MEDALLION POST ACUTE REHABILITATION — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

June 16, 2026

Last Inspection

S/S B Minimal potentialS/S D/E/F Potential for harmS/S G Actual harmS/S J Immediate jeopardy

The most recent inspection of MEDALLION POST ACUTE REHABILITATION on record is dated June 16, 2026. Across 25 published inspections, state surveyors cited 49 deficiencies, 5 of which reached actual harm or immediate jeopardy.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status

Active

Facility Type

SNF/NF Distinct Part

Administrator

Cook, Ronald

Owner

BIJOU HEALTHCARE LLC

Phone

(719) 381-4963

Payor Source

Medicare, Medicaid, Private Pay

City

COLORADO SPRINGS

ZIP

80909-5736

Inspections & Citations

25 inspections · 49 deficiencies

6/16/2026Complaint, Recertification Survey · ID 2351F5-H17 deficiencies▼

0000INITIAL COMMENTSSurveyor note2 building records▼

Findings · record 1 of 2

A recertification survey with complaint #CO2800411, #CO3013881, Incident #3031685 and Incident #3031711 was conducted on 6/10/26 to 6/16/26. Seven deficiencies were cited.

Findings · record 2 of 2

An emergency preparedness survey was conducted from 6/10/26 to 6/16/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0550Resident Rights/Exercise of Rights▼

Findings

Based on observations, record review and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to:-Maintain residents' dignity and ensure call lights were answered timely; and,-Ensure residents were treated with dignity by staff during meal service. Findings include:I. Failed to maintain residents' dignity and ensure call lights were answered timelyA. Facility policy and procedureThe Call Light/Bell policy and procedure, revised May 2007, was received from the director of nursing (DON) on 6/17/26 at 11:02 a.m. It read in pertinent part, “Procedures: Answer the light/bell within a reasonable time (approximately five minutes).“Leave the resident comfortable. Place the call device within resident’s reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor.”B. Resident and resident’s representative interviewsResident #3 was interviewed on 6/10/26 at 9:37 a.m. Resident #3 said sometimes staff did not treat her with respect and dignity. Resident #3 said a few weeks ago she laid in her bed for an hour and a half waiting for a staff member to come and help her get cleaned up after being incontinent. Resident #3 said it often took half an hour for a staff member to come when she used her call light. Resident #3 said the staff’s call light response times were worse at night and over the weekends. She said it did not seem like the facility was properly staffed. Resident #3 said she sometimes wondered why she even had a call light because the staff did not seem to respond to it and it made her feel worthless. Resident #3 said there were a lot of times where she had activated her call light and heard people outside her room talking and laughing but no staff members ever responded to her. Resident #3 said sometimes she would ask a certified nurse aide (CNA) to get a nurse’s attention for her but no staff member would ever return to her room. Resident #3 said the nurses all told her to let them know if she needed anything, but Resident #3 said it felt like there was no point in telling them. Resident #3 said she felt like her concerns did not matter and the staff would not help. Resident #3 said the issues with call light response times had been going on for a while and were not getting any better. Resident #3 said she was frustrated because she often was left lying in her own feces, which she said she was not supposed to do because it was damaging to her skin. She said when she was left soiled for too long, her skin became itchy. Resident #9 was interviewed on 6/10/26 at 2:12 p.m. Resident #9 said she usually had to wait an hour for her call light to be answered. Resident #9 said she used her call light to get staff assistance to change her colostomy bag or to go to the bathroom. Resident #9 said she felt disgusted when the nursing staff took a long time to answer her call light. Resident #9 said it seemed like the facility had enough people working, but sometimes they were all standing in a group talking and laughing in the hallway. Resident #9 said she had started getting herself up from bed because she did not want to wait. Resident #51 was interviewed on 6/10/26 at 10:55 a.m. Resident #51 said she thought the facility was understaffed and the staff were very overworked and exhausted. Resident #51 said it took a very long time at certain times of the day for staff to answer her call light. Resident #51 said staff generally would not respond to her call light for 45 minutes. She said she was blind and could not walk so she needed a lot of help from the facility staff. Resident #52 was interviewed on 6/10/26 at 2:53 p.m. Resident #52 said any time she hit her call button, the staff would come in and turn it off, repeating this process several times. Resident #52 said when a staff member turned her call light off, an hour would go by before they returned. Resident #52 said she usually used her call light to request her pain pill, as she tried to stay on top of her pain to keep it managed. Resident #52 said she felt aggravated by the long call light response time. Resident #52 said she put her call light on at 5:15 p.m. the other day but did not get the medication she requested until 8:30 p.m. Resident #5 and his representative were interviewed together on 6/10/26 at 3:22 p.m. Resident #5’s representative said it took the staff a while to come in when Resident #5 pressed his call light. Resident #5’s representative said it often took the staff 15 to 20 minutes to answer the resident’s call light, but it sometimes took 30 minutes or more. Resident #56 was interviewed on 6/10/26 at 3:28 p.m. Resident #56 said he sat in his bed for three hours the other night waiting for staff to answer his call light. He said he had activated his call light at 7:00 p.m. and no one came in until 10:00 p.m. Resident #56 said he used his call light to get assistance with getting his brief changed. Resident #56 said his roommate pushed his call light every five minutes so the staff thought when the call light activated it was just his roommate calling again. Resident #56 said he was angry when it took the staff so long to answer his call light. Resident #13 was interviewed on 6/10/26 at 2:02 p.m. Resident #13 said it sometimes took staff quite a while to get to her room when she had her call light on. Resident #13 said her roommate had her call light on for four hours the other night. She said the CNA kept coming in to turn her call light off so she kept having to turn it back on. Resident #13 said the facility’s administration had told the residents to turn their call light back on if a staff member turned it off, and to keep turning their call light on until their request was complete. C. Resident group interviewSix residents (#43, #56, #1, #19, #23 and #27) who frequently attended the monthly resident council meetings and were identified as alert and oriented by facility and assessment were interviewed on 6/15/26 at 10:01 a.m. All residents in attendance said they had issues with their call lights not being answered timely. Resident #19 and Resident #23 said they both often waited 30 minutes or more for their call lights to be answered. Resident #56 said he had to wait three hours for his call light to be answered the other day. Resident #43 said he usually waited 15 to 20 minutes for his call light to be answered. Resident #56 and Resident #19 said they used their call lights to have their briefs changed. Resident #23 and Resident #1 both said they had heard staff laughing and talking in the hallways while they waited for their call lights to be answered. Resident #56, Resident #1 and Resident #19 said they had sometimes had issues with nursing staff answering their call light but thinking it was their roommate that needed help, helping their roommate and leaving without assisting them with what they needed. All residents in attendance said they felt frustrated having to wait long periods for their call lights to be answered. D. ObservationsOn 6/15/26 at 2:30 p.m. four call lights were activated and visible on the switchboard by the nurses’ station. CNA #2 and an unidentified CNA were sitting in the charting area near the nurses’ station. One of the CNAs was looking down and using her phone. CNA #3 and CNA #4 were standing near the nurses’ station in the common area talking about their outfits. Two staff members approached CNA #3 and CNA #4 and requested their help with assisting residents. At 2:34 p.m. the unidentified CNA said she was not on her break period. The assistant director of nursing (ADON) approached CNA #2 and asked her to help her answer the call lights. E. Record reviewFacility grievances pertaining to call lights were provided by the nursing home administrator (NHA) on 6/11/26 at 3:07 p.m. and revealed the following:The facility received a total of 23 grievances, dated from 1/18/26 through 5/30/26, from residents, resident council meetings and frequent visitors of the facility regarding prolonged call light wait times. Review of these grievances revealed multiple residents reported waiting from 20 minutes to several hours for their call lights to be answered. Multiple residents reported experiencing extended call light wait times overnight. Resolutions to these grievances included staff education, initiating disciplinary actions for staff, and modification of residents’ care plans to include their preferred time to get up in the morning or go to bed. All of the grievance forms documented the residents were satisfied with the solution and completed.-However, residents continued to report extended call light wait times throughout the survey process. Quality assessment and performance improvement (QAPI) committee meeting minutes, dated 5/12/26 at 9:00 a.m., revealed the interdisciplinary team (IDT) met to identify and discuss projects and trends within the facility, and reviewed nursing performance improvement plans (PIP). The minutes documented there was an active PIP for call lights. The minutes documented call light audits were being conducted and showed some times of day were busier. Staff were educated in anticipating residents’ needs as well as ensuring there was nothing else the resident needed before the staff member left the room. The minutes documented it was mainly three individual residents who were saying they had issues with their call lights, and the staff were keeping in communication with them. The minutes documented the audits were continuing. Call light audits, dated 2/1/26 through 6/13/26, were received from the DON on 6/15/26 at 9:29 a.m. and revealed the following:The call light audits were conducted periodically for a few rooms each time and documented the room, the time the call light was turned on and the time the call light was answered. Call light audits, dated 2/2/26 through 2/19/26, revealed room #101 had ten call light audits conducted during the day shift (between 6:00 a.m. and 2:00 p.m.), five call light audits conducted during the evening shift (between 2:00 p.m. and 10:00 p.m.), and no call light audits conducted on the night shift (between 10:00 p.m. and 6:00 a.m.). On 2/16/26 a call light in room #101 was activated at 8:30 a.m. and answered at 8:47 a.m. Call light audits, dated 2/2/26 through 2/10/26, revealed room #106 had five call light audits conducted during the day shift, one call light audit conducted during the evening shift, and no call light audits conducted on the night shiftOn 2/13/26 a call light in room #106 was activated at 12:07 p.m. and answered at 12:28 p.m. On 2/13/26 a call light in room #106 was activated at 2:33 p.m. and answered at 2:52 p.m. A call light audit, dated 2/5/26, revealed room #104, room #105 and room #106 each had one call light audit conducted during the day shift. Call light audits, dated 3/2/26 through 3/17/26, revealed room #106 had 15 call light audits conducted during the day shift, 12 call light audits conducted during the evening shift, and no call light audits conducted on the night shiftOn 3/13/26 a call light in room #106 was activated at 8:00 a.m. and answered at 8:20 a.m. Call light audits, dated 3/18/26 through 4/23/26, revealed room #106 had 40 call light audits conducted, one of which was performed during the night shift. On 6/9/26 the call light in room #S2 was activated at 8:20 a.m. and answered at 8:45 a.m. An undated call light log, conducted some time during the weekend of 6/12/26 through 6/14/26 per the DON, revealed a call light was activated in room #S9 at 12:54 a.m. and answered at 1:13 a.m.-No call light audits were conducted during the night shift from 2/2/26 through 5/31/26. -Call light audits were not consistently conducted for any rooms other than room #101 and room #106 from 2/2/26 through 5/31/26.-Several call lights on the audit log were not answered for15 minutes or more. Resident council meeting minutes, dated March 2026, revealed residents attending the council meeting voiced concerns regarding staff prioritizing meal tickets and trays over resident care, waiting a long time in the morning to be assisted by staff with getting up and ready, and waiting a long time for their call lights to be answered in the evenings. Resolutions were listed for each concern and included staff education, investigation and resolution of the concern, and continuing call light audits and staff education, respectively. Resident council meeting minutes, dated April 2026, revealed residents attending the council meeting voiced concerns regarding staff turning off residents’ call lights before their request was completed and CNAs not helping cover other hallways. The resolution listed for both concerns was staff education. Resident council meeting minutes, dated May 2026, revealed residents attending the council meeting voiced concerns regarding night shift staff not getting coverage when the staff went on break, and staff turning off residents’ call lights before completing their request. The resolution listed for both concerns was staff education.-However, staff education was not effective, as residents continued to have multiple concerns regarding call light response times at the time of the survey (see resident interview above). F. Staff interviewsThe DON was interviewed on 6/15/26 at 9:29 a.m. The DON said the receptionist/central supply coordinator was the person who conducted call light audits during the day. The DON said the receptionist had worked during the evening shift for a few weeks to conduct call light audits at night when the administration had identified some concerns with the evening shift. The DON said she had appointed a lead CNA who worked nights, so she was the main person who conducted call light audits at night. The DON said the lead CNA position was created as an intervention for call light wait times, as the night shift staff became more relaxed when the administration team left.-However, review of the call light audits revealed only one night shift audit was documented on the audit log from 2/2/26 through 5/31/26 (see record review above). CNA #3 was interviewed on 6/16/26 at 8:35 am. CNA #3 said she felt like she could get all of her tasks done timely, but the workload was person-dependent. CNA #3 said if she came out of a resident’s room and saw multiple call lights were activated, she would answer whichever call light she saw first. CNA #2 was interviewed on 6/16/26 at 8:44 a.m. CNA #2 said she was not sure how to tell which call light to answer first if she left a resident’s room and saw multiple call lights were activated. CNA #2 said in that scenario, she would work her way down the hall and answer them in order, or use her judgement if she knew the residents and what they usually used their call light for. The DON was interviewed again on 6/16/26 at 10:44 a.m. The DON said it was the same residents who complained about call lights in each resident council meeting. The DON said when she spoke with those residents, they reported call light times had generally gotten better but there were one-off situations where their call lights took a longer time to be answered. The DON said there were situations where nursing staff would be attending to a resident who needed more assistance, which would delay them in answering other call lights, but residents generally reported their call light times were better. The DON said interventions the administration put in place to improve call light wait times included staff education, one-on-one education with specific staff members, initiating disciplinary action for staff members, shifting staffing positions to different areas, designating a shower aide in the evening shifts, creating the position of lead CNA and trying to identify a root cause. The DON said she was not able to determine a root cause for the long call light times because the call light concerns seemed to move from shift to shift and could not have a blanket answer for each instance. The DON said she was trying to hone in on some of the nursing staff to improve the issue. The DON said she was consistently trying to come up with new solutions to the issue, which was why the facility had conducted call light audits here and there. The DON said she did not want to say one specific call light wait time was her expectation, but said she would want to analyze a call light wait time of 15 or 20 minutes to see what happened and why it took that amount of time for staff to answer. The DON said for call light audits, the receptionist would watch the call light alert board for the residents’ rooms they identified from grievance forms and time the call light responses. The DON said she created the role of lead CNA to do the same process for rooms they had identified from grievance forms, and said the CNA would throw in other random rooms for the audit if they could. The DON said the nurses had been conducting the night shift call light audits and had been including CNAs into the audit workload as well. The DON said she had done call light audits sporadically whenever she received grievance forms. The DON said she and the ADON had come in on a few night shifts to perform call light audits but said the staff were more conscientious when they were in the building, so they did not accurately reflect what may have been happening, and the DON had not recorded or documented these audits. The DON said there were no documented call light audits completed by any members of the IDT.II. Failed to ensure residents were treated with dignity by staff during meal serviceA. Facility policy and procedureThe Dignity and Respect policy and procedure, revised February 2020, was received from the DON on 6/17/26 at 11:02 a.m. It read in pertinent part, “The staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.”B. ObservationsDuring a continuous observation of the lunch meal service on 6/10/26, beginning at 11:41 a.m. and ending at 12:13 p.m., the following was observed:At 11:41 a.m. CNA #3 was standing at a dining table where Resident #44 and Resident #10 were seated. CNA #3 asked an unidentified dietary aide if he had the two “feeder’s” meals coming up, and pointed at Resident #44 and Resident #10. -CNA #3 said this with a volume that was heard from the other end of the dining room and was within earshot of the other residents. C. Staff interviewsA social services support staff member, who was filling in for the social services director, was interviewed on 6/16/26 at 10:04 a.m. The social services support staff member said she would expect the facility staff to talk to residents with respect during meal service and talk to the residents themselves, rather than talking around them. The social services support staff member said it was not appropriate to refer to residents as “feeders” as it was an issue of dignity, and said she would not want to be called a “feeder.”The DON was interviewed on 6/16/26 at 10:44 a.m. The DON said facility staff should converse with the residents they were assisting with eating and should not refer to residents as “feeders.” The DON said being called a “feeder” would make her feel like she was not a part of everyone else.

