MOUNTAIN VIEW POST ACUTE

A survey prompted by #CO39277, #CO39339 and #CO39354 was conducted 2/25/25 to 2/26/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#2) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure services and individualized care approaches were provided, and monitored with ongoing assessment, for Resident #2 in order to meet the emotional and psychosocial needs of the resident. Findings include:I. Resident #2A. Resident statusResident #2, age 69, was admitted on 12/20/24 and discharged to another long-term care facility on 2/13/25. According to the February 2025 computerized physician orders (CPO), diagnoses included anxiety, head injury, dementia, depression and epilepsy. The 12/27/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) of eight out of 15. He required supervision with dressing, bathing, ambulation, transfers and hygiene. The assessment indicated the resident had no behaviors. B. Record reviewResident #2's psychosocial emotional trauma care plan, initiated 12/27/24, revealed the resident was at risk for psychosocial and adjustment issues related to emotional distress, ineffective coping skills, and poor impulse control with a history of traumatic events, to include the sudden and expected death of his wife and recent appointment of a guardian. Interventions included attempting non-pharmacological approaches, such as music therapy, breathing exercises, talking to the resident about his feelings, meditation, aroma therapy, offering reading materials and offering behavioral and psychological services as indicated. Review of Resident #2's February 2025 CPO revealed the following physician's orders:Trazodone 50 mg (milligrams), give one tablet by mouth for insomnia one time per day, ordered 12/20/24. Celexa 40 mg, give one tablet by mouth for depression one time per day, ordered 12/21/24 and discontinued 1/21/25. Behavior tracking for antidepressant medication-monitoring for self isolation and refusing to participate in activities. Document interventions attempted: one-on-one interaction and encouraging meditation, ordered 1/21/25. Write a behavior note every shift for discontinuation of Celexa and initiation of Zoloft, ordered 1/22/25. Zoloft 50 mg, give one tablet by mouth for depression one time per day, ordered 1/21/25 and discontinued 1/26/25. Sertraline (Zoloft) 100 mg, give one tablet by mouth for depression one time per day, ordered 1/26/25. Counseling for depression, ordered 1/26/25. Olanzapine 5 mg, give one time for aggression, ordered 2/11/25 and discontinued 2/12/25. Olanzapine 5 mg, give one tablet by mouth for aggression one time per day, ordered 2/11/25. Behavior tracking for antipsychotic medication-monitoring for verbal aggression and delusions. Document interventions attempted: redirection, removal from environment, music, and offer quiet environment, ordered 2/11/25. Review of Resident #2's electronic medical record (EMR) from 12/20/24 through 2/13/25 revealed the following progress notes:The behavior note, dated 12/20/24, revealed Resident #2 displayed visible distress shortly after admission. The resident paced and approached staff with delusions and paranoia. The resident told staff his wife was killed and his house was taken from him. He demanded from staff to tell him why he was in the facility or he would call the police. The staff encouraged the resident to express his concerns and reminded him that he was safe. The nurses requested a one-on-one staff member to sit with Resident #2 but the resident's guardian was unable to find anyone to sit with the resident. The guardian spoke with the resident over the phone and the physician ordered Trazodone to help the resident sleep. The 72-hour charting note, dated 12/22/24, revealed Resident #2 reported visual hallucinations of a dog to the staff. The nursing note, dated 12/23/24 at 5:32 a.m., revealed the resident expressed paranoia when staff requested to collect a urine sample from him to test for a possible infection. The resident told staff he believed the facility was testing him for drug use. The nursing note, dated 12/23/24 at 11:46 a.m., revealed Resident #2 told the staff he needed to leave and did not belong in the facility. The social services note, dated 12/27/24, revealed the resident was moved out of the memory support unit, which was not a locked secure unit, to the general population due to no longer showing interest in exit-seeking. The nursing note, dated 1/5/25, revealed Resident #2 became agitated when he told the nurse he was unable to reach his wife by phone. The resident said there were thugs in his home with his wife and he needed to go save her. The nurse told him the facility was now his home and his wife was not in danger. The resident continued to pace and search for an exit. The resident located an exit and threatened bodily harm to the staff if they attempted to prevent him from leaving the building. Resident #2 left the building and staff followed him until he calmed down and agreed to return. The social services note, dated 1/10/25, revealed Resident #2 told the social services staff he had heard from his son who informed him the resident's wife was deceased. The resident's guardian was contacted to provide comfort to the resident and to calm him down. The nursing note, dated 1/13/25, revealed the facility was seeking a facility with a locked secure memory care unit to move Resident #2 to. The nursing note, dated 1/17/25, revealed the pharmacy had to provide a week's supply of Celexa 40 for the resident until the prior authorization was complete. The nursing note, dated 1/21/25, revealed the physician had received the prior authorization for the Celexa but would wait to evaluate the necessity for the medication on his next visit with the resident then complete the authorization. The interdisciplinary team (IDT) note, dated 1/22/25, revealed Resident #2 missed nine doses of his antidepressant, Celexa. The Celexa was discontinued and Sertraline was started. The behavior note, dated 1/29/25, revealed Resident #2 attempted to leave the facility but was easily redirected. The social services note, dated 2/5/25, revealed the resident was accepted at another facility with a secure memory care unit. The behavior note, dated 2/6/25, revealed Resident #2 was packing his belongings and voicing he was going to leave that evening. The nurse was not able to redirect him. The social services note, dated 2/8/25, revealed the accepting facility said they could not accept the resident until 7/7/25. The behavior note, dated 2/9/25 at 2:49 a.m., revealed Resident #2 was displaying delusions and paranoia that staff had stolen items from him. He was perseverating and hyperfixating on the delusion and was not redirectable. The resident started to believe the staff were not going to help him and he began to threaten bodily harm. The resident began to beat his chest and started to chase the nurse. The police had to be contacted to defuse the situation. The change of condition note, dated 2/9/25, revealed the resident was displaying new or worsening delusions and hallucinations and was a danger to himself or others. The alert note, dated 2/10/25, revealed the facility was seeking alternative placement for the resident. The note instructed staff to approach the resident with care when he was distressed about missing clothing. The behavior note, dated 2/11/25 at 6:36 a.m., revealed Resident #2 claimed to staff that someone had entered his room and stolen his wallet. Staff were unable to redirect him and the resident began pacing and yelling. The resident began throwing items in the hallway from the nurses station and then made physical threats to the staff. The resident punched the glass at the nurses station, breaking it. The staff had to contact the resident's guardian to speak with him in order for him to calm down. The behavior note, dated 2/11/25 at 11:04 a.m., revealed the resident was perseverating on missing items and the staff spent two hours attempting to redirect the resident. The resident became angry and hit his fist into his forehead. The resident told the staff his wallet was missing and he was worried about his wife being upset if there were fraudulent charges on his cards. After staff helped the resident search his room and the laundry for missing items and the social services staff assured him they would assist with any fraud resources, the resident was redirectable and went to activities. The social services note, dated 2/13/25, revealed Resident #2 was accepted for admission at a secure unit long term care facility. The resident was discharged from the facility on 2/13/25. -Review of Resident #2's progress notes from 12/20/24 through 2/13/25 failed to reveal the social services director (SSD) followed up with the resident or the staff regarding the repeated behaviors or the interventions used to de-escalate the behaviors. -Review of Resident #2's EMR did not reveal any psychological and/or psychiatric behavior health provider notes or psychoactive drug meeting reviews regarding the resident. -A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 12/20/24 to 2/13/25 did not reveal any behaviors had been documented for Resident #2. -A review of the certified nurse assistant (CNA) task documentation records failed to reveal documentation of behaviors or interventions attempted for Resident #2. IV. Staff interviewsCNA #1 was interviewed on 2/25/25 at 12:45 p.m. CNA #1 said Resident #2 displayed behaviors of delusions, hallucinations and paranoia. She said the resident could become verbally aggressive. CNA #1 said the interventions the staff were to provide for the resident were redirection and reassurance. Licensed practical nurse (LPN) #1 was interviewed on 2/25/25 at 12:50 p.m. LPN #1 said Resident #2 was agitated when he was on the memory support unit and frequently wanted to leave. She said he could display paranoia when agitated and the staff were to provide redirection. The SSD, the social services director for the memory care unit (SSDMC), and the nursing home administrator (NHA) were interviewed together on 2/26/25 at 11:41 a.m. The SSDMC said Resident #2 came to the facility over the holiday break in December 2024. She said the resident's home environment was not appropriate, as he was living alone without food, water, lights or gas. The SSDMC said the resident had a son but the son did not act as a support unit for Resident #2. She said she did not know if the resident's wife had left him or if she had died and the facility chose not to ask. She said the wife was a trigger and Resident #2 would perseverate on where she was or what was happening to her. The SSDMC said Resident #2 had behaviors of wandering and becoming more agitated as the day progressed. She said when he became more agitated in the evening, Resident #2 would become increasingly possessive of his belongings and paranoid that people were stealing from him. She said in the evening, the resident would search for his items or pack his belongings and tell the staff he was going to leave. The SSDMC said the interventions the staff would try were to help the resident search for his belongings, redirecting and contacting the resident's guardian to talk to the resident. The SSDMC said the non-pharmacological interventions for Resident #2 included redirection, calling the resident's guardian, offering music therapy, breathing exercises, meditation, aroma therapy and offering reading materials to the resident. She said the IDT determined the behavior interventions, along with input from the unit manager. She said the unit manager communicated the person-centered interventions to the floor staff. The SSDMC said the CNAs documented behaviors in the CNA tasks and the tasks were personalized by the IDT to reflect person-centered behaviors and interventions. She said the interventions the nurses used with Resident #2 came from the behavior tracking order in the resident's physician's orders. The SSD said residents taking psychoactive medications would be added to a list to be reviewed in the monthly psychoactive drug meetings, which the behavioral health providers attended. She said a new resident with a diagnosis of cognitive deficits or mental illness who was also taking psychoactive medications was reviewed within the first sixty days of admission. She said if a resident was displaying behaviors, that would warrant including the resident to be reviewed in the psychoactive drug meeting. She said the facility conducted psychoactive drug meetings every third week of the month. The SSD said Resident #2 was not reviewed in the December 2024 or January 2025 psychoactive drug meeting reviews. She said Resident #2 was taking psychoactive medications and his medications were being monitored by a primary care physician. The SSD said she did not know why Resident #2 was not scheduled to be reviewed in the psychoactive drug meetings or why Resident #2 was never scheduled to be evaluated by the psychiatrist. The SSD said it was the responsibility of the social services department to send referrals to the behavioral health provider for counseling services, but she did not know why a referral was never sent for behavioral health counseling for Resident #2. The NHA said the facility began looking for alternative long-term care placement for Resident #2 in January 2025. He said it was determined Resident #2 needed to be in a facility that specialized in aggressive behaviors. The NHA acknowledged, without providing the resident with psychiatric or psychological support or a review in the psychoactive drug meeting, the NHA could not confirm the facility was unable to meet Resident #2's behavioral needs. The NHA acknowledged Resident #2 admitted to the facility with a traumatic history, such as caregiver and spousal loss, the inability to meet his basic needs and legal intervention to appoint a guardian to take over decision making for the resident. -Despite the traumatic history of the resident, the recent displacement from his home to a care facility, and the escalating behaviors displayed after admission, the facility failed to provide Resident #2 with all available resources to remain in the facility and receive psychosocial support.

A revisit survey was completed on 10/17/24 for all previous deficiencies cited on 9/5/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO37316, #CO37317, #CO37322, #CO37324, #CO37326 and #CO37327 and Incident #35800 was completed on 9/3/24 to 9/5/24. Four deficiencies were cited.

Based on observation, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#11) of three residents reviewed for services to maintain highest practicable quality of life out of 25 sample residents. Specifically, the facility failed to provide timely incontinence care for Resident #11. Findings include:I. Facility policy and procedureThe Supporting Activities of Daily Living (ADL) policy, revised March 2018, was received from the nursing home administrator (NHA) on 9/5/24 at 5:08 p.m. It revealed in pertinent part, "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene."Appropriate care and services will be provided for residents who are unable to carry out ADLsindependently, with the consent of the resident and in accordance with the plan of care, includingappropriate support and assistance with elimination (toileting)."II. Resident #11A. Resident statusResident #11, age less than 65, was admitted on 5/1/24. According to the September 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes with diabetic neuropathy (nerve damage caused by diabetes), benign prostatic hyperplasia (BHP) (a noncancerous enlargement of the prostate gland) and phantom limb syndrome with pain (the perception of pain or discomfort in a limb that is no longer there). The 8/6/24 minimum data assessment (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision to touching assistance with toileting hygiene and dressing. The resident was always incontinent of bowel and occasionally incontinent of bladder. B. Resident interview and observationsOn 9/4/24 during a continuous observation, beginning at 12:31 p.m. and ending at 3:16 pm., the following was observed:Resident #11 was interviewed on 9/4/24 at 12:31 p.m. Resident #11 said he was sitting in his own feces during the interview. Resident #11 said an unidentified certified nursing aide (CNA) had entered the room approximately five minutes before the interview and left to go get the supplies she needed to change his brief but had not yet returned. Resident #11 said it was a normal occurrence to have a CNA enter the room to turn off the call light and leave without addressing the resident's needs and that it happened more frequently on the weekends. The room had a strong fecal odor. At 1:07 p.m. several unidentified nursing staff members started passing out lunch trays for Resident #11's hallway.-The unidentified CNA that Resident #11 said had entered his room and turned off the call light did not return to provide him assistance. At 1:13 p.m. an unidentified CNA walked into Resident #11's room to deliver his lunch tray. The CNA walked out of the room promptly after delivering the tray. At 1:43 p.m. an unidentified staff member walked into Resident #11's room to retrieve his lunch tray. The staff member left the room promptly after retrieving the tray. At 2:58 p.m. Resident #11's call light was activated. At 3:00 p.m. CNA #2 entered Resident #11's room and shut the door to provide care for the resident. At 3:14 p.m. Resident #11 left his room. Resident #11 said his brief had just been changed.-Resident #11 waited two hours and 45 minutes for a staff member to assist him with his incontinence episode. Resident #11 was interviewed a second time on 9/5/24 at 10:57 a.m. Resident #11 said he had to wait a long time to have his brief changed on a daily basis and that he once had to wait for five hours. Resident #11 said he felt frustrated by this issue. D. Record reviewThe bladder incontinence care plan, initiated 5/10/24, revealed Resident #11 was at risk for incontinence due to reduced mobility and BHP. Pertinent interventions included ensuring Resident #11 had an unobstructed path to the bathroom, monitoring intake and output per facility policy and monitoring the resident for signs and symptoms of a urinary tract infection.-The care plan did not reveal any focus areas nor interventions related to his bowel incontinence or ADLs. The 8/22/24 annual exam notes revealed Resident #11 required moderate assistance for some ADLs. The provider also indicated Resident #11 was incontinent of both bowel and bladder. E. Staff interviewsCNA #2 was interviewed on 9/4/24 at 3:19 p.m. CNA #2 said she primarily did brief changes for Resident #11 and that he was independent for everything else. CNA #2 said Resident #11 was able to turn himself but she needed to perform the whole brief change and clean him, since he could not perform these activities himself. CNA #2 said Resident #11 was mostly incontinent of bowel. She said he was able to use the urinal himself. CNA #2 said Resident #11 used his call light whenever he had episodes of incontinence. CNA #2 said she checked incontinent residents every two hours to see if they needed incontinence care. CNA #2 said there was quite a lot of fecal matter and some urine in the brief that she had just changed for Resident #11. Licensed practical nurse (LPN) #1 was interviewed on 9/5/24 at 8:49 a.m. LPN #1 said residents regardless of their continence status should be checked at least three to four times each eight hour shift. LPN #1 said the length of time residents could go without having incontinence care depended on the staff that were on shift, but that wait times had improved. LPN #1 said she recently had a resident tell her a CNA came into their room, turned off their call light and left to go get supplies to provide incontinence care but never came back. LPN #1 said she immediately went to the CNA in question and had her correct this issue. LPN #1 also said she had residents tell her that they had been left for a while without having incontinence care performed. LPN #1 said she followed up with these residents to see if they spoke with their nurses and ensured their nurses were aware of the issue. CNA #1 was interviewed on 9/5/24 at 1:50 p.m. CNA #1 said incontinent residents should be checked every two hours. CNA #1 said this timeframe varied resident-to-resident and that some residents were incontinent more often than others. CNA #1 said Resident #11 needed help with incontinence care and changing his brief whenever he had bowel movements. The director of nursing (DON) was interviewed on 9/5/24 at 2:00 p.m. The DON said staff performed checks for incontinent residents. She said the care plan indicated if the resident was incontinent. The DON said the nursing staff tried to assess things like incontinence care when the resident was initially admitted and that the nursing staff and residents have their routines. The DON said the facility generally did not write their care plans to have specific timeframes on incontinence checks like saying they needed to be checked every two hours. Registered nurse (RN) #1 was interviewed on 9/5/24 at 2:06 p.m. RN #1 said Resident #11 needed help with changing his incontinence briefs and providing incontinence care. RN #1 said Resident #11 asked for help whenever he needed it, but that he waited longer than he should have when asking for help. RN #1 said incontinent residents should be checked at least every two hours.

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (#2, #12 and #7) out of 25 sample residents. Specifically, the facility failed to:-Ensure the physician's orders for skin and wound care were followed for Residents #2 and #12; and, -Ensure Resident #7 received medication as ordered by the physician. Findings include:I. Facility policy and procedureThe Wound Care policy, revised October 2010, was provided by the nursing home administrator (NHA) on 9/5/25 at 5:08 p.m. The policy read in pertinent part, "The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name and title of the individual performing the wound care, all assessment data (wound bed color, size, drainage) obtained when inspecting the wound, how the resident tolerated the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment and the reason(s) why, and the signature and title of the person recording the data. Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice."II. Resident #2A. Resident statusResident #2, age less than 65, was admitted on 6/3/24. According to the September 2024 computerized physician orders (CPO), the diagnoses included cerebral palsy (disorder affecting balance and posture), chronic respiratory failure, type 1 diabetes mellitus, muscle weakness, anxiety, necrotizing fasciitis (soft tissue infection) and osteomyelitis (bone infection) of the left tibia (shin bone). The 8/22/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial assistance to move left to right/right to left, to move from sitting to lying and sitting to stand in bed, and substantial assistance for transfers and lower body dressing. He needed moderate assistance for toileting and bathing, supervision for upper body dressing and oral hygiene and set up only for eating. The MDS assessment documented the resident was at risk of developing pressure ulcers and had an unhealed pressure ulcer present upon admission to the facility. B. Record reviewResident #2's skin care plan, revised on 8/7/24, documented he was at risk for skin breakdown related to anxiety, heart disease, chronic obstructive pulmonary disease (COPD), depression, existing other skin problems, impaired mobility, incontinence of bowel, incontinence of bladder, kidney disease, neuropathy, obesity, perspiration, a pressure ulcer of the right heel, surgical wounds, a history of wound infection, and diabetes. He scored as an at risk resident on the Braden Scale (pressure ulcer risk assessment) used to assess the risk of developing pressure ulcers. Pertinent interventions included to administer medications and administer treatments as ordered (initiated on 6/4/24) and elevating and off loading the right heel while in bed (initiated on 8/7/24). The 8/7/24 wound note revealed the resident was seen on 8/7/24 for an unstageable pressure ulcer to his right heel which was present upon admission. The note documented prevention interventions were in place which included staff encouragement for Resident #2 to float his heel while he was in bed. His risk factors included limited mobility, poor impulse control, poor safety awareness, a history of necrotizing fasciitis, a history of cellulitis to his right lower extremity, type two diabetes mellitus, history of below knee amputation, chronic kidney disease, and a preference to spend prolonged periods of time in a wheelchair despite educationand encouragement to lay down between meals. The August 2024 CPO revealed Resident #2 had the following physician's orders:-Cleanse and apply barrier cream to the peri-area every day and night shift for skin integrity, ordered on 6/4/24; hold administration from date 8/15/24 to 8/17/24.-Elevate and off load right heel and left below knee amputation while in bed every day and night shift for pressure injury to the right heel and left surgical wound, ordered on 8/7/24; hold administration from date 8/15/24 to 8/17/24.-A review of Resident #2's August 2024 medication administration record (MAR) and progress notes revealed the treatments (above) were documented as not administered per the physician orders on the 8/23/24 day shift and on the 8/27/24 and 8/31/24 overnight shifts. III. Resident #12A. Resident statusResident #12, age greater than65, was admitted on 9/3/23. According to the September 2024 CPO, the diagnoses included heart disease, high blood pressure, anxiety, type 2 diabetes mellitus and polyneuropathy (damage to multiple nerves throughout the body). The 6/27/24 MDS assessment revealed the resident was cognitively intact with aBIMS score of 15 out of 15. She required substantial/maximum assistance with oral, personal and toileting hygiene, bathing, dressing, transfers, and moving from sitting to standing position. She needed moderate assistance with lying to sitting/sitting to lying in bed, and set up help with eating. B. Resident #12's representative interviewResident #12's representative was interviewed on 9/4/24 at 1:07 p.m. She said Resident #12's post surgical skin treatments were not being provided as ordered and the facility nurses responded they were not aware of Resident 12's physician's orders for post surgical site care. C. Record reviewResident #12's skin care plan, revised on 5/31/24, documented she was at risk for skin breakdown due to impaired mobility, diabetes mellitus, cardiac disease, polyneuropathy, weakness, assistance with activities of daily living (ADL), a history of skin issues, incontinence, perspiration, shearing and friction risk, and impaired cognition. She scored as an at risk resident on the Braden Scale assessment (assessment used to assess the risk of developing pressure ulcers). Pertinent interventions, initiated on 9/5/23, included checking Resident #12's skin daily while providing care and to notify the physician of any abnormal findings. Resident #12's pressure ulcer care plan, revised on 3/27/24, documented she had potential for pressure ulcer development due to immobility, incontinence, impaired cognition, anxiety and aphasia (difficulty expressing and understanding language). Pertinent interventions, revised on 3/27/24, included following the facility policies and protocols for the prevention and treatment of skin breakdown. The August 2024 CPO revealed Resident #12 had the following physician's orders:-Treatment for surgical site to upper mid back: cleanse with warm water and soap, pat dry and pack wound with aquaphor and cover with a dry dressing twice daily two times a day for wound management, ordered on 8/19/24 and discontinued on 8/21/24. -Wound care for the surgical site to the upper mid back, cleanse with wound cleanser, pat dry, apply silver sulfadiazine cream, ag alginate to wound bed, cover with adhesive foamdressing. one time a day for wound management, ordered on 8/22/24 and discontinued on 8/26/24.-A review of Resident #2's August 2024 MAR, TAR and progress notes revealed the following treatments were documented as not administered and left blank per the physician orders on 8/20/24. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/5/24 at 8:49 a.m. LPN #1 said most physician's orders for skin or wounds were scheduled once each shift or twice a day. LPN #1 said nursing staff never knew which orders were completed because the orders were not always marked as completed on the treatment administration record (TAR) and dressings were not always dated or initialed to indicate the dressing was changed. Registered nurse (RN) #3 was interviewed on 9/5/24 at 3:26 p.m. RN #3 reviewed the MAR and confirmed there was no documentation on 8/23/24 indicated the wound care was completed. RN #3 said she was trying to figure out if Resident #2 was out for an appointment that day. RN #3 said it was possible that a nurse was not sure how to sign off in the MAR to indicate Resident #3 was out for an appointment. RN #3 said Resident #2 must have been out for an appointment the morning of 8/23/24 as his barrier cream and heel offloading tasks in the MAR were also left blank. RN #3 said she was not sure why they were left blank if Resident #2 was out for an appointment. RN #3 confirmed there were blank spots in the MAR for the barrier cream and heel unloading tasks on 8/27/24 and 8/31/24. RN #3 said she was not sure why they were blank.-However, there was no documentation that Resident #2 was out of the facility on 8/27/24 and 8/31/24. RN #3 said wound care was not marked as complete in the MAR for Resident #12 for one day. RN #3 said whenever residents missed wound treatments due to being out of the facility, the process was to let the nurse on the next shift know the resident still needed to have their wound treatment whenever the resident returned from their appointment. RN #3 said a blank spot in the MAR could be the result of a progress note not being saved by the software. RN #3 said the facility was having issues with their software in August 2024, that had since been resolved. The regional director of clinical services (RDCS) was interviewed on 9/5/24 at 2:00 p.m. The RDCS said the nurses should have documented in the medication administration record (MAR) if the resident refused a treatment or what the circumstance was. She said it was a missed opportunity to have the correct documentation. V. Resident #7A. Resident statusResident #7, age less than 65, was admitted to the facility on 4/15/21. According to the September 2024 CPO, diagnoses included non-pressure chronic ulcers to the left and right lower legs with fat layers exposed, cellulitis (a bacterial infection that affects the skin's deeper layers and underlying tissue) of the right lower limb, third degree burns to multiple sites over the left and right lower limbs and long-term use of opiate analgesics (pain medications). The 8/9/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status BIMS score of 15 out of 15. The assessment revealed the resident had chronic pain. B. Resident interviewResident #7 was interviewed on 9/5/24 at 10:03 a.m. Resident #7 said he had ongoing issues with his methadone (pain medication) being administered. Resident #7 said the pharmacy did not keep the medication in stock and there had been several instances where he ran out of the medication on a Friday and could not get it again until the following Monday. Resident #7 said he had to take Oxycodone (pain medication) more frequently when his methadone was out of stock, which led to him feeling doped up. Resident #7 said the other medications they use for his pain did not control his pain as effectively, and whenever the methadone was back in stock it took a while for his pain levels to become regulated again. C. Record reviewThe analgesic/opioid care plan, revised on 10/23/23, revealed Resident #7 may have side effects related to his use of methadone. Pertinent interventions included administering the methadone as ordered and not having any abrupt discontinuation as it could cause withdrawal symptoms. The chronic pain care plan, initiated on 4/8/21 and revised on 11/28/23, revealed Resident #7 was at risk for alterations in comfort related to chronic wounds on both of his lower extremities and chronic pain. Pertinent interventions included administering medications as ordered. A review of Resident #7's September 2024 CPO revealed a physician's order for Methadone HCl 10 milligram (mg) oral tablets. Instructionswere to give one tablet by mouth every eight hours for severe pain related to type two diabetes, ordered on 4/27/24. A review of Resident #7's MAR from June 2024 (6/1/24 to 6/30/24) revealed the following:-The 8:00 a.m. dose on 6/4/24 was marked with a nine, which indicated other/see nurses notes;-The 4:00 p.m. dose on 6/4/24 was marked with a nine, which indicated other/see nurses notes; and,-The 12:00 a.m. dose on 6/7/24 was marked with a nine, which indicated other/see nurses notes. A review of Resident #7's MAR from July 2024 (7/1/24 to 7/31/24) revealed the following:-The 8:00 a.m. dose on 7/8/24 was marked with a nine, which indicated other/see nurses notes; and,-The 4:00 p.m. dose on 7/8/24 was marked with a nine, which indicated other/see nurses notes.-Review of the progress notes from 6/1/24 to 8/30/24 did not reveal any nursing notes related to the missed doses on 6/4/24, 6/7/24 and 7/8/24. VI. Staff interviewsLPN #2 was interviewed on 9/5/24 at 7:47 a.m. LPN #2 said a nine marked on the MAR usually indicated a medication was on order. LPN #2 said there would be something recorded in the notes on the MAR if a nine was marked. RN #2 was interviewed on 9/5/24 at 8:00 a.m. RN #2 said a nine marked on the MAR meant "other". RN #2 said if this was marked, the nurse would put a note as to why the medication was not administered. RN #2 said this note would also appear in the progress notes. LPN #1 was interviewed on 9/5/24 at 8:49 a.m. LPN #1 said she had noticed medications had ran out of stock frequently. LPN #1 said there was not an established system of who was ordering what and when it was being ordered. LPN #1 said if a medication ran out, she needed to mark on the MAR that it was unavailable, call the pharmacy to try to get the medication in stock, and alert the DON. LPN #1 said she would alert the resident's provider if it was a medication that was dire or if the medication was not going to be in stock for an extended period of time. The DON was interviewed on 9/5/24 at 2:00 p.m. The DON said she had not heard about any delays from the pharmacy. The DON said if a medication ran out, the nursing staff should call the pharmacy to see when the medication was coming and to check the emergency medication back-up supply. The DON said her phone number was posted everywhere. The DON said with any missed doses the nursing staff needed to contact a provider. RN #1 was interviewed on 9/5/24 at 2:06 p.m. RN #1 said the process for reordering medications began with the nurse running the medication cart noticing a medication was starting to run low. RN #1 said the facility nurses were able to use their software to order the medication directly but the nurses could call the pharmacy if the medication was nearly out of stock. RN #1 said a nine in the MAR meant the medication was not administered and the nurse would have to put a note into the record indicating why the medication was not given. RN #1 said the note would be in the progress notes along with the MAR. RN #1 said she could not find any notes indicating why a nine was marked in the MAR for Resident #7's methadone. RN #1 said Resident #7's Methadone had last been refilled on 8/6/24 but none of the missed doses were around that refill date. RN #1 said Resident #7 was on the methadone for his neuropathy and his pain was very difficult to manage due to his chronic wounds.

Based on record review, observations and interviews, the facility failed to establish a system of records and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to determine that drug records are in order and that an account of all controlled substances is maintained and periodically reconciled. Specifically, the facility failed to:-Maintain a system of controlled substance records for discontinued controlled substances. Findings include:I. Facility policy and procedureThe Controlled Substance policy, revised November 2022, was provided by the nursing home administrator (NHA) on 9/5/24 at 10:56 a.m. The policy read in pertinent part,"The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications."Dispensing and reconciling controlled substances:-Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.-The system of reconciling the disposition of controlled substances includes the destruction and waste.-Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.-Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances.-The consultant pharmacist or designee routinely monitors controlled substance storage records." II. ObservationsOn 9/5/24 at 8:35 a.m., the inventory of discharged/discontinued controlled substances waiting for destruction was observed with the director of nursing (DON) and the NHA. The controlled medications were stored in a four drawer file cabinet that was secured with a padlock. The file cabinet was locked inside the DON's office. The DON unlocked and opened each file cabinet drawer. The drawers contained controlled medications and each drawer was completely full. The medications were dated March 2024 to September 2024. IV. Record review On 9/5/24 at 8:45 a.m., a request was made for the documentation that indicated a system was in place to ensure controlled drugs were periodically reconciled. The DON said there was not a system in place to document the process that medications were tracked after they were discontinued and taken into her custody for destruction (see interview below). V. Staff interviewsThe DON and the NHA were interviewed together on 9/5/24 at 8:45 a.m. The DON said when the medication nurses alerted her to remove controlled substance medications from the medication cart, she reviewed the controlled medication count and signed the control sheet with the nurse. She said after she took the medication into her custody, she stored the controlled medications in the locked file cabinet inside her office. The DON said the NHA and herself had keyed access to her office and she had the keys to the padlocks. The DON said the process to destroy medications included two nurses to witness every destruction and the destroyed items would be entered on a tracking log. She said she placed the discontinued medication in her office until she had the opportunity to complete destruction of the controlled substances. The DON said when she took custody of the controlled substance medication she did not have a system in place to reconcile the discontinued medications. The DON said she had not destroyed any items since took her position in February of 2024. The NHA and DON said the file cabinet drawers included medications from March 2024 to September 2024. The NHA said he was unaware of the large inventory of medications awaiting destruction. He said he would review the facility's resources and consider using a third party to assist in destroying the controlled medications. The NHA said that he contacted the facility pharmacy and said the pharmacist had not completed reconciliation monitoring of controlled substance destruction.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP). Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 9/9/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,"Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities."EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status."II. Facility policy and procedureThe Enhanced Barrier Precautions policy, revised March 2024, was received from the nursing home administrator (NHA) on 9/5/24 at 5:08 p.m. It read in pertinent part, "EBPs are used as an infection prevention and control intervention to reduce the transmission of MDROs to residents."EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity."Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include changing briefs or assisting with toileting."III. Observations On 9/4/24 at 12:31 p.m. a sign indicating that Resident #25 was on EBP was posted next to his door below the room number. The sign read in pertinent part, "everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting" At 3:16 p.m. certified nursing aide (CNA) #2 left a resident' s room across the hall from Resident #25 with a bag of soiled linens. CNA #2 put the soiled linens away then went into Resident #25' s room and closed the door to perform incontinence care (see interview below). -CNA #2 did not perform hand hygiene before entering the resident' s room, nor was she observed donning (putting on) the PPE necessary to perform EBP.IV. Record reviewThe September 2024 CPO revealed Resident #25 had a physician's order for EBP due to Resident #25' s chronic wound, ordered on 5/11/24 at 6:00 a.m. V. Staff interviewsCNA #2 was interviewed on 9/4/24 at 3:19 p.m. CNA #2 said she went into Resident #25' s room and interacted with that resident specifically. CNA #2 said during this interaction she checked to see if Resident #25 needed incontinence care. CNA #2 said to accomplish this she donned gloves, lifted the bed sheet and opened Resident #25' s brief to see if it was soiled. CNA #2 said Resident #25 had not been incontinent, so she wiped his peri-area with a wipe and put his brief back on. CNA #2 said she was not sure if the EBP signs meant the room itself needed EBP or if it was for a resident. CNA #2 said she did not see the EBP sign next to Resident #25' s door before she entered the room and that she did not wear any of the EBP PPE while she was in his room. Licensed practical nurse (LPN) #2 was interviewed on 9/5/24 at 7:47 a.m. LPN #2 said Resident #25 was on EBP for an open wound. LPN #2 said the EBP signs next to the resident' s door were there to let the staff know which precautions when caring for the residents. LPN #2 said the staff needed to don a gown and gloves when performing activities such as wound care, but would not need a gown for no-contact interactions such as setting a meal tray down. Registered nurse (RN) #2 was interviewed on 9/5/24 at 8:00 a.m. RN #2 said that EBP was used for residents with catheters, ports and wounds. RN #2 said any time the staff had to touch the resident or come into contact with their bodily fluids, they would need to wear PPE including a gown and gloves. RN #2 said checking or changing a brief would require EBP PPE. CNA #3 was interviewed on 9/5/24 at 1:29 p.m. CNA #3 said EBP meant the resident had a colostomy bag or a catheter. CNA #3 said this meant staff needed to wear PPE including gloves and a gown when working with those residents. CNA #1 was interviewed on 9/5/24 at 1:50 p.m. CNA #1 said EBP meant the resident had an open wound or catheter, and that the staff needed to wear a gown, mask and gloves when working with those residents. CNA #1 said she had not worn PPE while working with a resident that needed EBP the day prior, as she was moving so fast that she did not even look at the sign before she went in. The infection preventionist (IP) was interviewed on 9/5/24 at 4:42 p.m. The IP said she did rounds each morning and audits to see how well staff followed EBP when working with residents. The IP said she did training when the new EBP guidance was established and had started additional training that day (9/5/24). The IP said she had provided additional spot-trainings during her audits if she saw any staff failures to follow EBP. The IP said staff needed to wear a gown and gloves when making any sort of physical contact, including checking and changing a brief, for residents with wounds or indwelling devices. The IP said hand hygiene should be performed before entering an EBP room, if they become soiled during care, and after leaving the room.

A revisit tot he 2/5/2024 survey was completed on 4/17/2024. The facility was in compliance with the regulation surveyed.

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

A complaint survey, prompted by #CO34760 and #CO34873 was conducted on 2/5/24. One deficiency was cited.

Based on observations, record review and staff interviews the facility failed to provide services according to professional standards of practice for one (#1) out of three sample residents. Specifically, the facility failed to monitor Resident #1, who had a change of condition after suspected illicit drug use. Findings include:I. Facility policy and procedureThe Acute Condition Changes policy, revised March 2018, was received from the nursing home administrator (NHA) on 2/5/24 at 2:59 p.m. The policy documented in pertinent part, "The physician will help the staff monitor a resident with a recent acute changes of condition until the problem or condition resolved or stabilized."II. Resident #1Resident #1, less than age 65, was admitted on 5/9/19 and readmitted on 5/18/22. According to the February 2024 computerized physician order (CPO), diagnoses included diabetes mellitus, epilepsy (seizures), acute respiratory failure, bipolar disorder, anxiety and stimulant use. The 1/1/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independent with transfers, dressing, toileting and personal hygiene. III. Record reviewOn 2/2/24 at 6:16 a.m. the nursing notes documented a certified nurse aide had seen the resident getting out of a car the previous night around 11:00 p.m. -There were no progress notes regarding the resident getting out of a car on 2/1/24. On 2/2/24 at 7:32 a.m. the nursing notes documented the resident's blood pressure (BP) 156/126 mmHg (millimeters mercury), and 160/109 mmHg (elevated) when manually checked. Her pulse was 127 bpm (beats per minute). The resident's pupils were dilated. She denied shortness of breath and chest pain. The provider was notified. The resident's previous blood pressure and pulse were reviewed for January 2023 through November 2023. The resident's baseline pulse varied greatly from 72 bpm to 120 bpm. Her baseline blood pressure was documented as 98/65 mmHg to 137/73 mmHg. On 2/2/24 at 9:17 a.m. the provider ordered a urinalysis (UA) drug screen. The resident refused the drug screen and refused to go to the hospital. She said she wanted to go outside and smoke to calm down. On 2/2/24 at 9:30 a.m. a situation, background, assessment recommendation (SBAR) note documented the resident's blood pressure was 176/120 and her resting pulse was 131 and irregular. A UA and EKG (electrocardiogram) were ordered. On 2/2/24 at 5:17 p.m. the nursing notes documented the EKG showed sinus tachycardia (fast heartbeat) and the resident's blood pressure and pulse were still elevated. The blood pressure was now 160/109 and the pulse was 131 and irregular. The provider was texted the results of the EKG and was informed the nursing staff would monitor the resident's change of condition for the next 72 hours. On 2/2/24 at 5:26 p.m. the nursing notes documented the provider returned the nurses call and said of the resident refusal to do the UA or go to the hospital. The note documented the provider said if the resident showed signs of shortness of breath, chest pain or any other symptoms she must go to the emergency room-However, there were no further nursing notes, vital signs or assessment of the resident by the start of the survey on 2/5/24. -There was no documentation the resident refused vital signs or an assessment. IV. Staff interviewsThe interim director of nursing (IDON) was interviewed on 2/5/24 at 12:16 p.m. She said Resident #1 had been seen sitting in a car with a friend on 2/1/24 late at night. She said in the morning the staff called her and said the resident was acting differently. The staff said the resident was "easier to get along with" than she normally was, her pupils were dilated and her blood pressure and pulse were high. The IDON said the resident had a history of methamphetamine use while a resident and she refused a drug screen that day. The IDON looked at her laptop and said there was no follow up documented on the resident's status after 2/2/24. She said the staff should have assessed her for any changes for at least 72 hours. The IDON said the resident would be at risk for a heart attack or stroke with her elevated pulse and blood pressure. The IDON said she thought a nurse practitioner (NP) had come in to see the resident on 2/2/24. -However, she said there was no note from any provider. The IDON said the nursing staff should have been assessing the resident for any cardiac symptoms and checking her vital signs. She said if the resident had refused an assessment or vital signs that should be documented in the nursing notes. Licensed practical nurse (LPN) #1 was interviewed on 2/5/24 at 1:46 p.m. She said a resident should be monitored for 72 hours after a change of condition including vital signs. She said if a resident had an elevated pulse or blood pressure she would notify the provider and check the vital signs at least twice per shift. She said the licensed nurses were having difficulty tracking and following up on the changes of condition because the electronic medical record (EMR) system no longer flagged residents with a change of condition for follow up. The IDON walked up to the interview at that time. She said she would contact the third party provider of the EMR system for follow-up to correct the issue. Registered nurse (RN) #1 was interviewed on 2/5/24 at 1:56 p.m. She said if a resident's pulse was 130/110 and the pulse was high, the vital signs should be checked every 15 minutes until normal or otherwise directed by the provider. She said the resident should have been assessed for chest pain, shortness of breath, headache and diaphoresis (sweating). V. Facility follow upOn 2/5/24 1:37 p.m., after the IDON was interviewed regarding the facility's failure to monitor the resident, a late entry was added to the progress notes. A late entry nurses note documented in the progress notes, on 2/4/23 at 8:26 a.m. the resident refused vital signs. The note documented the nurse did not notice any abnormal breathing or dilated pupils.-However, there were no further notes regarding the resident's health status or vital signs on 2/4/24. There were no notes regarding the resident's health status or vital signs on 2/3/24. There were no further assessments or vital signs of the resident on 2/2/24 after 5:26 p.m. On 2/6/24 at 3:53 p.m, after the survey, the NHA emailed a progress note from a nurse practitioner (NP) dated 2/5/24 at 3:53 p.m. The note documented the resident was a known illicit drug substance abuser and was witnessed being dropped off at the nursing home late at night. The note documented the resident pulse was significantly elevated otherwise her vital signs were acceptable. The note documented the resident remained asymptomatic. The NP note documented the elevated pulse was likely due to illicit drug use. -However, there was no ongoing assessment of the resident to determine if the resident was asymptomatic.

