HILLTOP PARK POST ACUTE

A revisit survey was completed on 5/21/24 for all previous deficiencies cited on 3/07/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 5/21/24 for all previous deficiencies cited on 3/07/24. The facility is in compliance with all regulations surveyed.

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

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one and two-story construction. The first-story is a Type V (111) construction; the second floor is a Type II (111) construction. The first-story Type V (111) structure constructed in 1987 (based on wooden attic space) contained no two-hour fire separation between construction Types, therefor, the building construction is considered to be Type V (111), the lesser of the two construction types. The facility is protected throughout by National Fire Protection Association (NFPA) 13 automatic wet and dry fire suppression systems and is classified as Fully Sprinklered. The facility is license for 160 beds. This re-certification survey conducted on March 26, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Director of Maintenance during the exit conference conducted at the end on-site survey.

STANDARD not met based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. 1. No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds monthly or annually for not less than 1 ½ hours. 2. The battery-powered emergency lighting at the transfer switch would not illuminate when the test button was pressed. 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility.

STANDARD is not met based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the trans -filling of oxygen from one cylinder to another in accordance with NFPA 99 - Health Care Facilities, 11.5.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. The following evidenced this:The oxygen trans-filling room not mechanically ventilated correctly per NFPA 99, Life Safety Code 101-2012, 5.1.3.3.2 and 5.1.3.3.3.9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) off the floor and adjacent to the cylinder or containers. The Director of Maintenance acknowledged the ventilation issue during a tour of the facility.

A recertification survey with complaints #CO34158, #CO35162 and #CO35169 was completed on 3/4/24 to 3/7/24. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/4/24 to 3/7/24. No deficiencies were cited.

Based on record review, observations and interviews the facility failed to ensure seven (#25, #39, #40, #66, #70, #75 and #115) of 10 residents out of 46 sample residents were kept free from neglect. Specifically, the facility failed to provide adult briefs, wipes, linens, towels and washcloths to Resident #25, #39, #40, #66, #70, #75 and #115 as required to maintain their highest practicable well-being. Findings include:I. Facility policyThe Abuse and Neglect policy, revised March 2018, was provided by the director of nursing (DON) on 3/11/24 at 12:44 p.m. It read in pertinent part, "Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A sign of actual physical neglect is inadequate provision of care."II. Resident interviewsResident #40 was interviewed on 3/4/24 at 10:57 a.m. Resident #40 said she had been ordering her own adult briefs and keeping them in her room because the facility ran out of briefs frequently. Resident #115 was interviewed on 3/4/24 at 11:54 a.m. Resident #115 said he had asked for a shower or bed bath and was told he could not have one because there were no towels or washcloths available. He said he had not had a shower in seven days. He said his wife came to visit him and was going to give him a bed bath. Resident #115 said the staff brought him three washcloths to bathe with. He said he was a very clean person and not getting proper supplies for showers made him feel dirty. Resident #115 said on one occasion, when the facility did not have supplies, his wound doctor wanted him to get a shower prior to wound care and the staff did not have the supplies to shower him. Resident #39 was interviewed on 3/4/24 at 2:45 p.m. Resident #39 said the residents were constantly told the facility was out of wipes and the staff had to go hunt for them in other storage areas. She said the certified nurse aides (CNAs) could never find washcloths. She said she was lucky she could buy her own washcloths. She said she had been buying her own washcloths and sending them to the laundry, however, she said she would not get them back from laundry. Resident #39 said she might as well supply the facility with supplies since they did not have the supplies to care for her. Resident #66 was interviewed on 3/4/24 at 3:40 p.m. Resident #66 said the facility ran out of adult briefs frequently and the CNAs had to provide her with a smaller size which was uncomfortable. She said she wore double extra large and they only ever had regular extra large. Resident #70 was interviewed on 3/4/24 at 4:12 p.m. Resident #70 said she recently had diarrhea and her whole bedding needed changing. She said the facility was out of bed pads and wipes. She said the residents were hardly ever provided with wipes to clean themselves properly. Resident #75 was interviewed on 3/5/24 at 9:25 a.m. Resident #75 said she bought her own adult briefs because the facility always ran out of her size. She said she wore double extra large and the facility was always out of them. She said the prior Saturday (3/2/24), the facility ran out of wipes, and her sister had to have wipes delivered to her from the store. Resident #75 said she did not know what she was going to do when her last package of adult briefs ran out because she could not afford more. Resident #25 was interviewed on 3/5/24 at 10:05 a.m. Resident #25 said the facility did not have linens and wipes. She said staff always told her they were out of supplies and needed to go search in other storage areas. She said she did not know what staff were using when supplies ran out. She said she never knew if supplies would be available or not. Resident #25 said other residents had the same issues and it was brought up in their resident council meetings. She said she received two showers a week at 7:00 a.m. She said her bedding was supposed to be changed on her shower days but when she asked for fresh bed linens there were none available. She said laundry did not bring the clean linen to the unit until the afternoon. She said the CNA who provided her showers was unable to change her linens and by the time linens came to the floor it was change of shift and her bed linens would not get changed. Resident #25 said she had to shower early before the staff were too busy or she would not get her shower. She said she had her own towels with her name on them, however, she said they were never returned after laundering. She said the housekeeping supervisor (HKS) told her new towels had been ordered but they had never come. III. ObservationsOn 3/6/24 at 9:05 a.m., the second floor shower room was observed. -The linen cart was empty. -The second floor linen closet had no towels, washcloths or bed linens available to staff. At 9:25 a.m,. the first floor linen closet was observed. -There were no clean towels, washcloths, flat sheets, fitted sheets or pillow cases available for staff to care for the residents. At 10:06 a.m., the supply rooms were observed with the HKS. -The first floor supply room was out of double extra large briefs and underwear. -The second floor supply room was out of double extra large briefs and underwear. -A second supply room on the first floor was out of double extra large briefs and underwear. -The linen closet had no towels available and a CNA was giving showers. At 11:20 a.m., the outside locked storage container was observed. It was stocked with adult briefs, wipes and an unopened box of bed linens. -However, the supplies were not brought into the facility for to staff to use. IV. Staff interviewsCNA #1 was interviewed on 3/6/24 at 9:06 a.m. CNA #1 said the unit ran out of adult briefs, wipes, washcloths, towels and bed linen frequently. She said the CNAs would have to go to other units to look for supplies because they could not take supplies from other residents who needed them as well. She said the central supply storage room was locked and she did not know where to get the key from. She said she had complained to management about the unavailability of supplies but nothing had been done about it. CNA #2 was interviewed on 3/6/24 at 9:13 a.m. CNA #2 said the facility ran out of wipes and adult briefs. She said she would have to use a smaller brief on some of the residents. She said the laundry aides did not bring the laundry timely and she did not have washcloths or towels to shower the residents with. She said when the linen closet was empty she would go to the laundry room and see if washcloths, towels, or bed linens were dry so she could bring them to the unit. She said it took time away from caring for the residents when CNAs had to spend so much time looking for supplies. She said the central supply storage room was locked and she did not know where to get the key from. CNA #4 was interviewed on 3/6/24 at 12:50 p.m. CNA #4 said sometimes supplies were just not where they were supposed to be. She said supplies were in storage and not in the central supply room. She said staff did not have access to the storage container outside. She said she had to ask the HKS for supplies and on the weekend when the facility ran out of supplies and there were none in the central supply storage room; CNAs had to ask housekeeping to get them from storage. It could take 15 minutes or more to get the supplies which took time away from the residents' care. CNA #4 said when the facility did not have enough linen they had to wait for the laundry to be washed and go to the laundry room to get what they needed to care for the residents. The HKS was interviewed on 3/6/24 at 9:58 a.m. The HKS said she ordered supplies every week. She said there were four storage rooms for the adult briefs and wipes. She said she had a floor technician who stocked the supply rooms every morning at 5:30 a.m. She said English was not his first language and he often stocked the items in the wrong place. She said she recently placed an order for more linens, towels and washcloths. She said the nursing staff did have to go to the laundry room for linen that was still being washed. She said all staff had access to the central supply room and the outside storage needed a key. The HKS said she made rounds two to three times a day to check supply closets and make sure supplies were available. The DON was interviewed on 3/6/24 at 4:03 p.m. The DON said there were plenty of adult briefs and wipes for the residents' needs. She said the residents should not be buying their own supplies. She said the facility had plenty of towels, washcloths and bed linens to care for the residents. She said she did not know the nursing staff had to go to the laundry room to get the linens they needed. She said the facility would order supplies as needed.

Based on observations and interviews, the facility failed to ensure medications were dispensed according to professional standards of practice for two (#25 and #2) of 10 residents reviewed for medication administration out of 46 sample residents. Specifically, the facility failed to ensure nurses did not leave medications unattended at residents' bedsides. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. "Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: "1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."II. Facility policy and procedureThe Administering Medications policy and procedure, revised April 2019, was received on 3/7/24 at 9:04 a.m. from the nursing home administrator (NHA). It revealed in pertinent part, "Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision making capacity to do so safely."III. Resident #25A. Resident statusResident #25, age greater than 65, was admitted on 1/29/21. According to the March 2024 computerized physician orders (CPO), diagnoses included schizophrenia (delusions and false beliefs, disorganized thinking and speech), diabetes mellitus type two (pancreas does not produce enough insulin), anxiety and dysphagia (difficulty swallowing). The 10/18/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required set up assistance for eating. Shewas independent for toileting, personal hygiene, transfers and dressing. B. ObservationsOn 3/6/24 at 11:47 a.m., licensed practical nurse (LPN) #3 was administering medications to Resident #25. She dispensed 4 milligrams (mg) of Zofran (anti-nausea medication) and 750 mg Methocarbamol (muscle relaxer). LPN #3 entered Resident #25's room and left the medications on the resident's bedside table before exiting the room and returning to her medication cart down the hall. -Resident #25 took her medications, however, LPN #3 had already left the room and did not observe the resident taking her medications. C. Record review-The March 2024 CPO did not document a physician's order indicating Resident #25 was able to self administer her medications.-Review of Resident #25's assessments revealed there was no assessment completed to determine if Resident #25 was able to self administer her medications. IV. Resident #2A. Resident statusResident #2, age younger than 65, was admitted on 2/17/23. According to the March 2024 CPO, diagnoses included quadriplegia (paralysis of limbs) and chronic pain syndrome. The 2/21/24 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS score of 11 out of 15. He required maximum assistance with transfers, moderate assistance for personal hygiene, dressing and toileting. He required setup assistance for eating. B. ObservationsOn 3/6/24 at 11:51 a.m., LPN #3 was administering medications to Resident #2. LPN #3 dispensed 400 mg of gabapentin (nerve pain medication), 5 mg of Cyclobenzaprine (muscle relaxer) and 10 mg of Oxycodone (narcotic pain medication). LPN #3 entered Resident #2's room,left the medication on the resident's bedside table and walked out of the room prior to observing the resident swallowing themedications.-Resident #2 took his medications, however, LPN #3 had already left the room and did not observe the resident taking his medications. C. Record review -The March 2024 CPO did not document a physician's order indicating Resident #2 was able to self administer his medications. -Review of Resident #2's assessments revealed there was no assessment completed to determine if Resident #2 was able to self administer her medications. V. Staff interviewsLPN #3 was interviewed on 3/6/24 at 12:00 p.m. She said Resident #25 was able to self administer medications. LPN #3 was unsure if Resident #2 was able to self administer medications. LPN #3 said it was not best practice to leave medications at the bedside and nurses were to watch residents swallow the medications to ensure the resident took them and no other resident could get ahold of them. LPN #3 said she must have been in a hurry and left the medications with the residents. The director of nursing (DON) was interviewed on 3/7/24 at 4:29 p.m. The DON said medications should not be left at the bedside. She said nurses needed to watch residents take the medications to ensure they were taken and another resident did not get ahold of the medications. The DON said if a resident did not take the medications it could affect their health and if another resident was to get a hold of a medication not prescribed to them it could cause adverse effects. The DON reviewed the medical records for Resident #25 and #2 for orders to self administer medications and assessments of resident ability to self administer medications. The DON said neither resident was able to self administer medications.