Plan of correction · submitted by the facility

The facility will maintain residents’ dignity and ensure call lights are answered timely and that residents are treated with dignity during meal service. Correction:On 6/16 /2026 DON (director of nursing) immediately completed 1:1 education with C.N.A (certified nurse aide) #3 on always treating residents with dignity and specifically not referencing any resident as a “feeder”.On 6/25/2026 staff education on the expectation for prompt call light response times, prioritization of resident needs and the expectation of treating residents with dignity at all times and specifically not referencing any resident as a “feeder” was completed by DON/Designee. NHA/DON reviewed the call light audit process with residents and shared what attempts are being made to better our call light response times at the last resident council meeting 6-18-26. Identification of others:All residents at the facility have the potential to be affected. Systemic Changes:On or before 7/10/2026 NHA (nursing home administrator)/DON/ Designee will reeducate staff on the expectation for prompt call light response times, prioritization of resident needs and the expectation of always treating residents with dignity and specifically not referencing any resident as a “feeder” the expectation that call lights are to be answered timely. Additionally, the facility administrator, director of nursing / designee will educate staff on treating residents with dignity specifically during meal service. On or before 7/10/2026 DON/IDT (interdisciplinary team) to review and modify current PIP (performance improvement) on call light response times to include modification to night shift staffing assignments to improve call light response times. On or before 7/10/2026 IDT will begin ambassador rounding weekly to specifically conduct random call light response time audits and resident interviews related to being treated with dignity during mealtimes. Any concerns identified will be addressed on the spot with reeducation. On or before 7/10/2026 IDT members will be assigned to conduct random call light response time audits on night/weekend shifts. All nursing units in the SNF (skilled nursing facility) are included in the call light audits. Monitoring:Administrator / Designee will audit call light wait times 3 times a week x4 weeks, then 2 times a week x4 weeks, then 1 time a week x4 weeks ensuring that audits include day, evening and night shifts. Call light Audits will be documented on a Call Light Audit Form. Additionally, random meal service in the dining room will be observed 3 times a week x4 weeks, then 2 times a week x4 weeks, then 1 time a week x4 weeks to ensure residents are treated with dignity during meal service. Results of audits and any identified issues will be reviewed at QAPI (quality assurance performance improvement) monthly.

0678Cardio-Pulmonary Resuscitation (CPR)▼

Findings

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for two (#5 and #40) of 24 residents reviewed out of 41 sample residents. Specially, the facility failed to:-Ensure Resident #5’s medical orders for scope of treatment (MOST) form matched the computerized physician orders (CPO) for cardiopulmonary resuscitation (CPR); and,-Ensure Resident #40’s MOST form matched the CPO for no CPR.Findings include:I. Facility policy and procedureThe Advanced Directives policy and procedure, revised September 2024, was received from the director of nursing (DON) on 6/17/26 at 11:02 a.m. It read in pertinent part, “Once the advanced directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advanced directives so that, if necessary, appropriate orders can be documented in the resident’s medical record and plan of care. II. Resident #5A. Resident statusResident #5, age 77, was admitted on 5/3/26. According to the June 2026 CPO, diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, dementia and Alzheimer’s disease. The 5/9/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. B. Resident’s representative interviewResident #5’s representative, who was the resident’s power of attorney (POA) was interviewed on 6/15/26 at 2:24 p.m. The resident’s representative said she was not sure if she had filled out any documentation regarding her wishes for Resident #5’s code status (a set of medical orders directing what life-saving interventions a healthcare team should perform if a patient's heart or breathing stops) when he first admitted to the facility. The resident’s representative said she would want Resident #5 to receive CPR at that moment because he was still strong, but said her decision would depend on what his condition was at the time of the event. C. Record reviewResident #5’s MOST form, located in the advance directive binder at the nurses’ station and uploaded into the resident’s electronic medical record (EMR), revealed it was signed and dated on 5/3/26 by the resident’s POA. The MOST form indicated the resident’s/POA’s wishes were for Resident #5 to receive CPR with full treatment, including intravenous (IV) antibiotics and fluids and intubation. -However, review of Resident #5’s June 2026 CPO revealed a physician’s order for do not attempt resuscitation (DNR), ordered 5/3/26 and signed by Resident #5’s physician on 5/3/26. Another MOST form for Resident #5, dated 3/22/26, was uploaded to Resident #5’s EMR on 6/12/26 (during the survey process). The MOST form was signed by Resident #5’s POA on 3/22/26. The MOST form indicated no CPR and comfort-focused treatment, which included relieving pain using medication and manual treatment of airway obstruction. The form documented the director of nursing (DON) had reviewed the form on 5/3/26 and no changes had been made.-However, a second MOST form had been created and uploaded on 5/3/26 which indicated Resident #5’s POA did elect for the resident to receive CPR (see above). III. Resident #40A. Resident statusResident #40, age 67, was admitted on 2/18/26 and discharged to independent living on 6/12/26. According to the June 2026 CPO, diagnoses included fracture of right tibia, type 2 diabetes and atherosclerotic heart disease (plaque build-up inside the arteries that supply blood to the heart). The 6/1/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. B. Resident interviewResident #40 was interviewed on 6/11/26 at 10:28 a.m. Resident #40 said he had indicated on his admission paperwork that he did not want to receive CPR. Resident #40 said he had changed his decision a few days ago and elected to receive CPR without extreme measures.-However, a new MOST form was not completed for Resident #40 to reflect the update in his CPR elections (see record review below). -Additionally, Resident #40’s EMR and June 2026 CPO did not reflect his CPR elections on admission (see record review below). C. Record reviewResident #40’s MOST form, located in the advance directive binder at the nurses’ station and uploaded into the resident’s EMR, revealed it was signed and dated on 2/19/26 by the resident. The MOST form indicated the resident’s wishes were for no CPR with comfort-focused treatment which included do not intubate and to avoid intensive care. Review of Resident #40’s June 2026 CPO revealed the following physician’s orders:CPR/Full code, ordered 2/18/26 and discontinued 6/12/26; and,DNR/comfort measures, ordered 6/12/26 (during the survey process).-Resident #40’s physician’s order for code status was not updated to match what he elected on his 2/19/26 MOST form (DNR) until 6/12/26, during the survey process, and the day of the resident’s discharge from the facility. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/11/26 at 2:49 p.m. LPN #1 said the charge nurse was the person responsible for going through all of the newly admitted residents’ paperwork and uploading the information into their EMRs. He said the DON would follow up to ensure it was entered correctly. LPN #1 said the facility kept a physical copy of residents’ MOST forms in a binder at the nurses’ station. LPN #1 said in an emergency, he would generally check a resident’s EMR for their code status information first because it was easier to access. Registered nurse (RN) #5, who also served as a charge nurse, was interviewed on 6/11/26 at 2:53 p.m. RN #5 said the medical records official was the person responsible for entering MOST form information for newly admitted residents. RN #5 said he would use the resident’s EMR in an emergency to find their code status information and said he did not have to use the paper copy of the MOST form. RN #5 said if a resident wanted to change their code status, the staff would assist them in filling out a new MOST form. RN #5 retrieved the advanced directives binder from the nurses’ station and found Resident #5’s MOST form. He said the resident elected for a full code/CPR code status. RN #5 then found Resident #40’s MOST form in the binder which he said documented the resident wanted no CPR and comfort care.-However, the MOST forms RN #5 found in the advanced directives binder did not match the physician’s orders in the residents’ EMRs (see above). The medical records official was interviewed on 6/11/26 at 3:07 p.m. The medical records official said the facility had recently changed how new admission paperwork was handled. The medical records official said the nursing staff went through the new admission paperwork with the residents and their families, and said the charge nurse now uploaded that information to the residents’ EMRs. The medical records official said that documentation had previously come to her to be uploaded, but she had gotten too far behind in uploading it, and said the change in processes had happened the month prior (May 2026). The medical records official said the nursing staff were the responsible parties for entering the physician’s orders for whether the resident would receive CPR or was DNR in the resident’s EMR. The DON was interviewed on 6/11/26 at 3:17 p.m. The DON said when a new resident was admitted to the facility, the charge nurse would take the resident their admission packet, including the MOST form, and go through the admission information with the resident. The DON said she and the assistant director of nursing (ADON) would then enter all of the resident’s physician orders into their EMR. The DON said if a resident admitted with a MOST form, she would make sure those physician’s orders for code status were entered into their EMR, and if any changes needed to be made to their existing MOST form, the physician’s orders in their EMR would be changed. The DON said nursing staff should use the physical copy of the resident’s MOST form in the case of an emergency to identify the resident’s code status and treatment elections. The DON said the code status information in residents’ EMRs should match their MOST form. -However, interviews with nursing staff revealed they did not look for the physical copies of residents’ MOST forms in the event of an emergency, but relied on the information in the residents’ EMRs. The DON said she had identified the discrepancies between Resident #5 and Resident #40’s MOST forms and their EMRs that day (6/11/26) and said she was not sure what happened. The DON said if a resident wanted to change their code status, they would need to fill out a new MOST form. The DON said Resident #40 had just spoken with his physician the day prior (6/10/26) and may have reviewed his code status elections at that time. The regional nurse consultant was interviewed on 6/11/26 at approximately 5:15 p.m. The regional nurse consultant said she had found another MOST form for Resident #5 tucked away in the advanced directives binder, which she said was the most accurate form for the resident and matched what was in his EMR.-However, the MOST form, dated 3/22/26, had been filled out prior to the newer MOST form available in the advanced directives binder for Resident #5 (see record review above). RN #4 was interviewed on 6/16/26 at 10:34 a.m. RN #4 said in the event of an emergency, she would look for a resident’s code status information in their EMR. RN #4 said she thought there were also physical copies of residents’ MOST forms in a binder at the nurse’s station, but said she would look at the resident’s EMR first because it was faster. The DON was interviewed a second time on 6/16/26 at 10:44 a.m. The DON said Resident #5 had been admitted to the facility with an existing MOST form (the form dated 3/22/26). The DON said the regional nurse consultant had found Resident #5’s MOST form, and said it revealed the resident’s code status was DNR. The DON said the MOST form originally in Resident #5’s EMR was filled out by the resident himself, while the form dated 3/22/26 was filled out by the resident’s POA. The DON said since Resident #5 had cognitive impairments, the facility needed to use the MOST form filled out by his POA. -However, both the 5/3/26 and the 3/22/26 MOST forms were filled out and signed by Resident #5’s POA. -Additionally, the physical copy of the version of Resident #5’s MOST form the DON said was correct (3/22/26) was not readily available in the advanced directives binder at the nurses’ station for staff to use. V. Facility follow-upThe DON provided a copy of Resident #5’s MOST form via email on 6/17/26 at 11:02 a.m., after the survey exit The MOST form, dated 3/22/26, revealed Resident #5’s code status had been reviewed again on 6/12/26 without any changes. The MOST form indicated Resident #5’s representative elected not to have the resident receive CPR.-However, an interview with Resident #5’s representative on 6/15/26 revealed she did not recall reviewing Resident #5’s code status and wanted the resident to receive CPR at that time (see representative’s interview above).

