, the resident weighed 104 pounds; -On 2/23/24, the resident weighed 103.6 pounds; -On 3/1/24, the resident weighed 108.3 pounds; -On 3/18/24, the resident weighed 103.2 pounds; and,-On 3/19/24, the resident weighed 104.6 pounds. Resident #87's medical record revealed she experienced a significant unplanned weight loss of 10% or 11.7 pounds in six months from 10/5/23 to 3/19/24. The nutrition care plan, revised 1/22/24, revealed the resident had nutritional risks and potential for nutrition risks related to weight loss, dementia, psychotic disturbance, anxiety, hypothyroidism, prediabetes, osteoporosis, glaucoma, poor mobility and elevated LFT's (liver function tests). Interventions included encourage food and fluids at and between meals, honor food preferences, offer snacks daily, occasionally could feed self but usually required increased cueing and assistance at meals, monitor labs, weights, fluid volume status and skin integrity, provide supplements as ordered and monthly weights. The malnutrition care plan, revised 1/29/24, revealed the resident was at risk for malnutrition. The interventions included a complete mini nutritional evaluation, if malnourished consult dietitian and if mini nutritional evaluation results indicate risk, consult dietitian. The dementia care plan, revised on 1/27/23, revealed the resident would likely experience progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia. Interventions included a BIMS at each review or as needed to monitor for changes in cognition. The self care deficit, revised 1/29/24, revealed the resident was at risk for feeding. The interventions included to provide meal support per resident's needThe 2/22/24 dietitian progress note revealed she was not sure the 2/15/24 weight was accurate and changed monthly weights to weekly weights. The 2/28/24 dietitian progress note revealed the resident's weight was down significantly since December 2023. It read in pertinent part, "The resident's intake declined. Increased frequency of Ensure supplement. Possible effect by norovirus? Noticeable decrease intake and nausea. Continued weekly weights and relay concerns to nursing and social services." The 3/7/24 dietitian progress note revealed the resident was on weekly weights. The note documented in pertinent part, "Weight on 2/23/24 was 103.4 pounds. Variable intake through February (2024). No nausea, vomiting or diarrhea per progress notes. Follow weekly weights." The 3/8/24 nurse progress note for weekly weights said that weight was not obtained because weight was not due. -There was no documentation that the physician or dietitian were notified that the weight was not obtained. The 3/18/24 nurse progress note revealed the provider was notified about a new weight. The resident was already on Ensure (nutritional supplement), modified diet, recent illness and poor appetite. The provider ordered labs. The dietitian was notified and followed up once labs were completed. The resident was not experiencing difficulty with swallowing or a modified diet. -The 3/19/24 dietitian progress note (during the survey) revealed the resident had significant weight loss since December 2023. The note documented in pertinent part, "She declined medically since January 2024. She had increased temperature. Pneumonia was ruled out with chest x rays. Fluids were encouraged. She was in isolation due to an outbreak of norovirus but remained asymptomatic. Resident was weak, poor intake and temperature. Concerned with the resident's overall medical decline, advanced age, severe dementia and weight loss. Body mass index (BMI) decreased from 23.9 to 20.8. May consider hospice consultation if warranted. Continue weekly weights and supplements." The March 2024 CPO revealed the following: -Regular puree textured diet-Ensure plus, three times a day for poor intake. Offer after meals, 237 mls. Start 2/28/24. -Ensure plus, one time a day for poor intake and weight loss. Start 10/20/23, discontinued 2/28/24. -Give snacks at bedtime. Start 3/15/23. -Weigh weekly, one time a day every 7 days. Start 2/23/24. -The facility did not follow the weekly weight order between 3/1/24 and 3/17/24. -The Ensure supplement was not changed until 2/28/24, after the resident had lost 12.7 lbs since 1/4/24. The March 2024 meal intake records documented the resident consumed the following from 2/19/24 to 3/20/24. The records revealed the resident ate 76-100 percent on 20 occasions, 51-75 percent on seven occasions; 26-50 percent on 21 occasions, zero-25 percent on 20 occasions and refused five meals (3/11/24, 3/13/24, 3/15/24 and 3/19/24). The resident had less than three meals in a day recorded for several days from 2/19/24 to 3/20/24. The record revealed the resident ate two meals on six days (2/20/24, 3/6/24, 3/9/24, 3/14/24, 3/16/24 and 3/19/24) and only one meal on five days (2/22/24, 2/29/24, 3/1/24, 3/7/24 and 3/17/24). III. Resident #92 A. Resident status Resident #92, age 71 years old, was admitted on 5/12/24. According to the March 2024 CPO, the diagnoses included dementia, Alzheimer's, psychotic disturbance, mood disturbance, general anxiety disorder and osteoarthritis. The 2/15/24 facility assessment documented that the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident required partial assistance for oral hygiene, toileting, showering, dressing and personal assistance. The assessment documented the resident required partial assistance with eating and the resident had not experienced weight loss. and had experienced weight loss. Her height was 5 feet 4 inches and she weighed 147 pounds. She was on a mechanically altered diet. B. Observations and interviewsThe resident was observed on 3/13/24 from 12:11 p.m until 12:54 p.m. An unidentified certified nurse aide (CNA) and an unidentified nurse talked at 12:28 p.m. The CNA said the resident lost 20 pounds. The nurse went to the medication cart and came back to the resident with a shake in a plastic cup. The resident tried to drink the shake independently. Her hand was shaking and she almost spilled the shake. The shake was not reoffered. The CNA provided juice in a plastic cup and left the resident. The resident spilled the juice when the CNA walked away. C. Record reviewResident #92's weight loss history revealed significant weight loss as follows: -On 9/7/23, the resident weighed 153.2 pounds; -On 10/5/23, the resident weighed 151.6 pounds; -On 11/6/23, the resident weighed 152.7 pounds; -On 12/7/23, the resident weighed 150.6 pounds; -On 1/4/24, the resident weighed 151.5 pounds;-On 2/6/24, the resident weighed 147.3 pounds;-On 3/3/24, the resident weighed 132.4 pounds; -On 3/13/24, the resident weighed 126.6 pounds; and,-On 3/19/24, the resident weighed 131.4 pounds. -Despite the 15.1 pounds (10.12%) weight loss demonstrated in one month between 2/6/24 and 3/3/24, the facility did not add any nutritional interventions until ten days after the significant weight loss was documented. Resident #92's medical record revealed she experienced a significant unplanned weight loss of 17.36% or 26.6 pounds from 9/7/23 to 3/13/24. The nutrition care plan, revised 2/19/24, revealed the resident was at risk related to dementia, seasonal allergies, B12 vitamin deficiency, constipation and vitamin D deficiency. Interventions included encourage food at and between meals, Ensure twice a day, honor food preferences, offer snack daily, weekly weights, monitor labs and could sometimes eat independently but may need full assistance. The dementia care plan, revised 5/24/23, revealed the resident would likely experience progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia. Interventions included simplify tasks by breaking tasks into one step at a time and utilize approaches to maximize involvement in daily decision making and activity. The ADL self care performance deficit care plan, revised 5/25/23, revealed the resident had a deficit related to dementia. She was able to hold the cup, feed herself and eat foods independently. The eating care plan, revised 8/28/23, revealed the resident had her own teeth with some missing teeth. She was able to feed herself independently, follow staff set up, encouragement and cueing. Interventions included staff to provide set up assistance with feeding. Staff were to provide verbal cues, set up tray, pour liquids, cut foods and apply condiments with each meal. The 3/18/24 provider note documented Resident #92 was seen for gradual weight loss of 25 pounds over the past 12 weeks and six pounds over the past three weeks. Staff reported she often did not eat well, took two to three Ensures daily and took fluids with encouragement. Her weight loss was expected and unavoidable as her dementia advanced. The dentist was following for a tooth that periodically became abscessed, though it did not seem to interfere with her eating or cause pain. The staff should continue oral intake and supplementation as tolerated. -The provider had called the weight loss unavoidable, however, there were no interventions added when she had a significant weight loss from 2/6/24 to 3/13/24. In addition, the resident had an abscessed tooth that did not interfere with eating, however according to the dietitian's note (see below) she had poor appetite due to the abscessed tooth. The 3/16/24 nurse progress note revealed the resident was losing weight and had declined. The resident ate 100% at breakfast, lunch and dinner. The 3/15/24 nurse progress note revealed the resident was physically declining and failed to thrive. It documented in pertinent part, "Resident stayed in bed and encouraged fluids. Ensure ordered for two times a day. Resident was weak and left message for provider for labs." The 3/15/24 dietitian progress note (during the survey) documented the resident was treated for weight loss. It documented in pertinent part, "Resident started on Ensure twice a day. Resident refused to drink. Resident has poor appetite due to abscess on right side of face." The 3/13/24 dietitian progress note said the resident was treated for tooth abscess with oral antibiotics. The resident had decreased in oral intake over the last week. Requested resident was reweighed because weight was significantly down. Added oral supplement for calories and fluids. Resident did well with finger foods and needs cueing and encouragement with intake. Follow weights weekly. The 3/12/24 provider notes revealed the staff reported right sided facial swelling due to an abscessed tooth. The resident did not open her mouth. She had a slight right sided facial swelling with palpation. She refused to open her mouth for an oral exam and did not show any signs of pain when palpating. The plan was to continue with antibiotics and probiotics. The 3/8/24 social services note revealed a request for a dental appointment as soon as possible. -There was no documentation that a dentist saw the resident. A request for dental records was made and the previous dentist visit from 11/14/23 was provided. The medication administration record (MAR) was reviewed for March 2024. It revealed the following orders: -Monthly weights on the third of every month. Start 3/3/24. -Weekly weights; one time a day every seven days for weekly weights. Start 3/14/24. -Ensure plus three times a day. Offer three times a day. Offer after meals. Start 3/14/24. -Give snack at bed time. Document percent eaten. Start 5/12/23. -Clindamycin 150 mg. Take one capsule by mouth every six hours for abscess for five days. Take one tablet every six hours for five days followed by dentist visit. Start 3/7/24. The March 2024 meal intake records documented the resident consumed the following from 2/19/24 to 3/20/24. The records revealed the resident ate 76-100 percent on 45 occasions, 51-75 percent on eight occasions; 26-50 percent on 13 occasions, zero-25 percent on two occasions and refused four meals. The resident had less than three meals in a day recorded for several days from 2/19/24 to 3/20/24. The record revealed the resident ate two meals on seven days (2/20/24, 3/6/24, 3/9/24, 3/14/24, 3/16/24, 3/17/24 and 3/19/24) and only one meal on four days (2/22/24, 2/29/24, 3/1/24 and 3/7/24). IV. Staff interviews CNA #3 was interviewed on 3/19/24 at 3:56 p.m. She knew when to weigh a resident when the nurse provided a list and verbally told the CNA. She said the list was for residents who lost weight. Once she weighed the resident she told the nurse. She documented the weight in the resident's electronic medical record. She asked the nurse what the resident weighed the last time the resident was weighed. She said it was important to weigh a resident because it showed the resident's health status. CNA #3 said she was familiar with Resident #87. She did not know why the resident lost weight because she ate her pureed meal and she required assistance with meals. CNA #3 said she was familiar with Resident #92. She said the resident ate a lot at dinner but she did not eat as much at breakfast and lunch because she was sleeping. The director of nursing was interviewed on 3/20/24 at 12:49 p.m. She said she was not familiar with Resident #87 and Resident #92. She said all residents should be weighed at least monthly. She said it was important to monitor the resident's weight because if the resident lost weight it could indicate the resident was depressed or the resident did not like the food or consistency. She wanted to pay more attention to the resident and add interventions to prevent weight loss. She said the nursing staff collaborated with the dietitian to ensure weights were completed. The nurse told the CNA to weigh the resident. The nurse was responsible to notify the dietitian when the resident had weight loss. The dietitian was notified in a daily meeting. The DON was unable to say what defined significant weight loss. The unit manager (UM) was interviewed on 3/20/24 at 12:59 p.m. She said there was an issue with staff weighing residents as ordered. She said some staff did not like the scale in the unit where Residents #87 and #92 lived. She said there was not oversight to ensure weights were obtained based on the physician orders. She said the facility corrected the issue. The dietitian shared a list of residents who required weekly weights. The registered dietitian (RD) was interviewed on 3/20/24 at 10:06 a.m. She was responsible for completing the nutritional assessment and they were completed at time of admission, quarterly and if there was a change in condition. She was notified when a resident lost weight during a morning clinical meeting, if a provider notified her and she independently looked through a dashboard connected to the resident's weights on a weekly basis. She said significant weight loss was five percent in 30 days, seven and half percent in a quarter and more than ten percent in six months. She said interventions depended on the resident. If they did not like fluids, she would not add a liquid supplement. She would add a powder supplement to mashed potatoes or soups to increase calories. She tried liquid supplements. She wanted the liquid supplement to be administered when medications were administered. She tried different supplements if a resident only liked a specific flavor or if there was a supply issue. She added weekly weights as another intervention. She talked to speech therapy if the resident was on a pureed diet to see if the resident could move to a mechanical diet. She considered double portions for women if they had assistance at meals. She said double portions for elderly women was hard because the quantity was overwhelming. She considered changing from one supplement to another supplement if the resident had weekly weights and took 50% or less of the supplement. The RD said weekly weights were an intervention because it was an easy way to see an improvement or a decline. The first time a resident lost weight, she asked the staff to re-weigh in case the scale was not accurate. The nurse or nurse manager was responsible for notifying the family and the provider. If she was familiar with the family, she would notify them. She said the restorative program was responsible for weighing residents but in February 2024, the CNAs took over. She said CNAs did not do weekly weights. She would make requests but it did not happen. She sent lists to the DON. She said February 2024 was difficult because if she did not have the resident's weights, she was unable to do quarterly assessments or change in condition assessments. The RD said Resident #87 was always a good eater. She saw the resident's weight loss in February 2024. She was not notified in February 2024 that the resident was not eating well. She added weekly weights for the resident. She said the staff might not have weighed the resident because the scale the staff used regularly was in a different unit. The unit Resident #87 resided on was in an outbreak and staff might not have wanted to use the scale in the other unit. She was not sure why the resident was not eating in the past seven days. She said the resident was accepting the liquid supplements. She wanted the resident to gain one to two pounds a week. She was surprised the resident lost weight so she asked for a new weight. She said she would ask the kitchen to add more mashed potatoes to her meals. -However, mashed potatoes were not implemented based on the care plan and the RD's documentation (see above). The RD said Resident #92 required total assistance with her meals. She was not notified the abscess bothered the resident. If she was notified about the abscess she considered a downgrade in her diet so the food was easier for the resident to eat. The medical director (MD) was interviewed on 3/19/24 at 11:48 a.m. He said when a resident lost weight, he looked to see if the facility provided food that the resident liked, if food was given in a timely manner, where the resident ate and if the resident needed assistance. He looked at medical issues to see if there were medications that suppressed the resident's appetite. He checked labs to see if there was another cause of weight loss. He evaluated if the resident would tolerate a medication to stimulate the resident's appetite. He said weekly weights were an important intervention. He said he was unable to speak specifically about Resident #87 and Resident #92. -However many of the interventions the medical director suggested for weight loss were not implemented or tried to prevent the significant weight loss of Resident #87 and Resident #92.

Based on record review and interviews, the facility failed to ensure compliance with secure environment placement requirements for one (#17) of two residents out of 34 sample residents. Specifically, the facility failed to:-Ensure the designated evaluation team for placement on a secure unit consisted of a non-facility staff member with a mental health or social work background for Resident #17; and, -Ensure the resident's legal representative was consulted, involved in the care planning process and gave consent for Resident #17's move to the facility's secured unit before the move occurred. Findings include:I. Failure to follow secure placement requirementsChapter 5 Secure Environment Placement Requirements:"There shall be a designated team to evaluate placement of a resident in a secure environment. The team shall include, at a minimum, the director of nursing or designee, a social services staff member, the administrator or designee and an individual (with mental health or social work training as appropriate to the needs of the residents) who is not a facility staff member."An evaluation team finds, based on available evidence, that: Less restrictive alternatives have been unsuccessful in preventing harm to self or others. Written findings and the factual basis for the placement are documented in the health information record. The resident or resident representative has given informed, written consent."The evaluation team shall re-evaluate the placement of every resident 30 days after initial placement and no less often than every 180 days thereafter."II. Resident #17A. Resident statusResident #17, age greater than 65, was admitted on 8/22/19. According to the March 2024 computerized physician order (CPO), diagnoses included dementia, ischemic cardiomyopathy (decreased ability to pump blood), chronic kidney disease, heart failure and gout. B. Record reviewThe 2/9/24 secured unit placement admission team evaluation documented that the resident was placed in the secured unit because he was at risk of wandering away from a familiar setting with the inability to find his way home. -There was no documentation that less restrictive alternatives were attempted and had been determined unsuccessful and there was no documentation of factual basis that the resident could not be cared for in an unsecured less restrictive setting. The resident's medical record revealed that the resident had two elopement attempts on 3/7/24 at 2:30 p.m. and again at 3:07 p.m. but no additional attempts to elope the facility. Following these elopement attempts the facility made a decision to move the resident to the facility's secured unity without evidence of additional elopement attempts or attempting least restrictive measures to prevent the resident from future elopement attempts. III. InterviewsThe social services director (SSD) was interviewed on 3/19/24 at 4:18 p.m. The SSD said Resident #17 used to be busier and roam around the facility but he no longer attempted to leave the unit he was living in and staff did not need to redirect the resident because he did not wander. The SSD said the determination to move the resident to the secured unit was made by the facility's interdisciplinary team (IDT) without the involvement of the resident legal representation. The resident representative was informed of the resident's move after the resident was moved into the secured unity over the weekend of 2/9/24. The director of nursing (DON) was interviewed on 3/19/24 at 3:09 p.m. The DON said residents were placed in the secure unit because the resident attempted to exit the facility or the resident tried to hurt themselves. She said a physician was needed to determine if a resident should be placed in a secured unit. She said if the resident eloped, that was not a reason in itself to place a resident in a secured unit. The DON said an evaluation should be completed prior to a resident's placement in the secured unit and would have to check to see who should be part of the evaluation. She said it was important for an evaluation to be completed to show that the resident was placed in a secured unit based on behaviors. The DON said if staff knew a resident was a high risk for elopement based on documented behavior records then an assessment for secured placement needed to be completed. The DON did not know the frequency for reassessments once a resident was placed in the secured unit but said reassessments were necessary to determine if the resident demonstrated ongoing behaviors at the same level of intensity determined during the initial assessment or if the behaviors improved or worsened. The DON said if the resident did not demonstrate elopement, behaviors and was no longer a threat to themselves or others, the facility should look to moving the resident or the secured unit to a least restrictive living situation. The DON said the resident's family/legal representative should always be involved in the decision making and care planning process before a resident was moved to the secured unit, and the legal representative needs to give consent before the move occurs. The NHA was interviewed on 3/20/24 at 12:30 p.m. The NHA said the non-facility secured placement representative involved in evaluating facility residents for secured unit placement (the corporation's assisted living executive director) did not have a social services or mental health background. The NHA said he was unaware of that regulatory requirement.

A recertification survey with complaint #CO35224 was completed from 3/13/24 to 3/20/24. Fourteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/13/24 to 3/20/24. Three deficiencies were cited.

Based on record review and interviews, the facility failed to have an annual review of the complete emergency preparedness plan (EPP). Specifically, the facility failed to have an annual review of the EPP.Findings include:I. Record reviewThe emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) on 3/18/24 at approximately 10:00 a.m. -A review of the EPP revealed the facility did not have an annual review of the EPP. -The last documented review of the EPP was on 6/10/2020. II. Staff interviewThe EPP was reviewed with the NHA on 3/19/24 at 1:10 p.m. The NHA said that he was new to the position of NHA and he could not speak to what the previous administration had reviewed. The NHA was under the understanding that the previous NHA, governing body and leadership members had reviewed and updated the facility EPP on 12/28/23. -The facility was able to provide documentation that the facility assessment and the facility all hazards risk assessment were reviewed on 12/28/23, however, the facility was unable to provide any documentation that the facility EPP was also reviewed on that date.

Based on record review and interview, the facility failed to develop and implement emergency preparedness policies and procedures, based on the facility's emergency plan, risk assessment and communication plan, which were reviewed annually and updated as needed. Specifically, the facility failed to ensure the emergency preparedness policies and procedures:-Aligned with the facility's risk assessment and overall emergency preparedness program; and, -Were reviewed at least annually and updated as needed. Findings include: A. Facility emergency plan The facility's Emergency Preparedness Plan (EPP) policy manual was provided by the nursing home administrator (NHA) on 3/18/24 at approximately 10:00 a.m. -The EPP manual contained a document recording the last review of the facility EPP occurred on 6/10/2020. B. Record ReviewReviews by the facility of its EPP manual revealed the plan's policies were policies written by a corporation that provided long-term care providers documentation, references and educational resources. -The policies were not individualized to the facility's EPP and several fillable fields throughout the policies were left blank. -The policies contained in the (organization's name) policy manual were last revised between 2011 and 2020. C. Staff interviews The NHA was interviewed on 3/19/24 at 1:10 p.m. The NHA said he had recently started working in the facility. He found several binders and documents that made up the facility's EPP, however, he was unable to locate policies that were specific to the facility's EPP. The only policies he was able to locate were the policies provided for survey review (see above). The NHA said he would look for the facility's policies on such topics that included staffing strategies, addressing the 1135 waiver contingencies in the event of a state of emergency, communicating occupancy needs, sharing resident care information, maintaining the confidentiality of resident medical records and others. The NHA was interviewed on 3/20/24 at 1:34 p.m. The NHA said he was not able to locate any other policies that specifically addressed the facility's EPP response to emergencies occurring within the facility and how the facility responded to emergencies occurring in their community with the resident population.

Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness plan (EPP) training program that aligns with the facility's specific individualized EPP, annual risk assessment, facility EPP policies and procedures, 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 and annual training in emergency preparedness (EP) policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role; Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) on 3/18/24 at approximately 10:00 a.m. A review of the EPP revealed the facility provided staff a standardized industry training on emergency preparedness comprised of basic emergency practices in a long-term care setting. -However, the facility failed to provide annual training that was aligned with the procedures of the facility's EPP program so that staff knew how to respond to emergencies in the facility and the community setting. The EPP Disaster Training Policy, revised April 2019, read in part, "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."II. InterviewsThe NHA was interviewed on 12/6/23 at 12:33 p.m. The NHA said the facility had been providing facility staff a one-hour computerized training titled Emergency Preparedness and Environmental Safety developed by an emergency preparedness expert with 30 years of experience working with older adults across several settings including long-term care. The training objectives included:1. Identify three (3) safety focus areas in the long-term care setting. 2. Select four actions to promote environmental safety in a long-term care facility. 3. Identify three disasters that are covered in an emergency preparedness plan.-However, the training was not individualized to training staff on specific procedures and emergency responses within the facility EPP.

Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for two (#31 and #47) of five residents reviewed for unnecessary medication of out 34 sample residents. Specifically, the facility failed to ensure consents that reviewed the risk associated were obtained for the usage of psychotropic medications for Residents #31 and #47. Findings include: I. Facility policy and procedureThe Psychotropic Medication Use policy, revised October 2022, was received by the nursing home administrator (NHA) on 3/20/24 at 9:41 a.m. It read in pertinent part,"When psychotropic medications are ordered, the interdisciplinary team ( IDT) identifies target behaviors, medication side effects to be monitored and implements a resident centered care plan with both non-pharmacologic and pharmacological interventions. "Licensed nurse obtains informed consent for the use of psychotropic medications."II. Resident #31A. Resident statusResident #31, over the age of 65, was admitted on 9/11/23. According to the March 2024 computerized physician orders (CPO), diagnoses included dementia, insomnia, anxiety and major depressive disorderThe 12/18/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Record reviewThe comprehensive care plan, initiated on 12/27/23, revealed the resident took antidepressant medication related to her diagnosis of major depressive disorder. The interventions included giving antidepressant medications as ordered and educate the resident about the risks, benefits and side effects and/or toxic symptoms of antidepressant drugs to be given. -The care plan failed to identify the resident received antidepressant medication daily (Trazodone) to treat her insomnia. The March 2024 CPO revealed the following orders:-Trazodone 100 milligrams (mg), one tablet by mouth at bedtime for insomnia. Ordered on 1/2/24.-Vortioxetine 20 mg, one tablet by mouth one time a day for major depressive disorder. Ordered on 9/12/23. -A review of Resident #31's medical record failed to reveal an informed consent had been obtained from the resident or the resident's representative for the administration of the Trazadone or Vortioxetine. C. Staff interviewsThe director of nursing (DON) was interviewed on 3/19/24 at 12:42 pm. She said she was not aware the consents for psychotropic medications for Resident #31 had not been obtained. She said it was the responsibility of the nurse to obtain consent from the resident when the medication was ordered. The DON said she was new to her position and would follow up to obtain the consents from the resident. The social services director (SSD) was interviewed on 3/20/24 at 9:05 a.m. She said she audited resident medical records monthly during psychopharmacological meeting but was unsure why Resident #31 did not have signed consents for the ordered antidepressant medications. III. Resident #47A. Resident statusResident #47, age 86, was admitted on 6/30/17. According to the March 2024 CPO, diagnoses included dementia with behavioral disturbance, anxiety and depression. The 2/24/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. B. Record reviewThe March 2024 CPO revealed the following orders:-Zoloft Oral Tablet 47 mg by mouth one time a day for depression, ordered 10/13/23.-Lorazepam Oral Tablet 0.5 mg, give 0.5 mg by mouth two times a day for anxiety, ordered 1/19/24.-Seroquel Oral Tablet 25 mg, give one tablet by mouth two times a day for depression with psychosis, ordered 3/5/24. -A review of Resident #47's medical record failed to reveal an informed consent had been obtained from the resident or the resident's representative for the administration of the Zoloft, Lorazepam and Seroquel. C. Staff interviewsThe SSD was interviewed on 3/19/24 at 12:19 p.m. The SSD said the nursing staff was responsible for obtaining consent for the use of psychotropic medications. The SSD said she was aware Resident #47 did not have consent forms for the use of three psychotropic medications. Licensed practical nurse (LPN) #4 was interviewed on 3/19/24 at 1:46 p.m. LPN #4 said the nurse who completed the resident's admission was responsible for obtaining consents for psychotropic medications. LPN #4 said if the physician ordered a new psychotropic medication after the resident was admitted to the facility it was the nurse who was on duty at the time of the new order to obtain a consent from the resident or resident's representative. The DON was interviewed on 3/19/24 at 3:07 p.m. The DON said it was the nursing department's responsibility to obtain consents prior to the use of psychotropic medications. The DON said she was aware that Resident #47 did not have consents for the use of three psychotropic medications.

Based on interviews, observations and record review, the facility failed to ensure resident choices for two (#25 and #17) of three residents reviewed for activities of daily living out of 34 sample residents. Specifically, the facility failed to:-Ensure Resident #25 and Resident #17 received showers consistently according to their choice of frequency; and, -Ensure Resident #25's preferences were included in her plan of care. Findings include:I. Facility policy and procedureThe Bath, Shower, Tub policy, revised February 2018, was received from the nursing home administrator (NHA) on 3/20/24 at 12:42 p.m. It read in pertinent part, "Notify the supervisor if the resident refuses the shower/tub bath. Report other information in accordance with facility policy and professional standards of practice." II. Resident #25 A. Resident status Resident #25, age 89, was admitted on 9/1/23. According to the March 2024 computerized physician orders (CPO), diagnoses included polyneuropathy (nerve pain), dementia, squamous cell carcinoma of skin (skin cancer), psoriasis (autoimmune disease affecting the skin and joint disorder). The 12/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 14 out of 15. She required set-up assistance for eating, oral hygiene and dressing. She required supervision assistance for toileting, showering and personal hygiene. B. Resident interview Resident #25 was interviewed on 3/13/24 at 3:24 p.m. Resident #25 said she preferred to take showers on Saturday mornings. Resident #25 said Saturdays worked best for her schedule. Resident #25 said she preferred female caregivers to help her with her showers. Resident #25 said she did not like when male caregivers were able to see her naked. She said showers were a private time for her. Resident #25 said the facility had not asked her what her shower preferences were. C. Record review The activities of daily living (ADL) care plan, initiated on 9/14/23, revealed the resident needed assistance with dressing, personal hygiene and bathing due to her diagnosis of dementia. Resident #25 was able to perform most activities of daily living with minimal assistance. The interventions included in pertinent part: providing bathing on Mondays and Thursdays. -A review of the resident's comprehensive care plan revealed the care plan did not address Resident #25's current shower preferences. A review of the point of care documentation in the residents medical record indicated her shower days were Mondays and Thursdays. -The point of care documentation did not indicate the resident preferred female caregivers. Licensed practical nurse (LPN) #4 was interviewed on 3/19/24 at 3:04 p.m. LPN #4 revealed the shower binder at the nurses station documented the residents shower days were Wednesday and Saturday.-The shower binder at the nurses station and the point of care documentation did not match or meet the preferences of the resident. C. Staff interviewsLPN #4 was interviewed on 3/19/24 at 3:04 p.m. LPN #4 said Resident #25's shower days were on Wednesday and Saturday according to the shower book that was kept at the nurses station. LPN #4 said she was not aware that Resident #4 preferred female caregivers. LPN #4 said she was unsure how each resident's shower preferences were obtained. Certified nurse aide (CNA) #11 was interviewed on 3/19/24 at 4:28 p.m. CNA #11 said she was not familiar with Resident #25's shower preferences. CNA #11 said she would look at the shower book and the point of care system to determine Resident #25's preferences. -However, the shower book and the point of care system did not match and did not indicate the resident preferred female caregivers. The director of nursing (DON) was interviewed on 3/19/24 at 3:07 p.m. The DON said a resident's shower preferences should be obtained upon admission and reviewed regularly. The resident'spreference should also include if they prefer a male or female caregiver. The DON said she was not sure what Resident #25's shower preferences were. The DON said the resident's shower preferences should be included on the resident's plan of care and in the point of care system where staff document when showers were completed. III. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on 8/22/19. According to the March 2024 CPO, diagnoses included dementia, ischemic cardiomyopathy (decreased ability to pump blood), chronic kidney disease, heart failure and gout. The 1/2/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. He required substantial assistance with showering. He had no behaviors or rejections of care. B. Observation On 3/13/24 at 12:11 p.m., Resident #17 was in the dining room next to his room. His hair was sticking straight up and had not been combed. He was partially bald and his hair was approximately three inches. The front of his long sleeved shirt had a white stain in the middle of the shirt. C. Record review The resident's Kardex (tool utilized by staff to help provide consistent care of residents), reviewed on 3/20/24, revealed Resident #17 preferred a male staff member for showers and his preferred shower days were Tuesdays and Saturdays in the evening. He required one staff member and maximum assistance with bathing. The ADL care plan, initiated on 7/15/22 and revised on 10/12/23, revealed Resident #17 had a self care performance deficit related to dementia and weakness. Pertinent interventions included he required one staff participation in maximum assistance with bathing. -The care plan did not document the resident preferred male staff for bathing. Review of Resident #17's shower records from 2/19/24 to 3/20/24 revealed he had received three showers and refused three showers. -The refused showers revealed the staff were female, despite Resident #17's preference for male staff members for showers. D. Staff interviewsCNA #3 was interviewed on 3/19/24 at 3:56 p.m. CNA #3 said she knew which residents needed a shower based on the unit's shower book and Kardex. She said Resident #17's preference was to shower in the evening. CNA #3 said she did not know Resident #17 preferred a male staff member for showers. She said if a resident had a preference for a male staff member for showers, she would ask a male nurse who worked at night to give the resident his shower. The DON was interviewed on 3/19/24 at 3:09 pm. The DON said a resident's shower preference was determined at the time of admission. She said the evaluation determined if the resident wanted a shower or bath, a male or female staff member for bathing, time of day, how many times a week and what time of day the resident wanted to bathe. The DON said CNAs could look at the Kardex to determine a resident's bathing preferences. The DON said CNAs should document all attempts to shower a resident in the resident's electronic chart. She was not aware of Resident #17's preferences for bathing. She did not know why he only had three showers in the past 30 days. She said if a resident preferred a male staff member for personal care the female staff members should find a male staff member to perform the care. She said Resident #17's unit did not have a lot of male nurses and CNAs who worked on the unit.

Based on record review and interview, the facility failed to ensure all grievances were followed up on and resolved timely and appropriately. Specifically, the facility failed to make prompt efforts to resolve resident and resident representative grievances about a variety or concerns including: -Provision of timely care;-Responding to resident call lights;-Ensuring competent staff;-Ensuring agency staff performed care services as assigned; -Ensure a resolution to the resident's complaint about poor care and services; and, -Maintain evidence of the result of all grievances. Findings include:I. Facility policy and proceduresThe Grievances/Complaints, Filing Policy, revised April 2017, was provided by the nursing home administrator on 3/20/24 at 11:41 a.m. It read in pertinent part: "Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. "All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response."Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. The grievance officer, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken."The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.a. The administrator, or his or her designee, will make such reports orally within ___ (this line was left blank/ the number of days was not documented in the facility policy) working days of the filing of the grievance or complaint with the facility.b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office."II. Resident group interview Four alert and oriented residents (#63, #88, #33 and #4) who usually attended the resident council and were interviewed on 3/18/24 at 1:00 p.m. The residents all discussed how unhappy they were with the agency staff the facility had contracted to provide resident care. The group said the agency certified nurse aides (CNAs) were not oriented or trained on the expectations to provide resident care. Agency staff did not know how to operate the facility's call light system and they did not respond positively or timely to requests from residents for care assistance. The group said each time they got an agency staff responding to provide their care they had to train the staff themselves on how to perform their care and meet routine care requests in line with the established care plans because agency staff appeared to be unaware of their individualized care need. The group members said they often went without proper care due to the agency staff's lack of knowledge or unwillingness to perform their jobs appropriately. III. Resident interviews Resident #63 was interviewed on 3/19/24 at 9:21 a.m. She said the call lights did not work properly and/or they were not answered in a timely manner. She said she pushed her call light on 3/18/24 at 7:20 p.m. and staff did not answer her call until 8:30 p.m. She said sometimes her wait was longer. Resident #63 said she believed that the majority of the problem was the amount of agency staff that the facility used. She said the majority of all shifts were staffed with agency staff and they were not invested in providing good care in a timely manner. Resident #63 said that when an agency staff responded to provide care, she had to train the staff on how to respond and inform them of her care needs because they did not seem to have been trained properly to be able to provide good care. The staff were not responsive and timely to requests for care assistance. Resident #63 said she had talked with another resident in the facility and they told her agency staff were not providing good care to them either. Resident #63 said she had filed numerous complaints about the quality of care from agency staff but does not believe that the facility is taking grievance complaints seriously and has done little to resolve the numerous complaints they have received about nursing care and agency staff. Resident #88 was interviewed on 3/19/24 at 10:47 a.m. Resident #88 said management should focus on call light response times as that was a big problem in addition to providing agency staff with better training because there should be a higher work ethic for all staff. Resident #88 said the quality of care received and how quickly a call light gets answered depended on what time of day he needed assistance. Most of the agency staff hired just do not care and if no one was watching them most agency staff do not make the effort; they provide bad care and we have to wait a long time to receive that bad care. Resident #88 would like facility management to pay closer attention to the call lights and staff response to the resident's requests for care assistance. Resident #88 would like to see management staff hold agency staff accountable for providing good care and not have the resident be subject to poor care and service before they do something about the problem. Resident #33 was interviewed on 3/19/24 at 11:00 a.m. Resident #33 said evening shift call lights were not answered timely the response time averaged 45 minutes. The evening shift was mostly staff with agency CNAs who did not know her care needs, preferred routines or methods of care. Resident #4 was interviewed on 3/19/24 at 11:24 a.m. Resident #4 said the agency staff worked mostly evenings and nights and they were not prompt about answering call lights. Resident #4 said a good response time was 10 minutes; however, when agency staff were working she had to wait approximately 30 to 40 minutes for them to answer her call light and there were times when she went without care assistance well into the night because he staff did not respond to her call light at all. Resident #4 said it took two CNAs to transfer her in and out of bed and she said she needed her legs propped on a pillow at bedtime. She said the agency staff did not know how to do those things for her and she was often uncomfortable due to the agency staff's lack of knowledge or training on her specific care needs. Resident #4 said the agency staff needed to be trained properly so the residents received appropriate care. Resident #4 said she wanted the facility to hire more permanent staff so the residents did not need to explain to every new CNA how they should be providing competent care. Resident #63 was interviewed on 3/20/24 at 4:05 p.m. Resident #63 said she had filed several grievance reports with the same concerns about poor nursing care and response on several occasions and the facility continued to fail to address the root cause of her and similar concerns of her peers also living in the facility. Resident #63 said the facility used way too many agency staff who were poorly trained, had a bad attitude and bedside manner and then failed to hold those staff accountable to provide quality care. The resident said she chose this facility for its past reputation but lately, there had been so much turnover in leadership that no one was taking responsibility for ensuring the residents of the facility were receiving competent and quality care. Resident #63 said she was second guessing her decision to move into the facility. IV. Record reviewA request was made for a resident grievance concerns regarding nursing care from December 2023 to March 2024, 50 grievances were provided. A sampling of the grievance reviewed documented the following resident concerns. A resident grievance, filed on 12/7/23, revealed that an agency CNA performing an improper mechanical list caused her pain and discomfort in her foot. Resident #4 said the agency CNA was argumentative and disrespectful when she asked the CNA to change her approach to assisting her in a transfer with a mechanical lift. Per the resident, when she asked the staff to change her approach the CNA argued with her and told the resident she was the one who needed to be more respectful and not talk to staff in that tone. The facility responded by placing the agency CNA on a do not return status. -There were no other actions taken. A resident grievance, filed on 12/13/23, revealed an agency nurse was rude to a resident while administering a bedtime medication. The complainant said the nurse was impatient and rushed the resident through the medication administration process. Then when asked to leave the door open the nurse closed the door in a harsh manner. The facility responded to place the agency nurse on a do not return status.-There were no other actions taken. A resident grievance, filed on 12/22/23, revealed the resident activated his call light for staff assistance to get changed but no one answered his call light. The resident had to go down the hall to the nurse's station where three CNAs and a nurse were having a conversation and ask directly for staff to assist him with his care. The facility educated the CNAs that they needed to answer resident call lights and informed the resident/complainant that it was hard to educate agency staff who were not there on a regular basis.-There were no other actions were taken. A resident grievance, filed on 12/22/23, revealed one of the two agency staff on duty did not have a good bedside manner and everyone was upset with the scheduling of so many agency staff. The facility talked to the resident/complainant and explained that it was difficult to educate agency staff who were not there on a regular basis. -There were no other actions taken. A resident grievance, filed on 12/25/23, revealed that an agency was rough and non-caring and the resident/complainant and another resident did not want that CNA in their room again. The facility responded by placing the agency CNA on a do not return status.-There were no other interventions. A resident grievance, filed on 12/27/23, revealed that when a resident requested an accommodation based on preferred medication administration times and was told by the unit manager that nursing staff could honor that request. After the arrangements were documented, the nurse on duty told the complainant that she did not need her medications at that time. The facility's response included documentation that the resident's schedule was already in place and that staff knew the resident's actual preferred times.-There were no actions taken. A resident grievance, filed on 12/28/23, revealed the resident activated her call light and waited for two hours, the CNA did not respond. When the nurse on duty arrived to give the resident their medication three hours late the resident confronted the nurse and the nurse responded by telling the resident she did not like how she (the nurse) was binge-treated by the resident. The facility educated the nursing staff to answer call lights and administer medication timely and be respectful to the residents. Six separate resident grievances, filed on 12/29/23, revealed two residents had requested CNA #8 not be assigned to their care due to the CNA not providing care when they asked for assistance and when the CNA provided services she was rough with care. The facility educated theCNA.-There were no other actions taken to ensure the CNA was acting appropriately towards residents. A resident grievance, filed on 1/5/24, revealed an agency CNA put the resident to bed earlier than desired and was rude throughout the care process. After being put to bed the CNA would not speak to the resident. The resident feared retaliation for filing the grievance. The facility held an additional resident council meeting to discuss nursing concerns (see below). A resident grievance, filed on 1/9/24, revealed the resident asked for staff assistance to get dressed for bed and put on his pajama pants. The CNA threw the pajamas at the resident and told the resident to do it himself. When the grievance coordinator investigated the resident then responded to questioning that it only happened once and he was thankful for the other CNAs helping him. -The facility took no actions to address the resident initial grievance /complaint. A resident grievance, filed on 1/9/24, revealed a resident complaint about CNA turnover. The resident said facility staff were familiar with her routine and meeting her care needs. -The grievance form did not document if there were any actions taken to address the resident's grievance concerns. A resident grievance, filed on 1/10/24, revealed a resident complaint her medications were administered two and a half hours late because the agency nurse did not have access to the computerized medication administration record (MAR). -The grievance form did not document if there were any actions taken to address the resident's grievance concerns. The 1/31/24 resident council minutes revealed old business discussions included: poor call light responses. The previous director of nursing (DON) said agency staff were provided written instructions on how to use the call light system. Resident were encouraged to continue to use their call lights to request assistance. The DON said she would continue to educate staff and requested the resident to report concerns. Call light concerns were unresolved. New Business: The NHA started doing spot checks of the call lights systems and addressing staff directly. The NHA reported that the facility was making progress but the concerns were still a work in progress. Residents asked what was the reasonable timeline. The State would like the response to be 15 minutes at most; the NHA would like to get it a lot less. A resident grievance, filed on 1/22/24, revealed a resident activated his call light to request staff assistance to use the bathroom. A CNA responded and rudely told the resident "I do what I want to do" and slammed the resident door shut without helping the resident use the bathroom. The resident waited an hour and a half for staff to come and provide care and ended up urinating in his brief. The resident said this was not the first time he had problems with this CNA. The facility's response to the grievance was to interview the resident and when the resident said "I think the staff are trying."-There was no further action taken. A resident grievance, filed on 2/1/24, revealed a resident complained that she pressed her call light for staff assistance to get ready for and to go to bed. After waiting an hour and a half no staff responded to her call light so she started yelling for help, eventually, staff went to assist the resident with care and assist her to bed. The facility updated the resident care plan.-No further action was taken. A resident grievance, filed on 2/25/24, revealed a resident had to refile grievance concerns about long call light wait times, poor nursing care and poor medication time management because the resident's concerns were not addressed the first time she filed the grievance/complaints. The facility told the resident concerns were unresolved due to leadership turnover and said they would continue to follow up and communicate with her until her concerns were resolved. A resident grievance, filed on 3/5/24, revealed when the resident complained of being uncomfortable during the showing process and the CNA laughed and said you just lie to complain. The resident asked that the named CNA not be assigned to assist him with care in the future. The facility changed the CNA's assignment and the DON was to meet with the CNA prior to the CNA's return to work. -There was no documentation if the DON ever met with the CNA or what was discussed with the CNA. V. Staff interviews The staff development coordinator (SDC) was interviewed on 3/19/24 at 10:45 a.m. The SDC said the facility was actively recruiting nursing staff but relied heavily on agency CNAs and licensed nurses to meet the needs of residents in the facility. Each agency staff were to read the contents of the binder before starting work and sign an acknowledgment of understanding the contents of the binder. The binder contained information on the mission and vision of the facility, confidentiality, communication, directions for logging into and documenting resident care in the resident electronic medical record and operating and responding to resident call lights. The SDC said the CNA leaving shift would give report to the CNA common on shift. While the CNAs did their best to provide a thorough report the CNAs leaving shift may forget to pass some information along. The SDC said all agency staff had access to the resident's medical records so they could check car plan information if needed. The DON was interviewed on 3/19/24 at 4:00 p.m. The DON said the goal was to hire staff and reduce the use of agency staffing so that the facility could fully train their own staff and hold them accountable for providing quality care to the residents. The DON said the facility had a problem with staff answering call lights timely and consistently because the call lights did not always work properly. Staff had a hard time turning off the call lights once activated, due to a functional issue. When a call light was alarming the staff had a habit of thinking that it was already answered and they did not go back to check on the residents. The DON said the CNA should return to the resident's room to check on the resident and not leave the room until they successfully deactivated the call light. The DON said she was not sure what training agency staff received prior to starting their shift but knew they were supposed to get a status report on each resident on the reassignment before starting work from staff leaving shift. The DON said if agency staff were not providing appropriate care or not performing to the facility's standards the agency staff was placed on a do not return list.

