LITTLETON CARE AND REHABILITATION CENTER

Initial comments, identified under ID Prefix Tag K000, are informational in nature and are intended to reflect the general characteristics of the facility. This Life Safety Code survey was conducted in accordance with the Federal Register, 42 CFR §483.90(a). The facility is a one-story structure of Type V (111) construction, with a partial basement. The facility is licensed for 35 beds, with a resident census of 33 at the time of the survey. The survey was conducted on March 18, 2026, to determine compliance with the following applicable codes and standards:NFPA 101 (2012 Edition), Life Safety Code, Chapter 19 — Existing Health Care OccupanciesNFPA 99 (2012 Edition), Health Care Facilities CodeAll other applicable referenced standardsDeficiency findings identified during the survey were reviewed on-site and were subsequently discussed during the exit conference with the Executive Director and Maintenance Resource Director.

Based on ITM records review and staff interview, the facility failed to provide commercial hood cleaning in accordance with the requirements of Life Safety Code NFPA 101 (2012), and referenced standards. The executive director and maintenance resource director were present throughout the survey. Findings Include:Facility failed to provide ITM records indicating that the grease duct had been cleaned. Both semi-annual reports had a note from the vendor stating “duct has no access panel, so not able to clean.”Regulatory References:NFPA 101 (2012), § 19.3.2.5.1 – Cooking facilities shall be protected in accordance with 9.2.3NFPA 101 (2012), § 9.2.3 – Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. NPFA 96 (2012), § 11.4 – Schedule of Inspection for Grease Buildup (Semiannually)NPFA 96 (2012), § 11.6 – Cleaning of Exhaust Systems (inclusive) This deficiency has the potential to affect one of two smoke compartments within the facility, and all residents, visitors, and staff. Deficiency findings identified during the survey were reviewed on-site and were subsequently discussed during the exit conference with the Executive Director and Maintenance Resource Director.

Based on observation and staff interview, the facility failed to ensure that the Smoke Barrier Construction was inspected, tested and maintained in accordance with the requirements of Life Safety Code NFPA 101 (2012), NFPA 99 (2012), and referenced standards. The executive director and maintenance resource director were present throughout the survey. Findings Include:The Smoke Barrier in the attic space had multiple breaches including a large opening through the wall assembly, “scab patched” drywall around through penetrations, and through penetrations that were not protected per approved listed firestop systems. The horizontal Smoke Barrier between the basement and first floor had multiple penetrations that were not protected per approved listed firestop systems. Regulatory References NFPA 101 (2012), § 4.6.12.1 – Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 101 (2012), § 19.3.7.3 – Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). Not less than two separate smoke compartments shall be provided on each floor.*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. NFPA 101 (2012), § 8.5.2.2 – Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. NFPA 101 (2012), § 8.5.6.2 – Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. NFPA 101 (2012), § 8.5.6.3 – Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met. NFPA 101 (2012), § 8.3.5 Penetrations – The provisions of 8.3.5 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations in fire walls, fire barrier walls, and fire resistance–rated horizontal assemblies. The provisions of 8.3.5 shall not apply to approved existing materials and methods of construction used to protect existing through-penetrations and existing membrane penetrations in fire walls, fire barrier walls, or fire resistance–rated horizontal assemblies, unless otherwise required by Chapters 11 through 43. NFPA 101 (2012), § 8.3.5.1* Firestop Systems and Devices Required – Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly. NFPA 101 (2012), § 8.6.1 Floor Smoke Barriers. – Every floor that separates stories in a building shall meet the following criteria:(1) It shall be constructed as a smoke barrier in accordance with Section 8.5.(2) It shall be permitted to have openings as described by 8.6.6, 8.6.7, 8.6.8, 8.6.9, or Chapters 11 through 43. This deficiency has the potential to affect two of two smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the executive director and the maintenance resource director during the survey exit conference.

A recertification survey was conducted from 2/17/26 to 2/19/26. One deficiency was cited.