Plan of correction · submitted by the facility

The facility will document resuscitation choices accurately in the medical record for all facility residents. Correction:On 6/11/2026 The facility director of nursing reviewed and corrected Physician Orders to accurately reflect the current MOST(medical orders for scope of treatment) forms for both residents #5 and #40. Resident # 40 no longer resides in facility. Identification of others:All residents at the facility have the potential to be affected. An audit of all residents MOST forms and computerized physician orders was completed by 7-6-26 and no other concerns were identified. Systemic Changes:All licensed nursing staff and social service members were educated on the expectation that all residents MOST forms and computerized physician orders match. This education provided by facility director of nursing / designee by 7-10-26. Monitoring:Director of nursing / Designee will audit new admissions/readmissions resident MOST forms and computerized physician orders for accuracy the next business day, and during Care Conferences, ensuring that the records are accurate x12 weeks. A Most Form Audit Sheet will be used by DON/Designee to document admission/readmission/care conference/ MOST Form/ Physician Order Audits. Results of audits and any identified issues will be reviewed at QAPI (quality assurance performance improvement) monthly.

0698Dialysis▼

Findings

Based on observations, record review and interviews, the facility failed to communicate effectively with the dialysis centers for one (#3) of two residents reviewed for dialysis out of 41 sample residents. Specifically, the facility failed to ensure pre- and post-dialysis assessments for Resident #3 were completed and documented per professional standards. Findings include:I. Facility policy and procedureThe Renal Dialysis, Care of Resident, Hemodialysis Access Site policy and procedure, revised December 2025, was received from the director of nursing (DON) on 6/17/26 at 11:02 a.m. It read in pertinent part, “The facility licensed nurse will complete the baseline information, pre- and post-dialysis section of the nurses dialysis communication record.“Dialysis center licensed nurses will complete the dialysis center section of the nurses dialysis communication record.”II. Resident #3A. Resident statusResident #3, age 72, was admitted on 10/6/25. According to the June 2026 computerized physicians orders (CPO), diagnoses included end stage renal disease (the irreversible loss of 85% to 90% of kidney function, where the kidneys can no longer support life), type 2 diabetes mellitus, chronic respiratory failure and seizures. The 4/24/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required setup or cleanup assistance for most activities of daily living (ADL). The assessment documented the resident was receiving dialysis. B. Resident interviewResident #3 was interviewed on 6/11/26 at 9:26 a.m. Resident #3 said she had a dialysis binder at the nurses’ station and said the nursing staff were supposed to fill out information in the binder each time before she went to dialysis. Resident #3 said the facility’s nursing staff had not filled out her binder when she went to dialysis the day prior (6/10/26). Resident #3 said she kept asking the nursing staff to fill out her binder before her dialysis appointments because it was supposed to be done. Resident #3 said there was only one nurse who filled out her dialysis binder consistently. Resident #3 said the nursing staff usually assessed her blood pressure prior to her dialysis appointments but said she did not think they assessed it afterwards. Resident #3 said she felt frustrated and did not know why she had to keep reminding the nurses when it was supposed to be done, as the dialysis center staff appreciated seeing it was filled out. Resident #3 said there was an instance in December 2025 where the nursing staff had not looked at the notice posted on her dialysis binder from the dialysis center which revealed her dialysis appointment time had been changed due to an upcoming holiday. Resident #3 said she was still able to attend her appointment because the outside transportation company had arrived to pick her up, but said she was late to her appointment because the nursing staff had not prepared her to go to the appointment. Resident #3 said she should not have to do the facility nursing staff’s job for them. C. Record reviewThe dialysis care plan, revised 9/10/25, revealed Resident #3 needed dialysis to treat her end stage renal disease. Pertinent interventions included encouraging Resident #3 to go to her scheduled appointments on Mondays, Wednesdays and Fridays, checking the resident’s arteriovenous fistula every day for bruit (low pitched whooshing sound heard with a stethoscope over a fistula indicating healthy blood flow through the vascular access site) or thrill (physical vibration or buzzing sensation felt with the fingertips over a vascular access site), and monitoring, documenting and reporting to the physician any signs of bleeding, hemorrhage, bacteremia or septic shock. Review of Resident #3’s June 2026 CPO revealed the following physician’s order:Send Resident #3 with dialysis communication form. If the form is not returned, call the dialysis center and ask for it to be faxed to the facility, ordered 10/17/25 and revised 6/10/26 at 10:22 a.m. (during the survey process). Review of Resident #3’s dialysis communications forms, from 3/11/26 to 6/12/26, revealed the forms consisted of a pre-dialysis assessment section and a section which gave information and assessment results during the dialysis treatment. The pre-dialysis section was to be filled out by facility nursing staff and contained information about vital signs, weight, blood glucose level, assessment of the access site (the surgically created point on the body where blood was removed and returned during hemodialysis), the resident’s diet, medications administered pre-dialysis, diet and time of last meal, and any meals sent with the resident to the dialysis center. The dialysis center section of the communication form was to be filled out by dialysis staff. The section consisted of the dialysis center name, nephrologist (specialized physician who diagnoses and treats kidney diseases), vital signs taken, condition of the access site, whether or not a bruit and trill were present, type of vascular access site, and notes about amount of food consumed during the dialysis procedure. Review of Resident #3’s dialysis communication forms revealed the following:The pre-dialysis center information was not filled out in its entirety on 3/11/26. The dialysis center information section was not filled out and was blank or nearly blank on 4/8/26, 4/13/26 and 4/15/26. No dialysis communication form was provided, the pre-dialysis information was not filled out and the dialysis center wrote resident assessment information on a sticky note or blank piece of paper on 3/13/26, 3/16/26, 3/20/26, 3/23/26, and 6/10/26.-Review of Resident #3’s electronic medical record (EMR) did not reveal documentation to indicate the dialysis center information, from 4/8/26 through 4/15/26, had been obtained or recorded by the facility.-Review of Resident #3’s EMR did not reveal documentation to indicate Resident #3 was assessed or had her vital signs obtained consistently after dialysis, from 3/11/26 through 6/8/26. Review of Resident #3’s June 2026 medication administration record (MAR), from 6/1/26 through 6/15/26, revealed the following:-Resident #3’s vital signs were measured at 3:00 p.m. (pre-dialysis) and at 7:30 p.m. (post-dialysis) on 6/10/26, 6/12/26 and 6/15/26 and recorded in the order to send Resident #3 with her dialysis form. No other vital signs were recorded in the MAR before or after Resident #3’s dialysis appointments from 6/1/26 through 6/8/26. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/16/26 at 9:54 a.m. RN #1 said Resident #3 went to her dialysis appointments on Mondays, Wednesdays and Fridays each week. RN #1 said she checked Resident #3’s vital signs before and after her dialysis appointments and recorded them in her dialysis binder and in her EMR.RN #4 was interviewed on 6/16/26 at 10:34 a.m. RN #4 said residents receiving dialysis had a binder that was kept at the nurses’ station. RN #4 said to prepare a resident to go to dialysis, she would make sure the resident was dressed and ready, get their face sheet and any medications, and assess the resident’s vital signs. RN #4 said she would also assess the resident’s vital signs when they returned from their dialysis appointments. RN #4 said she would document the resident’s vital signs in their EMR. RN #4 said the nursing staff needed to obtain the resident’s vital signs before and after their dialysis appointments to establish their baseline and to assess the resident’s condition when they returned. The DON was interviewed on 6/16/26 at 10:44 a.m. The DON said there were dialysis communication sheets kept in the resident’s dialysis binder. The DON said on dialysis days, there were orders in the resident’s CPO to obtain vital signs before and after the dialysis appointment, monitor the shunt or fistula, and monitor pre- and post- dialysis weights. The DON said the nursing staff should record the resident’s vital signs in the dialysis communication binder and in their MAR. The DON said she had noticed an issue with Resident #3’s vital signs measurement order and had corrected it (on 6/10/26 during the survey process - see record review above). The DON said she expected the nursing staff to assess Resident #3’s vital signs after she returned from dialysis to see how her body handled the dialysis appointment.

Plan of correction · submitted by the facility

The facility will ensure pre and post dialysis assessments are completed and documented per professional standards. Correction:The facility director of nursing corrected the medical records for residents #3 with required documentation in the dialysis binder on 6-16 -26. Identification of others:All residents at the facility that receive dialysis have the potential to be affected. An audit of all residents receiving dialysis was completed by 7-6-26 by facility director of nursing and no other concerns were identified. Systemic Changes:On or before 7/10/2026 an audit of all resident’s currently receiving dialysis is to be completed by DON (director of nursing)/Designee to ensure all dialysis resident(s) assessment orders are in and that resident(s) are monitored pre and post dialysis treatment. On or before 7/10/2026 licensed nursing staff to be reeducated on the expectation that all residents receiving dialysis must have accurate documentation pre and post dialysis by DON/Designee. Monitoring:Director of nursing / Designee will audit all residents communication binders for all residents receiving dialysis for accuracy. Don/Designee will utilize a dialysis communicator audit sheet to document audit findings for all residents receiving dialysis for accuracy 3 times a week x4 weeks, then 2 times a week x4 weeks, then 1 time a week x4 weeks ensuring that the records are accurate. Results of audits and any identified issues will be reviewed at QAPI (quality assurance performance improvement) monthly.