Based on record review and interviews, the facility failed to ensure one (#115) of three residents out of 46 sample residents received treatment and care in accordance with professionalstandards of practice. Specifically, the facility failed to administer insulin (medication used to level blood glucose) in a timely manner per the physician orders. Findings include:I. Facility policyThe Administering Medications policy, revised April 2019, was received from the nursing home administrator (NHA) on 3/7/24 at 9:04 a.m. The policy revealed in pertinent part, "Medications were to be administered within one hour of their prescribed time, unless otherwise specified."II. Resident #115A. Resident statusResident #115, age younger than 65, was admitted on 1/26/24. According to the March 2044 computerized physician orders (CPO), diagnoses included sepsis (systemic infection), type two diabetes mellitus (pancreas doesn't produce enough insulin), hypertension (high blood pressure) and kidney failure. The 1/31/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He was dependent on staff for transfers. He required moderate assistance for bathing, dressing and personal hygiene. He required set up assistance for eating. The assessment documented the resident had received insulin since admission to the facility. B. Resident interviewResident #115 was interviewed on 3/4/24 at 11:53 a.m. Resident #115 said the nurses gave him his insulin at different times and he was concerned with not getting the medication on time. Resident #115 said he felt like his diabetes was not being controlled and it was important to his health. C. Record reviewThe 1/30/24 comprehensive care plan documented the resident had diabetes and was at risk for complications manifested by neuropathy (weakness, numbness and pain caused by nerve damage, usually in the hands and feet). The documented goal was to maintain blood glucose levels within range as established by the resident's physician. The intervention was to administer medications as ordered. The March 2024 CPO documented the following medication orders:Insulin Glargine, administer 28 units subcutaneously two times a day at 8:00 a.m. and 8:00 p.m., ordered on 1/26/24. Humalog Insulin, administer 7 units before meals for diabetes. Call the physician if blood sugar is less than 70 and greater than 350. Administer at 8:00 a.m., 12:00 p.m. and 5:30 p.m., ordered on 1/26/24. Review of the medication administration record (MAR) for February and March 2024 revealed the following:The Glargine insulin 8:00 a.m. dose was not administered timely on the following days:-2/7/24, the medication was administered at 10:24 a.m. (one hour and 24 minutes after the allowed administration time); and,-2/10/24, the medication was administered at 10:03 a.m. (one hour and three minutes after the allowed administration time). The Glargine insulin 8:00 p.m. dose was not administered timely on the following days:-2/1/24, the medication was administered at 10:23 p.m. (one hour and 23 minutes after the allowed administration time);-2/8/24, the medication was administered at 9:51 p.m. (51 minutes after the allowed administration time);-2/10/24, the medication was administered at 10:23 p.m. (one hour and 23 minutes after the allowed administration time);-2/11/24, the medication was administered at 9:47 p.m. (47 minutes after the allowed administration time);-2/14/24, the medication was administered at 10:43 p.m. (one hour and 43 minutes after the allowed administration time);-2/15/24, the medication was administered at 9:56 p.m. (56 minutes after the allowed administration time);-2/19/24, the medication was administered at 10:09 p.m. (one hour and nine minutes after the allowed administration time);-2/20/24, the medication was administered at 9:45 p.m. (45 minutes after the allowed administration time);-2/21/24, the medication was administered at 9:37 p.m. (37 minutes after the allowed administration time);-2/26/24, the medication was administered at 10:30 p.m. (one hour and 30 minutes after the allowed administration time);-2/27/24, the medication was administered at 10:00 p.m. (one hour after the allowed administration time);-2/29/24, the medication was administered at 10:40 p.m. (one hour and 40 minutes after the allowed administration time); and,-3/3/24, the medication was administered at 9:40 p.m. (40 minutes after the allowed administration time). The Humalog insulin 8:00 a.m dose was not administered timely on the following days:-2/7/24, the medication was administered at 10:24 a.m. (one hour and 24 minutes after the allowed administration time); and,-2/24/24, the medication was administered at 10:11 a.m. (one hour and 11 minutes after the allowed administration time). The Humalog insulin 12:00 p.m. dose was not administered timely on the following days:-2/28/24, the medication was administered at 1:58 p.m. (one hour and 58 minutes after the allowed administration time); and,-3/2/24, the medication was administered at 2:38 p.m. (two hours and 38 minutes after the allowed administration time). The Humalog insulin 5:30 p.m. dose was not administered timely on the following days:-2/7/24, the medication was administered at 8:43 p.m. (three hours and 43 minutes after the allowed administration time);-2/15/24, the medication was administered at 7:22 p.m. (one hour and 52 minutes after the allowed administration time);-2/19/24, the medication was administered at 7:22 p.m. (one hour and 52 minutes after the allowed administration time); and,-2/25/24, the medication was administered at 7:29 p.m. (one hour and 59 minutes after the allowed administration time).-There were no progress notes documenting the reason the insulin medications were administered late. III. Staff interviewsThe director of nursing (DON) was interviewed on 3/7/24 at 9:35 a.m. The DON said medications needed to be administered on time to get the desired outcome the resident needed. The DON said if a medication was given later than the allowed administration time the nurse should add a progress note to explain why it was administered late. The DON said insulin helped regulate blood glucose levels and it was important to be administered timely.

Based on observations, interviews and record review, the facility failed to assist residents with obtaining vision devices for one (#30) of two residents reviewed for vision/ancillary services out of 46 sample residents. Specifically, the facility failed to ensure Resident #30 received glasses in a timely after an optometry visit. Findings include:I. Facility policy and procedureThe Hearing and Vision services policy and procedure, undated, was received from the nursing home administrator (NHA) on 3/7/24 at 6:17 p.m. It revealed in pertinent part "To ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. "The social worker/social service designee was responsible for assisting residents, and their families, in locating and utilizing any available resources, for the provision of the vision and hearing services the resident needs."Assistive devices to maintain vision include, but not limited to: glasses, contact lenses, and magnifying lens or other devices that were used by the residents."II. Resident #30A. Resident statusResident #30, age greater than 65, admitted on 3/7/23. According to the March 2024 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), Bipolar (mental disorder affecting thinking), type two diabetes mellitus (abnormal insulin regulation) and hemiplegia (paralysis) affecting the right side. The 1/19/24 minimum data set (MDS) assessment documented the resident had moderately impaired cognition with a brief interview of mental status (BIMS) score of 10 out of 15. The assessment did not document the resident's need for glasses. B. Resident InterviewResident #30 was interviewed on 3/5/24 at 9:12 a.m. Resident #30 said he had an eye exam "months ago" but had not gotten his glasses. Resident #30 said he had spoken with the social worker and was told the glasses had to be approved by insurance first. Resident #30 said he needed glasses to see up close and far away. He said he did not have any glasses and he was struggling to see things at times while he waited for insurance to approve his glasses..C. Record reviewReview of Resident #30's electronic medical record (EMR) revealed he had an eye exam on 10/17/23 that documented the resident required glasses and the glasses were to be ordered once the Post Eligibility Treatment of Income (PETI) was approved. III. Staff interviewsThe social service director (SSD) was interviewed on 3/6/24 at 11:05 a.m. The SSD said residents were offered ancillary services, including vision, on admission and quarterly at care conferences. The SSD said the optometrist was usually in the facility every 30 to 60 days. The SSD said the PETI system could take three to four months for glasses to come in. The SSD said sometimes the optometrist had glasses which could be loaned to a resident until their glasses were received. The SSD was unsure where Resident #30's approval for glasses was in the PETI process. The SSD said the facility had had some issues with the PETI system since a new management company took over the facility in July 2023 and getting the PETI system up with the new company's NPI (national provider identifier ) number had been a challenge. The SSD said she did not have any explanation for why Resident #30 had been without the glasses ordered by the optometrist for five months. The social service assistant (SSA) was interviewed on 3/6/24 at 11:12 a.m. The SSA said his glasses were ordered through the PETI system but she was unaware when they should come in. The SSD was interviewed again on 3/6/24 at 5:14 p.m. The SSD said the facility had decided to pay for Resident #30's glasses (during the survey). The SSD provided the facility's receipt for Resident #30's glasses. The NHA was interviewed on 3/7/24 at 9:49 a.m. The NHA said the facility had purchased glasses for Resident #30 (during the survey) and was unsure why the glasses had taken so long to be approved by the PETI system.