Based on record review, observations and interviews, the facility failed to ensure two (#17 and #72) out of two residents out of 34 sample residents were free from involuntary seclusion. Specifically, the facility failed to ensure Residents #17 and #72 who resided in the secured unit, had the required assessment to justify such restrictions. Findings include: I. Facility policy The Wandering and Elopement policy, revised March 2019, was received by the nursing home administrator (NHA) on 3/20/24 at 12:42 p.m. It read in pertinent part: "The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. "-A policy for secured unit placement was requested but not received by exit on 3/20/24. II. Resident #17 A. Resident Status Resident #17, age greater than 65, was admitted on 8/22/19. According to the March 2024 computerized physician order (CPO), diagnoses included dementia, ischemic cardiomyopathy (decreased ability to pump blood), chronic kidney disease, heart failure and gout. The 1/2/24 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. He had an impairment on one side of his upper extremities and an impairment on both sides of his lower extremities. He used a manual wheelchair. He required supervision for oral hygiene and toileting, He required substantial assistance with showering. He required moderate assistance with dressing. It indicated that the resident did not exhibit any behaviors during the assessment period. The resident wandered during the assessment period. B. Observations During a continuous observation on 3/18/24 starting at 11:53 a.m. and ending at 1:13 p.m., Resident #17 did not wander or display any exit seeking behavior. The resident remained in his wheelchair. During a continuous observation starting at 3:10 p.m. and ending at 4:11 p.m., Resident #17 did not wander or display any exit seeking behavior. The resident remained in his wheelchair. C. Record reviewThe cognition and dementia care plan, revised 4/11/23, revealed the resident would likely experience a progressive decline in intellectual functioning characterized by a deficit in memory, judgment, decision making and thought process. The intervention was to utilize approaches that maximize involvement in daily decision making and activity. The psychosocial well-being care plan, revised 8/17/23, revealed the resident's psychosocial well-being may be impacted due to changes in living environment, loss of independence, extreme hearing loss, depression, general anxiety and loss of cognition. The resident was potentially at risk for negative social interactions due to a lack of social awareness of removing himself from escalating social situations. The intervention was to discuss beliefs, values, and cultural traditions significant to the resident and provide opportunities for the resident to follow when possible. The risk for wandering and elopement care plan, created and revised on 2/9/24, revealed the goal was for the resident to not leave the facility unattended and the resident's safety would be maintained. The interventions created and revised on 2/9/24 included increasing awareness and monitoring from staff, engaging resident in purposeful activity, evaluation for secured placement, family discussions for secured unit placement, identifying if there was a certain time of day for wandering and elopement attempts, identifying if there was a pattern for purposeful wandering, identify wandering and elopement de-escalating behaviors, provide care in a calm and reassuring manner, provider clear and simple instructions and provide reorientation to surroundings and environment. -The resident's electronic medical record did not reveal that the facility identified a certain time of day for wandering and elopement attempts. The resident's electronic medical record did not reveal that the facility identified a pattern for purposeful wandering. The facility did not identify wandering and elopement de-escalation behaviors. -The care plan was not revised when the resident moved to the secure unit on 2/22/24. The 6/18/23 elopement assessment documented the resident should be considered to be at risk for elopement if they score or higher. Resident #17 scored a four out of 10, which indicated the resident was a risk for elopement. It said the resident had a history of leaving the facility without informing staff, and expressed the desire to go home, the resident's behavior was likely to affect the safety or well-being of self or others, and wandering behavior was a pattern and goal directed. The suggestions were to monitor location frequently, use check-in and check out log, document specific behavior on the behavior log, review current medication regime and notify staff of elopement and wandering risk.-The resident's electronic chart revealed there were no elopement attempts between 6/18/23 and 2/7/24. The 2/7/24 at 2:30 p.m. elopement incident report was reviewed. It revealed the resident exited the building by the front door and walked approximately 10 feet down the front pathway. The receptionist had eyes on him the entire time. The resident said, "I wanted to go home." The immediate action was that the resident was encouraged to return to the building. The resident was agreeable to returning. -The incident report did not identify predisposing environmental factors, physiological factors and situational factors. The incident report revealed the resident's power of attorney was not notified. The 2/7/24 at 3:07 p.m. the elopement incident report was reviewed. It revealed the resident exited the building by the front door and walked approximately 10 feet down the front pathway. The receptionist had eyes on him the entire time. The resident said, "I went out for a breath of fresh air."The immediate action was that the resident was escorted to his room. The resident had a sitter until further steps were established. -The incident report did not identify predisposing environmental factors, physiological factors and situational factors. The incident report revealed the resident's power of attorney was not notified. The 2/7/24 nurse progress note from 4:38 p.m. documented the nurse was notified by the front desk that the resident was sitting outside with the receptionist. The resident told the nurse he was lost and wanted a bus to go to a casino and then home. An hour later, the nurse was notified by the receptionist that the resident left again. The resident was brought back inside. The director of nursing (DON) and the resident physician were notified. The resident was checked every 15 minutes; the resident remained in the dining room. The 2/7/24 nurse progress note from 4:46 p.m. documented that the DON wanted the 15-minute checks to stop and be replaced with a one-on-one sitter for the resident. The 2/8/24 provider progress note revealed the resident had exit seeking behavior last night. The resident attempted to leave the building and was confused about where he was. He was not on antipsychotics. The resident could move to a secured unit. The resident's power of attorney (POA) was notified to discuss reintroducing antipsychotic medication and/or moving to the secure unit. The resident's POA mentioned new environments were difficult for the resident. The provider's plan was to wait for lab results and monitor for further behaviors. The 2/9/24 provider progress note revealed there was no exit seeking behavior by the resident since last night. The resident was agitated and restless last night. The POA was notified to reconsider Seroquel if the resident had increased aggression or continued to exit seek. The 2/9/24 elopement evaluation documented the resident had a history of attempting to leave the facility without informing the staff, expressed the desire to go home, had a wandering behavior that was a pattern and goal directed. The resident's behavior was likely to affect the safety or well-being of self or others The suggestions were to monitor location frequently, utilize check-in and check log, document specific behaviors on the behavior log, review current medication regime and notify staff of elopement and wandering risk. The 2/9/24 secured unit placement admission team evaluation was reviewed by the facility's executive director, director of nursing, social services staff member and an assisted living facility's executive director. The assisted living facility's executive director was not a social worker and did not have a background in behavioral health. The power of attorney signed the evaluation on 2/22/24. The evaluation said the resident was at risk of wandering away from a familiar setting with the inability to find his way home. -The evaluation did not document if the resident had a significant behavioral health issue that seriously disrupted the rights of other residents, was at risk of danger to self or others, and what the less restrictive alternatives attempted and why such alternatives were unsuccessful in preventing harm to self or others. The 2/13/24 nurse progress note revealed the resident did not have exit seeking behaviors. There was no indication to move the resident to the memory care unit. The one on one sitter was discontinued and the resident was placed back on 15-minute checks. The 2/22/24 social services note summarized a care conference meeting with the POA, dietary services, nursing services and social services director (SSD). The note documented that the resident had two elopement attempts. The facility explained to the POA the rationale for moving the resident to the secured unit. The family was in agreement. The POA discussed the resident's preference to go outside, enjoy looking out the windows and other personal preferences to ensure success on the secured unit. The 2/26/24 provider progress note revealed the resident was at baseline, calm and pleasant. The March 2024 MAR was reviewed. There were no physician orders to monitor for elopement and wandering. III. Resident #72A. Resident status Resident #72, age greater than 65, was admitted on 2/9/21. According to the March 2024 CPO, diagnoses included vascular dementia, muscle weakness, anxiety, depression and dysphasia (swallowing difficulty). The 12/14/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He had an impairment on one side of his upper extremities and an impairment on both sides of his lower extremities. He used a manual wheelchair. He required substantial assistance with personal hygiene, oral hygiene, toileting, and dressing. He was dependent for showering. He required substantial assistance in mobility, including rolling left to right, sitting to lying and lying to sitting on the side of the bed. He was dependent to sit to stand and bed to chair transfers. The assessment revealed that the resident did not exhibit any behaviors during the assessment period. The resident wandered during the assessment period. B. Observations During a continuous observation on 3/18/24 starting at 11:53 a.m. and ending at 1:13 p.m., the resident did not wander or display any exit seeking behavior. The resident remained in his wheelchair. During a continuous observation on 3/18/24 starting at 3:10 p.m. and ending at 4:11 p.m., the resident did not wander or display any exit seeking behavior. The resident remained in his wheelchair. C. Record reviewThe psychosocial well-being care plan, initiated on 7/5/23, revealed the resident's psychosocial well-being may be impacted due to a change in living environment, loss of independence and loss of cognition. Interventions included encouraging socialization, monitoring for changes in mood and offering choices to promote a sense of independence, well-being and self-worth. The mood care plan, revised on 7/10/23, revealed the resident's coping was impaired due to anxiety, depression, and depression. The interventions included administering medications and assessing medication effectiveness. Additional interventions included encouraging the resident to reminisce about his life, encouraging socialization with others, encouraging supportive visits and if the resident appeared upset, unable to relax or yell at staff, encouraging the resident to verbalize needs and feelings. The cognition/dementia care plan, revised on 7/10/23, revealed the resident was likely to experience a progressive decline in intellectual functioning characterized by a deficit in memory, judgment, decision making and thought process related to dementia. The interventions included accessing family as needed, encouraging residents to voice needs, providing reminders and cues as needed and identifying self and what care was provided. The communication care plan, initiated on 2/17/21 and revised on 7/10/23 revealed the resident had communication deficits related to change in environment and routine. The interventions included inviting his power of attorney to his care conferences, observing and assessing for secure unit placement as needed and if a resident attempted to go into other rooms or leave the unit, showing the resident where his room was. The staff should attempt to meet his needs and distract him by providing him with reading materials, coloring materials and talking to him. Reassure residents that his power of attorney knows where he is. The secured unit care plan, initiated on 7/10/23 and revised on 10/9/23, revealed the resident demonstrated actions that warrant placement in a secured unit by recommendation of his primary care provider. Without appropriate oversight, the resident could pose a threat to himself or others. The intervention was to re-evaluate every 180 days to establish the resident still met the criteria to be in the secured unit. The impaired cognition care plan revised on 10/5/23, revealed the resident had impaired cognitive function related to the diagnosis of vascular dementia. The interventions included administering medications as ordered, using task segmentation to support short-term memory deficits and reviewing medications to report possible causes of cognitive medications. The depression care plan, revised on 10/5/23, revealed the resident used an antidepressant medication. The interventions included giving medications as ordered and monitoring signs and symptoms of depression. The anti-anxiety care plan, revised 10/5/23, revealed the resident used an anti-anxiety medication. The intervention was to give medications as ordered and to monitor side effects and effectiveness. The vulnerable care plan, revised 10/9/23, revealed the resident was vulnerable due to the loss of independence, cognitive loss, hard of hearing and vision impairments. The intervention was to administer medications as prescribed, monitor any concerns or changes to the provider and offer ancillary services. The behavior care plan, revised 10/9/23, revealed the resident had a history of verbalization of increased irritability, physically aggressive to staff. He kicked his legs high up to open doors and kicked his legs up on his bed, couch and recliners. He liked to explore and was prone to wandering. Interventions included administering medications as ordered, discussing options for appropriate channeling of anger with the resident and keeping the schedule routine and predictable. -The resident's electronic medical record did not reveal that the facility identified a certain time of day for wandering and elopement attempts. The resident's electronic medical record did not reveal that the facility identified a pattern for purposeful wandering. The facility did not identify wandering and elopement de-escalation behaviors. The 12/5/22 and 3/22/23 elopement assessments documented that Resident #72 scored high on both assessments and was considered to be at risk for elopement. The assessment documented that the resident had a history of or attempted elopement while at home; had a history of leaving the facility without informing staff; expressed the desire to go home; wandered; had a wandering behavior that was goal directed; wandered aimlessly; and was likely to affect the safety or well being of self and others; likely to affect the privacy of others; and was not accepting the situation. -There was no clarification if the resident's elopement behaviors remained the same, worsened or improved between assessments and there were no suggested interventions. The 3/22/23 elopement incident report revealed the resident wandered outside the front door. The resident was in front of the building near the front doors. Resident #72 said he wanted to chase the geese and go home. He agreed to come back to the facility. Post elopement interventions included 15-minute checks. The resident was oriented to himself. The predisposed physiological factors were that he was confused and had impaired memory. The predisposed situation factor was that he was an active exit seeker and wanderer. The 5/14/23 elopement incident report revealed the resident was outside in the secured patio area. He tried to open the gate on the patio. A nurse saw him when she was in another resident's room and was able to redirect him back inside without incident. The resident was oriented to himself. The predisposing physiological factors were that he was confused, had impaired memory, was sedated and had a change in medications. The predisposed situation factor was that he was a wanderer. The 5/14/23 elopement evaluation documented the resident's history of elopement behaviors but did not document current elopement behaviors. The assessment interventions included: staff were to monitor the resident's location frequently; document specific observed behaviors on the behavior log; encourage the resident to participate in recreational activities; personalize the resident's room with familiar objects; review the resident's current medication regimen; and notify nursing staff of elopement and wandering behaviors. The 5/15/23 interdisciplinary note revealed the resident was moved to the secure unit. The 5/22/23 social services progress note revealed the resident moved to the secure unit. The 5/23/23 secure unit placement admission evaluation was determined to be at risk for wandering from a familiar setting with the inability to find his way home, at risk of danger to self and less restrictive alternatives have been unsuccessful in preventing harm to self. -There was a note on the secured admissions evaluation from the POA documenting that they were not part of the secured placement admission evaluation team meeting. The POA wrote that the resident did not have a significant behavioral health issue that seriously disrupts the rights of other residents. The POA indicated the resident was not at risk of danger to others. The 5/24/23 nurse progress note revealed the resident went to different rooms and tried to open the door with his feet. The resident was easy to redirect. The 6/21/23 social services progress note revealed the resident experienced signs and symptoms of depression. The provider ruled out clinically related concerns regarding change. The change was discussed with the interdisciplinary team on how to support the resident. The 6/22/23 nurse progress note revealed the resident called another resident a pig. He was disturbed by his roommate and another resident who yelled all day. He was sad and angry all day. The recommendation was to move the resident to another room. He had exit seeking behavior. He kicked the front door with his legs. He was redirected. His appetite was poor. The 7/26/23 nurse progress was note revealed the resident was agitated when he received activities of daily living care. He hit and kicked the staff. The 10/18/23 secure unit placement admission evaluation revealed the resident was determined to be at risk for wandering away from a familiar setting with the inability to find his way home and at risk of danger to himself or others. The 12/8/23 elopement evaluation documented that the resident did not have any elopement and wandering behavior and did not have suggested interventions or consider if the resident's placement in the secured unit continued to be appropriate. The 1/16/24 180-day review secure unit placement evaluation revealed the resident was determined to be at risk for wandering away from a familiar setting with the inability to find his way home. The March 2024 MAR did not document a physician's order to monitor for elopement and wandering and revealed the resident did not exhibit any behaviors. IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 3/19/24 at 3:56 p.m. She said residents were in the secure unit because they had Alzheimer's. She said the residents tried to go home because they wanted to see their family or children or due to their behavior. CNA #3 said she was familiar with Resident #72 and Resident #17. She said Resident #72 had been in the secured unit for the past two weeks. She said he wanted to do his own thing. She said he liked to drink coffee and eat sweets like donuts. She said he liked to participate in activities, watch a movie and sit at the end of the unit to watch cars drive by the facility. Before he moved to the secured unit, he liked to be in the dining room because there was a bird cage and he liked to see the birds. She said he was not combative nor did he try to leave the secured unit. CNA #3 said Resident #17 was combative around agency staff because the agency staff did not know him and that made him combative. She said if the staff explained to the resident what they were trying to do, he did not exhibit any behaviors. She said if residents exhibited any exit seeking behaviors she documented in their electronic medical records. Licensed practical nurse (LPN) #2 was interviewed on 3/20/24 at 11:13 a.m. She said residents were in the secure unit for different reasons. Some residents were admitted to the secure unit straight from their home because there was a safety concern and sometimes residents were admitted to the secured unit from another unit in the facility. When an internal move occurred there should be a physician's order prior to moving a resident to the secured unit. LPN #2 said the purpose of a secured unit was to keep the resident from physical harm and prevent elopement and exit seeking. She said staff were to monitor resident activities based on the resident's identified behaviors. If a resident was exit seeking, staff would monitor if they were wandering and/or trying to leave the facility. LPN #2 said it was important for an assessment of the resident to be completed prior to the move to the secured unit so the staff knew what to monitor for and knew how to ensure the resident remained safe. She said it was important to have the resident's family/POA involved in decision making because they knew the resident best. LPN #2 said she was familiar with Resident #72. She said Resident #72 was in the unit because he started to wander out of the facility. She did not see the resident show any exit seeking behaviors from the resident and she did not get a report from other nurses working on the unit that the resident was actively exit seeking. LPN #2 said Resident #72 enjoyed participating in activities programming; liked to watch television, exercise and liked to talk to other residents and staff. LPN #2 said she was familiar with Resident #17. She said Resident #17 was admitted to the facility in 2021 from an assisted living and was recently admitted to the secure unit because he had exit seeking behaviors and wandered in other resident's rooms. She said he liked to do therapy and participate inactivities. She did not see the resident show any exit seeking behaviors since he moved to the secured unit. The director of nursing (DON) was interviewed on 3/19/24 at 3:09 p.m. She said the residents were placed in the secure unit because the residents attempted to exit the facility or the residents tried to hurt themselves. She said a physician was needed to determine if a resident should be placed in a secured unit. She said if the resident eloped, that was not a reason in itself to place a resident in a secured unit. She said an evaluation should be completed prior to placement. She would check to see who should be part of the evaluation. The DON said it was important for an evaluation to be completed to show that the resident was placed in a secured unit based on behaviors for their safety. She said staff knew a resident was a high risk for elopement based on observation and documentation of those behaviors in the resident's medical record. The DON said a periodic reassessment for secured placement needed to be completed to determine if the resident demonstrated the behaviors were at the same level at time of initial assessment or if the behaviors improved or worsened. The DON was new to her position in the last few days and said she would have to look up the frequency of the secured unit reassessments. The DON said if the resident did not demonstrate elopement, behaviors or a threat to themselves or others, the facility should look to move the resident off of the secured unit to a less restrictive placement if assessed to be possible. This would depend on an assessment to determine if the resident was still trying to elope, wanted to go home or go shopping or hallucinating. The DON said she was not familiar with Resident #72 or Resident #17. She said a resident's care plan should have been in place to show what interventions were attempted prior to the move to the secured unit. She reviewed the provider note for Resident #72. She said the decision was to try medications to reduce behaviors or place the resident in the secured unit. The social services director (SSD) was interviewed on 3/19/24 at 4:18 p.m. She said residents were placed in the secure unit because they were a risk to themselves or if they wondered. The SSD said the interdisciplinary team (IDT) were part of the evaluation process. She staff knew a resident was a high risk for elopement based on the care plan and secured unit assessment. The SSD said a secured unit placement reassessment was required every 180 days but the facility did it quarterly. She said the behaviors monitored in the secure unit depended on the resident's actions. The SSD said she was familiar with Resident #17. She said he was found in places in the facility that he should not have been in. She said he was generally a pleasant resident and was not exit seeking. She said the resident used to be a lot busier and roamed around. The resident declined medically and physically and the staff no longer needed to redirect the resident because he did not wander. She said some residents would be determined to leave the secured unit. The SSD said that based on Resident #17's current behavior, it would be appropriate to re-evaluate his secured unit placement to see if he should transfer out of the secured unit. The SSD said that Resident #17's family did not have involvement in the plan to move the resident to the secured unit and the POA was not consulted properly. She said the placement to move the resident to the secured unit happened over the weekend without the family's consent. She said the family came to the facility and did not know that the resident had been moved. The SSD said she was familiar with Resident #72. She said he just moved to the secured unit after two elopement attempts where he was easily redirected to go back to the facility. She said the family was resistant to Resident #72 move to the secured unit because they thought the move would take his freedom away and they knew how much he enjoyed being in the dining room and around familiar staff and residents. She said the facility initiated a one-on-one sitter but the sitter was removed because he was not showing any exit seeking behavior and it was unrealistic to have a sitter for the long term. Instead, the IDT recommended the resident move to the secured unit because he was assessed to be an elopement risk. The SSD said the facility did not have a wander management system such as a wander guard for residents who were at risk for elopement. The facility did have door alarms on the facility doors when they were locked in the evening from 7:00 p.m. to 7:00 a.m.