0732Posted Nurse Staffing Information▼

Findings

Based on observations, record review and staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to ensure the correct nurse staffing information was updated daily. Findings include:I. ObservationsObservations in the facility on 6/11/26 at 9:30 a.m. revealed the nurse staffing information was posted, however, the date on the posting was 5/18/26 with a census of 59 residents. Observations in the facility on 6/15/26 at 9:08 a.m. revealed the nurse staffing information was posted, however, the date on the posting was 5/18/26 with a census of 59 residents.-The facility failed to update the actual working hours for the nursing staff, the date of the information and the resident census (the facility’s census during the survey was 57 residents). II. Staff interviewThe director of nursing (DON) was interviewed on 6/15/26 at 10:10 a.m. The DON said the scheduler was responsible for updating the daily nurse staff posting but she was on a leave of absence. She said since the scheduler was out on leave, the charge nurse was responsible for updating the posting. She said she did not think about ensuring the charge nurse was completing the task. She said the nurse staffing information posting had not been updated since 5/18/26. She said she would immediately update the posting and ensure it was completed daily.

Plan of correction · submitted by the facility

The facility will ensure that correct nurse staffing information is posted daily. Correction:The facility director of nursing completed the nurse staffing information and posted it on 6-16-26. Identification of others:All residents at the facility have the potential to be affected. Systemic Changes:All charge nurses and lead CNA (certified nurse aide) were educated on the expectation that correct nurse staff information be posted daily. This education provided by facility director of nursing / designee by 7-10-26. Monitoring:Director of nursing / Designee will audit that correct nurse staff information is posted. DON/Designee will utilize a daily staffing audit sheet to document audit results to ensure the required daily staffing information is posted 3 times a week x4 weeks, then 2 times a week x4 weeks, then 1 time a week x4 weeks ensuring that the records are accurate. Results of audits and any identified issues will be reviewed at QAPI (quality assurance performance improvement) monthly.

0761Label/Store Drugs and Biologicals▼

Findings

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in one of two medication carts and one of one medication storage room. Specifically, the facility failed to:Ensure medications were labeled with the date they were opened;-Ensure expired medications were disposed of; and, -Ensure there were no loose pills in the bottom of the medication cart’s drawers. Findings include:I. Professional referenceThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use ExpiredMedicines (revised 10/31/24) was retrieved on 6/21/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, "Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and subpotent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it."According to the manufacturer's recommendations for Latanoprost 0.005% ophthalmic solution, retrieved 7/21/26 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf, “Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (C)/77 degrees Fahrenheit (F) for six weeks.”According to the manufacturer's recommendations for Flonase, retrieved on 6/21/26 from https://www.flonase.com/products/sensimist/faqs/,, “Flonase Sensimist: A 60-spray bottle will last you two weeks and a 120-spray bottle will last you four weeks. Standard Flonase/Fluticasone Propionate is good for up to 60 days after opening.” According to Health Direct Pharmacy Services (6/22/26), RX Guides: Select Medications with Shortened Expiration Dates., retrieved on 6/24/26 fromhttps://www.hdrxservices.com/rx-guides-select-medications-with-shortened-expiration-dates/“Ipratropium Albuterol three months after first actuation or when the device locks out.”According to the manufacturer’s recommendations for azelastine HCl ophthalmic solution 0.05%, retrieved on 6/24/26 from https://www.medicines.org.uk/emc/files/pil. 11152.pdf,“Once opened: Do not use this medicine if the bottle has been open for longer than 28 days. This medicine does not require any special storage conditions.”II. Facility policy and procedureThe Medication storage policy, dated 10/1/23, was provided by the nursing home administrator (NHA) on 6/11/26 at 4:21 p.m. It revealed in pertinent part,“All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Outdated medications are immediately removed from inventory and disposed of in accordance with medication disposal procedures. Medication storage conditions are monitored every month by the consultant pharmacist. Multiple-dose ophthalmic products, once opened, require an expiration date that is shorter than the manufacturer’s expiration date to ensure medication purity and potency. When the original seal of a manufacturer’s container or vial is initially broken, the container or vial will be dated. The nurse shall place a ‘Date opened’ sticker and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.”III. ObservationsThe medication room was observed with the director of nursing (DON) on 6/11/26 at 11:29 p.m. The following item was found:-One bottle of latanoprost 0.005% eye drops which expired on 1/25/26. Medication cart one was observed with registered nurse (RN) #5 on 6/11/26 at 2:00 p.m. The following items were found:-One bottle of latanoprost ophthalmic solution 0.005 % was not labeled with the date it was opened; -One bottle of fluticasone propionate nasal suspension 50 microgram per actuation (mcg/act) was not labeled with the date it was opened; -One bottle of fluticasone propionate nasal suspension 50 mcg/act was not labeled with the date it was opened;-Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml inhaler was not labeled with the date it was opened;-One bottle of azelastine HCl ophthalmic solution 0.05% was not labeled with the date it was opened; and,-One bottle of fluticasone propionate nasal suspension was not labeled with a resident’s name or the date it was opened. -There were 33 unidentified pills loose on the bottom of the medication cart’s first and second drawers. IV. Staff interviewsRN #5 was interviewed on 6/11/26 at 2:20 p.m. RN#5 said the nurse who opens a medication should mark the open date and expiration date on the medication. He said each nurse on their shift should clean the medication carts. He said the night nurses should be checking for expiration dates and open dates on the medication. He said expiration dates should be clearly marked to prevent administration of expired medication. He said if medications were expired, the medication may not be effective. RN #5 said the pharmacy consultant completed monthly rounds to check medication expiration dates. The DON was interviewed on 6/11/26 at 3:29 p.m.. The DON said the night shift nurses had the task of checking the medication room and the medication carts for open dates and expiration dates on medications. She said all the nurses should clean the medication carts on their shift. The DON said the night shift nurses should discard expired medications according to the policy. She said the pharmacy consultant completed a monthly audit of the medication carts and medication room. The DON said expired medications may not be as effective.

Plan of correction · submitted by the facility

The facility will ensure that drugs and biologicals are properly stored, secured and labeled in accordance with accepted professional standards. Correction:On 6/11/2026 the director of nursing removed all undated or expired medications from cart/medication room inventory and placed them in area designated for medication destruction to ensure medications were not utilized. On 6/11/2026 Medication nurse on North Cart did complete an audit of his medication care to identify any expired, undated or loose pills in medication cart. No issues identified. Identification of others:All residents at the facility have the potential to be affected. Systemic Changes:On or before 7/10 2026 DON/Designee to reeducate licensed nurses on medication storage policy and the expectation that all medications be appropriately stored, dated upon opening, discarded when expired and that no loose pills are accumulating at the bottom of medication carts. Consultant Pharmacist will continue to conduct monthly audits of medication room and medication carts. Monitoring by consultant pharmacist will be ongoing and completed each month on a pharmacy consultant audit form. Any identified issues will be reported to the NHA (nursing home administrator)/DON (director of nursing) for immediate correction. Any identified issues or trends will be included in monthly QAPI (quality assurance performance improvement) report.

0791Routine/Emergency Dental Srvcs in NFs▼

Findings

Based on observations, record review and interviews, the facility failed to ensure received routine dental care obtaining routine and 24-hour emergency dental care for one (#7) of three residents reviewed for ancillary services out of 41 sample residents. Specifically, the facility failed to provide dental services for Resident #7, who had been identified as having dental decay. Findings include:I. Facility policy and procedureThe Dental Services policy and procedure, revised November 2019, was received from the director of nursing (DON) on 6/17/26 at 11:02 a.m. It read in pertinent part, “It is the policy of this facility, in accordance with residents’ needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care.“The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location.“All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident’s medical record.”II. Resident #7A. Resident statusResident #7, age 75, was admitted on 2/20/25, discharged home on 3/20/26 and readmitted on 4/12/26. According to the June 2026 computerized physician orders (CPO), diagnoses included cellulitis of the right lower limb, need for assistance with personal cares, epilepsy and adult failure to thrive. According to the 4/18/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup or cleanup assistance from staff for oral hygiene and required partial to maximal assistance from staff for most other activities of daily living (ADL). The assessment documented the resident had obvious or likely cavities or broken natural teeth. B. Resident interview and observationsResident #7 was interviewed on 6/11/26 at 9:41 a.m. Resident #7 said she had one tooth that felt tender. Resident #7 said she had seen the dental hygienist once but had not seen a dentist in a while. Resident #7 said she thought she should see a dentist. Resident #7 held the upper left side of her mouth as she spoke about her sore tooth. C. Record reviewThe dental care plan, revised 4/20/26, revealed Resident #7 had oral/dental health problems resulting from poor oral hygiene. Pertinent interventions included coordinating arrangements for dental care and providing transportation as needed, and monitoring and reporting to Resident #7’s physician any signs of oral/dental problems needing attention, including pain or her teeth being missing, loose, broken, eroded or decayed. A dental hygiene treatment chart, dated 9/18/25, revealed Resident #7 was seen by the dental hygienist for an exam and prophylaxis. Resident #7 was documented to have complained of upper left and lower right quadrant mouth pain. Resident #7 had severe inflammation, high decay rate, heavy bleeding, plaque and calculus and poor oral hygiene. Resident #7 had possible decay for teeth #3, #14 and #18. The note documented Resident #7 needed extractions and recommended an appointment for scaling and root planing (a dental cleaning procedure used to treat gum disease). A dental visit note, dated 10/8/25, revealed Resident #7 was seen by a dentist for a comprehensive exam. Resident #7 had moderate plaque accumulation throughout her dentition and moderate to severe bone loss. Resident #7 was interested in extracting tooth #15 (a tooth on the upper left quadrant) at her next visit. The dentist documented tooth #15 was not able to be restored, and had a fluoride application applied to the cavity surfaces. The dentist documented Resident #7’s recommended treatments included a hygienist visit and extraction of tooth #15. The dentist documented Resident #7 would have tooth #15 extracted at her next visit.-However, review of Resident #7’s electronic medical record (EMR) did not reveal documentation to indicate any follow-up dental appointments to remove tooth #15 were scheduled. A social services note, dated 11/28/25 at 1:38 p.m., revealed Resident #7 was reviewed by the social services team. The note documented Resident #7 had last been seen for a dental exam on 10/8/25 and visited the dental hygienist on 9/18/25.-The note did not document any dental follow-up appointments were needed for Resident #7. A dental hygiene treatment chart, dated 12/9/25, revealed Resident #7 was seen by the dental hygienist for a scale and root planing. Resident #7 had severe inflammation, high decay rate, heavy bleeding, plaque and calculus and poor oral hygiene. Resident #7 had possible decay for tooth #15. The hygienist recommended Resident #7 have a visit for periodontal maintenance (a maintenance hygienist visit typically performed every three to four months to treat gum disease).-However, review of Resident #7’s EMR did not reveal documentation to indicate any follow-up dental appointments were scheduled. A social services note, dated 2/26/26 at 3:30 p.m., revealed Resident #7 was reviewed by the social services team. The note documented Resident #7 had last been seen by the dentist on 12/9/25.-The note did not document any dental follow-up appointments were needed for Resident #7. A readmission assessment tool, dated 4/12/26 at 3:57 p.m., revealed Resident #7 was assessed by a member of the facility’s nursing staff on admission. Resident #7’s oral/dental status was not evaluated at the time. A social services progress note, dated 4/17/26 at 10:52 a.m., revealed Resident #7 was reviewed by the social services team. The note revealed Resident #7 did not have any immediate ancillary requests. A care plan review note, dated 4/17/26 at 3:10 p.m., revealed Resident #7 attended a care conference. The social services plan of care section of the review note revealed Resident #7 had last been seen for dental services on 12/9/25.-The note did not document any dental follow-up appointments were needed for Resident #7. A progress note, dated 5/22/26 at 1:59 p.m., revealed Resident #7 had obvious or likely cavities or broken natural teeth. Review of Resident #7's electronic medical record (EMR) did not reveal any care conference documentation or any documentation pertaining to dentistry referrals following her readmission on 4/12/26. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/16/26 at 9:54 a.m. RN #1 said the facility kept a list of residents who needed to see the dentist or other ancillary staff, and said the charge nurse was responsible for adding residents to those lists. RN #1 said the charge nurse would then let the nursing staff know who needed to go to which appointments after they were scheduled. A social services support staff member, who was filling in for the social services director (SSD), was interviewed on 6/16/26 at 10:04 a.m. The social services support staff member said the facility’s dentist usually came in once per month. The social services support staff member said if a resident had an identified cavity or needed a dental appointment to examine a toothache and the dentist was not due to arrive soon, she would arrange for the resident to be seen by another dentist in the community. The social services support staff member said if a resident needed a tooth extracted and needed a follow-up appointment to have the tooth extracted, residents were sometimes referred to an oral surgeon. The social services support staff member said she usually tried to schedule the follow-up extraction appointments within a few days of the initial dental exam. The social services support staff member said she was not familiar with Resident #7 but would look into her case. RN #4 was interviewed on 6/16/26 at 10:34 a.m. RN #4 said if a resident told her they had any issues with their teeth, she would first assess the resident to see if the issue was urgent. RN #4 said after her assessment, she would let her charge nurse know about the issue. RN #4 said the facility kept a list of residents who needed to be seen by the dentist. The DON was interviewed on 6/16/26 at 10:44 a.m. The DON said the dentist came to the facility on a quarterly basis. The DON said if a resident attended an appointment and the provider recommended a follow-up visit, the charge nurse or assistant director of nursing (ADON) would identify that information on their discharge paperwork and submit it to the facility’s scheduler to get the resident’s appointment scheduled. The DON said she expected the SSD to follow up and ensure any follow-up dental appointments were scheduled. The DON said she was not aware of any dental issues for Resident #7. IV. Facility follow-upThe DON submitted additional information via email on 6/17/26 at 1:24 p.m. (after survey exit), including a written statement, care conference notes, dental records for Resident #7 (see record review above) and the resident’s weight history. The written statement, undated, revealed Resident #7 had been seen by the dentist for a new patient comprehensive examination and fluoride application for tooth #15, at which time the dentist recommended Resident #7 have another hygiene visit and extraction of tooth #15. Resident #7 was seen again by the dental hygienist on 12/9/25 with a recommendation for perio-maintenance, which would have been due in March 2026 or April 2026, and was scheduled 3/25/26. The statement documented after the facility communicated with the dentistry service provider on 6/16/26 (during the survey process), they found since Resident #7 had been discharged from the facility on 3/20/26, her dental appointment on 3/25/26 was not able to be completed. Resident #7 was then added to the dentistry service provider’s list to be seen by the dentist on 7/2/26 and the hygienist on 7/9/26. An email from the dentistry service provider, dated 6/17/26 at 12:22 p.m., revealed Resident #7 was initially scheduled to be seen by the dentist on 3/25/26, but her appointment had been canceled as the resident was discharged from the facility at that time. The service provider confirmed Resident #7 was on their schedule to be seen 7/9/26, and added she could be seen on 7/2/26 if her tooth needed to be extracted more emergently. -However, Resident #7 was not scheduled to be seen by the dentist until 6/16/26 (during the survey process), which was 59 days after the resident’s MDS assessment identified she had decay or cavities and 27 weeks after Resident #7’s dentist recommended she have tooth #15 extracted.