Based on observation, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#102) of three residents reviewed with a feeding tube out of 46 sample residents. Specifically, the facility failed to ensure Resident #102 received her tube feeding administrations as ordered by the physician. Findings include:I. Facility policy and procedureThe Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 3/6/24 at 1:24 p.m. It read in pertinent part, "Adequate nutritional support through enteral nutrition is provided to residents as ordered. "The dietician, with input from the provider and nurse:"-Estimate calorie, protein, nutrient, and fluid needs;"-Determines whether the resident's current intake is adequate to meet his or her nutritional needs;"-Recommends special food formulations; and "-Calculates fluids to be provided (beyond free fluids in formula)."Examples of potential benefits of using a feeding tube include:"-Addressing malnutrition and dehydration;"-Promoting wound healing; and/or"-Allowing a resident to gain strength that may allow him or her to return to oral nutrition."II. Resident statusResident #102, age above 65, was admitted on 9/16/23 and readmitted 2/13/24. According to the March 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, need for assistance with personal care, cerebral infarction (stroke), encephalopathy (functioning of the brain is affected), hypertension (high blood pressure) and heart failure. The 2/20/24 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status score (BIMS). She had short and long term memory problems. Her cognitive skills for daily decision making were moderately impaired. She was dependent on staff for all activities of daily living (ADL). The assessment revealed the resident had a feeding tube and received a therapeutic diet. The resident received 51% or more of her nutrition and hydration via a feeding tube. She received nutrition or hydration interventions to manage skin problems. III. ObservationsOn 3/4/24 at 10:35 a.m., Resident #102 was laying in her bed. -Her scheduled tube feeding for 6:00 p.m. to 12:00 p.m. was not running and there was no feeding bag hanging. IV. Record reviewResident #102's malnutrition care plan, revised 12/12/23, revealed the resident was at risk for malnutrition related to encephalopathy, severe sepsis, hypertension and dysphagia (difficulty swallowing). The interventions included:-Encourage adequate nutrition and hydration;-Enteral (feeding tube) nutrition as ordered; and-Observe for signs and symptoms of malnutrition;-There was no tube feeding care plan. The March CPO documented the following physician orders for Resident #102:Enteral feed order one time a day for enteral feeding. Vital AF 1.2 (tube feeding solution) at 67 ml (milliliters) an hour for 18 hours daily. Run between 6:00 p.m. and 12:00 p.m. -Review of Resident #102's progress notes revealed there were no progress notes which addressed Resident #102's tube feeding not running until 12:00 p.m. V. Staff interviews Licensed practical nurse #2 (LPN) was interviewed on 3/6/24 at 8:40 a.m. LPN #2 said Resident #102's tube feeding started at 6:00 p.m. in the evening and ran until 12:00 p.m. the following day. She said the feeding should be given the full 18 hours for the resident to receive the proper nutrition. She said if the tube feeding was held or stopped early the nurse would document the reason why in the progress notes. The director of nursing (DON) was interviewed on 3/6/24 at 4:03 p.m. The DON said Resident #102's tube feeding should be administered for the full 18 hours for the calories and wound healing. She said if the tube feeding was not given or completed in the order time the nurse should document in the progress note the reason and that the physician was notified. The registered dietician (RD) was interviewed on 3/7/24 at 2:18 p.m. The RD said Resident #102's tube feeding should be given the full 18 hours to meet her nutritional needs and for wound healing.