An Emergency Preparedness survey was conducted from 2/17/26 to 2/19/26. No deficiencies were cited.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for one of two units reviewed. Specifically, the facility failed to:-Ensure staff wore the appropriate personal protective equipment (PPE) for Resident #11, who was on enhanced barrier precautions (EBP);-Ensure proper infection control practices were followed during wound care;-Ensure hand hygiene was appropriately performed during wound care; and,-Ensure hand hygiene was appropriately performed during medication administration. Findings include:I. EBP failuresA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Home to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 4/2/24, retrieved on 2/23/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html: “Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities.“Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.“Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (ex. central line, urinary catheter, feeding tube, tracheostomy/ventilator), or wound care (any skin opening requiring a dressing).“In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk."B. ObservationsOn 2/17/26 at 11:16 a.m., a sign on the back of Resident #11’s room door indicated the resident was on EBP. The sign indicated a gown and gloves must be worn for high-contact resident care activities, including: dressing, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting, and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies, and wound care. Resident #11 had open wounds to his left buttocks and left heel. On 2/18/26 at 3:07 p.m., registered nurse (RN) #3 was observed performing wound care on Resident #11. The following observations were made:At approximately 3:10 p.m. RN #3 entered Resident #11’s room. Upon entering the room, RN #3 donned (put on) on a pair of gloves, and began performing wound care on Resident #11’s left buttocks wound. -RN #3 failed to don a gown after entering Resident #11’s room and before beginning the resident’s wound care. II. Wound care failuresA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Hand Hygiene for Healthcare Workers, updated 2/27/24, retrieved on 2/23/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html: "Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal."Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings, always clean your hands after removing gloves, remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil your hands."B. Facility policy and procedureThe Clean Dressing change policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 2/19/26 at 10:00 a.m. It read in pertinent part, “Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.“Compliance Guidelines: Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application:-If the table is soiled, wipe clean.-Place a disposable cloth or linen saver on the overbed table.-Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape).-If performing photo documentation, label measuring guide with patient identifier and date.-Use no-touch techniques to remove ointments and creams from their containers (use tongue blade or applicator). Liquid solutions should be poured directly onto gauze sponges.“Establish area for soiled products to be placed (Chux or plastic bag).“Wash hands and put on clean gloves.“Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites.“Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape.“Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle.“Wash hands and put on clean gloves.“Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (clean outward from the center of the wound). Pat dry with gauze.“Measure wound using disposable measuring guide. This is done weekly with wound rounds.“Wash hands and put on clean gloves.“Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant.“Secure dressing. Mark with initials and date. (Add time if dressing is more than once daily.)“Discard disposable items and gloves into appropriate trash receptacle and wash hands.”B. ObservationsOn 2/18/26 at 3:07 p.m. RN #3 was performing wound care on Resident #11‘s left buttocks wound. The following observations were made:RN #3 walked to the wound cart, and retrieved one normal saline bullet (single-use vials used in wound care), one calcium alginate dressing, and one bordered gauze dressing. RN #3 placed supplies on top of the wound cart. RN #3 said she needed to verify Resident #11’s wound care orders. RN #3 picked up the supplies and placed them on top of her medication car. After verifying Resident #11’s wound care orders, RN #3 went into the medication storage room, grabbed two packages of two inch by two inch gauze, exited the storage room, picked up Resident #11’s wound supplies on top of her medication cart, and walked to Resident #11’s room. RN #3 entered Resident #11’s room, performed hand hygiene upon entering the room, and grabbed a pair of gloves. Resident #11 was sitting in his wheelchair with his back to RN #3. RN #3 placed wound care supplies on the edge of Resident #11’s dresser then donned her gloves. Resident #11 stood up and pulled down his shorts and underwear to expose a previous dressing.-RN #3 failed to establish a clean wound care field for wound supplies on top of Resident #11’s dresser. RN #3 removed the dressing from Resident #11’s left buttocks wound, walked into the resident’s bathroom, and discarded the dressing. RN #3 opened both two by two gauze packages and the normal saline bullet, and squirted the normal saline onto the gauze. RN #3 wiped the surface and perimeter of the wound approximately 11 times, using the same side of the gauze each time. RN #3 walked to Resident #11’s bathroom and discarded the gauze and her gloves in the trash can. -RN #3 failed to discard and replace her gloves, or perform hand hygiene, after removing Resident #11’s old dressing and before cleansing the resident’s left buttocks wound. RN #3 retrieved and donned a new pair of gloves, reached into her left scrub pants pocket with her left hand, and removed a Sharpie from her pocket. RN #3 opened the bordered gauze dressing and dated and initialed it with the Sharpie. RN #3 opened the calcium alginate dressing. Using her left hand, RN #3 placed the calcium alginate dressing on top of Resident #11’s wound and held it in place. Using her right hand, RN #3 placed the bordered gauze over the calcium alginate dressing and adhered it to Resident #11. RN #3 gathered the wound care supply trash and discarded it into Resident #11’s bathroom trash can. RN #3 removed the trash bag and placed a new bag in Resident #11’s trash can. RN #3 removed the glove from her right hand, discarded it into the trash bag, and tied the bag closed. RN #3 exited Resident #11’s room carrying the trash bag with gloved left hand, and disposed of the bag in the dirty utility room. -RN #3 failed to perform hand hygiene before donning a new pair of gloves and continuing Resident #11’s wound care. RN #3 failed to maintain a clean field by reaching into her scrub pants pocket and retrieving a marker to sign and date Resident #11’s bordered gauze dressing. RN #3 failed to discard her gloves, perform hand hygiene, and don a new pair after dating the dressing and before continuing wound care on Resident #11. II. Medication administration failuresA. Facility policy and procedureThe Medication Administration policy and procedure, dated May 2016, was provided by the NHA on 2/19/26 at 10:00 a.m. It read in pertinent part,“Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.”The Hand Hygiene policy and procedure, revised April 2025, was provided by the NHA on 2/19/26 at 10:00 a.m. It read in pertinent part,“It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene.“Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:-Before and after coming on duty;-Before and after direct contact with residents; -Before preparing or handling medications;-Before performing any non-surgical invasive procedures;-Before and after handling an invasive device (e.g., urinary catheters, IV access sites);-Before donning sterile gloves;-Before handling clean or soiled dressings, gauze pads, etc.;-Before moving from a contaminated body site to a clean body site during resident care;-After contact with a resident's intact skin;-After contact with blood or bodily fluids;-After handling used dressings, contaminated equipment, etc.;-After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;-After removing gloves;-Before and after entering isolation precaution settings;-Before and after eating or handling food;-Before and after assisting a resident with meals; and-After personal use of the toilet or conducting your personal hygiene.