A revisit survey was completed on 1/23/24 for all previous deficiencies cited on 11/16/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/23/24 for all previous deficiencies cited on 11/16/23. The facility is in compliance with all regulations surveyed.

An emergency preparedness revisit survey was completed on 1/23/24 for all previous deficiencies cited on 11/16/23. The facility is in compliance with all regulations surveyed.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one (1) story, Type V (111) construction with a partial basement that is used for support services only. The facility is licensed for 159 beds and the census on the date of the survey was 141. The facility was constructed in 1973 and 1985. The facility opened a remodeled physical therapy wing in 2008. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system that consists of a wet fire sprinkler system and 3 antifreeze systems. This survey was conducted on December 15, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Delayed Egress Door signage needed by room 14092. Egress Door by 1705 racked Door #103. Delayed egress by sitting room in memory not starting irreversible process | No signage NFPA 101, 7.2.1.6.1.1 A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS or PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 30 SECONDS (if approved by the local fire department) (3)*An irreversible process shall release the lock in the direction of egress within 15 secondsNFPA 101 7.2.1.4.2 Door Leaf Swing Direction. Door leaves required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel under any of the following conditions:(1) Where serving a room or area with an occupant load of 50 or more, except under any of the following conditions:(a) Door leaves in horizontal exits shall not be required to swing in the direction of egress travel where permitted by 7.2.4.3.8.1 or 7.2.4.3.8.2.(b) Door leaves in smoke barriers shall not be required to swing in the direction of egress travel in existing health care occupancies, as provided in Chapter 19.(2) Where the door assembly is used in an exit enclosure, unless the door opening serves an individual living unit that opens directly into an exit enclosure(3) Where the door opening serves a high hazard contents areaThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:1. Need to fix exit sign to memory care | arrows point both ways Life Safety Code Section 19.2.10.1 to comply with 7.10Life Safety Code Section 7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101.1. Game room needs self closure used as storage NFPA 101 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101.1. Backflow stated that tamper switch activates fire alarm needs to be repaired 2. Corroded sprinkler heads in laundry room 3. Loaded(dirty) sprinkler heads in laundry 4. Sprinkler head within 18 inches of a vent in laundry room 5. No sprinkler coverage basement stair exit path | Under Exit Stairs NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 8.5.1.2 Sprinklers shall be positioned to provide protection of the area consistent with the overall objectives of this standard by controlling the positioning and allowable area of coverage for each sprinkler. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. 1. Kitchen in extinguisher mounted to high 5 ' 3" | Should be below 5 ft 2. Need Class K extinguisher sign-age "A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher." NFPA 10 6.1.3.8 Installation Height. 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. 5.5.5* Class K Cooking Media Fires. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. 5.5.5.1 Class K fire extinguishers manufactured after January 1, 2002, shall not be equipped with extended wand–type discharge devices. 5.5.5.2 Fire extinguishers installed specifically for the protection of cooking appliances that use combustible cooking media (animal or vegetable oils and fats) without a Class K rating shall be removed from service. 5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1. Penetration in door 102 over handle and medical records room 2. Door 306 did not latch during survey 3. Door 507, Rehab Gym door needs to be sealed at top 4. Fire Roll down doors | Doors need to be inspected/repaired and returned to service NFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire Drill not conducted at varied times | Qrt 1,2, and 3 1st shift conducted within an hour of each otherNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A licensure survey was completed on 11/13/23 to 11/16/23. Two deficiencies were cited.

Based on observations, record review and interviews the facility failed to ensure two (#93 and #62) of three out of 51 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure:Resident #93, who was at high risk for developing pressure wounds and an increased risk for developing infections, developed a sacral skin wound on 5/25/23 that progressed to a stage 4 sacral pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #63 from the development of pressure wounds. The facility failed to assess, monitor and document skin assessments and pressure wounds. The facility failed to place timely interventions in the prevention of the development and progression of the pressure wound.-Due to facility failures, the resident experienced a stage 4 sacral pressure wound that became infected and required hospitalization and a surgical washout and debridement. Resident #62, who was on hospice and had an increased risk of developing pressure wounds experienced the the following worsening wounds: A pressure wound on the left heel started on 6/22/23 that progressed to an unstageable wound, a stage 2 pressure wound on the left buttock started on 8/28/23, and a pressure wound to the right buttock on started on 10/18/23 which progressed to a stage 3 pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #62 from the development of pressure wounds. The facility failed to accurately assess and monitor and document skin assessment and pressure wounds. The facility failed to communicate and coordinate with hospice in assessing, monitoring, documenting and treating the pressure wounds. -Due to the facility failures, the resident experienced a worsening of her pressure wounds and the formation of new pressure wounds. Findings included:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 11/29/23, "Pressure ulcer classification is as follows: "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). "Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. "Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendonis not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable "Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment." II. Facility policy and procedureThe Prevention of Pressure Injuries policy, revised April 2020, was provided by the nursing home administrator (NHA) on 11/15/23 at 4:34 p.m., read in pertinent part,"Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL). "Select appropriate support surfaces based on the resident ' s risk factors, in accordance with current clinical practice."Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis."The Pressure Ulcer/Skin Breakdown Clinical Protocol policy and procedure, last revised April 2018), was provided by the NHA on 11/15/23 at 4:34 p.m., read in pertinent part,"The nursing staff and practitioner will assess and document an individual ' s significant risk factors for developing pressure ulcer; for example, immobility, recent weight loss, and a history of pressure ulcers."In addition the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; Pain assessment; Resident ' s mobility status; Current treatment, including support surfaces; and All active diagnoses."III. Resident #93A. Resident statusResident #93, age 74, was admitted on 4/6/23 and readmitted on 7/25/23. According to the November 2023 computerized physician ' s orders (CPO), the diagnoses included stage 4 sacral pressure ulcer acquired during stay, chronic leukemia and dementia. A comprehensive assessment completed on 10/2/23 revealed the resident had moderate cognitive impairment. He was dependent, needing staff assistance with toileting and transfers, required substantial/maximal assistance with personal hygiene and bed mobility and was independent with eating. The comprehensive assessment indicated the resident had an unhealed stage 4 pressure ulcer not present upon admission and was at risk for developing pressure ulcers. B. ObservationsOn 11/15/23 at 1:30 p.m. licensed practical nurse (LPN) #6 was observed removing the old dressing on the sacral wound. The sacral wound bed was difficult to visualize due to the depth of the wound. There was no redness or drainage noted around the wound site. Resident #93 was observed on an air mattress. C. Record reviewThe skin breakdown care plan, initiated on 5/10/23 revised on 9/12/23, documented Resident #93 had actual skin breakdown related to decreased mobility, morbid obesity, edema and respiratory failure. It documented Resident #93 had a stage 4 pressure wound to the sacrum (triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis) with a history of infection and debridement. Interventions included preventative skin care, assist the resident to turning and repositioning frequently, encourage fluids, observe skin condition daily with ADL care, obtain dietician consult, pressure redistribution surface to bed and chair, wound treatment, weekly skin checks, weekly wound assessment to include measurements and description of wound. A comprehensive review of the care documented that not all of the care plan interventions were in place had not been initiated on the care plan until 7/27/23 after the resident returned from the hospital from sepsis and surgical debridement of an infected sacral stage 4 pressure wound that he developed in the facility prior to going to the hospital. The documentation failed to reveal personalized interventions that were in place prior to the development of the stage 4 pressure wound. The CPO documented an order for a pressure redistribution mattress to bed, ordered 4/6/23. The 5/25/23 nursing progress notes revealed a change of condition note with an open skin wound or ulcer noted on Resident #93 ' s lower back. The wound nurse assessed the area and cleansed with wound cleanser, medihoney (a wound dressing gel or paste treatment that promotes wound healing) was applied to the wound bed and covered with bordered foam dressing. No documentation of the resident ' s physician being notified. The 5/25/23 physician order documented to cleanse sacral skin tear with wound cleanser, pat dry with gauze, apply medihoney cover with foam border once a day, ordered 5/25/23. The 5/31/23 Braden score (an assessment tool used to predict pressure ulcers) was 12 out of 23 the lower score indicated Resident #93 was at high risk for developing pressure ulcers. The CPO documented an order for resident to be followed by the facility wound specialist, ordered 6/7/23. The 6/8/23 wound care physician note revealed the resident had a stage 4 pressure ulcer on the sacrum. The wound measurements were 6.8 x 9.4 x 2.5 centimeters (cm). with 20% slough and 80% eschar. The 6/12/23 nutrition progress note revealed resident was complaining of his butt being sore with the 6/7/23 and documented that Resident #93 ' s skin and wound had moisture associated skin damage (MASD). The 6/13/23 at 7:30 p.m. the change of condition nursing progress notes documented the resident ' s pressure wound had , foul smelling drainage coming from the sacral wound, the resident ' s skin was cold and clammy, and the resident ' s labs (bloodwork) showed an elevated white blood cell count (indicating a likely infection) The resident was transferred to the hospital. On 6/14/23 hospital admission and surgical records revealed Resident #93 was admitted to the hospital with septic shock secondary to an unhealed infected stage 4 pressure wound and a urinary tract infection (UTI). On 6/16/23 hospital records revealed Resident #93 underwent a surgical washout and debridement of sacral wound with application of wound vac (vacuum) therapy (a dressing connected to a vacuum pump to pull fluid, bacteria and debris out of the wound). The 6/22/23 wound care physician note revealed the wound measurements were 9.2 x 11.5 x 4.5 cm with 80% granulation and 20% slough and was documented as improved. The CPO documented an order for an air mattress, ordered on 6/28/23 discontinued on 7/3/23The CPO documented an order for a low air mattress, ordered on 7/5/23.-A comprehensive review of the medical record revealed an order for an air mattress on 6/28/23, after the resident had been hospitalized for sepsis and underwent surgical debridement of his stage 4 sacral pressure wound. The 7/11/23 wound care physician note revealed the wound measurements were 6 x 8.5 x 2 cm with 100% granulation and was documented as improved. The 7/18/23 wound care physician note revealed the wound measurements were 6 x 8 x 1.7 cm with 60% granulation and 40% slough. The 8/7/23 wound care physician note revealed the wound measurements were 5.9 x 4.6 x 1.5 cm with 100% granulation and was documented as improved. The 8/25/23 wound care physician note revealed the wound measurements were 5.6 x 4.2 x 1 cm with 80% granulation and 20% slough and was documented as improved. The 8/29/23 wound care physician note revealed the wound measurements were 5.6 x 3.2 x 1.2 cm and was documented as improved .The 9/12/23 wound care physician note revealed the wound measurements were 4.5 x 3.5 x 0.8 cm and was documented as improved. The 9/19/23 wound care physician note revealed the wound measurements were 4.5 x 3.5 x 0.8 cm and was documented as improved. The 9/26/23 wound care physician note revealed the wound measurements were 3.9 x 3.1 0.8 cm and was documented as improved. A comprehensive review of the medical record revealed an order for the resident to be followed by a wound care specialist until 6/7/23, 12 days after the wound was identified on 5/25/23. A comprehensive review of the wound physician notes revealed no documentation by the wound care physician before 7/11/23. D. Staff interviewsLPN #6 was interviewed on 11/15/23 at 1:30 p.m. LPN #6 said the wound had improved over the last several months. He said wound care has been following the resident and is seen weekly by the wound physician. He said Resident #93 had been on a different air mattress but had switched to a pump air mattress within the last two months. LPN #4 was interviewed on 11/16/23 at 10:00 a.m. LPN #4 said when a new skin condition was identified an incident report and a change of condition needed to be completed. She said nurses do a weekly skin condition assessment and documented the findings on the skin assessment form. She said after a skin issue was identified the wound nurse, the DON and the physician were notified. The wound care nurse (WD) was interviewed on 11/16/23 at 2:15 p.m. The WD said Resident #93 ' s stage 4 pressure wound had improved and had started as a skin tear that progressed to MASD then to a stage 4 pressure wound. She said she was unable to recall the timeline. She said the previous wound nurse had indicated that the resident had refused dressing changes and repositioning. She said she did not know what interventions were in place when the pressure wound started. She said the resident eventually had to be hospitalized for the pressure wound and had returned with a wound vacuum. She said he had improved since the wound vacuum was removed. The director of nursing (DON) was interviewed on 11/16/23 at 12:12 p.m. She said when a new skin condition was identified staff would notify wound care and the DON by phone or text. She said staff would then notify the physician to obtain orders. Nursing should do weekly formal skin checks and certified nurse aides do daily skin checks with daily care. IV. Resident #62A. Resident statusResident #62, age 79. was admitted on 12/10/20. According to the November 2023 CPO, the diagnoses included cerebral infarction (stroke), epilepsy and malignant breast cancer. The 8/15/23 MDS assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. She was dependent with bed mobility, toileting, personal hygiene, transfers and eating. The MDS documented that the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcers. B. ObservationsOn 11/15/23 at 3:00 p.m. LPN #6 was observed removing dressings from wounds on the left heel and over sacrum and right buttock. -Left heel had eschar noted on the medial (inside) aspect of heel. Heel boots were in place.-Right buttock was observed with an area covered in slough -Coccyx/sacral area with an abrasion and pink wound bed. Resident #62 was observed on a regular non air mattress. C. Record reviewThe skin bruising and skin tear care plan, initiated on 7/18/18 revised 10/25/18, revealed Resident #62 was at risk for bruising and skin tears due to a seizure disorder. Interventions included observe skin daily with ADL care, provide skin tear treatment per physician order and report changes, and weekly skin assessment by licensed nursing personnel. The skin breakdown care plan, initiated 6/3/19 revised 3/23/23, documented Resident #62 was at risk for breakdown due to limited mobility and a splint to hand. Interventions included check frequently under splint, pat skin when drying, encourage resident to consume all fluids, observe skin for signs of skin breakdown, observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed, obtain dietician consult, pressure redistribution surface to bed and chair, provide supplements, weekly skin assessment by licensed nurse. The nutrition care plan, initiated on 7/31/18 revised 11/6/23, documented Resident #62 was on hospice services on 3/1/21 and hospice was following the resident for skin care. A comprehensive review of the care plan failed to document personalized interventions or coordination with hospice services for pressure ulcer monitoring, prevention or interventions. The 10/1/23 nursing weekly comprehensive skin evaluation assessment documented no new skin wounds or concerns. It documented no additional interventions were in place in the prevention of wounds. The 10/8/23 nursing weekly comprehensive skin evaluation assessment documented a pressure ulcer at left gluteal fold (crease under buttock). It did not document the appearance of the wound. It documented no interventions were in place. It documented notification was not required. The 10/15/23 nursing weekly comprehensive skin evaluation assessment documented a pressure wound on the left gluteal fold. It did not document the appearance, stage or size of the wound. It documented no additional interventions were in place. It documented no notification was required. The 10/22/23 nursing weekly comprehensive skin evaluation assessment documented a wound in the right gluteal area. It did not document the appearance, stage or size of the wound. It documented that hospice had a preventative treatment in place for sacral area for protection and that hospice was notified on 10/17/23. It documented that hospice was in to evaluate on 10/18/23. It documented dietary interventions were in place for treatment. The 10/29/23 nursing weekly comprehensive skin evaluation assessment documented an open area at sacrum and left heel. It did not document the appearance, stage or size of the wounds. It did not document additional interventions were in place. It documented no notification was required. The 11/6/23 nursing weekly comprehensive skin evaluation assessment documented a pressure wound on sacrum and left heel. It did not document the appearance, stage or size of the wounds. It did not document additional interventions were in place. It documented no notification was required. A comprehensive review of the nursing weekly comprehensive skin evaluation assessment did not consistently or accurately document the presence, location, appearance, interventions or notification of appropriate providers. The 11/8/23 Braden scale documented that Resident #62 had a score of 13 and was at a moderate risk for pressure ulcer injury. The hospice progress notes documented a left medial heel pressure wound.-On 6/22/23 it was documented as a new onset and the stage was not documented. was documented as red and the size was 4 x 3.75 centimeters (cm). -On 7/6/23 the stage and appearance was not documentedand the size was 3.5 x 3.5 cm.-On 7/13/23 the stage and appearance was not documented and the size was 3.5 x 3.5 cm.-On 7/20/23 the stage and appearance was not documented and the size was 3.5 x 3.5 x 0.1 cm.-On 7/24/23 the stage, appearance and size were not documented.-On 8/2/23 the stage, appearance was not documented and the size was 3 x 3 x 0.1 cm.-On 8/7/23 the stage and size was documented and the appearance was black and necrotic.-On 8/15/23 the stage was not documented, the appearance was black and the size was 2 x 2.5 x 0.2 cm.-On 8/24/23 the stage and appearance was not documented and the size was 2 x 2 x 0.1 cm.-On 8/28/23 the stage, appearance and size was not documented.-On 9/5/23 the stage was not documented, the appearance was black and the size was 2 x 2 x 0.2 cm.-On 9/11/23 the stage and size was not documented, the appearance was black and necrotic.-On 11/3/23 the stage was not documented the wound bed was black and necrotic and the size was 3 x 3 x 3 cm.-There was no documentation of the left heel wound between 9/11/23 and 11/3/23. A comprehensive review of the residents medical record including available hospice notes failed to t reveal consistent or accurate documentation of the wound staging, appearance, measurements or response to treatments. The hospice progress notes documented a left buttock pressure wound.-On 8/28/23 it was documented as a new onset stage 2 pressure wound with the wound bed appearing pink and pale and the size was 1 x 0.75 x 0 cm.-On 8/31/23 it was documented as stage 2 with a red wound bed and 3 x 2 cm in size.-On 9/5/23 it was documented as stage 2 with a red and bloody wound bed and 4.5 x 1 x 0.2 cm in size.-On 11/3/23 the wound bed was documented as pink and healthy with a size of 1.5 x 0.75 x 0 cm. There was no further documentation of the left buttock pressure wound between 9/5/23 and 11/3/23. The hospice progress notes documented a right buttock wound.-On 10/18/23 it was documented as stage 1 and new in onset. The appearance and size was not documented.-On 10/25/23 it was documented as a stage 3 and the size was 2 x 2 cm. There was no further documentation of the right buttock pressure wound after 10/25/23. The 11/15/23 hospice wound care orders documented-Right gluteal fold (crease in buttock) twice weekly and as necessary cleanse with wound cleanser, pat dry, skin prep peri wound, apply medihoney to wound bed and cover with foam dressing. -Left medial heel apply betadine and cover with foam dressing every other day and as necessary for dislodgement. There was no documentation of wound care order for coccyx/sacral or left buttock area. The November 2023 CPO documented wound care and prevention orders-Pressure redistribution mattress, ordered 11/25/22.-Apply optifoam dressing over sacrum every other day and as needed for the prevention of skin breakdown, ordered 1/19/23.-Float heels and apply heel boots, ordered 6/24/23.-Betadine left heel for deep tissue injury every day and as necessary, ordered 6/24/23. There was no documentation of additional interventions put into place after the left heel was identified was identified as black and necrotic on 8/7/23, after a stage 2 left buttock or coccyx wound was identified on 8/28/23 and a right buttock pressure wound was identified on 10/18/23. D. Staff interviewsLPN #6 was interviewed on 11/15/23 at 3:00 p.m. He said that hospice nurse had been rounding on Resident #62 for wound care and dressing changes. He said the staff changed the dressing over the sacrum every other day and also when it became dislodged. He said the staff changed the dressing change on the left heel every day. He said the resident wore heel boots at all times. He said that the resident was on a regular pressure reduction mattress. He said they had not tried any other mattress for the resident after she developed the current pressure wounds. He said that the facility nursing skin documentation should match the hospice wound documentation notes. He said hospice provider should upload their notes into the medical record for staging and measurements and should be documented on the facility skin tracking form. The hospice nurse (HN) was interviewed on 11/15/23 at 3:14 p.m. The HN said the Resident #62 ' s right buttock wound was healed on 11/3/23 and found again on 11/10/23 and was assessed and documented as unstageable. Wound care ordered medihoney and covered it with foam dressing. She said the left heel pressure wound had been present for a period of time but it was documented as improving. She said the wound care orders were to paint the left heel with betadine and cover with a foam dressing and application of heel boots. She said she was not aware of a coccyx/sacral or right buttock wound. She said that the hospice noted for the resident had to be requested by the facility. She said the resident had a history of previous pressure wounds and with the development of the current pressure wounds put the resident at a higher risk of developing pressure wounds. She said additional interventions such as an air mattress would be appropriate to help heal and prevent further formation of pressure wounds. She said she was unaware the resident was not on an air mattress. She said the resident should be on an air mattress and would order one for the resident. The WD was interviewed on 11/16/23 at 2:08 p.m. The WD said that she had not been aware of any pressure wounds for Resident #62. She said nursing staff and the hospice staff had not reported any to her. She said when any resident was identified with pressure wounds or skin issues it needed to be documented in the comprehensive skin assessment and reported to the wound care nurse and the appropriate provider. The DON was interviewed on 11/16/23 at 2:15 p.m. The DON said when a resident was on hospice with hospice doing the nursing skin assessments and wound care for a resident with pressure wounds or skin issues the facility skin assessment documentation should reflect the hospice documentation. She said that the facility and hospice should be in direct communication regarding the assessment and the care of the pressure wounds. She said that the communication between hospice and the facility about the pressure wounds was done informally with the nurses on the unit. The NHA was interviewed on 11/16/23 at 2:20 p.m. The NHA said there was not a good process between the facility and hospice regarding communication on the assessment and care of the pressure wounds for Resident #62.

Based on observations, record review and interviews the facility failed to ensure for four (#75, #79, and #111) of five residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 54 sample residents. Specifically, the facility failed to follow physician orders for significant weight loss, consistently put interventions in place and timely address Resident #75 nutritional needs. Specifically, the facility failed to follow physician orders for weight loss, consistently put interventions in place and timely address Resident #79 nutritional needs. Resident #75 experienced a significant, unplanned weight loss of 12 % in three months. Resident #79 experienced an unplanned weight loss of 5.56 % in one month. Record review and interviews revealed the facility failed to ensure supplements ordered by the physician were being provided to Resident #75 and Resident #79 and additional interventions were assessed for the resident ' s weight loss. Interviews confirmed the facility lacked a system to ensure supplements were being consistently given, change of condition for feeding assistance was being assessed, and potential swallowing difficulties were being evaluated related to significant weight loss. The facility's failure to have a system that ensured physician orders were followed, changes in resident ' s assistance needs and dietary needs were monitored contributed to Resident #75 and Resident #79's weight loss. Resident #111 who was identified as had increased nutritional risk related to dementia and dysphagia experienced a significant weight loss of 7.88% in a one months period of time; however the facility did not initiate timely interventions to prevent the resident from experiencing and additional significant weight loss o 16.55% weight loss in a three months time frame. The facility failed to ensure effective and timely interventions were in place to prevent Resident #111, initially when the resident triggered with significant weight loss. The facility failed to monitor weekly weights, failed to consistently monitor meal intakes, failed to increase a house supplement until after triggering a significant weight loss of 16.55% three months after the resident experienced a significant weight loss of 16.55%. Addidioally, the facility failed to consistently monitor the resident ' s intake of prescribed health nutritional shake supplements when intakes were mostly less than 50%; failed to monitor as necessary health shakes were provided by the nursing staff; and, failed to conduct weekly interdisciplinary (IDT) nutrition assessments. -Due to the facility failures, the resident experienced continued downward trending weight loss. Findings include: I. Facility policy and procedure The Nutrition/Unplanned Weight Loss policy and procedure, revised September 2017, was provided by the nursing home administrator (NHA) on 11/18/23 at 3:51 p.m. It revealed, in pertinent part, "The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. "The physician will review and rule out medical causes of oral or swallowing problems before authorizing other consults or interventions to modify diet consistency. "The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes" II. Resident #75A. Resident statusResident #75, age 92, was admitted on 9/25/2020. According to the November 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, anorexia, and dysphagia oropharyngeal phase (difficulty initiating swallowing). A comprehensive assessment completed on 9/27/23 revealed the resident rarely understood conversation and communication and had short and long term memory deficits and moderately impaired decision making abilities. The comprehensive assessment documented that the resident was independent with eating and did not require assistance from staff. The resident was at risk for malnutrition with no swallowing issues. B. ObservationResident #75 was observed on 11/14/23 from 12:21 p.m. to 12:59 p.m. The resident was sitting in bed in her room when certified nursing aide (CNA) #7 brought in the meal tray. The CNA adjusted the resident ' s bed to a 135 degree angle and repositioned the resident so she was in front of the meal tray on the bedside table. The resident was not able to participate in repositioning. The CNA uncovered the resident ' s food but did not cut up the meal. After the CNA exited the room, Resident #75 took one of the whole meatballs on her plate and put the entire meatball in her mouth. She accompanied the meatball with fluids and began to cough and expressed difficulty breathing. After a minute, the resident stopped coughing but still had not swallowed the meatball in her mouth. Resident #75 finished chewing the meatball at 12:40 p.m. She then picked up a cup of peaches and attempted using her knife in the position of a chopstick to eat the peaches. The resident was able to consume the entire cup of peaches in this manner. The resident attempted to cut up the remaining meatball and put pieces in her mouth while still chewing on the peaches. She took sips of fluids while still chewing peaches and meatballs. At 12:54 p.m. the resident spit the pieces of meatball she had been trying to eat into her hand. She placed the pieces onto her plate. She attempted to drink her milk, but because of the angle of the bed, she spilled the whole cup of milk onto her bed. At 12:59 p.m. the resident tried to eat more of the meatball she had cut up but began coughing while eating. The resident spit out the meatball pieces into her hand and pushed the plate away. C. Representative interviewResident #75 ' s representative was interviewed on 11/13/23 at 3:34 p.m. She stated the resident did not have family involvement and she was a longtime friend of the resident. The representative stated the resident had not been eating well and the facility asked her to prepare and bring in Korean food for the resident but she was not able to come in often enough. The facility kitchen used to make more noodles and rice and Resident #75 would eat those. D. Record reviewResident #75's weight record revealed she experienced a significant, unplanned weight loss of 12 lbs (pounds) and 12 % from 9/3/23 to 11/3/23 (a two month period). The weight and vital record revealed:The resident weighed 100 lbs on 9/1/23. The resident weighed 92 lbs on 10/1/23, a loss of 8% in 30 days. The resident weighed 88 lbs on 11/3/23, a loss of 12% in 60 days. The comprehensive care plan, revised 10/01/23, revealed the resident was at nutritional risk due to dementia and varying appetite. Interventions were to honor the residents' food preferences. The resident liked Korean food and the facility was to prepare preferred Korean food as capable. Provide supplements as ordered and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss, and abnormal labs) and report to nutritionist and physician. The November 2023 CPO revealed the following physician orders:Regular diet with regular texture- ordered on 9/25/23;House supplement- two times a day for weight maintenance- ordered on 9/22/23 discontinued 11/3/23;House supplement- three times a day for weight maintenance- ordered on 11/3/23;Speech assessment with swallow study to ensure correct diet- ordered on 11/14/23 (during survey); and,Regular diet, dysphagia texture advanced texture- ordered on 11/14/23 (during survey). The September 2023 medication administration record (MAR) reviewed from 9/22/23 through 9/30/23 revealed:The resident drank 50% of the house supplement two times. The resident drank 25% of the house supplement one time. The resident drank 0% of the house supplement one time. The resident did not receive the house supplement two times. The October 2023 MAR reviewed from 10/1/23 through 10/31/23 revealed:The resident drank 50% of the house supplement two times. The resident drank 25% of the house supplement two times. The resident drank 0% of the house supplement five times. The resident did not receive the house supplement six times. The November 2023 MAR reviewed from 11/1/23 through 11/16/23 revealed:The resident drank 50% of the house supplement eight times. The resident drank 25% of the house supplement one time. The resident drank 0% of the house supplement three times. The resident did not receive the house supplement two times. A review of the progress notes dated 9/3/23 through 11/16/23 revealed:Nutrition narrative note dated 11/14/23 (during survey) at 6:20 p.m. revealed the registered dietitian (RD) spoke with speech therapy and requested resident being assessed with swallow study to ensure resident had the safest and most effective diet. Nutrition narrative note dated 11/14/23 (during survey) at 8:01 p.m. revealed the RD observed the resident during dinner with downgraded diet texture. The resident ate 75% of her meal independently with initial prompting. -There were no prior nutrition notes between 9/3/23 to 11/13/23. -According to medication administration notes reviewed from 9/3/23 through 11/16/23, the resident did not receive the house supplement nine times in September 2023 due to the supplement not being available.-The resident did not receive the house supplement six times in October 2023 due to the supplement not being available.-The resident did not receive the house supplement one time in November 2023 due to the supplement not being available. Nutritional assessments reviewed from 9/3/23 through 11/16/23 revealed:-No nutritional assessments conducted after 8/7/23. Weight variance assessment dated 10/2/23 documented the resident had a 8 % weight loss and was attributed by nursing to varying meal intake and dementia. The resident showed a preference to sugary food so the staff held the dessert from meals to encourage the resident to eat more of the regular meal. RD to trail Mirtazapine 7.5 milligram (mg) for thirty days to stimulate appetite. RD asked the resident ' s power of attorney (POA) to bring in Korean foods for the resident to increase intake. The Mirtazapine was discontinued after 10/31/23 without further information. Weight variance assessment dated 11/3/23 documented the resident had a 12% weight loss and was attributed by nursing to varying meal intake and refusing meals. The resident had increased sleeping and was refusing meals. Weight loss was determined to be due to furthering dementia. Residents POA was bringing in Korean food for the resident which the resident frequently refused. -However, record review showed the facility failed to put further interventions in place to mitigate weight loss beyond house supplement drinks which were provided inconsistently. The resident was not assessed for changes in feeding needs or changes in swallowing or chewing functioning until the survey observations were brought to staff's attention. III. Resident #79A. Resident statusResident #79, age 70, was admitted on 10/20/2020. According to the November 2023 CPO, diagnoses included unspecified dementia. A comprehensive assessment completed on 8/17/23 documented the resident was rarely understood and had short and long term memory deficits and moderately impaired decision making abilities. She was assessed to be independent with eating and did not require assistance from staff. B. ObservationOn 11/14/23 at 11:40 a.m. Resident #79 was observed sitting in the memory care dining room. The resident sat at her table and did not have any drinks. Resident #79 was served her meal at 12:12 p.m. The resident did not eat or attempt to eat her meal. Resident #79 did not receive any encouragement from staff to eat. She was not offered an alternative since she was not eating her meal. At 12:39 Resident #79 still had not eaten any of her meals. At 12:51 CNA #7 came and took the resident ' s meal without offering any alternative. C. Record reviewResident #79's weight record revealed she experienced an unplanned weight loss of six lbs and 5.56% from 9/1/23 to 11/3/23 (a two month period). The weight and vital record revealed:The resident weighed 108 lbs on 9/1/23. The resident weighed 102 lbs on 10/1/23, a loss of 5.56% in 30 days. The resident weighed 102 lbs on 11/3/23. The comprehensive care plan, revised 5/25/23, revealed the resident was at nutritional risk due to dementia. The resident had increased nutrient needs related to excess energy expenditure, constant wandering and pacing. Interventions were to provide nourishment as ordered, offer finger foods, staff assistance at meals to cut food into smaller pieces, supplements as ordered and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss, and abnormal labs) and report to nutritionist and physician. The November 2023 CPO revealed the following physician orders:Regular diet with regular texture- ordered on 11/3/2020;House nourishment- two times a day for weight stability. Chocolate pudding or equivalent offered by kitchen- ordered on 10/6/23;House supplement- one time a day for weight stability- ordered on 10/7/23;Speech assessment for evaluation only- ordered on 11/15/23 (during survey). The September 2023 MAR reviewed from 9/1/23 through 9/30/23 revealed:The resident did not receive house supplements or house nourishments in the month of September 2023. The October 2023 MAR reviewed from 10/7/23 through 10/31/23 revealed:The resident drank 50% of the house supplement five times. The resident drank 0% of the house supplement two times. The resident did not receive the house supplement ten times. The resident consumed 25% of the house nourishment one time. The resident consumed 0% of the house nourishment four times. The resident did not receive the house nourishment nine times. The November 2023 MAR reviewed from 11/1/23 through 11/16/23 revealed:The resident drank 0% of the house supplement three times. The resident did not receive the house supplement three times. The resident consumed 50% of the house nourishment three times. The resident consumed 0% of the house nourishment four times. The resident did not receive the house nourishment four times. A review of the progress notes dated 9/3/23 through 11/14/23 revealed:-The resident did not receive the house nourishment fourteen times in September 2023 due to the nourishment not being available.-The resident did not receive the house nourishment four times in October 2023 due to the nourishment not being available. The resident did not receive the house supplement three times in October 2023 due to the supplement not being available.-The resident did not receive the house nourishment three times in November 2023 due to the nourishment not being available. The resident did not receive the house supplement two times in November 2023 due to the supplement not being available. Assessments reviewed from 9/3/23 through 11/16/23 revealed:-No nutritional assessments conducted after 8/14/23. Weight variance assessment dated 10/6/23 documented the resident had a 5.6 % weight loss in one month and was attributed by nursing to varying meal intake and falling asleep during meals. When the resident was offered a peanut butter and jelly sandwich for a snack, she would consume 100 %. The resident slept through breakfast so the RD ordered peanut butter and jelly sandwiches for a snack and supplement drinks. Nutritional risk review dated 11/6/23 documented the resident would eat sandwiches offered but not the entire sandwich. The resident liked cheeseburgers and the RD would add cheeseburgers to her meals once a week and change snacks from sandwiches to pudding. The RD had reviewed the care plan for the risk review. -However, record review showed the facility failed to put further interventions in place to mitigate weight loss beyond house supplement drinks and nourishment snacks which were provided inconsistently. The facility failed to follow the care plan interventions of cutting the resident ' s food and providing finger foods. IV. Staff interviews CNA #7 was interviewed on 11/14/23 at 1:30 p.m. She stated Resident #75 ate a regular diet. Resident #75 could be selective with the food she ate but if she liked the food she would eat a lot of it. She preferred rice and noodles. CNA #7 said Resident #79 wandered the unit frequently and sometimes would not sit down for a meal. If the staff provided her food inside of a cup with a utensil and allowed her to walk with it, she would eat the food. When the resident did sit down for meals, she preferred finger foods but did not receive these often from the kitchen. Licensed practical nurse (LPN) #5 was interviewed on 11/14/23 at 1:45 p.m. She said Resident #75 and Resident #79 were prescribed house supplement drinks for weight loss but the unit often did not get the supplements from the kitchen. When the nurse requested the supplements from the kitchen, they would be told the kitchen was too short staffed to bring any over or the kitchen had run out of supplements. The dietary manager (DM) was interviewed on 11/14/23 at 1:51 p.m. She stated the kitchen sent supplements to Resident #75 and Resident #79 ' s unit three times a day. She did not know if the nursing staff passed the supplements to the residents. The DM had been receiving the drink buckets with the unopened supplements sent back from nurses and let the RD know. The director of nursing (DON) was interviewed on 11/14/23 at 2:09 p.m. The DON said Resident #75 needed staff to set up her meals, with additional encouragement and reminders to eat. The facility had not requested a speech evaluation after the resident ' s significant weight loss because the resident ' s daughter did not want an evaluation. The resident ' s code status was do not resuscitate (DNR) or withhold cardiopulmonary resuscitation if found without a pulse or heartbeat. The daughter did not want any changes to her diet preferences or diet texture due to this. -However, there was no family involvement according to the resident's representative who was trying to help the facility find food the resident liked to eat (see interview above). The DON was not aware if the resident was at risk for choking or had difficulty swallowing. The DON said Resident #79 required set up for her meals. The resident was at nutritional risk but there had not been a speech evaluation ordered for possible changes in eating assistance or eating abilities. The resident preferred finger foods but there was no order to ensure the resident received finger foods. The DON had not heard from the nurses the residents had not been receiving house supplements consistently as ordered. If a resident had significant weight loss, the RD would complete an observation of the resident when eating to see if additional interventions were needed. The RD was interviewed on 11/14/23 at 2:36 p.m. The RD said Resident #75 was receiving a regular diet with regular textures. The resident was to receive supplement shakes three times a day, hot chocolate with milk, chocolate pudding and cookies to add calories. The RD did not observe residents while eating, instead she relied on feedback about the resident eating habits and ability from the nurses. The nurses had told the RD that Resident #75 sometimes consumed her supplements and meals and sometimes she did not and attributed this to her advancing dementia. The RD had not evaluated if the resident required more eating assistance and was no longer appropriate or able to be eating independently. The RD said Resident #79 was to receive house nourishments three times a day and these consisted of pudding or snacks. The resident was to be given a supplement shake for weight management. The RD had ordered the resident a burger once a week. She did not know why the resident was not being provided more finger foods and had not observed the resident eating. The RD said she relied on the nurses for feedback and had not followed up with any additional evaluations or assessments to address her weight loss. The RD was aware there was a discrepancy between the nursing and the kitchen staff over whether or not the kitchen was failing to send supplements or if the nurses were failing to pass out the supplements. This had been going on for two months and the RD had not taken any action to resolve the discrepancy. The RD said if a resident had weight loss with snacks and supplements ordered and it was not impacting their weight loss, the RD would look into changes in swallowing or cognitive ability to eat without increased assistance. -However, there was not record of these approaches being attempted with either Resident #75 or Resident #79. V. Resident #111A. Resident statusResident #111, age 96, was admitted on 6/2/23. According to the November 2023 CPO the diagnoses included cerebral infarction (stroke), heart failure and moderate protein calorie malnutrition. A comprehensive assessment completed on 9/4/23 revealed the resident had severe cognitive impairment. He was dependent on staff assistance for toileting, personal hygiene, transfers and required substantial to maximal assistance with bed mobility and eating. The resident had or was at risk for malnutrition. B. Record reviewThe nutrition care plan, initiated on 6/5/23 and revised on 11/7/23, indicated that Resident #111 had increased nutritional risk related to dementia and dysphagia, Interventions included fortified foods, honoring food preferences, weigh and alert the dietician and physician to any significant loss or gain, monitor for changes in nutritional status, including changes in intake and ability to feed self, monitor intake at all meals, offer alternate choices, alert dietician and physician to any decline in intake, total assistance required at meals (initiated 6/5/23), and offer alternative food choices if less than 50% consumed at mealtime. A comprehensive review of the care plan failed to reveal personalized interventions for weight loss for Resident #111 until 11/7/23 with a loss of 5.1% in one month. The resident ' s weights were documented as follows:-6/2/23 165 lbs (pounds)-7/11/23 152 lbs-8/1/23 142.7 lbs-8/4/23 142.4 lbs-9/1/23 137.7 lbs-10/6/23 136.8 lbs-11/3/23 130.1 lbs-11/13/23 131.4 lbsA comprehensive review of the resident ' s weights revealed a weight loss of 7.88% in one month (6/2/23-7/11/23) and a loss of 16.55% in three months (6/2/23-9/1/23). The November CPO indicated an order for weekly weights every Monday, ordered on 6/5/23 and reordered on 11/6/23. A comprehensive review of the CPO and the medical record failed to reveal documentation of weekly weights from 6/5/23 until 11/7/23. The November CPO indicated an order for the resident to be assisted with every meal, ordered on 8/10/23. The November CPO indicated an occupational therapy order for staff to continue to provide the resident feeding assistance for all meals, ordered on 8/11/23. The 9/1/23 quarterly nutritional risk review documented that Resident #111 had a weight loss trend and triggered significant weight loss of 16.5% in three months. A comprehensive review of the interdisciplinary team weight variance documentation did not indicate any further documentation before 9/1/23. A comprehensive review of the CPO revealed the following diet and supplementation orders:-House supplement once a day for weight loss for poor oral intake with weight loss, ordered 7/12/23 discontinued 9/1/23.-Med pass (fortified nutritional shake) twice a day for three months, ordered on 8/10/23, discontinued on 9/1/23.-Liquid protein supplement for low protein labs for two months ordered 9/1/23-House supplement twice a day for weight loss for three months, ordered 9/2/23-Health shake PRN (as necessary), Ensure provided by family, if resident consumes less than 50% of his meal, ordered on 9/1/23 discontinued 11/8/23. No documentation of it being given in October or November.-Two gram sodium dysphagia advanced texture diet, with large portions of protein ordered 9/26/23. The October 2023 medication and treatment administration record (MAR/TAR) indicated an order for a health shake as needed for weight loss, provided the resident consumes less than 50% of his meals. There was no documentation if a health shake was provided. The 10/6/23 interdisciplinary team weight variance assessment documented Resident #111 ' s weight of 136.8 pounds (lbs) with a previous weight of 152 lbs and indicated a weight loss of 10% in three months. The November 2023 MAR/TAR indicated an order for health shakes as needed for weight loss. There was no documentation to show if the health shake was provided. The 11/8/23 IDT (interdisciplinary team) weight variance assessment documented Resident #111 ' s weight of 130.1 lbs with a weight loss of 5.1% in one month. The 11/10/23 nutrition progress notes documented communication with the resident ' s daughter regarding updating the resident ' s food preferences and reviewing current supplementation. -There was no detail on the outcome of the communication. A comprehensive review of the nutrition progress notes did not indicate any further documentation before 11/10/23. A comprehensive review of meal intakes revealed inconsistent documentation of the resident food intake. There were several days when staff failed to record the resident's meal intake including:-On 10/17/23 no documentation of intake for breakfast-On 10/19/23 documentation of lunch refusal by resident-On 10/20/23 no documentation of intake for breakfast or lunch-On 10/25/23 no documentation of intake for breakfast or lunch-On 11/4/23 no documentation of intake for breakfast or lunch-On 11/5/23 documentation of 25% or less for breakfast, less than 50% for lunch-On 11/6/23 no documentation of intake for dinner-On 11/7/23 no documentation of intake for dinner-On 11/9/23 documentation of 25% or less for breakfast, no documentation of intake for dinnerA comprehensive review of diet and supplementation orders and oral intake indicated that house supplementation was not increased to twice a day until 9/2/23 after Resident #111 had triggered a weight loss of 16.55% for three months. The medical record indicated no documentation of the health shake (Ensure) being provided or the amount when the resident refused meals or had an intake of 50% or less. It indicated that oral intake was not being consistently documented. C. Staff interviewsCertified nurse assistant (CNA) #3 was interviewed on 11/16/23 at 9:50 a.m. She said residents with weight loss or significant weight loss have an order to be weighed weekly, other residents were weighed monthly. She said Resident #111 was a resident that required one to one assistance with meals. Licensed practical nurse (LPN) #4 was interviewed on 11/16/23 at 10:00 a.m. She said residents were usually weighed monthly. Residents with weight loss or significant weight loss had an order to be weighed weekly. The registered dietician (RD) was interviewed on 11/16/23 at 9:00 a.m. She said that Resident #111 was on a dysphagia advanced diet with additional portions of protein and required one to one assistance while eating. She said he had inconsistent intakes for meals. She said that he was on a house supplement twice a day, a Boost shake once a day, and his daughter brought in Ensure, which the daughter offered. She said that he had been on the Med Pass fortified shake, but was discontinued because he did not like it. She said he has had a significant weight loss of 20.4% over the past five months. She said his current supplements were started in September, with one being started in November. She said they discussed significant weight loss daily in morning meetings. She said weekly weights had not been done until they had been ordered in November. The corporate nurse consultant (CNC) was interviewed on 11/16/23 at 9:10 a.m. She said it was an expectation that all residents who triggered for significant weight loss were to be weighed weekly and the IDT was to conduct a weekly nutrition review and conduct a quarterly IDT review.