Plan of correction · submitted by the facility

The facility will assist residents in receiving routine and 24-hour emergency dental care. Correction:The facility has scheduled dental services for resident #7 to be completed on 7-9-26. This appointment was made by facility social services on 6-16-26. Identification of others:All residents at the facility have the potential to be affected. An audit of all residents was completed to identify any unmet dental service needs. This audit was completed by facility social services / designee by 7-10-26. No additional concerns were identified. Systemic Changes:On or before 7/10/2026 SS (social services) Department to be educated by LCSW (licensed clinical social worker) on review of dental service policy and expectation that residents receive assistance with obtaining routine and emergency dental care when needed. On or before 7/10/2026 DON (director of nursing)/Designee will provide education to licensed nurses on the dental service policy and expectation that residents receive assistance with obtaining routine and emergency dental care when needed. On or before 7/10/2026 An ancillary service appointment tracking log will be reimplemented by social service department to track dental service appointments for residents to ensure unmet dental needs are addressed timely. Monitoring:SSD (social services director)/Designee will review/audit the ancillary service appointment tracking log weekly to ensure residents with unmet dental needs receive dental services timely. SSD will review/audit the ancillary service appointment tracking log weekly ongoing to ensure residents with unmet dental needs receive dental services timely. SSD/Designee will report results of weekly reviews/audits and any issues or trends identified monthly to QAPI (quality assurance performance improvement) until sustained compliance is determined by IDT (interdisciplinary team).

0925Maintains Effective Pest Control Program▼

Findings

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Ensure the facility was kept free from mice, spiders and other insects; and,-Consistently follow recommendations from the pest control company to decrease the potential for mice, spiders and other insects to enter the facility. Findings include: I. Professional reference According to the Centers for Disease Control(CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (revised July 2019), retrieved on 6/19/26 from https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf,"From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: eliminating food sources, indoor habitats, and other conditions that attract pests; excluding pests from entering the indoor environments; and applying pesticides as needed. “Rodents can transmit viruses such as lymphocytic choriomeningitis, bacteria such as campylobacteriosis, leptospirosis, plague, salmonellosis, tularemia, yersiniosis, and fungi such as dermatophytosis.” “Spiders and mice are among the typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms or as active participants in the disease transmission process as vectors. “Sealing windows helps to minimize insect intrusion. When windows need to be opened for ventilation, ensuring that screens are in good repair and closing doors to the outside can help with pest control. A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods.”II. Facility policy and procedure The Pest Control Program policy, dated January 2025 and revised 6/9/26, was received from the nursing home administrator (NHA) on 6/17/26 at 11:02 a.m. It read in pertinent part,“The policy is to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis.“The facility will utilize a variety of methods in controlling certain seasonal pests. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.”III. Facility observations staff interviewOn 6/10/26 at 8:51 a.m. a tour of the kitchen was conducted. The door to the alleyway in the back of the kitchen was observed to be propped open and no staff members were walking in or out of the doorway. On 6/10/26 at 9:21 a.m. a gap was observed under the emergency exit door at the end of the Breckenridge hallway, which exited to the outside of the facility. There was daylight visible through the gap. On 6/10/26 at 2:40 p.m. a spider was observed crawling on the floor in the middle of the hallway at the intersection of the Silverthorn and Aspen unit hallways. Resident #51 was walking with a member of the therapy staff. The therapy staff member crushed the spider with her shoe. Resident #51 told the therapy staff member that she had seen spiders in her room. On 6/10/26 at 3:22 p.m. a large spider was observed by the doorframe of the exit door at the eastern end of the Silverthorne hallway. On 6/12/26 at 1:30 p.m. there were two mousetrap boxes observed on the floor at the end of the 100 hallway. On 6/16/26 at 11:53, following an initial interview (see interview below), the maintenance director went to Resident #3 and Resident #7’s shared room. The maintenance director said that there were no spiders in that room. He said that there were sticky traps in the residents’ room because when one resident requested a sticky trap, they were placed in every residents’ room. Resident #7 said she did see spiders in their room. Resident #3 said she saw a centipede at night but she had not yet reported it. The maintenance director proceeded to remove the sticky traps that had been placed under each sink in Resident #3’s room. He confirmed that the first sticky trap had one spider and mouse droppings on it and the second sticky trap had bugs and mouse droppings on it. The maintenance director said the sticky traps were changed out every Friday. He said he would spray for insects when the NHA asked him to spray. During the interview, a bug was observed walking across the floor. The maintenance director said the bug was a glow bug. IV. Resident interviews and observationsResident #51 was interviewed on 6/10/26 at 10:55 a.m. Resident #51 said she had spiders in her room and saw them every day. Resident #51 said she had previously had an ant issue in her room and the sanitary conditions of the facility “left something to be desired.” A glue trap was observed under Resident #51’s sink. The glue trap had several spiders of varying sizes on it and a spider was observed walking across the resident’s wall during the interview. Resident #27 was interviewed on 6/10/26 at 4:56 p.m. Resident #27 said he had seen a mouse in his room and the last time he had seen it was two days (6/8/26) ago, around 3:00 p.m., by the radiator. During the interview, several mouse droppings were observed by the window sill and under the sink. There was a mouse trap underneath the radiator and under the sink. Resident #27 said he did not like having a mouse in his room. Resident #7 was interviewed on 6/11/26 at 9:41 a.m. Resident #7 said she had seen a spider on her bed the other day and said she had seen several large spiders crawling under her bed and on her walls. During the interview, a glue trap was observed under the resident’s sink. The glue trap contained several mouse droppings on it. Resident #48 was interviewed on 6/11/26 at 9:50 a.m. Resident #48 said she had mouse droppings in her room. She said she reported it to the facility staff. Resident #48 said she cleaned out her room and removed all food from her room to try to eliminate the mouse problem. Resident #25 was interviewed on 6/11/26 at 10:00 a.m. Resident #25 said she had seen mouse droppings in her room and she had cleaned out all her food from her room. She said she did not have any food in her drawers. Resident #25 said she hoped not to see any more mice because she did not like them. Resident #3 was interviewed on 6/11/26 at 10:18 a.m. Resident #3 said she had seen a “bug parade” on her floor this morning (6/11/26). She said she had seen several insects crawling along her floor. V. Resident group interviewSix residents (#43, #56, #1, #19, #23 and #27) who frequently attended the monthly resident council meetings and who were identified as alert and oriented by facility and assessment were interviewed on 6/15/26 at 10:01 a.m. Resident #19 and Resident #43 both reported seeing spiders in their rooms and both residents said they had been bitten by spiders in the facility recently. Resident #1 and Resident #19 said the facility had “tons” of mice. Resident #19 said the residents had been voicing their concerns about mice each month in resident council meetings since January 2026. Resident #19 said he had found several mice in his room and had seen mouse feces on his bed. He said the way the facility was trying to treat the mice problem was not working. Resident #27 said he saw mice running from resident room to resident room and down the facility’s hallways. VI. Resident council meeting minutesReview of the facility’s resident council meeting minutes, from December 2025 through May 2026 revealed the following:The 12/29/25 resident council meeting minutes documented there was a continued mouse problem and the facility would continue checking the traps and putting new traps down. The 1/15/26 resident council meeting minutes documented would continue to monitor mice in the building and the mouse traps. The minutes did not identify that the concern regarding the mouse problem had been resolved. The 2/19/26 resident council meeting minutes did not identify that the facility’s mouse problem had been discussed at the meeting or that the concern regarding the mouse problem had been resolved. The March 2026 (no day specified) resident council meeting minutes documented there were no unresolved issues from the February 2026 resident council meeting. However, the meeting minutes additionally documented that maintenance would continue checking the mouse traps daily. The April 2026 (no day specified) resident council meeting minutes did not identify that the facility’s mouse problem had been discussed at the meeting or that the concern regarding the mouse problem had been resolved. The 5/21/26 resident council meeting minutes documented that mouse traps in resident rooms had been observed to have mouse activity and the traps were checked daily.-Review of the resident council meeting minutes, from December 2025 through May 2026 did not identify that the facility was attempting to address the mouse problem in other ways besides placing and checking mouse traps. VII. Additional record reviewReview of pest control service invoices were provided by the facility for 1/13/26, 2/5/26, 3/6/26, 4/15/26, 5/8/26 and 6/1/26. The 4/25/26 pest control service invoice documented that the pest control company identified an area in the facility that had a door gap and a door that was open when it was not in use. The recommendation was for the facility to add/repair the door sweep (the plastic or rubber part that attaches to the bottom of the door). Additionally, the 4/15/26 pest control service invoice documented the pest control company identified a second area in the facility that had a door gap. The recommendation was for the facility to seal the gap. The 5/8/26 pest control service invoice documented the pest control company identified that the door to the dumpster area outside the facility had a door gap and was observed to be open when not in use. The service invoice documented the concern remained an open action issue from the April 2026 service visit. The recommendations were for the facility to add/repair the door sweep and keep the door closed. The service invoice documented that a resolution by the facility was needed. The 6/1/26 pest control service invoice documented the openings around the penetration points (entry points into the facility) remained an open action issue from the April 2026 visit and the status of the resolution was still pending.-However, observations during the survey revealed the door to the alleyway in the back of the kitchen was propped open when it was not in use and there was a gap under the emergency exit door at the end of the Breckenridge hallway, which exited to the outside of the facility (see facility observations above). VIII. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/15/26 at 11:40 a.m. CNA #1 said he had seen a spider in the charting room. He said he killed it and disposed of it. CNA #1 said he did not report it. CNA #1 said he had heard discussions about mice being an issue in the facility from residents and other staff members. Housekeeper (HK) #1 was interviewed on 6/16/26 at 11:15 a.m. HK #1 said she had heard residents complain about mice. She said she attended the resident council meetings and had heard the residents' discussion of pests leaving droppings in the residents' rooms. The maintenance director was interviewed on 6/16/26 at 11:45 a.m. The maintenance director said the pest control company came to the facility monthly to address the issues with mice. He said he called the pest control company to come out more frequently when needed. He said he had requested two additional mousetrap boxes for the facility and said the facility had a total of six mousetrap boxes. He said he had requested that housekeeping frequently check the residents’ rooms and floors after meals to sweep up and clean crumbs. The maintenance director said he had not seen any notes regarding doors being left open or other recommendations on the pest control invoices. The maintenance director said when he received invoices from the pest control company, he looked at what services were provided and what they cost. He said he must have missed the notes in the service invoices regarding the pest control company’s recommendations (see record review above).