-After removing and disposing of personal protective equipment.”B. ObservationsDuring a continuous observation, on 2/19/26, from 7:22 a.m. to 7:57 a.m., licensed practical nurse (LPN) #1 was observed administering medications to residents on the south hallway. The following observations were made: At 7:22 a.m. LPN #1 was at Resident #7’s bedside administering her oral medications. Resident #7’s tube feeding was running, via pump, per order and connected to her PEG tube. LPN #1 said it was time to disconnect Resident #7’s tube feeding. LPN #1 donned a pair of gloves and raised Resident #7’s shirt, exposing the PEG tube connection site. LPN #1 disconnected the tube feeding from Resident #7’s PEG tube, secured the PEG tube cap in place, lowered Resident #7’s shirt, and hung the tube feeding cord on the medication pole in the resident’s room. -LPN #1 failed to perform hand hygiene after administering Resident #7’s medications and before donning gloves. LPN #1 lowered Resident #7’s shirt a second time, repositioned the resident’s bedside table closer to her, grabbed the plastic box of glucometer supplies, exited Resident #7’s room, unlocked and stored the plastic box in the bottom drawer of the medication cart, discarded his gloves, then walked into room #16.-LPN #1 failed to perform hand hygiene after exiting Resident #7’s room, storing her glucometer and supplies, and before entering room #16. At 7:27 a.m. LPN #1 exited room #16, returned to his medication cart, and began preparing medications for Resident #18. LPN #1 donned a pair of gloves, retrieved a medication cup from the medication cart, and dispensed medications from blister pill packets into the cup. LPN #1 removed a plastic box from the bottom of the medication cart, individualized with the resident's name and room number, and placed it on top of the medication cart. LPN #1 opened the box, grabbed the glucometer, opened an alcohol pad, and wiped all sides of the glucometer with the alcohol pad. LPN #1 poured a cup of water, picked up the plastic box and medication cup, and walked into Resident #18’s room. -LPN #1 failed to perform hand hygiene after exiting room 16 and before donning gloves and preparing Resident #18’s medications. At 7:33 a.m. LPN #1 entered Resident #18’s room, wearing the same gloves he donned before preparing her medications. LPN #1 repositioned Resident #18’s bedside table so he was able to stand right next to the resident’s bed. LPN #1 checked Resident #18’s glucose using a disposable lancet. LPN #1 obtained an alcohol pad, wiped all surfaces of the glucometer, and placed it in the plastic box. LPN #1 removed gloves and handed Resident #18 her oral medications. After verifying Resident #18 took her medications, LPN #1 repositioned Resident #18’s bedside table closer to her and exited the resident’s room. LPN #1 performed hand hygiene upon return to his medication cart.-LPN #1 failed to change gloves and perform hand hygiene before checking Resident #18’s blood sugar and administering the resident her medications. At 7:40 a.m. LPN #1 opened a cart drawer, retrieved a plastic box labeled with Resident #32’s name and room number, and placed it on top of the cart. LPN #1 donned a pair of gloves, opened the box, opened an alcohol pad, and wiped all sides of the glucometer. LPN #1 retrieved a bottle of liquid protein from a drawer in the cart and poured Resident #32’s prescribed amount into aseparate medication cup. LPN #1 placed the liquid protein back in the cart drawer, poured a cup of water, picked up the two medication cups, the water, and the glucometer kit, and entered Resident #32’s room. At 7:44 a.m. LPN #1 entered Resident #32’s room wearing the same gloves he used to prepare the resident’s medications. LPN #1 placed the water, medications, and glucometer on Resident #32’s bedside table. After obtaining and wiping one of Resident #32’s fingers with an alcohol pad, LPN #1 used a disposable lancet to check Resident #32’s blood glucose level. LPN #1 obtained an alcohol pad and wiped all sides of the glucometer before placing it back in the resident’s glucometer box. LPN #1 removed and discarded his gloves, and handed Resident #32 her oral medications. After verifying Resident #32 took her medication, LPN #1 picked up the resident’s glucometer, exited Resident #32’s room, returned to the medication cart, and placed the glucometer back inside. -LPN #1 failed to change his gloves and perform hand hygiene after preparing Resident #32’s medications, after he entered the resident’s room, and before he checked Resident #32’s blood sugar. Additionally, LPN #1 failed to perform hand hygiene upon returning to the medication cart after exiting Resident #32’s room. At 7:48 a.m. LPN #1 began preparing medications for Resident #11. LPN #1 retrieved a medication cup from the cart and retrieved and dispensed 11 medications into the medication cup, opening and closing multiple drawers in the cart to obtain the medications. Resident #11 self-propelled himself to the side of the medication cart while LPN #1 prepared his medications. LPN #1 poured a cup of water and placed it on top of the medication cart. LPN #1 opened a cart drawer, opened and measured out the prescribed amount of a dissolvable medication, and poured the medication into the cup of water. LPN #1 obtained a plastic spoon from the medication cart and mixed the dissolvable medication into the cup of water, then discarded the spoon. LPN #1 handed the medication cup and the cup of water to Resident #11, and verified Resident #11 took his medications. LPN #1 asked to check a patch, located on Resident #11’s right chest, and pulled Resident #11’s shirt to the side to visualize the patch after approval was given. LPN #1 turned back to the medication cart and began documenting medication administration. -LPN #1 failed to perform hand hygiene before he began preparing Resident #11’s medications, before he gave the resident his medications, and after completing medication administration. III. Staff interviewsRN #3 was interviewed on 2/18/26 at 3:15 p.m. RN #3 confirmed Resident #11's left buttock wound was open. RN #3 said EBP should be worn when treating open wounds. RN #3 said there was a recent facility in-service,, which discussed when EBP should be used. RN #3 said she did not think to wear a gown while performing Resident #11’s wound care due to the small size of the wound. RN #3 said wearing EBP during resident care was important to help prevent cross-contamination and potential splashback of bodily fluids. RN #3 said hand hygiene should be performed when entering or exiting a resident’s room, or when hands were visibly soiled. RN #3 said she should have performed hand hygiene when discarding her old gloves and before applying new ones. RN #3 said appropriate hand hygiene was important to help decrease the spread of infection. LPN #1 was interviewed on 2/19/26 at 7:57 a.m. LPN #1 said hand hygiene should be performed before and after every medication administration. LPN #1 said proper hand hygiene was important to help protect residents from exposure to pathogens. LPN #1 was interviewed a second time on 2/19/26 at 10:40 a.m. LPN #1 said EBP should be utilized during resident care and medication administration. LPN #1 said using appropriate PPE was important to help prevent introducing pathogens to residents. LPN #1 was unable to state why he failed to perform proper hand hygiene during medication administration. The assistant director of nursing (ADON) and director of nursing (DON) were interviewed together on 2/19/26 at 11:05 a.m. The ADON said hand hygiene should be performed before/after administering medications, before/during/after resident treatments, and upon exiting a resident's room. The ADON said it was important for infection control and preventing the spread of organisms. The ADON said EBP signs were placed on the back of resident doors throughout the facility due to facility residents requesting discretion. The DON said facility staff were given routine training on EBP use and appropriate hand hygiene during annual skills fairs and monthly staff meetings. The ADON said facility staff should wear a gown when performing wound care on any sized wounds that were open and producing discharge. The ADON said staff should change gloves and perform hand hygiene after removing the old dressing, before completing the remainder of wound care, and after wound care was completed. The ADON said facility staff should establish a clean wound care field by placing a Chux pad on top of a surface before wound care supplies. The DON said if a Chux pad was not used, she expected facility staff to cleanse the surface using an antimicrobial wipe to establish a clean field. The DON said performing appropriate hand hygiene, glove changes, and establishing a clean field were important to decrease potential infection risk and the transmission of germs to residents.