A recertification survey with complaint #CO34157 was completed from 11/13/23 to 11/16/23. Twenty-one deficiencies were cited.

An Emergency Preparedness survey was conducted from 11/13/23 to 11/16/23. Four deficiencies were cited.

Based on record review and interviews, the facility failed to have a complete emergency preparedness communication plan. Specifically, the facility failed to have a complete communication plan that included an updated emergency use contact list to include all contact information for entities providing services under arrangement which included physician providers, oxygen suppliers and durable medical equipment suppliers. Findings include: I. Record review The emergency preparedness plan (EPP) was provided by the maintenance director (MTD) and environmental consultant (EC) 11/16/23 9:30 a.m. Review of the EPP revealed the facility did not have all contact information for staff, entities providing services under arrangements, and all resident physicians included in the EPP. II. Staff interview The EPP was reviewed with the MTD and EC on 11/3/22 at 10:00 a.m. The MTD said the facility did not have all contact information for staff, entities providing services under arrangements, and all residents ' physicians included in the EPP. The MTD said it was important to have all the contact information in case the facility needed to contact staff, entities providing services under arrangements, and all residents ' physicians ' in the event of an emergency.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program, annual risk assessment, facility EP policies and procedures, and the communication plan that was delivered to all staff annually.. Specifically, the facility failed to provide an emergency preparedness training and testing program for current and new staff. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the maintenance director (MTD) and environmental consultant (EC) on 11/16/23 at 9:30 a.m. Review of the EPP revealed the facility did not have an emergency preparedness training and testing program for current and new staff. II. Staff interview The EPP was reviewed with the MTD and EC on 11/16/23 at 9:30 a.m. The MTD said the facility did not have a current training or testing program for staff and new hires included in the EPP. He said it was important to have an EPP training and testing program to ensure the staff were up to date on the most current information available to provide the best care possible to the residents who resided in the facility. The MTD said they had completed training yesterday on the EP. The training only showed if staff knew where the EP book was located. Three staff interviews were completed. Registered nurse (RN) #2 was interviewed on 11/16/23 at 2:30 p.m. RN #2 said she knew where the EPP book was but didn ' t know what it was for. RN #3 was interviewed on 11/16/23 at 2:50 p.m. RN #3 said he knew the EPP book was on each nursing station but if there was a problem the director of nursing would be contacted. Certified nurse aide (CNA) #4 was interviewed on 11/16/23 at 2:56 p.m. She said no one had spoken to her about the EPP book.

Based on record review and interview, the facility failed to develop a training and testing program based on the emergency plan that was delivered to all staff upon hire and annually thereafter. Additionally, the facility will extend training to volunteers and contracted providers who provide care and services in the facility environment. Specifically, the facility failed to provide emergency preparedness training at least annually and maintain documentation of the training. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the maintenance director (MTD) and environmental consultant (EC) on 11/16/23 at 9:30 a.m. Review of the EPP revealed the facility failed to provide emergency preparedness training at least annually and maintain documentation of the training. II. Staff interview The EPP was reviewed with the MTD on 11/16/23 at 9:30 a.m. The NHA said the facility failed to provide emergency preparedness training at least annually and maintain documentation of the training. The MTD said he had just recently been hired and had started reviewing the EPP and would start to update the EPP annually and as needed to keep up with the requirements. Registered nurse (RN) #2 was interviewed on 11/16/23 at 2:30 p.m. RN #2 said she did not know what the EPP book was for. RN #3 was interviewed on 11/16/23 at 2:50 p.m. RN #3 said he knew the EPP book was on each nursing station but if there was a emegency he relied on the the director of nursing (DON) to tell sataff what to do. Certified nurse aide (CNA) #4 was interviewed on 11/16/23 at 2:56 p.m. She said did not know anything about the EPP.

Based on record review and interview, the facility failed toconduct two exercises annually to test the facility ' s emergency plan and maintain documentation of the facility ' s response to all drills, tabletop exercises, and emergency events and then revise the facility's emergency plan, as needed. Specifically, the facility failed to conduct an additional full-scale exercise, individual facility based functional exercise, mock disaster drill, table top exercise or workshop in the last year. Findings include: I. Testing requirement The emergency preparedness plan (EPP) was provided by the maintenance director (MTD) and environmental consultant (EC) on 11/16/23 at 9:30 a.m. Review of the EPP revealed the facility had not conducted a second exercise of choice in the past year. II. Staff interview The MTD and the EC were interviewed on 11/16/23 at 9:30 a.m. The MTD said he was recently hired to the facility and did not know if the facility had participated in a second exercise to test the facility's EPP in the past year. He was unable to find any records of a second event and said in the last year the facility had not completed the second exercise required. The MTD said it was important to train and test the EPP annually to keep up with the requirements and ensure the EPP was effective.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity for five (#29, #35, #45, 85 and #329) of six reviewed out of 54 sample residents. Specifically, the facility failed to:-Ensure residents were treated with dignity when staff failed to respond timely to call lights for Residents (#29, #35, #45, #85, #329); -Ensure staff provided a structured daily routine when possible for dementia care; and, -Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served their meals. Findings include: I. Facility policies and procedures The Resident Rights policy, dated December 2016, was requested and received from the nursing home administrator (NHA) on 11/15/23 and read in pertinent part:"Employees shall treat all residents with kindness, respect, and dignity. "Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to:-A dignified existence;-Be treated with respect, kindness, and dignity;-Self-determination;-Be supported by the facility in exercising his or her rights;-Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility;-Be informed about his or her rights and responsibilities;-Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal;-Have the facility respond to his or her grievances;-Privacy and confidentiality."Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents ' rights." B. The Answering the Call Light policy, dated October 2010, was requested and received from the NHA on 11/15/23 and read in pertinent part: "The purpose of this procedure is to respond to the resident ' s requests and needs. "General guidelines-Be sure the call light is always plugged in;-When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident;-Some residents may not be able to use their call light. Be sure to check these residents frequently;-Report all defective call lights to the nurse supervisor promptly;-Answer the resident ' s call as soon as possible;-Be courteous in answering the resident ' s call." Steps in the procedure-Turn off the signal light;-Identify yourself and call the resident by his/her name;-Listen to the resident ' s request;-Do what the resident asks of you if permitted. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident ' s request, ask the nurse supervisor for assistance;-If you promised the resident you will return with an item or information, do so promptly."II. ObservationsDuring a continuous observation on 11/14/23 beginning at 8:30 a.m. and ending at 10:45 a.m., the following was observed:A. Resident #329-At 8:48 a.m., Resident #329 activated the call light. -At 9:07 a.m. CNA #1 entered the room and turned the call light off. The CNA exited the room and left the hallway. -At 10:39 CNA #1 returned to assist the resident. Resident #329 waited 111 minutes for staff assistance. Resident #329 was interviewed at 10:55 and he said that he called out for help getting out of bed. He was told he had to wait for the nurse to perform his wound dressing change and then the CNA would get a second staff to assist with getting him changed and getting out of bed.. B. Resident #29-At 9:38 a.m. Resident #29, activated the call light; -At 10:03 a.m. Resident #29 self propelled his wheelchair into the hallway, towards the nurses' desk. He requested assistance from a CNA and returned to his room to wait. At 10:04 a.m.. The CNA entered the resident ' s room, turned off the call light, and told the resident she would return to assist him with his request. The CNA walk out of the resident ' s room and then left the unit hallway.-At 10:19 a.m. Resident # 29 self propelled his wheelchair to the hallway. The LPN asked the resident what he needed and he said that he was told the CNA would return to change his wet brief and he was still waiting for help. The LPN told him he should not be in the hallway and told him to return to his room. The resident told the nurse he would stay in his room if he was not ignored and that he did not think he should wait so long for assistance. The LPN left the hallway.-At 10:25 the LPN returned to the resident ' s room with a Hoyer lift and a CNA. They assisted the resident and changed the resident ' s brief. Resident #29 waited 47 minutes for staff assistance to have his soiled brief changed. C. Other observationsDuring the continuous observation, on 11/14/23, staff entered the hallway without checking on residents who had their call lights on and were waiting for staff assistance. Observations revealed: -At 8:48 a.m., the call light for room #1308 was activated;-At 9:14 a.m., CNA and LPN walked by room #1308 without acknowledgment of the Resident ' s call light;-At 9:38 a.m., the call light for room #1303 was activated;-At 9:41 a.m., A CNA and LPN walked by rooms #1303 and #1308 without acknowledgment of the residents call light;-At 9:54 a.m. the call light for room #1304 was activated;There were no staff members present in the #1300 hallway.-At 10:04 a.m., a CNA entered the unit and walked by all rooms with call lights activated. She did not respond or open the doors to visualize the residents who were waiting for assistance. -At 10:22 a.m., a CNA entered the hallway with a linen cart. The CNA glanced at the call lights and left the hallway without first checking on those waiting for assistance.-At 10:25 a.m., an LPN and CNA responded to the resident in room #1303 - did not check other residents with their lights on.-At 10:26 a.m. the dietician entered the 1300 hallway. She checked the supplies in the personal protective equipment drawers that were located outside the isolation rooms. She walked past every room with a call light activated, did not respond to the residents as they waited, and closed the door for room #1304 without first speaking to the resident. III. Residents 1. Resident #29A. Resident statusResident #29, age 74, admitted on 6/22/18. According to the November 2023 computerized physician orders (CPO) the diagnoses included chronic kidney disease, diabetes, hemiplegia and hemiparesis (one-sided paralysis), right and left leg amputations, stroke, history of falling, muscle weakness, and lack of coordination. The 8/17/23 minimum data set (MDS) assessment documented the was cognitively intact with a score of 15 of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance from two or more staff members for bed mobility, dressing and personal hygiene. He was totally dependent on two or more staff members for transfers and toilet use and was independent with eating. The resident was always incontinent of bowel and bladder and was not on a toileting program. B. Resident interviewResident #29 was interviewed on 11/16/23 at 8:53 a.m. Resident #29 said he was upset about the long wait times when he activated his call light. He said wait times for a response from staff varied from 30 minutes to two hours. He said the wait times were worse on the night shift and weekends. He said he needed assistance from staff to change his wet brief and waiting two hours was not acceptable to him. The resident said that on the morning of 11/16/23, a certified nurse assistant (CNA) responded to his call light by standing in his doorway and yelling at him that she would "be right back" without first asking why he requested help. The resident said she did not return until after breakfast and he had to eat while wearing a soiled and wet brief. The resident said the staff often raised their voice when responding to his call light and when they did he felt tense and a need to be defensive. He said he is a calm man but he sometimes had to yell out in order to have staff respond to his requests for assistance. He said that he had been told his yelling behavior was not appropriate and he was frustrated because that is what it took for a timely response from staff. 2. Resident #35A. Resident status Resident #35, age 71, was admitted on 9/6/23. According to the November 2023, CPO diagnoses included major depression disorder, post traumatic stress disorder (PTSD), bipolar disorder, muscle weakness, overactive bladder and cognitive communication deficit. The 9/20/23 MDS assessment documented the resident was cognitively intact with a score of 15 of 15 BIMS. On the Resident Mood Interview (PHQ-9), the severity score for depression was minimal with a score of four out of 27. The resident required extensive assistance from one or more staff members for bed mobility, dressing, and personal hygiene and was totally dependent on one or more staff members for transfers and toilet use. She was independent with eating. The resident was always incontinent of bowel and bladder. B. Resident interviewResident #35 was interviewed on 11/14/23 at 9:18 a.m. She said she had multiple concerns about the nursing care in the facility. She said she has had poor care since she was admitted. She said facility staff did not respond to her call light for hours. She said she had recently called for assistance to have her wet brief changed. After she waited for two hours, she managed to remove the wet brief herself and then used her bedsheet as a new brief until staff responded to her call. Resident #35 said while she waited she was naked, cold, and scared because no one checked on her. The resident said she called her son and asked him to contact staff on the telephone. She said he tried but the facility telephone was not answered. She said she tried using her own telephone to call the facility and no one answered her calls. The resident said she had called 911 for assistance because the staff had not responded. She said the 911 operator tried to contact staff in the facility and no one answered the telephone. Resident #35 said staff were rude, and rushed her when she needed time and felt that was inhumane. The resident said the lack of caring concerned her and had contributed to her PTSD triggers. She said she took photographs of herself when she had to use the bedsheet as a new brief, on her electronic tablet and sent the pictures to her son, her therapist, and the facility administrator. She said she did not know why staff were allowed to not respond and why staff made her feel like she was the problem when she was persistent. 3. Resident #45A. Resident statusResident #45, age 80, was admitted on 5/3/23. According to the November 2023 CPO, diagnoses included stroke, lung disease, hemiplegia and hemiparesis (one-sided paralysis), dementia, depression, and hypertension. The 10/24/23 MDS assessment documented the resident was moderately cognitively impaired with a score of 12 out of 15 on the BIMS. The resident had impairments with upper and lower extremity range of motion. The resident required moderate assistance from one or more staff for bed mobility, hygiene, toileting, and transfers, maximum assistance from one or more staff members for dressing, and was independent with eating. The resident was not ambulatory and used a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. B. Resident interviewResident #45 was interviewed on 11/15/23 at 10:08 a.m. He said that it took a very long time for staff to respond to call lights. He said waiting was longer on the weekends but it was never good. He said it sometimes took two hours for staff to provide him assistance to turn and reposition in his bed or to have his wet brief changed. He said he felt staff did not care about answering call lights and when they did staff were rude. He said he had become very frustrated and afraid to ask for assistance and said he hoped the care would improve. 4. Resident #329A. Resident statusResident #329, age 60, was admitted on 10/24/23. According to the November 2023 CPO, diagnoses included chronic respiratory failure, hypertension, pulmonary edema, congestive heart failure, kidney disease that required dialysis, presence of a cardiac pacemaker, dysphagia, pressure injury and muscle weakness. The 10/24/23 MDS assessment documented the was cognitively intact with a score of 15 of 15 on the BIMS. The resident required extensive assistance from one or more staff members for bed mobility, dressing, hygiene, toileting and was dependent on two staff members for transfers using a Hoyer lift. The resident used a manual wheelchair and required assistance for mobility. The resident had a pressure ulcer on his coccyx that was present when admitted. The resident was at risk for cardiac complications and had a cardiac pacemaker. B. Resident interviewThe resident and his son were interviewed together on 11/15/23 at 11:23 a.m. The resident ' s son said staff take a long time to answer call lights and when they do they say they will return but then do not return timely or not at all. He said he was concerned because his father was weak and required assistance with a lot of his care, especially changing out of his soiled brief. He said he was also concerned staff would not respond timely in the event his father had cardiac distress. The resident said he did not know how long it took for help with staff but it was a long time. He said that he was frequently left in his soiled brief all day. He said he felt ignored by staff and said his only choice was to just wait until someone helped him. 5. Resident #85A..Resident statusResident #85, age 70, was admitted to the facility on 12/20/22. According to the November 2023 CPO, diagnoses included Alzheimer ' s disease, dementia, stroke, hypertension and dysphagia. The 8/28/23 MDS assessment revealed the resident had severe cognitive impairment with BIMS score of six out of 15. The resident required substantial assistance from one or more staff members for toileting, dressing, bed mobility and hygiene. B. Observations and interviewsResident #85 was interviewed on 11/13/23 at 1:42 p.m. The resident was in his bed, covered with bed linens and facing the hallway. The room was darkened by closed blinds and the lights were off. The resident appeared with a flat affect. When questioned about his care and routine, specifically if he wished to get out of bed, the resident said, "maybe but they don ' t care". During a continuous observation on 11/14/23 beginning at 8:30 a.m. and ending at 10:45 a.m. Residnet was yelling out, staff members walked by the residents room without entering, while the resident remained in bed waiting for staff to get him up. The door to the resident ' s room left open; the following was observed:-At 9:14 and 9:41a.m. CNA #1 and LPN #2 walked by the resident ' s room and did not acknowledge or check on the resident;-At 10:04 a.m. CNA #1 and #3 walked by the resident ' s room and failed to acknowledge or check on the resident;-At 10:22 a.m. CNA #3 entered the hallway with a linen cart, placed the cart across the hallway from the resident ' s room and did not acknowledge the resident;-At 10:24 a.m., the dietician walked by the resident ' s room twice and failed to greet or acknowledge the resident;-At 10:25 a.m., LPN #2 and CNA #1 walked by the resident ' s room and did not acknowledge the resident. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 11/14/23 at 10:40 a.m. CNA #1 said that she was employed by an agency and contracted to work in the facility. She said she answered call lights and helped residents when they asked for help. She said it took her longer to respond to call lights when she was helping other residents or when she needed to wait for another CNA to help with resident care when the resident required the assistance of two staff members. She said she also was called away from the hallway to assist other CNAs with their residents. CNA #1 said she asked the nurse for help with transfers but the nurse was also busy. CNA #1 said she did not receive report or information about the resident ' s prior to her shift and was unaware of specific needs of the resident on the unit. CNA #3 was interviewed on 11/14/23 at 11:03 a.m. She said she worked at the facility for three years. She said she had not received training specific on how to care for a resident with dementia. She said it was her job to answer call lights as fast as possible and then she helped the resident. She said she Resident #85 did not use his call light so until he asked for help before she entered his room. LPN #2 was interviewed on 11/14/23 at 12:10 a.m. She said it was her first day working in the facility and was employed by a local staffing company. She said she did not receive orientation or training from the facility prior to the start of her shift. She said she received a nurse report prior to assuming care for the shift but the report did not include information about resident specific needs. LPN #2 said she did not know where the resident ' s care plan was located but she always treated elderly residents with respect. Licensed practical nurse (LPN) #1 was interviewed on 11/14/23 at 1:20 p.m. He said he worked for an agency. He said the CNAs tried to respond timely to call lights but they were in resident rooms for long periods of time because of isolation precautions due to a COVID-19 outbreak and some residents required assistance for several needs. He said when he saw call lights activated he checked on the resident. The director of nursing (DON) and NHA were interviewed together on 11/14/23 at 3:33 p.m. The DON said staff receive orientation and education to respond promptly and politely when call lights are activated. She said if the CNA was unable to provide care at the time, an explanation should be given to the resident. She said that any staff member who noticed that a call light was activated should check on the resident and then notify the CNA or nurse if the resident required assistance. The DON said that she will evaluate frequently incontinent residents for a toileting program which might reduce resident incontinence. The NHA said he had talked to Resident #35 regarding her complaints about her care concerns and had worked extensively with her to come up with a solution she would be satisfied with. The NHA even said he gave the resident his contact information so she could report her concerns directly to his attention for quicker resolution.. The NHA said the resident had specific preferences for her care and staff made attempts to anticipate her needs. The NHA and DON were unaware of the resident calling 911 for assistance.

Based on observations, record review and interviews, the facility failed to assist one (#38) of two residents reviewed for preferences out of 54 sample residents. Specifically, the facility failed to:-Ensure staff provided assistance and encouragement for the resident (#38) to treat the edema in both of his lower legs; -Ensure the resident could comfortably elevate his legs while in his bed and in his room;-Ensure resident was treated with kindness, respect and dignity when he practiced self advocacy to alter his environment to meet his needs; and,-Ensure the resident ' s care plan was updated timely to reflect the Resident #38 ' s unique needs and preferences within his environment that facilitated the treatment of the edema in his legs. Findings include:I. Facility policy A. The Statement of Resident Rights, undated, included with each admission packet was received on 11/15/23 by the nursing home administrator (NHA). The document read in pertinent part:"You have the right to be informed on, and participate in your treatment. "You have the right to participate in the development and implementation of your person-centered plan of care, including the right to participate in the planning process, the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency and duration of care, the right to be informed, in advance, of changes to the plan of care, the right to receive services and items included in the plan of care and the right to see the plan of care."You have the right to reside and receive services in the facility with reasonable accommodation of your needs and preferences."You have the right to and the facility must promote and facilitate, your self-determination through support of resident choice, including but not limited to;-The right to make choices about aspects of your life in the facility that are significant to you,-The right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. -You have the right to privacy in treatment and caring for personal needs, confidentiality in the treatment."B. The Resident Rights policy, revised December 2016, was received on 11/15/23 by the NHA. The policy read in pertinent part:" Employees shall treat all residents with kindness, respect, and dignity;"Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to;-A dignified existence;-Be treated with respect, kindness, and dignity;-Self-determination;-Be informed of, and participate in his or her care planning and treatment;-Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents ' rights."II. Resident statusResident #38, age 68, was admitted on 2/3/23. According to the November 2023 computerized physician orders (CPO), diagnoses included hypertension, chronic kidney disease, congestive heart failure, shortness of breath, diabetes, venous insufficiency, atrial fibrillation and stroke. The 10/11/23 minimum data set (MDS) assessment revealed the resident was not cognitively impaired impairment with a brief interview for mental status (BIMS) score 15 out of 15. He was independent with all of his activities of daily living. III. Resident observation and interviewOn 11/14/23 at 11:12 a.m., Resident #38 was observed The resident resided in a semi-private room. His bed was positioned perpendicular to the doorway. The curtain was drawn between roommates. The resident had a chest of drawers, night stand, wheelchair and rollator walker positioned on his side of the room. Personal belongings were stored in the closet, in laundry baskets, and under the bed. The bed was unmade and bedding was rolled up against the wall. The resident ' s breakfast tray was on his bed. The room smelled musty and of body odors. There was not a stationary chair or reclinerin the resident ' s living space and the head of the resident ' s bed was elevated to a sitting position and the foot of the bed was flat. Resident #38 was interviewed on 11/14/23 at 11:12 a.m. He said the care in the facility was poor. He was frustrated at the significant edema in his lower legs that was caused by his heart and kidney failure but told by staff it was because he drank too many beverages. The resident said he knew he could elevate his legs to help reduce the edema and said he would elevate his legs but his bed did not adjust to elevate the foot of the bed. He said to use the bed, he had to flip around in the bed, placing his feet at the head of the bed. He said turning in his bed was a problem because then his upper body was flat and made it more difficult to breathe because of his heart failure and high blood pressure. The resident said a recliner was available in the atrium but the facility had a COVID-19 outbreak and did not feel comfortable sitting in a common area for an extended time and using furniture not sanitized after use by others. The resident said he felt staff did not care and did only what was required to check their boxes. The resident said his bedding had not been changed in five days and the room was dirty. He said the room was not cleaned well which made it less appealing to spend time in his bed. IV. Record reviewOn 10/25/23 the resident ' s care plan was updated and included a treatment goal to monitor for side effects, complications, or adverse reaction to diuretic medications. The resident was prescribed Bumetanide for treatment of congestive heart failure, hypertension and edema. The interventions included monitoring for medication side effects. The care plan failed to include specific treatment, goals and interventions for the resident ' s bilateral edema. However, the care plan failed to document a care focus for the resident environmental preference focused on treating his edema. On 11/8/23 Resident #38 was evaluated by the primary care physician for acute renal failure, diabetes and congestive heart failure. The physician noted the resident had edema in both of his lower legs. The physician referred the resident to see a kidney specialist which was scheduled for early December 2023. On 11/10/23 the resident was evaluated by the facility provider for chronic and acute kidney injury. The plan to help manage the resident ' s leg edema was to have the staff encourage the resident to spend time in his bed each day to elevate his lower legs. V. Staff InterviewsCertified nurse aide (CNA #1) was interviewed on 11/14/23 at 11:39 a.m. CNA #1 said she was uncertain about specific needs for the resident. She said she was agency staff but had cared for the resident for three days prior. She said the resident was independent and she provided assistance with activities when he requested. Licensed practical nurse (LPN) #1 was interviewed on 11/14/23 at 11:47 a.m. LPN #1 said he did not have specific orders or information on the resident ' s care plan to help the resident with his edema. He said the resident was able to elevate his legs in a recliner available in the atrium. He said the resident could also sit in his wheelchair and use his bed to elevate his legs. The LPN said he had not specifically encouraged the resident to elevate his legs because the resident was independent. The director of nursing (DON) was interviewed on 11/16/23 at 3:35 p.m The DON said the resident was independent and had the ability to use his bed to elevate his legs. She said he had been non-compliant with his diet and he had an upcoming appointment for his edema. She said she was unaware the foot of the bed did not rise and the resident had to flip around in his bed to elevate his legs. The DON said the resident could also use a recliner in the atrium. If he did not want to sit in the atrium, a recliner could be placed in his room. However, the resident was against rearranging his furniture to make space for a recliner. She said she will follow up on how to accommodate the resident so he could comfortably elevate his legs.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents, in 22 of 105 resident rooms in six hallways. Specifically, the facility failed to -Ensure heating units in resident rooms and in common resident shared areas were in good repair; and,-Ensure that the walls, baseboards, ceilings, counters, and doors in resident rooms and common resident areas were properly maintained. Findings include:I. ObservationsObservations of the resident living environment were conducted on 11/15/23 at 9:11 a.m. revealed:The heater in the main hallway had an area approximately five feet long by 14 inches high with an unfinished sheetrock patch area with several large copper pipes exposed and coming out of the side of the heater. A second heater in the main hallway had the same damage and unfinished sheetrock; the copper pipes were covered. Room #509: The wall next to the resident ' s bed had deep scratches approximately seven feet long by four feet high from the bed scraping the wall as it was being lifted and lowered. Room #507: The wall behind the resident ' s recliner had deep scratches from the chair hitting the wall. Room #504: The wall heater had an area on top approximately 14 inches long by two inches wide with the outside visible through a hole. The entrance door had large chips, wood splinters and missing wood approximately seven inches high by three inches wide. There were several screws sticking out of the wall next to the resident bed. The sheetrock had peeling and damaged sheetrock. Room #503: The wall next to the bed had deep scratches approximately four feet long by two feet high from the bed being lifted and lowered. The corner next to the sink and area was approximately 12 inches high by two inches wide with chipped and peeling plaster with the metal corner piece being exposed. The laminate below the sink was missing a section approximately 36 inches long by five inches wide. The wood door frame had splintering and chipped wood approximately 24 inches high by four inches wide. Room #500: The wood door frame into the restroom had an area approximately two feet high by four inches wide with chipped and splintering wood from the frame being hit by the wheelchair. The wall behind the recliner had deep scratches and gouges from the recliner hitting the wall. There were several wood screws sticking out of the wall next to the resident bed. Room #603: The light above the bathroom sink was not working. The bathroom door had areas of unpainted and matching paint. The wall behind the recliner was damaged from the recliner hitting the wall. The wall in the memory care unit had a wall approximately 12 feet long by four feet high with damaged sheetrock. The door that leads into the kitchen area had a damaged corner and the corner wall had chipped and peeling sheetrock with the metal joints being visible. Room #700: the wall behind the resident ' s bed had deep scratches from the bed scraping the wall as it was being lifted and lowered. The wall outlet in the middle of the room was missing. Room #704: The wall behind the resident's bed had deep scratches from the bed scraping the wall as it was being lifted and lowered. The resident oxygen concentrator was plugged into a non medical grade power strip. Room #801: The wall next to the sink had chipped and missing sheetrock with the metal exposed. The wall next to the bed had deep scratches from the bed scraping the wall as it was being lifted and lowered. Room #807: The wall next to the resident ' s entrance had peeling and missing sheetrock approximately four inches long by three inches wide. The wall next to the resident ' s bed had exposed peeling pipes sticking out of the walls. The corner next to the sink had damaged sheetrock with the metal corner piece exposed. Room #806: The heater next to the resident's bed had been removed with the outline approximately five feet long by four feet high with water damage on the floor and the wall. The heater vents in the facility chapel, library and all residents ' rooms had a thick layer of black dirt and dust buildup on the external and removable internal filter. The wall outside of room #1110 had four nickel-sized hoes. Room #1104: The heater cover was falling off the wall. The wall next to the resident ' s bed had four quarter-sized holes. The wall next to the resident ' s bed was damaged from the bed being lifted and lowered. There was an area approximately eight inches long by seven inches wide with missing sheetrockRoom 1204: The wall behind the resident ' s recliner had deep scratches and gouges approximately 36 inches wide by four feet high. The wall next to the heater had several pipes exposed. Room #1307: The entrance door had an area of peeling paint approximately 14 inches high by three inches wide. The wall behind the resident's bed was damaged from the bed being lifted and lowered. Room #1308: The wall next to the resident ' s bed, had several quarter sized holes from a television bracket being removed. The wall behind the bed was damaged from the bed being lowered and lifted. The baseboard cove had an area approximately 14 inches long by four inches wide. The corner wall next to the restroom had damaged and peeling sheetrock with the internal metal corner piece exposed. The corner molding next to the entrance door was missing a section approximately four feet by four inchesThe shower room on the 1400 hall had a large hole next to the tube which was approximately eight inches long by seven inches wide. Room #1408: The wall next to the resident ' s bed was damaged from the bed scraping the wall as it was being lifted and lowered. The wall next to the door had an area approximately seven inches long by five inches wide. The ceiling at the end of 1500 hall had water damage approximately seven feet long by six feet wide. Room #1506: The resident ' s headboard was unattached from the bed and was leaning against the wall. There was a larger white spot approximately 35 inches in circumference next to the resident ' s bed. The wall next to the bed had deep scratches from the bed scraping the wall as it was being lifted and lowered. Room # 1604: The heater had been removed with the outline of the old heater visible with five pipes exposed and sticking out of the wall. Room #1610: The heating vents were dirty and had a thick layer of dark grey dust build-up. Room #1703: The room was cold with the resident utilizing towels on the window sill to keep the cold out. II. Environmental tour and staff interviewThe environmental tour was conducted with the maintenance director (MTD) and environment consultant on 11/16/23 at 9:25 a.m. The above detailed observations were reviewed. The MTD documented the environmental concerns. The MTD said the facility utilized work orders as well as a computer system to identify environmental issues. The MTD said he did not have work orders for the damage identified during the environmental tour. The MTD said the above-mentioned damage and other areas of concern should have been repaired and addressed in a timely manner.

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Based on record review, resident and staff interviews, the facility failed to investigate one allegation of resident to resident altercation physical abuse for two (#29, and #99) of five residents reviewed for abuse of 54 sample residents. Findings include: I. Facility Policy The Abuse Prevention and Reporting Guideline, dated 12/31/15, was provided by the nursing home administrator (NHA) on 11/15/23 at 3:54 p.m. It read in pertinent part: "Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friend, or other individuals. "To ensure the resident ' s rights are protected by providing a method for prevention, reporting and investigation of any type of alleged resident abuse." II. Resident #29 A. Resident status Resident #29, age 74, was admitted on 10/3/22. According to the November 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, diabetes mellitus, acquired absence of right leg, absence of left leg above the knee, and history of falls. According to the 11/8/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. B. Record Review The comprehensive care plan initiated on 10/3/22 and revised on 9/27/23 identified the resident had the potential to demonstrate verbal behaviors related to a history of verbal outbursts directed toward others, use of abusive language toward staff members, and pattern of challenging/confrontational verbal behavior. Interventions include monitoring medical conditions that may contribute to verbal behaviors. Monitor medications, especially new/changed/discontinued medications, for side effects and Resident ' s response contributing to verbal behaviors. Nursing note dated 9/27/24 at 12:32 p.m. read "Nurse witnessed resident in an altercation with another resident at 10:30 a.m. Initially heard this resident yelling angrily in the 1300 hall. When this writer came around the corner he witnessed both residents hitting each other. This nurse intervened with the director of nursing (DON) and residents were separated and assessed with no injuries noted" III. Resident #99 A. Resident status Resident #99, age 73, was admitted on 8/4/23. According to the November 2023 CPO, diagnoses included dementia, chronic kidney disease, senile degeneration of the brain, and diabetes mellitus. According to the 11/3/23 MDS assessment, the resident was not administered the brief interview for mental status (BIMS). The resident had severe cognitive impairment with deficits in short and long-term memory. The resident displayed physical behavioral symptoms directed towards others on two days in the seven-day assessment period which put the resident at significant risk for physical injury; interfered with the resident's care and put another resident at significant risk for physical injury. The resident had wandering behaviors. He required supervision for bed mobility, transfers, grooming and toilet use. B. Record reviewThe comprehensive care plan, initiated on 8/4/23 and revised on 11/17/23, identified the resident had the potential to exhibit physical behaviors (hitting out) related to cognitive loss/dementia, and poor impulse control due to dementia. Interventions include evaluating the nature and circumstances (i.e., triggers) of the resident ' s physical behavior. Discuss findings with residents and family members/caregivers and adjust care delivery appropriately. Evaluate the need for psychiatric/behavioral health consult. Explain all care, including procedures (one step at a time), and the reason for performing the care before initiating. Observe for non-verbal signs of physical aggression (rigid body position, clenched fists, agitation, and pacing). Nursing note dated 9/27/24 at 12:25 p.m. read: "Nurse witnessed resident in an altercation with another resident at 10:30 a.m. Initially heard this resident yelling angrily in the 1300 hall. When this writer came around the corner he witnessed both residents hitting each other. This nurse intervened with the director of nursing (DON) and residents were separated and assessed with no injuries noted" On 11/15/23 at 3:10 p.m., a request was made for the facility ' s occurrence/abuse investigation for the incident on 9/27/23 between Resident #29 and Resident #99, the facility was unable to provide documentation of an investigation being conducted. . D. Staff interviewThe corporate nurse consultant (CNC) was interviewed on 11/16/23 at 3:29 p.m. The CNC said the facility did not have an occurrence or investigation on the resident or resident physical abuse incident that occurred between Resident #99 and #29 on 9/27/23. The CNC said an investigation should have been completed and the incident should have been thoroughly investigated.