Based on interviews, observations, and record review, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for four (#174, #99, #20, and #95) of four residents reviewed for respiratory care out of 46 sample residents. The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice.-The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe.-The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a Trilogy ventilator (ventilator) at bedtime and managed her trach care and ventilator care herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the resident's bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) responded and placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services, including a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation of immediate jeopardy for serious harm. Findings include:I. Immediate jeopardyA. Findings of immediate jeopardyThe facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice.-The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe.-The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a ventilator at bedtime and managed her trach care and ventilator herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services. Moreover, the facility lacked a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation of immediate jeopardy for serious harm. B. Facility notice of immediate jeopardyOn 3/7/24 at 10:55 a.m. the nursing home administrator (NHA) and director of nursing (DON) were notified that the facility's failure to ensure staff was aware of the status of respiratory equipment, and understood respiratory care procedures for residents with trachs and ventilators, created a situation of immediate jeopardy for serious harm. C. Plan to remove immediate jeopardy 1. The planOn 3/7/24 the NHA presented the following plan to address the immediate jeopardy situation which read in pertinent part:"Identification of residents affected or likely to be affected: the facility took the following actions to address the citation and prevent any additional residents from suffering any adverse outcomes. "On 3/6/24 the respiratory provider evaluated all current residents with a tracheostomy. "The DON/designee audited residents with tracheostomy medical records to ensure the presence of physician's orders and resident specific care plan interventions for the care of their tracheostomy."The DON/designee obtained a bedside supply list and assessed all current residents with a tracheostomy to ensure that any needed tracheostomy care equipment and supplies were at the bedside. "The facility took the following actions to prevent any adverse outcomes from reoccurring. "On 3/7/24, the policy for tracheostomy care and suctioning were reviewed/revised. Removed aseptic technique for trach care. "On 3/6/24 the respiratory provider provided education to licensed nursing staff on tracheostomy care, suctioning, placement of the Trilogy (ventilator), providing nebulizers via trach and following the individualized interventions in each resident care plan, physician's orders for trach care and ensuring trach care equipment/supplies were readily available at the bedside. By 3/15/24, staff who were not present during training will be educated prior to their next working shift and provide return demonstration with training listed above. "On 3/7/24 a PRN (as needed) order was added to Trilogy (ventilator) residents orders on placing residents on the Trilogy in the event the resident is not able to provide self-care."On 3/7/24 the DON/designee placed a respiratory flow sheet at the bedside for tracheostomy care documentation. "On 3/7/24 the DON/designee provided training to licensed staff on the bedside supply list, respiratory flow sheet for documentation. "The DON/designee will audit respiratory flowsheets five times weekly for 30 days, then three times weekly, for 30 days, then one time weekly for 30 days. Results will be reviewed in QAPI to determine further monitoring. "Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. "The respiratory provider will audit supplies weekly and provide trach supplies for tracheostomy residents. In the event a supply is running low, nursing will reach out and order additional supplies from the provider. "In the event of a respiratory change a Licensed nurse will evaluate the resident, provide care within their scope of practice, for further needs a provider will be contacted to provide further orders. If further emergency management is needed 911 will be contacted for hospital transfer." 2. Interviews with staff involved in the training outlined in the plan above revealed a continued lack of understanding regarding specialized respiratory care and services. Registered nurse (RN) #2 was interviewed on 3/7/24 at 5:47 p.m. She said she received training from the respiratory therapist (RT) on 3/6/24. She said she did not receive any instruction on how to work with the ventilator machine. She said she did not usually work with that resident and did not have contact with it. RN #3 was interviewed on 3/7/24 at 5:50 p.m. The RN said she had training on 3/6/24 on suctioning and trach care with a return demonstration. She said she did not receive ventilator training from the facility. LPN #6 was interviewed on 3/7/24 at 5:50 p.m. LPN #6 said she had done the training, however, she did not perform a return demonstration and only repeated the information back verbally. She said she did not get training on the ventilator. LPN #7 was interviewed on 3/7/24 at 5:54 p.m. LPN #7 said she had training on the suction machine and humidifier with the RT. She said she had received training on the ventilator on 1/31/24 before the resident was admitted. RN #4 was interviewed on 3/7/24 at 5:55 p.m. RN #4 said she received training but did not do a return demonstration and did not receive training for the ventilator or on administering a nebulizer treatment through a trach. LPN #5 was interviewed on 3/7/24 at 5:55 p.m. LPN #5 said she received training on 3/6/24 but not on the ventilator as she does not have one on her floor. 3. Based on the interviews above, the facility conducted a second training with licensed nursing staff later in the day on 3/7/24. LPN #7 was interviewed on 3/7/24 at 7:45 p.m. LPN #7 said the staff had training on trach care, trach mask nebulizer treatments, suctioning, connecting the resident to the ventilator, updating the resident care plan, setting up an aerosol, changing the inner cannula, and connecting the ventilator to oxygen. She said the staff did return demonstrations on everything in the training. RN #3 was interviewed on 3/7/24 at 7:45 p.m. RN #3 said the training included suctioning, physician's orders, plans of care, trach site cleaning, nebulizer treatments and where to find supplies. She said supplies were in the crash (emergency) cart and resident rooms. She said the training also included information about the ventilator and how to put it on a resident. She said the staff performed return demonstrations. LPN #5 was interviewed on 3/7/24 at 7:46 p.m. LPN #5 said staff were re-shown how to do trach care with the insertion and removal of inner cannulas, sectioning sterile technique, how to apply nebulizer treatment to a trach, the ventilator machine application, compressor, humidifier adjustments based on oxygen level, cleaning the stoma (the area of skin around the trach), replacing the trach tube, what to do in an emergency, where the supplies are located in the resident's room and on the crash cart, how to suction through the ventilator, ventilator care plans, and physician orders. RN #4 was interviewed on 3/7/24 at 7:50 p.m. RN #4 said the training included suctioning, nebulizer, and connecting a resident to a ventilator machine. She said there was information on supplies and where to get them. She said the staff did a return demonstration. RN #2 was interviewed on 3/7/24 at 7:51 p.m. She said the staff were re-educated on trach care, cleaning, sterile suction, how to use the ventilator, nebulizer treatments given through the trach, care plans, and physician orders. She said the staff were also trained on where equipment and supplies were to be at the bedside, on the crash cart, and in the oxygen room. D. Removal of immediate jeopardyOn 3/7/24 at 8:01 p.m., the NHA and the DON were notified that the immediate jeopardy was lifted based on evidence of the facility's implementation of the plan. However, the deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Facility policy and procedureA. The tracheostomy care policy and procedure, dated 8/2013, was provided by the DON at 1:25 p.m., it read in pertinent part: "The purpose of the procedure is to guide tracheostomy care and the cleansing of reusable tracheostomy cannulas. "Tracheostomy care should be provided as often as needed, at least once daily."A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. "Check physician orders."Clean the removable inner cannula. Unlock the inner cannula. Gently remove the inner cannula by rotating counterclockwise while lifting away from the resident. Clean with a brush. Rinse with saline and dry with pipe cleaners. Replace the cannula carefully and lock in place. "Ensure there is an emergency tracheostomy set at the resident's bedside."B. The mechanical ventilation: setup and monitoring policy and procedure, revised 10/2010, was provided by the respiratory care director (RCD) on 3/6/24 at 1:17 p.m. It read in pertinent part:"The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency. Verify there is a physician's order for this procedure. Review the physician's orders, including instructions for:"Tidal volume (the size of the breath);"Ventilatory rate (the number of breaths);"Pressure limits (how high or low the pressure delivered by the machine should go). In an emergency, a qualified nurse may initiate (start) mechanical ventilation and then obtain specific orders. Review the resident's care plan to assess for any special needs of the resident. Only a qualified nurse or respiratory therapist can initiate mechanical ventilation, based on an appropriate physician order. Steps in the procedure. Check for proper functioning of the lights, alarms, filters, fittings and the humidifier. Start the ventilator. Listen to the resident's lungs and document breath sounds. Connect the ventilator to the resident. Adjust the ventilator alarms so they can be heard by staff responsible for monitoring the resident. Document the resident's status and chart all ventilator settings."III. Resident #174 A. Resident #174, age 62, was admitted to the facility on 3/2/24 and readmitted on 3/3/24 from the hospital. According to the March 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (low oxygen), chronic respiratory failure with hypoxia, pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, pneumonia, acute respiratory distress, pulmonary disease, chronic obstructive pulmonary disease (COPD), and hemiplegia (paralysis of one side of the body) and hemiparesis following cerebral infarctions (stroke) affecting right dominant side. 1. The 3/2/24 minimum data set (MDS) assessment documented the resident was unable to perform the brief interview for mental status (BIMS). The resident was dependent on maximal assistance for eating, personal hygiene, toileting, bathing, upper and lower body dressing, rolling left and right, and moving from sitting to lying in bed. 2. Admission orders dated 3/2/24 read the resident had a tracheostomy with an inner cannula. An admission summary note on 3/2/24 at 2:09 p.m. documented the resident was unable to successfully use a speaking valve via his trach tube. 3. A review of the resident's record and observations revealed a brief hospitalization on 3/2/24, readmission on 3/3/24 with secretions and the need for suctioning, and respiratory distress on 3/6/24 when a mucus plug obstructed his airway. A respiratory therapy assessment and evaluation dated 3/2/24 at 12:17 p.m. documented the resident had coarse crackles bilaterally (both lungs) and had a strong productive cough with thick mucus. An Admission summary note dated 3/2/24 at 12:22 p.m. documented the resident often needed suctioning. An alert note dated 3/2/24 revealed the resident was discharged to the hospital for a displaced trach tube. He returned to the facility on 3/3/24 with a diagnosis of pneumonia, and care plans for his trach care, respiratory care, and pneumonia were initiated. A medication administration note dated 3/5/24 at 10:04 p.m. documented that the resident required suctioning. A medication administration note dated 3/6/24 at midnight documented the resident required suction and that treatment was effective. A nurse's note dated 3/6/24 at 7:15 a.m. documented trach care rendered including suctioning several times with sizable phlegm (mucus). An observation of the resident on 3/6/24 at 2:05 p.m. during a brief tour with the respiratory care director (RCD) revealed Resident #174 was struggling to breathe. B. Staff interviews revealed the facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs and failed to outline procedures and responsibilities to obtain such supplies. 1. At the time of the observation of Resident #174 struggling to breathe (see above), the RCD said the resident's trach tube did not have the inner cannula in place. Further, the nurse said there were no suction catheters in the room; the RCD had to leave the room to obtain more supplies. 2. The RCD was interviewed on 3/6/24 at 12:52 p.m. and 1:43 p.m., and again on 3/7/24 at 9:00 a.m. -He said Resident #174 had a mucus plug on 3/6/24 at 2:05 p.m. when he was observed in respiratory distress. He said he had removed the inner cannula to the trach on 3/6/24 at 9:00 a.m. -He said Resident #174 had three inner cannulas when he returned from the hospital on 3/3/24 and the inner cannula he removed at 9:00 a.m. was the last inner cannula provided by the hospital. He said he had informed the DON that morning that the resident needed more inner cannulas due to the resident being out of supply. He saidthe nursing staff should have called the respiratory provider for supplies on 3/4/24 or 3/5/24. -He said the tracheostomy residents in the building did not have the supplies they needed for care. 3. The DON was interviewed on 3/6/24 at 2:50 p.m. and again on 3/7/24 at approximately 9:10 a.m. -She said she had called the respiratory service provider on 3/6/24 at 11:45 a.m. after the RCD informed her Resident #174 was out of inner cannulas and the inner cannulas were delivered at 2:00 p.m. She said nursing staff should contact the respiratory vendor when the last box of inner cannulas is opened. She said the resident had a history of plugging his trach with mucus plugs. -She said the facility could have requested a monitor that alarmed from the respiratory service provider for Resident #174 but had not done so. 4. Licensed practical nurse (LPN) #8 was interviewed on 3/7/24 at 9:22 a.m. -LPN #8 said the RCD had informed her of the removal of the resident's inner cannula on themorning of 3/6/24. She said Resident #174 had a lot of secretions and needed to be cleaned and suctioned frequently and that morning, they had increased their monitoring of the resident to hourly.-She said she had put her head into the resident's room on 3/6/24 and he had waved her into the room for care when he was having difficulty breathing. She said she had not realized the resident was out of inner cannulas before 3/6/24. She said she had checked the suction supplies but not the inner cannula supply on 3/4/24 and she had not called the respiratory service provider because she did not realize there was a problem. She said she believed the RCD was to call for supplies. 4. The certified respiratory therapist (CRT) from the respiratory service provider was interviewed on 3/6/24 at approximately 2:50 p.m. -The CRT said their service came to the facility as needed or when a request was made for supplies. He said a member of customer service came to the facility once a week; however, that person did not carry supplies. He said the service only comes to the facility if the facility calls in a request. -The CRT said he comes to the facility once a month to perform trach changes. He said not having an inner cannula on the resident's type of trach (Shiley XLT) meant an ambu-bag could not be connected if there was an emergency. He said a resident could develop a plug if an inner cannula was not in place.-The CRT said he had done nurse training on trach care and suctioning in January 2024. IV. Resident #99A. Resident #99, under age 65, was admitted on 10/14/23 and readmitted on 1/24/24. According to the March CPO, diagnoses included obesity with alveolar hypoventilation (low ventilation of the lungs), acute pulmonary edema, tracheostomy, obesity, fluid overload, hypertension (high blood pressure), pulmonary hypertension (high blood pressure affecting the lungs), history of pulmonary embolism (blood clot), and history of Covid-19.1. According to the 1/24/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident respiratory requirements were not listed in the MDS or the person-centered care plan. 2. Record review revealed the resident had a trach tube and used a Trilogy ventilator (ventilator). A nurse's note dated 10/14/23 at 8:26 p.m. documented the resident was dependent on a trach tube with oxygen and used a ventilator at bedtime. A nurse note dated 10/21/23 at 5:55 a.m. documented the resident required assistance with trach care. A physician history and physical note dated 10/24/23 at 6:10 a.m. documented the resident was admitted with chronic hypoxic (low oxygen) respiratory failure and continued on the ventilator. Resident #99 had 2 liters (L) of oxygen requirement while resting and 3L with exertion and nighttime ventilator use since February 2022. A readmission summary note, dated 1/24/24, documented the resident returned from the hospital and was trach-dependent with 2L of oxygen. B. The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. 1. Resident interviewResident #99 was interviewed on 3/6/24 at 1:35 p.m. She said she did her own trach care and suctioning. She also said she put the ventilator on herself at night; however, she said she did not know what her ventilator settings were. 2. Record reviewOn 3/6/24, at the time of the survey, the resident's care plan for respiratory care initiated on 2/7/24 documented the resident was at risk for complications with the respiratory system due to chronic respiratory failure. Interventions included administering IS (incentive spirometry) every two hours as needed. -However, Resident #99 did not have a care plan for tracheostomy care, suctioning, trach changes, or use of the ventilator at night. On 3/6/24, at the time of the survey, a review of Resident #99's orders revealed the orders did not address the ventilator she wore at her trach tube (invasive ventilation) at night. On 3/6/24, a review of Resident #99's record revealed no evidence that the facility documented her use of the ventilator at night. 3. ObservationsOn 3/6/24 at approximately 1:45 p.m. during a brief tour with the RCD of Resident #99's room, there was no ambu-bag at the bedside, the water in the humidification chamber was pink in color instead of clear, there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. 4. Staff interviewsThe DON was interviewed on 3/6/24 at 1:40 p.m. She said there was a ventilator in the building used for invasive ventilation at night through Resident #99's trach tube. She said there should be orders and a care plan for the tracheostomy and ventilator settings. She said the facility did not think about the ventilator being a ventilator, only as a BIPAP (bilevel 2 positive airway pressure support). She said the night shift took care of the resident's ventilator care. The RCD was interviewed on 3/6/24 at 1:43 p.m. He said there should be a care plan and orders for the ventilator and it should be plugged into a red outlet. He said there should be a backup trach set at the bedside. The DON was interviewed again on 3/6/24 at approximately 2:50 p.m. She said the ventilator should be plugged into a red outlet in case of a power outage. She said it could lead to death if the ventilator should stop working while the resident was attached to it and the power went out. V. Resident #95 A. Resident #95 was admitted to the facility on 2/14/24 with diagnoses that included acute respiratory failure with hypoxia, pneumonia, tracheostomy, chronic respiratory failure, obstructive sleep apnea, hypertension, reduced mobility, and convulsions. The resident's record revealed the resident had a tracheostomy. B. The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95.1. ObservationsRegistered nurse (RN) #1 was observed on 3/5/24 at 1:02 p.m. administering medications to Resident #95. RN #1 went into the resident's room to administer an Albuterol nebulizer treatment via trach. She said she was unsure how to apply the nebulizer treatment to the resident's trach and she called for assistance. The assistant director of nursing (ADON) came to help. The ADON said the resident was able to hold the nebulizer in her mouth; however, the nebulizer device did not have a mouthpiece attached to it. The resident was unable to hold it on her own; staff had to hold it for her. The ADON placed the corrugated end of the nebulizer into the resident's mouth and held it for the resident. RN #1 and the ADON were needed elsewhere and they requested another nurse come to hold the nebulizer treatment in the resident's mouth until it was completed. LPN #1 came into the resident's room and said the nebulizer should not have been in the resident's mouth, but rather attached to the trach. LPN #1 turned off the nebulizer machine and attached the nebulizer to the resident's trach for proper administration. 2. Staff interviewsLPN #1 was interviewed at 1:35 p.m. and said the resident may not have gotten the effect of the medication since it was not initially delivered via the trach. LPN #1 reviewed the resident's orders and they did not direct the resident to receive the nebulizer treatment via her mouth. The RCD was interviewed on 3/5/24 at 1:40 p.m. He said nebulizer treatments should be given via trach if the resident had one to ensure medication reached the lungs. The CRT was interviewed on 3/6/24 at 3:02 p.m. The CRT said the easiest way to administer the nebulizer via trach is by way of the trach mask. He said when a nebulizer is administered via mouth, it should have a mouthpiece. He said the corrugated end should not be in the resident's mouth. The ADON was interviewed on 3/7/24 at 2:35 p.m. The ADON said she was flustered and should have taken the time to appropriately administer the nebulizer treatment. She said giving the medication via mouth may not have been as effective as if the resident had gotten it via the trach. She said the mouthpiece was missing from the nebulizer and she should have gotten a new setup or applied it directly to the trach. VI. Resident #20A. Resident #20 was admitted to the facility on 1/9/24 with diagnoses that included pneumonia and respiratory failure. A review of the resident's record revealed the resident had a tracheostomyB. The facility failed to ensure proper trach care for Resident #20.1. ObservationsResident #20's trach care was observed on 3/6/24 at 8:40 a.m. LPN #9 performed trach care on Resident #20. LPN #9 used four swabs, swabbing all the way around the tracheostomy site with each swab. LPN #1 said the inner cannula was to be changed every three days and she had checked it earlier in the morning and it was clean. 2. InterviewThe CRT was interviewed on 3/6/24 at approximately 2:50 p.m. He said staff should be using a one-swab technique for trach care, using one swab on top and tossing it in the trash, one swab on the bottom and tossing it, and the same on the other side of the trach tube. He said staff should not go all the way around the trach tube with one swab, stating it could create infection or cause problems in the area around the tube.