A licensure survey was completed on 2/17/26 to 2/19/26. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5.26.1 The facility shall have an infection control program that provides annual in-service training on infection control and shall have current infection control policies and procedures available to all staff members.

A complaint survey, prompted by #CO38698 and #CO38773 was conducted on 12/23/24 to 12/24/24. No deficiencies were cited.

A revisit to the 10/3/2024 survey was completed on 12/12/2024. The facility was in compliance with the regulations surveyed.

A revisit to the 10/3/2024 survey was completed on 12/12/2024. The facility was in compliance with the regulations surveyed.

A survey prompted by complaint #CO37988 was completed on 10/2/24 to 10/3/24. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure two (#1 and #5) 11 residents out of 12 sample residents were kept free from abuse. Resident #1, who had limited mobility and required staff assistance with bed mobility and transfers due to a recent hip surgery, was admitted to the facility on 7/21/24. On the night of 7/21/24, Resident #1 used her call light to request staff assistance with being repositioned in bed. The resident later used her call light to request staff assistance with going to the bathroom. Both times, when staff had not responded to the resident's call light in over one hour, the resident called her legal representative. Both times, the resident's representative called the facility and staff eventually answered Resident #1's call light. Early in the morning on 7/22/24, Resident #1 again called her representative. The resident was crying and scared and wanted to leave the facility. Resident #1 reported that registered nurse (RN) #1 had come into her room, got close to her face and yelled at her to stop using her call light. According to Resident #1, RN #1 told her if she did not stop using her call light, staff would not come to assist her. Resident #1's representative arrived at the facility after receiving the phone call and removed Resident #1 from the facility due to the resident crying hysterically, being scared and not wanting to remain in the facility. The resident's representative reported the incident to the local police department on 7/22/24. Certified nurse aide (CNA) #1, who witnessed the incident between RN #1 and Resident #1, wrote a statement on 7/22/24 which documented RN #1 had spoken sternly to the resident and told her to stop using her call light and nobody was going to answer the call light. The facility completed a grievance related to the allegation but failed to investigate the incident until 9/12/24, over one month later, when the facility was alerted by the state board of nursing that RN #1's nursing license was being investigated for an allegation of abuse. The facility failed to conduct a complete investigation of the incident or report the allegation to the State Agency on 9/12/24 and RN #1 continued to work at the facility. Additionally, on 10/3/24, during a group interview during the survey, Resident #5, who also required staff assistance, reported he waited for 45 minutes to answer his call light. When nobody came, Resident #5 began yelling for help. He said RN #1 came to the doorway of his room and yelled at him to shut up and quit using his call light. Resident #5 said he was angry at being treated that way by RN #1. Due to the facility's failures to ensure residents were kept free from abuse, Resident #1 and Resident #5 experienced psychosocial harm when RN #1 yelled at the residents for using their call lights and threatened that staff would not answer their call lights if they continued to use them. Findings include:I. Facility policy and procedureThe Abuse Investigation and Reporting policy, revised August 2024, was provided by the nursing home administrator (NHA) on 10/3/24 at 8:39 a.m. It read in pertinent part, "It is the policy of this facility that reports of abuse, neglect, misappropriation of property and exploitation are promptly and thoroughly investigated. "The investigation process will consist of at least the following:-A review of the completed complainant report;-An interview with the person(s) reporting the incident;-Interviews with any witnesses to the incident;-An interview with the resident, if possible;-A review of the resident's medical record;-An interview with staff members having contact with the resident during the period/shift of the alleged incident, if applicable;-Interviews with resident's roommate, family members, and visitors, if applicable; and,-A review of all circumstances surrounding the incident."Employees of this facility accused of resident abuse shall immediately be barred from any further contact with the residents ofthe facility, pending the outcome of further investigation, prosecution or disciplinary action against the employee."The summary of the investigation will be recorded and attached to the report."Should the investigation reveal that the abuse occurred, the administrator would report such findings to the State Licensing Agency, as necessary, health department within (24 hours) and police department within two (2) hours as necessary with the results of the completion of the investigation. The administrator or designee will complete a copy of the Resident Abuse Investigation Report Form within five (5) working days of the reported incident." II. Incident of verbal abuse on 7/22/24 between Resident #1 and RN #1A. Facility investigationThe facility's investigation of the incident was provided by the NHA on 10/2/24 at approximately 2:00 p.m. A statement written by CNA #1 on 7/22/24 revealed resident #1 was admitted to the facility on the afternoon of 7/21/24. CNA #1 said the resident was using her call light throughout the day and night (on 7/21/24 into 7/22/24). CNA #1 said resident #1 requested assistance with the television, toileting assistance, retrieving food and repositioning in bed. CNA #1 reported RN #1 went into Resident #1's room and sternly told her she needed to stop taking advantage of her call light because the staff had had other residents to attend to. CNA #1's written statement further documented the resident's daughter arrived and removed Resident #1 from the facility.-Despite CNA #1's written statement of the incident, the facility completed a grievance for Resident #1's call light not being answered timely but failed to initiate an investigation for potential verbal abuse until 9/12/24 (see below). On 9/12/24, the facility was notified by the state board of nursing that RN #1 was being investigated for potential abuse. Upon receiving the notification from the state board of nursing, the facility spoke to CNA #1 and reviewed a written statement from RN #1 to the state board of nursing. A statement written by the NHA on 9/12/24 dated 9/12/24 documented his conversation via phone with Resident #1. The statement documented Resident #1 was asked if she recalled an incident with RN #1. The resident responded RN #1 had asked her to stop ringing the call light so frequently and had leaned over the bed and spoken loudly to her. Resident #1 reported she did not remember where or why she was at the facility because she had been on strong antibiotics and was having hip issues. Resident #1 said that she currently lived with her representative and had memory issues. According to the written statement, the NHA asked Resident #1 "if she had planned to report RN#1 to the state or get her in trouble." Resident #1 indicated that was not her intention and she just wanted to get out of the facility.