Based on observation, record review and interviews, the facility failed to ensure one (#72) out of 34 sample residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure preventative measures were put in place for Resident #72's hand contracture. Findings include: I. Facility policy and procedureThe Restorative Nursing Services policy and procedure, revised July 2017, was received by the nursing home administrator (NHA) on 3/20/24 at 12:42 p.m. It read in pertinent part: "Residents will receive restorative nursing care as needed to help promote optimal safety and independence."Restorative goals may include, but are not limited to supporting and assisting the resident in:adjusting or adapting to changing abilities; developing, maintaining or strengthening his/her physiological and psychological resources; maintaining his/her dignity, independence and self-esteem; and participating in the development and implementation of his/her plan of care."II. Resident #72 A. Resident status Resident #72, age greater than 65, was admitted on 2/9/21. According to the March 2024 computerized physician order (CPO), diagnoses included vascular dementia, muscle weakness, anxiety, depression and dysphasia (swallowing difficulty). The 12/14/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He had an impairment on one side of his upper extremities and an impairment on both sides of his lower extremities. He used a manual wheelchair. He required substantial assistance with personal hygiene, oral hygiene, toileting and dressing. He was dependent for showering. He required substantial assistance in mobility, including rolling left to right, sit to lying, and lying to sitting on the side of the bed. He was dependent to sit to stand and bed to chair transfers. The resident did not have occupational or physical therapy during the review period. He had three out of seven days of active range of motion. B. Observations On 3/18/24 at 11:12 a.m. Resident #72 was in the dining area. The resident had a left hand contracture. He did not have a brace, splint or other assistive device on his hand. From 11:53 a.m to 1:13 p.m. Resident #72 was near the front door of the secured unit. At 12:22 p.m. the resident was assisted to the first dining table closest to the nurse's station. The resident had a left hand contracture. He did not have a brace, splint or other assistive device on his hand. From 3:10 p.m. to 4:11 p.m. Resident #72 was in his wheelchair in the dining area. The resident had a left hand contracture. He did not have a brace, splint or other assistive device on his hand. C. Record review The restorative range of motion care plan, revised on 3/12/24, revealed the resident required active range of motion due to muscular weakness, vascular dementia. He was at risk for decline in mobility due to the disease process of dementia and increased weakness and coordination. Interventions included an active range of motion program. The restorative splint care plan, revised on 2/15/24, revealed the resident had a splint that needed to be worn six to eight hours through day or night. Interventions included staff assistance to place blue hand splint on the left hand each morning and replace with white splint at night. The March 2024 treatment administration record (TAR) was reviewed. It revealed the following: -Left hand resting forearm splint (blue splint) on from 7:00 am. To 9:00 p.m. Notify the restorative nurse if the resident removes at night. Start 5/26/23. On 3/19/24, it was documented that the splint was off. -Left hand soft white finger separator/splint. On before bed and take off in AM. Notify the restorative nurse if the resident removes at night. Start 5/25/23. On 3/2/24, 3/3/24, 3/4/24 and 3/9/24 the MAR documented the splint was off. -The resident's electronic chart revealed there was no documentation why the splint was off. -The resident's electronic chart revealed there was no documentation that the restorative nurse was notified when the splint was removed. There was no documentation that the resident refused to wear the splint. III. Staff interviews The director of nursing (DON) was interviewed on 3/19/24 at 3:09 p.m. She did not know the contracture management program for hand contractures. She said interventions used in a contracture management program were exercise, physical therapy and rolled towels in between the fingers and palm of the hand. She was not familiar with Resident 17's contracture plan. She said a splint was used to prevent the contracture from worsening. Licensed practical nurse (LPN) #2 was interviewed on 3/20/24 at 11:13 a.m. She said the restorative contracture plan for Resident #17 was to have a left hand splint from 7:00 a.m. to 9:00 p.m. The unit nurse or restorative nurse was responsible for putting the splint on and off. He wore a different brace at night. She knew he wore the splint when she did her assessment and she documented he wore his splint in the resident's TAR. She said he wore a brace to prevent his contractures from worsening. The restorative nurse was interviewed on 3/20/24 at 12:41 p.m. He said the contractures management program for hand contractures included splints, brace and a rolled washcloth between the fingers and palm of the hand. He said the restorative contracture plan for Resident #17 was to wear a hand splint six to eight hours a day. The goal was to decrease the edema. He wore a blue splint during the day and a white splint during the night. The certified nurse aide (CNA) and nurse were responsible for ensuring the splint was worn. The CNA knew Resident #17 needed to wear a brace and the nurse knew the resident needed to wear a brace by reading the care plan. The CNA documented in the electronic chart and the nurse did not document it. Resident #17 wore the brace to prevent the contracture from worsening. He was not aware the resident did not wear the splint on 3/19/24. He said the contracture program was based on the resident's tolerance level. The staff should not force the resident to wear it. If the brace was off, they should find out why it was off. IV. Facility follow upThe facility followed up on 3/22/24. It documented the hand splint was documented as off in the TAR per the instructions in the order and the hand splint was removed. In addition, the CNA staff helped to perform his splint restorative program. This meant an effort that the staff attempted to continue to apply the splint. The resident had the right not to wear the splint and it was documented in the TAR that the splint was off. He wore a different splint during the night, which the documentation showed for the date in question. Based on the TAR, the resident wore his splint regularly with assistance from staff. The restorative nursing splint assistance program documentation provided by the facility on 3/22/24 documented the CNAs to place blue hand splint on the left hand each morning and replace with white splint at night. On 3/19/24, documentation showed CNAs did something at 1:47 p.m. and 3:10 p.m. -There was no documentation that the resident refused to wear the splint or why the splint was not on the resident's hand.

Based on observations, record review and interviews, the facility failed to two (#87 and #92) of three residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 34 sample residents. Resident #87 was admitted on 1/12/23. Her admission weight was 113.8 pounds (lbs). The resident maintained a weight between 113 lbs and 118 lbs between January 2023 and January 2024. The resident lost 12.3 pounds between 1/4/24 and 2/15/24. The facility did not weigh the resident monthly despite a physician's order for monthly weights. The registered dietitian (RD) recommended weekly weights and weights were not consistently obtained on a weekly basis. The resident had poor meal intake and refused meals. There were no preventative measures implemented to address her eating patterns to ensure her intake was adequate. Due to the facility's failure to implement nutritional interventions, Resident #87 sustained a severe weight loss of 10% or 11.7 pounds in six months. Resident #92 was admitted on 5/12/24. Her admission weight was 152 lbs. The resident maintained a weight between 147.3 lbs and 153.2 lbs between 5/12/23 and 2/6/24. Weekly weights and weights were not consistently obtained on a weekly basis. There were no nutritional interventions implemented between 2/6/24 and 3/3/24 when she sustained a 15.1 lbs weight loss. Due to the facility's failure to implement nutritional interventions, Resident #92 sustained a severe weight loss of 17.36% or 26.6 pounds in six months. Findings include: I. Facility policy The Nutritional Assessment policy, revised October 2017, was received by the nursing home administrator (NHA) on 3/20/24 at 12:42 p.m. It read in pertinent part, "The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition.""Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences."The Weight Assessment policy, revised March 2022, was received by the NHA on 3/20/24 at 12:42 p.m. It read in pertinent part, "Resident weights are monitored for undesirable or unintended weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss."II. Resident #87 A. Resident status Resident #87, age 87 years old, was admitted on 1/12/23. According to the March 2024 computerized physician orders (CPO), diagnoses included prediabetes, osteoporosis, abnormal weight loss, major depressive order, vascular dementia with behavioral disturbance, atherosclerosis of native artery, chronic obstructive pulmonary disease and gastro-esophageal reflux disease (GERD). The 1/17/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required set up assistance for eating. She required substantial assistance with oral hygiene, personal hygiene, toileting and showering. The assessment documented the resident required set up assistance with eating and the resident had not experienced weight loss. Her height was 4 feet 11 inches and she weighed 116 pounds. Her diet was a mechanically altered diet. B. Observations and interviewThe resident was in the dining area of the secured unit on 3/13/24 from 12:11 p.m until 12:46 p.m. She required complete assistance with her meal. She consumed less than 25% of her meal. On 3/18/24 the resident was in her room due to contact isolation measures. The nurse brought the resident lunch at 12:41 p.m. The nurse left the room at 1:09 p.m. The nurse said the resident ate about 25 percent of her meal. The nurse said the resident did well with a nutritional supplement shake and liquids but not the actual meal. The meal intake record documented she consumed less than 25% of her meal. C. Record reviewResident #87's weight loss history revealed significant weight loss as follows: -On 10/5/23, the resident weighed 116.3 pounds; -On 11/6/23, the resident weighed 118.3 pounds; -On 12/2/23, the resident weighed 117.8 pounds; -On 1/4/24, the resident weighed 116.3 pounds; -On 2/15/24, the resident weighed 104 pounds; -On 2/23/24, the resident weighed 103.6 pounds; -On 3/1/24, the resident weighed 108.3 pounds; -On 3/18/24, the resident weighed 103.2 pounds; and,-On 3/19/24, the resident weighed 104.6 pounds. Resident #87's medical record revealed she experienced a significant unplanned weight loss of 10% or 11.7 pounds in six months from 10/5/23 to 3/19/24. The nutrition care plan, revised 1/22/24, revealed the resident had nutritional risks and potential for nutrition risks related to weight loss, dementia, psychotic disturbance, anxiety, hypothyroidism, prediabetes, osteoporosis, glaucoma, poor mobility and elevated LFT's (liver function tests). Interventions included encourage food and fluids at and between meals, honor food preferences, offer snacks daily, occasionally could feed self but usually required increased cueing and assistance at meals, monitor labs, weights, fluid volume status and skin integrity, provide supplements as ordered and monthly weights. The malnutrition care plan, revised 1/29/24, revealed the resident was at risk for malnutrition. The interventions included a complete mini nutritional evaluation, if malnourished consult dietitian and if mini nutritional evaluation results indicate risk, consult dietitian. The dementia care plan, revised on 1/27/23, revealed the resident would likely experience progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia. Interventions included a BIMS at each review or as needed to monitor for changes in cognition. The self care deficit, revised 1/29/24, revealed the resident was at risk for feeding. The interventions included to provide meal support per resident's needThe 2/22/24 dietitian progress note revealed she was not sure the 2/15/24 weight was accurate and changed monthly weights to weekly weights. The 2/28/24 dietitian progress note revealed the resident's weight was down significantly since December 2023. It read in pertinent part, "The resident's intake declined. Increased frequency of Ensure supplement. Possible effect by norovirus? Noticeable decrease intake and nausea. Continued weekly weights and relay concerns to nursing and social services." The 3/7/24 dietitian progress note revealed the resident was on weekly weights. The note documented in pertinent part, "Weight on 2/23/24 was 103.4 pounds. Variable intake through February (2024). No nausea, vomiting or diarrhea per progress notes. Follow weekly weights." The 3/8/24 nurse progress note for weekly weights said that weight was not obtained because weight was not due. -There was no documentation that the physician or dietitian were notified that the weight was not obtained. The 3/18/24 nurse progress note revealed the provider was notified about a new weight. The resident was already on Ensure (nutritional supplement), modified diet, recent illness and poor appetite. The provider ordered labs. The dietitian was notified and followed up once labs were completed. The resident was not experiencing difficulty with swallowing or a modified diet. -The 3/19/24 dietitian progress note (during the survey) revealed the resident had significantweight loss since December 2023. The note documented in pertinent part, "She declined medically since January 2024. She had increased temperature. Pneumonia was ruled out with chest x rays. Fluids were encouraged. She was in isolation due to an outbreak of norovirus but remained asymptomatic. Resident was weak, poor intake and temperature. Concerned with the resident's overall medical decline, advanced age, severe dementia and weight loss. Body mass index (BMI) decreased from 23.9 to 20.8. May consider hospice consultation if warranted. Continue weekly weights and supplements." The March 2024 CPO revealed the following: -Regular puree textured diet-Ensure plus, three times a day for poor intake. Offer after meals, 237 mls. Start 2/28/24. -Ensure plus, one time a day for poor intake and weight loss. Start 10/20/23, discontinued 2/28/24. -Give snacks at bedtime. Start 3/15/23. -Weigh weekly, one time a day every 7 days. Start 2/23/24. -The facility did not follow the weekly weight order between 3/1/24 and 3/17/24. -The Ensure supplement was not changed until 2/28/24, after the resident had lost 12.7 lbs since 1/4/24. The March 2024 meal intake records documented the resident consumed the following from 2/19/24 to 3/20/24. The records revealed the resident ate 76-100 percent on 20 occasions, 51-75 percent on seven occasions; 26-50 percent on 21 occasions, zero-25 percent on 20 occasions and refused five meals (3/11/24, 3/13/24, 3/15/24 and 3/19/24). The resident had less than three meals in a day recorded for several days from 2/19/24 to 3/20/24. The record revealed the resident ate two meals on six days (2/20/24, 3/6/24, 3/9/24, 3/14/24, 3/16/24 and 3/19/24) and only one meal on five days (2/22/24, 2/29/24, 3/1/24, 3/7/24 and 3/17/24). III. Resident #92 A. Resident status Resident #92, age 71 years old, was admitted on 5/12/24. According to the March 2024 CPO, the diagnoses included dementia, Alzheimer's, psychotic disturbance, mood disturbance, general anxiety disorder and osteoarthritis. The 2/15/24 MDS assessment documented that the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident required partial assistance for oral hygiene, toileting, showering, dressing and personal assistance. The assessment documented the resident required partial assistance with eating and the resident had not experienced weight loss. and had experienced weight loss. Her height was 5 feet 4 inches and she weighed 147 pounds. She was on a mechanically altered diet. B. Observations and interviewsThe resident was observed on 3/13/24 from 12:11 p.m until 12:54 p.m. An unidentified certified nurse aide (CNA) and an unidentified nurse talked at 12:28 p.m. The CNA said the resident lost 20 pounds. The nurse went to the medication cart and came back to the resident with a shake in a plastic cup. The resident tried to drink the shake independently. Her hand was shaking and she almost spilled the shake. The shake was not reoffered. The CNA provided juice in a plastic cup and left the resident. The resident spilled the juice when the CNA walked away. C. Record reviewResident #92's weight loss history revealed significant weight loss as follows: -On 9/7/23, the resident weighed 153.2 pounds; -On 10/5/23, the resident weighed 151.6 pounds; -On 11/6/23, the resident weighed 152.7 pounds; -On 12/7/23, the resident weighed 150.6 pounds; -On 1/4/24, the resident weighed 151.5 pounds;-On 2/6/24, the resident weighed 147.3 pounds;-On 3/3/24, the resident weighed 132.4 pounds; -On 3/13/24, the resident weighed 126.6 pounds; and,-On 3/19/24, the resident weighed 131.4 pounds. -Despite the 15.1 pounds (10.12%) weight loss demonstrated in one month between 2/6/24 and 3/3/24, the facility did not add any nutritional interventions until ten days after the significant weight loss was documented. Resident #92's medical record revealed she experienced a significant unplanned weight loss of 17.36% or 26.6 pounds from 9/7/23 to 3/13/24. The nutrition care plan, revised 2/19/24, revealed the resident was at risk related to dementia, seasonal allergies, B12 vitamin deficiency, constipation and vitamin D deficiency. Interventions included encourage food at and between meals, Ensure twice a day, honor food preferences, offer snack daily, weekly weights, monitor labs and could sometimes eat independently but may need full assistance. The dementia care plan, revised 5/24/23, revealed the resident would likely experience progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia. Interventions included simplify tasks by breaking tasks into one step at a time and utilize approaches to maximize involvement in daily decision making and activity. The ADL self care performance deficit care plan, revised 5/25/23, revealed the resident had a deficit related to dementia. She was able to hold the cup, feed herself and eat foods independently. The eating care plan, revised 8/28/23, revealed the resident had her own teeth with some missing teeth. She was able to feed herself independently, follow staff set up, encouragement and cueing. Interventions included staff to provide set up assistance with feeding. Staff were to provide verbal cues, set up tray, pour liquids, cut foods and apply condiments with each meal. The 3/18/24 provider note documented Resident #92 was seen for gradual weight loss of 25 pounds over the past 12 weeks and six pounds over the past three weeks. Staff reported she often did not eat well, took two to three Ensures daily and took fluids with encouragement. Her weight loss was expected and unavoidable as her dementia advanced. The dentist was following for a tooth that periodically became abscessed, though it did not seem to interfere with her eating or cause pain. The staff should continue oral intake and supplementation as tolerated. -The provider had called the weight loss unavoidable, however, there were no interventions added when she had a significant weight loss from 2/6/24 to 3/13/24. In addition, the resident had an abscessed tooth that did not interfere with eating, however according to the dietitian's note (see below) she had poor appetite due to the abscessed tooth. The 3/16/24 nurse progress note revealed the resident was losing weight and had declined. The resident ate 100% at breakfast, lunch and dinner. The 3/15/24 nurse progress note revealed the resident was physically declining and failed to thrive. It documented in pertinent part, "Resident stayed in bed and encouraged fluids. Ensure ordered for two times a day. Resident was weak and left message for provider for labs." The 3/15/24 dietitian progress note (during the survey) documented the resident was treated for weight loss. It documented in pertinent part, "Resident started on Ensure twice a day. Resident refused to drink. Resident has poor appetite due to abscess on right side of face." The 3/13/24 dietitian progress note said the resident was treated for tooth abscess with oral antibiotics. The resident had decreased in oral intake over the last week. Requested resident was reweighed because weight was significantly down. Added oral supplement for calories and fluids. Resident did well with finger foods and needs cueing and encouragement with intake. Follow weights weekly. The 3/12/24 provider notes revealed the staff reported right sided facial swelling due to an abscessed tooth. The resident did not open her mouth. She had a slight right sided facial swelling with palpation. She refused to open her mouth for an oral exam and did not show any signs of pain when palpating. The plan was to continue with antibiotics and probiotics. The 3/8/24 social services note revealed a request for a dental appointment as soon as possible. -There was no documentation that a dentist saw the resident. A request for dental records was made and the previous dentist visit from 11/14/23 was provided. The medication administration record (MAR) was reviewed for March 2024. It revealed the following orders: -Monthly weights on the third of every month. Start 3/3/24. -Weekly weights; one time a day every seven days for weekly weights. Start 3/14/24. -Ensure plus three times a day. Offer three times a day. Offer after meals. Start 3/14/24. -Give snack at bed time. Document percent eaten. Start 5/12/23. -Clindamycin 150 mg. Take one capsule by mouth every six hours for abscess for five days. Take one tablet every six hours for five days followed by dentist visit. Start 3/7/24. The March 2024 meal intake records documented the resident consumed the following from 2/19/24 to 3/20/24. The records revealed the resident ate 76-100 percent on 45 occasions, 51-75 percent on eight occasions; 26-50 percent on 13 occasions, zero-25 percent on two occasions and refused four meals. The resident had less than three meals in a day recorded for several days from 2/19/24 to 3/20/24. The record revealed the resident ate two meals on seven days (2/20/24, 3/6/24, 3/9/24, 3/14/24, 3/16/24, 3/17/24 and 3/19/24) and only one meal on four days (2/22/24, 2/29/24, 3/1/24 and 3/7/24). IV. Staff interviews CNA #3 was interviewed on 3/19/24 at 3:56 p.m. She knew when to weigh a resident when the nurse provided a list and verbally told the CNA. She said the list was for residents who lost weight. Once she weighed the resident she told the nurse. She documented the weight in the resident's electronic medical record. She asked the nurse what the resident weighed the last time the resident was weighed. She said it was important to weigh a resident because it showed the resident's health status. CNA #3 said she was familiar with Resident #87. She did not know why the resident lost weight because she ate her pureed meal and she required assistance with meals. CNA #3 said she was familiar with Resident #92. She said the resident ate a lot at dinner but she did not eat as much at breakfast and lunch because she was sleeping. The director of nursing was interviewed on 3/20/24 at 12:49 p.m. She said she was not familiar with Resident #87 and Resident #92. She said all residents should be weighed at least monthly. She said it was important to monitor the resident's weight because if the resident lost weight it could indicate the resident was depressed or the resident did not like the food or consistency. She wanted to pay more attention to the resident and add interventions to prevent weight loss. She said the nursing staff collaborated with the dietitian to ensure weights were completed. The nurse told the CNA to weigh the resident. The nurse was responsible to notify the dietitian when the resident had weight loss. The dietitian was notified in a daily meeting. The DON was unable to say what defined significant weight loss. The unit manager (UM) was interviewed on 3/20/24 at 12:59 p.m. She said there was an issue with staff weighing residents as ordered. She said some staff did not like the scale in the unit where Residents #87 and #92 lived. She said there was not oversight to ensure weights were obtained based on the physician orders. She said the facility corrected the issue. The dietitian shared a list of residents who required weekly weights. The registered dietitian (RD) was interviewed on 3/20/24 at 10:06 a.m. She was responsible for completing the nutritional assessment and they were completed at time of admission, quarterly and if there was a change in condition. She was notified when a resident lost weight during a morning clinical meeting, if a provider notified her and she independently looked through a dashboard connected to the resident's weights on a weekly basis. She said significant weight loss was five percent in 30 days, seven and half percent in a quarter and more than ten percent in six months. She said interventions depended on the resident. If they did not like fluids, she would not add a liquid supplement. She would add a powder supplement to mashed potatoes or soups to increase calories. She tried liquid supplements. She wanted the liquid supplement to be administered when medications were administered. She tried different supplements if a resident only liked a specific flavor or if there was a supply issue. She added weekly weights as another intervention. She talked to speech therapy if the resident was on a pureed diet to see if the resident could move to a mechanical diet. She considered double portions for women if they had assistance at meals. She said double portions for elderly women was hard because the quantity was overwhelming. She considered changing from one supplement to another supplement if the resident had weekly weights and took 50% or less of the supplement. The RD said weekly weights were an intervention because it was an easy way to see an improvement or a decline. The first time a resident lost weight, she asked the staff to re-weigh in case the scale was not accurate. The nurse or nurse manager was responsible for notifying the family and the provider. If she was familiar with the family, she would notify them. She said the restorative program was responsible for weighing residents but in February 2024, the CNAs took over. She said CNAs did not do weekly weights. She would make requests but it did not happen. She sent lists to the DON. She said February 2024 was difficult because if she did not have the resident's weights, she was unable to do quarterly assessments or change in condition assessments. The RD said Resident #87 was always a good eater. She saw the resident's weight loss in February 2024. She was not notified in February 2024 that the resident was not eating well. She added weekly weights for the resident. She said the staff might not have weighed the resident because the scale the staff used regularly was in a different unit. The unit Resident #87 resided on was in an outbreak and staff might not have wanted to use the scale in the other unit. She was not sure why the resident was not eating in the past seven days. She said the resident was accepting the liquid supplements. She wanted the resident to gain one to two pounds a week. She was surprised the resident lost weight so she asked for a new weight. She said she would ask the kitchen to add more mashed potatoes to her meals. -However, mashed potatoes were not implemented based on the care plan and the RD's documentation (see above). The RD said Resident #92 required total assistance with her meals. She was not notified the abscess bothered the resident. If she was notified about the abscess she considered a downgrade in her diet so the food was easier for the resident to eat. The medical director (MD) was interviewed on 3/19/24 at 11:48 a.m. He said when a resident lost weight, he looked to see if the facility provided food that the resident liked, if food was given in a timely manner, where the resident ate and if the resident needed assistance. He looked at medical issues to see if there were medications that suppressed the resident's appetite. He checked labs to see if there was another cause of weight loss. He evaluated if the resident would tolerate a medication to stimulate the resident's appetite. He said weekly weights were an important intervention. He said he was unable to speak specifically about Resident #87 and Resident #92. -However many of the interventions the medical director suggested for weight loss were not implemented or tried to prevent the significant weight loss of Resident #87 and Resident #92.

Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standard of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#25 and #7) of three residents reviewed for pain out of 34 sample residents. Specifically, the facility failed to:-Offer non-pharmacological pain interventions For Resident #25 and Resident #7; and,-Determine an acceptable pain level for Resident #25 and Resident #7. Findings include:I. Facility policy and procedureThe Pain Assessment and Management policy, dated October 2022, was provided by the nursing home administrator (NHA) on 3/19/24 at approximately 1:00 p.m. It read in pertinent part, "The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. "The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. "Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. "Pain management is a multidisciplinary care process that includes the following: assessing the potential for pain; recognizing the presence of pain; identifying the characteristics of pain; addressing the underlying causes of the pain; developing and implementing approaches to pain management; identifying and using specific strategies for different levels and sources of pain; monitoring for the effectiveness of interventions; and, modifying approaches as necessary. "For stable chronic pain the resident's pain and consequences of pain are assessed at least weekly. "The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain."Document the resident's reported level of pain with adequate detail (i.e., enoch information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program."II. Resident #25A. Resident statusResident #25, age 89, was admitted on 9/1/23. According to the March 2024 computerized physician orders (CPO), diagnoses included polyneuropathy (nerve pain), dementia, squamous cell carcinoma of skin (skin cancer) and psoriasis (autoimmune disease affecting the skin and joint disorder. The 12/7/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 14 out of 15. She required set-up assistance for eating, oral hygiene and dressing. She required supervision assistance for toileting, showering and personal hygiene. The MDS indicated the resident was on a scheduled pain medication regimen, received as needed pain medication or was offered as needed pain medication and did not receive non-medication interventions for pain. The resident said she had occasionally pain, pain made it difficult for her to sleep at night and limited her day-to-day activities. The resident rated her pain level at a 5 on a 1 to 10 scale. B. Resident interview and observationsResident #25 was interviewed on 3/13/24 at 3:24 p.m. Resident #25 said she had a skin cancer legion to her left upper arm. Resident #25 pointed to her arm that revealed a bandage covering an area on her arm. Resident #25 said the area caused her a lot of pain. Resident #25 said the pain radiated up into her shoulder and down her arm. Resident #25 said the facility did not provide any non-pharmacological pain interventions to help with her pain. Resident #25 said she received pain medications which helped alleviate some of thepain. C. Record reviewThe March 2024 CPO revealed Resident #25 had the following physician orders for pain management:-Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligram), give one tablet by mouth every eight hours as needed for pain, give prior to wound care and every eight hours as needed, ordered 10/6/23 and discontinued 3/6/24.-Norco Oral Tablet 5-325 mg, give one tablet by mouth every six hours as needed for pain related to cancer, ordered 3/11/24.-Tylenol Tablet (Acetaminophen), give 650 mg by mouth every four hours as needed for pain, not to exceed three gm (grams) in a 24 hour period, ordered 10/1/23.-The physician order did not specify when to give the Norco Oral Tablet 5-325 mg versus the Tylenol Tablet 650 mg. The 3/3/24 pain assessment and interview documented the resident occasionally had pain. The assessment documented the resident said her pain occasionally affected her sleep, her ability to participate in therapy activities and interfered with her day-to-day activities. The resident rated her pain level as a 6 on a scale from 1 to 10. The resident reported her pain was moderate. The resident had vocal complaints and facial expressions of pain. The resident had pain on her left shoulder where a wound was present. The assessment documented wound dressing changes, bumping the area or touching the area increased the pain. The assessment documented Norco and leaving the area alone help relieve the resident's pain. The resident had a cancer lesion that was causing her pain. The current pain medication regimen was narcotics. The resident received as needed pain medications or was offered as needed pain medications and declined. The resident received non-medication interventions for pain which included relaxation techniques and distraction. The resident said she knew she could get a pain pill when she wanted it but forgot to ask sometimes.-The pain assessment failed to identify an acceptable level of pain for the resident. The pain care plan, initiated on 9/1/23, revealed the resident had acute and chronic pain. The intervention was to utilize non-medication interventions for pain relief. -A review of the resident's EMR did not reveal documentation of person-centered non-pharmacological pain interventions or documentation that non-pharmacological pain interventions were attempted. A review of Resident #25's January 2024 medication administration record (MAR) (1/1/24 to 1/31/24) documented the resident was administered Hydrocodone-Acetaminophen 5-325 mg when Resident #25 rated her pain level as a 0 on 1/5/24, 1/18/24 and 1/19/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when Resident #25 rated her pain level as a 5 on 1/25/24 and 1/28/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when she rated her pain level as a 7 on 1/30/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when Resident #25 rated her pain level at an 8 on 1/30/24 and 1/31/24. A review of Resident #25's February 2024 MAR (2/1/24 to 2/29/24) documented the resident was administered Hydrocodone-Acetaminophen 5-325 mg when Resident #25 reported her pain level was a 0 on 2/1/24, 2/9/24, 2/22/24, 2/23/24, 2/24/24 and 2/29/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when Resident #25 reported her pain level was a 4 on 2/25/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when Resident #25 reported her pain level was a 5 on 2/25/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when Resident #25 reported her pain level was a 7 on 2/4/24 and 2/28/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when she reported her pain level was an 8 on 2/1/24 and 2/20/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when she reported her pain level was a 9 on 2/2/24, 2/6/24, 2/10/24, 2/18/24 and 2/20/24. A review of Resident #25's March 2024 MAR (3/1/24 to 3/18/24) revealed Resident #25 was administered Hydrocodone-Acetaminophen 5-325 mg when the resident reported her pain level was a 4 on 3/1/24. The resident was administered Hydrocodone-Acetaminophen 5-325 mg when she reported her pain level was a 7 on 3/5/24. A review of Resident #25's treatment administration record (TAR) revealed the resident received wound treatment daily. -However, Resident #25 was not administered Hydrocodone-Acetaminophen 5-325 mg daily prior to wound treatment to the cancer lesion on her left upper arm. The resident was only administered the Hydrocodone-Acetaminophen eight of 31 days in January 2024, 15 of 29 days in February 2024 and two of 18 days reviewed for March 2024. A review of Resident #25's March 2024 MAR (3/1/24 to 3/18/24) revealed Resident #25 was administered Norco 5-325 mg when she reported her pain level as a 6 on 3/18/24. The resident was administered Norco 5-325 mg when she reported her pain level was a 7 on 3/11/24. The resident was administered Norco 5-325 mg when she reported her pain level was a 9 on 3/15/24. A review of Resident #25's March MAR (3/1/24 to 3/18/24) revealed the resident was administered Tylenol on 3/6/24 when she reported her pain level as a 5. III. Resident #7A. Resident statusResident #7, over the age of 65, was admitted on 10/3/17. According to the March 2024 CPO, diagnoses included anxiety and dementia. The 12/15/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required set-up assistance for eating. She required substantial assistance for toileting and dressing. She required supervision for oral hygiene. She was dependent for showering. The MDS assessment indicated the resident was on a scheduled pain medication regimen, did not receive as needed pain medication or was offered as needed pain medication and did not receive non-medication interventions for pain. The resident said she frequently had pain, pain made it difficult for her to sleep at night and limited her day-to-day activities. The resident rated her pain level at a 6 on a 1 to 10 scale. B. Resident interview Resident #7 was interviewed on 3/13/24 at 10:54 a.m. Resident #7 said she had a lot of pain to her upper body, especially her left arm and shoulder. Resident #7 said she received pain medications which helped alleviate some of the pain. Resident #7 said the facility used to provide non-pharmacological pain interventions that helped with her pain but recently have not been offering them to her. She said she enjoyed movement as she used to be an aerobic teacher. C. Record reviewThe March 2024 CPO revealed Resident #25 had the following physician orders for pain management:-Tylenol Tablet (Acetaminophen), give 650 mg by mouth two times a day for pain, not to exceed three gms in 24 hours, ordered 9/17/2020.-Morphine Sulfate (Concentrate) Solution 20 mg/ml (milliliter), give 0.5 ml by mouth four times a day for pain, ordered 5/17/22.-Hydromorphone HCI Tablet 2 mg, give 2 mg by mouth every 12 hours as needed for chronic pain osteoarthritis, ordered 8/10/22.-Morphine Sulfate (Concentrate) Solution 20 mg/ml, give 0.5 ml by mouth every 24 hours as needed for chronic back and shoulder pain, ordered 5/17/22.-Tylenol Tablet (Acetaminophen), give 650 mg by mouth every four hours as needed for pain or fever greater tan 100.4, not to exceed three gm in 24 hour period, ordered 9/16/2020.-The physician order did not specify when to give the Hydromorphone HCI Tablet 2 mg, Morphine Sulfate (Concentrate) Solution 20 mg/ml or the Tylenol Tablet. The 3/15/24 pain assessment revealed the resident frequently had pain. The resident's pain occasionally effected her sleep and frequently affected her day-to-day activities. The resident reported her pain was moderate and voiced complaints of pain. The resident said she had pain daily. The resident had pain to both knees and her left shoulder. The assessment documented weather and movement increased the residents pain. Medications and hot/cold compresses relieved the residents pain. The resident had arthritis and osteoporosis that contributed to her pain. The resident received acetaminophen and narcotics. The resident did not received as needed pain medications or was offered as needed pain medications and declined. The resident had not received non-medication interventions for pain. -The pain assessment failed to identify an acceptable level of pain for the resident. A review of Resident #7's December 2023 (12/1/23 to 12/31/23) MAR revealed Resident #7 was administered as needed Tylenol Tablet 650mg for a pain level of 5 on 2/25/23. Resident #7 was administered as needed Morphine on 12/30/23 for a pain level of 8. A review of Resident #7's January 2024 (1/1/24 to 1/31/24) MAR revealed Resident #7 was administered as needed Tylenol on 2/28/24 for a pain level of 9. A review of Resident #7's February 2024 (2/1/24 to 2/29/24) MAR revealed Resident #7 was administered as needed Tylenol on 2/19/24 and 2/27/24 for a pain level of 3. Resident #7 was administered as needed Tylenol on 2/20/23, 2/27/24 and 2/28/24 for a pain level of 5. Resident #7 was administered as needed Tylenol on 2/20/24 for a pain level of 5. A review of the resident's medical record revealed the resident's pain was last assessed on 2/29/24. The pain care plan, initiated on 10/9/17 and revised on 10/4/23, revealed the resident was at risk for pain or alteration in comfort related to her diagnosis of osteoarthritis (degenerative joint disease) and chondrocalcinosis (excessive calcium in the bones). The interventions included: acknowledging the presence of pain and discomfort, assessing gastrointestinal status and tolerance to medications, identifying pain location type and raining, promoting relaxation with back-rubs, soft music and reading materials, reporting unrelieved pain to the physician, following up with the pain clinic as needed, administering pain medications per physician orders, providing as needed medications for breakthrough per physician orders and document effectiveness, acknowledging presence of pain and discomfort and implementing relaxation techniques to assist with pain. -A review of the resident's EMR did not reveal documentation of person-centered non-pharmacological pain interventions or documentation that non-pharmacological pain interventions were attempted. IV. Staff interviewsLicensed practical nurses (LPN) #4 was interviewed on 3/19/24 at 1:46 p.m. LPN #4 said Resident #25 had pain to her left upper arm. LPN #4 said Resident #25 had a cancer legion that caused the resident pain. LPN #4 said Resident #25 had Norco and Tylenol for as needed pain for Resident #25. LPN #4 said she used her nursing judgment to decide to give Resident #25 the Norco versus the Tylenol. LPN #4 said Resident #25 responded well to distraction as a non-pharmacological pain intervention. LPN #4 said she thought Resident #25's acceptable pain level was a 2 or 3 but was not sure where that was documented in the resident's medical record. LPN #4 said Resident #7 had chronic pain to her left shoulders and knees. LPN #4 said Resident #7 had three as needed pain medications. LPN #4 said she used her nursing judgment to determine which pain medication to administer. LPN #4 said Resident #7 was on Morphine four times a day. LPN #4 said Resident #7's pain needed to be assessed on a numerical level. LPN #4 said the facility was asking and documenting if the resident was in pain and did not assess the resident's pain level daily. LPN #4 said Resident #7 responded well to distraction as a non-pharmacological pain intervention. LPN #4 said she thought Resident #7's acceptable pain level was zero but was not sure where that was documented in the resident's medical record. The director of nursing (DON) was interviewed on 3/19/24 at 3:07 p.m. The director of nursing (DON) said if a resident had more than one as needed pain medications the physician needed to put parameters in the orders to give the nurse direction on which medication to administer. The DON said it was not within a licensed nurse's scope of practice to determine which pain medication should be administered. The DON said an acceptable pain level for each resident needed to be established and documented in the resident's medical record. The DON said non-pharmacological pain interventions needed to be person centered and included on the care plan. The DON said attempts for non-pharmacological pain interventions needed to be documented in the medical record. The DON said she was not familiar with Resident #25 or Resident #7's pain regimen. The DON said she would review the residents.

Based on observation, interview and record review, the facility failed to ensure the correct installation, use and maintenance of transfer bar, (fixed bed rail assistive device) for three of three residents (#37 and #42) using bed canes or transfer bars (type of bed rail) for positioning out of 34 sample residents. Specifically, the facility did not ensure resident safety risk when the use of transfer bar/rails were in use, for Residents #37 and #42 by failing to:-Attempt to use appropriate alternatives prior to installing bed rails/transfer bars/rails;-Assess each resident for risk of entrapment from bed rails prior to installation;-Assess and review the risks and benefits of the bed transfer bar assistive device with the resident and or the resident's representative;-Obtain informed consent from the resident and or the resident representative for the use of the assistive device prior to instillation; and,-Ensure periodic assessment of the residents' use of the bed rails after they were installed. Findings include: I. Professional standard The U.S. Food and Drug Administration (FDA) Recommendations for Health Care Providers about Bed Rails, last updated 2/7/23, retrieved on 3/20/24, from https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/BedRailSafety/ucm362848.htm; the reference included the following recommendations: "Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bedside rail, and mattress should leave no gap wide enough to entrap a patient's head or body. "Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail. "Regularly assess that bed rails remain appropriately matched to the equipment and to the patient's needs, considering all relevant risk factors. "Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. "Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or water bed. "Re-assess the person's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. This should be done immediately because fatal "repeat" events can occur within minutes of the first episode."II. Facility policy and procedure The Bed Safety and Bed Rails policy, reviewed August 2022, was received by the director of nursing (DON) on 3/19/24 at 1:28 a.m. It read in pertinent part: "Policy interpretation and implementation: -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. -Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. "Use of bed rails:-The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation (IDT), resident assessment, and informed consent. -If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This IDT evaluation includes:-An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs;-The resident's risk associated with the use of bed rails;-Input from the resident and/or representative; and,-Consultation with the attending physician. -The resident assessment to determine the risk of entrapment includes medical diagnoses, conditions, symptoms and/or behavioral symptoms. -The resident assessment determines potential risks to the resident associated with the use of bed rails including the following, accident hazards, restricted mobility and psychosocial outcomes. -The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following, accident hazards, the resident could attempt to climb over, around, between, or through the rails and a resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress. -Before using bed rails the staff shall inform the resident or resident representative regarding the benefits and potential hazards associated with bed rails and obtain informed consent."III. Resident #37 A. Resident status Resident #37, over the age of 65, was admitted on 9/18/23. According to the March 2024 computerized physician orders (CPO), diagnoses included bilateral knee arthritis, hypertension and unspecified convulsions. The 12/22/23 minimum data set (MDS) assessment revealed the resident was mildly cognitively impaired with a brief interview for mental status (BIMS) score of 13 of 15. The resident was dependent on staff for transfers, required substantial to maximum assistance from staff for showers, dressing and partial to moderate assistance from staff for personal hygiene, bed rolling and for changing positions from sitting on her bed to lying on her bed. The assessment revealed the resident did not use bed rail physical restraints. B. Resident interview and observationsOn 3/13/24 at 1:45 p.m., Resident #37's bed was observed. The bed was positioned with the left side against the wall and a U-shaped bed cane was attached to the right side upper half of the bed frame. There was no visual gap between the bed cane and mattress, however during a physical assessment, there was a gap of three fingers between the bed cane and the mattress. The bed cane wobbled side to side when inspected. The resident was interviewed on 3/20/24 at 12:25 p.m. She sat in her wheelchair next to her bed. Resident #37 said she used the bed cane daily and used it to help her lay down on her bed. She said she was aware the bed cane was loose and did not remember if staff checked the bed cane for proper fitting. During the interview, the resident's spouse sat on Resident #37's bed and then laid on the resident's bed. When he sat down, the mattress compressed his weight and slid towards the wall. When the mattress moved, a gap of three fingers was created between the bed cane and the mattress. Resident #37's spouse said that he liked using the bed cane when he was in her bed and said he used the bed cane to help himself sit up and then stand from the bed. The resident spouse was not a resident of the facility and said he was unaware a gap between the bed cane and mattress was a safety concern. C. Record review Resident #37's CPO, dated 12/4/23, revealed the following order: "Bed cane-use as directed. No directions specified for use." -Review of Resident #37's record revealed no evidence that Resident #37 was fully assessed/evaluated by the interdisciplinary team (IDT) before using the bed cane. There was a Bed Rail Risk Assessment, dated 9/18/23, completed by the MDS coordinator (MDSC). The assessment read the resident could benefit from quarter side rails to enable bed mobility and assist the resident with repositioning in her bed. -However, a bed cane was ordered instead of the quarter side rail by the physician.-A review of the record revealed no evidence of consultation from the physician for the use of bed rails, when the resident had an increased safety risk due to a medical history of convulsions, documentation of tried and failed alternatives or timely informed consent for the use of the bed cane. The record review revealed on 3/15/24, after the start of the survey, the resident signed a Resident Assistive Device and/or Restraint Consent form. The consent form read the consent was for a right quarter side rail and instead, a bed cane was attached to the right side of her bed. -The consent failed to include Resident #37's applicable medical condition/diagnosis for the bed cane. -The 1/17/24 comprehensive care plan revealed the facility failed to identify why Resident #37 required the bed cane restraint attached to her bed and how it should be used by the resident. IV. Resident #42 A. Resident status Resident #42, over the age of 65, was admitted on 5/13/23. According to the March 2024 CPO diagnoses included dementia, vascular Parkinsonism, anxiety and hypertension. The 2/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 of 15. The resident was dependent on staff for transfers, repositioning from lying to sitting in bed, showers and lower body dressing and maximum assistance from staff for upper body dressing, bed positioning, moving from sit to lie in bed. The assessment revealed the resident did not use bed rail physical restraints. B. Resident interview and observationsOn 3/13/24 at 2:23 p.m., Resident #42's bed was observed. The bed was positioned with the right side against the wall and had bilateral U-shaped bed canes attached to the upper half of the bed frame. When inspected, there was no visual gap, however during a physical assessment, a gap of a fist was present on the left hand side between the bed cane and the mattress. The left hand bed cane wobbled side to side when inspected. The resident was interviewed on 3/20/24 at 8:55 a.m. She sat in her wheelchair next to her bed. Resident #42 said she did not know why the bed canes were present. She said she did not remember if staff checked the bed cane for proper fitting but was aware there was a gap in the mattress and the bed cane wobbled. She said she thought the bed canes were used to keep her from rolling out of the bed. She said previously rolled out of her bed and was stuck between the mattress and the bed cane and required assistance from a staff member to be freed. C. Record reviewResident #42's CPO, dated 4/11/23, revealed the following order: "Bilateral bed canes to bed to help increase bed mobility and functional independence. No directions specified for use." -Review of Resident #42's record revealed no evidence that Resident #42 was fully assessed/evaluated by the interdisciplinary team (IDT) before using the bed cane. There was a Side Rail/transfer Bar evaluation, dated 4/10/23. The assessment read the resident could benefit from bilateral bed canes to enable bed mobility for increased functional independence in bed. -The assessment omitted Resident #42's BIMS, diagnoses and ability to understand the risk and use of the bed canes. -A review of the record revealed no evidence of tried and failed alternatives or timely informed consent for the use of the bed cane. -There was no documentation that the IDT completed a reassessment after Resident #42 rolled out on her bed on 12/4/23 and was found by staff entrapped, her left arm wedged between the bed cane and bed mattress. The record review revealed on 3/15/24, after the start of the survey, the resident signed a Resident Assistive Device and/or Restraint Consent form for bilateral bed canes. -The consent failed to include Resident #42's applicable medical condition/diagnosis for the bilateral bed canes. The 2/29/24 comprehensive care plan revealed on 12/8/22 Resident # 42 had a care focus for activities of daily living (ADL) for her self care deficit due to her dementia. On 7/8/22 the ADL care plan read the resident required one-two staff members to reposition and turn in her bed. Care plan interventions included: resident benefits from two u-shaped mobility devised (one on each side) to help increase bed mobility and functional independence. On 12/4/23 Resident #42 had a fall. The 12/4/23 fall investigation revealed: "resident had an unwitnessed fall in her room. Resident was found sitting on the floor with her back against the bed with her left arm wedged in between the bedrail and the bed mattress, her left leg was laying on the bottom of the side table. Resident #42's description of the fall was 'I am not sure how I got this way, I just rolled over.'" The fall investigation dated 12/4/23 at 12:19 p.m. read the resident had injury to her left arm and left hip but injury type was undetermined. Predisposing situation factors read the side rails were up. The physician was notified on 12/4/23. V. Staff interviewsThe DON was interviewed on 3/19/24 at 12:42 p.m. She said it was the policy of the facility to complete a bed rail assessment prior to attaching bed rails to a bed. She said she did not know who was responsible for completing bed rail assessments and thought it was completed by the social workers. She said once the decision was made to attached bed rails to a resident's bed frame, it was the responsibility of nursing personnel to obtain informed consent from the resident. She said consent could be obtained at the time of admission, or at a later date when the decision was made to use the bed rails. The DON said it was the responsibility of either the unit nurse manager or the MDSC to update a resident care plan to identify the bed rail use directions and intervention. The DON said she was unaware of any occurrences in the facility that involved bed rails. The DON said when bed rails and bed canes were attached to resident bed frames, staff should check the safety of the equipment but was unaware who and when safety checks should be completed. She said she had been the DON for approximately two months. The social services director (SSD) was interviewed on 3/20/24 at 9:05 a.m. She said it was the policy of the facility to complete a bed rail use assessment prior to attaching bed rails to the bed frame. The SSD verified the bed rail assessment was completed by the MDSC on 4/11/23. The SSD said she was unable to locate documentation for Residents #37 and #42 that the facility tried alternatives prior to attaching bed rails/bed canes to their bed. The SSD was unable to locate follow up assessments or IDT documentation that related to the 12/4/23 incident when Resident #42 had been entrapped between the bed mattress and the bed cane. The SSD verified the facility failed to obtain timely consents from Resident #37 and #42 and the consents were obtained after the start of the survey.