Plan of correction · submitted by the facility

The facility will ensure the facility is kept free from mice, spiders and other insects. The facility will follow the recommendations from the pest control company to decrease the potential for mice, spiders and insects in the facility. Correction:The facility has scheduled the services of the pest control company for a Comprehensive Visit that included mitigation and intervention for Pest and Insect Control. This appointment was made by facility plant director 6-28-26 for visit to facility on 6-29-2026Identification of others:All residents at the facility have the potential to be affected. An audit of all resident rooms and common areas was completed to identify any unmet pest control needs. This audit was completed by facility plant director and Pest Control Provider on 6-29-26. No additional concerns were identified. Systemic Changes:Facility staff were educated on the expectation that any pests including mice, spiders and insects be reported to the facility plant director to be addressed. This education provided by facility administrator / designee by 7-10-26. Monitoring:Facility administrator / Designee will audit resident rooms and common areas ensuring that any mice, spiders or insects in the facility are addressed. Facility Administrator/Designee will utilize a facility Room Roster to document observations/audits of resident rooms and common areas 3 times a week x4 weeks, then 2 times a week x4 weeks, then 1 time a week x4 weeks ensuring that any mice, spiders or insects in the facility are addressed. Results of audits and any identified issues will be reviewed at QAPI (quality assurance performance improvement) monthly.

6/16/2026Licensure Complaint Survey · ID 23523F-H11 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A survey with #CO2800412 was conducted on 6/10/26 to 6/16/26. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

2701Pest Control▼

Findings

Plan of correction · submitted by the facility

6/10/2025Revisit: Licensure Complaint Survey · ID 2DSO12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 6/10/25 for all previous deficiencies cited on 4/22/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

6/10/2025Revisit: Complaint Survey · ID M7GO12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 6/10/25 for all previous deficiencies cited on 4/22/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/22/2025Licensure Complaint Survey · ID 2DSO111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A survey prompted by complaint #CO39948 was completed on 4/22/25. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0701Resident Care - Overall Care of the Residents▼

Findings

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) of three residents out of nine sample residents. Resident #2, who had a history of falling and previous fractures that included a burst fracture of the thoracic vertebra (bone in the upper spine caused by trauma), was admitted to the facility on 10/9/24. On 2/11/25 at 6:45 a.m. Resident #2, who ambulated independently with her walker, slipped and fell while walking to the bathroom. After the fall, Resident #2 was heard yelling. A licensed practical nurse (LPN) went to check on the resident and found her lying on her left side, complaining of 8 out of 10 pain, on a 1 to 10 pain scale, to her left shoulder and left hip. According to the LPN's documentation of the fall, Resident #2 refused to allow nursing staff to remove her clothing for a skin evaluation and she requested to be transported to the hospital at that time. The LPN notified the director of nursing (DON), who was the registered nurse (RN) on-call, to notify her of his findings, which included Resident #2's complaints of 8 out 10 pain to her left shoulder and left hip. Resident #2 was assisted into a wheelchair by the LPN and a certified nurse aide (CNA). The 2/11/25 at 6:50 a.m. nursing progress note, written by the DON, documented a RN assessment conducted by the DON, based on the findings reported from the LPN on-site at the time of the resident's fall. It indicated Resident #2 had slipped and fallen while ambulating to the bathroom. It documented Resident #2 was able to move all extremities without injury or noted deformity. It documented Resident #2 was to be transported to the hospital after Resident #2 and Resident #2's representative insisted the resident be evaluated at the hospital.-However, there was no RN in the facility at the time of the fall to conduct a hands-on physical assessment of the resident. Resident #2 was moved off the floor and into a wheelchair, despite her complaints of significant pain, refusal to remove her clothes for a skin evaluation and her request to be sent to the hospital. Resident #2 was transported to the hospital on 2/11/25 at 7:48 a.m. after Resident #2's representative was notified of the resident's fall and insisted on Resident #2 being evaluated at the hospital (63 minutes after Resident #2 initially requested to go to the hospital). At the hospital, the resident was diagnosed with a dislocated and fractured left shoulder and a fractured left hip that required surgical intervention,The facility's failure to accurately assess and evaluate Resident #2 after she experienced a fall and complained of acute pain of 8 out of 10 to her left shoulder and left hip, and the facility's failure to honor the resident's request to be sent to the hospital immediately after the fall resulted in Resident #2 not being transported to the hospital in a timely manner for evaluation and treatment of her acute fractures. Findings include:I. Professional referenceAccording to The Cleveland Clinic (5/11/23) Dislocated Shoulder, retrieved on 4/24/25 from https://my.clevelandclinic.org/health/diseases/17746-dislocated-shoulder,"The most common symptoms of a dislocated shoulder include extreme pain, weakness, inability to move arm, shoulder being visibly out of place, swelling, bruising and muscle spasms."Any force that is strong enough to push your shoulder joint out of place can cause a dislocation. The most common causes include falls, care accidents and sports injuries."Go to the emergency room right away if you think your shoulder might be dislocated."According to Johns Hopkins Medicine (2025) Hip Fracture, retrieved on 4/24/25 from https://www.hopkinsmedicine.org/health/conditions-and-diseases/hip-fracture#:~:text=What%20is%20a%20hip%20fracture,of%20patients%20experience%20spontaneous%20fractures,"A hip fracture is a partial or complete break of the femur (thigh bone), where it meets your pelvic bone. It is aserious injury that requires immediate medical attention."II. Facility policy and procedureThe Fall Management System policy and procedure, revised November 2022, was provided by the director of nursing (DON) on 4/22/25 at 3:50 p.m. It read in pertinent part,"When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record."The Monitoring for Significant Change in Condition policy and procedure, revised May 2007, was provided by the DON on 4/22/25 at 3:50 p.m. It read in pertinent part,"If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the nurse supervisor should be made aware of and he/she will monitor."Change in ability to ambulate or propel wheelchair."Change in ability to transfer or position self."There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation."II. Resident #2A. Resident statusResident #2, age 86, was admitted on 10/9/24 and discharged to the hospital on 2/11/25. According to the February 2025 computerized physician orders (CPO), diagnoses included hypertension, protein/calorie malnutrition, opioid dependence and a fracture of thoracic vertebra (bone in the upper spine). The 1/13/25 facility assessment revealed the resident was cognitively intact. She required set up assistance with eating, personal hygiene and was independent with toileting, bed mobility and transfers. The assessment indicated Resident #2 used a walker to assist with ambulation. B. Resident representative interviewResident #2's representative was interviewed on 4/22/25 at 9:03 a.m. The representative said Resident #2 had a history of falls prior to being admitted to the facility. He said while she resided at the facility, she fell again (on 2/11/25). He said he was notified by the nurse on duty that his Resident #2 had fallen, approximately 30 minutes after the event. He said he asked the nurse if she was in pain and the nurse responded yes. He said he asked if the resident had requested to go to the hospital and the nurse had responded yes. The representative said he asked the nurse why emergency medical services (EMS) had not been called yet and he said he demanded the resident be sent to the hospital immediately. He said when he met Resident #2 at the hospital she was "writhing" and screaming out in pain. He said he was frustrated that she was not sent to the hospital when she had sustained multiple fractures, was in a lot of pain and when she had requested to go. C. Record reviewThe acute/chronic pain care plan, initiated 10/10/24, indicated Resident #2 had acute and chronic pain management issues related to low back pain, history of falling and chronic pain. Interventions included administering analgesia (pain) medication per physician's orders, anticipating the resident's need for pain relief and responding immediately to any complaint of pain and identifying, recording and treating the resident's existing conditions, which may increase pain and or discomfort.-However, the care plan did not indicate the resident had chronic pain in her left shoulder or left hip. The 2/11/25 at 6:50 a.m. nursing progress note documented a registered nurse (RN) assessment, conducted by the DON . Resident #2 was noted on the floor lying on her left side by the bathroom. Resident #2 said that she was walking to the bathroom and had slipped. Resident #2 was able to move all extremities with no signs of injury or deformity. It documented that neurological checks were started and at baseline for the resident. It documented that, based on the resident and resident representative's insistence, the resident would be sent to the emergency room for evaluation.-However, the DON's assessment was based upon the reported findings from the LPN who was on-site at the time of the fall (see interviews below).-Additionally, the nursing note was not created in the resident's electronic medical record (EMR) by the DON until 9:39 a.m. The 2/11/25 at 8:14 a.m. nursing progress note, written by the LPN on-site at the time of the resident's fall, documented that at 6:45 a.m. Resident #2 was heard yelling and was found lying on her left side on the floor in front of the bathroom. Resident #2 said she was ambulating with her walker to the bathroom and slipped. Resident #2 complained of pain at an 8 out of 10 to her left arm and left hip and requested to be sent to the hospital. Resident #2 refused to remove her clothing for a skin evaluation. Resident #2 was assisted into a wheelchair by the LPN and a CNA. The resident's representative was contacted and he requested for Resident #2 to be sent out to the hospital. The nurse practitioner (NP) and the DON were notified and Resident #2 was sent to the hospital.-However, the progress note failed to document whether or not the physician was notified that Resident #2 was reporting 8 out of 10 pain in her left shoulder and left hip and refusing to allow the nursing staff to remove her clothing for a skin evaluation, prior to moving the resident off of the floor. -Additionally, the progress note failed to document that physician's orders were obtained for Xrays, based on the resident's reports of 8 out of 10 pain in her left shoulder and left hip and her refusal to allow the nursing staff to remove her clothing for a skin evaluation, prior to Resident #2's representative insisting the resident be sent to the hospital. The 2/11/25 at 9:53 a.m. interdisciplinary team (IDT) fall committee progress note documented Resident #2 had an unwitnessed fall without injuries. It documented Resident #2 was lying on her left side on the floor in front of the bathroom. Resident #2 was sent to the emergency room for evaluation after Resident #2's, per the resident representative's insistence. It documented no injuries or deformities were noted by facility staff.-However, RN #1, who was not at the facility to physically assess Resident #2 at the time of the fall but received a shift hand-off report from the LPN that was on duty indicated the resident's shoulder looked odd (see interview below).-A comprehensive review of Resident #2's EMR failed to reveal documentation of a physician's order to obtain Xrays of the resident's left shoulder and/or left hip. The 2/11/25 hospital progress note documented Resident #2 had a left shoulder dislocation with a proximal humerus fracture (a break in the long bone of the arm close to the shoulder) and a displaced left femur (thigh bone) fracture. It documented the resident's left shoulder was reduced (a procedure where the shoulder was placed back into position) in the emergency room by the orthopedic surgeon and the emergency room physician. The 2/12/25 hospital progress note documented Resident #2 underwent a left hip nailing (a surgical procedure to realign the bone and stabilize the fracture). III. Staff interviewsRN #1 was interviewed on 4/22/25 at 1:50 p.m. RN #1 said Resident #2 had a walker which she used independently to walk around the facility. She said Resident #2 had a soft call light which she only used when she wanted her pain medications. She said the resident would not use the call light to ask for assistance prior to getting out of bed and walking with her walker. She said she took care of Resident #2 on the day she fell, but she said the resident had already fallen and been assisted into a wheelchair before she arrived in the facility for her shift. She said the previous nurse (LPN) had said that the physician had ordered Xrays and the facility was waiting for those Xrays to be obtained on her shoulder. She said Resident #2's left shoulder looked odd. She said the facility sent Resident #2 to the emergency room because the facility could not obtain the Xrays in a timely manner.-However, RN #1 did not document a progress note in Resident #2's EMR regarding her assessment that indicated the resident's shoulder looked odd (see record review above).-Additionally, progress notes indicated Resident #2 was sent to the hospital due to the resident representative's request that the resident be sent to the hospital, not because Xrays could not be obtained in a timely manner (see record review above). RN #1 was interviewed a second time on 4/22/25 at 1:55 p.m. RN #1 said she had reviewed her progress notes in Resident #2's EMR. She said Resident #2 had asked to go to the hospital and the LPN had called the physician but he had not received a return call. She said she was the one that had called the physician again and received an order for the resident to be sent to the emergency room because the Xrays could not be completed timely. She said that was the reason why there was a delay of over an hour between when the resident fell and when the resident was sent to the emergency room. RN #1 said the facility's process, unless a situation was immediately life-threatening, was not to call EMS first, but to call the physician to obtain a physician's order to transfer a resident to the hospital. She said the facility did this even if the resident had requested to go to the emergency room.-However, there was no documentation in Resident #2's EMR to indicate RN #1 or the LPN called the physician to obtain physician's orders for Xrays of the resident's left shoulder and left hip (see record review above). The DON was interviewed on 4/22/25 at 2:45 p.m. The DON said the facility's process was to call the physician first to obtain a physician's order to transfer residents to the hospital to mitigate unnecessary hospitalizations, unless it met criteria for an immediate transfer. She said Resident #2 did not meet criteria for immediate transfer to the hospital. She said immediate criteria was any instance that was immediately life threatening. She said Resident #2 did not request to go to the hospital. She said Resident #2 was at baseline for her pain and she complained of pain normally at an 8 out of 10 pain scale.-However, the note documented by the LPN on 2/11/25 at 8:14 a.m. indicated Resident #2 requested to go to the hospital immediately after her fall (see record review above).-Additionally, Resident #2's acute/chronic pain care plan indicated the resident had chronic pain related to low back pain, not left shoulder or left hip pain (see record review above). The DON said Resident #2 normally, at baseline, did not have full range of motion in all of her extremities. She said the facility had contacted the physician and had obtained a physician's order for Xrays, since the facility could do these in the facility. She said Resident #2's representative was contacted and he insisted that Resident #2 be sent to the hospital. She said the facility sent Resident #2 to the hospital after Resident #2's representative insisted and the facility had obtained a physician's order from the NP to transport the resident to the hospital. The DON was interviewed a second time on 4/22/25 at 3:50 p.m. The DON said a RN was not in the facility when the fall occurred. She said she was the RN on-call and she had documented the RN assessment for Resident #2. She said the facility's process when an RN was not in the building was that the LPN would follow a post-fall check list and they would call the RN on-call. She said she was told by the LPN on-site that Resident #2 was not experiencing any pain or range of motion outside of her normal baseline. She said she did not come into the facility to personally assess the resident. She said Resident #2 was moved off the floor and into the wheelchair before the oncoming RN arrived at the facility.-However, the DON said in her previous interview on 4/22/25 at 2:45 p.m. that Resident #2 was at her baseline level of pain at the time of the fall (see interview above).-Additionally, the LPN's progress note documented Resident #2 was complaining of a pain level of 8 out of 10 to her left shoulder and left hip after the fall. -Additionally, the resident's representative indicated Resident #2 was in extreme pain when she arrived at the hospital (see resident representative's interview). IV. Facility follow-upOn 4/23/25 at 1:53 p.m., after the survey exit, the DON provided the following timeline of Resident #2's fall via email:"On 2/11/25 at 6:45 a.m. Resident #2 was heard yelling from the hallway and a nurse entered the room."On 2/11/25 at 6:50 a.m. the DON was called during the resident's evaluation as part of the required RN assessment."On 2/11/25, between 6:50 a.m to 7:30 a.m: An RN assessment was conducted. Resident #2 was noted on the floor laying on her left side by the bathroom. Resident #2 stated that she was walking to the bathroom and slipped. Resident #2 is able to move all extremities with no signs of injury or deformity. Neurological checks initiated and at baseline for this resident. Resident #2 was assisted up to her wheelchair by LPN and CNA. "A call was made to the provider who gave orders for in-house Xrays."A call was placed to the resident's representative to report the incident and the representative requested Resident #2 be sent to the hospital. "The provider called back and was informed of Resident #2's representative request to send the resident out to the hospital; an order was received from the provider."-However, a RN was not in the facility to conduct the assessment and the evaluation was provided by a LPN to the DON and Resident #2 was assisted up to the wheelchair by the LPN and a CNA before a RN was in the facility. The DON's 4/23/25 email additionally included the following EMS timeline from 2/11/25, which was provided to the facility by a dispatcher at (name of the EMS provider):"On 2/11/25 at 7:30 a.m. call received by EMS from facility;On 2/11/25 at 7:44 a.m. EMS enroute to facility;On 2/11/25 at 7:48 a.m. EMS arrived to facility;On 2/11/25 at 8:07 a.m. EMS departed from the facility;On 2/11/25 at 8:16 a.m. EMS arrived at the hospital; and,On 2/11/25 at 8:19 a.m. Resident #2 was admitted to the hospital."