-The facility's investigation of the incident failed to include additional interviews with other staff members or residents and the incident was not reported to the State Agency (see interviews below). B. Resident #11. Resident statusResident #1, age greater than 65, was admitted on 7/21/24 and discharged home with her representative on 7/22/24. According to the July 2024 computerized physician's orders (CPO), diagnoses included unilateral primary osteoarthritis, right total hip arthroplasty (hip replacement surgery), depression, unspecified and anxiety disorder. The 7/21/24 nursing admission assessment and functional performance assessment documented the resident was alert and oriented to person, place and time. The resident had limited range of motion of leg including hip and knee, used a walker for mobility and was unable to be evaluated for transfers due to a medical condition or safety concerns. She required substantial to maximum assistance for all other activities of daily living (ADL). The assessment indicated the resident did not have any behavior issues. C. Resident representative interview The resident's representative was interviewed on 10/2/24 at 4:27 p.m. The representative said Resident #1 was admitted to the facility for rehabilitation after a hip surgery. She said the resident arrived at the facility on the afternoon of 7/21/24. She said Resident #1 called her in a panic around 6:00 p.m. (on 7/21/24), because she needed to be repositioned in bed and staff was not answering her call light. The representative said Resident #1 called her again an hour later, still needing assistance. The representative said she called the facility to request assistance for Resident #1. The resident's representative said Resident #1 called her again at approximately 9:00 p.m. (on 7/21/24), when her call light was again not answered for over an hour and she needed to use the bathroom. The representative said she called the facility a second time to request help for Resident #1. The representative said, at 1:21 a.m. on 7/22/24, she received a hysterical phone call from Resident #1. She said the resident was crying and was scared and terrified. She said the resident wanted to call the police. She said Resident #1 told her that RN #1 got into her face, within two inches, and yelled at her to stop using the call light and that she was not allowed to use the call light. The representative said the resident reported RN #1 told her if she continued to use her call light, nobody was going to answer it. The resident's representative said she immediately went to the facility and found Resident #1 scared and terrified and she did not want to stay in the facility. She said because Resident #1 was scared and hysterically crying, she could not leave her at the facility and she took her out of the facility. She said a CNA helped carry the resident's belongings out of the facility and she told the CNA the reason she was taking Resident #1 out of the facility. The representative said the facility wanted her to sign an Against Medical Advice form (AMA), but she refused. The resident's representative said she did not receive any phone calls from the facility after the incident. She said she called the police on 7/22/24 to report the abuse. The representative said the police substantiated the allegation as abuse. D. Police interviewThe police officer who investigated the incident on 7/22/24 was interviewed on 10/3/24 at 9:56 a.m. The police officer said he was the investigator on the reported abuse of Resident #1. He said the resident had been threatened and yelled at by RN #1 to not use her call light. He said he had attempted to call RN #1 three times during his investigation of the incident and never received a call back. He said,through secondary interviews, he was able to substantiate the abuse and he reported RN #1 to the state board of nursing. E. Staff interviewsThe NHA and the director of nursing (DON) was interviewed on 10/2/24 at 3:32 p.m.. The NHA said he did not have a full investigation of abuse involving Resident #1. The DON said he recalled Resident #1 was at the facility for about eight hours and the resident's representative picked her up in the middle of the night. He said the resident's representative requested that CNA #1 help her get the resident into her car. He said while CNA #1 was helping transfer Resident #1 to the representative's car, CNA #1 requested that the representative sign a form to have the resident leave AMA but the representative refused to sign the AMA form. The DON said CNA #1 informed him the representative was not happy with RN #1 and her response to Resident #1 using her call light. The DON said a grievance was filed due to the concerns of call light response time. He said a call light tracking was completed as part of the follow-up to the grievance filed. The NHA said he was not employed at the facility in July 2024. However, he said he had received notification from the state board of nursing in regards to RN #1's involvement in an abuse allegation. The NHA said he had not conducted a complete investigation which included other residents and staff or reported the abuse allegation to the State Agency. He said because the state board of nursing letter was on state letterhead, he thought the State Agency was aware of the incident. The NHA said, after receiving the letter, he contacted Resident #1 on 9/12/24 to get information related to the incident. He said the resident said she vaguely recalled the incident. The NHA said he attempted to contact Resident #1's representative twice on 9/12/24 with no response. The corporate consultant (CC) was interviewed on 10/3/24 at 8:49 a.m. The CC said the abuse policy was reviewed with both the NHA and the DON were educated on 10/2/24 (during the survey) regarding how to timely investigate abuse allegations. III. Incident of verbal abuse between Resident #5 and RN #1A. Resident #51. Resident statusResident #5, age 82, was admitted on 5/3/16. According to the October 2024 CPO, diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following unspecified cerebrovascular disease (stroke) affecting the left dominant side. The 8/28/24 facility assessment revealed the resident was cognitively intact. He required up to two-person assistance with bed mobility, transfers and all ADLs. The assessment indicated the resident did not have any behaviors. B. Resident interviewResident #5 was interviewed on 10/3/24 at 9:30 a.m. Resident #5 said the other night (no date specified) he had his call light on in the evening and he waited for 45 minutes for someone to answer it. He said no one showed up or looked in the door which led to him screaming for help. He said RN #1 came to his room, stood in the doorway and started yelling at him from the door, telling him to shut up and quit calling on his call light. Resident #5 said he had not reported the incident to anyone at the facility. He said the treatment he received from RN #1 made him "pissed off" that he was treated in this manner. The NHA was informed of the abuse allegation on 10/3/24 at 10:20 a.m. C. Facility follow-upOn 10/3/24 at 11:48 a.m., the NHA provided an update regarding Resident #5's abuse allegation. The NHA said the police were notified of the allegation, the interdisciplinary team (IDT) were conducting staff and resident interviews and RN #1 had been removed from the facility's schedule pending the facility's investigation of the allegation.