Based on observation and interviews, the facility failed to ensure medications and biologicals were stored in accordance with professional standards for four of six medication carts. Specifically, the facility failed to ensure:-Medication carts were cleaned with no loose medication; and,-Food was not stored in the medication carts. Findings include:I. Facility policy and procedure The Storage of Medication policy and procedure, revised November 2020, was received from the nursing home administrator (NHA) on 3/7/24 at 6:19 p.m. It revealed in pertinent part, "The nursing staff are responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manor. "Medications are stored separately from food and are labeled appropriately."II. Observations and staff interviewsOn 3/7/24 at 11:16 a.m., the Heritage Way West medication cart was observed with licensed practical nurse (LPN) #4. -There were seven whole tablets and one half tablet of medication loose in the medication cart. LPN #4 said she was unable to identify any of the loose tablets. LPN #4 said the night shift nurses were responsible for cleaning the medication carts but she was not aware how often they cleaned the carts. On 3/7/24 at 11:28 p.m.,the Heritage Way East medication cart was observed with LPN #2. -There were 20 whole tablets and seven half tablets of medication loose in the medication cart. -Additionally, the medication cart had an open, undated cup of apple sauce stored in a drawer with medications. LPN #2 said food should not be stored in medication carts due to the risk of cross contamination. LPN #2 said it was the responsibility of all nurses who worked the medication carts to keep the carts clean. LPN #2 said night shift nurses were supposed to do a more thorough cleaning of the medication carts. LPN #2 was able to identify three of the tablets as apixaban (blood thinner), one cymbalta (anti-depressant) and one pantoprazole (stomach acid reducer). On 3/7/24 at 11:42 a.m., the Grand Heritage medication cart #2 was observed with LPN #1. -There were two whole tablets loose in the medication cart. LPN #1 said it was the night shift nurses responsibility to clean the medication cart. On 3/7/24 at 11:49 a.m., the Grand Heritage medication cart #1 was observed with LPN #3. -There were nine capsules, 37 whole tablets and 8.5 half tablets of medication loose in the medication cart. LPN #3 said the supervisors were responsible for cleaning the medication carts. LPN #3 was unaware of how often the medication carts were cleaned. LPN #3 was only able to identify three capsules of Gabapentin (used for neuropathy pain) and one Tamsulosin capsule (bladder relaxer). III. Additional interviewsThe assistant director of nursing (ADON) was interviewed on 3/7/24 at 2:35 p.m. The ADON said the night shift nurses were responsible for cleaning the medication carts nightly. The ADON said food should not be stored in the medication carts as it increased the risk of contamination of medications and food. The director of nursing (DON) was interviewed on 3/7/24 at 4:49 p.m. The DON said medication carts were cleaned nightly by the night shift nurses by wiping from top to bottom on the outside with a disinfectant wipe. The DON said the nurses did not wipe down the inside of the medication carts but looked in the drawers for loose medications or spilled medications. The DON said there should not be any loose medications in the medication carts. The DON said there should not be any food items in the medication carts due to the risk of cross contamination.

Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to follow proper personal protective equipment (PPE) procedures when entering residents' isolation rooms. Findings include:I. Professional referenceAccording to the Center for Disease Control and Prevention (CDC) Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 (6/3/2020), retrieved on 3/11/24 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/communication/print-resources/A_FS_HCP_COVID19_PPE_card.pdf, "PPE must be donned correctly before entering the patient area (isolation rooms, unit if cohorting). PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (e.g., retying gown, adjusting respirator/face mask) during patient care. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. A step-by-step process should be developed and used during training and patient care."II. Facility policyThe COVID-19 policy, revised May 2023, was provided by the nursing home administrator (NHA) on 3/6/24 at 1:24 p.m. It read in pertinent part,"This facility follows infection prevention and control (ICP) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. "The infection prevention and control measures include:"-Encouraging staff, residents, and visitors to remain up-to-date with all COVID-19 vaccine doses;"-Implementing source control measures;"-Implementing universal use of PPE; and"-Following current environmental infection prevention and control recommendations."III. ObservationsOn 3/4/24 at 12:55 p.m., certified nurse aide (CNA) #2 was observed entering room #105 to deliver his lunch tray. The resident was on isolation for COVID-19 and signage was posted along with an isolation cart containing the required PPE. CNA #2 had a N95 respirator mask on. -She did not use alcohol based hand sanitizer (ABHR) before entering the room. -She did not wear a gown, gloves or eye protection. CNA #2 placed the food tray on the resident's over bed table, removed the lid and exited the room. -She did not use ABHR after exiting the room and continued to pass lunch trays to other residents. On 3/6/24 at 8:51 a.m., the activities assistant (AA) was observed entering room #105. The AA did not use ABHR before entering the room. She had a N95 respirator mask on as well as gloves. -The AA did not wear a gown or eye protection. She gave the resident a copy of the day's activities. -The AA did not remove her gloves and use ABHR after exiting the room. She kept the same gloves on and continued from room to room passing out activity fliers and a picture to color. On 3/6/24 at 9:05 a.m., CNA #2 was again observed entering room #105. CNA #2 had a N95 respirator mask on. -She did not use ABHR before entering the room. -She did not wear a gown, gloves or eye protection. CNA #2 picked up the resident's breakfast tray and exited the room. -She did not use ABHR after exiting the room and placed the food tray on the food cart with the other residents' trays. IV. Staff interviews CNA #1 was interviewed on 3/6/24 at 9:10 a.m. CNA #1 said an N95 respirator mask, a gown, gloves and eye protection should be worn before going into a COVID-19 positive room. She said ABHR should be used prior to donning gloves and after removing gloves. She said PPE should be worn anytime staff entered an isolation room. Licensed practical nurse (LPN) #2 was interviewed on 3/6/24 at 9:20 a.m. LPN #2 said facility staff should always wear PPE when entering a COVID-19 positive room. She said the PPE included an N95 respiratormask, an isolation gown, gloves and a face shield. She said ABHR should be used prior to donning gloves and after removing gloves. She said it was important to wear the proper PPE to prevent the spread of COVID-19 to others. The director of nursing (DON) was interviewed on 3/6/24 at 4:03 p.m. The DON said when entering a COVID-19 isolation room, PPE should be worn to protect the residents as well as the staff. She said staff should not be wearing the same gloves and go room to room, especially after leaving a COVID-19 positive room. The DON said she would immediately educate staff on the proper use of PPE and hand hygiene.

A licensure survey was completed on 3/4/24 to 3/7/24. One deficiency was cited.