Plan of correction · submitted by the facility

Failure to provide treatment and care in accordance with professional standard. Resident specific: Resident #5640 discharged on 2/11/25Corrections: A full house audit of current change in condition with timely hospitalizations from 4/13/25 to 5/14/25 was completed on 5/14/25. Identification of others: There were no other residents affected by the deficient practice. Systemic changes: DON (director of nursing)/designee will educate all staff on policy and procedure related to change in condition including completing and documenting a review of systems, fall management with immediate need to transfer the resident to the hospital if experiencing acute pain by 5/14/25. Monitoring: The facility will continue to monitor falls through risk management, change in condition and identify need for transfer to hospital (with audit forms) three times a week x 4 weeks, then twice a week x 4 weeks and then weekly x 4 weeks. QAPI-Data obtained, and issues and successes identified from audits, along with medical records will be reviewed and analyzed for trends and reported monthly to the Quality Assurance and Performance Improvement committee. QAPI will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure sustained compliance x three months. Compliance date 5/14/25

4/22/2025Complaint Survey · ID M7GO111 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO39617, #CO39619, Incident #39453, and Incident #39455 was completed on 4/22/25. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0684Quality of CareS/S G▼

Findings

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#2) of three residents out of nine sample residents. Resident #2, who had a history of falling and previous fractures that included a burst fracture of the thoracic vertebra (bone in the upper spine caused by trauma), was admitted to the facility on 10/9/24. On 2/11/25 at 6:45 a.m. Resident #2, who ambulated independently with her walker, slipped and fell while walking to the bathroom. After the fall, Resident #2 was heard yelling. A licensed practical nurse (LPN) went to check on the resident and found her lying on her left side, complaining of 8 out of 10 pain, on a 1 to 10 pain scale, to her left shoulder and left hip. According to the LPN's documentation of the fall, Resident #2 refused to allow nursing staff to remove her clothing for a skin evaluation and she requested to be transported to the hospital at that time. The LPN notified the director of nursing (DON), who was the registered nurse (RN) on-call, to notify her of his findings, which included Resident #2's complaints of 8 out 10 pain to her left shoulder and left hip. Resident #2 was assisted into a wheelchair by the LPN and a certified nurse aide (CNA). The 2/11/25 at 6:50 a.m. nursing progress note, written by the DON, documented a RN assessment conducted by the DON, based on the findings reported from the LPN on-site at the time of the resident's fall. It indicated Resident #2 had slipped and fallen while ambulating to the bathroom. It documented Resident #2 was able to move all extremities without injury or noted deformity. It documented Resident #2 was to be transported to the hospital after Resident #2 and Resident #2's representative insisted the resident be evaluated at the hospital.-However, there was no RN in the facility at the time of the fall to conduct a hands-on physical assessment of the resident. Resident #2 was moved off the floor and into a wheelchair, despite her complaints of significant pain, refusal to remove her clothes for a skin evaluation and her request to be sent to the hospital. Resident #2 was transported to the hospital on 2/11/25 at 7:48 a.m. after Resident #2's representative was notified of the resident's fall and insisted on Resident #2 being evaluated at the hospital (63 minutes after Resident #2 initially requested to go to the hospital). At the hospital, the resident was diagnosed with a dislocated and fractured left shoulder and a fractured left hip that required surgical intervention,The facility's failure to accurately assess and evaluate Resident #2 after she experienced a fall and complained of acute pain of 8 out of 10 to her left shoulder and left hip, and the facility's failure to honor the resident's request to be sent to the hospital immediately after the fall resulted in Resident #2 not being transported to the hospital in a timely manner for evaluation and treatment of her acute fractures. Findings include:I. Professional referenceAccording to The Cleveland Clinic (5/11/23) Dislocated Shoulder, retrieved on 4/24/25 from https://my.clevelandclinic.org/health/diseases/17746-dislocated-shoulder,"The most common symptoms of a dislocated shoulder include extreme pain, weakness, inability to move arm, shoulder being visibly out of place, swelling, bruising and muscle spasms."Any force that is strong enough to push your shoulder joint out of place can cause a dislocation. The most common causes include falls, care accidents and sports injuries."Go to the emergency room right away if you think your shoulder might be dislocated."According to Johns Hopkins Medicine (2025) Hip Fracture, retrieved on 4/24/25 from https://www.hopkinsmedicine.org/health/conditions-and-diseases/hip-fracture#:~:text=What%20is%20a%20hip%20fracture,of%20patients%20experience%20spontaneous%20fractures,"A hip fracture is a partial or complete break of the femur (thigh bone), where it meets your pelvic bone. It is aserious injury that requires immediate medical attention."II. Facility policy and procedureThe Fall Management System policy and procedure, revised November 2022, was provided by the director of nursing (DON) on 4/22/25 at 3:50 p.m. It read in pertinent part,"When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record."The Monitoring for Significant Change in Condition policy and procedure, revised May 2007, was provided by the DON on 4/22/25 at 3:50 p.m. It read in pertinent part,"If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the nurse supervisor should be made aware of and he/she will monitor."Change in ability to ambulate or propel wheelchair."Change in ability to transfer or position self."There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation."II. Resident #2A. Resident statusResident #2, age 86, was admitted on 10/9/24 and discharged to the hospital on 2/11/25. According to the February 2025 computerized physician orders (CPO), diagnoses included hypertension, protein/calorie malnutrition, opioid dependence and a fracture of thoracic vertebra (bone in the upper spine). The 1/13/25 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. She required set up assistance with eating, personal hygiene and was independent with toileting, bed mobility and transfers. The assessment indicated Resident #2 used a walker to assist with ambulation. B. Resident representative interviewResident #2's representative was interviewed on 4/22/25 at 9:03 a.m. The representative said Resident #2 had a history of falls prior to being admitted to the facility. He said while she resided at the facility, she fell again (on 2/11/25). He said he was notified by the nurse on duty that his Resident #2 had fallen, approximately 30 minutes after the event. He said he asked the nurse if she was in pain and the nurse responded yes. He said he asked if the resident had requested to go to the hospital and the nurse had responded yes. The representative said he asked the nurse why emergency medical services (EMS) had not been called yet and he said he demanded the resident be sent to the hospital immediately. He said when he met Resident #2 at the hospital she was "writhing" and screaming out in pain. He said he was frustrated that she was not sent to the hospital when she had sustained multiple fractures, was in a lot of pain and when she had requested to go. C. Record reviewThe acute/chronic pain care plan, initiated 10/10/24, indicated Resident #2 had acute and chronic pain management issues related to low back pain, history of falling and chronic pain. Interventions included administering analgesia (pain) medication per physician's orders, anticipating the resident's need for pain relief and responding immediately to any complaint of pain and identifying, recording and treating the resident's existing conditions, which may increase pain and or discomfort.-However, the care plan did not indicate the resident had chronic pain in her left shoulder or left hip. The 2/11/25 at 6:50 a.m. nursing progress note documented a registered nurse (RN) assessment, conducted by the DON . Resident #2 was noted on the floor lying on her left side by the bathroom. Resident #2 said that she was walking to the bathroom and had slipped. Resident #2 was able to move all extremities with no signs of injury or deformity. It documented that neurological checks were started and at baseline for the resident. It documented that, based on the resident and resident representative's insistence, the resident would be sent to the emergency room for evaluation.-However, the DON's assessment was based upon the reported findings from the LPN whowas on-site at the time of the fall (see interviews below).-Additionally, the nursing note was not created in the resident's electronic medical record (EMR) by the DON until 9:39 a.m. The 2/11/25 at 8:14 a.m. nursing progress note, written by the LPN on-site at the time of the resident's fall, documented that at 6:45 a.m. Resident #2 was heard yelling and was found lying on her left side on the floor in front of the bathroom. Resident #2 said she was ambulating with her walker to the bathroom and slipped. Resident #2 complained of pain at an 8 out of 10 to her left arm and left hip and requested to be sent to the hospital. Resident #2 refused to remove her clothing for a skin evaluation. Resident #2 was assisted into a wheelchair by the LPN and a CNA. The resident's representative was contacted and he requested for Resident #2 to be sent out to the hospital. The nurse practitioner (NP) and the DON were notified and Resident #2 was sent to the hospital.-However, the progress note failed to document whether or not the physician was notified that Resident #2 was reporting 8 out of 10 pain in her left shoulder and left hip and refusing to allow the nursing staff to remove her clothing for a skin evaluation, prior to moving the resident off of the floor. -Additionally, the progress note failed to document that physician's orders were obtained for Xrays, based on the resident's reports of 8 out of 10 pain in her left shoulder and left hip and her refusal to allow the nursing staff to remove her clothing for a skin evaluation, prior to Resident #2's representative insisting the resident be sent to the hospital. The 2/11/25 at 9:53 a.m. interdisciplinary team (IDT) fall committee progress note documented Resident #2 had an unwitnessed fall without injuries. It documented Resident #2 was lying on her left side on the floor in front of the bathroom. Resident #2 was sent to the emergency room for evaluation after Resident #2's, per the resident representative's insistence. It documented no injuries or deformities were noted by facility staff.-However, RN #1, who was not at the facility to physically assess Resident #2 at the time of the fall but received a shift hand-off report from the LPN that was on duty indicated the resident's shoulder looked odd (see interview below).