Based on record review and interviews the facility failed to complete and transmit encoded, accurate Minimum Data Set (MDS) data to the CMS (Center for Medicare and Medicaid Services) system for one (#58) of three out of 54 sample residents. Specifically, the facility failed to complete MDS Discharge assessment upon Resident #58 ' s discharge from the facility to the community. Findings included: I. Facility policy The Resident Assessment policy, revised in March 2022, was provided by the nursing home administrator (NHA) on 11/15/23 at 11:30 a.m. The policy read in pertinent part: "A comprehensive assessment of every resident ' s needs is made at intervals designated by OBRA (Omnibus Budget Reconciliation Act) and PPS (prospective payment system) requirements. "OBRA-Required Assessments - are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. "The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:-a. OBRA required assessments - conducted for all residents in the facility: (7) Discharge Assessment (return anticipated and return not anticipated).-b. PPS required assessments - conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A SNF (skilled nursing facility) benefits: (3) Part A PPS Discharge Assessment." II. Resident #58A.Resident Status Resident #58, age 72, was admitted on 3/19/23 and discharged to the community on 8/31/23. According to the November 2023 computerized physician ' s orders (CPO) diagnoses included hypertension, diabetes, and kidney disease. The last MDS admission assessment was conducted on 7/11/23 to meet the annual review requirement. -There was no discharge (return not anticipated) assessment for the resident completed for the resident ' s 8/31/23 discharge. B. Record reviewAccording to the discharge summary, dated 8/30/23, Resident #58 transitioned to the community to a home (address documented) with the help of (provider name) care transition services. The resident ' s discharge date was documented as 8/31/23. III. Staff interviewsThe director of nursing (DON) was interviewed on 11/16/23 at 12:10 p.m. The DON said MDS assessments should be completed and transmitted on time per State and Federal time frames. The DON did not know why the resident ' s assessment had not been completed but said it would be completed.

Based on observations, record review and interviews the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for one (#51) of four residents reviewed for meaningful activity programming activities out of 54 sample residents. Specifically, the facility failed to ensure:-Resident #51 received individualized meaningful activities to meet her social, emotional and recreational needs;-Resident #58 was consistently offered her eyeglasses so she could see fine details and possibly participate in preferred independent activities; and,-Review with Resident #58 her activity preferences and update the resident ' s changes in activity preferences on a quarterly basis. Findings include: I. Facility policy and procedure The Activities Program policy, revised August 2006, was provided by the nursing home administrator (NHA) on 11/14/23 at 3:30 p.m. The policy read in pertinent part: "Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities are scheduled 7 (seven) days a week. "Individualized and group activities are provided that:-Reflect the schedules, choices, and rights of the residents;-Are offered at hours convenient to the residents, including evenings, holidays, and weekends;-Reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents; and,-Appeal to men and women as well as those of various age groups residing in the facility." The Activities Evaluation policy, revised February 2023, was provided by the NHA on 11/16/23 at 3:30 p.m. The policy read in pertinent part: "In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect their participation in planned activities. "An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident."The completed activity evaluation is part of the resident's medical record and is updated as necessary, but at least quarterly." II. Resident #58 A. Resident status Resident #58, age 86, was admitted on 12/10/22. According to the November 2023 computerized physician orders (CPO), diagnoses included chronic pulmonary disease, anxiety and mild dementia. The 8/22/23 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of three out of 15. The resident had clear speech, was able to express ideas and wants and was able to understand verbal content with clear comprehension. The resident had impaired vision requiring the use of corrective lenses. The 12/14/22 Admission MDS assessment documented that the resident said it was very important to listen to the music she liked, be around pets, participate in her favorite activities including religious services and it was somewhat important to go outside in good weather. The resident said it was not important to keep up with the news, have books, newspapers, or magazines to read or participate in group activities. B. Resident observations Resident #58 was observed throughout the survey from 11/13/23 to 11/16/23. The resident did not leave her room and did not have any independent activities within view and/or within the resident ' s reach in her room. On 11/13/23 at 10:10 p.m., Resident #58 was lying in bed with the radio on. There were no items in the resident's reach or in view to facilitate the resident ' s participation in an independent activity while she was in isolation for coronavirus (SARS-CoV2 virus - COVID-19) illness (see below). She had no television in her room. On 11/15/23 at 3:49 p.m., Resident #58 was lying in bed staring out the window. The resident ' s room was decorated nicely with many personal items and posters. The radio was playing in the resident ' s room. She had no items to engage in any type of independent activity. The resident was not wearing her eyeglasses. C. Resident and resident representative interview Resident #58 ' s friend and power of attorney (POA) legal representative was interviewed on 11/13/23 at 1:46 p.m. The resident ' s representative said he had been a friend of the resident's since her admission as her family was not involved in her life. The representative said he was concerned that the resident was not being offered any activity programming. The representative said every time he visited, Resident #58 ' s biggest complaint was that she was not being assisted with activities and she was bored because there was nothing to do. The resident ' s representative said he had asked facility staff on numerous occasions to get her up for activities and to offer the resident opportunities to participate in meaningful activities but he did not believe staff were being responsive. The representative said since Resident #58 got sick she had not been receiving visits from the activities department. Resident #58 was interviewed on 11/15/23 at 3:49 p.m. Resident #58 said she had nothing to do and spent most of her time in bed looking at her posters. Resident #58 said she was in isolation due to a COVID-19 infection and was not able to leave the room even though she did not really feel sick. Resident #58 said no facility staff had offered her things to do in her room during her isolation. Resident #58 said prior to getting sick she had been asking staff to get her up so she could get out of her room and participate in activities but the staff did not get her up as much as she would have liked. Resident #58 said she could not see fine detail and she did not think there was much she could do from her bed. She said she had eyeglasses but did not know where they were. She said she did not have a television nor did she like to watch television. Resident #58 said though staff turned the radio on for her, she really did not like to listen to the music but did so anyway. Resident #58 expressed some interest in learning more about books on tape and said she did not know much about them and had not been offered that as an option. D. Record review Resident #58 ' s comprehensive care plan activity focus, last revised on 6/29/23, revealed that Resident #58 said "it was important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. She is of the Christian faith. She can make her activity needs known. She primarily prefers to be in her room and in bed. Leisure activities listening to music, coloring, resting, relaxing, napping taking care of her personal belongings talking on the phone and visits from friends. She accepts the Daily Chronicle (newsletter), verse of the day, puzzles, weekly portable carts of latte, refreshments and snacks. With encouragement, she will participate in gardening, music and an occasional food activity. Utilizes assistance in a wheelchair to and from activities of choice. Wears eyeglasses." Care plan interventions included (last revised 6/28/23: "Offer reminders of daily activities. Encourage and facilitate resident ' s activity preferences: listening to music, coloring, portable carts of refreshments, lattes, snacks, reading cart and mobile country store. Occasionally offer garden, music and food activities.- Resident enjoys listening to music and prefers religious, 50's and country western.-Resident likes to do crosswords/puzzles/games, look out the window, lay down/rest, pray, read, and think. Offer large print reading material and puzzles. Will accept verbal readings.-Declined to have a personal television in her room.-Resident #58 said she would benefit from accommodations for visual impairments byhaving someone to read to her and to be offered large print materials while wearing prescription eyeglasses. Declined talking book subscription but will accept verbal readings." The resident medical record revealed the resident had been diagnosed with COVID-19 on 11/10/23 and had been confined to her room in isolation for 10 days, since that date. The activities director (AD) provided the resident ' s activities participation records for October 2023 and November 2023. There was no record of the resident being offered any activity programming for November 2023. The October 2023 activity participation record documented that the resident had been independently watching television and using a tablet/computer or electronic device every day; and had audio or large print books for independent use every Monday to Friday of October 2023.. -However, the resident did not have a television, tablet/computer, or smartphone in her room. -Additionally, the resident said she did not have access to books on tape or large print books and none were observed in her room during the survey days from 11/13/2 to 11/16/23 (see resident observation and care plan documentation above). III. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 11/15/23 at 12:33 p.m. CNA #2 said Resident #58 usually spent her day listening to music in her room and preferred to remain in bed most days. CNA #2 said the resident was in isolation and could not leave her room. CNA #2 said she did not know Resident #58 liked to do other activities. The AD was interviewed on 11/16/23 at 10:27 a.m. The AD said he had only been working in his role for a couple of months and was still getting to know the resident The AD said he was not familiar with Resident #58 but thought she was very active in activities programming and that the resident participated in many craft programs and other group activities, went out with family, participated in daily television watching and used a personal computerized tablet independently. -This information was in contradiction to the resident ' s care plan and resident and resident representative interview. The AD said he would review the resident ' s record and speak to the resident to work with the resident to develop some creative in-room activities that the resident would enjoy.

Based on observations, record review and interviews the facility failed to ensure two (#93 and #62) of three out of 51 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure:Resident #93, who was at high risk for developing pressure wounds and an increased risk for developing infections, developed a sacral skin wound on 5/25/23 that progressed to a stage 4 sacral pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #63 from the development of pressure wounds. The facility failed to assess, monitor and document skin assessments and pressure wounds. The facility failed to place timely interventions in the prevention of the development and progression of the pressure wound.-Due to facility failures, the resident experienced a stage 4 sacral pressure wound that became infected and required hospitalization and a surgical washout and debridement. Resident #62, who was on hospice and had an increased risk of developing pressure wounds experienced the the following worsening wounds: A pressure wound on the left heel started on 6/22/23 that progressed to an unstageable wound, a stage 2 pressure wound on the left buttock started on 8/28/23, and a pressure wound to the right buttock on started on 10/18/23 which progressed to a stage 3 pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #62 from the development of pressure wounds. The facility failed to accurately assess and monitor and document skin assessment and pressure wounds. The facility failed to communicate and coordinate with hospice in assessing, monitoring, documenting and treating the pressure wounds. -Due to the facility failures, the resident experienced a worsening of her pressure wounds and the formation of new pressure wounds. Findings included:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 11/29/23, "Pressure ulcer classification is as follows: "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). "Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. "Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendonis not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable "Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment." II. Facility policy and procedureThe Prevention of Pressure Injuries policy, revised April 2020, was provided by the nursing home administrator (NHA) on 11/15/23 at 4:34 p.m., read in pertinent part,"Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL). "Select appropriate support surfaces based on the resident ' s risk factors, in accordance with current clinical practice."Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis."The Pressure Ulcer/Skin Breakdown Clinical Protocol policy and procedure, last revised April 2018), was provided by the NHA on 11/15/23 at 4:34 p.m., read in pertinent part,"The nursing staff and practitioner will assess and document an individual ' s significant risk factors for developing pressure ulcer; for example, immobility, recent weight loss, and a history of pressure ulcers."In addition the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; Pain assessment; Resident ' s mobility status; Current treatment, including support surfaces; and All active diagnoses."III. Resident #93A. Resident statusResident #93, age 74, was admitted on 4/6/23 and readmitted on 7/25/23. According to the November 2023 computerized physician ' s orders (CPO), the diagnoses included stage 4 sacral pressure ulcer acquired during stay, chronic leukemia and dementia. The 10/2/23 minimus data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He was dependent, needing staff assistance with toileting and transfers, required substantial/maximal assistance with personal hygiene and bed mobility and was independent with eating. The MDS indicated the resident had an unhealed stage 4 pressure ulcer not present upon admission and was at risk for developing pressure ulcers. B. ObservationsOn 11/15/23 at 1:30 p.m. licensed practical nurse (LPN) #6 was observed removing the old dressing on the sacral wound. The sacral wound bed was difficult to visualize due to the depth of the wound. There was no redness or drainage noted around the wound site. Resident #93 was observed on an air mattress. C. Record reviewThe skin breakdown care plan, initiated on 5/10/23 revised on 9/12/23, documented Resident #93 had actual skin breakdown related to decreased mobility, morbid obesity, edema and respiratory failure. It documented Resident #93 had a stage 4 pressure wound to the sacrum (triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis) with a history of infection and debridement. Interventions included preventative skin care, assist the resident to turning and repositioning frequently, encourage fluids, observe skin condition daily with ADL care, obtain dietician consult, pressure redistribution surface to bed and chair, wound treatment, weekly skin checks, weekly wound assessment to include measurements and description of wound. A comprehensive review of the care documented that not all of the care plan interventions were in place had not been initiated on the care plan until 7/27/23 after the resident returned from the hospital from sepsis and surgical debridement of an infected sacral stage 4 pressure wound that he developed in the facility prior to going to the hospital. The documentation failed to reveal personalized interventions that were in place prior to the development of the stage 4 pressure wound. The CPO documented an order for a pressure redistribution mattress to bed, ordered 4/6/23. The 5/25/23 nursing progress notes revealed a change of condition note with an open skin wound or ulcer noted on Resident #93 ' s lower back. The wound nurse assessed the area and cleansed with wound cleanser, medihoney (a wound dressing gel or paste treatment that promotes wound healing) was applied to the wound bed and covered with bordered foam dressing. No documentation of the resident ' s physician being notified. The 5/25/23 physician order documented to cleanse sacral skin tear with wound cleanser, pat dry with gauze, apply medihoney cover with foam border once a day, ordered 5/25/23. The 5/31/23 Braden score (an assessment tool used to predict pressure ulcers) was 12 out of 23 the lower score indicated Resident #93 was at high risk for developing pressure ulcers. The CPO documented an order for resident to be followed by the facility wound specialist, ordered 6/7/23. The 6/8/23 wound care physician note revealed the resident had a stage 4 pressure ulcer on the sacrum. The wound measurements were 6.8 x 9.4 x 2.5 centimeters (cm). with 20% slough and 80% eschar. The 6/12/23 nutrition progress note revealed resident was complaining of his butt being sore with the 6/7/23 and documented that Resident #93 ' s skin and wound had moisture associated skin damage (MASD). The 6/13/23 at 7:30 p.m. the change of condition nursing progress notes documented the resident ' s pressure wound had , foul smelling drainage coming from the sacral wound, the resident ' s skin was cold and clammy, and the resident ' s labs (bloodwork) showed an elevated white blood cell count (indicating a likely infection) The resident was transferred to the hospital. On 6/14/23 hospital admission and surgical records revealed Resident #93 was admitted to the hospital with septic shock secondary to an unhealed infected stage 4 pressure wound and a urinary tract infection (UTI). On 6/16/23 hospital records revealed Resident #93 underwent a surgical washout and debridement of sacral wound with application of wound vac (vacuum) therapy (a dressing connected to a vacuum pump to pull fluid, bacteria and debris out of the wound). The 6/22/23 wound care physician note revealed the wound measurements were 9.2 x 11.5 x 4.5 cm with 80% granulation and 20% slough and was documented as improved. The CPO documented an order for an air mattress, ordered on 6/28/23 discontinued on 7/3/23The CPO documentedan order for a low air mattress, ordered on 7/5/23.-A comprehensive review of the medical record revealed an order for an air mattress on 6/28/23, after the resident had been hospitalized for sepsis and underwent surgical debridement of his stage 4 sacral pressure wound. The 7/11/23 wound care physician note revealed the wound measurements were 6 x 8.5 x 2 cm with 100% granulation and was documented as improved. The 7/18/23 wound care physician note revealed the wound measurements were 6 x 8 x 1.7 cm with 60% granulation and 40% slough. The 8/7/23 wound care physician note revealed the wound measurements were 5.9 x 4.6 x 1.5 cm with 100% granulation and was documented as improved. The 8/25/23 wound care physician note revealed the wound measurements were 5.6 x 4.2 x 1 cm with 80% granulation and 20% slough and was documented as improved. The 8/29/23 wound care physician note revealed the wound measurements were 5.6 x 3.2 x 1.2 cm and was documented as improved .The 9/12/23 wound care physician note revealed the wound measurements were 4.5 x 3.5 x 0.8 cm and was documented as improved. The 9/19/23 wound care physician note revealed the wound measurements were 4.5 x 3.5 x 0.8 cm and was documented as improved. The 9/26/23 wound care physician note revealed the wound measurements were 3.9 x 3.1 0.8 cm and was documented as improved. A comprehensive review of the medical record revealed an order for the resident to be followed by a wound care specialist until 6/7/23, 12 days after the wound was identified on 5/25/23. A comprehensive review of the wound physician notes revealed no documentation by the wound care physician before 7/11/23. D. Staff interviewsLPN #6 was interviewed on 11/15/23 at 1:30 p.m. LPN #6 said the wound had improved over the last several months. He said wound care has been following the resident and is seen weekly by the wound physician. He said Resident #93 had been on a different air mattress but had switched to a pump air mattress within the last two months. LPN #4 was interviewed on 11/16/23 at 10:00 a.m. LPN #4 said when a new skin condition was identified an incident report and a change of condition needed to be completed. She said nurses do a weekly skin condition assessment and documented the findings on the skin assessment form. She said after a skin issue was identified the wound nurse, the DON and the physician were notified. The wound care nurse (WD) was interviewed on 11/16/23 at 2:15 p.m. The WD said Resident #93 ' s stage 4 pressure wound had improved and had started as a skin tear that progressed to MASD then to a stage 4 pressure wound. She said she was unable to recall the timeline. She said the previous wound nurse had indicated that the resident had refused dressing changes and repositioning. She said she did not know what interventions were in place when the pressure wound started. She said the resident eventually had to be hospitalized for the pressure wound and had returned with a wound vacuum. She said he had improved since the wound vacuum was removed. The director of nursing (DON) was interviewed on 11/16/23 at 12:12 p.m. She said when a new skin condition was identified staff would notify wound care and the DON by phone or text. She said staff would then notify the physician to obtain orders. Nursing should do weekly formal skin checks and certified nurse aides do daily skin checks with daily care. IV. Resident #62A. Resident statusResident #62, age 79. was admitted on 12/10/20. According to the November 2023 CPO, the diagnoses included cerebral infarction (stroke), epilepsy and malignant breast cancer. The 8/15/23 MDS assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. She was dependent with bed mobility, toileting, personal hygiene, transfers and eating. The MDS documented that the resident was at risk of developing pressure ulcers and had no unhealed pressure ulcers. B. ObservationsOn 11/15/23 at 3:00 p.m. LPN #6 was observed removing dressings from wounds on the left heel and over sacrum and right buttock. -Left heel had eschar noted on the medial (inside) aspect of heel. Heel boots were in place.-Right buttock was observed with an area covered in slough -Coccyx/sacral area with an abrasion and pink wound bed. Resident #62 was observed on a regular non air mattress. C. Record reviewThe skin bruising and skin tear care plan, initiated on 7/18/18 revised 10/25/18, revealed Resident #62 was at risk for bruising and skin tears due to a seizure disorder. Interventions included observe skin daily with ADL care, provide skin tear treatment per physician order and report changes, and weekly skin assessment by licensed nursing personnel. The skin breakdown care plan, initiated 6/3/19 revised 3/23/23, documented Resident #62 was at risk for breakdown due to limited mobility and a splint to hand. Interventions included check frequently under splint, pat skin when drying, encourage resident to consume all fluids, observe skin for signs of skin breakdown, observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed, obtain dietician consult, pressure redistribution surface to bed and chair, provide supplements, weekly skin assessment by licensed nurse. The nutrition care plan, initiated on 7/31/18 revised 11/6/23, documented Resident #62 was on hospice services on 3/1/21 and hospice was following the resident for skin care. A comprehensive review of the care plan failed to document personalized interventions or coordination with hospice services for pressure ulcer monitoring, prevention or interventions. The 10/1/23 nursing weekly comprehensive skin evaluation assessment documented no new skin wounds or concerns. It documented no additional interventions were in place in the prevention of wounds. The 10/8/23 nursing weekly comprehensive skin evaluation assessment documented a pressure ulcer at left gluteal fold (crease under buttock). It did not document the appearance of the wound. It documented no interventions were in place. It documented notification was not required. The 10/15/23 nursing weekly comprehensive skin evaluation assessment documented a pressure wound on the left gluteal fold. It did not document the appearance, stage or size of the wound. It documented no additional interventions were in place. It documented no notification was required. The 10/22/23 nursing weekly comprehensive skin evaluation assessment documented a wound in the right gluteal area. It did not document the appearance, stage or size of the wound. It documented that hospice had a preventative treatment in place for sacral area for protection and that hospice was notified on 10/17/23. It documented that hospice was in to evaluate on 10/18/23. It documented dietary interventions were in place for treatment. The 10/29/23 nursing weekly comprehensive skin evaluation assessment documented an open area at sacrum and left heel. It did not document the appearance, stage or size of the wounds. It did not document additional interventions were in place. It documented no notification was required. The 11/6/23 nursing weekly comprehensive skin evaluation assessment documented a pressure wound on sacrum and left heel. It did not document the appearance, stage or size of the wounds. It did not document additional interventions were in place. It documented no notification was required. A comprehensive review of the nursing weekly comprehensive skin evaluation assessment did not consistently or accurately document the presence, location, appearance, interventions or notification of appropriate providers. The 11/8/23 Braden scale documented that Resident #62 had a score of 13 and was at a moderate risk for pressure ulcer injury. The hospice progress notes documented a left medial heel pressure wound.-On 6/22/23 it was documented as a new onset and the stage was not documented. was documented as red and the size was 4 x 3.75 centimeters (cm). -On 7/6/23 the stage and appearance was not documented and the size was 3.5 x 3.5 cm.-On 7/13/23 the stage and appearance was not documented and the size was 3.5 x 3.5 cm.-On 7/20/23 the stage and appearance was not documented and the size was 3.5 x 3.5 x 0.1 cm.-On 7/24/23 the stage, appearance and size were not documented.-On 8/2/23 the stage, appearance was not documented and the size was 3 x 3 x 0.1 cm.-On 8/7/23 the stage and size was documented and the appearance was black and necrotic.-On 8/15/23 the stage was not documented, the appearance was black and the size was 2 x 2.5 x 0.2 cm.-On 8/24/23 the stage and appearance was not documented and the size was 2 x 2 x 0.1 cm.-On 8/28/23 the stage, appearance and size was not documented.-On 9/5/23 the stage was not documented, the appearance was black and the size was 2 x 2 x 0.2 cm.-On 9/11/23 the stage and size was not documented, the appearance was black and necrotic.-On 11/3/23 the stage was not documented the wound bed was black and necrotic and the size was 3 x 3 x 3 cm.-There was no documentation of the left heel wound between 9/11/23 and 11/3/23. A comprehensive review of the residents medical record including available hospice notes failed to t reveal consistent or accurate documentation of the wound staging, appearance, measurements or response to treatments. The hospice progress notes documented a left buttock pressure wound.-On 8/28/23 it was documented as a new onset stage 2 pressure wound with the wound bed appearing pink and pale and the size was 1 x 0.75 x 0 cm.-On 8/31/23 it was documented as stage 2 with a red wound bed and 3 x 2 cm in size.-On 9/5/23 it was documented as stage 2 with a red and bloody wound bed and 4.5 x 1 x 0.2 cm in size.-On 11/3/23 the wound bed was documented as pink and healthy with a size of 1.5 x 0.75 x 0 cm. There was no further documentation of the left buttock pressure wound between 9/5/23 and 11/3/23. The hospice progress notes documented a right buttock wound.-On 10/18/23 it was documented as stage 1 and new in onset. The appearance and size was not documented.-On 10/25/23 it was documented as a stage 3 and the size was 2 x 2 cm. There was no further documentation of the right buttock pressure wound after 10/25/23. The 11/15/23 hospice wound care orders documented-Right gluteal fold (crease in buttock) twice weekly and as necessary cleanse with wound cleanser, pat dry, skin prep peri wound, apply medihoney to wound bed and cover with foam dressing. -Left medial heel apply betadine and cover with foam dressing every other day and as necessary for dislodgement. There was no documentation of wound care order for coccyx/sacral or left buttock area. The November 2023 CPO documented wound care and prevention orders-Pressure redistribution mattress, ordered 11/25/22.-Apply optifoam dressing over sacrum every other day and as needed for the prevention of skin breakdown, ordered 1/19/23.-Float heels and apply heel boots, ordered 6/24/23.-Betadine left heel for deep tissue injury every day and as necessary, ordered 6/24/23. There was no documentation of additional interventions put into place after the left heel was identified was identified as black and necrotic on 8/7/23, after a stage 2 left buttock or coccyx wound was identified on 8/28/23 and a right buttock pressure wound was identified on 10/18/23. D. Staff interviewsLPN #6 was interviewed on 11/15/23 at 3:00 p.m. He said that hospice nurse had been rounding on Resident #62 for wound care and dressing changes. He said the staff changed the dressing over the sacrum every other day and also when it became dislodged. He said the staff changed the dressing change on the left heel every day. He said the resident wore heel boots at all times. He said that the resident was on a regular pressure reduction mattress. He said they had not tried any other mattress for the resident after she developed the current pressure wounds. He said that the facility nursing skin documentation should match the hospice wound documentation notes. He said hospice provider should upload their notes into the medical record for staging and measurements and should be documented on the facility skin tracking form. The hospice nurse (HN) was interviewed on 11/15/23 at 3:14 p.m. The HN said the Resident #62 ' s right buttock wound was healed on 11/3/23 and found again on 11/10/23 and was assessed and documented as unstageable. Wound care ordered medihoney and covered it with foam dressing. She said the left heel pressure wound had been present for a period of time but it was documented as improving. She said the wound care orders were to paint the left heel with betadine and cover with a foam dressing and application of heel boots. She said she was not aware of a coccyx/sacral or right buttock wound. She said that the hospice noted for the resident had to be requested by the facility. She said the resident had a history of previous pressure wounds and with the development of the current pressure wounds put the resident at a higher risk of developing pressure wounds. She said additional interventions such as an air mattress would be appropriate to help heal and prevent further formation of pressure wounds. She said she was unaware the resident was not on an air mattress. She said the resident should be on an air mattress and would order one for the resident. The WD was interviewed on 11/16/23 at 2:08 p.m. The WD said that she had not been aware of any pressure wounds for Resident #62. She said nursing staff and the hospice staff had not reported any to her. She said when any resident was identified with pressure wounds or skin issues it needed to be documented in the comprehensive skin assessment and reported to the wound care nurse and the appropriate provider. The DON was interviewed on 11/16/23 at 2:15 p.m. The DON said when a resident was on hospice with hospice doing the nursing skin assessments and wound care for a resident with pressure wounds or skin issues the facility skin assessment documentation should reflect the hospice documentation. She said that the facility and hospice should be in direct communication regarding the assessment and the care of the pressure wounds. She said that the communication between hospice and the facility about the pressure wounds was done informally with the nurses on the unit. The NHA was interviewed on 11/16/23 at 2:20 p.m. The NHA said there was not a good process between the facility and hospice regarding communication on the assessment and care of the pressure wounds for Resident #62.

Based on observation, record review and interviews, the facility failed to ensure supervision and assistive devices to prevent accidents for one (#186) of three residents reviewed for falls of 54 sample residents. Specifically, the facility failed to implement fall prevention care planned interventions for resident #186 who experienced several recent falls. Findings included: I. Facility policyAssessing falls and their causes, dated March 2018, was provided by the nursing home administrator (NHA) on 11/15/23 at 3:54 p.m. It read in pertinent part:"The purpose of this procedure is to provide guidelines for assessing a resident after a fall to assist staff in identifying causes of the fall."II. Resident #186A. Resident statusResident #186, age 40, was admitted on 10/27/23. According to the November 2023 computerized physician orders (CPO), diagnoses included quadriplegia, dysphagia, anoxic brain injury, anxiety, and depression, According to the 11/6/23 minimum data set (MDS) assessment, the resident has impaired cognition and was not administered the brief interview for mental status (BIMS). The resident had shor and longterm memory problems and had poor decision making skills with regard to making decisional about tasks of his daily life and had no behavioral symptoms. He required depenendt on staff to preform all activities of daily living including mobility tasks (transfering, sitting upland laying down. He did not walk. The resident ' s fall history was unknown. B. Record Review The comprehensive care plan, initiated 10/27/23, documented that the resident was at risk for falls with or without injury related to altered mental status and a diagnosis of anoxic brain damage, quadriplegia, contractures, muscle spasms, and anxiety. Interventions include anticipating and meeting the resident ' s needs. Keep the bed in a low position with the brakes locked. Monitor for changes in condition affecting risk for falls and notify physicians if observed. The November 2022 CPO included an order to keep the resident ' s bed in a low position when the resident was in bed. Start date 10/28/23. B. Observations On 11/14/23 at 1:50 p.m., Resident #186 was observed lying in his bed. The bed was in a high position with the resident legs hanging off the side of the bed. D. Interviews Registered nurse (RN) #5 was interviewed on 11/14/23 at 1:56 p.m. RN #5 said the resident was at high risk for falls. RN #5 said that, as a result, the resident required frequent monitoring. She said the resident should always be in a low position while he was in his bed. RN #5 went to the resident's room and verified the resident was lying in bed in the highest position. RN #5 immediately lowered the resident ' s bed to the lowest position and repositioned Resident #186 feet on the bed and placed him in the middle of the bed. The director of nursing (DON) was interviewed on 11/16/23 at 12:09 p.m. The DON said staff should place the resident in the middle of the bed and the bed in the lowest position. Staff should use the fall mat and keep the resident ' s call light cord within his reach. The DON said failing to provide care planned interventions could contribute to further falls for this high-risk resident.