Based on interviews, observations, and record review, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for four (#174, #99, #20, and #95) of four residents reviewed for respiratory care out of 46 sample residents. The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice.-The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe.-The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a Trilogy ventilator (ventilator) at bedtime and managed her trach care and ventilator care herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the resident's bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) responded and placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services, including a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation for serious harm if the failures were not immediately corrected. Findings include:I. Respiratory care failuresThe facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice.-The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe.-The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a ventilator at bedtime and managed her trach care and ventilator herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services. Moreover, the facility lacked a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation for serious harm if the failures were not immediately corrected. On 3/7/24 at 10:55 a.m. the nursing home administrator (NHA) and director of nursing (DON) were notified that the facility's failure to ensure staff was aware of the status of respiratory equipment, and understood respiratory care procedures for residents with trachs and ventilators, created a situation for serious harm if the failures were not immediately corrected. On 3/7/24 the NHA presented the following plan to address the situation which read in pertinent part:"Identification of residents affected or likely to be affected: the facility took the following actions to address the citation and prevent any additional residents from suffering any adverse outcomes. "On 3/6/24 the respiratory provider evaluated all current residents with a tracheostomy. "The DON/designee audited residents with tracheostomy medical records to ensure the presence of physician's orders and resident specific care plan interventions for the care of their tracheostomy."The DON/designee obtained a bedside supply list and assessed all current residents with a tracheostomy to ensure that any needed tracheostomy care equipment and supplies were at the bedside. "The facility took the following actions to prevent any adverse outcomes from reoccurring. "On 3/7/24, the policy for tracheostomy care and suctioning were reviewed/revised. Removed aseptic technique for trach care. "On 3/6/24 the respiratory provider provided education to licensed nursing staff on tracheostomy care, suctioning, placement of the Trilogy (ventilator), providing nebulizers via trach and following the individualized interventions in each resident care plan, physician's orders for trach care and ensuring trach care equipment/supplies were readily available at the bedside. By 3/15/24, staff who were not present during training will be educated prior to their next working shift and provide return demonstration with training listed above. "On 3/7/24 a PRN (as needed) order was added to Trilogy (ventilator) residents orders on placing residents on the Trilogy in the event the resident is not able to provide self-care."On 3/7/24 the DON/designeeplaced a respiratory flow sheet at the bedside for tracheostomy care documentation. "On 3/7/24 the DON/designee provided training to licensed staff on the bedside supply list, respiratory flow sheet for documentation. "The DON/designee will audit respiratory flowsheets five times weekly for 30 days, then three times weekly, for 30 days, then one time weekly for 30 days. Results will be reviewed in QAPI to determine further monitoring. "Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. "The respiratory provider will audit supplies weekly and provide trach supplies for tracheostomy residents. In the event a supply is running low, nursing will reach out and order additional supplies from the provider. "In the event of a respiratory change a Licensed nurse will evaluate the resident, provide care within their scope of practice, for further needs a provider will be contacted to provide further orders. If further emergency management is needed 911 will be contacted for hospital transfer." 2. Interviews with staff involved in the training outlined in the plan above revealed a continued lack of understanding regarding specialized respiratory care and services. Registered nurse (RN) #2 was interviewed on 3/7/24 at 5:47 p.m. She said she received training from the respiratory therapist (RT) on 3/6/24. She said she did not receive any instruction on how to work with the ventilator machine. She said she did not usually work with that resident and did not have contact with it. RN #3 was interviewed on 3/7/24 at 5:50 p.m. The RN said she had training on 3/6/24 on suctioning and trach care with a return demonstration. She said she did not receive ventilator training from the facility. LPN #6 was interviewed on 3/7/24 at 5:50 p.m. LPN #6 said she had done the training, however, she did not perform a return demonstration and only repeated the information back verbally. She said she did not get training on the ventilator. LPN #7 was interviewed on 3/7/24 at 5:54 p.m. LPN #7 said she had training on the suction machine and humidifier with the RT. She said she had received training on the ventilator on 1/31/24 before the resident was admitted. RN #4 was interviewed on 3/7/24 at 5:55 p.m. RN #4 said she received training but did not do a return demonstration and did not receive training for the ventilator or on administering a nebulizer treatment through a trach. LPN #5 was interviewed on 3/7/24 at 5:55 p.m. LPN #5 said she received training on 3/6/24 but not on the ventilator as she does not have one on her floor. 3. Based on the interviews above, the facility conducted a second training with licensed nursing staff later in the day on 3/7/24. LPN #7 was interviewed on 3/7/24 at 7:45 p.m. LPN #7 said the staff had training on trach care, trach mask nebulizer treatments, suctioning, connecting the resident to the ventilator, updating the resident care plan, setting up an aerosol, changing the inner cannula, and connecting the ventilator to oxygen. She said the staff did return demonstrations on everything in the training. RN #3 was interviewed on 3/7/24 at 7:45 p.m. RN #3 said the training included suctioning, physician's orders, plans of care, trach site cleaning, nebulizer treatments and where to find supplies. She said supplies were in the crash (emergency) cart and resident rooms. She said the training also included information about the ventilator and how to put it on a resident. She said the staff performed return demonstrations. LPN #5 was interviewed on 3/7/24 at 7:46 p.m. LPN #5 said staff were re-shown how to do trach care with the insertion and removal of inner cannulas, sectioning sterile technique, how to apply nebulizer treatment to a trach, the ventilator machine application, compressor, humidifier adjustments based on oxygen level, cleaning the stoma (the area of skin around the trach), replacing the trach tube, what to do in an emergency, where the supplies are located in the resident's room and on the crash cart, how to suction through the ventilator, ventilator care plans, and physician orders. RN #4 was interviewed on 3/7/24 at 7:50 p.m. RN #4 said the training included suctioning, nebulizer, and connecting a resident to a ventilator machine. She said there was information on supplies and where to get them. She said the staff did a return demonstration. RN #2 was interviewed on 3/7/24 at 7:51 p.m. She said the staff were re-educated on trach care, cleaning, sterile suction, how to use the ventilator, nebulizer treatments given through the trach, care plans, and physician orders. She said the staff were also trained on where equipment and supplies were to be at the bedside, on the crash cart, and in the oxygen room. On 3/7/24 at 8:01 p.m., the NHA and the DON were notified that the situation was removed based on evidence of the facility's implementation of the plan. II. Facility policy and procedureA. The tracheostomy care policy and procedure, dated 8/2013, was provided by the DON at 1:25 p.m., it read in pertinent part: "The purpose of the procedure is to guide tracheostomy care and the cleansing of reusable tracheostomy cannulas. "Tracheostomy care should be provided as often as needed, at least once daily."A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. "Check physician orders."Clean the removable inner cannula. Unlock the inner cannula. Gently remove the inner cannula by rotating counterclockwise while lifting away from the resident. Clean with a brush. Rinse with saline and dry with pipe cleaners. Replace the cannula carefully and lock in place. "Ensure there is an emergency tracheostomy set at the resident's bedside."B. The mechanical ventilation: setup and monitoring policy and procedure, revised 10/2010, was provided by the respiratory care director (RCD) on 3/6/24 at 1:17 p.m. It read in pertinent part:"The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency. Verify there is a physician's order for this procedure. Review the physician's orders, including instructions for:"Tidal volume (the size of the breath);"Ventilatory rate (the number of breaths);"Pressure limits (how high or low the pressure delivered by the machine should go). In an emergency, a qualified nurse may initiate (start) mechanical ventilation and then obtain specific orders. Review the resident's care plan to assess for any special needs of the resident. Only a qualified nurse or respiratory therapist can initiate mechanical ventilation, based on an appropriate physician order. Steps in the procedure. Check for proper functioning of the lights, alarms, filters, fittings and the humidifier. Start the ventilator. Listen to the resident's lungs and document breath sounds. Connect the ventilator to the resident. Adjust the ventilator alarms so they can be heard by staff responsible for monitoring the resident. Document the resident's status and chart all ventilator settings."III. Resident #174 A. Resident #174, age 62, was admitted to the facility on 3/2/24 and readmitted on 3/3/24 from the hospital. According to the March 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (low oxygen), chronic respiratory failure with hypoxia, pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, pneumonia, acute respiratory distress, pulmonary disease, chronic obstructive pulmonary disease (COPD), and hemiplegia (paralysis of one side of the body) and hemiparesis following cerebral infarctions (stroke) affecting right dominant side. 1. The 3/2/24 facility assessment documented the resident was unable to perform the brief interview for mental status (BIMS). The resident was dependent on maximal assistance for eating, personal hygiene, toileting, bathing, upper and lower body dressing, rolling left and right, and moving from sitting to lying in bed. 2. Admission orders dated 3/2/24 read the resident had a tracheostomy with an inner cannula. An admission summary note on 3/2/24 at 2:09 p.m. documented the resident was unable to successfully use a speaking valve via his trach tube. 3. A review of the resident's record and observations revealed a brief hospitalization on 3/2/24, readmission on 3/3/24 with secretions and the need for suctioning, and respiratory distress on 3/6/24 when a mucus plug obstructed his airway. A respiratory therapy assessment and evaluation dated 3/2/24 at 12:17 p.m. documented the resident had coarse crackles bilaterally (both lungs) and had a strong productive cough with thick mucus. An Admission summary note dated 3/2/24 at 12:22 p.m. documented the resident often needed suctioning. An alert note dated 3/2/24 revealed the resident was discharged to the hospital for a displaced trach tube. He returned to the facility on 3/3/24 with a diagnosis of pneumonia, and care plans for his trach care, respiratory care, and pneumonia were initiated. A medication administration note dated 3/5/24 at 10:04 p.m. documented that the resident required suctioning. A medication administration note dated 3/6/24 at midnight documented the resident required suction and that treatment was effective. A nurse's note dated 3/6/24 at 7:15 a.m. documented trach care rendered including suctioning several times with sizable phlegm (mucus). An observation of the resident on 3/6/24 at 2:05 p.m. during a brief tour with the respiratory care director (RCD) revealed Resident #174 was struggling to breathe. B. Staff interviews revealed the facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs and failed to outline procedures and responsibilities to obtain such supplies. 1. At the time of the observation of Resident #174 struggling to breathe (see above), the RCD said the resident's trach tube did not have the inner cannula in place. Further, the nurse said there were no suction catheters in the room; the RCD had to leave the room to obtain more supplies. 2. The RCD was interviewed on 3/6/24 at 12:52 p.m. and 1:43 p.m., and again on 3/7/24 at 9:00 a.m. -He said Resident #174 had a mucus plug on 3/6/24 at 2:05 p.m. when he was observed in respiratory distress. He said he had removed the inner cannula to the trach on 3/6/24 at 9:00 a.m. -He said Resident #174 had three inner cannulas when he returned from the hospital on 3/3/24 and the inner cannula he removed at 9:00 a.m. was the last inner cannula provided by the hospital. He said he had informed the DON that morning that the resident needed more inner cannulas due to the resident being out of supply. He saidthe nursing staff should have called the respiratory provider for supplies on 3/4/24 or 3/5/24. -He said the tracheostomy residents in the building did not have the supplies they needed for care. 3. The DON was interviewed on 3/6/24 at 2:50 p.m. and again on 3/7/24 at approximately 9:10 a.m. -She said she had called the respiratory service provider on 3/6/24 at 11:45 a.m. after the RCD informed her Resident #174 was out of inner cannulas and the inner cannulas were delivered at 2:00 p.m. She said nursing staff should contact the respiratory vendor when the last box of inner cannulas is opened. She said the resident had a history of plugging his trach with mucus plugs. -She said the facility could have requested a monitor that alarmed from the respiratory service provider for Resident #174 but had not done so. 4. Licensed practical nurse (LPN) #8 was interviewed on 3/7/24 at 9:22 a.m. -LPN #8 said the RCD had informed her of the removal of the resident's inner cannula on the morning of 3/6/24. She said Resident #174 had a lot of secretions and needed to be cleaned and suctioned frequently and that morning, they had increased their monitoring of the resident to hourly.-She said she had put her head into the resident's room on 3/6/24 and he had waved her into the room for care when he was having difficulty breathing. She said she had not realized the resident was out of inner cannulas before 3/6/24. She said she had checked the suction supplies but not the inner cannula supply on 3/4/24 and she had not called the respiratory service provider because she did not realize there was a problem. She said she believed the RCD was to call for supplies. 4. The certified respiratory therapist (CRT) from the respiratory service provider was interviewed on 3/6/24 at approximately 2:50 p.m. -The CRT said their service came to the facility as needed or when a request was made for supplies. He said a member of customer service came to the facility once a week; however, that person did not carry supplies. He said the service only comes to the facility if the facility calls in a request. -The CRT said he comes to the facility once a month to perform trach changes. He said not having an inner cannula on the resident's type of trach (Shiley XLT) meant an ambu-bag could not be connected if there was an emergency. He said a resident could develop a plug if an inner cannula was not in place.-The CRT said he had done nurse training on trach care and suctioning in January 2024. IV. Resident #99A. Resident #99, under age 65, was admitted on 10/14/23 and readmitted on 1/24/24. According to the March CPO, diagnoses included obesity with alveolar hypoventilation (low ventilation of the lungs), acute pulmonary edema, tracheostomy, obesity, fluid overload, hypertension (high blood pressure), pulmonary hypertension (high blood pressure affecting the lungs), history of pulmonary embolism (blood clot), and history of Covid-19.1. According to the 1/24/24 facility assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident respiratory requirements were not listed in the facility assessment or the person-centered care plan. 2. Record review revealed the resident had a trach tube and used a Trilogy ventilator (ventilator). A nurse's note dated 10/14/23 at 8:26 p.m. documented the resident was dependent on a trach tube with oxygen and used a ventilator at bedtime. A nurse note dated 10/21/23 at 5:55 a.m. documented the resident required assistance with trach care. A physician history and physical note dated 10/24/23 at 6:10 a.m. documented the resident was admitted with chronic hypoxic (low oxygen) respiratory failure and continued on the ventilator. Resident #99 had 2 liters (L) of oxygen requirement while resting and 3L with exertion and nighttime ventilator use since February 2022. A readmission summary note, dated 1/24/24, documented the resident returned from the hospital and was trach-dependent with 2L of oxygen. B. The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. 1. Resident interviewResident #99 was interviewed on 3/6/24 at 1:35 p.m. She said she did her own trach care and suctioning. She also said she put the ventilator on herself at night; however, she said she did not know what her ventilator settings were. 2. Record reviewOn 3/6/24, at the time of the survey, the resident's care plan for respiratory care initiated on 2/7/24 documented the resident was at risk for complications with the respiratory system due to chronic respiratory failure. Interventions included administering IS (incentive spirometry) every two hours as needed. -However, Resident #99 did not have a care plan for tracheostomy care, suctioning, trach changes, or use of the ventilator at night. On 3/6/24, at the time of the survey, a review of Resident #99's orders revealed the orders did not address the ventilator she wore at her trach tube (invasive ventilation) at night. On 3/6/24, a review of Resident #99's record revealed no evidence that the facility documented her use of the ventilator at night. 3. ObservationsOn 3/6/24 at approximately 1:45 p.m. during a brief tour with the RCD of Resident #99's room, there was no ambu-bag at the bedside, the water in the humidification chamber was pink in color instead of clear, there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. 4. Staff interviewsThe DON was interviewed on 3/6/24 at 1:40 p.m. She said there was a ventilator in the building used for invasive ventilation at night through Resident #99's trach tube. She said there should be orders and a care plan for the tracheostomy and ventilator settings. She said the facility did not think about the ventilator being a ventilator, only as a BIPAP (bilevel 2 positive airway pressure support). She said the night shift took care of the resident's ventilator care. The RCD was interviewed on 3/6/24 at 1:43 p.m. He said there should be a care plan and orders for the ventilator and it should be plugged into a red outlet. He said there should be a backup trach set at the bedside. The DON was interviewed again on 3/6/24 at approximately 2:50 p.m. She said the ventilator should be plugged into a red outlet in case of a power outage. She said it could lead to death if the ventilator should stop working while the resident was attached to it and the power went out. V. Resident #95 A. Resident #95 was admitted to the facility on 2/14/24 with diagnoses that included acute respiratory failure with hypoxia, pneumonia, tracheostomy, chronic respiratory failure, obstructive sleep apnea, hypertension, reduced mobility, and convulsions. The resident's record revealed the resident had a tracheostomy. B. The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95.1. ObservationsRegistered nurse (RN) #1 was observed on 3/5/24 at 1:02 p.m. administering medications to Resident #95. RN #1 went into the resident's room to administer an Albuterol nebulizer treatment via trach. She said she was unsure how to apply the nebulizer treatment to the resident's trach and she called for assistance. The assistant director of nursing (ADON) came to help. The ADON said the resident was able to hold the nebulizer in her mouth; however, the nebulizer device did not have a mouthpiece attached to it. The resident was unable to hold it on her own; staff had to hold it for her. The ADON placed the corrugated end of the nebulizer into the resident's mouth and held it for the resident. RN #1 and the ADON were needed elsewhere and they requested another nurse come to hold the nebulizer treatment in the resident's mouth until it was completed. LPN #1 came into the resident's room and said the nebulizer should not have been in the resident's mouth, but rather attached to the trach. LPN #1 turned off the nebulizer machine and attached the nebulizer to the resident's trach for proper administration. 2. Staff interviewsLPN #1 was interviewed at 1:35 p.m. and said the resident may not have gotten the effect of the medication since it was not initially delivered via the trach. LPN #1 reviewed the resident's orders and they did not direct the resident to receive the nebulizer treatment via her mouth. The RCD was interviewed on 3/5/24 at 1:40 p.m. He said nebulizer treatments should be given via trach if the resident had one to ensure medication reached the lungs. The CRT was interviewed on 3/6/24 at 3:02 p.m. The CRT said the easiest way to administer the nebulizer via trach is by way of the trach mask. He said when a nebulizer is administered via mouth, it should have a mouthpiece. He said the corrugated end should not be in the resident's mouth. The ADON was interviewed on 3/7/24 at 2:35 p.m. The ADON said she was flustered and should have taken the time to appropriately administer the nebulizer treatment. She said giving the medication via mouth may not have been as effective as if the resident had gotten it via the trach. She said the mouthpiece was missing from the nebulizer and she should have gotten a new setup or applied it directly to the trach. VI. Resident #20A. Resident #20 was admitted to the facility on 1/9/24 with diagnoses that included pneumonia and respiratory failure. A review of the resident's record revealed the resident had a tracheostomyB. The facility failed to ensure proper trach care for Resident #20.1. ObservationsResident #20's trach care was observed on 3/6/24 at 8:40 a.m. LPN #9 performed trach care on Resident #20. LPN #9 used four swabs, swabbing all the way around the tracheostomy site with each swab. LPN #1 said the inner cannula was to be changed every three days and she had checked it earlier in the morning and it was clean. 2. InterviewThe CRT was interviewed on 3/6/24 at approximately 2:50 p.m. He said staff should be using a one-swab technique for trach care, using one swab on top and tossing it in the trash, one swab on the bottom and tossing it, and the same on the other side of the trach tube. He said staff should not go all the way around the trach tube with one swab, stating it could create infection or cause problems in the area around the tube.