A survey prompted by #CO37546 and #CO37552 was conducted 10/2/24 to 10/3/24. Three deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow-up with concerns that were brought up by the group of residents during the resident council meetings regarding resident care and life in the facility. Findings include: I. Facility policyThe Grievance Policy, dated 10/3/24, was provided by the social services consultant (SSC) on 10/3/24 at 11:47 a.m. It read in pertinent part, "To address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. To make prompt efforts to resolve grievances the resident may have."The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility."The Grievance Official or designee responds to the individual expressing the concern within three (3) working days of the initial concern to acknowledge receipt and describe steps taken toward resolution."The Grievance Official/Designee completes the Grievance Resolution Forms, takes appropriate corrective action in accordance with State law if the alleged violation of resident's right is confirmed by the facility or an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency within its area of responsibility. The Grievance Official or designee will contact all parties with the outcome."The grievance log is maintained by the Grievance Official and reviewed by the Quality Assessment & Assurance Committee and shall not become part of the medical record. Results of grievance will be maintained no less than 3 years from issuance of the grievance decision."II. ObservationsOn 10/2/24 at 9:55 a.m. the north and south hallways were observed to be cluttered with wheelchairs, oxygen concentrators, bedside commodes, empty boxes near the storage room and medication carts with computers. The floors of the hallways and the dining room had bits of trash and food on them. III. Resident InterviewsResident #6 was interviewed on 10/2/24 at 2:38 p.m. Resident #6 said the staff took a long time to answer the call lights in the evenings and at night. Resident #4 was interviewed on 10/2/24 at 2:59 p.m. Resident #4 said there were not enough staff to take care of everyone without having to wait a long time for call lights to be answered. She said the rooms were not cleaned daily. IV. Resident group interviewThe resident group interview was conducted on 10/3/24 at 9:30 a.m. The group consisted ofseven residents ( #5, #6, #7, #8, #9, #10 and #11) who were interviewable based on assessment and the facility. The residents all said they continued to have concerns with the facility's follow-up on grievances. The concerns were as follows:-The facility failed to act upon grievances;-The facility had a lot of turnover and therefore the grievances were not acted upon;-The facility did not listen to the resident council group in order to help resolve issues;-The residents did not hear back from staff in regards to any grievances filed; and, -The facility continued to have complaints regarding staffing issues, call lights not being answered, clutter in the hallways and cleanliness of the building. V. Resident council meeting minutesThe resident council meeting minutes for July 2024, August 2024 and September 2024 were provided by the director of nursing (DON) on 10/2/24 at 10:37 a.m. The 7/22/24 resident council meeting minutes documented the following resident concerns:The old business section (from June 2024) documented resident concerns of trash not being emptied, the utilization of agency staff during night of care (NOC) and not enough towels or washcloths for residents. The status update documented by the interdisciplinary team (IDT) said they were trying to minimize using agency staff. Resident concerns for the month of July 2024 included call light times were too long at night, there were too many wheelchairs and equipment in the hallways, and staff left wet towels in resident rooms and were not cleaning the toilet stools after use. -There was no documentation in the minutes which indicated how the facility planned to follow up on the resident concerns. The 8/19/24 resident council meeting minutes documented the following resident concerns:Hallways were cluttered with wheelchairs, commodes and supplies when the delivery trucks came and the residents did not have enough towels or wash cloths.-There was no documentation in the minutes which indicated how the facility planned to follow up on the resident concerns. The 9/23/24 resident council meeting minutes documented the following resident concerns:The old business section (from August 2024) documented resident concerns that hallways and shower rooms were cluttered, that all wheelchairs and bedside commodes be moved and that call lights were not being answered on time. -There was no documentation in the minutes which indicated how the facility had followed up on the resident concerns. VI. Staff interviewsThe activity director (AD) was interviewed on 10/3/24 at 10:37 a.m. The AD said resident council meetings were held once a month. She said all administrative team members were present and the residents and staff discussed resident concerns during the meetings. She said she was responsible for writing down meeting minutes. She said she provided the meeting minutes to the social services director (SSD), who was also the facility's grievance official. The AD said the SSD was responsible for filling out grievance forms based on the grievances voiced in the resident council meetings. The SSD was interviewed on 10/3/24 at 11:00 a.m. The SSD said she was the grievance official for the facility. She said she received the resident council meeting minutes from the AD. She said she filled out grievance forms based on the resident concerns brought up in the meetings. She said she would give the grievance forms to the appropriate department head to resolve the issue. The SSD said grievances were to be resolved within 48 hours of receiving the grievance form. She said she was supposed to follow up on grievances if the form was signed as resolved and a resolution was not actually obtained. After reviewing her grievance log, the SSD said she had two grievances filed from July 2024, however, she said they were not followed up on appropriately to ensure an actual resolution was obtained. She said she had no grievance forms filled out for the resident concerns brought up in the August 2024 and September 2024 resident council meetings.