Based on observations, record review and interviews the facility failed to ensure for four (#75, #79, and #111) of five residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 54 sample residents. Specifically, the facility failed to follow physician orders for significant weight loss, consistently put interventions in place and timely address Resident #75 nutritional needs. Specifically, the facility failed to follow physician orders for weight loss, consistently put interventions in place and timely address Resident #79 nutritional needs. Resident #75 experienced a significant, unplanned weight loss of 12 % in three months. Resident #79 experienced an unplanned weight loss of 5.56 % in one month. Record review and interviews revealed the facility failed to ensure supplements ordered by the physician were being provided to Resident #75 and Resident #79 and additional interventions were assessed for the resident ' s weight loss. Interviews confirmed the facility lacked a system to ensure supplements were being consistently given, change of condition for feeding assistance was being assessed, and potential swallowing difficulties were being evaluated related to significant weight loss. The facility's failure to have a system that ensured physician orders were followed, changes in resident ' s assistance needs and dietary needs were monitored contributed to Resident #75 and Resident #79's weight loss. Resident #111 who was identified as had increased nutritional risk related to dementia and dysphagia experienced a significant weight loss of 7.88% in a one months period of time; however the facility did not initiate timely interventions to prevent the resident from experiencing and additional significant weight loss o 16.55% weight loss in a three months time frame. The facility failed to ensure effective and timely interventions were in place to prevent Resident #111, initially when the resident triggered with significant weight loss. The facility failed to monitor weekly weights, failed to consistently monitor meal intakes, failed to increase a house supplement until after triggering a significant weight loss of 16.55% three months after the resident experienced a significant weight loss of 16.55%. Addidioally, the facility failed to consistently monitor the resident ' s intake of prescribed health nutritional shake supplements when intakes were mostly less than 50%; failed to monitor as necessary health shakes were provided by the nursing staff; and, failed to conduct weekly interdisciplinary (IDT) nutrition assessments. -Due to the facility failures, the resident experienced continued downward trending weight loss. Findings include: I. Facility policy and procedure The Nutrition/Unplanned Weight Loss policy and procedure, revised September 2017, was provided by the nursing home administrator (NHA) on 11/18/23 at 3:51 p.m. It revealed, in pertinent part, "The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. "The physician will review and rule out medical causes of oral or swallowing problems before authorizing other consults or interventions to modify diet consistency. "The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes" II. Resident #75A. Resident statusResident #75, age 92, was admitted on 9/25/2020. According to the November 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, anorexia, and dysphagia oropharyngeal phase (difficulty initiating swallowing). The 9/27/23 minimum data set (MDS) assessment documented the resident was unable to participate in the brief interview of mental status (BIMS) because the resident rarely understood conversation and communication. Staff interview section showed the resident had short and long term memory deficits and moderately impaired decision making abilities. The assessment documented that the resident was independent with eating and did not require assistance from staff. The resident was coded for being at risk for malnutrition with no swallowing issues. B. ObservationResident #75 was observed on 11/14/23 from 12:21 p.m. to 12:59 p.m. The resident was sitting in bed in her room when certified nursing aide (CNA) #7 brought in the meal tray. The CNA adjusted the resident ' s bed to a 135 degree angle and repositioned the resident so she was in front of the meal tray on the bedside table. The resident was not able to participate in repositioning. The CNA uncovered the resident ' s food but did not cut up the meal. After the CNA exited the room, Resident #75 took one of the whole meatballs on her plate and put the entire meatball in her mouth. She accompanied the meatball with fluids and began to cough and expressed difficulty breathing. After a minute, the resident stopped coughing but still had not swallowed the meatball in her mouth. Resident #75 finished chewing the meatball at 12:40 p.m. She then picked up a cup of peaches and attempted using her knife in the position of a chopstick to eat the peaches. The resident was able to consume the entire cup of peaches in this manner. The resident attempted to cut up the remaining meatball and put pieces in her mouth while still chewing on the peaches. She took sips of fluids while still chewing peaches and meatballs. At 12:54 p.m. the resident spit the pieces of meatball she had been trying to eat into her hand. She placed the pieces onto her plate. She attempted to drink her milk, but because of the angle of the bed, she spilled the whole cup of milk onto her bed. At 12:59 p.m. the resident tried to eat more of the meatball she had cut up but began coughing while eating. The resident spit out the meatball pieces into her hand and pushed the plate away. C. Representative interviewResident #75 ' s representative was interviewed on 11/13/23 at 3:34 p.m. She stated the resident did not have family involvement and she was a longtime friend of the resident. The representative stated the resident had not been eating well and the facility asked her to prepare and bring in Korean food for the resident but she was not able to come in often enough. The facility kitchen used to make more noodles and rice and Resident #75 would eat those. D. Record reviewResident #75's weight record revealed she experienced a significant, unplanned weight loss of 12 lbs (pounds) and 12 % from 9/3/23 to 11/3/23 (a two month period). The weight and vital record revealed:The resident weighed 100 lbs on 9/1/23. The resident weighed 92 lbs on 10/1/23, a loss of 8% in 30 days. The resident weighed 88 lbs on 11/3/23, a loss of 12% in 60 days. The comprehensive care plan, revised 10/01/23, revealed the resident was at nutritional risk due to dementia and varying appetite. Interventions were to honor the residents' food preferences. The resident liked Korean food and the facility was to prepare preferred Korean food as capable. Provide supplements as ordered and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss, and abnormal labs) and report to nutritionist and physician. The November 2023 CPO revealed the following physician orders:Regular diet with regular texture- ordered on 9/25/23;House supplement- two times a day for weight maintenance- ordered on 9/22/23 discontinued 11/3/23;House supplement- three times a day for weight maintenance- ordered on 11/3/23;Speech assessment with swallow study to ensure correct diet- ordered on 11/14/23 (during survey); and,Regular diet, dysphagia texture advanced texture- ordered on 11/14/23 (during survey). The September 2023 medication administration record (MAR) reviewed from 9/22/23 through 9/30/23 revealed:The resident drank 50% of the house supplement two times. The resident drank 25% of the house supplement one time. The resident drank 0% of the house supplement one time. The resident did not receive the house supplement two times. The October 2023 MAR reviewed from 10/1/23 through 10/31/23 revealed:The resident drank 50% of the house supplement two times. The resident drank 25% of the house supplement two times. The resident drank 0% of the house supplement five times. The resident did not receive the house supplement six times. The November 2023 MAR reviewed from 11/1/23 through 11/16/23 revealed:The resident drank 50% of the house supplement eight times. The resident drank 25% of the house supplement one time. The resident drank 0% of the house supplement three times. The resident did not receive the house supplement two times. A review of the progress notes dated 9/3/23 through 11/16/23 revealed:Nutrition narrative note dated 11/14/23 (during survey) at 6:20 p.m. revealed the registered dietitian (RD) spoke with speech therapy and requested resident being assessed with swallow study to ensure resident had the safest and most effective diet. Nutrition narrative note dated 11/14/23 (during survey) at 8:01 p.m. revealed the RD observed the resident during dinner with downgraded diet texture. The resident ate 75% of her meal independently with initial prompting. -There were no prior nutrition notes between 9/3/23 to 11/13/23. -According to medication administration notes reviewed from 9/3/23 through 11/16/23, the resident did not receive the house supplement nine times in September 2023 due to the supplement not being available.-The resident did not receive the house supplement six times in October 2023 due to the supplement not being available.-The resident did not receive the house supplement one time in November 2023 due to the supplement not being available. Nutritional assessments reviewed from 9/3/23 through 11/16/23 revealed:-No nutritional assessments conducted after 8/7/23. Weight variance assessment dated 10/2/23 documented the resident had a 8 % weight loss and was attributed by nursing to varying meal intake and dementia. The resident showed a preference to sugary food so the staff held the dessert from meals to encourage the resident to eat more of the regular meal. RD to trail Mirtazapine 7.5 milligram (mg) for thirty days to stimulate appetite. RD asked the resident ' s power of attorney (POA) to bring in Korean foods for the resident to increase intake. The Mirtazapine was discontinued after 10/31/23 without further information. Weight variance assessment dated 11/3/23 documented the resident had a 12% weight loss and was attributed by nursing to varying meal intake and refusing meals. The resident had increased sleeping and was refusing meals. Weight loss was determined to be due to furthering dementia. Residents POA was bringing in Korean food for the resident which the resident frequently refused. -However, record review showed the facility failed to put further interventions in place to mitigate weight loss beyond house supplement drinks which were provided inconsistently. The resident was not assessed for changes in feeding needs or changes in swallowing or chewing functioning until the survey observations were brought to staff's attention. III. Resident #79A. Resident statusResident #79, age 70, was admitted on 10/20/2020. According to the November 2023 CPO, diagnoses included unspecified dementia. The 8/17/23 MDS assessment documented the resident was unable to participate in the BIMS because she was rarely understood. Staff interview section showed the resident had short and long term memory deficits and moderately impaired decision making abilities. She was assessed to be independent with eating and did not require assistance from staff. B. ObservationOn 11/14/23 at 11:40 a.m. Resident #79 was observed sitting in the memory care dining room. The resident sat at her table and did not have any drinks. Resident #79 was served her meal at 12:12 p.m. The resident did not eat or attempt to eat her meal. Resident #79 did not receive any encouragement from staff to eat. She was not offered an alternative since she was not eating her meal. At 12:39 Resident #79 still had not eaten any of her meals. At 12:51 CNA #7 came and took the resident ' s meal without offering any alternative. C. Record reviewResident #79's weight record revealed she experienced an unplanned weight loss of six lbs and 5.56% from 9/1/23 to 11/3/23 (a two month period). The weight and vital record revealed:The resident weighed 108 lbs on 9/1/23. The resident weighed 102 lbs on 10/1/23, a loss of 5.56% in 30 days. The resident weighed 102 lbs on 11/3/23. The comprehensive care plan, revised 5/25/23, revealed the resident was at nutritional risk due to dementia. The resident had increased nutrient needs related to excess energy expenditure, constant wandering and pacing. Interventions were to provide nourishment as ordered, offer finger foods, staff assistance at meals to cut food into smaller pieces, supplements as ordered and monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss, and abnormal labs) and report to nutritionist and physician. The November 2023 CPO revealed the following physician orders:Regular diet with regular texture- ordered on 11/3/2020;House nourishment- two times a day for weight stability. Chocolate pudding or equivalent offered by kitchen- ordered on 10/6/23;House supplement- one time a day for weight stability- ordered on 10/7/23;Speech assessment for evaluation only- ordered on 11/15/23 (during survey). The September 2023 MAR reviewed from 9/1/23 through 9/30/23 revealed:The resident did not receive house supplements or house nourishments in the month of September 2023. The October 2023 MAR reviewed from 10/7/23 through 10/31/23 revealed:The resident drank 50% of the house supplement five times. The resident drank 0% of the house supplement two times. The resident did not receive the house supplement ten times. The resident consumed 25% of the house nourishment one time. The resident consumed 0% of the house nourishment four times. The resident did not receive the house nourishment nine times. The November 2023 MAR reviewed from 11/1/23 through 11/16/23 revealed:The resident drank 0% of the house supplement three times. The resident did not receive the house supplement three times. The resident consumed 50% of the house nourishment three times. The resident consumed 0% of the house nourishment four times. The resident did not receive the house nourishment four times. A review of the progress notes dated 9/3/23 through 11/14/23 revealed:-The resident did not receive the house nourishment fourteen times in September 2023 due to the nourishment not being available.-The resident did not receive the house nourishment four times in October 2023 due to the nourishment not being available. The resident did not receive the house supplement three times in October 2023 due to the supplement not being available.-The resident did not receive the house nourishment three times in November 2023 due to the nourishment not being available. The resident did not receive the house supplement two times in November 2023 due to the supplement not being available. Assessments reviewed from 9/3/23 through 11/16/23 revealed:-No nutritional assessments conducted after 8/14/23. Weight variance assessment dated 10/6/23 documented the resident had a 5.6 % weight loss in one month and was attributed by nursing to varying meal intake and falling asleep during meals. When the resident was offered a peanut butter and jelly sandwich for a snack, she would consume 100 %. The resident slept through breakfast so the RD ordered peanut butter and jelly sandwiches for a snack and supplement drinks. Nutritional risk review dated 11/6/23 documented the resident would eat sandwiches offered but not the entire sandwich. The resident liked cheeseburgers and the RD would add cheeseburgers to her meals once a week and change snacks from sandwiches to pudding. The RD had reviewed the care plan for the risk review. -However, record review showed the facility failed to put further interventions in place to mitigate weight loss beyond house supplement drinks and nourishment snacks which were provided inconsistently. The facility failed to follow the care plan interventions of cutting the resident ' s food and providing finger foods. IV. Staff interviews CNA #7 was interviewed on 11/14/23 at 1:30 p.m. She stated Resident #75 ate a regular diet. Resident #75 could be selective with the food she ate but if she liked the food she would eat a lot of it. She preferred rice and noodles. CNA #7 said Resident #79 wandered the unit frequently and sometimes would not sit down for a meal. If the staff provided her food inside of a cup with a utensil and allowed her to walk with it, she would eat the food. When the resident did sit down for meals, she preferred finger foods but did not receive these often from the kitchen. Licensed practical nurse (LPN) #5 was interviewed on 11/14/23 at 1:45 p.m. She said Resident #75 and Resident #79 were prescribed house supplement drinks for weight loss but the unit often did not get the supplements from the kitchen. When the nurse requested the supplements from the kitchen, they would be told the kitchen was too short staffed to bring any over or the kitchen had run out of supplements. The dietary manager (DM) was interviewed on 11/14/23 at 1:51 p.m. She stated the kitchen sent supplements to Resident #75 and Resident #79 ' s unit three times a day. She did not know if the nursing staff passed the supplements to the residents. The DM had been receiving the drink buckets with the unopened supplements sent back from nurses and let the RD know. The director of nursing (DON) was interviewed on 11/14/23 at 2:09 p.m. The DON said Resident #75 needed staff to set up her meals, with additional encouragement and reminders to eat. The facility had not requested a speech evaluation after the resident ' s significant weight loss because the resident ' s daughter did not want an evaluation. The resident ' s code status was do not resuscitate (DNR) or withhold cardiopulmonary resuscitation if found without a pulse or heartbeat. The daughter did not want any changes to her diet preferences or diet texture due to this. -However, there was no family involvement according to the resident's representative who was trying to help the facility find food the resident liked to eat (see interview above). The DON was not aware if the resident was at risk for choking or had difficulty swallowing. The DON said Resident #79 required set up for her meals. The resident was at nutritional risk but there had not been a speech evaluation ordered for possible changes in eating assistance or eating abilities. The resident preferred finger foods but there was no order to ensure the resident received finger foods. The DON had not heard from the nurses the residents had not been receiving house supplements consistently as ordered. If a resident had significant weight loss, the RD would complete an observation of the resident when eating to see if additional interventions were needed. The RD was interviewed on 11/14/23 at 2:36 p.m. The RD said Resident #75 was receiving a regular diet with regular textures. The resident was to receive supplement shakes three times a day, hot chocolate with milk, chocolate pudding and cookies to add calories. The RD did not observe residents while eating, instead she relied on feedback about the resident eating habits and ability from the nurses. The nurses had told the RD that Resident #75 sometimes consumed her supplements and meals and sometimes she did not and attributed this to her advancing dementia. The RD had not evaluated if the resident required more eating assistance and was no longer appropriate or able to be eating independently. The RD said Resident #79 was to receive house nourishments three times a day and these consisted of pudding or snacks. The resident was to be given a supplement shake for weight management. The RD had ordered the resident a burger once a week. She did not know why the resident was not being provided more finger foods and had not observed the resident eating. The RD said she relied on the nurses for feedback and had not followed up with any additional evaluations or assessments to address her weight loss. The RD was aware there was a discrepancy between the nursing and the kitchen staff over whether or not the kitchen was failing to send supplements or if the nurses were failing to pass out the supplements. This had been going on for two months and the RD had not taken any action to resolve the discrepancy. The RD said if a resident had weight loss with snacks and supplements ordered and it was not impacting their weight loss, the RD would look into changes in swallowing or cognitive ability to eat without increased assistance. -However, there was not record of these approaches being attempted with either Resident #75 or Resident #79. V. Resident #111A. Resident statusResident #111, age 96, was admitted on 6/2/23. According to the November 2023 CPO the diagnoses included cerebral infarction (stroke), heart failure and moderate protein calorie malnutrition. The 9/4/23 (MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He was dependent on staff assistance for toileting, personal hygiene, transfers and required substantial to maximal assistance with bed mobility and eating. The MDS documented that Resident #111 had or was at risk for malnutrition. It did not indicate that he had a weight loss of 5% or more in one month or a weight loss of 10% in 6 months. B. Record reviewThe nutrition care plan, initiated on 6/5/23 and revised on 11/7/23, indicated that Resident #111 had increased nutritional risk related to dementia and dysphagia, Interventions included fortified foods, honoring food preferences, weigh and alert the dietician and physician to any significant loss or gain, monitor for changes in nutritional status, including changes in intake and ability to feed self, monitor intake at all meals, offer alternate choices, alert dietician and physician to any decline in intake, total assistance required at meals (initiated 6/5/23), and offer alternative food choices if less than 50% consumed at mealtime. A comprehensive review of the care plan failed to reveal personalized interventions for weight loss for Resident #111 until 11/7/23 with a loss of 5.1% in one month. The resident ' s weights were documented as follows:-6/2/23 165 lbs (pounds)-7/11/23 152 lbs-8/1/23 142.7 lbs-8/4/23 142.4 lbs-9/1/23 137.7 lbs-10/6/23 136.8 lbs-11/3/23 130.1 lbs-11/13/23 131.4 lbsA comprehensive review of the resident ' s weights revealed a weight loss of 7.88% in one month (6/2/23-7/11/23) and a loss of 16.55% in three months (6/2/23-9/1/23). The November CPO indicated an order for weekly weights every Monday, ordered on 6/5/23 and reordered on 11/6/23. A comprehensive review of the CPO and the medical record failed to reveal documentation of weekly weights from 6/5/23 until 11/7/23. The November CPO indicated an order for the resident to be assisted with every meal, ordered on 8/10/23. The November CPO indicated an occupational therapy order for staff to continue to provide the resident feeding assistance for all meals, ordered on 8/11/23. The 9/1/23 quarterly nutritional risk review documented that Resident #111 had a weight loss trend and triggered significant weight loss of 16.5% in three months. A comprehensive review of the interdisciplinary team weight variance documentation did not indicate any further documentation before 9/1/23. A comprehensive review of the CPO revealed the following diet and supplementation orders:-House supplement once a day for weight loss for poor oral intake with weight loss, ordered 7/12/23 discontinued 9/1/23.-Med pass (fortified nutritional shake) twice a day for three months, ordered on 8/10/23, discontinued on 9/1/23.-Liquid protein supplement for low protein labs for two months ordered 9/1/23-House supplement twice a day for weight loss for three months, ordered 9/2/23-Health shake PRN (as necessary), Ensure provided by family, if resident consumes less than 50% of his meal, ordered on 9/1/23 discontinued 11/8/23. No documentation of it being given in October or November.-Two gram sodium dysphagia advanced texture diet, with large portions of protein ordered 9/26/23. The October 2023 medication and treatment administration record (MAR/TAR) indicated an order for a health shake as needed for weight loss, provided the resident consumes less than 50% of his meals. There was no documentation if a health shake was provided. The 10/6/23 interdisciplinary team weight variance assessment documented Resident #111 ' s weight of 136.8 pounds (lbs) with a previous weight of 152 lbs and indicated a weight loss of 10% in three months. The November 2023 MAR/TAR indicated an order for health shakes as needed for weight loss. There was no documentation to show if the health shake was provided. The 11/8/23 IDT (interdisciplinary team) weight variance assessment documented Resident #111 ' s weight of 130.1 lbs with a weight loss of 5.1% in one month. The 11/10/23 nutrition progress notes documented communication with the resident ' s daughter regarding updating the resident ' s food preferences and reviewing current supplementation. -There was no detail on the outcome of the communication. A comprehensive review of the nutrition progress notes did not indicate any further documentation before 11/10/23. A comprehensive review of meal intakes revealed inconsistent documentation of the resident food intake. There were several days when staff failed to record the resident's meal intake including:-On 10/17/23 no documentation of intake for breakfast-On 10/19/23 documentation of lunch refusal by resident-On 10/20/23 no documentation of intake for breakfast or lunch-On 10/25/23 no documentation of intake for breakfast or lunch-On 11/4/23 no documentation of intake for breakfast or lunch-On 11/5/23 documentation of 25% or less for breakfast, less than 50% for lunch-On 11/6/23 no documentation of intake for dinner-On 11/7/23 no documentation of intake for dinner-On 11/9/23 documentation of 25% or less for breakfast, no documentation of intake for dinnerA comprehensive review of diet and supplementation orders and oral intake indicated that house supplementation was not increased to twice a day until 9/2/23 after Resident #111 had triggered a weight loss of 16.55% for three months. The medical record indicated no documentation of the health shake (Ensure) being provided or the amount when the resident refused meals or had an intake of 50% or less. It indicated that oral intake was not being consistently documented. C. Staff interviewsCertified nurse assistant (CNA) #3 was interviewed on 11/16/23 at 9:50 a.m. She said residents with weight loss or significant weight loss have an order to be weighed weekly, other residents were weighed monthly. She said Resident #111 was a resident that required one to one assistance with meals. Licensed practical nurse (LPN) #4 was interviewed on 11/16/23 at 10:00 a.m. She said residents were usually weighed monthly. Residents with weight loss or significant weight loss had an order to be weighed weekly. The registered dietician (RD) was interviewed on 11/16/23 at 9:00 a.m. She said that Resident #111 was on a dysphagia advanced diet with additional portions of protein and required one to one assistance while eating. She said he had inconsistent intakes for meals. She said that he was on a house supplement twice a day, a Boost shake once a day, and his daughter brought in Ensure, which the daughter offered. She said that he had been on the Med Pass fortified shake, but was discontinued because he did not like it. She said he has had a significant weight loss of 20.4% over the past five months. She said his current supplements were started in September, with one being started in November. She said they discussed significant weight loss daily in morning meetings. She said weekly weights had not been done until they had been ordered in November. The corporate nurse consultant (CNC) was interviewed on 11/16/23 at 9:10 a.m. She said it was an expectation that all residents who triggered for significant weight loss were to be weighed weekly and the IDT was to conduct a weekly nutrition review and conduct a quarterly IDT review.

Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#185, and #2) of four residents reviewed for supplemental oxygen use out of 54 sample residents. Specifically, the facility failed to administer oxygen therapy at the appropriate rate/ liter flow in accordance with the physician's order for Residents #185 and #2. Findings include: I. Facility policy The Oxygen Administration Policy revised 4/14/23, was provided on 10/25/23 at 1:55 p.m. by the nursing home administrator (NHA). It read in pertinent part, "Oxygen is administered and stored to residents who need it, consistent with professional standards of practice, comprehensive person centered care plans, and the resident ' s goal and preferences." II. Resident #185 A. Resident status Resident #185, age 78, was admitted on 11/1/23. According to the November 2023 computerized physician orders (CPO), diagnoses included end stage renal disease, diabetes mellitus, and hypoxemia, obstructive uropathy. According to the 11/7/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. B. Observation On 11/13/23 at 2:31 p.m. Resident #185 was sitting in his recliner with his oxygen cannula tubing hanging over his oxygen concentrator. The resident's oxygen concentrator was set on three liters per minute (LPM). -However, the physician ' s order for oxygen therapy was for the resident to receive 2 LPM continuously (see below). On 11/14/23 at 10:03 a.m. Resident #185 was sitting in his recliner in his room not wearing his oxygen. Resident #185 was coughing and was having difficulty catching his breath. -Registered nurse (RN) was called to the resident ' s room. -At 10:06 a.m. RN #2 entered Resident #185 ' s room. Resident #185 was sitting in his recliner without his oxygen on. The RN had a pulse oximeter and placed it on the resident ' s finger. RN #2 read the pulse oximeter which read 95% oxygen saturation rate. RN #2 put Resident #185 ' s cannula on and had him take several deep breaths. The resident continued to take deep breaths and was able to catch his breath. C. Record review The comprehensive care plan initiated on 11/2/23 identified the resident required the use of oxygen continuously related to hypoxia, hospice care, and end stage renal disease (ESRD). Interventions included: Administer oxygen per order via nasal cannula. Change and label humidification and oxygen (O2) tubing as indicated. Monitor and report signs of hypoxia (cyanosis, tachypnea, dyspnea, confusion, restlessness, nasal flaring, elevated blood pressure, increased respirations, and increased pulse) to physicians. The November 2023 CPO included an order dated 11/2/23 for oxygen at 2 LPM continuously, via nasal cannula, every shift, due to diagnosis of hypoxia.-The resident ' s medical record had no documentation that the resident refused to wear his oxygen or took his oxygen off. D. Staff interviews RN #2 was interviewed on 11/14/23 at 10:09 a.m. RN #2 said she was familiar with Resident #185. She said Resident #185 did not like to wear his oxygen. She said if staff saw him not wearing his oxygen they should encourage the resident to put his oxygen on. She said oxygen was a medication and should be administered per the physician's order. The director of nursing (DON) was interviewed on 11/16/23 at 12:09 p.m. The DON said oxygen was a medication. She was told of the observation above. She said staff should be encouraging the resident to wear his oxygen and report the refusal to wear his oxygen. She said staff should report the resident ' s refusal to wear his oxygen to his physician so he can assess the resident and change the order as needed. -However, the resident's medical record did not have any documentation that the resident was refusing to wear his oxygen as ordered. The DON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls and hypoxic events and could have put the residents in respiratory distress. III. Resident #2 A. Resident status Resident #2, age 65, was admitted on 11/7/22. According to the November 2023 CPO, diagnoses included depression, diabetes mellitus, chronic atrial fibrillation, and chronic obstructive pulmonary disease. According to the 9/27/23 MDS assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. She required supervision for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. B. Observation and interviewOn 11/13/23 at 10:09 a.m. Resident #2 was observed sitting on the edge of her bed reading a book with her oxygen cannula on. The resident's oxygen concentrator was set on 4LPM. On 11/14/23 at 10:38 a.m. Resident #2 was observed lying down in her bed reading with her oxygen cannula on. Her oxygen concentrator was on 4 LPM. Resident #2 said she did not touch the oxygen concentrator or equipment she relied on nursing staff to set the machine and assist her with putting on and taking off the tubing.-However, there was an order for 3 LPM continuously (see below). C. Record reviewThe care plan, initiated on 11/7/22 and revised on 10/14/23, identified the resident exhibits or was at risk for respiratory complications related to asthma and COPD. Interventions include obtaining labs as ordered and reporting to physicians as indicated. Medicate as ordered and monitor for effectiveness and observe for signs/symptoms of side effects. Report to the resident ' s physician as indicated. Provide oxygen therapy as ordered via a nasal cannula. The November 2023 CPO included an order dated 9/4/23 for oxygen at 3 LPM continuously via nasal cannula every shift due to a diagnosis of chronic obstructive pulmonary disease (COPD). D. Staff interviewRN #1 was interviewed on 11/14/23 at 10:40 a.m. RN #1 said oxygen was a medication. She said the resident was supposed to be on 3 LPM continuously. RN #1 said she adjusted Resident #2's LPM to three where it should have been. She said a negative outcome could be the resident receiving too much oxygen causing hypercapnia (too much carbon dioxide in the bloodstream). The DON was interviewed on 11/16/23 at 12:09 p.m. She said oxygen was a medication. She said Resident #2's oxygen should have been administered at the rate that the provider ordered it.

Based on observations, record review and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (#66) of two residents ' reviewed for dialysis out of 54 sample residents. Specifically, the facility:-Failed to ensure communication between the dialysis center and the facility;-Failed to have a physician's order for dialysis treatment or orders to assess the shunt site for thrill and bruit (for blood flow);-Failed to consistently assess the shunt site for thrill/bruit and the resident post dialysis; and,-Failed to have an individualized person-centered dialysis care plan. Findings included:I. Facility policyA request was made for the facility dialysis policy on 11/16/23 at 5:40 p.m., The dialysis policy was not provided at time of exit on 11/16/23. II. Resident #66A. Resident statusResident #66, under the age 65, was admitted on 9/9/23. According to the November 2023 computerized physician orders (CPO), diagnoses included cerebral infarction, end stage renal disease, dependence on renal dialysis. According to the 9/14/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. MDS revealed the resident received dialysis treatments. B. Resident interviewResident #66 was interviewed on 11/13/23 at 1:17 p.m. Residnet #66 said he went to dialysis three days a week. He stated he went to dialysis on Monday, Wednesday, and Friday. He said his dialysis today was cut short because he had an accident while on dialysis and the facility was unable to provide care as the facility had no one who could change the resident. He said he told the transportation driver and a nurse but did not remember the name of the nurse he told. He said the dialysis provider would no longer transfer him, because they had a Hoyer lift which did not accommodate his size and they almost dropped him when transferring him. C. Record reviewThe comprehensive care plan, initiated 9/11/23 and revised 10/10/23, identified the resident received dialysis by an arteriovenous fistula (AV) fistula graft. Interventions include ensuring clothing is not restricted over hemodialysis access sites. Follow physician orders for dialysis dressing care. Observe access/shunt/catheter site for signs or symptoms of complication, i.e., redness, pain, bleeding, unusual bruising, pus/drainage, absent thrill/bruit over graft site, complaints of coldness/numbness of hand/arm or chest pain and report abnormal findings to physician. -The care plan failed to address assessment of thrill and bruit within the shunt for patency, failed to address the frequency of the assessment, failed to identify a communication system between the dialysis center and the facility, and failed to address the frequency of hemodialysis treatment.-The resident CPO failed to document physician's orders for the resident ' s dialysis access care, dialysis schedule, individualized dialysis prescription such as the number of treatments per week; length of treatment time, type of dialyzer, specific parameters of the dialysis delivery system (electrolyte composition of the dialysate, blood flow rate, and dialysate flow rate), anticoagulation; fluid restrictions, target weight, blood pressure monitoring), and pertinent diagnosis. Review of the resident ' s medical records did not document any early release from dialysis on 11/13/23 or issues Resident #66 had regarding the ability to complete his dialysis treatment. III. Staff interviewsRegistered nurse (RN) #5 was interviewed on 11/14/23 at 1:56 a.m. RN #5 said she had not heard of any issues with Resident #66 while he was at dialysis. She said she would check and report back.-However, RN #5 never follow up with her findings. The corporate nurse consultant (CNC) was interviewed on 11/16/23 at 12:09 p.m. The CNCsaid when a resident was receiving dialysis they needed a physician ' s order, to order who was providing the dialysis and what days and times the resident was to go to dialysis. There should also be an order for nursing staff to check thrill/bruit, vital signs, weight among other things. The CNCpulled up the resident CPO and said all appropriate dialysis orders had just been updated (on 11/16/23). The director of nursing (DON) was interviewed on 11/16/23 at 12:15 a.m. The DON said the facility realized after record request during the survey (11/13/23 to 11/16/23) that Resident #66 did not have full physician ' s orders for dialysis treatments. The DON was unaware that the resident did not get a full dialysis treatment due to having a bowel accident and the dialysis provider not being able to assist the resident with his toileting needs. The DON said this was the first time she heard of any problem with dialysis. The DON said her expectation would be better communication between the dialysis and facility to ensure the resident receives his full dialysis treatments. The DON said the care plan should be person centered and individualized, and include a care focus for dialysis with all appropriate interventions documented in the plan. The DON said it would update the residents' care as soon as possible.

Based on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#90, #83, #42, #79, and #85) of 6 out of 51 sampled residents. Specifically, the facility failed to consistently provide person-centered approaches to Residents #90, #83, #42, and #79, who had diagnoses of dementia, involved in resident to resident altercations on the secured unit (cross-reference F600 for abuse). Findings include:I. Memory support unit activities programming The memory support unit activities calendar for 11/13/23 through 11/14/23 revealed the scheduled activities for those days included:11/13/23 Activities programming schedule 8:45 a.m. daily chronicles9:00 a.m. verse of the day11/14/23 Activities programming schedule 1:00 p.m. bowling1:00 group manicures-However, none of the scheduled activities occurred. Music played in the backgroundII. Resident #90A. Resident statusResident #90, age 81, was admitted on 6/3/22. According to the November 2023 computerized physician ' s orders (CPO), diagnoses included dementia with mood disturbance. The 8/24/23 minimum data set (MDS) assessment documented the resident was unable to participate in the BIMS due to she was rarely understood. She was unable to walk and used a manual wheelchair for mobility. The staff interview section showed the resident had short and long-term memory deficits and moderately impaired decision making abilities. She had behaviors of inattention and becoming easily distracted. B. Observations Resident #90 was observed on 11/13/23 at 8:38 a.m. to 10:58 a.m. propelling herself through the memory support unit hallways; Resident #90 was tearful. Staff did not stop to provide her reassurance or provide redirection or alternative activities. No recreational or therapeutic activities were provided to the resident. Resident #90 was observed on 11/14/23 at 1:20 p.m. propelling herself through the memory support unit hallway asking staff where she was supposed to be. Staff did not stop to provide her reassurance. No recreational or therapeutic activities were provided to the resident. C. Record reviewThe November 2023 CPO revealed the following physician orders:-Behavior monitoring for yelling and striking out related to dementia with behaviors and excessive tearfulness- ordered on 4/27/23;-Behavior monitoring for depression as evidenced by tearfulness, quiet, and withdrawal- ordered on 9/26/23. The comprehensive care plan was initiated on 6/26/23, documenting it was important for the resident to engage in meaningful activities such as going outdoors, socializing, coloring, spiritual groups, reminiscing, and manicures. Interventions included providing the resident with daily reminders of activities. The resident is at risk for elopement and resides in a memory support unit. Interventions included offering the resident activities of preference and allowing her time to express her emotions. She had behaviors of yelling out at others and interventions included speaking gently to the resident and providing reassurance. Activity participation notes or an activities assessment were not located in the resident ' s records. III. Resident #83A. Resident statusResident #83, age 80, was admitted on 1/20/22. According to the November 2023 CPO, diagnoses included unspecified dementia with agitation. The 10/12/23 MDS assessment documented the resident was unable to participate in the BIMS due to he was rarely understood. He ambulated independently. Staff interview section showed the resident had short and long-term memory deficits and moderately impaired decision making abilities. He had behaviors of inattention. B. Observations Resident #83 was observed from 11/13/23 at 8:38 a.m. to 10:58 a.m. sleeping on the sofa in the common area No recreational or therapeutic activities were provided to the resident. Resident #83 was observed on 11/14/23 from 8:45 a.m. to 10:28 a.m. sleeping on the sofa in the common area No recreational or therapeutic activities were offered to the resident. C. Record reviewThe November 2023 CPO revealed the following physician orders:-Behavior monitoring for anger, agitation, anxiety, and yelling at other residents. - ordered on 3/29/22. The comprehensive care plan was initiated on 5/3/23, documenting it was important to the resident to engage in meaningful activities such as hand massages, reminiscing, religious activities of preference, snack cart, and the daily chronicles. Interventions included encouraging the resident ' s activity preferences and providing daily chronicles and other reading materials. The resident was at risk for elopement and resides in a memory support unit. Interventions included offering the resident activities of preference and allowing him time to express his emotions. Activity assessment dated 10/23/23 revealed it was important to the resident to have snacks, be part of religious services, be around animals, and get fresh air outside. Activity participation notes were not located in the resident ' s records. IV. Resident #42A. Resident statusResident #42, age 97, was admitted on 3/3/19. According to the November 2023 CPO, diagnoses included unspecified dementia. The 10/5/23 MDS assessment documented the resident was unable to participate in the BIMS due to she was rarely understood. She was unable to walk and used a manual wheelchair for mobility. The staff interview section showed the resident had short and long-term memory deficits and moderately impaired decision making abilities. She had no behaviors. B. Observations Resident #42 was observed on 11/13/23 from 12:30 p.m. to 3:10 p.m. Redidnet #42 was in the dining room sitting in her wheelchair She remained just sitting in the dining room until 2:20 p.m. when she propelled herself into the hallway and then fell asleep in her wheelchair and remained asleep until observations ended at 3:10 p.m. Staff did not interact with the resident and no recreational or therapeutic activities were provided to the resident. . Certified nurse aide (CNA) # 9 was observed at 1:43 p.m. on 11/13/23 entering the dining room but failed to acknowledge the resident. Licensed practical nurse (LPN) #5 was observed at 1:57 p.m. on 11/13/23 entering the dining room but failed to acknowledge the resident. CNA #10 was observed at 2:19 p.m. on 11/13/23 entering the dining room and asking the resident, in English, if she needed anything. An unidentified housekeeper (HSK) was observed at 2:22 p.m. on 11/13/23 entering the dining room/ The HSK asked the resident, in English, if the resident was doing alright. Resident #42 was observed sitting in her wheelchair in the hallway on 11/14/23 at 9:30 a.m. Staff were not interacting with the resident. She remained in the hallway until falling asleep in her wheelchair at 11:23 a.m. No recreational or therapeutic activities were provided to the resident.. C. Resident interviewResident #42 was interviewed on 11/14/23 at 9:48 a.m. The resident could not understand English; however, when provided with basic questions written in Korean, she was able to read and answer the questions. She was able to provide her name and age and said she was bored. D. Record reviewThe comprehensive care plan was initiated on 5/3/23, documented it was important for the resident to engage in meaningful activities such as hand massages, exercise, arts and crafts, snack cart, reading magazines, and music. Interventions included encouraging the resident ' s activity preferences and providing reading material in Korean (the resident ' s first language). The resident used hand gestures and body language to express her needs. The resident had impaired communication abilities related to dementia and a language barrier. Interventions included educating the staff on using an interpreter line, picture books, and hand gestures. The resident is at risk of experiencing adjustment issues due to communication barriers. Interventions included monitoring conditions contributing to social isolation and encouraging participation in activities of preference. Activity assessment dated 10/19/23 revealed it was important to the resident to have snacks and be part of group activities. Activity participation notes were not located in the resident ' s records. IV. Resident #79A. Resident #79, age 70, was admitted on 10/20/2020. According to the November 2023 CPO, diagnoses included unspecified dementia. The 8/17/23 MDS assessment documented the resident was unable to participate in the BIMS due to she was rarely understood. The staff interview section showed the resident had short and long-term memory deficits and moderately impaired decision making abilities. She was able to ambulate independently. She had no behaviors indicated. B. ObservationsResident #79 was observed on 11/13/23 from 8:33 a.m. through 9:45 a.m. sleeping on a sofa in the common area. She then was taken to the dining room to eat her breakfast. At 10:25 a.m. the resident was asleep in the dining room. No recreational or therapeutic activities were provided to the resident. Resident #79 was observed on 11/14/23 from 8:45 a.m. to 10:19 a.m. wandering the hallways of the memory support unit without staff interaction. No recreational or therapeutic activities were provided to the resident. C. Record reviewThe comprehensive care plan, revised 3/4/21, documented that it was important to the resident to engage in meaningful activities such as walking, listening to music, hand massages, snack carts, and pet visits. Interventions included encouraging the resident to listen to music, watch videos on the tablet, walk outside, and have staff read to her. encouraging the resident ' s activity. The resident was at risk for elopement and resides in a memory support unit. Interventions included offering the resident activities of preference and allowing him time to express her emotions. The resident had the potential to display physical behaviors including the destruction of inanimate objects. She also had a history of wandering into other resident ' s rooms. Staff were to redirect the resident, observe for nonverbal signs of agitation, and provide structured routines and activities. Activity assessment dated 11/11/23 revealed it was important to the resident to have choices, snacks, be around animals, be part of group activities, be involved in activities of preference, and get fresh air outside. Activity participation notes were not located in the resident ' s records. V. Other resident interviewResident #279 was interviewed on 11/14/23 at 9:51 a.m. The resident said he was staying in the memory support unit because he had been quarantined for COVID-19 before moving to his permanent room. He had been on the unit for three days. He said he was concerned about the other residents on the unit because he only ever saw them sitting in the common area staring off and not speaking to anyone. Resident #279 said he never saw any activities or any staff doing any activities with the residents on the unit. VI. Staff interviews LPN #5 was interviewed on 11/15/23 at 10:08 a.m. She said there have not been activities on the memory support unit since the summer of 2023. LPN #5 said the CNAs and nurses tried to do activities with the residents when possible, but with all the care needs of the residents, there was little opportunity to provide activities programming, and the activities department did not leave any activity supplies. LPN #5 said the incidents or resident-to-resident altercations increased when the frequency of activities programming decreased due to a lack of activities. When they had activities on the unit the resident altercations decreased. LPN #5 said this was the daily music playing in the background on the stero in the common area of the unit was considered the activity for the residents. CNA #7 was interviewed on 11/15/23 at 10:10 a.m. She said activities staff do not come to the memory support unit to provide activities. Activities director (AD) was interviewed via phone call on 11/15/23 at 2:00 p.m. with NHA present. The AD said he and his two assistants were out of the facility due to contracting COVID-19, but he was all due back later in the week. Activities had been canceled during their absence. The AD said had just started working at the facility at the end of August 2023 and was still unfamiliar with some of the resident ' s. The assistant hired to work with the memory unit residents had just started the second week of October 2023. She was to have started the resident one-on-one activities in the last three weeks. The AD was aware when he was hired at the facility the memory support unit needed improvements to the activity program. The AD said typical memory support activities included exercise, arts and crafts, and the coffee/hot chocolate cart, among other things. The AD said activities programming maintained the residents' cognition and morale and without activities, the residents could experience increased depression, altercations, and increased negative behaviors. The memory support unit was intended for residents who required lower stimulation due to cognitive deficits. He said he was surprised the staff on the unit said there were no activities being provided. The NHA said the facility did not have an established plan for how activities would continue in the event that the AD and both activities assistants were out of the facility. Going forward, the plan would be to attempt to borrow activity staff from the sister facility that was approximately thirty minutes away or from the next-door independent living community (also a part of the corporation). The corporate nurse consultant (CNC) was interviewed on 11/16/2023 at 10:04 a.m. The CNC said the memory support unit was intended for residents who needed an environment with decreased stimulation. The facility management team needed to work on increasing activities on the unit and revising the plan for when activities staff were out of the building. The CNC said she would talk to the NHA to come up with a plan to train the CNAs on the memory support unit to assist with activities going forward. The AD was interviewed with NHA on 11/16/23 at 10:30 a.m. AD was aware there were very few activities scheduled on the memory support unit after 1:00 p.m. when residents would have increased behaviors due to sundowning (a state of increased confusion later in the day and evening attributed to forms of dementia). The AD said he had just started working with a new staff member to provide activities in the evening. The AD said most group activities that the facility provided occurred off of the memory support unit so the activity staff would take a few of the residents off of the unit to go to those group activities. Unfortunately, all group activities had been canceled since the facility was in outbreak status from a COVID-19 facility-wide outbreak (starting 11/4/23). The AD said he had been working on developing a one-on-one activity program for the last three weeks. This would be intended for residents who are not able to participate in group or independent activities and needed one-on-one activities with one of the activity staff members. The AD said the activities department provided the memory support unit with independent activities items that they could offer to residents on the memory support unit; such as copies of coloring materials, magazines, and books. The AD said the supplies were stored in an activities closet located in a sitting room on the memory support unit accessible to the unit nurses and CNA to offer the residents. The AD attempted to show what independent items were in the closet, but the closet was locked and he did not have a key to unlock it. LPN #5, the unit nurse, was asked if she had a key and she said the staff on the unit did not have a key to open the closet. The closet remained locked. VII. Training recordsA request was made to the CNC for dementia training records for the staff working on the memory support unit including LPN #5, CNA #7, CNA #8, CNA #9, CNA #10, the director of nursing (DON), AD, and the two activity assistants (AA). The CNC was interviewed on 11/16/23 at 11:40 a.m. The CNC said the facility did not have proof of dementia training for any of the staff records requested. VII. Facility follow upAD provided activity participation records on 11/16/23 at 10:30 a.m. The records included participation records for Residents #90, Resident #83, Resident #42, and Resident #79. The records documented the residents participated in some activities programming for September 2023 and October 2023, but there were no records of any of the residents (#90, #83, #42, or #79) receiving any activity programming in the month of November 2023. September 2023 Resident #90 participated in independent activities such as watching television, socializing, arts/crafts, listening to music, exercising, and using electronics daily from 9/1/23 through 9/19/23. The resident participated in group activities such as music daily from 9/1/23 through 9/19/23. The resident was offered one-on-one room visits fifteen times and refused to participate. No activities were offered from 9/19/23 through 9/30/23. October 2023 Resident #90 participated in independent activities such as watching television, socializing, arts/crafts, listening to music, exercising, and using electronics daily from 10/1/23 through 10/31/23 with the exception of one day. The resident participated in group activities such as music daily from 10/1/23 through 10/15/23. She participated in one group activity on 10/19/23 but no other groups for the rest of the month. The resident was active in one-on-one room visits everyday with the exception of two days. September 2023 Resident #83 participated in independent activities such as watching television, socializing, reading, exercising, and resting daily from 9/1/23 through 9/19/23. The resident participated in group activities such as music daily from 9/1/23 through 9/19/23. The resident was active in one-on-one room visits everyday from 9/1/23 through 9/19/23 with the exception of three days. No activities were offered from 9/19/23 through 9/30/23. October 2023 Resident #83 participated in independent activities such as watching television, socializing, reading, exercising, and resting daily from 10/1/23 through 10/31/23 with the exception of two days. The resident did not participate in group activities for the month of October. The resident was active in one-on-one room visits everyday from 10/1/23 through 10/31/23. September 2023 Resident #42 participated in independent activities such reading, exercising, and resting daily from 9/1/23 through 9/19/23. The resident participated in group activities such as music daily from 9/1/23 through 9/19/23. The resident was active in one-on-one room visits everyday from 9/1/23 through 9/19/23 with the exception of three days. No activities were offered from 9/19/23 through 9/30/23. October 2023 Resident #42 participated in independent activities such reading, exercising, and resting daily from 10/1/23 through 10/31/23 with the exception of two days. The resident only participated in bingo for a group activity thirteen times for the month of October. The resident was active in one-on-one room visits everyday from 10/1/23 through 10/31/23 with the exception of one day. September 2023 Resident #79 participated in independent activities such exercising and resting daily from 9/1/23 through 9/19/23. The resident participated in group activities such as music daily from 9/1/23 through 9/19/23. The resident was active in one-on-one room visits one time in the month. No activities were offered from 9/19/23 through 9/30/23. October 2023 Resident #79 participated in independent activities such exercising and resting daily from 10/1/23 through 10/31/23 with the exception of two days. The resident only participated in bingo for a group activity five times for the month of October. The resident was active in one-on-one room visits everyday from 10/1/23 through 10/31/23 with the exception of two days.