A revisit survey was completed on 12/21/23 for all previous deficiencies cited on 10/25/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 12/12/23 for all previous deficiencies cited on 9/28/23. The facility is in compliance with all regulations surveyed.

A survey for Incident #33981 was conducted 10/24/23 to 10/25/23. One deficiency was cited.

Based on record review and interviews, the facility failed to conduct a preadmission screening resident review (PASRR) for individuals remaining in a facility 30 days past provisional admission approval for one (#3) of three residents reviewed for PASRR out of 10 sample residents. Specifically, the facility failed to submit a new PASRR level I once an automatically approved provisional admission from a hospital had expired for Resident #3 after she resided in the facility for more than 30 days. Findings include:I. Facility policy The Admission Criteria policy, revised March 2019, was received from the nursing home administrator (NHA) on 10/25/23 at 4:17 p.m. It read in pertinent part:"All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. The social worker is responsible for making referrals to the appropriate state-designated authority. The preadmission screening program requirements do not apply to residents who, after being admitted to the facility, were transferred to a hospital. The state may choose not to apply the preadmission screening requirement if:a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care;b. the individual requires facility services for the condition for which he or she received care in the hospital; andc. the attending physician has certified (prior to admission) that the individual will likely need less than 30 days of care at the facility."II. Resident statusResident #3, age under 65, was admitted on 8/8/23 and discharged on 10/10/23. According to the October 2023 computerized physician orders (CPO), diagnoses included major depressive disorder. According to the 8/14/23 minimum data set (MDS), the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She had a score of three out of 27 on the patient health questionnaire, indicating minimal depression. III. Record reviewAccording to the 8/7/23 requested PASRR review, Resident #3 was provided an auto approved provisional admission to remain in the facility for 30 days. It read in pertinent part:"The facility is responsible for submitting a new Level 1 PASRR Screen if the member is anticipated to reside in the facility beyond the approved provisional admission timeline as noted below."Exempted Hospital Discharge = The need for nursing home (NH) regarding convalescent (recovering from an illness or operation) care due to a discharge from an acute care hospital where the rehabilitation care relates to the reason for the hospitalization and has been certified by the attending physician to likely require fewer than 30 days of nursing services." IV. Interviews The social service director (SSD) was interviewed on 10/24/23 at 1:30 p.m. She reviewed the auto approved provisional admission and said Resident #3 had remained in the facility over 30 days and a new level I PASRR should have been submitted. She said she had not done so and did not know if one had been submitted. She said she was not familiar with the provisional admission process. The PASRR program administrator was interviewed on 10/25/23 at 3:34 p.m. She said a new level I PASRR for Resident #3 had not been submitted by the facility when the 30 day provisional admission had expired. She said it was the responsibility of the facility to submit a new level I.

A focused infection control survey was conducted on 9/28/23. 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, #5, #6 and #8) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to:-Offer Resident #1 and #8 the pneumococcal vaccine upon admission; -Offer additional doses of the pneumococcal vaccine to Resident #2, #3 and #5; and,-Have a signed consent of a refusal for Resident #6. 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 9/28/23, 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, revised March 2022 was provided by the nursing home administrator (NHA) on 9/28/23. It read in pertinent part, "All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 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 #1Resident #1, age 70, was admitted on 7/31/23. According to the September 2023 computerized physician orders (CPO) diagnoses included chronic obstructive pulmonary disease, dysphasia and dementia. The 8/22/23 minimum data set assessment (MDS) revealed Resident #1 had memory impairments and had moderately impaired decision making. -The MDS inaccurately documented, that the resident was offered and declined the pneumococcal vaccination. B. Record reviewA review of Resident #1's electronic medical record (EMR) revealed the immunization tracking sheet did not show the resident received the pneumococcal vaccination.-The EMR failed to show that the resident had not been offered the pneumococcal vaccination on admission. The Colorado Immunization Information System (CIIS) showed the PPSV23 was recommended on 7/6/22IV. Resident #2A. Resident #2Resident #2, age 89, was admitted on 9/29/2020. According to the September 2023 CPO diagnoses included chronic obstructive pulmonary disease, palliative care and heart failure. The 8/23/23 minimum data set assessment (MDS) revealed Resident #2 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 offered and declined the pneumococcal vaccination. -However, a review of Resident #2's electronic medical records (EMR) revealed the resident had not been offered the pneumococcal vaccine. B. Record reviewA review of Resident #2's electronic medical record (EMR) revealed the immunization tracking sheet showed the resident refused both the Prevnar 13 and the Polysaccharide (PPSV23) 23. -However, the immunization tracking sheet had no date did not show the resident received the pneumococcal vaccination.-The EMR showed a consent which he signed as a decline, however, there is no date of when it was signed. There was no evidence that the resident had been offered the pneumococcal vaccine any other date. V. Resident #3Resident #3, age 89, was admitted on 7/1/13. According to the September 2023 CPO diagnoses included hemiplegia and hemiparesis (paralysis) following unspecified cerebrovascular disease (stroke) affecting left non-dominant side and osteoarthritis. The 7/5/23 minimum data set assessment (MDS) revealed Resident #3 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record reviewThe immunization record showed the resident received "pneumovax dose 1" on 1/1/05. The resident received the Prevnar 13 on 1/17/18. -There was no evidence that the resident had been offered the pneumococcal vaccine any other date. VI. Resident #5A. Resident #5Resident #5, age 93, was admitted on 11/10/18. According to the September 2023 CPO diagnoses included legal blindness, vascular dementia and hypertension. The 7/26/23 minimum data set assessment (MDS) revealed Resident #5 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 reviewThe immunization record showed the resident received "pneumovax dose 1" on 3/22/10. The resident received the Prevnar 13 on 7/5/16. -There was no evidence the resident was offered the Prevnar 20. VII. Resident #6Resident #6, age 77, was admitted on 3/12/21. According to the September 2023 CPO diagnoses included, traumatic subarachnoid hemorrhage without loss of consciousness, epilepsy, and history of brain injury. The 9/5/23 minimum data set assessment (MDS) failed to assess the residents mental status. The MDS assessment documented the resident was offered and declined the pneumococcal vaccination. B. Record reviewThe immunization record documented, the resident refused the pneumococcal vaccination, however, there was no date. Although, the EMR failed to show a consent which showed the resident refused. VIII. Resident #8 Resident #8, age 71, was admitted on 6/16/23. According to the September 2023 CPO diagnoses included disorder of kidney, benign prostatic hyperplasia, and cerebral infarction. The 7/20/23 minimum data set assessment (MDS) revealed Resident #8 had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. -The MDS assessment inaccurately documented the resident was offered and declined the pneumococcal vaccination. B. Record review-The EMR failed to show any evidence the resident had been offered the pneumococcal vaccination. XI. Staff interviewsThe director of nurses (DON) and the nursing home administrator (NHA) were interviewed on 9/28/23 at 11:30 a.m. The DON said the facility offered residents pneumonia vaccinations. She said at admission the resident's vaccination record was obtained. She said that Colorado Immunization Information System (CIIS) was utilized. 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 that if the resident refused then the resident signed the consent form. She said she wanted the resident to ask again in a few days after refusal, as the resident may of not been feeling well or may not of understood. If they refuse again, then the resident should be asked annually. The DON and the infection preventionist (IP) were interviewed again on 9/28/23 at 12:00 p.m. The DON said she reviewed the medical records for the specific residents (see above). She said the CIIS was not utilized. She said it was only used for Resident #1. She said reviewing the other records, she said there were different issues with each of the resident's pneumococcal vaccinations. The DON said that if a resident refused, the signed consent needed to be in the medical record and dated. She said they would complete an audit to ensure vaccination records were up to date.

A complaint survey, prompted by #CO31917 was conducted on 5/12/23 to 5/16/23. No deficiencies were cited.

A revisit survey was completed on 5/5/23 for all previous deficiencies cited on 3/1/23. The facility is in compliance with all regulations surveyed.