Based on staff interviews and record review, the facility failed to ensure licensed nurses and certified nurse aides (CNA) were evaluated for competency and skill sets necessary to care for residents' needs as identified through residents' assessments and care plans. Specifically, the facility failed to have completed competency and skill sets training with licensed practical nurse (LPN) #3 and CNA#4, #5, #6, #7 and #8. Cross-reference to:-F585 failure to resolve resident grievance about agency nursing staff's competency while providing care assistance; -F692 failure to ensure residents received care and services to meet their nutritional needs; -F700 failure to assess and monitor the use of bed rails; and,-F880 failure to implement and practice proper infection control practices during a respiratory syncytial virus (RSV) outbreak. Findings include:I. Facility Policy-A request was made for the facility's policy on assessing nursing staff's competencies, however, the policy was not provided. The In-Service Training, All Staff policy, revised August 2022, was provided by the nursing home administrator (NHA) on 3/20/24 at 11:41 a.m. It revealed in pertinent part: "The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training."II. Record reviewOn 3/19/24 at 10:32 a.m., a request was made for the staff competencies assessments for five CNAs (#4, #5, #6, #7 and #8) and LPN #3 who were selected at random from all facility hired nursing staff. -The facility was unable to provide proof that any of the selected staff members had been assessed for competency in providing resident care and services. III. Staff interviewsThe staff development coordinator (SDC) was interviewed on 3/19/24 at 10:45 a.m. The SDC said she was new to the position and was not sure when nursing staff were assessed for competencies. The director of nursing (DON) was interviewed on 3/19/24 at 4:00 p.m. The DON said she was new to her position and had been in the facility for only a couple of days. The DON was unsure of the status of competency assessments for the facility's nursing staff. The NHA was interviewed on 3/20/24 at 1:34 p.m. The NHA said he was not sure when the facility last assessed the competency of nursing staff. The NHA said they had no documentation to show proof that nursing staff, including CNAs and/or licensed nurses, were assessed for competencies in the last 12 months.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure standards of practice were followed for a respiratory syncytial virus (RSV) outbreak in the secured unit were followed;-Ensure Resident #17, #31, #7, #36 and #11 received the RSV vaccination upon consenting for it; and, -Ensure the facility had a water monitoring program to prevent the potential spread of Legionella and other waterborne pathogen infections. Findings include:I. RSV outbreakA. Professional referenceThe Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on 4/2/24 from https://www.cdc.gov/handhygiene/providers/guideline.html included the following recommendations, in pertinent part for hand hygiene, "Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal."B. Facility policy and procedureThe Standard Precautions policy, dated September 2022, was provided by the nursing home administrator (NHA) on 31/8/24 at approximately 11:00 a.m. It read in pertinent part, "Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. "Personnel are trained in various aspects of standard precautions to ensure appropriate decision-making in various clinical situations. "After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to residents or environments."The Isolation - Categories of Transmission-Based Precautions policy, dated September 2022, was provided by the NHA on 3/18/24 at approximately 11:00 a.m. It read in pertinent part, "Transmission-based precautions are initiated when ar resident develops signs and symptoms of a transmissible infections; arrives for admission with symptoms of an infection; ar has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. "Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne."When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC (centers for disease control) precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room. Signs and notifications comply with the resident's right to confidentiality or privacy. "Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material. Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. "Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). Masks are worn when entering the room. Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions." C. ObservationsOn 3/13/24 at 12:43 p.m. an unidentified staff member went into an isolation room for Resident #17. The staff member did not change the mask before she went into the isolation room. At 12:46 p.m., the same staff member left the isolation room. She did not change masks. There was a sign that indicated the resident was on droplet and contact precautions. The sign documented to remove the face mask prior to exiting the room. During a continuous observation on 3/19/24 beginning at 7:41 a.m. and ending at 9:02 a.m. the following was observed:At 7:42 a.m. licensed practical nurse (LPN) #5 pulled down her mask within six feet of a resident and blew her nose. At 7:43 a.m. certified nurse aide (CNA) #9 exited a resident's room who was positive for RSV with a surgical mask below her nose. CNA #9 did not change her mask upon exiting the room. At 7:48 a.m. CNA #9 began putting on a gown. CNA #9 then reached into her pockets and got a pair of gloves. CNA #9 did not put perform hand hygiene prior to putting on gloves and entered a resident room on isolation for RSV positive. At 7:57 a.m. CNA #9 left the RSV positive room. She removed all personal protective equipment (PPE) in the room except for the surgical mask. CNA #9 did not change her mask upon exiting the room. CNA #9 applied hand sanitizer for six seconds. -However, hand hygiene needs to be completed for at least 15-20 seconds. CNA #9 asked CNA #10 for assistance in the RSV positive room. CNA #9 began putting on a gown and got gloves out of her pocket and put them on. CNA #9 did not perform hand hygiene prior to putting gloves on. CNA #10 put a pair of gloves on and then put a mask on. The room CNA #9 and CNA #10 entered, had a sign on the door that indicated they needed to wear an N95 mask. Neither CNA put on a N95 mask. At 8:03 a.m. LPN #5 pulled her mask down and blew her nose within six feet of residents. LPN #5 applied sanitizer and rubbed her hands together for eight seconds. She then shook her hands in the air to dry them. Her hands were still visibly wet when she began touching the mouse to the medication cart computer. At 8:06 a.m. without performing additional hand hygiene LPN #5 administered a resident his medications. At 8:08 a.m. CNA #9 exited the RSV positive room wearing the same surgical mask. CNA #9 did not change the surgical mask upon exiting the room. At 8:14 a.m. LPN #5 took Resident #17's blood pressure in the dining room. Resident #17 was RSV positive. The licensed nurse did not encourage the resident to go to his room since he was RSV positive. LPN #5 returned the blood pressure cuff to the medication cart without sanitizing the cuff. LPN #5 did not perform hand hygiene. LPN #5 then touched her mask. At 8:15 a.m. Resident #17 entered his room. LPN #5 entered Resident #17's room without PPE and took the resident's pulse. At 8:20 a.m. CNA #9 and CNA #10 began passing out beverages to the residents who were in the dining room. Resident #17 was not encouraged to go to his room to consume his drinks and food. Resident #17 took his mask down near other residents in the dining room and began drinking his coffee. At 8:34 a.m. LPN #5 entered an unidentified resident to administer medications. LPN #5 exited the resident's room and did not perform hand hygiene. LPN #5 touched the mouse to the computer and opened up the medication cart to retrieve medications. At 8:47 a.m. CNA #9 put a gown on and then put a pair of gloves on without performing hand hygiene and entered an RSV positive room. At 8:57 a.m. LPN #5 put a gown on and then gloves. LPN #5 did not perform hand hygiene prior to putting on gloves. CNA #10 put on a pair of gloves without performing hand hygiene and then put a gown on. LPN #5 and CNA #10 entered an RSV positive room. At 8:59 a.m. CNA #10 exited the room. CNA #10 applied hand sanitizer and rubbed her hands together for nine seconds. At 9:00 a.m. LPN #5 exited the room. LPN #5 did not change her mask upon exiting the room. LPN #5 left the door open and said Resident #72 was going to come out to the dining room for breakfast. Resident #72 was RSV positive. At 9:01 a.m. the staff assisted Resident #72 to the dining room. D. Staff interviewsThe infection preventionist (IP) was interviewed on 3/19/24 at 10:27 a.m. The IP said the first resident tested positive for RSV on 3/8/24. The IP said nine residents on the secured unit have tested positive for RSV. The IP said the staff were encouraging residents to stay in their room who were RSV positive or under monitoring for RSV symptoms. The IP said the staff had a difficult time encouraging the residents to stay in their rooms since they had dementia. The IP said LPN #5 and CNA #10 should have not brought Resident #72 to the dining room for breakfast. The IP said the staff knew who was positive for RSV through the report and the end of the shift. The IP said she needed to implement a plan to ensure agency staff were educated on which residents had RSV or were under isolation for RSV symptoms. The IP said she had spoken with the health department and the staff needed to wear a surgical mask, gown and gloves into the RSV positive rooms. The IP said the staff needed to put on the gown then the gloves. The IP said hand hygiene needed to be performed before and after gloves usage. The IP said N95 masks and eye protection did not need to be worn in the RSV positive rooms. She said she needed to review the isolation posting signs in the secured unit to ensure they were all up to date. The IP said the surgical mask that was worn into an RSV room needed to be removed and a new one needed to be worn after exiting an RSV positive room. The IP said hand hygiene needed to be completed after exiting an RSV positive room. The IP said hand sanitizer could be used for hand hygiene. The IP said the staff needed to apply hand sanitizer and rub their hands together until they were completely dry. The IP said it was not appropriate for the staff to shake their hands through the air to dry them. The IP said it was important to ensure their hands were completely dry prior to touching items. The IP said she had attempted to educate all of the staff prior to the start of their shirts on proper PPE usage and hand hygiene. The IP said LPN #5 was an agency staff member and she had not provided education to her yet. The IP said she called the health department today (3/19/24) to determine the length of isolation needed for RSV. The IP said LPN #5 needed to be away from residents when she removed her mask to blow her nose. The IP said LPN #5 needed to complete thorough hand hygiene after blowing her nose. The IP said the residents who were positive for RSV were on droplet and contact precautions. The medical director was interviewed on 3/19/24 at 11:35 a.m. The medical director said the most important step to reducing the spread of infection was proper hand hygiene. The medical director said the facility needed to notify and educate the staff on which residents were RSV positive. III. RSV immunizationsA. Facility policy and procedureThe Vaccination Policy-Residents, undated, was provided by the NHA on 4/19/24 at approximately 10:30 a.m. It read in pertinent part, "All residents will be offered vaccines that aid in preventinginfectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated."B. Resident #171. Resident statusResident #17, over the age of 65, was admitted on 7/17/19 and readmitted on 8/22/19. According to the March 2024 computerized physician orders (CPO), diagnoses included dementia, heart failure and chronic kidney disease. 2. Record review-A review of the resident's electronic medical record (EMR) on 3/18/24 revealed the resident had not received the RSV vaccination after the resident's representative consented for the resident to receive the vaccination on 10/18/23. C. Resident #311. Resident statusResident #31, age 66, was admitted on 9/11/23. According to the March 2024 CPO, diagnoses included fracture of left tibia (leg) and respiratory failure. 2. Record review-A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV vaccination after she consented to receive the pneumococcal vaccination on 10/24/23. D. Resident #71. Resident statusResident #7, over the age of 65, was admitted on 10/3/17. According to the March 2024 CPO, diagnoses included anxiety and dementia. 2. Record review-A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV vaccination after she consented to receive the vacation on 10/24/23. E. Resident #361. Resident statusResident #36, age 81, was admitted on 2/21/23. According to the March 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney disease, type two diabetes mellitus and gastro-esophageal reflux disease (GERD). 2. Record review-A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV vaccination after she consented to receive the vacation on 10/24/23. F. Resident #11 1. Resident statusResident #11, over the age of 65, was admitted on 11/21/17. According to the March 2024 CPO, diagnoses included Alzheimer's disease, morbid obesity and gastro-esophageal reflux disease (GERD). 2. Record review-A review of the resident's EMR on 3/18/24 revealed the resident had not received the RSV after the resident's representative consented for the resident to receive the vaccination on 10/12/23. G. Staff interviewsThe infection preventionist (IP) was interviewed on 3/19/24 at 10:27 a.m. The IP said she recently started working at the facility. The IP said when residents admitted to the facility their immunization history needed to be researched and documented in the medical record. The IP said the residents needed to be offered the immunizations they needed. The IP said Resident #17, #31, #7, #36 and #11 were offered the RSV vaccination in October 2023 and had not received the vaccination yet. The IP said she was unsure why the residents had not received the vaccination yet. IV. Water management programA. Professional referenceAccording to Center for Disease Control (CDC), "Legionella (Legionnaires Disease and Pontiac fever), last reviewed 3/25/21, retrieved from on 4/1/24: https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, "Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. "Legionella bacteria are typically found naturally in freshwater environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. "Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. "The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. "Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. "Seven key elements of a Legionella water management program are to:-Establish a water management program team-Describe the building water systems using text and flow diagrams-Identify areas where Legionella could grow and spread-Decide where control measures should be applied and how to monitor them-Establish ways to intervene when control limits are not met-Make sure the program is running as designed (verification) and is effective (validation)-Document and communicate all the activities. "Principles: In general, the principles of effective water management include:-Maintaining water temperatures outside the ideal range for Legionella growth- Preventing water stagnation-Ensuring adequate disinfection-Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. "Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. "A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs."According to Center for Disease Control (CDC), "Controlling Legionella in Potable Water Systems, reviewed 2/3/21, retrieved from on 4/1/24: "Store hot water at temperatures above 140? and ensure hot water in circulation does not fall below 120?. Recirculate hot water continuously, if possible. "Store and circulate cold water at temperatures below the favorable range for Legionella (77-113?); Legionella may grow at temperatures as low at 68?."B. Facility policy and procedureThe Legionella Water Management Program policy, revised September 2022, was provided by the NHA on 3/18/24 at approximately 10:00 a.m. It read in pertinent part, "Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. "As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. "The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease."The water management program is reviewed at least once a year, or sooner if any of the following occur: the control limits are consistently not met; there is a major maintenance or water service change; there are any disease cases associate with the water system; or there are changes in laws, regulations, standards or guidelines."C. Record reviewThe NHA provided the Legionella water management plan on 3/18/24. -The water management plan was undated. The water management plan did not include how the facility was monitoring for Legionella. The water management plan had worksheets for the facility to utilize to help develop the water management plan. -The templates were not filled out to include specifics of the facility. The NHA provided temperature logs the maintenance department utilized to track the water temperature throughout the building. The water logs specified the water needed to be below 120?. A review of the temperature logs revealed the following temperatures that did not meet the standards of practice for water temperatures for Legionella management:-On 2/2/24 the water temperature in thespecial care unit kitchen was 86?, 110? in the therapy room, 118? in the east common area sink and 118? in the west common area sink. -On 2/9/24 the water in the special care unit kitchen was 89?, 112? in the therapy room, 118? in the east common area sink and the west common area sink. -On 2/16/24 the water temperature in the special care unit kitchen was 95?, 110? in the therapy room and 120? in the east common area sink and the west common area sink. -On 2/23/24 the water in the special care unit was 100?, 110? in the therapy room, 120? in the east common area sink and 119? in the west common area sink. -On 3/1/24 the water in the special care unit kitchen was 118?, 119? in the therapy room, 115? in the east common area sink and 117? in the west common area sink. -On 3/8/24 the water in the special care unit kitchen was 116?, 120? in the therapy room, 115? in the east common area sink and 118? in the west common area sink. -On 3/15/24 the water in the special care unit kitchen was 114?, 120? in the therapy room, 117? in the east common area sink and 119? in the west common area sink. -The temperature logs did not include resident rooms, boilers, water holding tanks or eye washing stations. D. Staff interviewsThe maintenance director (MTD) and the NHA were interviewed on 3/19/24 at 12:43 p.m. The MTD said they did not have a system in place to monitor how long resident rooms were empty and if the water needed to be flushed. The MTD said the facility did not test the water temperature at the boilers and the water holding tanks. The MTD said the staff member who documented on the temperature logs was new and needed to be educated on how to take temperatures of the water. The MTD and the NHA said they were unsure the correct temperature the water needed to be when monitoring for Legionella. The NHA said he was unsure the last time the water management plan was reviewed. He said the staff that were listed on the last revision had not been at the facility for a while. The NHA said they would review and update the water management plan to make it more thorough and ensure it met the regulations.

Based on record review and interviews, the facility failed to establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program. Specifically, the facility failed to have a process in place to track antibiotic usage in the facility. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on 4/1/24, included the following recommendations: "Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections."II. Facility policy and procedureThe Antibiotic Stewardship policy, revised December 2016, was provided by the nursing home administrator (NHA) on 3/18/24 at approximately 10:30 a.m. It read in pertinent part, "Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program."The Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes policy, dated December 2016, was provided by the NHA on 3/18/24 at approximately 10:30 a.m. It read in pertinent part, "Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship."As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designess."The IP (infection preventionist), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics."III. Antibiotic tracking system and staff interviewsThe IP was interviewed on 3/19/24 at 10:27 a.m. The IP said she was new to her position and recently began working at the facility. The IP said corporate nurse consultant (CNC) #1 and/or CNC #2 would be at the facility until she finished her training. The IP said she was unsure which criteria the facility used for antibiotic stewardship. CNC #2 joined the interview at 11:15 a.m. CNC #2 said the facility used McGreer's criteria for antibiotic use. CNC #2 said the facility used a program embedded into the electronic medical records to track antibiotics. CNC #2 and the IP said they were unsure of which residents were on antibiotics in the facility and if they met McGreer's criteria. CNC #2 said Resident #63 frequently called her physician outside the facility and asked for antibiotics. CNC #2 said the physician could order whatever medications they wanted. The IP said she was unsure how to use the antibiotic tracking system embedded into the electronic medical record. The IP said she found a map used to track infections for February 2024 that CNC #1 had made prior to leaving on vacation. The IP said she would create maps to track infections for January 2024 and March 2024. The medical director was interviewed on 3/19/24 at 11:35 a.m. He said he was not aware that Resident #63 had called her physician outside the facility to request antibiotics. He said he would review the resident's chart and provide education if a physician was providing antibiotics regularly that did not meet criteria.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#17, #31, #7, #36 and #11) of seven residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to:-Administer the pneumococcal vaccination after consent was provided for Resident #17, #31, #7 and #11; and,-Document risk versus benefit education for the pneumococcal vaccination for Resident #36. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 4/1/24, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, "Routine vaccination-pneumococcal-For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20)." "For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20."Special situations: Age 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups."Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies."Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies."II. Facility policy and procedureThe Vaccination Policy-Residents, undated, was provided by the nursing home administrator (NHA) on 4/19/24 at approximately 10:30 a.m. It read in pertinent part, "All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated."Prior to receiving vaccinations, the resident or legal representative will be provided with information and education regarding the benefits and potential side effects of the vaccinations."Provision of such education shall be documented in the resident's medical record. All new residents shall be assessed for current vaccination status upon admission. The resident or the resident's legal representative may refuse vaccines for any reasons. If vaccines are refused, the refusal shall be documented in the resident's medical record." III. Resident #17A. Resident statusResident #17, over the age of 65, was admitted on 7/17/19 and readmitted on 8/22/19. According to the March 2024 computerized physician orders (CPO), diagnoses included dementia, heart failure and chronic kidney disease. The 1/2/24 minimum data set (MDS) assessment indicated the resident was not up to date on his pneumococcal vaccination but did not specify a reason. B. Record review-A review of the resident's electronic medical record (EMR) on 3/18/24 revealed the resident had not received the pneumococcal vaccination after the resident's representative consented for the resident to receive the vaccination on 10/24/23. IV. Resident #31A. Resident statusResident #31, age 66, was admitted on 9/11/23. According to the March 2024 CPO, diagnoses included fracture of left tibia (leg) and respiratory failure. The 3/11/24 MDS assessment indicated the resident was up to date on her pneumococcal vaccination. B. Record review-A review of the resident's EMR on 3/18/24 revealed the resident had not received the pneumococcal vaccination after she consented to receive the pneumococcal vaccination on 10/24/23. V. Resident #7A. Resident statusResident #7, over the age of 65, was admitted on 10/3/17. According to the March 2024 CPO, diagnoses included anxiety and dementia. The 12/15/24 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not specify a reason. B. Record review-A review of the resident's EMR on 3/18/24 revealed the resident had not received the pneumococcal vaccination after she consented to receive the vacation on 10/24/23. VI. Resident #36A. Resident statusResident #36, age 81, was admitted on 2/21/23. According to the March 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney disease, type two diabetes mellitus and gastro-esophageal reflux disease (GERD). The 2/22/24 MDS assessment indicated the resident was up to date on her pneumococcal vaccination. B. Record reviewA review of Resident #36's EMR revealed the resident refused the pneumococcal vaccination on 10/24/23. The 10/24/23 communication with resident progress note documented in pertinent part, the resident was offered the pneumococcal vaccination and the resident stated she had already had them and been tested for pneumonia. The resident declined the vaccination. -However, there was no documentation educating the resident on receiving an updated pneumococcal vaccination. VII. Resident #11 A. Resident statusResident #11, over the age of 65, was admitted on 11/21/17. According to the March 2024 CPO, diagnoses included Alzheimer's disease, morbid obesity and gastro-esophageal reflux disease (GERD). The 1/10/24 MDS assessment indicated the resident was not up to date on her pneumococcal vaccination but did not specify a reason. B. Record review-A review of the resident's EMR on 3/18/24 revealed the resident had not received the pneumococcal vaccination after the resident's representative consented for the resident to receive the vaccination on 10/12/23. VIII. Staff interviewsThe infection preventionist (IP) was interviewed on 3/19/24 at 10:27 a.m. The IP said she recently started working at the facility. The IP said when residents admitted to the facility their immunization history needed to be researched and documented in the medical record. The IP said the residents needed to be offered the immunizations they needed. The IP said Resident #17, #31, #7 and #11 were offered the pneumococcal vaccination in October 2023 and had not received the vaccination yet. The IP said she was unsure why the residents had not received the vaccination yet. The IP said Resident #36 refused the pneumococcal vaccination because she had already received it. The IP said if the resident was up to date on the pneumococcal vaccination the facility should have not offered the vaccination to the resident. The IP said if the resident was due for an updated pneumococcal vaccination the facility should have provided education to the resident on the importance of the updated vaccination. The IP said she needed to review the CDC guidance on offering pneumococcal vaccinations.