Based on interviews, observations and record review, ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to:-Ensure resident food was palatable in taste, temperature, texture and appearance; and, -Address resident food complaints. I. Facility policy and procedure The Food and Nutritional Services policy, revised September 2017, was provided by the nursing home administrator on 11/16/23 at 4:34 p.m. It revealed in pertinent part, "Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident." II. Resident and resident representative interviews All residents were identified by facility and assessment as interviewable. Resident #29 was interviewed on 11/13/23 at 9:49 a.m. He said we still had a long wait for food and it was cold when "I get it." Resident #2 was interviewed on 11/13/23 at 10:07 a.m., Resident #2 said, not only were mealtimes a problem, so was the kitchen taking our orders. She said I asked for two fried eggs but got scrambled instead and the toast was as hard as a rock. She said another issue was the food selection because all we have are scrambled eggs for breakfast and the kitchen was always running out of food. Resident #111's representative was interviewed on 11/13/23 at 12:20 p.m. The representative said she visited often and observed that Resident #111 did not particularly like the facility and did not seem to eat well, so she stocked Resident #111 room with Ensure drinks that he likes (strawberry and vanilla). She states at least he drank one ensure a day. The representative said that the resident really enjoyed meat and potatoes. Resident #66 was interviewed on 11/13/23 at 1:19 p.m. Resident #66 said, "I have dialysis on Monday, Wednesday and Friday and I get back into my room after 2:00 p.m. and my meal was on my bedside table and I don ' t know how long it had been there." He said the food was always dry and tough. Resident #35 was interviewed on 11/13/23 at 3:50 p.m. She said the food was awful and always cold. She said she ate a spoonful of cauliflower and one spoonful of broccoli and a stale piece of cake and could not eat anymore. Resident #84 was interviewed on 11/13/23 at 4:26 p.m. She said the food was always overcooked and the kitchen served too many scrambled eggs. They have no variety in the food selection Resident #6 was interviewed on 11/13/23 at 4:33 p.m. She said the food was terrible. Resident #38 was interviewed on 11/14/23 at 10:00 p.m. He said meal times have not gotten any better. He said meals were always late and the food was always cold. Resident #31 was interviewed on 11/14/23 at 1:58 p.m. She said, "Are we going to get our lunch today? She said they are always late in getting us our food." Resident # 28 was interviewed on 11/15/23 at 3:02 p.m. She said the kitchen was always late in delivering our meals. She said, "I don ' t have a choice in what I get to eat because I get what they deliver and if I don ' t like it that is too bad". Resident #87 was interviewed on 11/15/23 at 3:25 a.m. She said, "I am always asking for apple juice for my cereal because I cannot drink milk and the kitchen was always out of it and other things." III. ObservationsA test tray for a regular diet, puree, and mechanically altered meal was evaluated immediately after the last resident had been served their room tray for lunch on 11/16/23 at 1:39 p.m. The CK and dietary staff were observed plating the last resident hall meal trays starting at 1:33 p.m. At the end of the service, a request was made for a test tray. The CK marked three plates with a black warmer lid to identify the test trays that were requested. The test trays of meals were placed on a large plastic open cart with four shelves. The meal cart was not heated. DA #1 was followed to the resident unit, with the resident meal trays and the test trays, where the DA delivered the resident's meal trays. DA #1 left the meal cart will all meal trays including the test tray on the unit next to the nursing station. CNA #11 started delivering meals along with two other unknown CNAs. CNA #11 delivered the last resident meal tray at 1:39 p.m., and the test tray meals were taken to the conference room for temperature and taste testing. The test trays were assessed promptly at 1:40 p.m. A test tray of the main meal for a regular diet, puree and mechanically altered meal was evaluated immediately after the last resident had been served their room tray for lunch on 11/16/23 at 1:40 p.m.-The kitchen ran out of alternate meals. The test tray consisted of an open-faced roast pork sandwich, mashed potatoes, herbed green beans, and lemon cake with lemon icing. The alternative menu consisted of marinated chicken breast, buttered noodles, Brussel sprouts, and dinner roll/bread.-The open-faced pork roast sandwich was dry and tough. The temperature was 123 degrees F. -The green beans had no flavor and were bland. The temperature was 112 degrees F.-The mashed potatoes were bland with no taste. The gravy had no flavor or seasoning. The temperature was 123 degrees F.-The lemon cake was very dry and had burnt edges.-The puree open-faced sandwich had no seasoning and was grainy in taste. The temperature was 111 degrees F. -The green beans had no flavor and were bland. The temperature was 110 degrees F.-The pureed bread was gummy and pasty and was stale.-The mashed potatoes were bland with no taste. The gravy had no flavor or seasoning. The temperature was 115 degrees F.-No pureed lemon cake was provided-The mechanically altered open-faced sandwich had no seasoning and was dry. The temperature was 110 degrees F. -The green beans had no flavor and were bland. The temperature was 106 degrees F.-The mashed potatoes were bland with no taste. The gravy had no flavor or seasoning. The temperature was 109 degrees F. IV. Staff Interview Certified nurse aide (CNA) #1 was interviewed on 11/14/23 at 9:47 a.m. The CNA was picking up residents ' breakfast trays. She showed five meal trays where the residents did not even eat their food. She said the residents told her that the food tasted so bad that they could not eat any of it. The resident also told her that they were tired of getting the same thing over and over again. She said the kitchen does not even give these residents a choice of what they want to eat, they are served the main meal and if they do not eat it they do not offer the resident an alternative meal. .The dietary manager (DM) was interviewed on 11/16/23 at 8:32 a.m. The DM was told of the observation above. She said the main issue was the lack of communication between the kitchen and the nursing staff; the kitchen sent out the meals and the nursing staff were not delivering the meals timely, which was affecting the temperature which then affected the flavor of the food. The DM said there was also a lack of communication between the kitchen staff and the staff who were taking resident orders, which affected food choices and resident satisfaction with the meals they were served. The nursing home administrator (NHA) was interviewed on 11/16/23 at 12:08 p.m. He was told of the observations above. He said the facility was working on a performance improvement plan and a new system with a new meal program. The facility hired a new consultant and was working on getting some new equipment for the kitchen which would allow better delivery of food to the residents.

Based on observations, record review and interviews, the facility failed to provide food that accommodated resident allergies, intolerances and preferences for three (#87, #84 and #53) of three residents out of 54 sample residents. Specifically, the facility failed to:-Ensure Resident #87 received an accommodation for a food allergy and food intolerance by receiving her preferred beverage for her morning cereal and coffee;-Ensure Resident #84 received his preferred side of brown sugar with his morning oatmeal; and,-Ensured that Resident #53 received his preferred breakfast meal. Findings include:I. Facility policy and procedureThe Food Allergies and Intolerances policy, revised August 2017, was provided by the corporate nurse consultant (CNC) on 11/16/23 at 3:45 p.m. The policy read in pertinent part: "Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat."The Food and Nutrition Services policy, revised October 2017, was provided by the dietary manager (DM) on 11/15/23 at 10:30 a.m. The policy read in pertinent part: "Reasonable efforts will be made to accommodate resident choices and preferences."If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued."II. Resident #87A. Resident statusResident #87, age 74, was admitted on 6/21/23. According to the November 2023 computerized physician orders (CPO), diagnoses included hypertension, gastroesophageal reflux disease (GERD) and hypertrophic pyloric stenosis (swelling in the muscles between the stomach and intestines). Allergies included berries, milk and milk products. The 9/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. The resident did not need any assistance with eating and drinking. B. InterviewResident #87 was interviewed on 11/13/23 at 9:43 a.m. Resident #87 said the food was terrible and the one thing she liked to eat for breakfast she could not eat because they had not brought her apple juice again today. Resident #87 said she was allergic to berries and lactose intolerant. The only thing that tasted good on her cereal was apple juice and the staff frequently told her they ran out of it. Resident #87 said she would really like a cup of coffee but needed cream and sugar in her coffee but the kitchen did not accommodate her needs and did not ever offer lactose-free milk. Resident #87 said when she drank any milk product she had a lot of stomach and intestinal distress. Certified nurse aide (CNA) #1 was interviewed on 11/13/23 at 9:46 a.m. CNA #1 said the kitchen never sent enough drinks to serve all residents in the unit. The unit had seven wings; the CNA said she started delivering drinks on the 1100 hall and by the time she was a little more than halfway through drink delivery she ran out of coffee and most of the juices. Many residents were unable to get their preferred drinks and had only the option of water to drink with the meal. The CNA said she was agency staff and was not aware that Resident #87 had food intolerance and allergies, CNA #1 said yesterday she ran out of apple and orange juice by the time she got to Resident #87's room; so Resident #87 was not able to eat her cereal and she had no lactose free milk or coffee to provide the resident. CNA #1 said it was not unusual for the kitchen to run out of drink and food items leaving the resident to go without. Residents complaining of not getting sides, condiments, and drinks were a common occurrence. CNA #1 said she was out of drinks today as well but she had saved Resident #87 one cup of apple juice for her cereal. Resident #87 was interviewed on 11/16/23 at 11:00 a.m. Resident #87 said she had not been able to eat her cereal all week because the kitchen was still out of apple juice. Resident #87 said she found a baggie in her dresser and had been storing up her cereal for when the facility got some apple juice so she could eat the cereal. Resident #87 said if I could at least get apple juice daily for my morning cereal and lactose-free milk on occasion for a cup of coffee "it would be great."C. Record reviewThe resident's nutritional assessment, dated 6/22/23, documented that the resident was on a regular diet and had allergies to berries, strawberries, hot pepper, milk and milk products. The resident received large breakfast portions and her nutritional goal was to stop losing weight. Resident #87 food preferences assessment, dated 11/16/23, documented an extensive list of dislikes and intolerances. The resident's special requests included daily cereal for breakfast.-The assessment did not include specifications for apple juice to pour over the cereal. Additionally, there were several requested food items that contained milk products, like sherbet and pudding on the resident's list of requested items but the document did not specify that the resident needed a lactose-free version of that food item. The resident's comprehensive care plan, last reviewed on 10/23/23, did not have a care focus to address the resident's specific food allergies and intolerances. However, nutritional interventions included honoring the resident's food preferences within the meal plan and offering fluids of choice. III. Resident #53A. Resident statusResident #53, under the age of 65, was admitted on 6/3/22. According to the November 2023 CPO, diagnoses included cerebral vascular disease (impaired blood flow in the brain), aphasia (difficulty communicating) and adjustment disorder. The 9/1/23 MDS assessment revealed the resident had impaired cognition and was not able to complete the BIMS exam. The resident had short and long-term memory problems but was able to recall the seasons, location of his room, staff names and knew he was in a nursing facility. The resident needed some supervision with eating. B. Observations and interviewResident #53's breakfast tray was delivered to his room on 11/14/23 at 8:46 a.m. Resident #53 was observed on 11/14/23 at 9:08 a.m. Resident #53 was yelling out loudly and could be heard from down the hall. Several staff were observed walking past his room and not checking on the resident. The resident was sitting up in his wheelchair beside his bed. The resident's breakfast tray was on the bed beside him. Resident #53 had not started to eat his meal. Resident #53 was interviewed on 11/14/23 at 9:12 a.m. Resident #53 was pointing and waving at his food tray. Resident #53 had difficulty speaking understandable words. He had two bowls of oatmeal on his food tray and picked up one bowl of oatmeal and began waving it around before he put it down and made a circular gesture with his thumb and pointer finger and tipped his hand as if pouring something into his oatmeal. After a couple of questions, the resident was able to give a thumbs up to wanting brown sugar for his oatmeal. The resident then held up three fingers to say he wanted three sides of brown sugar. Once this was repeated back to the resident he calmed and stopped yelling. A passing CNA was alerted to the resident's need for brown sugar. Several minutes later the CNA returned with some brown sugar for the resident. The resident smiled and ate his food quietly. Resident #53 was interviewed on 11/15/23 at 10:45 a.m. The resident gestured that his breakfast was good and that he frequently did not get brown sugar with his oatmeal. CNA #13 was interviewed on 11/15/23 at 11:04 a.m. CNA #13 said Resident #53 was difficult to understand and he often yelled out when he wanted something. Licensed practical nurse (LPN) #6 was interviewed on 11/15/23 at 1:33 p.m. LPN #6 said Resident #53 often yelled when he was not happy about something or was waiting for staff to provide care. C. Record reviewThe resident's nutritional risk review, dated 8/30/23, documented that the resident was on a regular diet with double portion sizes. Resident #53 food preferences assessment, dated 11/16/23, documented a list of dislikes and intolerances. The resident's special requests included daily oatmeal.-The assessment did not specify oatmeal toppings. The resident's comprehensive care plan, last reviewed on 9/14/23, documented a nutrition care focus; interventions included honoring the resident's food preferences within the meal plan and offering fluids of choice. IV. Resident #84A. Resident statusResident #84, under the age of 65, was admitted on 4/15/21. According to the November 2023 CPO, diagnoses included hypertension, depression and diabetes. The 8/22/23 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. He did not require assistance for eating or drinking. B. Resident interviewResident #84 was interviewed on 11/13/23 at 4:26 p.m. Resident #84 said the facility food was terrible and mostly overcooked. He had asked facility staff to provide him with a breakfast alternative besides the daily pile of scrambled eggs he was served every morning for breakfast. The resident said he had asked for ham, bacon or sausage to be served with his breakfast for added protein to facilitate better wound healing but the facility never offered anything other than eggs and cold cereal for his breakfast. Resident #84 said he did not want scrambled eggs. C. Record reviewThe resident's nutritional risk review, dated 11/13/23, documented that the resident was on a regular diet with double protein portions. Resident #84's food preferences assessment, dated 11/16/23, documented a list of dislikes and intolerances. The list of dislikes included scrambled eggs while the special request list included scrambled eggs. The resident's comprehensive care plan, reviewed on 9/7/23, documented a nutrition care focus; interventions included honoring the resident's food preferences within the meal plan and offering fluids of choice. V. Other observationsOn 11/14/23 at 11:39 a.m., CNA # 1 was observed serving drinks to residents on the Columbine unit during the lunch meal. CNA #1 offered Resident #29 a beverage for his lunch. When the resident asked what beverages were available, CNA #1 told him he could choose from water, coffee or watered down lemonade. Resident #29 asked why the lemonade was watered down and CNA #1 said the lemonade pitcher was nearly empty and did not have enough for other residents. The resident declined the watered down lemonade and just asked for water. VII. Staff interviewsThe dietary manager (DM) was interviewed on 11/15/23 at 12:30 p.m. The DM said the reason the facility was out of some food items was because the order delivery was late. The DM said if the staff serving meals ran out of drinks they could call the kitchen for more drinks. The DM said menus were made up by the food services company, the facility recognized there was little variety in meal planning and residents were complaining so they had contracted with a new company to make changes in the facility menu and increase resident satisfaction. The nursing home administrator (NHA) and CNC were interviewed on 11/16/23 at 12:10 p.m. The CNC said each resident should be offered a choice between the main meal of the alternative meal and if the resident wanted something different from what they received staff should contact the kitchen for the meal alternative. The facility was working on educating the CNAs to deliver and offer alternative meals if the residents were not happy with the meals they received. The NHA said the facility had identified mealtime concerns and they were looking at different programs and meal services. The NHA and CNC said the CNAs could contact the kitchen for more drinks to service residents as needed and for items that were missing from the residents' meal orders.

Based on observations, record review, and interviews the facility failed to ensure each resident received their meals, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Specifically, the facility failed to ensure the residents did not have prolonged wait times of 30 minutes or longer for their meal to be served; and that meals were served to the residents at the regular posted meal times. Findings included:I Facility policy and procedure The Food and Preparation policy and procedure, no date, provided by the nursing home administrator (NHA) on 11/16/23 at 4:14 p.m., read in pertinent part: "Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food and handling practices." II. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:15 a.m., lunch at 11:15 a.m. and dinner at 4:45 p.m. III. Resident interviews Resident #29 was interviewed on 11/13/23 at 9:49 a.m. He said we still have a long wait for food. Resident #2 was interviewed on 11/13/23 at 10:07 a.m., Resident #2 said food delivery was still an issue for all meals. Resident #66 was interviewed on 11/13/23 at 1:19 p.m. Resident #66 said, the kitchen never delivered meals on time and the food was always cold. He said, "I have dialysis on Monday, Wednesday, and Friday and I get back into my room after 2:00 p.m. and find my meal sitting on my bedside table and I don ' t know how long it had been there." Resident #185 was interviewed on 11/13/23 at 2:21 p.m. He said, "It does take a long time to get our meals."Resident #38 was interviewed on 11/14/23 at 10:00 p.m. He said meal times have not gotten any better. Resident #31 was interviewed on 11/14/23 at 1:58 p.m. She said, "Are we going to get our lunch today? She said, "The kitchen is always late in getting us our food." Resident # 28 was interviewed on 11/15/23 at 3:02 p.m. She said the kitchen was always late in delivering our meals. She said supper was supposed to be at 4:45 or 5:00 p.m., but yesterday I didn ' t get my meal until 6:40 p.m. Resident #87 was interviewed on 11/15/23 at 3:25 a.m. She said she was always getting her meals late and she really didn ' t understand why because her room was so close to the dining room. " IV. Observations Meal delivery was observed being delivered late on 11/15/23-From 8:49 a.m. to 9:10 a.m., breakfast room trays were being delivered on the 1300, 1400, 1600, and 1700 hallways; over one hour and 30 minutes late.-At 11:55 a.m., the first meal cart was sent out of the kitchen with the lunch meals to the resident floors for delivery; 40 minutes late.-At 1:48 the last meal cart was sent out; over two and a half hours late. Meal delivery was observed being delivered late on 11/16/23-At 8:58 a.m. breakfast room trays were being delivered to Hall 1400 and 1500; over 30 minutes late. V. Staff interview The dietary manager (DM) was interviewed on 11/16/23 at 8:32 a.m. The DM was told of the observation above. She said the kitchen staff delivered the meal carts to each hall and notified nursing staff that the carts were there. She said delivery of the meals to the residents depended on how busy the floor staff were and how fast the meals could be delivered to the residents. She said there still was a miscommunication between nursing staff and getting the meals served in a timely manner. The nursing home administrator (NHA) was interviewed on 11/16/23 at 12:08 p.m. He said the facility was working on a new system and is working on a new meal program. The facility hired a new consultant and was working on getting some new equipment for the kitchen which would allow better delivery of food to the residents.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure:-Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process;-Cutting boards were free from deep scratches and stains;-Follow accepted hand hygiene practices during meal preparation; and,-Kitchen and food service areas were kept clean Findings include:Facility policy The Food Preparation and Service policy, revised November 2022, was provided by the corporate numse consultant (CNC)on 11/16/23 at 3:45 p.m. It read in pertinent part: "Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices." I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code, current as of 11/7/23 retrieved 11/22/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 "Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds.""Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long."B. Observations and staff interview On 11/15/23 at 10:26 a.m., Cook (CK) had prepared the roasted pork for the lunch menu. The CK placed several pieces of roasted pork into the food processor and proceeded to puree the pork. The CK poured broth into the roasted pork until the puree reached the right consistency. The CK placed the pureed pork into a metal pan and proceeded to wrap it with aluminum foil. The CK was asked what the temperature of the pureed pork was. The CK stated the temperature of the pureed pork was 119 degrees F. She then wrapped the metal container and placed it into the warming oven. The CK proceeded to complete the same process for the minced meat mechanical soft roasted pork. She then placed approximately 24 pieces of the roasted pork into the blender and proceeded to finish the minced meat mechanical soft pork. After getting it to the correct consistency she grabbed another metal pan and poured the pork into the pan. She placed it on the counter and took the temperature, which was 118 degrees F. She wrapped it with aluminum foil and placed it into the oven. The CK pureed the green beans in the same process, with the temperature of the green beans being 121 degrees F. She then wrapped the metal container and placed it into the warming oven. The CK placed several pieces of chicken breast into the food processor and proceeded to puree the chicken. The CK poured the broth into the chicken breasts until the puree reached the right consistency. The CK placed the pureed chicken into a metal pan and took the temperature, which was 117 degrees F. She then wrapped the metal container and placed it into the warming oven. The CK was asked if he checked the temperature of the minced moist foods and pureed food after pureeing them. The CK said, "No, I do not, but I would take the temperatures before serving them and they should be at 160 degrees F." On11/15/23 at 11:44 a.m., the dietary manager (DM) again took the temperature of all items listed above. The roasted pork minced meat mechanical soft was at 163 degrees F, the pureed roasted pork was at 162 degrees F, and the pureed green beans were at 163 degrees F. C. Additional interview The DM was interviewed on 11/16/23 at 8:32 a.m. She said she spoke with the CK and the CK stated she took the temperatures of the food before she placed it in the warming oven. She said she was aware that the temperatures of the modified food dropped at times. She said, "I thought that the food was okay as long as it reached 165 degrees F before serving." She said dietary staff would be educated immediately to ensure the modified consistency of food reached proper temperatures and time frames. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, retrieved 11/23/23 from https://cdphe.colorado.gov/environment/food-regulations "Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized." B. Observation The initial kitchen tour conducted on 11/13/23 at 8:41 n a.m. revealed eight large cutting boards. There was one green, one blue, two red, two white, three yellow, and one brown cutting board. All cutting boards were heavily scored and stained. On 11/15/23 at 11:34 a.m., dietary aide (DA) #3 was cutting hot dogs on the white cutting board that was observed to be heavily scored and stained (see above).-At 11:58 a.m., the DM was observed cutting tomatoes, cucumber, and ham on the green cutting board observed to be heavily scored and stained (see above). C. Staff Interview The DM was interviewed on 11/16/23 at 8:32 a.m. The DM was told of the observations of the cutting boards in the kitchen. She acknowledged the cutting boards were visibly stained and showed wear. She said he would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. III. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, retrieved 8/23/23 from https://cdphe.colorado.gov/environment/food-regulations "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and:-Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. "Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, and areas between the fingers, hands, and arms for at least 15 seconds, followed by;2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device." B. Observations Observation of meal service was conducted on 11/15/23 at 10:30 a.m. Dietary aide (DA) #1 placed the pan of lemon cake on the end of the counter, removed the plastic wrap, and proceeded to throw the plastic wrap into the trash can. DA #1 moved the trash can lid with his hand and pushed the plastic wrap into the trash can. DA #1 returned to the counter without performing hand hygiene DA#1 put on a pair of gloves and started cutting the cake using the metal spatula as a measuring device. DA #1 picked up each piece of cake with his gloved hand placed it into a desert dish and then covered it with plastic wrap. DA #1 would place the plastic dessert cups on a large metal tray and then place them on a metal rack. DA #1 picked up his pants with his gloved hands and returned to plating the deserts. DA #1 did not perform hand hygiene during this process. DA #4 was observed doing dishes. DA #4 would grab the dirty dishes from the outside corner of the dishwashing room, rinse the dirty dishes, and then place them into the dishwasher. DA #4 then remove the clean dishes and place them on a metalrack. DA #4 would then return and rinse the dirty dishes. This process was done three more times. DA #4 did not perform hand hygiene during this process. DA #1 was asked to get the bread for the opened faced sandwiches. DA #1 walked back to the storage area and returned with four loaves of bread. He grabbed a large metal container and proceeded to open the bags of bread. DA #1 picked up his pants and proceeded without performing hand hygiene to put on a pair of plastic gloves. DA #1 opened the bread, grabbed five slices of bread at a time, and placed the bread in the metal container until the bag was empty. He did this until he used all of the four loaves of bread. He then walked over to the trash can, lifted the lid with his gloved hand, placed the plastic bag into the trash can, and then returned to the counter with the bread. DA #1 would be adjusting his mask with his gloved hand. DA#1 then returned to the storage area, grabbed three more loaves of bread, and proceeded to open the bread and place the bread into the metal container. DA #1 did not perform hand hygiene during this process. DA #2 was outside of the kitchen helping load the meal carts with the resident food trays. DA #2 was asked to come into the kitchen and assist on the serving line. DA #2 came into the kitchen and without performing hand hygiene proceeded to get the meal plates and place them on the tray as well as the service ware. DA #2 grabbed the plates and plate warmers and placed them onto the trays. DA #2 then grabbed a piece of green garnish with his bare unwashed hands hand and placed a piece on each resident's meal plate. While DA #2 was waiting for the cook to serve the meals he would wait with his bare hand pressing on the plate. DA #2 did this process through the whole meal process. DA #2s chef ' s coat was large and overhung on his wrist. The coat was dirty and particularly so on the sleeve and would hang touching the resident's meal plates. DA #2 would adjust his mask with his hands throughout the meal service. DA #2 did not perform hand hygiene during this process. The DM was preparing chef salads for two meal orders. The DM entered the walk-in refrigerator and returned with a bag of cheese, tomatoes, cucumber, and a plastic container of ham. After touching the door handles and several other surfaces on the way to and from the walk-in refrigerator the DM without performing hand hygiene put on a pair of gloves and proceeded to open the bag of lettuce, grabbing several handfuls of lettuce and placing it on the plate. Some leaves of lettuce fell off the plate and the DM picked them up and placed them onto the plate. The DM then proceeded to go over to the counter and cut the tomatoes on the green cutting board. The DM did not perform hand hygiene during this process. The DM then grabbed the cut tomato slices and placed them on the salad plate. The DM returned to the counter, removed the plastic wrap from the cucumber, and proceeded to cut the cucumber with the same knife. The DM grabbed several slices of the cucumber and placed them on the plate. The DM then opened the plastic container with her gloved hand reached in and grabbed two slices of ham. She proceeded to cut the ham with the same knife and placed the cut ham onto the salad plates. She wiped her hand on the side of her pants and continued to reach into the bag of cheese and pulled out a handful of chess and placed it onto the salad pressing down on the salad. She wrapped the chef's salads with plastic wrap and placed them onto a tray of ice. The DM did not perform hand hygiene during this process. DA #1 was preparing several hot dogs for special meal orders. While he was warming the hotdogs he was asked to prepare two chefs salads. DA #1 placed the hotdogs into a metal container and placed them on the top shelf of the counter. Without performing hand hygiene he then grabbed two large handfuls of lettuce and placed them onto the plates. He then proceeded to walk over to the counter where he had placed the green cutting board (see cutting board section above) and cut tomato slices. He then grabbed the sliced tomatoes and placed them on the plates. He wiped his hands on the side of his pants. He then returned to the counter and cut cucumber slices and then placed them on the two plates. He grabbed four slices of ham and proceeded to cut them with the same knife used for the other vegetables. He held the ham in his cupped hands and placed them onto the two salads. He then would push down on the salad of the plates. He reached into the bag of cheese, grabbed two handfuls of cheese, and placed them on the salads. He picked up his pants with his gloved hands. He proceeded to wrap the salads with plastic wrap and then placed them onto the tray of ice. DA #1 did not perform hand hygiene during this process. C. Staff Interview The dietary manager (DM) was interviewed on 11/16/23 at 8:32 a.m. She said all kitchen staff needed to wash their hands when their hands became contaminated. She said all staff must wash their hands before handling or serving food. Staff should also wash their hands when they leave the kitchen and dining area. The DM said staff should wash their hands and change gloves before and after touching ready to eat foods. The DM said it was her expectation all dietary staff would wash their hands between tasks to avoid cross contamination IV. Kitchen and Food Service Areas Professional Reference Colorado Retail Food Establishment Rules and Regulations, effective 1/19/19, section 6-602-603 Nonfood-Contact Surfaces retrieved 11/23/23 from https://cdphe.colorado.gov/environment/food-regulations read, "Nonfood-contact surfaces of equipment, including transport vehicles, shall be cleaned as often as necessary to keep the equipment free from the accumulation of dust, dirt, food particles, and other debris." "Section 6-401 Cleaning Physical Facilities read, "Floors, mats, duckboards, walls, ceilings, and attachments (e.g., light fixtures, vent covers, wall and ceiling mounted fans, and similar equipment), and decorative materials (e.g., signs and advertising materials), shall be kept clean." 2. Observations A tour of the kitchen was completed on 11/13/23 at 8:41 a.m. and revealed the following: -The walls above the hand washing sink and three-compartment sinks had peeling and damaged sheetrock.-The refrigerator/freezer and other appliances were soiled with food debris on the handles, front, and sides of the units.-Countertops and backsplash/walls were soiled with food debris.-The oven and steamer doors including the front and sides of the stove contained an accumulation of dry food spills and grease-Floors throughout the kitchen, storage room, and under appliances contained food crumbs and debris.-The dishwasher had hard water deposits on the face and top of the dishwasher. The dishwasher had a buildup of rust and other water damage on top. There was a build-up of dried food and crumbs around the dishware. The wall around the dishwasher had food debris and rust. The caulking around the rinse sink was peeling with food debris. A second observation of the kitchen was conducted on 11/14/23 from 8:40 a.m. to 8:53 a.m., during a daily kitchen tour and observations revealed the same concerns identified above during the initial tour of the kitchen. A third observation of the kitchen was conducted on 11/15/23 from 110:30 a.m. to 1:28 p.m., during meal preparation when the mechanical and puree meals were being prepared for the residents' dinner, observations revealed the same concerns identified during the initial tour on 11/13/23. A fourth observation of the kitchen was conducted on 11/16/23 at 8:25 a.m., in the presence of the DM observations identified the same concerns as identified on 11/13/23 during the initial tour. 3. Staff interviews. The DM was interviewed on 11/16/23 at 8:32 a.m. The DM said the kitchen cleaning schedule included cleaning counters, backsplashes, and cabinets. The stove was to be cleaned daily. The floors were swept and mopped daily, and staff were supposed to clean up spills as they occurred or when noticed. DM said the staff completed a deep cleaning weekly. The DM said she would provide a copy of the cleaning schedule and completed tasks; however, that documentation was not provided by the time of the survey ' s exit on 11/16/23. The DM said the kitchen should be cleaned routinely to prevent illness to the residents.

Based on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#185) of three residents reviewed for hospice services out of 54 sample residents. Specifically, the facility failed to:-Have a written plan of care for Resident #185, including both the most recent hospice plan of care and a description of the services furnished by the long-term care (LTC) facility; and-Ensure that facility staff provided orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff who provide resident care in the facility environment. Findings include: I. Facility policyA request was made for the hospice policy on 11/16/23 at 5:40 p.m. The policy was not provided at the time of survey exit on 11/16/23. II. Resident #185 A. Resident status Resident #185, age 78, was admitted on 11/1/23. According to the November 2023 computerized physician orders (CPO), diagnoses included end stage renal disease, diabetes mellitus, and hypoxemia, obstructive uropathy. According to the 11/7/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy and hospice services. B. Record reviewThe comprehensive care plan initiated on 11/2/23, revealed that the resident required hospice care and was at risk for rapid decline in ADL function, sudden onset or worsening skin integrity, weight loss, nausea/vomiting, pain, abnormal breathing, and impaired psychosocial well-being related to terminal illness. Interventions included coordinating residents' needs with hospice staff. Provide emotional support to the resident and family as death comes near. -The care plan failed to define the responsibilities of the facility versus what the hospice would provide in terms of services. -The facility failed to have the hospice aide/nurse notes available in the resident's file for the nursing staff ' s reference. -The facility failed to have a designated staff member with a clinical background, to coordinate care for the resident between the hospice agency and the facility. C. Interviews Certified nurse aide (CNA) #4 was interviewed on 11/14/23 at 10:49 a.m. CNA #4 said she knew Resident #185 was on hospice but she said she didn ' t know when hospice came into the facility or what care they provided for Resident #185. CNA #12 was interviewed on 11/14/23 at 1:18 p.m. CNA #12 said she was not aware the resident was receiving hospice care. The hospice nurse (HN) was interviewed on 11/14/23 at 3:47 p.m. The HN said she was the resident ' s hospice nurse. The HN said she was familiar with the facility but had not received an orientation to the facility's practices or procedures. She said her documentation about hospice care provided to the resident went to the hospice company and she gave facility staff a short verbal report if there were any issues that arose during the visit. The HN said she did not document in the facility software and she was not familiar with the facility's care plan but utilized the hospice care plan in her delivery of care to the resident. The HN said she was not aware of who the contact person was for the facility and resident care needs but relied on the floor nurse to pass relevant information along to facility leadership. The director of nursing (DON) was interviewed on 11/16/23 at 12:15 p.m. She said she was not familiar with the regulations specific to hospice care. She said she thought social services was the coordinator between all hospice providers but she was not sure. She said she would check. She said the facility had no formal orientation for hospice aides. The corporate nurse consultant (CNC) was interviewed on 11/16/23 at 12:20 p.m. She said the nursing home administrator (NHA) would now be the facility coordinator for all hospice providers.

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#43) of five residents reviewed for immunizations out of 54 sample residents. Specifically, the facility failed to offer and provide the pneumococcal conjugate vaccine (PCV13) and or pneumococcal polysaccharide vaccine (PPSV23) to Resident #43. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2024, retrieved on 11/15/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, The document read in pertinent part: "Routine vaccination - pneumococcal:-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."For guidance for patients who have already received a previous dose of PCV13 and/or PPSV23, see www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm."II. Facility policyThe Pneumococcal Vaccine policy, revised March 2023, was received by the nursing home administrator (NHA) on 11/13/23. It read in pertinent part; "All residents are offered pneumococcal vaccines to aid in preventing pneumonia infections."Upon admission residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission."III. Resident statusResident #43, over the age of 65, was admitted on 12/21/21. According to the November 2023 computerized physician orders (CPO) diagnoses included heart failure, respiratory failure, hypertension, renal failure, thyroid disease, anxiety, depression, and dementia. The 9/12/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a score of 3 of 15 on the brief interview for mental status (BIMS). The resident required supervision from one staff member for bed mobility and transfers, moderate assistance from one staff member for toileting, dressing, and hygiene and ate independently. The assessment documented the pneumonia vaccine had not been administered and was not offered. IV. Record reviewA review of the resident ' s record documented the resident ' s decision maker/legal representative signed the facility consent for the resident to receive the pneumonia vaccine on 7/15/21 and the vaccine was not administered. A second consent for the pneumonia vaccine was obtained on 11/6/23 and the vaccine again had not been administered. V. Staff interviewsThe infection preventionist (IP) was interviewed on 11/16/23 at 10:15 a.m. The IP said when a resident was admitted to the facility, the admitting nurse was responsible to offer vaccines to residents and then was responsible to follow up on tracking for vaccine administration. The IP said she completed a facility-wide vaccine audit in October 2023, and determined Resident #43 had not received the pneumonia vaccine. The director of nursing (DON) was interviewed on 11/16/23 at 3:20 p.m. The DON said Resident #43 did not receive the pneumonia vaccine in 2021 and the vaccine was ordered from the pharmacy today, (on 11/16/23). The DON said the pneumonia vaccine would be delivered to the facility and administered to Resident # 43 later on in the day (on 11/16/23).

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on the hand held shower hose in room #1307, #1308 and the shower room on 1400 hall, increasing the risk of contamination to the facility's main water supply. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Distribution System Water Quality Protecting Water Quality through Cross-Connection Control and Backflow Prevention, October 2021 rerieved on line 11/22/23 from: https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, "Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection, which can result in a potentially serious public health hazard. A cross-connection control and backflow prevention program helps prevent contaminants from entering a drinking water distribution system. This fact sheet is part of EPA's (Environmental Protection Agency) Distribution System Toolbox developed to summarize best management practices that public water systems (PWSs), particularly small systems, can use to maintain distribution system water quality and protect public health." B. Observation Observations of the resident living environment conducted on 11/15/23 at 3:30 p.m. revealed: The hand held shower head on the 1400 hall shower room, showers in resident room #1307, and #1308 did not have a backflow prevention valve on them. The hand held shower head was long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pans. II. Staff InterviewThe maintenance director (MTD) was interviewed on 11/16/23 at 10:13 a.m. He acknowledged he was not familiar with the backflow valve protocol. The MTD was given a description of what the backflow prevention valve was and its purpose. The MTD said the hose on the 1400 hall shower and the hand held showers in resident room #1307, and #1308 should have had a backflow prevention valve. He said he would check to see where he could get one.

A revisit survey was completed on 11/10/23 for all previous deficiencies cited on 9/27/23. The facility is in compliance with all regulations surveyed.

A focused infection control survey with complaints #CO33632, CO#30437, CO#30113 and CO#33609 was conducted on 9/14/23 to 9/27/23. Nine deficiencies were cited.