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

A complaint survey, prompted by #CO30992 was conducted on 3/1/23. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for two (#1 and #6) of three out of seven sampled residents. Specifically, the facility failed to ensure records were provided timely upon request for Resident #1 and Resident #6. Findings include:I. Resident #1A. Resident statusResident #1, age younger than 55, was admitted on 11/24/22, readmitted on 12/5/22 and discharged 2/25/23. According to the February 2023 computerized physician orders (CPO), the diagnoses included a history of falling and acute pancreatitis. The 2/23/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required supervision with all activities of daily living. B. Record reviewThe 12/13/22 request for medical records was provided to the facility on 12/13/22 from another skilled nursing facility, for a transfer according to the resident's family request. On 1/30/23 another request was sent to the facility, indicating the request had not been fulfilled from 12/13/22. According to the facility documentation, the facility provided the documentation on 1/30/23, six weeks after the first request. The 12/23/22 request for medical records was provided to the facility from a State Agency to determine the resident's eligibility for financial support. On 1/27/23, an additional request was sent to the facility. It was marked, "second request."II. Resident #6A. Resident statusResident #6, age 60, was admitted on 7/19/22 and discharged 8/19/22. According to the August 2022 CPO, the diagnoses included a stage three pressure injury to the sacrum. The 7/25/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. B. Record reviewThe 11/14/22 request for medical records letter was faxed to the facility on 11/14/22 for Resident #6 from a financial institution. The 12/5/22 request for medical records letter was faxed to the facility on 12/5/22 by a financial institution. It indicated the request was urgent, as they had not received communication back from the facility regarding the request sent on 11/14/22. III. Staff interviewsThe director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 3/1/22 at 2:40 p.m. The NHA said the medical records manager was on leave from the facility during the survey process. The NHA said she thought the facility had 30 days to provide medical records upon request. She said she was unaware of the language of the federal regulation. She said the medical records for both Resident #1 and Resident #6 were not provided timely. She said she was unsure why there was a delay in providing medical records for both Resident #1 and Resident #6.

Based on record reviews and interviews, the facility failed to ensure three (#1, #2 and #3) of three residents reviewed for falls out of seven sample residents received services by a qualified person. Specifically, the facility failed to ensure that Residents #1, #2 and #3 were assessed by a registered nurse (RN) following a fall. Findings include:I. Professional referenceColorado Department of Regulatory Agencies, State Board of Nursing: Practice Act and Laws. 2022. https://dpo.colorado.gov/Nursing/Laws retrieved on 11/8/22 at 3:07 p.m."The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the registered nurse (RN) or medical doctor (MD) for further or 'full' assessment."II. Resident #2A. Resident statusResident #2, age under 65 years, was admitted on 3/29/22. According to the March 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD) and malignant neoplasm (cancer) of the liver. The 12/28/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of seven out of 15. She required extensive assistance of one person with transfers, dressing, toileting, personal hygiene, limited assistance of one person with bed mobility, and supervision of one person with eating. 2. Record reviewThe 1/8/23 nursing progress notes revealed Resident #2 was found by licensed practical nurse (LPN) #2 on the floor of her room. The resident said that she fell on her left knee and caught herself with her left hand. -A review of the resident's medical record did not reveal documentation that an RN had completed an assessment of the resident following the fall and prior to being moved off the ground. The 1/29/23 nursing progress notes documented Resident #2 was found by LPN #3 on the floor of her room, sitting on the left side of her bed, after she had called out for help.-A review of the resident's medical record did not reveal documentation that an RN had completed an assessment of the resident following the fall and prior to being moved off the ground. III. Resident #3 A. Resident statusResident #3, age 79, was admitted on 7/19/16 and readmitted on 2/14/17. According to the March 2023 CPO, the diagnoses included unspecified dementia without behavioral disturbance, mood disturbance, anxiety, bipolar disorder and Parkinson's disease. The 2/16/23 MDS assessment revealed the brief interview for mental status was not completed. She required limited assistance of one person with bed mobility, transfers, toileting, bathing and dressing. It indicated the resident had sustained one fall with no injury during the assessment period. B. Record reviewThe fall care plan, initiated on 7/19/2016 and updated on 2/20/23, documented the resident was at risk for falls due to potential medication side effects. The interventions included encouraging the resident to transfer and change positions slowly, have commonly used articles within reach, ensuring the resident used nonskid footwear, providing frequent toileting and encouraging the resident to call for assistance. The 2/14/23 progress note of 2/14/23 documented the resident was found sitting on the floor while trying to get up. It indicated the licensed practical nurse (LPN) conducted an assessment and found the resident's range of motion was within normal limits with no injury noted.-A review of the resident's medical record did not reveal documentation an RN assessment had been completed following the resident's fall and prior to the resident being assisted off the floor. IV. Resident #1A. Resident statusResident #1, age younger than 65, was admitted on 11/24/22, readmitted on 12/5/22 and discharged 2/25/23. According to the February 2023 CPO, the diagnoses included a history of falling and acute pancreatitis. The 2/23/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required supervision with all activities of daily living. B. Record review The 12/4/22 nursing progress note documented the resident was found on the floor, lying on his stomach with the walker close by. It indicated licensed practical nurse (LPN) #1 assessed the resident and called the ambulance to send the resident to the hospital. -The resident's medical record did not contain documentation that the resident had been assessed by a registered nurse before being transported to the hospital. The 12/11/22 nursing progress note documented that LPN #1 was at the front desk when Resident #1 fell backwards on the door to his room, slamming the door shut. LPN #1 assisted the resident, contacted the physician, called for a registered nurse (RN) to assess the resident and called for the resident to be transported to the hospital. -The resident's medical record did not include documentation that an RN assessment had been completed of the resident following the fall and prior to being transported to the hospital. V. Staff interviews The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 3/1/23 at 2:55 p.m. The DON said an RN assessment should be completed after each incident of falls, prior to the resident being moved from the floor. She said it was not within a LPNs scope of practice to perform an assessment. She said the RN assessment should be documented in the resident's medical record. Registered nurse (RN) #1 was interviewed on 3/1/23 at 3:00 p.m. She said following a fall, the resident should be assessed by a registered nurse. She said the assessment must be done before the resident was moved off of the floor. She said the RN assessment should be documented in the resident's medical record.

A revisit survey was completed on 2/27/23 for all previous deficiencies cited on 12/15/22. 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 01/30/2023 and 02/05/2023, 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.

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 01/16/2023 and 01/22/2023, 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 01/09/2023 and 01/15/2023, 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 01/02/2023 and 01/08/2023, 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). The facility is a one and two-story construction. The first-story is a Type V (111) construction, the second floor is a Type II (111) construction. The first-story Type V (111) structure constructed in 1987 (based on wooden attic space) contained no two-hour fire separation between construction Types, therefor, the building construction is considered to be Type V (111), the lesser of the two construction types. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet and dry fire suppression systems and is classified as Fully Sprinklered. The facility is license for 160 beds. This re-certification survey conducted on January 4, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies". The deficiencies cited were discussed with the Director of Nursing during the exit conference conducted at the end on-site survey.

STANDARD is not met as evidenced by: During the review of the facility records, with the staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system inspection as required by NFPA 96, (Chapter 11, Section 11.2.1). This deficient practice could affect all residents, and staff should a fire occur due to failure to operate effectively due to non-code compliant operation and servicing. This was evidence by the following. Record review indicated when tested the hood exhaust fan shut down during activation of extinguishing system and has not been corrected. NFPA 96 section 8.2.3.1 A hood exhaust fan(s) shall continue to operate after the extinguishing system has been activated unless fan shutdown is required by a listed component of the ventilation system or by the design of the extinguishing system. The Facility Director acknowledge the non-compliant condition of the kitchen hood exhaust fan during record review.

STANDARD is not met as evidenced by: Through observation and staff interview of the fire alarm system during the survey, the facility failed to install and maintain the Interior wall and ceiling finishes in accordance with NFPA 101 Life Safety Code (2012 Edition), section 19.3.3.1 and 10.2. Failure to maintain the flame spread rating of a Class A or B has the potential to harm all occupants, staff and visitor if a fire was to occur. This was evidenced by the following:1) Cart wash room has several missing ceiling tiles. 2) Kitchen above dish machine damage ceiling tiles. The Facility Director acknowledge the deficient condition of the missing ceiling tile during the tour of the facility. 19.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B.Life Safety Code section 19.3.3.1 to comply with section 10.2. Section 10.2.3 requires, in part, interior wall and ceiling finish that is required elsewhere in the Code to be Class A, Class B, or Class C shall be classified based on the test results from ASTM E 84.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following. 1) Fire extinguisher on second floor Medbridge nurse's station is past its 6 year maintenance. 2) Fire extinguisher in the kitchen storage room pin has been removed and is no longer secured. Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire ExtinguishersThe Facility Director acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the door opining on cross-corridor doors in accordance with the Life Safety Code Section 19.3.6.3, 19.3.7.7 and 8.3.4 This deficient practice could affect all residents within wing smoke compartments should the egress become untenable, due to smoke and heat transfer. This was evidenced by the following:1) Door opening in the Heritage Hall cross-corridor would not close completely into the door frame creating a 20-minute smoke barrier. 2) Resident's room 104 door will not close without excessive force. The Facility Director acknowledge the corridor doors condition during the facility tour. Door openings in smoke barriers have at least a 20-minute fire protected rating or are at least 1 3/4- inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets; bevels or astragals are required at the meeting adages.

STANDARD is not met as evidenced by: Based on observation and staff interview during the tour of the facility, it was determined the facility failed to maintain the Heating, Ventilating, and Air-Conditioning Systems in accordance with Section 9.2, 19.5.2.1.9.2, NFPA 90A and 19.5.2.2. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. This was evidenced by the following: 1) The joints on the exhaust vents on both Type 2 clothes dryers in the laundry were connected by sheet metal screws. 2) Fire/smoke damper labeled 014 failed 4 year testing inside room 214. NFPA 54, Section 10.4.4.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system. NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. The dryer vent deficiencies and damper were discussed with the Facility Director during the survey and again during the exit conference with the Director of Nursing.

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

STANDARD is not met as evidenced by: Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment within the facility. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following. A non- documented portable baseboard space heater used for heat was in operation during the walk-through located in the Environmental Services room. The facility acknowledge the deficiency of the prohibited space heaters during the facility tour. Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee's areas where the heating elements of such devices do not exceed 212? F (100? C).

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evidenced by the following. 1) The facility failed to provide documentation at the time of the survey to reflect that the emergency generator was exercised under load at 30 % of the EPS nameplate KW rating in the past 12 months. 2) At the time of the survey no records were available to verify testing and recording of batteryconductance testing in connection with the emergency power supply system (Emergency Generator) monthly. The emergency power supply system deficiency item was discussed with the Maintenance Director during the survey and again during the exit conference with the Administrator. NFPA 110, section 8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate KW rating of the EPS. NFPA 110, Section 8.3.7. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

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.