Based on observations and interviews, the facility failed to maintain emergency response carts equipment in safe operating condition for one out of three emergency carts. Specifically, the facility failed to ensure the emergency response carts were cleaned, maintained and ready for use. Findings include: I. Facility policyThe Crash Cart policy statement, undated, was received by the director of nursing (DON) on 3/19/24 at 3:08 p.m. It read in pertinent part, "It is the policy of Mountain Vista to standardize the contents of all crash carts and when utilized, provide quality control of all emergency equipment."Policy-Crash carts will be maintained and supplied in accordance with the crash cart minimum requirement list (see list). The list was not provided.-Additional supplies and/or equipment may not be added to the crash cart.-If additional equipment or medications are required by a clinical area, it must be maintained and stored separately.-All emergency equipment and crash carts will be checked minimally weekly on Friday utilizing the crash cart supply list."Procedure for crash carts-Crash carts should be accessible at all times. At least one a week the carts should be opened and checked for outdated supplies. Internal and external equipment should be checked by ensuring proper function of oxygen tank/gauge and suction equipment.-Charge nurses and clinical managers should participate in the weekly checking.-All nurses should be familiar with the cart contents and content locations.-Crash cart checks should be documented on the lists maintained on the cart." II. Observations and interviewsOn 3/19/24 at 12:28 p.m. the special care unit crash cart was observed with licensed practical nurse (LPN) #1. The crash cart check/signature sheet was stored in the medication cart three-ring binder. LPN#1 verified the daily checks had not been completed for 3/1-3/16/24. The check was completed on 3/17/24 and not for 3/18-3/19/24. LPN #1 said that it was the responsibility of the night shift nurses to check the crash cart nightly for supplies to ensure the emergency equipment was ready for use. The crash cart was covered with debris of food crumbs, dust and hair. LPN #1 said when the crash cart was checked, the cart should also be cleaned ready for use. LPN #1 verified the crash cart contained several miscellaneous items and medical supplies that were not listed on the crash cart inventory list. The crash cart did not include medications (as indicated in the director of nurses interview (see below). III. Administrative interviewThe director of nurses (DON) was interviewed on 3/19/24 at 12:42 p.m. The DON said she was unsure how frequently the crash cart/emergency equipment cart should be checked by staff. She said crash carts should be checked monthly. The DON then said crash cart checks of the emergency oxygen supply should be done weekly or after it was used and the checks were completed by the pharmacy contractor. The DON said after the crash carts emergency kits were opened or used, the medications were exchanged with the pharmacy.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for four of five CNAs (#4, #5, #6 and #7) reviewed for annual training requirements. Specifically, the facility failed to ensure CNAs #4, #5, #6 and #7 received 12 hours of annual training in all required training topics areas including dementia management training and resident abuse prevention training. Findings include:I. Facility policy and procedureThe In-Service Training, All Staff policy, revised August 2022, was provided by the nursing home administrator (NHA) on 3/20/24 at 11:41 a.m. It documented in pertinent part, "All staff must participate in initial orientation and annual in-service training."The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training."Required training topics include the following:-Effective communication with residents and family (direct care staff);-Resident rights and responsibilities;-Preventing abuse, neglect, exploitation, and misappropriation of resident property including activities that constitute abuse, neglect, exploitation or misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property;-Dementia management and resident abuse prevention;-Elements and goals of the facility QAPI (quality assurance and performance improvement) program;-The infection prevention and control program standards, policies and procedures;-Behavioral health; and,-The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.)"II. Training record reviewFive randomly selected CNA training records were reviewed. Of the five employees reviewed, four CNAs (#4, #5, #6 and #7) did not receive a full 12 hours of annual training and did not receive all of the required training topics.-CNA #4, hired on 3/14/23, had participated in four hours of training during the employee annual training year and had no record of completing dementia management training. -CNA #5, hired on 8/1/22, had no record of completing dementia management training. -CNA #6, hired on 12/8/22, had participated in nine and a half hours of annual training during her first year of employment (December 2022 to December 2023). -CNA #7, hired on 2/9/23, had not participated in any of the required annual training topics and there was no record of CNA #7 completing annual dementia management training and resident abuse prevention training. III. Staff interviewsThe staff development coordinator (SDC) was interviewed on 3/19/24 at 10:45 a.m. The SDC said the facility staff were assigned training topics and were required to complete all assigned training topics. The director of nursing (DON) was interviewed on 3/19/24 at 4:00 p.m. The DON said the goal of directly hiring CNAs over using agency staff was to ensure staff were fully trained and to hold them responsible for providing competent care. The NHA was interviewed on 3/20/24 at 1:22 p.m. The NHA said nursing staff were assigned specific training modules monthly and were expected to complete the assigned training to work their assigned shifts. The NHA looked for additional training records for the five CNAs reviewed and said the facility had provided all proof of training and competency assessments available. He was unable to locate additional training records to show proof that the CNAs reviewed had completed the required training modules (see training record review above). The NHA said, moving forward, the employees would be required to complete all required training modules or they would be taken off the schedule until they completed their assigned training.

A revisit survey was completed on 12/18/2023 for all previous deficiencies cited on 11/1/2023. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 12/18/23 for all previous deficiencies cited on 11/1/23. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO34142 was completed 10/30/23 to 11/1/23. One deficiency was cited.

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#1) of three residents out of three sample residents reviewed for accident hazards. The facility failed to ensure measures were in place to prevent Resident #1's fall with injuries. Resident #1 was identified as a high fall risk on her 8/6/23 Fall Risk Assessment and the 8/9/23 facility assessment documented Resident #1 required extensive assistance of two persons for bed mobility, transfers, toileting and bathing. Resident #1's care plan prior to her fall did not have interventions that included assistance from two people for bed mobility, transfer, toileting and bathing. She sustained a fall out of bed on 10/2/23 while receiving incontinence care followed by a bed bath from certified nurse aide (CNA) #1. Resident #1's injuries included a two and a half centimeter left forehead laceration, skin tears on both elbows, bruising and swelling to both cheeks, bruising to the nose and across her upper chest and on her left forearm. She was transported to the hospital where she received sutures to her forehead laceration and returned to the facility on 10/2/23. Resident #1's care plan was updated to include providing care with two staff for Resident #1 after the fall. Documentation of completed tasks in the electronic medical record from 10/3/23 to 10/31/23 revealed staff continued to provided Resident #1 care from one staff member instead of two for toileting and bathing. Findings include:I. Facility policy and procedureThe Safe Patient Handling policy and procedure, dated October 2022, was provided by the nursing home administrator (NHA) on 11/1/23 at 4:04 p.m. It revealed in pertinent part, "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents."Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: resident preferences for assistance; resident mobility and degree of dependency; resident size, weight-bearing ability, cognitive status; and whether the resident is usually cooperative with staff. Safe lifting and movement of residents is part of an overall facility employee health and safety program."II. Resident statusResident #1, age 88, was admitted on 5/4/23. According to the November 2023 computerized physician orders (CPO), the diagnoses included respiratory failure, chronic bronchitis, type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), obesity, dementia and congestive heart failure. The 8/9/23 facility assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required extensive physical assistance of two people with bed mobility, transfers, toileting and bathing. She needed supervision and set up help only with eating, and extensive physical assistance of one person for personal hygiene. She needed substantial to maximum assistance to roll left or right in bed, to move from sitting to lying on the bed and from lying to sitting on the bed, and for toileting hygiene and showering and bathing. III. Resident observation and representative interviewResident #1's representative was interviewed on 11/1/23 at 12:35 p.m. The representative said Resident #1 had only one staff member providing care when Resident #1 fell and the representative thought Resident #1 should have had two people providing care at the time. The representative said she thought if the facility had two staff members attending to Resident #1 then maybe Resident #1 would not have fallen. Resident #1 was observed on 11/1/23 at 2:28 p.m. Resident #1 had light red bruising and swelling on both cheeks right below the eye and on the bridge of her nose. The left cheek had yellow bruising. Resident #1 still had a bandaid above her left eyebrow that covered a scab. She had visible yellow and purple bruises across her chest above the breast area. IV. Record reviewA. Care plan and assessmentsResident #1's fall care plan focus initiated 5/17/23 documented she was a high risk for falls due to confusion, deconditioning, gait and balance problems, incontinence and psychoactive drug use, with an intervention to have activities that minimized the potential for falls while providing diversion and distraction. Resident #1's activities of daily living (ADL) focus documented she had a self care performance deficit due to fatigue and impaired balance, with a goal to maintain her current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Pertinent interventions included bathing and total dependance on staff to provide a bath twice weekly as necessary; bed mobility and maximum assistance on staff for repositioning and turning in bed, all initiated on 5/17/23. Resident #1's mobility care plan focus documented Resident #1 needed maximum assistance with a full body lift with ambulation and transfers. Pertinent interventions included to provide assistance with bed mobility as necessary and staff assistance of two people to assist the resident in transferring with a full body lift, all initiated on 8/14/23.-Resident #1's care plan interventions did not include staff assistance of two people with bed mobility, transfers, toileting and bathing. Resident #1's quarterly Fall Risk Assessment completed 8/6/23 documented she was a high fall risk. She had intermittent confusion, was non ambulatory and needed assistance with elimination. Gait balance was not assessed as the resident was unable to complete the assessment. The 8/9/23 restorative screening progress note written at 5:36 p.m. documented Resident #1 was dependent on care staff in the following areas: self-care, and shower/bathe self, meaning the care staff did all of the effort or the assistance of two or more helpers were required for the resident to complete the activity. B. Fall 10/2/23The 10/2/23 progress note written at 1:50 p.m. documented Resident #1 suffered a fall from her bed at approximately 1:00 p.m. while she was being changed by CNA #1. CNA #1 reported while she was changing Resident #1 and turned Resident #1 on her side, Resident #1 rolled out of bed without CNA #1 having time to catch Resident #1 before the resident fell. Resident #1 had a laceration on her forehead that was bleeding, skin tears to both elbows, along with several bruises on the left forearm. Resident #1 complained of pain and she was given tylenol and sent to the hospital for further evaluation and treatment. The 10/2/23 progress note written at 3:30 p.m. revealed verbal training was provided to CNA #1 regarding the rolling technique to clean Resident #1.-There was no documentation of additional staff training aside from CNA #1. A review of hospital records revealed Resident #1 was admitted to the hospital on 10/2/23 with head, face and neck trauma with pain. Resident #1 had significant left frontal forehead swelling, bleeding and facial tenderness, a two and a half centimeter laceration to the left side of her forehead and was bleeding significantly upon arrival. She had left cheek and periorbital (around the eye) soft tissue swelling. Resident #1 was provided with wound compression to control bleeding and then sutures. She was discharged the same day on 10/2/23 with follow up orders for wound monitoring and suture removal. C. Facility fall investigation and follow upThe 10/5/23 physician progress note 10/5/23 written at 9:54 a.m. documented Resident #1 was seen at the facilityfor post hospital follow up. Resident #1 stated that her face no longer hurt. Resident #1 reported no pain in her upper extremities, check or neck area. The facility staff reported the incident occurred when CNA #1 tried to change Resident #1 and the bed was elevated. When CNA #1 rolled Resident #1 to the side to change her Resident #1 continued to roll and fell off the other side of the bed between the wall and the bed. EMS (emergency medical services) was notified and Resident #1 was subsequently taken to the emergency department for further evaluation. Resident #1's post fall facility investigation notes were provided by the NHA on 11/1/23 at 9:45 a.m. The investigation was documented as completed by the social services director (SSD). The summary of the interview with CNA #1 revealed CNA #1 reported Resident #1 had an episode of severe diarrhea. CNA #1 placed Resident #1 in bed to perform a bed bath. Resident #1 was in bed and CNA #1 rolled Resident #1 toward the wall while Resident #1 was lying on her side. When CNA #1 turned to grab more care supplies, Resident #1 rolled towards the wall and the resident fell to the floor between the wall and the bed. CNA #1 proceeded to notify a nurse and a nurse came into the room to assess the resident. CNA #1 denied unlocking the wheels on the bed prior to performing care. CNA #1 stated Resident #1's bed was flush against the wall. The facility investigation conclusion revealed Resident #1 would benefit from two person cares. Resident #1's bed was repositioned so that staff could get to both sides of the bed. Fall mats were placed on either side of the bed for the resident's safety. The facility investigation follow-up documented the following updates: Update Resident #1's care plan to reflect two person cares; update the kardex (task list) to reflect two person cares; pull resident's bed out from wall, keeping the bed in lowest position when resident was in bed and staff was not present; fall mats on both sides of Resident #1's bed to prevent injury. The late entry 10/20/23 progress note written on 10/23/23 at 3:33 p.m. documented two person cares were initiated for Resident #1's overall safety by request of the family. Resident #1's bed was to be moved from the wall for care to allow staff members access to the other side of the bed and help with changing the resident. The 10/24/23 progress note written at 9:26 p.m. documented CNAs were educated to provide Resident #1 cares in pairs for resident safety. D. Post fall care plan and task updatesResident #1's fall care plan plan focus documented updated interventions post fall that included two person assistance for changing briefs (no date was included for the added intervention); educate the resident, family, and caregivers about safety reminders and what to do if a fall occurred, revised 10/25/23; anticipate and meet the resident's needs initiated 10/25/23. Resident #1's updated ADL care plan focus documented updated interventions post fall that included two person assistance with checks and changes for peri care (no date was included for the added intervention); Resident #1 needed maximum assistance from staff for repositioning and turning in bed for bed mobility and ensure two person assistance, revised 10/20/23. Resident #1's mobility care plan focus documented updated interventions post fall that included to assist Resident #1 with bed mobility with two person assistance (no date was included for the added intervention); provide assistance with bed mobility as necessary, revised on 10/20/23. The task list in Resident #1's electronic medical record for ADL bed mobility documented Resident #1 required assistance from two people. Bed mobility included how the resident moved to and from lying position, turned side to side and positioned their body while in bed or sleeping. The ADL task completions were reviewed for 29 days from 10/3/23 to 10/31/23 for bed mobility. Staff documented they performed one person assistance instead of two person assistance for Resident #1's ADLs on 26 out of 29 days. The task list in Resident #1's electronic medical record for ADL toilet use documented Resident #1 required assistance from two people. Toilet use included how a resident used the commode, bed pan, or urinal, cleansed self after elimination and changed pad. The ADL task completions for toileting were reviewed for 29 days from 10/3/23 to 10/31/23. Staff documented they performed one person assistance instead of two person assistance for Resident #1's ADLs on 18 out of 29 days. V. Staff interviewsCNA #1 was interviewed on 11/1/23 at 12:45 p.m. CNA #1 said she was working with Resident #1 the day she fell because Resident #1 had an incontinence episode. CNA#1 said she and another staff member transferred Resident #1 into bed with a hoyer (mechanical) lift. CNA #1 said she changed the resident, cleaned her and gave her a bed bath without an additional staff member. CNA #1 said Resident #1 just rolled off the opposite side of the bed from where CNA #1 stood. CNA #1 said she was right next to Resident #1 and she was washing off Resident #1's backside. CNA #1 said Resident #1 was lying on her side one second and then Resident #1 started to roll and fell down between her bed and the wall. CNA #1 said she had one hand on the resident and did not have time to grab Resident #1 and Resident #1 landed face down on the floor. CNA #1 said she had to push the bed out further to get to Resident #1 who had fallen all the way to the floor. CNA #1 said she ran out of the room and called for the nurse right away. CNA #1 said she was unsure if Resident #1 needed assistance from two people for bed mobility and bathing. She said the staff used handheld computer tablets to see residents' tasks for care. CNA #1 said Resident #1's fall was very unexpected. Licensed practical nurse (LPN) #1 and CNA #2 were interviewed on 11/1/23 at 1:00 p.m. LPN #1 and CNA #2 said they used the handheld tablets to look at resident tasks and see how many people were needed for resident assistance. CNA #2 said Resident #1 could assist with showers so CNA #2 was able to provide assistance from one person for Resident #1 instead of two people. LPN #1 said he followed up with other care staff as needed to let the staff know if a resident's abilities or status changed. The facility coordinator (FC) was interviewed on 11/1/23 at 1:30 p.m. He said he provided verbal education to CNA #1 after Resident #1's fall. He said typically Resident #1 required one person assistance with a roll in bed and when CNA #1 turned to grab a care item when Resident #1 fell. He said CNA #1 was alone with Resident #1 when Resident #1 fell. He said the staff typically used the task list for resident cares located on their handheld tablets. He said there probably should have been two people in the room when Resident #1 was changed. He said the follow up training was provided to CNA #1 initially but not all staff. He said he updated on the task list for Resident #1 that she needed two person assistance and could provide education to additional staff members that afternoon. The SSD was interviewed on 11/1/23 at 2:09 p.m. She said there was no further education provided to staff other than CNA #1 after Resident #1's fall. The SSD interviewed the resident by herself and the resident could not remember the incident which was baseline for the resident. The SSD said CNA #1 gave Resident #1 a bath and cleaned her up after her incontinence episode. The SSD said CNA #1 turned to grab more supplies when Resident #1 fell. CNA #1 did not indicate to the SSD how far away the supplies were or if she was still touching the resident when she turned to grab more supplies. The SSD said CNA #1 was the only staff member assisting the resident. The SSD said she was not aware if there was not a process to ensure completed resident care plans matched the facility assessment. LPN #2 and CNA #3 were interviewed on 11/1/23 at 3:00 p.m. LPN #2 and CNA #3 said the facility recentlyprovided gait belt training. LPN #2 said a restorative staff member did the training for gait belts and transfers and she signed a document that she attended. CNA #3 said the training also covered hoyer transfers were always a two person lift. CNA #3 said if the task documented a resident required assistance from two staff members, the staff always completed the task with two staff members. LPN #2 said staff always ensured a second staff member was present if a resident required assistance transferring from two people. LPN #2 said to never have only staff member present if two staff members were required. The director of nursing (DON) and NHA were interviewed on 11/1/23 at 3:30 p.m. The DON said the facility did not provide all staff training after Resident #1's fall since she did not feel there was a lack of training issue. The DON said CNA #1 did not do anything wrong while providing care to Resident #1 and she was using the correct procedure. The DON said the facility updated Resident #1's care plan to reflect mats were on Resident #1's floor at bedside, the bed was pulled out from the wall and she was a wheelchair to bed transfer. The DON said Resident #1 should have care in pairs meaning two staff members provided care at all times and that included bathing. The DON said she had not yet audited the tasks completed in the electronic medical record to see staff recorded they provided Resident #1 with two person assistance. The DON said she put care in pairs in the special instructions so the nurses saw care in pairs when they opened Resident #1's electronic medical record and nurses assisted floor staff to ensure they were compliant with care requirements. The NHA said the last training for transfers and resident assistance was April and May 2023. She said on 11/1/23 and 11/2/23 the facility provided additional resident transfer training. The NHA said the facility provided a body mechanics training on 5/24/23 which included resident transfers and assistance. The NHA said a quarterly care conference was the time to review resident status changes. The NHA said a unit nurse would communicate resident status to the DON or another nursing supervisor. Two nurses were on the unit and were responsible for medications, treatment and directing care of the CNAs. V. Facility follow upFacility NHA and DON said they were in process of providing additional staff training resident transfers and assistance on 11/1/23.

A complaint survey, prompted by #CO33910 was conducted on 10/30/23-11/1/23. One deficiency was cited.