An Emergency Preparedness focus infection control survey was conducted 9/14/23 to 9/27/23. No deficiencies were cited.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the dining room. Findings include: I. Facility policy and procedure The Food and Preparation policy and procedure, no date, provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m., it read in pertinent part: "Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food and handling practices." II. Meals served timely A. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:15 a.m., lunch at 11:15 a.m. and dinner at 4:45 p.m. B. Resident observations and interviews On 9/20/23 at 10:34 a.m., Resident #18 was sitting in his recliner chair in his room getting ready to go to lunch. He said there was a really big problem with the kitchen services. He said the meals were always late, no matter what time of the day. He said breakfast was supposed to start being served at 7:15 a.m. but this morning they did not get served until well after 8:40 a.m. He said something went wrong from when the food was cooked until it got to all the residents. He said all of the residents get a meal ticket but by the time staff get the orders written and to the kitchen, the meals were already late. He said staff did not even get their drinks till right before they took their orders. Resident #27 was interviewed on 9/20/23 at 12:01 p.m. Resident #27 said, "Meals were always late and the food was cold by the time I got it." She said they were always serving chicken salad and chicken and the chicken was always dry. Resident #11 was interviewed on 9/20/23 at 3:19 p.m. He said the dining room was terrible because the meals were always late. He said the kitchen staff was always late with serving the residents food and we got cold. He said by the time the staff took the orders and it got to the kitchen staff the meal was going to be late. C. Additional observations 9/20/23 -At 11:10 a.m. there were three residents sitting in the dining room. Two residents were in wheelchairs and the third utilized a front wheeled walker. -At 11:22 a.m. There were nine residents sitting in the dining room. Eight residents were in wheelchairs. -At 11:39 a.m. 12 residents were observed sitting in the dining room. -At 11:45 a.m. one female resident was observed sleeping with her head on the table. -At 11:49 a.m. facility staff started passing out drinks and started taking residents' orders. -At 11:52 a.m. several residents were sleeping in their wheelchairs. -At 11:53 a.m. Resident #9 walked out of the dining room.-At 12:15 p.m. the first meal was served. -At 12:27 p.m. four female residents were sitting at their table. None of the residents were conversing. -At 12:20 p.m. 16 residents were sitting at various tables in the dining room. -At 12:34 p.m. 23 residents were in the dining room. -At 12:38 p.m. the last meal was served. -At 12:40 p.m. room trays were started. 9/25/23 -At 11:14 a.m. there were three residents in the dining room. Two in residents in wheelchairs. -At 11:19 a.m. there were eight residents sitting in the dining room. -At 11:20 a.m. one resident was assisted into the dining room and placed at the table. -At 11:25 a.m. two more residents were assisted into the dining room and their wheelchairs and placed at their table. -At 11:38 a.m. 13 residents were seated in their wheelchairs in the dining room. -At 11:40 a.m. one more resident was assisted into the dining room. -At 11:51 a.m. dining staff st

Based on observations, record review and interviews, the facility failed to meet professional standards of quality for two (#30 and #11) of four residents reviewed of 30 sample residents. Specifically, the facility failed to ensure scheduled medications were given to Resident #9, #10, #11 and #12 in a timely manner. Findings include: I. Facility policy and procedure The Administration Medication policy, revised April 2019, provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m., it read in pertinent part: "Medications are administered in a safe and timely manner, and as prescribed." II. Resident #9 A. Resident status Resident #9, age 74, was admitted on 6/21/23. According to the September 2023 computerized physician orders (CPO), diagnoses included essential hypertension, delusional disorder, gastro-esophageal reflux disease, schizoaffective disorder, delusional disorder, congestive heart failure and chronic obstructive pulmonary disorder. According to the 6/25/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. She required supervision for bed mobility, transfers, grooming and toilet use. B. Record review The care plan, initiated 7/2/21 and revised 6/30/23, identified the resident was at risk for alterations in comfort related to fibromyalgia, neuropathy, migraine headache, chronic pain syndrome. Interventions include evaluating pain characteristics: quality, severity, location, precipitating/relieving factors. Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. Monitor frequency of episodes of breakthrough pain to determine the need for pain med adjustment. The September 2023 CPO included:Aspirin 81 oral tablet chewable aspirin. Give one tablet by mouth one time a day for secondary prevention. Start date 8/12/23. 7:00 a.m. Tylenol extra strength tablet 500 mg. give two tablets by mouth three times a day for pain. Start date 12/6/22. House nourishment three times a day for weight control. Labeled snack: please provide chocolate pudding and graham crackers TID (three times a day). Start date 8/4/23 Risperidone one mg. Give one tablet by mouth daily. Start date 8/10/23 at 8:00 a.m. Furosemide oral tablet 20 mg. give one tab in the morning for edema. Start date 6/22/23 at 7:00 a.m. Klor-Con 10 oral tablet extended release 10 MEQ. Give one tab by mouth in morning for supplement. Start date 6/22/23 at 7:00 a.m. Levothyroxine sodium oral tablet 50 MG MCG. Give one tablet by mouth in the morning for hypothyroidism. Start date 7/9/23 at 8:00 a.m. Oxycodone HCI tablet 10mg. Give one 10 mg tab by mouth every six hours for pain. Start date Risperdal oral tablet1 mg. Give one tablet by mouth one time a day for irritability related to schizoaffective disorder. Start date 8/10/23 at 8:00 a.m. Gabapentin capsule 400 mg. Give one capsule by mouth three times a day for neuropathy. Start date 9/18/23 at 12:00 p.m. Creon oral capsule delayed release particles 24000-78000 units. Give one capsule by mouth with meals for chronic pancreatitis. Start date 6/22/23 at 7:30 a.m. Acyclovir oral tablet 400 mg. Give one tab by mouth two times a day for herpes. Start date 6/22/23 at 9:00 a.m. Diclofenac sodium external gel 1%. Apply to painful areas topically three times a day for arthritis two gram dose. Start date 6/22/23 at 9:00 a.m. Sennosides tablet 8.6 mg. Give two tablets by mouth BID (twice) a day for constipation. Start date 9/9/21 at 9:00 p.m. The medication review audit documented: Aspirin scheduled 9/25/23 at 7:00 a.m., administration date/time 9/25/23 1:39 p.m. Tylenol scheduled 9/25/23 at 3:00 p.m., administration date/time 9/25/23 at 5:21 p.m. House nourishment scheduled 9/25/23 at 2:00 p.m., administration date/ti

Based on observations, record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) receives the necessary services and assistance during showers and baths for three (#2, #8 and #3) of three residents reviewed for hygiene assistance of 30 sample residents. Specifically, the facility failed to provide scheduled showers and baths or offer an alternative for Resident #2, #8 and #3. Findings include: I. Facility policy The Activities of daily living (ADLs) policy, reviewed March 2018, was provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m. The policy read in part, "Residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene." II. Resident #2 A. Resident status Resident #2, age 70, was admitted on 12/20/22. According to the September 2023 computerized physician orders (CPO), diagnoses included Alzheimer's, dementia, and unilateral (primary) osteoarthritis of right hip. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident had no behaviors. He required extensive assistance for bed mobility, transfers, grooming, bathing and toilet use. The resident was at risk for pressure ulcers. B. Resident interview Resident #2 was interviewed on 9/25/23 at 3:42 p.m. He said he could use a shower. C. Record review The care plan, initiated 12/28/21 and revised 9/6/23, identified the resident was at risk for skin breakdown related to cognitive impairment, incontinence, and assistance with ADLS. Interventions include pat (do not rub) skin when drying. Provide preventative skin care i.e. lotions, barrier creams as ordered. Assist the resident in turning and repositioning frequently. The care plan, initiated 12/28/21 and revised 9/6/23, identified the resident requires assistance/is dependent for ADL care related to history of cerebral vascular accident. Interventions include extensive assistance of one to two with transfers and bed mobility; able to self-propel wheelchair with staff assist as needed and was non-ambulatory. Requires extensive assistance with dressing, grooming, and bathing/showers. -There was no documentation for resident shower preference in the resident's care plan The point of care (POC) response history documented showers from the last 30 days documented the resident two showers. One on 9/17/23 and on 9/27/23. III. Resident #8 A. Resident status Resident #8, age 86, was admitted on 10/12/22. According to the September 2023 CPO, diagnoses included dementia, acute kidney failure, altered mental state, anxiety and chronic obstructive pulmonary disease. According to the 8/22/23MDS assessment, the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. B. Record review The care plan, initiated 12/13/22 and revised 9/4/23, identified the resident required assistance/is dependent for ADL care related to: diagnosis to include heart failure, chronic obstructive pulmonary disease, chronic kidney disease, dementia, depression, anxiety; limited mobility. Interventions include providing the resident/patient with extensive assistance for personal hygiene (grooming). Provide resident/patient with extensive assistance for bathing.-There was no documentation for resident shower preference in the resident's care plan The point of care (POC) response history documented showers from

Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries out of 30 sample residents. Specifically, the facility failed to implement interventions to prevent pressure injuries for Resident #4, who was at risk for pressure injuries. Findings include: I. Professional Reference According to the National Pressure Injury Advisory Panel, Pressure Injury Prevention Points, April 2016, retrieved from: http://www.npuap.org/wp-content/uploads/2023/06/Pressure-Injury-Prevention-Points-2023.pdf, the following recommendations were identified:-Cleanse the skin promptly after episodes of incontinence.-Reposition weak or immobile individuals in chairs hourly.-Ensure the heels are free from the bed.-Use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. II. Facility policy and procedure The Preventions of Pressure Ulcers policy and procedure, revised April 2020, provided by the nursing home administrator on 9/27/23 at 4:14 p.m. The policy read in part, "The purpose of this procedure was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors." III. Resident #4 A. Resident status Resident #4, age 87, was admitted on 3/8/23. According to the September 2023 computerized physician orders (CPO), diagnoses included cerebrovascular disease affecting the right dominant side, adult failure to thrive, dementia, anxiety and history of falls. According to the 7/21/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident was at risk for pressure ulcers. B. Observations/resident interview The resident was observed continuously on 9/20/23 from 1:10 p.m. to 3:45 p.m. At 1:12 p.m. Resident #4 was sitting in her wheelchair in her room sleeping. At 1:45 p.m., Resident #4 was leaning forward in her chair sleeping. She stayed sleeping until approximately 2:23 p.m. At 2:28 p.m., Resident #4 said, "the staff don't care about us because I just stay in this wheelchair and do nothing. I told the staff I want to go to bed because my butt hurts but they tell me it was too early to go to bed." At 2:45 p.m., resident was sitting in the doorway to her room At 3:45 p.m. certified nurse aide (CNA) #1 woke her up and provided incontinence care for Resident #4. -Observations revealed staff failed to implement existing care plan interventions for turning and respositing the resident. The resident was observed continuously on 9/26/23 from 10:09 a.m. to 1:45 p.m. At 10:09 a.m. the resident was sitting in her wheelchair in her room in front of her bed. She said, "I am so sleepy, I just want to go to bed but nobody would help me." She said staff would always tell her she did not need to go to bed and would leave her in her wheelchair for hours. At 10:10 a.m., Resident #4's call light was on the floor. The resident was not able to grab her call light. At 10:26 a.m., CNA #3 was called into Resident #4's room to assist with call light. CNA #3 found the call light which was not within reach of Resident #4 and placed it on the Resident #4's bed and exited the resident's room. CNA #3 said the call light should be within reach of all residents in the event of a fall or requiring care. At 10:33 a.m., Resident #4 pressed the call light and requested to be put into bed. An unidentified CNA came in and turned off Resident #4's call light. The CNA did not ask what Resident #4 needed or how she could help her. At 11:09 a.m., Resident #4 was sleeping in her whee

Based on observations, record review and interviews, the facility failed to provide necessary ostomy care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#6) of one resident reviewed for ostomy care out of 30 sample residents. Specifically, the facility failed to provide routine monitoring of the coloostomy ensuring the coloostomy was not leaking and properly secured to Resident #6. Findings include: I. Facility policy The Colostomy/Ileostomy Care policy, revised October 2019, was provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m. The policy read in pertinent part: "The purpose of this procedure was to provide guidelines that would aid in preventing exposure of the resident's skin to fecal matter." The policy described the procedures to take when changing an ostomy. According to the policy when changing an ostomy, staff should: "Preparation 1. Review the resident's care plan to assess any special needs of the resident. 2. Assemble the equipment and supplies as needed."Equipment and SuppliesThe following equipment and supplies will be necessary when performing this procedure:1. Skin cleansing preparation;2. Clean drainage bag;3. Soap and water;4. Barrier creams and lotions (as indicated); and 5. Personal protective equipment (gowns, gloves, mask, etc., as needed). "Steps in the Procedure 1. Place the clean equipment on the bedside stand or over bed table. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Put on a gown if soiling of clothing with feces is likely. 4. Put on gloves. 5. Remove the drainage bag. 6. Remove gloves, wash hands, put on clean gloves. 7. Cleanse skin with appropriate skin cleansing preparation. 8. When evaluating the condition of the resident's skin, note the following: Breaks in the skin. Excoriation. Signs of infection (heat, swelling, pain, redness, purulent exudate, etc.). 9. Remove soiled items. Do not place it on the bed table. Replace with a clean drainage bag. 10. Place disposable bags into appropriate receptacles. 11. Discard disposable items into designated containers. 12. Remove and discard the gown into a designated container. 13. Remove and discard gloves into designated containers. Wash and dry your hands thoroughly. 14. Reposition the bed covers. Make the resident comfortable. 15. Place the call light within easy reach of the resident. 16. Clean the over bed table and return it to its proper position. 17. Wash and dry your hands thoroughly. 18. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. 19. Document the procedure in the resident's documentation form. "DocumentationThe following information should be recorded in the resident's medical record:1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual(s) who provided the colostomy/ileostomy care. 3. Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling,temperature), or excoriation of skin. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. "Reporting 1. Notify the supervisor if the resident refuses the colostomy/ileostomy care. 2. Notify the supervisor of any abnormal findings (breaks in skin, excoriation, signs of infection.). 3. Report other information in accordance with facility policy and professional standards of practice." III. Resident #6 A. Resident status Resident #6, age 83, was admitted on 4/7/19. According to the September 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, mild cognitive impairment, major depression, dementia and encounter for attention tocolostomy According to the 9/6/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident had no behavioral symptoms. She was independent for bed mobility, transfers and grooming. She was extensive assist with toileting. Resident #6 had an colostomy bag B. Resident interview/observation Resident #6 was interviewed on 9/26/23 at 3:05 p.m. She said the facility was not ordering the style of bag that she used to have. She said she did not like the new style of bag because her bag was leaking out of the side. She said the new style of bag would always leak and she had to change it a lot. She said she spoke with a nurse who said they were not making the style of bag she liked anymore. She said she did not remember the nurse name she told. She said staff have not checked her leaking bag. During interview/observation Resident #6's room had a strong odor of urine and bowel movement. C. Record review The care plan, initiated 4/7/19 and revised 9/20/23, identified the resident had a colostomy related to perforated bowel. Interventions include colostomy care per policy/procedure. Notify the medical doctor if increased abdominal cramping, increased abdominal pain, blood in stool, absence of stool. Resident was independent with colostomy care; assist as needed. The September 2023 CPO included:-Colostomy q-shift (every shift). Start date 3/22/23.-Change wafer appliances every Thursday. Start date 10/14/14.-Review of the medical chart had no documentation on colostomy every shift. -Review of the medical chart had no documentation on change of wafer appliance by staff or resident.-Review of medical chart revealed no assessment identifying Resident #6 was assessed or provided education to provide self-care of her colostomy bag or physicians notes. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 9/25/23 at 10:40 a.m. She said Resident #6 was independent with placement of colostomy bags but she did have a problem with them leaking. CNA #2 said there was a strong odor of urine and bowel movement always coming from resident's rooms and staff had to change her linen because of colostomy bag leakage. Registered nurse (RN) #4 was interviewed on 9/25/23 at 2:52 p.m.. She said she was not aware of any documentation or monitoring required for Resident #6 on colostomy placement. The DON was interviewed on 9/26/23 at approximately 3:10 p.m. She said it was the first she had heard of Resident #6's issues of her colostomy bag leaking. She said she would look into the problem with the bag. The DON was interviewed again on 9/26/23 at 3:20 p.m. The DON said she spoke with medical supply and they were working on getting the old style of bag back for Resident #6. She said the replacement style of bag that Resident #6 was not a good quality and the bags were not the right fit. She said the medical supply was aware of the issue of the leaking bags. The DON was told of the observations and strong odor coming from the resident's room. The DON said the resident should have been assessed and educated on correct placement of the bag and she should have been followed by the nursing staff to ensure the placement was secure and not leaking. The DON said the facility was utilizing the MDS assessment as their assessment tool for residents with catheters and quarterly assessments. The DON said a negative outcome from inproprer catheter care could be skin problems, major leaks, bleeding, retracted or prolapsed stoma and blockage or bowel obstruction.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff to ensure the residents receive the care and services they required in keeping with their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically,-Eight interviewable residents (#5, #4, #20, #22, #24, #26, #12 and #3) out of 30 sample residents and two family members said the facility failed to provide sufficient staff which resulted in delayed and/or inadequate care;-Observations made during survey from 9/14/23 to 9/27/23 revealed care and services not being provided timely; and,-Call lights not accessible to residents. Cross-reference citations: -F550 the facility failed to honor residents rights to timely meal service.-F658 the facility failed to provide medications timely. -F677 the facility failed to provide activity of daily living (ADL) for dependent residents. -F686 the facility failed to provide services to prevent pressure injuries. -F807 the facility failed to provide adequate hydration to residents. Findings include: I. Resident Census and Conditions The census and conditions of residents form, provided by the facility and dated 9/20/23, revealed 124 residents resided in the facility. Care needs of the residents were documented as follows: -Seven residents were dependent on staff for bathing and 67 residents needed the assistance of one or two staff to bath;-One resident was dependent on staff for dressing and 105 residents needed the assistance of one or two staff to dress;-15 residents were dependent on staff to transfer and 58 residents needed the assistance of one or two staff to transfer;-30 residents were dependent on staff for toilet use and 69 residents needed the assistance of one or two staff to the toilet;-Three residents were dependent on staff to eat and 46 residents needed the assistance of one or two staff to eat;-101 residents were frequently incontinent of bladder;-66 residents were frequently incontinent of bowel;-64 residents were in their wheelchairs all or most of the time;-44 residents had a diagnosis of dementia;-Three residents had current pressure injuries and 118 residents received preventive skin care;-Seven residents received hospice services;-45 residents received respiratory care;-32 residents had contractures; and,-81 residents were on a pain management program. On 9/27/23 at 2:41 p.m. a request was made for the previous 90 days of the staff working schedule. At time of exit on 9/27/23 the staff working schedule was not received. II. Resident interviews Resident #5's power of attorney was interviewed on 9/20/23 at 9:58 a.m. Resident #5's power of attorney (POA) was visiting with Resident #5. She said the facility was short staffed and Resident #5 had to wait to receive care. Resident #4 was interviewed on 9/20/23 at 10:09 a.m. She said it could take as long as 15-25 minutes to answer my call light. She said, "I am blind. I cannot stand up by myself because I have fallen and I get scared because I don't want to fall and I need help getting out of my wheelchair and into bed." Resident #20 was interviewed on 9/20/23 at 11:10 a.m. She said call lights take forever to get answered. She said it could take up to an hour to get your call light answered. She said one night a male certified nurse aide (CNA) did not even show up for his shift and residents never get their call lights answered. She said the facility was under new ownership and they promised it would be getting better but it had only gotten worse. Resident #22 was interviewed on 9/20/23 at 11:20 a.m. Resident #22 was lying in her bed talking with her power of attorney (POA). Resident #22's POA said the facility was short staffed and there were a lot of other issues surrounding the care of residents. He said they did not bring water around and residents had to request water. He said staff would come into the room and turn the call light off and then staff would never return. He said he came in the morning and Resident #22 had not been changed all morning. He said there was a care planning meeting yesterday and they talked about how the facility was low staffed but the facility was trying to resolve the issues. Resident #24 was interviewed on 9/20/23 at 11:46 a.m. Resident #24 was sitting in his room next to this bed. He said staffing was a serious problem at the facility. He said a bunch of CNAs had quit because they were so short staffed. He said it took staff forever to answer call lights and get care. He said, "It was difficult for me because I don't have any legs." Resident #26 was interviewed on 9/20/23 at 11:49 a.m. Resident #26 was sitting on her bed going through old letters. Resident #24 had been waiting approximately 25 minutes to have her call light answered. Resident #26 said staffing was so bad residents could wait up to an hour to get their call lights answered. She said she had to call staff to request water or get it out of the sink if she really need it. She said, "I have a bad shoulder and I need my medication but with the staff problem I get my medications at least one to one and a half hours late." Resident #12 was interviewed on 9/20/23 at 3:19 p.m. Resident #12 was sitting in his wheelchair next to his bed. Resident #12 said the facility was so short staffed residents were not getting their basic needs met. He said, "I don ' t even get fresh water when I want it." He said, "I feel sorry for the residents who can ' t get out of their rooms because at least I can go out and get my own iced water." He said, "My medication was late almost every day because of the lack of staff." He said, "I have to use my urinal and it will spill over and it will make a mess." He said, "I can really use someone looking in on me much more often."Resident #3 was interviewed on 9/25/23 at 10:53 a.m. Resident #3 said staffing was a really big problem. She said she had to wait over an hour to get her call light answered at times. She passed out medication was a problem due to no staff. She said, "My pain medication was always late." She said staff would come in and turn off my call light and they would never return. Resident #3 said there was no continuity of care here. She said the CNAs were running around trying the provide care but they were being stretched too thin. She said the lack of staff affected all areas from dining, showers, medication administration and incontinent care. He said there are not enough staff to meet the resident needs of the facility. C. Observation On 9/20/23 at 10:02 a.m., Resident #14 was in his room lying in bed. Resident #14 was yelling from his room asking for help. CNA #3 entered the resident's room and exited the room after asking what he wanted. Resident #14 kept yelling out saying "I can't get this call light to work." An unidentified nurse entered the resident's room and exited immediately, closing the resident's door. Resident #14 could be heard saying nobody wants to help me. The nurse entered the room again and Resident #14 said he needed his brief changed. At 10:13 a.m., CNA #3 entered the room again asking the resident what he needed, to which he replied some water. CNA #3 exited the resident's room, grabbed a cup from the nurse cart and filled the water in the sink. CNA #3 exited the room as the resident continued to yell. At 10:25 a.m., Resident #14 continued to yell from his bed. The director of nursing (DON) entered the resident's room and closed the door. Resident #14 was yelling "nobody wants to help me." At 10:35 a.m. Resident #14 had not been provided or checked for incontinence. At 10:12 a.m., the resident in room #1400 call light was on the ground out of reach of the resident. At 10:38 a.m., Residents #13 call light was under the blanket along the wall inaccessible to Resident #13. At 11:15 a.m., call lights were on in room #1603 and #1602. A nurse was observed walking by both rooms and did not check to see if the residents needed help. Call lights in both rooms did not get a response for approximately 27 minutes. An unidentified CNA entered room #1603 at 11:42 a.m. and the call light was turned off. At 11:44 a.m. the same CNA entered room #1602 and provided incontinence care. The CNA exited the room carrying a plastic bag with dirty linen. At 11:23 a.m., call lights were turned on in room #1400, room #1300 and room #1200. Call lights were not answered until 11:56 a.m. At 1:55 p.m. call light was pressed for room #1008, #1408 and #1410. Call lights still were on at 2:27 p.m. and not answered. On 9/25/23 at 2:40 p.m., Resident #28 was lying in his bed watching television. He did not have a call light in his room. III. Staff Interviews Licensed practical nurse (LPN) #1 was interviewed on 9/20/23 at 2:35 p.m. She said the facility was so short staffed that it was affecting the care the residents received. She said the facility used to have four nurses but the new facility owners cut it down to three nurses, which makes it overwhelming to try and provide care to all the residents. She said, "I make sure that I have to take extra time to make sure all the medication matches each residents physician orders." She said this made her late with giving the residents their medications. She said, "Today I am an hour to an hour and a half behind on giving medications because I have three halls." LPN #5 was interviewed on 9/25/23 at 10:33 a.m. She said all staff were getting concerned the facility was short staffed. She said, "I have to finish my own job and then I have to stop and go into the dining room to help, which put me further behind. This puts my medication behind." She said the facility was using a certified nurse aide with medication authroity in the evening to assist with medication administration butthey couldonly give out medications. CNA #2 was interviewed on 9/25/23 at 1:24 p.m. She said, "Yes we are short and we have more work because of being short staffed." The lack of staff had been a problem for getting residents their care, showers and their meals because they have to help in the dining room, which took away from resident care during meals. She said, "The hall which I am working on has three Hoyer (mechanical) lifts which require two CNAs and then that takes away from resident care." She said the average wait for residents was 25-30 minutes. CNA #1 was interviewed on 9/25/23 at 2:12 p.m. He said the facility had a total of seven halls and all of the CNAs had to work in all halls because they were short of help. He said it was a challenge because they were rushed to provide care. He said, "I am asked to work overtime at least three times a week because the facility was so short of help." LPN #2 was interviewed on 9/25/23 at 2:58 p.m. She said, "Yes we are short staffed and it was affecting the care of the residents." She said facility staff have been complaining to supervisors but the complaints were falling on deaf ears. She said the facility used to have four nurses on shift but the facility had cut it down to three nurses with four carts, which made it impossible to administer medications on time. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 9/27/23 at 11:26 a.m. They were told of the observations and interviews above. The DON said they staffed the facility based on their census, acuity and the need of their residents. She said all managers helped on the floor during the day and they worked as a team. She said if they had call-ins they tried to find coverage and they offered incentives. She said they used a lot of agency nurses and as needed (PRN) staff. The ADON and the DON said people had their own perceptions of the facility being short staffed. She said they had been trying to get rid of the bad apples by holding them accountable and theyplanned to replace them with good staff. She said the challenges of staffing was monitoring burnout and ensuring staff were not working too many hours. She said a negative outcome would be lack of care for all of the residents in the facility. CNA #6 was interviewed on 9/27/23 at 11:44 a.m. She said the facility did have a shower aide but the facility would take her off showers when the facility was short staffed. Then CNAs were supposed to give showers on top of providing total care for the residents. She said residents were supposed to get two showers a week but that was not happening. CNA #6 said "Yes we are short staff and it was stressful."

Based on interviews, observations and record review,ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to:-Ensure resident food was palatable in taste, temperature, texture and appearance; and, -Address resident food complaints. I. Facility policy and procedure The Food and Nutritional Services policy, revised September 2017, was provided by the nursing home administrator on 9/27/23 at 4:14 p.m. It revealed in pertinent part, "Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident." II. Resident and representative interviews All residents were identified by facility and assessment as interviewable. Resident #5's power of attorney was interviewed on 9/20/23 at 9:58 a.m. Resident #5's power of attorney (POA) was visiting with Resident #5. She said she would have to bring in snacks into the facility because the kitchen was always running out of food and the food was terrible and cold. Resident #4 was interviewed on 9/20/23 at 10:09 a.m. She said the food was always served late and by the time it was delivered to her room it was cold. She said, "I ask staff to warm it up but when it came back the food was always dry and didn't taste good." Resident #18 was interviewed on 9/20/23 at 10:34 a.m. He said there was a really big problem with the kitchen services. He said the meals were always late, no matter what time of the day. He said, "I ordered a hamburger and the tomatoes were thicker than the meat." The hamburger and French fries were cold and tasted like cold grease. He said the kitchen was always running out of food. This morning they ran out of coffee and milk. He said the kitchen did not even have enough cereal for me to eat and the eggs were cold and small portions. He said if the kitchen staff would just go around after meals and see that residents were not eating their meals they would get a better picture. Resident #20 was interviewed on 9/20/23 at 11:10 a.m. She said he food was not good. She said they usually would serve meals at 12:30 or 1:00 p.m. and when they did deliver it was always cold. She said, "I have my family bring me meals to eat when they visit." Resident #22 was interviewed on 9/20/23 at 11:20 a.m. Resident #22 was lying in her bed talking with her power of attorney (POA). Resident #22's POA said the problem with the kitchen was they did not honor Resident #22's food choices. He said Resident #22 did not like eggs but every morning they gave her eggs and food was late and cold. Resident #24 was interviewed on 9/20/23 at 11:46 a.m. Resident #24 was sitting in his room next to this bed. He said the food was terrible and had no taste. He said the kitchen would always run out of food. Resident #26 was interviewed on 9/20/23 at 11:49 a.m. Resident #26 said the food was terrible. She said they never got her order right and they did not honor her food choices. She said, "I can't have pepper on my food and every day they season my food with pepper. I used to send it back but it was easier to just scrap off the pepper." She had her meal ticket documented she wanted three hard boiled eggs and toast but she got a peanut butter sandwich. She said the kitchen just gave her what they have to serve because they were always running out of food. Resident #26's meal ticket documented no pepper. Resident #12 was interviewed on 9/20/23 at 3:19 p.m. Resident #12 said the food in the facility was awful. He said the food was always cold and never had any seasoning. Half the time the kitchen was out of food, condiments and other things. He said he had to buy his own food and cereal because they were always out of cereal and he liked Cheerios. Resident #11 was interviewed on 9/25/23 at 10:00 a.m. Resident #11 was visiting with her daughter. The daughter said the food was terrible and the kitchen would always run out of food. Resident #11's daughter said she bought her mom extra food so when she did not get enough at meals. The daughter stated the kitchen was always running out of cereal and Resident #11 liked her Cheerios. Resident #11's daughter said she even had to buy Resident #11 her supplemental drinks, which she had in a small refrigerator in the room. Resident #3 was interviewed on 9/25/23 at 10:53 a.m. Resident #3 said the food was terrible. She said, "I don't even get a choice of what I want to eat because I just get what they send me." She said it was terrible. Resident #28 was interviewed on 9/25/23 at 2:40 p.m. Resident #28 said the food was terrible. III. Observations On 9/25/23 at 12:01 p.m. Resident #27 was observed in the dining room for lunch. She said they serve a lot of chicken and hamburger patties and they were always dry. She said, "I play it safe and I eat a lot of chef salads because you can't really mess up a salad." During a continuous observation on 9/26/23 beginning at 9:46 a.m. and ended at 1:16 p.m. the following was observed:Approximately six trays of prepared fruit cup with dairy whipped topping was stored on a metal rack. It did not appear to be on ice. Dietary aide (DA) #1 was preparing Caesar salad. DA #1 mixed the salad and added a large container of ranch dressing and mixed the salad. She placed the salad on the serving line. It did not appear to be on ice. The cook took the temperature of the Ceasar salad and it read 60F.Dietary aide (DA) #1 was preparing a grilled cheese sandwich for special orders. DA #1 asked the dietary manager (DM) if they had sliced cheese and butter. DA #1 walked into the walk-in refrigerator and pulled out a bag of shredded cheese and a handful of individual pads of butter to make the grilled cheese sandwich. DA #3 was asking if the kitchen had any more mustard dipping sauce for the chicken as the resident wanted two for his chicken. DA #3 found one and stated this was the last one. A test tray for a regular diet, puree and mechanical altered meal was evaluated immediately after the last resident had been served their room tray for lunch on 9/26/23 at 1:00 p.m. The test tray consisted of spaghetti, Caesar salad, green beans, garlic bread and fruit cup. The alternative menu consisted of honey Dijon chicken, mashed potatoes and hamburger patty.-The spaghetti noodles were not cooked and were hard. They had no flavor. -The garlic bread was a roll with no garlic flavor.-The green beans had no flavor and were bland. Temperature was 112 degrees F.-The kitchen ran out of Ceasar salad.-The kitchen ran out of honey Dijon chicken.-The mashed potatoes were bland with no taste. The gravy had no flavor or seasoning. Temperature was 109 degrees F. -The hamburger patty was dry and had no flavor. Temperature was 100 degrees F.-The fruit cup with dairy whipped topping was warm and had no flavor. Temperature 71 degrees F. -Puree and mechanical altered meals were not tested as the kitchen ran out of the food items. IV. Staff Interview The cook was interviewed on 9/26/23 at 12:01 p.m. The cook said she was new to the facility and had been at this facility for approximately two weeks. She said she was still learning how to cook for a large group of people. She said the kitchen routinely ran out of food and had to make whatever the kitchen had. DA #1 was interviewed on 9/26/23 at 12:13 p.m. She said the kitchen did run out of food and other items regularly. The dietary manager (DM) was interviewed on 9/27/23 at 9:55 a.m. The DM was told of the observations during kitchen observations and results of the test tray. She said staff were supposed to take food temperatures of the food items beginning at food service, half way through meal service and at the end to ensure all temperatures were maintained. The DM said all kitchen staff were new and they were still learning the process of what was expected of them. The DM said she would educate all kitchen staff again to appropriate procedures of the kitchen from temperatures and food palatability. The DM said there was a lack of communication between the kitchen staff and the staff who were assisting in the dining room and delivering room trays. The DM was told of the observations, resident interviews about lack of food and running out. The DM said she was familiarizing herself with the ordering process. The DM was on the phone prior to the interview making an order for the end of the week. The DM said she was aware of the residents' complaints about running out of milk. She said the evening dietary staff had left the milk out and it was at room temperature and they had to discard all of the milk. She said she was not aware of the residents having to bring in their own food. The DM said the facility should not run out of food. The dietary manager (DM) was interviewed on 9/27/23 at 9:55 a.m. The DM was told of the interviews of residents above. She said certified nurse aides (CNAs) were supposed to be taking the room trays orders. She said she was not aware they were not taking the resident orders. The DM said there was a lack of communication between the kitchen staff and the staff who were taking resident orders. The nursing home administrator (NHA) was interviewed on 9/27/23 at 11:08 a.m. She was told of the observations above. She said the facility had just hired a new company for the kitchen. She said the kitchen was currently having their challenges and the facility was working on them. She said the room tray delivery system needed to be evaluated on how the room trays were delivered and how residents' meals orders were taken. She said this was not happening and the facility had tried other models to make mealtimes more effective but they have not been working. She said the residents should have been served food which was at correct temperatures and was palatable. She said the residents' meal orders and choices should have been honored.

Based on observations, record review and interviews, the facility failed to the facility failed to ensure drinks and other fluids were provided and consistent with the care plan, preferences and choices. Specifically, the facility failed to consistently offer, encourage and provide fluids for residents in between meals. Findings include: I. Facility policy and procedure The Hydration Clinic Protocol policy, revised September 2017, was provided by the nursing home administrator (NHA) on 9/27/23 at 4:14 p.m. The policy read in pertinent part: "Assessment and Recognition 1. The physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). a. The physician will distinguish various types of fluid and electrolyte imbalance (for example,hyponatremia, hypernatremia, pre-renal azotemia) From true dehydration (clinically significant loss of total body water). 2. The staff, with the physician's input, will identify and report to the physician individuals with signs and symptoms (for example, delirium, lethargy, increased thirst) or lab test results (for example, hypernatremia, azotemia.) that might reflect existing fluid and electrolyte imbalance. 3. The physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance; for example, individuals with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well." II. Resident observations and interviews On 9/20/23 at 9:48 a.m. Resident #5 was in his room sitting in his chair. The resident did not have a water container on his bedside table or anywhere in his room. Resident #5's power of attorney (POA) was visiting with Resident #5. She said she had to ask staff to provide water when the resident requested it. She said she would bring Resident #5 bottled water so he could have fresh cold water. -At 9:59 a.m., Resident #13 was sitting in her wheelchair sleeping in front of her bed. The resident's bedside table did not have a water container and the water container could not be found in the resident's room. The resident's call light was along the wall hidden by the bed blankets. -At 10:02 a.m., Resident #14 could be heard yelling in his room. Resident #14 was yelling, "I can't find my call bell." He continued to yell unit certified nurse aide (CNA) #3 entered the room. Resident #14 could be heard telling the CNA he could not find his call bell and nobody listened to him. CNA #3 said the call light was on the floor and then asked Resident #14 what he wanted and he responded with some water. CNA #3 exited Resident #14's room and grabbed a small plastic cup from the nurse cart. She walked back into the resident's room and filled the cup in the sink and gave it to Resident #14. She exited the room.-At 10:09 a.m., Resident #4 was sitting in her wheelchair in front of her bed. Her bedside table did not have a water container in her room. She said, "I have to ask for water if I want to get some." The resident's roommate did not have a water container on her bedside table or anywhere in her room.-At 11:10 a.m., Resident #20 was lying in bed. She said she had to request water to be refilled as when she wanted fresh water. -At 11:20 a.m., Resident #22 was lying in her bed talking with her POA. He said they were short staffed in this facility and there were many other issues surrounding the care of residents (cross-reference F725). He said they do not bring water around and residents have to request water. -At 11:46 a.m., Resident #24 was sitting in his room next to this bed. He said staffing was a serious problem at the facility. He said a bunch of CNAs had quit because they were so short staffed (cross-reference F725). He said it tooks staff forever to answer call lights and get care. He said it was faster for him to get his own water then have staff get it for him. -At 11:49 a.m., Resident #26 was sitting on her bed going through old letters. Resident #26 had been waiting approximately 25 minutes to have her call light answered. Resident #26 said staffing was so bad residents could wait up to an hour to get their call lights answered. She said the residents had to call staff to request water or get it out of the sink if we really need it. -At 3:19 p.m., Resident #12 was sitting in his wheelchair next to his bed. Resident #12 said the facility was so short staffed residents were not getting their basic needs met. He said, "I don't even get fresh water when I want it." He said, "I feel sorry for the residents who can't get out of their rooms because at least I can go out and get my own iced water." On 9/25/23 at 10:53 a.m. Resident #3 was lying in bed. She said, "we never get fresh water on a daily basis. She said we have to use our call button and request water." She said was if they would even answer the call light. She said she had a thermal tumbler which kept her water cold because she never knew when she was going to get fresh water. -At 2:40 p.m., Resident #28 was lying in his bed watching television. He said, "I don't get much water around here." He said it has been a while since he had any fresh water. CNA #4 was in the resident's room. CNA #4 said Resident #28 should have had a water cup in his room. She said the kitchen was supposed to pass around the hydration cart daily. -At 2:50 p.m., the secured unit revealed no water cups in room #404, #403 and #402. Resident room #405 had a water cup on her dresser, which had seven ounces of water. On 9/26/23 at 3:45 p.m., resident rooms #405, #404, #403, and #402 were observed. The drinking cup in resident room #405 was in the same position and had seven ounces of water. CNA #6 said the water cup had seven ounces of water in the cup. CNA #6 said, "The secured unit does not have a hydration cart at this time." During observations from 9/20/23-9/27/23 no hydration cart was observed in the facility. III. Interviews Licensed practical nurse (LPN) #5 was interviewed on 9/25/23 at 10:33 a.m. She said the facility used to have a hydration cart but there had not been one for a while. She said staff would give the residents water per their request. LPN # 2 was interviewed on 9/25/23 at 2:58 p.m. She said, "No we do not have a hydration cart for the residents." CNA #3 was interviewed on 9/26/23 at 10:26 a.m. She said, "we used to have a hydration cart but we are so short staffed we give water on request."The dietary manager (DM) was interviewed on 9/27/23 at 9:55 a.m. She said kitchen staff were not responsible for the hydration cart. The activity director was interviewed on 9/27/23 at 10:44 a.m. He said he was not in charge of the hydration cart. The AD said he passed coffee and hot chocolate once a week to residents. The director of nursing (DON) was interviewed on 9/27/23 at 10:07 a.m. The DON was told of the observations and interviews above. The DON said the AD was in charge of the hydration cart. The DON said the resident should have a drinking cup or a small drinking pitcher. The DON said all residents should have a drinking cup in their rooms and the drinking cups should be within reach. She said new and fresh water pitchers were supposed to be given out every evening to ensure fresh water for all residents. She said a negative outcome from not having sufficient fluids would be delirium, shortness of breath, low blood pressure, dizziness and increased falls.

Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#4 and #8) of five residents reviewed for vaccinations of 30 sample residents. Specifically, the facility failed to ensure Resident #4 was educated on refusal of pneumococcal and Resident #8 received pneumococcal immunization. Findings include: I. Professional reference According to the Center for Disease Control and Prevention (CDC), reviewed 11/21/22, retrieved on 9/27/23 from ttps://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, "If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged 65 years (or older), the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. In the majority of seasons, influenza vaccines will become available to long-term care facilities beginning in September, and influenza vaccination should be offered by the end of October. Informed consent is required to implement a standing order for vaccination, but this does not necessarily mean a signed consent must be present. Although vaccination by the end of October is recommended, influenza vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons because the duration of the season is variable, and influenza activity might not occur in certain communities until February or March." According to the CDC Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 9/27/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part, "The pneumococcal vaccine was to be administered to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23. "For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals aged 19-64 years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23." III. Resident #4 Resident #4, age 87, was admitted on 3/8/23. According to the September 2023 computerized physician orders (CPO), diagnoses included cerebrovascular disease affecting right dominant side, adult failure to thrive, dementia, anxiety and history of falls. Resident #4 had a pneumococcal consent form but it identified authorization to receive the pneumococcal shot but also had the box checked to decline. -The facility did not have evidence of education offered for refusal of the pneumococcal vaccine. IV. Resident #8Resident #8, age 86, was admitted on 10/12/22. According to the September 2023 computerized physician orders (CPO), diagnoses included dementia, acute kidney failure, altered mental state, anxiety and chronic obstructive pulmonary disease. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. VI. Interview The infection control nurse (IFC) and assistant director of nursing (ADON) were interviewed on 9/27/23 at 11:40 a.m. The IFC nurse said the facility was currently conducting an audit of the residents and would be contacting the providers. She said Resident #8 would be part of the audit. She said Resident #4 had a pneumococcal consent form but it identified authorization to receive the pneumococcal shot but had the box checked to decline. She said there should have been confirmation of the resident's choice and if she refused the shot the facility should have provided education on the importance of the pneumococcal shot. She said it would be important to offer the vaccine to help prevent pneumonia.

A revisit survey was completed on 5/9/23 for all previous deficiencies cited on 3/2/23. The facility is in compliance with all regulations surveyed.

A survey was prompted by complaint #CO31023 and Incident #30915 was conducted from 3/1/23 to 3/2/23. Four deficiencies were cited.

Based on observations, record review and interviews, the facility failed to promote self-determination for three (#10, #4 and #13) of six residents reviewed for preferences and choices of 13 sample residents. Specifically, the facility failed to assess the resident daily preferences for care routine; identify interventions to meet the daily routine/care provision preferences of each resident; communicate the resident preference to staff through a plan of care and implement care based on resident self-determined preferences. Identified resident preferences included:-Ensure residents had the opportunity to explore options; daily life choices; and participate in the development of individualized person centered interventions for having a sense of control over daily life and self-determination while living in the facility;-Provide Resident #10 the opportunity to choose and participate in activities of interest;-Ensure Resident #10, #4 and #13 was able to determine their desired bathing schedule;and,-Ensure resident care plans document specific person centered information about a resident's individualized self-determined choice for daily routines and activity preferences, for Resident #10, #4 and #13. Findings include: I. Facility policy The Self-determination policy was provided by the nursing home administrator (NHA) on 3/2/23 at 3:38 p.m. It read in pertinent part: "The patient/resident (hereinafter 'patient') has the right to, and the Center must promote and accommodate, patient self-determination through support of patient choice including, but not limited to the right to:-Choose activities, schedules (including sleeping/waking times, eating, bathing), health care, and providers of health care services consistent with their interests, assessments, and plan of care;-Make choices about aspects of their life in the (facility name) that are significant to the patient;-Interact with members of the community and participate in community activities both inside and outside the Center;-Participate in other activities including social, religious, and community activities that do not interfere with the rights of other patients in the Center. "Purpose: To ensure each patient has the opportunity to exercise his/her autonomy regarding those things that are important in their life." The Treatment: Considerate and Respectful policy, revised 7/1/19, was provided by the NHA on 3/2/23 at 3:38 p.m. It read in pertinent part: "(Facility name) will promote respectful and dignified care for patients in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life while recognizing each patient's individuality.-Dignity means that in their interactions with patients, any staff, including temporary or volunteers, carry out activities that assist the patient to maintain and enhance his/her self esteem and self-worth and incorporate the patient's needs, preferences, and choices. "To provide patients the right to a quality of life that supports independent expression, decision making, and respect. "Staff will show respect when communicating with, caring for, or talking about patients. Examples of promoting dignity include, but are not limited to, the following:-Grooming: Patients will be groomed as they wish to be groomed;-Activities: Assist patients to attend activities of their own choosing:" II. Resident #10 A. Resident status Resident #10, age 82, was admitted on 7/14/19. According to the March 2023 computerized physician's orders (CPO) diagnoses included legal blindness, anxiety disorder, major depressive disorder and lower back pain. According to the 1/20/23 minimum data set (MDS) assessment, the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15; no delirium or behavioral symptoms were documented. The resident was unable to walk and needed extensive assistance mobility, transfers, toileting and limited and guided assistance with dressing, personal grooming and bed mobility. The resident needed substantial/maximal assistance with showering where the helper does more than half the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort. Bathing however, did not occur during the assessment. The assessment documented it was very important to the resident to choose what clothes to wear; take care of personal belongings; to choose bed time; to have books, newspapers and magazines to read; and to do favorite activities. It was somewhat important to choose the way a bath was provided. B. Resident interview Resident #10 was interviewed on 3/2/23 at 11:00 a.m. Resident #10 said she had not had a shower since Thanksgiving 2022. On that day a certified nurse aide (CNA) assisted her to the shower room in a poorly fitting rolling shower chair. The chair caused her a great deal of pain due to its large size and poor fit. Resident #10 said facility staff told her another community within the corporation had a shorter small shower chair they would borrow but it never happened. The resident said she would really like a shower instead of the occasional bed bath staff provided. The shower chairs in the facility cause so much pain that the resident was unwilling to be put back into the chair until the facility gets a better fitting shower chair because she was worried about re-experiencing pain. Resident #10 said a shower would make her feel better and she would like to take a shower twice a week Resident #10 also said learning and education was very important to her, she wanted to find a way to take some college courses and earn a college degree. Resident #10 said she knew she would not be able to attend college in person, she did not have a computer or laptop and she had no idea what her options for continuing education were. Resident #10 said activities staff visited her regularly. Resident #10 said she enjoyed the visits, but activities staff had never taken her education goals seriously nor had anyone helped her explore her options. "At the very least I would like to get an accessible computer to write my story but no one ever takes the time to ask what I crave or what would stimulate my mind. I still have my mind and I believe I have several more years of life left, I want to feel productive and accomplished in the time I have left." Resident #10 said she had books on tape and a roommate she enjoyed living with but that was not enough for her. Resident #10 said she would be interested in looking into some low cost or free online educational opportunities..C. Record review Resident #10's comprehensive care plan documented a care focus for daily routines. The care focus last revised 1/2/23, documented "While in the facility, Resident #10 will engage in daily routines that are meaningfully relative to her preferences. She prefers to stay in her room by choice. Prefers her own leisure interests, television, family, and spirituality. She does have talking books.-Resident #10 states she is not a crowd person so she is not interested in any groups.-Resident #10 has a good relationship with her roommate. She does enjoy the Daily Chronicleand verse of the day, activity staff reads it to her as she allows." -The care plan did not document resident specific preferences for learning or a desire to pursue higher education. -Additionally, the care plan did not document the resident's preferences for showering. III. Resident #4 A. Resident status Resident #4, age 77, was admitted on 1/13/23. According to the March 2023 CPO, diagnoses included history of stroke, osteoarthritis, kidney failure and weakness. According to the 1/19/23 MDS assessment, the resident had intact cognitive ability with a BIMS score of 15 out of 15; no behavioral symptoms were documented. The resident was unable to walk and needed extensive assistance with bed mobility, toileting, dressing, personal grooming and transfers. Bathing/showering did not occur during the assessment period so the resident bathing needs were not assessed. Resident #4's preferences revealed it was important for the resident to choose the type of bathing received. B. Resident interview Resident #4 was interviewed on 3/1/23 at 2:42 p.m. Resident #4 said she had not had regular showering assistance since admission (1/13/23). Resident #4 said she really wanted to take showers three times a week. Resident #4 said she asked one of the CNAs to help her in the shower but no staff had been able to assist her to take a shower nor had any staff asked her about her showering preferences. C. Record review Resident #4's comprehensive care plan initiated 1/16/23 failed to document the resident's bathing needs or preferences. The residents' care task record documented the resident was scheduled to get showers twice a week Wednesday and Saturday evenings. The task record documented the resident had two showers in the last 30 days (2/12/23 and 2/27/23). IV. Resident #13 A. Resident status Resident #13, age of 94, was admitted on 8/12/22. According to the March 2023 CPO diagnoses included legal blindness, hypertension, pain and chronic falling. According to the 2/8/23 MDS assessment, the resident had intact cognition with a BIMS score of 12 out of 15; no behavioral symptoms were documented. The resident had highly impaired vision - object identification in question, but eyes appear to follow objects. The resident was able to walk with an assistive device (walker) and was independent with activities of daily living (ADLs) once staff assisted the resident with set up. The resident needed substantial/maximal assistance with showering where the helper does more than half the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort. The resident's bathing needs were not assessed and bathing did not occur during the assessment. The assessment documented it was very important to the resident to choose what clothes to wear; take care of personal belongings; to choose bed time; to have books, newspapers and magazines to read; and to do favorite activities. It was somewhat important to choose the way a bath was provided. The resident preferences were not assessed. B. Resident interview Resident #13 was interviewed on 3/2/23 at 12:52 p.m. Resident #13 said she did not remember the last time she had a shower but it had been a while. "I feel cleaner when I shower." Resident #13 said staff did not provide her regular showing assistance but she would have liked to shower twice a week; instead, she was giving herself a sponge bath. C. Record review Resident #13's comprehensive care plan revised 9/8/22; read in part: "While in the facility, Resident #13 states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. It is important for me to choose between a tub bath, shower, bed bath or sponge bath." The residents care task record documented the resident had two showers in the last 30 days (2/10/23 and 2/17/23). V. Staff Interviews CNA #1 was interviewed on 3/1/23 at 1:33 p.m. CNA #1 said resident showers were provided based on the care plan schedule as documented on the resident's task record. The documented schedule was to be followed. If the resident refused a shower time the CNA could ask the CNA on the next shift to offer the resident a shower during the next shift. The CNAs were to document the resident shower and response to the shower on the task record. The facility did not use any other method of documenting a resident shower being successfully given or refused. Registered nurse (RN) #1 was interviewed on 3/1/23 at 3:02 p.m. RN #1 said as far as she was aware residents were being offered showers based on the shower schedule. Shower schedules were documented in the resident's care plan and ADL task record. If a resident refused a shower the CNA was expected to report the refusal to the nurse and the nurse was expected to encourage the resident to shower. If the resident continued to refuse showers, the nurse was to document the attempts and resident's response. The CNA was to document the resident's refusal in the resident's task record. The nurse was not aware of any concerns with either Resident #4 or #13 not receiving regular showering assistance. Licensed practical nurse (LPN) #1 was interviewed on 3/1/23 at 1:50 p.m. LPN #1 said shower schedules were documented in the ADL task record. If a resident reused a shower the CNA was expected to report the refusal to the nurse and the nurse was expected to make an attempt to convince the resident to shower. If the resident refused the offered shower, the nurse was to document the attempts and resident response. The CNA would document the refusal in the resident's record and on the shift report and staff could give the resident a shower opportunity the next shift or the next day. LPN #1 had no concerns that residents were not being offered regular showering assistance. LPN #2 was interviewed on 3/1/23 at 5:02 p.m. LPN #2 said residents sometimes missed showers when the CNAs were short staffed. However, when staff were unable to assist a resident with showers staff were expected to provide the resident an alternative shower time to make up for the missed showers. All showering assistance was to be documented in the resident's record whether they accepted or refused showering assistance. Due to staff availability and resident needs, it was possible for a resident to miss a scheduled shower not due to the resident's refusal. The NHA and unit nursing manager (UNM) were interviewed on 3/2/23 at 2:00 p.m. The NHA said Resident #10 had a history of refusing showers but acknowledged she was unaware of why the resident had been refusing showers. The NHA was not aware the resident wanted showers but refused because she was fearful of being in pain from sitting in the shower chair. The NHA said the facility had several shower chair options that might work for the resident. The NHA said Resident #10 received in room visits from the activities department. The NHA was unaware of the resident desire to pursue educational opportunities. The NHA said she would ask activities to talk to the resident about her preferences. The NHA said the CNAs were expected to offer residents showering assistance based on the resident's showering schedule; if the resident refused then were to reproach later in the day. If the resident continued to refuse, the CNA was to report to the floor nurse and the nurses were to attempt to offer the resident a shower. The nurse was to document attempts to offer the resident showering assistance and the CNA was to document the resident response on offers to receive a shower. The NHA said she was not sure why Resident #13 was not getting showers but though it was likely, the resident was refusing showers when offered. The NHA and UNM reviewed Resident #13 ADL task record and acknowledged there was no documentation of the resident refusing showers. The NHA said Resident #4 had moments of confusion and thought she might be confused about not getting regular showering assistance. The NHA and UNM reviewed the resident task record and acknowledged there was no documentation of Resident #4 refusing showers. The NHA was interviewed on 3/2/23 at 4:00 p.m. The NHA said there was a glitch in the task record system for some residents where the CNAs were not able to document the resident response to showing assistance and if the shower was given or not. The UNM was currently reviewing the resident records and fixing the entry glitch so staff could accurately document the resident's response to showering assistance.

Based on record review and interviews, the facility failed to ensure notification of change for one resident (#2) of three residents reviewed out of 13 sample residents. Specifically, the facility failed to make a timely notify Resident #2's legal representative of a medication change, timely. Findings include: I. Resident status Resident #2, age under 65 years old, was admitted on 10/21/22. According to March 2023 computerized physician orders (CPO), diagnoses included paranoid schizophrenia, drug induced subacute dyskinesia (involuntary movements), ischemic attack (stroke), and cognitive communication deficits. The 1/23/23 minimum data set (MDS) assessment revealed Resident #2 did not complete the brief interview for mental status (BIMS); staff instead assessed the resident's cognition. The assessment revealed staff assessed the resident to have short-term memory impairment but had no impairment with long-term memory. The resident was able to recall the seasons; location of the room and names and faces of the staff. The resident had impaired skill for daily decision making and had some difficulty in new situations. The resident had no symptoms of delirium or disorganized thinking. The resident was taking daily antipsychotic and antidepressant medications on a routine basis. II. Record review Review of the resident record and interviews revealed the resident's legal representative was not notified by facility nursing staff or by the resident prescribing physician of changes in the resident psychotropic medication or results of diagnostic testing regarding unresolved leg pain. Care plan meeting note dated 12/27/22 at 12:05 p.m. read in pertinent part: (Resident #2 was having leg pain) "Nursing will request an x-ray to see if there is anything else going on with the resident's foot that may keep him from reaching rehab potential. Referring to the resident to get an x-ray to see what is going on with leg and help him get back to baseline so that he can (gain full) rehabilitation." Nursing note dated 1/6/23 at 8:57 a.m., read: "Per (resident's medical power of attorney), resident was supposed to have an x-ray done on both feet and ankle following the care plan meeting back on 12/27/22. Spoke with (the resident's physician) and received routine diagnostic orders for the x-ray to be completed." The x-ray was completed on 1/6/23 with no significant findings. Neither the progress notes or physician notes document next steps or discussion with the resident or medical power of attorney (MDPOA) on next steps and goals for pain relief. Practitioner visit note dated 2/24/23, read in pertinent part: "This resident was seen and evaluated yesterday. Resident was in good spirits, without evidence of psychosis, and without any known incidents. (The resident) continues having a noticeable tremor, and obvious drooling, almost certainly a result of treatment with Haldol (antipsychotic medication). (The resident) was informed that these symptoms were from Haldol, and that he is taking an excessive amount of this drug. When initially seen, he was resistant to changing any of his medication; this may have been partly due to his (legal representatives input). (The resident) asked me to inform (the legal representative) of any med (medication) changes. (Resident) was told that facility nursing staff would advise (the legal representative) of any medication changes. It was emphasized to (the resident) that any medication changes made, are to help him functionally, as it is unnecessary to take the amount of medications that he is taking. (The resident) stated that he would like Haldol 5 mg (milligrams) daily be stopped, so the medication was discontinued as this writer also agrees that this is the best place to start. (The resident) was also informed about Ipratropium Bromide 0.06% nasal spray, which can be used as a spray below the tongue for his sialorrhea (hyper salivation or excessive drooling). (The resident) agreed to a trial of this med which was ordered at a starting dosage of 1 spray under the tongue." -The resident's progress notes failed to document notification to the resident's legal representative. III. Resident representative interviewThe resident's legal representative/medical durable power of attorney (MDPOA) was interviewed on 3/2/23 at 2:01 p.m. The MDPOA expressed several concerns about the resident care including lack of communication about medical treatment and care. The MDPOA said neither nursing staff nor the facility social worker made any attempt to communicate the resident's recent medication change regarding discontinuing the resident's Haldol. The MDPOA said the resident was the one who had made the notification that the practitioner had made change in the medication regime but was not able to specify when the change occurred or why the change occurred. The MDPOA would have liked to have been informed so there could have been a discussion about the reasons for the medication change and the goals of psychotropic medication changes. The MDPOA said it had been difficult getting notification and return calls about Resident #2's care. The MDPOA had to go in person to discuss the resident care and some of the nurses were not able to answer questions fully without having to wait for the nurse to call the provider and get back with answers. The MDPOA would like more regular communication from the facility about treatment decisions in order to be an active partner in developing an appropriate care plan for the resident. The MDPOA also said the resident was supposed to be assessed for pain in the lower extremities but was not sure of the outcome of diagnostic treatment or next steps in treatment. The resident was still experiencing pain and still had no relief. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/2/23 at 1:50 p.m. LPN #1 acknowledged being Resident #2's regular daytime nurse. LPN #1 said there had not been any occasion to call the resident's legal representative, so the LPN had never talked with the resident's legal representative. The LPN acknowledged the resident had recently been taken off Haldol due to developing drug induced Parkinson's-like symptoms and said the resident was doing much better. The NHA and unit nurse manager were interviewed on 3/2/23 at 3:33 p.m. The NHA was not aware the Resident #2's legal representative was requesting regular communication from the facility regarding the resident's care and treatment. The NHA said the facility recently had a care conference on 12/27/22 to discuss resident care but she did not remember if medications were discussed at that meeting. The NHA had some recollection of a discussion around the resident's leg pain but did not recall the outcome of medical assessments. The NHA said she would contact the resident legal representative and offer to set up routine calls, in person meetings, or provision of a weekly written status report at a frequency beneficial to facilitate communication with the resident's MDPOA.

Based on observations and interviews the facility failed to provide a clean, safe, homelike environment for the residents, on the east side of the building in six of eight resident units/halls and in resident common areas. Specifically the facility failed to:-Ensure the environment resident halls and common area spaces were free of offensive bathroom odors and other body odors;-Ensure the handrails in resident halls were securely fastened to the walls;-Ensure resident rooms and hallways were clean and free from debris left on the floors;-Ensure the walls in resident rooms and halls looked home like; and were maintained in good condition;-Ensure cables and power cords were not loosely hanging from the wall or laying in walkways;-Ensure the rubber wall molding in resident rooms was securely attached to the wall and not hanging off the wall into walkways;-Ensure resident space was accessible to store and display personal items; and,-Consistently provide clean linens to the residents. Findings include: I. Facility policy The Accommodation of Needs policy, revised 2/1/23, was provided by the nursing home administrator (NHA) on 2/3/23 at 6:15 p.m. It read in part: "The resident/patient (hereinafter 'patient') has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. "The (facility's name) physical environment and staff behaviors should be directed toward assisting the patient in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible in accordance with the patient's own needs and preferences. The (facility's name) must provide:-A safe, clean, comfortable, and homelike environment, allowing the patient to use his/her personal belongings to the extent possible.-This includes ensuring that the patient can receive care and services safely and that the physical layout of the Center maximizes patient independence and does not pose a safety risk.-Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.-Clean bed and bath linens that are in good condition.-Private closet space in each patient room."II. Resident interviewsResident #4 was interviewed on 3/1/23 at 2:42 p.m. Resident #4 said she had talked to the maintenance director (MTD) several times about environmental concerns of a safety and accommodation of space nature, but the requests had not yet been addressed and it had been over a month since she made the requests. Resident #8 was interviewed on 3/2/23 at 10:55 a.m. Resident #8 said lingering foul odors throughout the halls were problematic. Smells traveled into her room from the hall. Resident #8 wanted to get an electronic odor diffuser but was unable due to a potential fire hazard so the resident opted for a tabletop air freshener. The resident pointed to her dresser where there was an air freshener that was mostly dry. Resident #8 said the air freshener was not effective to eliminate odors unless it was newly opened and right next to her bed. Resident #8 did not have any towels in the room and said she only got fresh towels if she asked for them. Resident #6 was interviewed on 3/2/23 at 11:33 a.m. Resident #6 said the facility environment needed a lot of improvement. She and several other residents complained about maintenance and housekeeping jobs not being compiled timely or effectively. Resident #6 kept a log of concerns to address with the resident council. Most of the time maintenance blamed delays on being short staffed; however, there were times when the maintenance department was not short staffed and they still did not complete repairs and upkeep in a timely manner. Resident #6 pointed to the wall in her room. The resident said the paint on that wall had been gouged with exposed plaster since moving into the room more than a year ago. Resident #6 said many other resident rooms and hallway walls were in the same disrepair. Resident #6 said housekeeping was much the same way resident rooms were not cleaned daily; she was luckier than most that she could tidy up her own room in housekeeping absence. Resident #7 was interviewed on 3/2/23 at 4:20 p.m. Resident #7 said there were strong smells on her unit that lingered and bothered her. Resident #7 said she had to open her window or spray room spray in order to get fresh smelling air. III. Observations On 3/1/23 at 1:46 p.m., resident room #1403 has a slight smell of sweat and body odor; the bedside table has dried spilled chocolate milk over the surface, the trash can was overflowing with trash and empty chocolate milk containers. -At 1:55 p.m., resident room #1403 was observed; the bedside table still had dried chocolate milk on it in addition to a spilled clear brown liquid and there was an open soda bottle on the tabletop. -Between 2:20 pm and 3:45 p.m., units 1100, 1200, 1300, 1400, 1500, and 1600 were observed: The hallways on units 1200 and 1300 were littered with small scraps of paper on the floor and empty alcohol swab packets. Observations on hallways 1100, 1200. 1300, 1400, 1500, and 1600 revealed:-The walls were soiled underneath the grab bars with several drips of dried liquid of a light tannish in color; the liquid was translucent and was dripping down the wall in several areas up and down the hall. The same walls were streaked with black marks and scrapes;-The majority of the residents' doors on each of the resident halls were scrapped at knee level and below down several layers of wood. There were several door jams and hall entry edges were the plaster was broken off;-Several walls had gouges exposing bare plaster. Some of the gouged areas were plastered but not painted;-In hallway 1300, there was a grab bar off the wall on the left side; the area had three large plastered areas. The plaster was dry and hardened, but left unpainted;-The shower room door to the hallway in hall 1300 and resident room #1301 had old white/soiled half-inch tape still stuck on the door; the tape was frayed with black stains;-The 1400 hall had a slight odor; the odor resembled body odor sweat that was permeating from resident rooms;-In 1600 hall, not far into the hall, on the left side there was a grab bar hanging down and off the wall connected only by one side. The grab bar was wobbly and pull further away from the wall when grabbed; and,-None of the resident rooms had fresh towels for resident use. Observations of individual resident rooms revealed:-Several resident rooms on each unit had chipped paint from the walls by the residents' beds;-The areas around the sinks had chipped and peeling paint exposing plaster; and,-Several rooms had loose cable cords laying on the floor inches from the wall and laying in walkways. Observation of resident room #1101 revealed:-Approximately, two feet of rubber molding, in the walkway to bathroom, was peeling away from the wall in and hanging into the walkway;-The window had a long crack that had spread from one end to the other;-The bathroom had several areas of chipped paint under and around the sink and by the toilet;-There was no shower head sprayer on the shower spicket;-The walls under the heater on both sides of the room had plaster repaired walls that were not painted;-The residents' did not have any linens; -The resident had no place to store toiletries in the bathroom and had to keep toothbrushes on the windowsill that was next to the toilet, with in use toilet paper. There were shelves in the bathroom but they were placed high on the wall above the toilet where the resident in a wheelchair could not safely reach; and, -The closet space was not accessible to the resident because it was blocked by an unused television set. Other resident room observations:-Room #1402, the wall beside the bed closest to the door, at the location where the resident's upper body would lie had dried brown matter; and, -Room #1406, the wall next to the window at knee level had dried brown matter on it. On 3/2/23 at 9:45 a.m., units 1600 and 1300 had a strong lingering body and sweat odor. hall 1300 also had a strong urine odor. -At 4:00 p.m. unit 1300 and a strong odor of body and urine odor. The common area around the East side lobby connecting to the resident units had a strong linger odor of feces. III. Record review Facility work request records for September 2022 to February 2023 were reviewed, records revealed there were needed repairs for plumbing, heating air conditioner units, lighting, resident equipment, along with odd job requests from residents', in addition to: On 11/23/22, staff reported a broken handrail on the 1100 hall. The repair was listed a medium priority. Maintenance documented on entry that the repair was made on 12/11/22. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/1/23 at 4:55 p.m. LPN #1 said the large plastered area in hall 1300 had been left up painted for a couple of weeks. LPN #1 was not sure how long the handrail in hallway 1600 had been broken and hanging off the wall. LPN #2 was interviewed on 3/1/23 at 5:02 p.m. LPN #2 said several handrails were broken throughout the facility going back to September 2022. It took several months for maintenance to remove and fix the handrails. LPN #2 said the handrail on hallway 1600 had been hanging off the wall for quite a while. The MTD was interviewed on 3/1/23 at 6:00 p.m. The MTD said the building needed a lot of repairs and he had a plan to complete the needed repairs over the next 12 months starting with safety issues first. The MTD said the system for repairs was for staff to put in a computerized repair request and then place the request on a clipboard list of need where repairs involving safety hazards got first priority. The MTD acknowledged delays in completing facility repairs was due to being understaffed. The MTD said the maintenance department was fully staffed and the first safety repair priority over the next 30 days was to secure loose cable and electrical cords in resident rooms. The MTD acknowledged there were a lot of loose and hanging cords in the resident room that needed securing, due to a potential of being a safety hazard. The MTD attributed the cause of this problem to frequent resident rooms moves and residents families desire to rearrange furniture which often left electric and cable cords in unsafe places. What made it harder to keep up was that the nursing staff did not always notify the maintenance department of repair needs and they did not have the capacity to make daily checks in each resident's rooms for areas needing repairs. The MTD said he would address the hanging handrail on 1600 immediately to get it secured to the wall; and fix the hanging cable cord and baseboard in Resident #4's room. Then NHA and unit nursing manager (UNM) were interviewed on 3/2/23 at 2:00 p.m. The NHA said the maintenance department had struggled to hire staff up until recently. The NHA said there was a priority list for repairs. The housekeeping supervisor (HSKS) was interviewed on 3/2/23 at 4:19 p.m. The HSKS said resident rooms were supposed to be cleaned daily; however, that did not always occur due to staffing shortages. The HSKS was working on retraining the housekeepers (HSKP) to make sure to move furniture and resident beds so they could thoroughly clean the entire floor in each room. The HSKP where to use peroxide while cleaning plus use an enzyme clean chemical to cut odors particularly in the bathrooms where odors linger from spills and accidents involving bodily fluids. The HSPS acknowledged the walls in the hallways were soiled and needed to be cleaned. The HSKS said she started to clean the walls in the common area this morning and would make the hall a special project. Other special projects involved floor clearing; the facility hired a floor technician and the staff's training started. The HSKS said in addition to the daily cleaning tasks, deep cleaning for the resident hallways was once a week and once a month for resident rooms. The HSKS said she looked at the wall next to the resident's bed in room #1402; it appeared the resident was spitting on the wall and no staff cleaned it. The wall was cleland and HSKP staff were alerted to monitor and clean the wall when cleaning the rest of the room.

Based on observations, record review and interviews, the facility failed to prevent an accident involving hot liquid which caused a second degree burn with one (#1) of three out of 13 sample residents. On 1/21/23 at 2:45 p.m. Resident #1 was found to have a large blistered and reddened area on the right thigh. Nursing staff were unable to explain how the injury occurred. A physical assessment and investigation was initiated. Nursing staff revealed the resident was assessed to have two burn sites on the right thigh. The resident was experiencing pain at the burn site (see more information below). On 1/24/23, the resident was examined for an initial evaluation with a wound care physician. The physician diagnosed the resident with a second-degree burn to the upper right thigh. The physician measured the burn site. The total wound surface burn site with blistering, measured 3.0 centimeters (cm) by 9.3 by 0.1 cm (length by width by depth). There were two other burn site area one reddened and blistered and the other reddened and non-blistered the proximal (closer to the torso) area of redness measured 1.0 cm by 3.0 cm by 0.0 cm; the distal (furthest from the torso) area measured 2.5 cm by 2.8 cm by 0.0 cm. According to the investigative summary dated 1/29/23, documented that during incontinent care performed on 1/21/23 at approximately 2:45 p.m., Resident #1 was found with redness and blisters on the upper right thigh; staff providing care had no indication what had caused the injury. After further interviews with staff over the next couple of days, it was determined the injury was a burn caused by an unknown substance. The facility failed to provide appropriate supervision and ensure a safe environment for Resident #1 to prevent the resident from sustaining a second-degree burn with redness and blistering, to the thigh. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 3/1/23 to 3/2/23, resulting in the deficiency being cited as past noncompliance with a correction date of 1/27/23. I. Facility policy The Food Handling policy, revised on 6/15/18, was received from the nursing home administrator (NHA) on 3/1/23 at 1:24 p.m. It read in pertinent part: "Hot beverages are to be served at a pleasing temperature, to the residents, but in a manner that reduces the risk for burns. Follow recommendations for reheating beverages in the microwave found in (Guidelines for Hot Beverages). Hot beverages such as coffee, tea and hot chocolate are held at high temperatures (160-185) degrees Fahrenheit (F). Brief exposures to liquids at these temperatures can cause significant scald burns."When serving hot liquids to residents, consider the following:-Dispense the beverage in a plastic mug; not a styrofoam cup.-Do not overfill the drinking cups.-Place the beverage away from the edge of the table and near the patient's dominant hand.-Explain to the patient that a hot liquid is being served.-Place the beverage in the patient's field of vision.-Transfer the hot beverage from the coffee urn to a serving container."II. Resident #1A. Resident statusResident #1, under the age of 65, was admitted on 3/21/19. According to the March 2023 computerized physician orders (CPO) the diagnosis included burns of unspecified degree to the right thigh, underweight, anemia, dementia, and major depressive disorder. The 2/6/23 minimum data set (MDS) revealed the resident was not able to be assessed with the brief interview for mental status (BIMS) due to short-term and long-term memory impairments. The resident had disorganized thinking and was not able to focus attention on conversations nor was the resident able to make herself understood or understand most conversations. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, hygiene, bathing, and moving back and forth on the unit. The resident was independent with eating once set up. B. Record reviewBurn incident investigationOn 1/21/23 an internal investigation report documented Resident #1 received a second degree burn to the right upper thigh over 0.5 percent of the body. The initial proximal blistered wound measured 1.7 cm by 2.1 cm by 0.0 cm; the distal blistered wound measured 3.0 cm by 9.3 by 0.1 cm; the proximal non -listered reddened wound measures 1.0 cm by 3.0 cm by 0.0 cm; the distal non-blistered reddened wound measured 2.5 cm by 2.8 cm by 0.0 cm. The actual cause of the burn was undetermined. The burn injury was discovered on 1/21/23 at approximately 2:45 p.m., shortly after change of shift with incontinent care during first rounds. The certified nurse aide (CNA) working the prior shift denied any knowledge of how the resident could have sustained the second degree burn and denied observing any redness when the resident was last changed on the day shift (reportedly 11:00 a.m.). Initial wound care treatment included a cold compress followed by application of a non-stick bandage pending physician assessment and treatment recommendations. The investigation documented the facility was unable to determine the exact time the resident's burn was sustained. Incident note dated 1/21/23 at 7:20 p.m., documented the resident was assessed after staff observed reddened and blistering areas on the top of the resident's right thigh. During nursing assessment, the resident experienced moderate pain as evidenced by a score of 5 out of 10 (with 10 being the worst pain on the scale) on the pain assessment in advanced dementia (PAINAD) scale. Symptoms of pain included occasional moan or groan; low level of speech with a negative quality; facial grimacing; and, tense distressed pacing. Nursing note dated 1/21/23 at 7:29 p.m, documented: A change in condition reported: "Evaluation are/were: Change in skin color or condition. Nursing observations, evaluation, and recommendations are: Attending nurse requested assistance with assessment of residents leg. Leg appeared reddened in areas, rounded. Several of the red areas had what appeared to be blisters. On call provider was notified; treatment orders were given." Physicians orders read "Silvadene (silver sulfadiazine) external cream 1 percent. Apply to the right anterior thigh topically, two times a day for wound care. Gently cleanse the area with wound cleanser- apply silvadene-cover with a sterile bandage and kerlix." Order date 1/21/23. Physician's visit note read in part: "Date of encounter: 1/24/23. Medical necessity of visit: follow up on burns. Chief complaint: Resident #1 has two different areas to her right upper leg, the distal area is second degree burn, no open or fluid filled blistering noted, the proximal burn area is a second degree burn, there was a fluid filled blister but this has opened. Staff report that they believe she poured hot coffee on her leg which caused the burn."Wound care physicians note dated 1/24/23 documented the resident was examined for initial assessment and treated for second degree burns to the upper right thigh, four days after the injury was sustained. The resident wounds were cleansed and an antimicrobial dressing was applied with a dry outer dressing. The resident experienced pain during care responding with occasional negative vocalizations, a sad frightened frown, tense body language but was consoled. The comprehensive care plan revised 1/24/23, documented Resident #1 was at risk for burns from hot beverages due to no safety awareness as evidenced by a history of wandering and grabbing cups and objects from tables and counters. The gaol was "resident will have no further injuries from hot beverage spills onto lap."Interventions included:-Increase visual checks for safety during meals to aid in preventing Resident #1 fromgrabbing other items from the table that do not belong to her;-Seating arrangements to allow Resident #1 to sit with other residents that do not drink hot beverages; and,-Provide resident/patient with set-up and supervision with cues to extensive assistfor eating. C. ObservationsOn 3/1/23 at 5:24 p.m., Resident #1 was observed self propelling throughout the unit in a manual wheelchair reaching out to grab at staff and residents as they walked passed by. A CNA on the unit approached and assisted the resident to the dining room. The resident was seated away from others with hot liquids in front of a table tray and served the dinner meal. Resident #1 at the meal remaining in place until the meal was done. When the resident was finished eating, the CNA removed the table tray and the resident continued roaming around the unit touching every person who she passed. III. Staff interviewsThe dietary manager (DM) was interviewed on 3/1/23 at 1:30 p.m. The DM said the coffee was brewed in one machine in the kitchen and then transferred to a stainless steel thermos dispenser to be served to the residents. The coffee was tempted prior to being taken to the dining room and resident floors for service. The DM said the temperature of the coffee should be 160 degrees F or lower. If steam was coming off the poured coffee it was most likely too hot to serve. Staff were educated to monitor the coffee dispenser and inspect any resident attempting to operate the dispenser on their own. The DM said hot liquid at above 160 degrees had the potential to cause scalding burns. CNA #2 was interviewed on 3/2/23 at 10:20 a.m. CNA #2 said she was working from 6:00 a.m. to 2:00 p.m., on 1/21/23, the day this resident was burned. CNA #2 she had not observed the resident spilling any ot liquids and had not observed any signs that there was any hot liquid spilled around the resident; and Resident #1 never complained of pain throughout the day shift. CNA #2 said she provided incontinent care for Resident #1 just before lunch, at approximately 11:00 a.m. The resident's pants were wet around the brief but not on the resident's legs. Unit nurse manager (UNM) was interviewed on 3/2/23 at 11:10 a.m. The UNM said Resident #1 needed to be monitored because she was reaching to grab items from other residents' tables and the drink carts which caused a safety concern. The UNM said no staff knew what time the resident burn occurred on 1/21/23 or how the burn occurred, but it might be possible that the resident spilled some hot liquid on herself. The NHA was interviewed on 3/2/23 at 12:00 p.m. The NHA said Resident #1 had sustained a second degree burn to the right thigh, requiring the resident to start seeing the wound care physician to treat the burn. The wound was healing but still required ongoing wound care treatment and monitoring by nursing staff and the wound physician. Immediately following the discovery of the resident burn, the facility investigated for possible causes and preventative measures. The resident care plan was updated with new safety interventions and all staff were educated to follow the revised care plan to maintain the resident's safety. Licensed practical nurse (LPN) #4 was interviewed on 3/2/23 at 1:00 p.m. LPN #4 said Resident #1 was impulsive and was touching things all the time. LPN #4 said the resident was non-verbal so staff were unable to find out exactly how the resident was injured. CNA #3 was interviewed on 3/2/23 at 3:30 p.m. CNA #3 said she worked on 1/21/23, during the evening shift from 2:00 p.m. to 11:00 p.m. CNA #3 said she came on shift and started rounding and checking on resident needs. Resident #1's briefs were soiled upon checking in on the resident. CNA #3 provided Resident #1 incontinence care at approximately 2:45 p.m. and noticed redness and blisters on the resident's right thigh. CNA #3 reported the resident's injury to the nurse for further assessment. Because no staff on duty know how the injury occurred, CNA #3 called CNA #2, as that CNA had worked with the resident on the prior shift. CNA #3 said CNA #2 denied knowledge of Resident #1 injury and said the resident did not have any signs or symptoms of an injury or burn during the day shift. IV. Facility correctionsInterview and record review during the complaint investigation revealed the facility investigated this singular event and implemented corrective actions to prevent reoccurance. The care plan was revised with interventions for staff to set Resident #1 up to be separated from other residents who drank hot liquids. Since Resident #1 did not consume hot liquids. The resident was not in jeopardy of being burned by her own drinks but was at risk from grabbing hot liquids from peers consuming such beverages. The care plan interventions included placing Resident #1 away from hot liquids at meals and monitoring the resident during the meal. Observations and interviews during the survey revealed staff were consistently following the care plan interventions and the resident had not experienced any further problems being injured by hot liquids. The facility determined all residents in the facility were at risk for being burned by hot coffee or any other hot beverage such as tea or hot chocolate, if not properly brought to a safe temperature for serving. The dietary department educated dining aides to make sure hot liquids did not exceed 160 degrees F when serving to a resident. Coffee for example was to be tempted properly, in the kitchen at each service, to make sure its temperature met the recommended 160 degrees F prior to taking it to the dining room or to the resident units for service to the residents. Additionally, staff were instructed that residents were not permitted to dispense coffee directly from the stainless dispensers. Signs were posted on the coffee and hot water dispensing containers warning residents to ask for assistance due to the risk of being burned. All nursing staff were educated to follow Resident #1's revised care plan intervention to prevent reoccurance of the resident being burned as of 1/27/23. Interviews with the NHA confirmed the corrective actions, and therefore the facility's substantial compliance, by 1/27/23, at the time of the survey conducted between 3/1//23 to 3/2/23.