Based on record review and interviews, the facility failed to ensure two (#1 and #5) 11 residents out of 12 sample residents were kept free from abuse. Resident #1, who had limited mobility and required staff assistance with bed mobility and transfers due to a recent hip surgery, was admitted to the facility on 7/21/24. On the night of 7/21/24, Resident #1 used her call light to request staff assistance with being repositioned in bed. The resident later used her call light to request staff assistance with going to the bathroom. Both times, when staff had not responded to the resident's call light in over one hour, the resident called her legal representative. Both times, the resident's representative called the facility and staff eventually answered Resident #1's call light. Early in the morning on 7/22/24, Resident #1 again called her representative. The resident was crying and scared and wanted to leave the facility. Resident #1 reported that registered nurse (RN) #1 had come into her room, got close to her face and yelled at her to stop using her call light. According to Resident #1, RN #1 told her if she did not stop using her call light, staff would not come to assist her. Resident #1's representative arrived at the facility after receiving the phone call and removed Resident #1 from the facility due to the resident crying hysterically, being scared and not wanting to remain in the facility. The resident's representative reported the incident to the local police department on 7/22/24. Certified nurse aide (CNA) #1, who witnessed the incident between RN #1 and Resident #1, wrote a statement on 7/22/24 which documented RN #1 had spoken sternly to the resident and told her to stop using her call light and nobody was going to answer the call light. The facility completed a grievance related to the allegation but failed to investigate the incident until 9/12/24, over one month later, when the facility was alerted by the state board of nursing that RN #1's nursing license was being investigated for an allegation of abuse. The facility failed to conduct a complete investigation of the incident or report the allegation to the State Agency on 9/12/24 and RN #1 continued to work at the facility. Additionally, on 10/3/24, during a group interview during the survey, Resident #5, who also required staff assistance, reported he waited for 45 minutes to answer his call light. When nobody came, Resident #5 began yelling for help. He said RN #1 came to the doorway of his room and yelled at him to shut up and quit using his call light. Resident #5 said he was angry at being treated that way by RN #1. Due to the facility's failures to ensure residents were kept free from abuse, Resident #1 and Resident #5 experienced psychosocial harm when RN #1 yelled at the residents for using their call lights and threatened that staff would not answer their call lights if they continued to use them. Findings include:I. Facility policy and procedureThe Abuse Investigation and Reporting policy, revised August 2024, was provided by the nursing home administrator (NHA) on 10/3/24 at 8:39 a.m. It read in pertinent part, "It is the policy of this facility that reports of abuse, neglect, misappropriation of property and exploitation are promptly and thoroughly investigated. "The investigation process will consist of at least the following:-A review of the completed complainant report;-An interview with the person(s) reporting the incident;-Interviews with any witnesses to the incident;-An interview with the resident, if possible;-A review of the resident's medical record;-An interview with staff members having contact with the resident during the period/shift of the alleged incident, if applicable;-Interviews with resident's roommate, family members, and visitors, if applicable; and,-A review of all circumstances surrounding the incident."Employees of this facility accused of resident abuse shall immediately be barred from any further contact with the residents ofthe facility, pending the outcome of further investigation, prosecution or disciplinary action against the employee."The summary of the investigation will be recorded and attached to the report."Should the investigation reveal that the abuse occurred, the administrator would report such findings to the State Licensing Agency, as necessary, health department within (24 hours) and police department within two (2) hours as necessary with the results of the completion of the investigation. The administrator or designee will complete a copy of the Resident Abuse Investigation Report Form within five (5) working days of the reported incident." II. Incident of verbal abuse on 7/22/24 between Resident #1 and RN #1A. Facility investigationThe facility's investigation of the incident was provided by the NHA on 10/2/24 at approximately 2:00 p.m. A statement written by CNA #1 on 7/22/24 revealed resident #1 was admitted to the facility on the afternoon of 7/21/24. CNA #1 said the resident was using her call light throughout the day and night (on 7/21/24 into 7/22/24). CNA #1 said resident #1 requested assistance with the television, toileting assistance, retrieving food and repositioning in bed. CNA #1 reported RN #1 went into Resident #1's room and sternly told her she needed to stop taking advantage of her call light because the staff had had other residents to attend to. CNA #1's written statement further documented the resident's daughter arrived and removed Resident #1 from the facility.-Despite CNA #1's written statement of the incident, the facility completed a grievance for Resident #1's call light not being answered timely but failed to initiate an investigation for potential verbal abuse until 9/12/24 (see below). On 9/12/24, the facility was notified by the state board of nursing that RN #1 was being investigated for potential abuse. Upon receiving the notification from the state board of nursing, the facility spoke to CNA #1 and reviewed a written statement from RN #1 to the state board of nursing. A statement written by the NHA on 9/12/24 dated 9/12/24 documented his conversation via phone with Resident #1. The statement documented Resident #1 was asked if she recalled an incident with RN #1. The resident responded RN #1 had asked her to stop ringing the call light so frequently and had leaned over the bed and spoken loudly to her. Resident #1 reported she did not remember where or why she was at the facility because she had been on strong antibiotics and was having hip issues. Resident #1 said that she currently lived with her representative and had memory issues. According to the written statement, the NHA asked Resident #1 "if she had planned to report RN#1 to the state or get her in trouble." Resident #1 indicated that was not her intention and she just wanted to get out of the facility.-The facility's investigation of the incident failed to include additional interviews with other staff members or residents and the incident was not reported to the State Agency (see interviews below). B. Resident #11. Resident statusResident #1, age greater than 65, was admitted on 7/21/24 and discharged home with her representative on 7/22/24. According to the July 2024 computerized physician's orders (CPO), diagnoses included unilateral primary osteoarthritis, right total hip arthroplasty (hip replacement surgery), depression, unspecified and anxiety disorder. The 7/21/24 nursing admission assessment and functional performance assessment documented the resident was alert and oriented to person, place and time. The resident had limited range of motion of leg including hip and knee, used a walker for mobility and was unable to be evaluated for transfers due to a medical condition or safety concerns. She required substantial to maximum assistance for all other activities of daily living (ADL). The assessment indicated the resident did not have any behavior issues. C. Resident representative interview The resident's representative was interviewed on 10/2/24 at 4:27 p.m. The representative said Resident #1 was admitted to the facility for rehabilitation after a hip surgery. She said the resident arrived at the facility on the afternoon of 7/21/24. She said Resident #1 called her in a panic around 6:00 p.m. (on 7/21/24), because she needed to be repositioned in bed and staff was not answering her call light. The representative said Resident #1 called her again an hour later, still needing assistance. The representative said she called the facility to request assistance for Resident #1. The resident's representative said Resident #1 called her again at approximately 9:00 p.m. (on 7/21/24), when her call light was again not answered for over an hour and she needed to use the bathroom. The representative said she called the facility a second time to request help for Resident #1. The representative said, at 1:21 a.m. on 7/22/24, she received a hysterical phone call from Resident #1. She said the resident was crying and was scared and terrified. She said the resident wanted to call the police. She said Resident #1 told her that RN #1 got into her face, within two inches, and yelled at her to stop using the call light and that she was not allowed to use the call light. The representative said the resident reported RN #1 told her if she continued to use her call light, nobody was going to answer it. The resident's representative said she immediately went to the facility and found Resident #1 scared and terrified and she did not want to stay in the facility. She said because Resident #1 was scared and hysterically crying, she could not leave her at the facility and she took her out of the facility. She said a CNA helped carry the resident's belongings out of the facility and she told the CNA the reason she was taking Resident #1 out of the facility. The representative said the facility wanted her to sign an Against Medical Advice form (AMA), but she refused. The resident's representative said she did not receive any phone calls from the facility after the incident. She said she called the police on 7/22/24 to report the abuse. The representative said the police substantiated the allegation as abuse. D. Police interviewThe police officer who investigated the incident on 7/22/24 was interviewed on 10/3/24 at 9:56 a.m. The police officer said he was the investigator on the reported abuse of Resident #1. He said the resident had been threatened and yelled at by RN #1 to not use her call light. He said he had attempted to call RN #1 three times during his investigation of the incident and never received a call back. He said,through secondary interviews, he was able to substantiate the abuse and he reported RN #1 to the state board of nursing. E. Staff interviewsThe NHA and the director of nursing (DON) was interviewed on 10/2/24 at 3:32 p.m.. The NHA said he did not have a full investigation of abuse involving Resident #1. The DON said he recalled Resident #1 was at the facility for about eight hours and the resident's representative picked her up in the middle of the night. He said the resident's representative requested that CNA #1 help her get the resident into her car. He said while CNA #1 was helping transfer Resident #1 to the representative's car, CNA #1 requested that the representative sign a form to have the resident leave AMA but the representative refused to sign the AMA form. The DON said CNA #1 informed him the representative was not happy with RN #1 and her response to Resident #1 using her call light. The DON said a grievance was filed due to the concerns of call light response time. He said a call light tracking was completed as part of the follow-up to the grievance filed. The NHA said he was not employed at the facility in July 2024. However, he said he had received notification from the state board of nursing in regards to RN #1's involvement in an abuse allegation. The NHA said he had not conducted a complete investigation which included other residents and staff or reported the abuse allegation to the State Agency. He said because the state board of nursing letter was on state letterhead, he thought the State Agency was aware of the incident. The NHA said, after receiving the letter, he contacted Resident #1 on 9/12/24 to get information related to the incident. He said the resident said she vaguely recalled the incident. The NHA said he attempted to contact Resident #1's representative twice on 9/12/24 with no response. The corporate consultant (CC) was interviewed on 10/3/24 at 8:49 a.m. The CC said the abuse policy was reviewed with both the NHA and the DON were educated on 10/2/24 (during the survey) regarding how to timely investigate abuse allegations. III. Incident of verbal abuse between Resident #5 and RN #1A. Resident #51. Resident statusResident #5, age 82, was admitted on 5/3/16. According to the October 2024 CPO, diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following unspecified cerebrovascular disease (stroke) affecting the left dominant side. The 8/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required up to two-person assistance with bed mobility, transfers and all ADLs. The assessment indicated the resident did not have any behaviors. B. Resident interviewResident #5 was interviewed on 10/3/24 at 9:30 a.m. Resident #5 said the other night (no date specified) he had his call light on in the evening and he waited for 45 minutes for someone to answer it. He said no one showed up or looked in the door which led to him screaming for help. He said RN #1 came to his room, stood in the doorway and started yelling at him from the door, telling him to shut up and quit calling on his call light. Resident #5 said he had not reported the incident to anyone at the facility. He said the treatment he received from RN #1 made him "pissed off" that he was treated in this manner. The NHA was informed of the abuse allegation on 10/3/24 at 10:20 a.m. C. Facility follow-upOn 10/3/24 at 11:48 a.m., the NHA provided an update regarding Resident #5's abuse allegation. The NHA said the police were notified of the allegation, the interdisciplinary team (IDT) were conducting staff and resident interviews and RN #1 had been removed from the facility's schedule pending the facility's investigation of the allegation.