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#1) of three residents out of three sample residents reviewed for accident hazards. The facility failed to ensure measures were in place to prevent Resident #1's fall with injuries. Resident #1 was identified as a high fall risk on her 8/6/23 Fall Risk Assessment and the 8/9/23 minimum data set (MDS) assessment documented Resident #1 required extensive assistance of two persons for bed mobility, transfers, toileting and bathing. Resident #1's care plan prior to her fall did not have interventions that included assistance from two people for bed mobility, transfer, toileting and bathing. She sustained a fall out of bed on 10/2/23 while receiving incontinence care followed by a bed bath from certified nurse aide (CNA) #1. Resident #1's injuries included a two and a half centimeter left forehead laceration, skin tears on both elbows, bruising and swelling to both cheeks, bruising to the nose and across her upper chest and on her left forearm. She was transported to the hospital where she received sutures to her forehead laceration and returned to the facility on 10/2/23. Resident #1's care plan was updated to include providing care with two staff for Resident #1 after the fall. Documentation of completed tasks in the electronic medical record from 10/3/23 to 10/31/23 revealed staff continued to provided Resident #1 care from one staff member instead of two for toileting and bathing. Findings include:I. Facility policy and procedureThe Safe Patient Handling policy and procedure, dated October 2022, was provided by the nursing home administrator (NHA) on 11/1/23 at 4:04 p.m. It revealed in pertinent part, "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents."Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: resident preferences for assistance; resident mobility and degree of dependency; resident size, weight-bearing ability, cognitive status; and whether the resident is usually cooperative with staff. Safe lifting and movement of residents is part of an overall facility employee health and safety program."II. Resident statusResident #1, age 88, was admitted on 5/4/23. According to the November 2023 computerized physician orders (CPO), the diagnoses included respiratory failure, chronic bronchitis, type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), obesity, dementia and congestive heart failure. The 8/9/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required extensive physical assistance of two people with bed mobility, transfers, toileting and bathing. She needed supervision and set up help only with eating, and extensive physical assistance of one person for personal hygiene. She needed substantial to maximum assistance to roll left or right in bed, to move from sitting to lying on the bed and from lying to sitting on the bed, and for toileting hygiene and showering and bathing. III. Resident observation and representative interviewResident #1's representative was interviewed on 11/1/23 at 12:35 p.m. The representative said Resident #1 had only one staff member providing care when Resident #1 fell and the representative thought Resident #1 should have had two people providing care at the time. The representative said she thought if the facility had two staff members attending to Resident #1 then maybe Resident #1 would not have fallen. Resident #1 was observed on 11/1/23 at 2:28 p.m. Resident #1 had light red bruising and swelling on both cheeks right below the eye and on the bridge of her nose. The left cheek had yellow bruising. Resident #1 still had a bandaid above her left eyebrow that covered a scab. She had visible yellow and purple bruises across her chest above the breast area. IV. Record reviewA. Care plan and assessmentsResident #1's fall care plan focus initiated 5/17/23 documented she was a high risk for falls due to confusion, deconditioning, gait and balance problems, incontinence and psychoactive drug use, with an intervention to have activities that minimized the potential for falls while providing diversion and distraction. Resident #1's activities of daily living (ADL) focus documented she had a self care performance deficit due to fatigue and impaired balance, with a goal to maintain her current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Pertinent interventions included bathing and total dependance on staff to provide a bath twice weekly as necessary; bed mobility and maximum assistance on staff for repositioning and turning in bed, all initiated on 5/17/23. Resident #1's mobility care plan focus documented Resident #1 needed maximum assistance with a full body lift with ambulation and transfers. Pertinent interventions included to provide assistance with bed mobility as necessary and staff assistance of two people to assist the resident in transferring with a full body lift, all initiated on 8/14/23.-Resident #1's care plan interventions did not include staff assistance of two people with bed mobility, transfers, toileting and bathing. Resident #1's quarterly Fall Risk Assessment completed 8/6/23 documented she was a high fall risk. She had intermittent confusion, was non ambulatory and needed assistance with elimination. Gait balance was not assessed as the resident was unable to complete the assessment. The 8/9/23 restorative screening progress note written at 5:36 p.m. documented Resident #1 was dependent on care staff in the following areas: self-care, and shower/bathe self, meaning the care staff did all of the effort or the assistance of two or more helpers were required for the resident to complete the activity. B. Fall 10/2/23The 10/2/23 progress note written at 1:50 p.m. documented Resident #1 suffered a fall from her bed at approximately 1:00 p.m. while she was being changed by CNA #1. CNA #1 reported while she was changing Resident #1 and turned Resident #1 on her side, Resident #1 rolled out of bed without CNA #1 having time to catch Resident #1 before the resident fell. Resident #1 had a laceration on her forehead that was bleeding, skin tears to both elbows, along with several bruises on the left forearm. Resident #1 complained of pain and she was given tylenol and sent to the hospital for further evaluation and treatment. The 10/2/23 progress note written at 3:30 p.m. revealed verbal training was provided to CNA #1 regarding the rolling technique to clean Resident #1.-There was no documentation of additional staff training aside from CNA #1. A review of hospital records revealed Resident #1 was admitted to the hospital on 10/2/23 with head, face and neck trauma with pain. Resident #1 had significant left frontal forehead swelling, bleeding and facial tenderness, a two and a half centimeter laceration to the left side of her forehead and was bleeding significantly upon arrival. She had left cheek and periorbital (around the eye) soft tissue swelling. Resident #1 was provided with wound compression to control bleeding and then sutures. She was discharged the same day on 10/2/23 with follow up orders for wound monitoring and suture removal. C. Facility fall investigation and follow upThe 10/5/23 physician progress note 10/5/23 written at 9:54 a.m. documented Resident #1 was seen at thefacility for post hospital follow up. Resident #1 stated that her face no longer hurt. Resident #1 reported no pain in her upper extremities, check or neck area. The facility staff reported the incident occurred when CNA #1 tried to change Resident #1 and the bed was elevated. When CNA #1 rolled Resident #1 to the side to change her Resident #1 continued to roll and fell off the other side of the bed between the wall and the bed. EMS (emergency medical services) was notified and Resident #1 was subsequently taken to the emergency department for further evaluation. Resident #1's post fall facility investigation notes were provided by the NHA on 11/1/23 at 9:45 a.m. The investigation was documented as completed by the social services director (SSD). The summary of the interview with CNA #1 revealed CNA #1 reported Resident #1 had an episode of severe diarrhea. CNA #1 placed Resident #1 in bed to perform a bed bath. Resident #1 was in bed and CNA #1 rolled Resident #1 toward the wall while Resident #1 was lying on her side. When CNA #1 turned to grab more care supplies, Resident #1 rolled towards the wall and the resident fell to the floor between the wall and the bed. CNA #1 proceeded to notify a nurse and a nurse came into the room to assess the resident. CNA #1 denied unlocking the wheels on the bed prior to performing care. CNA #1 stated Resident #1's bed was flush against the wall. The facility investigation conclusion revealed Resident #1 would benefit from two person cares. Resident #1's bed was repositioned so that staff could get to both sides of the bed. Fall mats were placed on either side of the bed for the resident's safety. The facility investigation follow-up documented the following updates: Update Resident #1's care plan to reflect two person cares; update the kardex (task list) to reflect two person cares; pull resident's bed out from wall, keeping the bed in lowest position when resident was in bed and staff was not present; fall mats on both sides of Resident #1's bed to prevent injury. The late entry 10/20/23 progress note written on 10/23/23 at 3:33 p.m. documented two person cares were initiated for Resident #1's overall safety by request of the family. Resident #1's bed was to be moved from the wall for care to allow staff members access to the other side of the bed and help with changing the resident. The 10/24/23 progress note written at 9:26 p.m. documented CNAs were educated to provide Resident #1 cares in pairs for resident safety. D. Post fall care plan and task updatesResident #1's fall care plan plan focus documented updated interventions post fall that included two person assistance for changing briefs (no date was included for the added intervention); educate the resident, family, and caregivers about safety reminders and what to do if a fall occurred, revised 10/25/23; anticipate and meet the resident's needs initiated 10/25/23. Resident #1's updated ADL care plan focus documented updated interventions post fall that included two person assistance with checks and changes for peri care (no date was included for the added intervention); Resident #1 needed maximum assistance from staff for repositioning and turning in bed for bed mobility and ensure two person assistance, revised 10/20/23. Resident #1's mobility care plan focus documented updated interventions post fall that included to assist Resident #1 with bed mobility with two person assistance (no date was included for the added intervention); provide assistance with bed mobility as necessary, revised on 10/20/23. The task list in Resident #1's electronic medical record for ADL bed mobility documented Resident #1 required assistance from two people. Bed mobility included how the resident moved to and from lying position, turned side to side and positioned their body while in bed or sleeping. The ADL task completions were reviewed for 29 days from 10/3/23 to 10/31/23 for bed mobility. Staff documented they performed one person assistance instead of two person assistance for Resident #1's ADLs on 26 out of 29 days. The task list in Resident #1's electronic medical record for ADL toilet use documented Resident #1 required assistance from two people. Toilet use included how a resident used the commode, bed pan, or urinal, cleansed self after elimination and changed pad. The ADL task completions for toileting were reviewed for 29 days from 10/3/23 to 10/31/23. Staff documented they performed one person assistance instead of two person assistance for Resident #1's ADLs on 18 out of 29 days. V. Staff interviewsCNA #1 was interviewed on 11/1/23 at 12:45 p.m. CNA #1 said she was working with Resident #1 the day she fell because Resident #1 had an incontinence episode. CNA#1 said she and another staff member transferred Resident #1 into bed with a hoyer (mechanical) lift. CNA #1 said she changed the resident, cleaned her and gave her a bed bath without an additional staff member. CNA #1 said Resident #1 just rolled off the opposite side of the bed from where CNA #1 stood. CNA #1 said she was right next to Resident #1 and she was washing off Resident #1's backside. CNA #1 said Resident #1 was lying on her side one second and then Resident #1 started to roll and fell down between her bed and the wall. CNA #1 said she had one hand on the resident and did not have time to grab Resident #1 and Resident #1 landed face down on the floor. CNA #1 said she had to push the bed out further to get to Resident #1 who had fallen all the way to the floor. CNA #1 said she ran out of the room and called for the nurse right away. CNA #1 said she was unsure if Resident #1 needed assistance from two people for bed mobility and bathing. She said the staff used handheld computer tablets to see residents' tasks for care. CNA #1 said Resident #1's fall was very unexpected. Licensed practical nurse (LPN) #1 and CNA #2 were interviewed on 11/1/23 at 1:00 p.m. LPN #1 and CNA #2 said they used the handheld tablets to look at resident tasks and see how many people were needed for resident assistance. CNA #2 said Resident #1 could assist with showers so CNA #2 was able to provide assistance from one person for Resident #1 instead of two people. LPN #1 said he followed up with other care staff as needed to let the staff know if a resident's abilities or status changed. The MDS coordinator (MDSC) was interviewed on 11/1/23 at 1:30 p.m. He said he provided verbal education to CNA #1 after Resident #1's fall. He said typically Resident #1 required one person assistance with a roll in bed and when CNA #1 turned to grab a care item when Resident #1 fell. He said CNA #1 was alone with Resident #1 when Resident #1 fell. He said the staff typically used the task list for resident cares located on their handheld tablets. He said there probably should have been two people in the room when Resident #1 was changed. He said the follow up training was provided to CNA #1 initially but not all staff. He said he updated on the task list for Resident #1 that she needed two person assistance and could provide education to additional staff members that afternoon. The SSD was interviewed on 11/1/23 at 2:09 p.m. She said there was no further education provided to staff other than CNA #1 after Resident #1's fall. The SSD interviewed the resident by herself and the resident could not remember the incident which was baseline for the resident. The SSD said CNA #1 gave Resident #1 a bath and cleaned her up after her incontinence episode. The SSD said CNA #1 turned to grab more supplies when Resident #1 fell. CNA #1 did not indicate to the SSD how far away the supplies were or if she was still touching the resident when she turned to grab more supplies. The SSD said CNA #1 was the only staff member assisting the resident. The SSD said she was not aware if there was not a process to ensure completed resident care plans matched the MDS assessment. LPN #2 and CNA #3 were interviewed on 11/1/23 at 3:00 p.m. LPN #2 and CNA #3 said the facility recently provided gait belt training. LPN #2 said a restorative staff member did the training for gait belts and transfers and she signed a document that she attended. CNA #3 said the training also covered hoyer transfers were always a two person lift. CNA #3 said if the task documented a resident required assistance from two staff members, the staff always completed the task with two staff members. LPN #2 said staff always ensured a second staff member was present if a resident required assistance transferring from two people. LPN #2 said to never have only staff member present if two staff members were required. The director of nursing (DON) and NHA were interviewed on 11/1/23 at 3:30 p.m. The DON said the facility did not provide all staff training after Resident #1's fall since she did not feel there was a lack of training issue. The DON said CNA #1 did not do anything wrong while providing care to Resident #1 and she was using the correct procedure. The DON said the facility updated Resident #1's care plan to reflect mats were on Resident #1's floor at bedside, the bed was pulled out from the wall and she was a wheelchair to bed transfer. The DON said Resident #1 should have care in pairs meaning two staff members provided care at all times and that included bathing. The DON said she had not yet audited the tasks completed in the electronic medical record to see staff recorded they provided Resident #1 with two person assistance. The DON said she put care in pairs in the special instructions so the nurses saw care in pairs when they opened Resident #1's electronic medical record and nurses assisted floor staff to ensure they were compliant with care requirements. The NHA said the last training for transfers and resident assistance was April and May 2023. She said on 11/1/23 and 11/2/23 the facility provided additional resident transfer training. The NHA said the facility provided a body mechanics training on 5/24/23 which included resident transfers and assistance. The NHA said a quarterly care conference was the time to review resident status changes. The NHA said a unit nurse would communicate resident status to the DON or another nursing supervisor. Two nurses were on the unit and were responsible for medications, treatment and directing care of the CNAs. V. Facility follow upFacility NHA and DON said they were in process of providing additional staff training resident transfers and assistance on 11/1/23.

A revisit survey was conducted on 10/30/23-10/31/23 for all previous deficiencies cited on 9/25/23. The facility is in compliance with all regulations surveyed.

A focused infection control survey was conducted on 9/25/23. One deficiency was cited.

An Emergency Preparedness focused infection control survey was conducted 9/25/23. No deficiencies were cited.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for six (#1, #2, #3, #4, #5 and #6) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to:-Offer Resident #4 and #6 the pneumococcal vaccine upon admission; and,-Offer additional doses of the pneumococcal vaccine to Resident #1, #2, #3 and #5. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 9/27/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: "Routine vaccination - pneumococcal-For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20)." (see notes)-For those "over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20." "Special situations: Age 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups.-Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies.-Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies." II. Facility policy The Pneumococcal Vaccine policy, dated October 2019 was provided by the nursing home administrator (NHA) on 9/25/23. It revealed in pertinent part, "Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, wil be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination."III. Resident #1A. Resident statusResident #1, age 94 , was admitted on 9/29/22. According to the September 2023 computerized physician orders (CPO) diagnoses included unspecified osteoarthritis, chronic kidney disease, and personal history of transient ischemic attack (stroke). The 6/23/23 minimum data set assessment (MDS) revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record reviewA review of Resident #1's electronic medical record (EMR) revealed the resident received the pneumococcal vaccine, Prevenar 13 on 5/10/17. -The EMR failed to show that the resident had not been offered an additional dose since. IV. Resident #2A. Resident status Resident #2, age 71, was admitted on 8/1/23. According to the September 2023 CPO diagnoses included, personal history of transient ischemic attack and Alzheimer's disease. The 8/4/23 MDS assessment revealed Resident #2 had severe cognitive impairment with a score of one out of 15 on the BIMS. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record reviewA review of Resident #2's EMR revealed the resident received the pneumococcal vaccine, Prevenar 13 on 12/20/21. -The EMR failed to show that the resident had not been offered an additional dose since. V. Resident #3A. Resident statusResident #3, age 86, was admitted on 8/10/2020. According to the September 2023 CPO diagnoses included, type II diabetes, chronic obstructive pulmonary disease and vascular dementia. The 8/23/23 MDS assessment showed the resident had cognitive impairment with a score of three out of 15 on the BIMS. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record reviewA review of Resident #3's EMR revealed the resident received the pneumococcal vaccine, Prevenar 13 on 11/6/2020. -The EMR failed to show that the resident had not been offered an additional dose since. VI. Resident #4A. Resident statusResident #4, age 90, was admitted on 11/4/22. According to the September 2023 diagnoses included depression, and hypertension. The 8/7/23 MDS assessment showed the resident had severe cognitive impairment with a score of five out of 15 on the BIMS. -The MDS assessment inaccurately documented the resident was offered and declined the pneumococcal vaccination. -However, a review of Resident #4's electronic medical records (EMR) revealed the resident had not been offered the pneumococcal vaccine. B. Record review Resident #4's EMR did not document if Resident #4 had been offered the pneumococcal vaccination or declined to receive it. VII. Resident #5A. Resident statusResident #5, age 69, was admitted on 2/1/21. According to the September 2023 diagnoses included, hypertensive heart disease and dementia. The 9/14/23 MDS assessment showed the resident had severe cognitive impairment with a score of three out of 15 on the BIMS. -The MDS assessment inaccurately documented the resident was up to date on the pneumococcal vaccination. B. Record reviewA review of Resident #5's EMR revealed the resident received the pneumococcal vaccine, Prevenar 13 on 2/11/21. -The EMR failed to show that the resident had not been offered an additional dose since. VIII. Resident #6A. Resident statusResident #6, age 89, was admitted on 5/13/22. According to the September 2023 CPO diagnoses included, atrial fibrillation, peripheral vascular disease and vascular dementia. The 8/9/23 MDS assessment showed the resident had moderate cognitive impairment with a score of 10 out of 15 on the BIMS. -The MDS assessment inaccurately documented the resident was offered and declined the pneumococcal vaccination. -However, a review of Resident #6's electronic medical records (EMR) revealed the resident had not been offered the pneumococcal vaccine. B. Record reviewThe EMR showed there was no consent and documentation the current recommended pneumococcal vaccine was offered and that education was provided to the resident or resident's representative. VIIII. InterviewsThe infection preventionist (IP) was interviewed on 9/25/23 at 10:51 a.m. The IP said the Colorado Immunization Information System (CIIS) database was utilized to ensure the resident's vaccination record was received. She said if there was no information on the CIIS then she would gothrough the hospital documents. She said the admitting nurse would then offer and provide education to the resident in regard to the importance of being vaccinated against pneumonia. She said if the resident accepted the pneumonia vaccination then the consent was signed and the vaccination was administered after receiving the physician's order. She said if the resident refused then the resident signed the consent form. She said that the resident should be asked again within a year. She said that the facility followed the CDC pneumococcal vaccination timing for adults. She said the Pneumococcal 20 was new and she had not received information and had not offered. The IP was interviewed again on 9/25/23 at 2:00 p.m. The IP said she reviewed the medical records for the specific residents (see above). She said the CIIS was not utilized and there were issues with each of the resident's pneumococcal vaccinations. She said they would complete an audit to ensure vaccination records were up to date.

A complaint survey, prompted by #CO33079 and Incident #30768 on 8/7/23. No deficiencies were cited.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/24/2023 and 04/30/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/06/2023 and 03/12/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 2/24/23 for all previous deficiencies cited on 12/8/22. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/06/2023 and 02/12/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/23/2023 and 01/29/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on January 3, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This facility consists of two structures of different construction types that are separated by a common wall having a two-hour fire rating. This structure is a one (1) story with a partial basement and is approximately 45% Type II (000) and was built in 1963. 55% of the structure is Type V (111) (VA) construction. There is a partial basement that has no resident access. The facility is licensed for 168 beds and the census on the date of the survey was 108. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. The wet-pipe system protects the main level. There is an anti-freeze loop sprinkler system that protects the main entrance canopy. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Plant Operations Director during the exit conference conducted on January 3, 2023.

Based on observation during the survey, it was determined that the facility failed to maintain the Means of Egress in accordance with Life Safety Sections 19. 3.6.3.5 and 7. 1.10.1. This was evidence by the following:A.Lock on egress courtyard North S C U Door 311-2 does not latchB.Rm 304-2 Wheel chairs blocking egressC.East wing fire door does not latchD.Curtain obstructing door rm143, 245 bed obstruct door 246 NFPA 101, 7.1.10.1 * General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 19.3.6.3.5 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 deficient practice could affect all residents, staff, and visitors should this exit door be needed during an emergency. The Maintenance Director acknowledged that the exit door deficiency during the tour of the facility. This deficiency was discussed during the exit conference.

Based 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. This was evidenced by the following: (A)No records or documentation for 2-year smoke detector sensitivity testing.(B)Smoke detector not secured to base in Rm118NFPA 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. NFPA 101, 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 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. NFPA 72, 14.4.4.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. NFPA 72, 14.4.4.3.1 Sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.4.3.2 Sensitivity shall be checked every alternate year. 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. This deficiency was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidence by the following.(A)Escutcheon in rehab hallway bathroom loose, rm 315,304-2,102,116, 136, 137 (B)Rust on sprinkler head in refrigerator and freezer walk NFPA 25, Section 5.2.1.1.1Any sprinkler that shows signs of any of the following shall be replaced:" (1)Leakage"(2)Corrosion detrimental to sprinkler performance"(3)Physical damage"(4)Loss of fluid in the glass bulb heat-responsive element"(5)Loading detrimental to sprinkler performance"(6)Paint other than that applied by the sprinkler manufactureNFPA 25, Section 5.2.1.1.5 Escutcheons and coverplates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or coverplate if found missing during the inspection. NFPA 25, Section 13.5.2.1.1.5.1Where the listed escutcheon or coverplate from a listed assembly is missing and is no longer commercially available, the sprinkler shall be replaced. The Maintenance Director acknowledge the lack of maintenance for sprinkler system during the survey. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. These deficiencies were discussed with the Maintenance Director

Based record review it was determined that the facility failed to maintain elevator inspection records in accordance with the Life Safe Code Section 9.6.1.5. This was evidenced by the following: (A)No records or documentation of elevator testing and inspection. NFPA 101, 9.4.6.1 Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. Failure to maintain the elevators has the potential to harm occupants, staff, and visitors within the elevators should a malfunction occur due to non-code compliant inspection and maintenance practices. This deficiency was discussed during the exit conference.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/26/2022 and 01/01/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.