Based on observations, record reviews, and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to:-Ensure nurse staffing data was posted on a consistent daily basis;-Ensure when nurse staffing data was posted, that it was posted in a prominent location, readily accessible to residents and visitors; and,-Ensure records of nurse staffing data were retained for 18 months. Findings include:I. ObservationsObservations in the facility on 10/2/24 at 9:55 a.m. revealed that the nurse staffing hours were not posted for the day. Observations in the facility on 10/3/24 at 10:03 a.m. revealed the nurse staffing hours were posted for 10/3/24, however, they were posted behind the main nurse's station and were not easily accessible to residents and visitors. II. Staff interviewsThe facility's scheduler was interviewed on 10/3/24 at 11:35 a.m. The scheduler said she was responsible for scheduling the nursing staff. She said she was responsible for posting the nurse staffing hours daily and that she was not sure why the nurse staffing hours information had not been posted on 10/2/24. The scheduler clarified the facility's director of nursing (DON) was responsible for posting nurse staffing hours and she was responsible for posting the schedule. The DON was interviewed on 10/3/24 at 1:15 p.m. He said during the week he would print the staffing information and post it, however, for the weekends, he said he would print the nursing staff data and the facility staff were responsible for hanging it. He said the information was not posted on 10/2/24 because he forgot to post it due to the arrival of the survey team. The DON said he did not keep the printed versions or the electronic copies of the nurse staff postings. He said he was not aware copies of the nurse staffing data needed to be retained for 18 months.

A revisit to the 1/9/24 survey was completed on 3/26/24. The facility was in compliance with the regulations surveyed.

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