-A comprehensive review of Resident #2's EMR failed to reveal documentation of a physician's order to obtain Xrays of the resident's left shoulder and/or left hip. The 2/11/25 hospital progress note documented Resident #2 had a left shoulder dislocation with a proximal humerus fracture (a break in the long bone of the arm close to the shoulder) and a displaced left femur (thigh bone) fracture. It documented the resident's left shoulder was reduced (a procedure where the shoulder was placed back into position) in the emergency room by the orthopedic surgeon and the emergency room physician. The 2/12/25 hospital progress note documented Resident #2 underwent a left hip nailing (a surgical procedure to realign the bone and stabilize the fracture). III. Staff interviewsRN #1 was interviewed on 4/22/25 at 1:50 p.m. RN #1 said Resident #2 had a walker which she used independently to walk around the facility. She said Resident #2 had a soft call light which she only used when she wanted her pain medications. She said the resident would not use the call light to ask for assistance prior to getting out of bed and walking with her walker. She said she took care of Resident #2 on the day she fell, but she said the resident had already fallen and been assisted into a wheelchair before she arrived in the facility for her shift. She said the previous nurse (LPN) had said that the physician had ordered Xrays and the facility was waiting for those Xrays to be obtained on her shoulder. She said Resident #2's left shoulder looked odd. She said the facility sent Resident #2 to the emergency room because the facility could not obtain the Xrays in a timely manner.-However, RN #1 did not document a progress note in Resident #2's EMR regarding her assessment that indicated the resident's shoulder looked odd (see record review above).-Additionally, progress notes indicated Resident #2 was sent to the hospital due to the resident representative's request that the resident be sent to the hospital, not because Xrays could not be obtained in a timely manner (see record review above). RN #1 was interviewed a second time on 4/22/25 at 1:55 p.m. RN #1 said she had reviewed her progress notes in Resident #2's EMR. She said Resident #2 had asked to go to the hospital and the LPN had called the physician but he had not received a return call. She said she was the one that had called the physician again and received an order for the resident to be sent to the emergency room because the Xrays could not be completed timely. She said that was the reason why there was a delay of over an hour between when the resident fell and when the resident was sent to the emergency room. RN #1 said the facility's process, unless a situation was immediately life-threatening, was not to call EMS first, but to call the physician to obtain a physician's order to transfer a resident to the hospital. She said the facility did this even if the resident had requested to go to the emergency room.-However, there was no documentation in Resident #2's EMR to indicate RN #1 or the LPN called the physician to obtain physician's orders for Xrays of the resident's left shoulder and left hip (see record review above). The DON was interviewed on 4/22/25 at 2:45 p.m. The DON said the facility's process was to call the physician first to obtain a physician's order to transfer residents to the hospital to mitigate unnecessary hospitalizations, unless it met criteria for an immediate transfer. She said Resident #2 did not meet criteria for immediate transfer to the hospital. She said immediate criteria was any instance that was immediately life threatening. She said Resident #2 did not request to go to the hospital. She said Resident #2 was at baseline for her pain and she complained of pain normally at an 8 out of 10 pain scale.-However, the note documented by the LPN on 2/11/25 at 8:14 a.m. indicated Resident #2 requested to go to the hospital immediately after her fall (see record review above).-Additionally, Resident #2's acute/chronic pain care plan indicated the resident had chronic pain related to low back pain, not left shoulder or left hip pain (see record review above). The DON said Resident #2 normally, at baseline, did not have full range of motion in all of her extremities. She said the facility had contacted the physician and had obtained a physician's order for Xrays, since the facility could do these in the facility. She said Resident #2's representative was contacted and he insisted that Resident #2 be sent to the hospital. She said the facility sent Resident #2 to the hospital after Resident #2's representative insisted and the facility had obtained a physician's order from the NP to transport the resident to the hospital. The DON was interviewed a second time on 4/22/25 at 3:50 p.m. The DON said a RN was not in the facility when the fall occurred. She said she was the RN on-call and she had documented the RN assessment for Resident #2. She said the facility's process when an RN was not in the building was that the LPN would follow a post-fall check list and they would call the RN on-call. She said she was told by the LPN on-site that Resident #2 was not experiencing any pain or range of motion outside of her normal baseline. She said she did not come into the facility to personally assess the resident. She said Resident #2 was moved off the floor and into the wheelchair before the oncoming RN arrived at the facility.-However, the DON said in her previous interview on 4/22/25 at 2:45 p.m. that Resident #2 was at her baseline level of pain at the time of the fall (see interview above).-Additionally, the LPN's progress note documented Resident #2 was complaining of a pain level of 8 out of 10 to her left shoulder and left hip after the fall. -Additionally, the resident's representative indicated Resident #2 was in extreme pain when she arrived at the hospital (see resident representative's interview). IV. Facility follow-upOn 4/23/25 at 1:53 p.m., after the survey exit, the DON provided the following timeline of Resident #2's fall via email:"On 2/11/25 at 6:45 a.m. Resident #2 was heard yelling from the hallway and a nurse entered the room."On 2/11/25 at 6:50 a.m. the DON was called during the resident's evaluation as part of the required RN assessment."On 2/11/25, between 6:50 a.m to 7:30 a.m: An RN assessment was conducted. Resident #2 was noted on the floor laying on her left side by the bathroom. Resident #2 stated that she was walking to the bathroom and slipped. Resident #2 is able to move all extremities with no signs of injury or deformity. Neurological checks initiated and at baseline for this resident. Resident #2 was assisted up to her wheelchair by LPN and CNA. "A call was made to the provider who gave orders for in-house Xrays."A call was placed to the resident's representative to report the incident and the representative requested Resident #2 be sent to the hospital. "The provider called back and was informed of Resident #2's representative request to send the resident out to the hospital; an order was received from the provider."-However, a RN was not in the facility to conduct the assessment and the evaluation was provided by a LPN to the DON and Resident #2 was assisted up to the wheelchair by the LPN and a CNA before a RN was in the facility. The DON's 4/23/25 email additionally included the following EMS timeline from 2/11/25, which was provided to the facility by a dispatcher at (name of the EMS provider):"On 2/11/25 at 7:30 a.m. call received by EMS from facility;On 2/11/25 at 7:44 a.m. EMS enroute to facility;On 2/11/25 at 7:48 a.m. EMS arrived to facility;On 2/11/25 at 8:07 a.m. EMS departed from the facility;On 2/11/25 at 8:16 a.m. EMS arrived at the hospital; and,On 2/11/25 at 8:19 a.m. Resident #2 was admitted to the hospital."

Plan of correction · submitted by the facility

2/13/2025Complaint Survey · ID YJM4111 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO39189, Incident #38948, #38950 and #39238 was conducted on 2/12/25 to 2/13/25. One deficiency were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0689Free of Accident Hazards/Supervision/DevicesS/S J▼

Findings

Based on record review and interviews, the facility failed to ensure one (#1) of three residents at risk for elopement out of seven sample residents received adequate supervision and were kept free from elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopement. The facility failures created a situation with serious harm and a situation of likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with metabolic encephalopathy (improper brain function due to underlying medical condition), unspecified psychosis (mental condition caused by loss of contact with reality), dementia and anxiety, eloped from the facility on 2/1/25 at an unknown time. Facility staff were unaware Resident #1 was missing until after 6:00 a.m. on 2/2/25 when certified nurse aide (CNA) #2 began answering call lights at the start of her shift. At approximately 6:20 a.m. on 2/2/25, CNA #2 noticed Resident #1's dinner tray, untouched, in the resident's room. Resident #1's roommate reported to CNA #2 she had not heard Resident #1 in the room since approximately 5:30 p.m. on 2/1/25, the previous day. CNA #2 reported this to a nurse on duty and the assistant director of nursing (ADON) was notified at approximately 6:30 a.m. A full facility check was conducted, the staff checked the surrounding neighborhood and the resident was unable to be located. At 8:10 a.m. the admissions coordinator (AC) informed the interdisciplinary team (IDT) that Resident #1 had been located at a local hospital. The facility began investigating the incident immediately after Resident #1 was discovered in care of the local hospital and determined Resident #1 eloped from the facility after CNA #1 and licensed practical nurse (LPN) #1 failed to monitor Resident #1 every two hours per facility protocol and due to Resident #1's refusal to wear a wanderguard. Findings include:Observations, interviews and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/12/25 to 2/13/25, resulting in the deficiency being cited as past noncompliance with a correction date of 2/4/25. I. Situation of serious harmThe facility failed to ensure the facility staff performed a check of Resident #1 every two hours throughout the evening on 2/1/25 resulting in the facility being unaware of Resident #1's whereabouts for approximately 12 to 15 hours. Resident #1 eloped from the facility on 2/1/25 and was found by the local police approximately 0.3 miles from the facility. She was taken to a local hospital for evaluation where she was admitted at 8:36 p.m. and treated for a urinary tract infection (UTI). II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #1's elopement incident on 2/2/25 was provided by the clinical resource (CR) on 2/12/25 at 2:30 p.m. A. Immediate actionOne-on-one education was provided to the staff who worked on the 2/1/25 overnight/evening shift and CNA #1 and LPN #1 were placed on suspension pending the investigation of Resident #1's elopement. A facility wide resident count was conducted and all other residents were accounted for. An assessment was conducted of all exterior doors and doors and door alarms were all functioning properly. The incident investigation began immediately and was conducted by the director of nursing (DON) and the nursing home administrator (NHA). B. Identification of others affectedThe facility determined the deficient practice had the potential to affect all the residents in the facility. C. Systemic changesThe DON educated all of the staff on the importance of staff expectations with rounding, high risk for elopement residents (if a resident had not been seen in a few hours), reviewing the resident sign out book, any resident that required one-to-one staff to resident monitors, frequent or 15-minute checks and the post test for elopement. Residents in the facility were interviewed and educated on the use of the resident sign out log. D. MonitoringThe facility would evaluate the effectiveness of the plan in quality assurance and program improvement (QAPI) committee meetings for three months and implement additional interventions as needed to ensure sustained compliance. Audits, along with resident records reviewed and analysed for trends, would be reported monthly to the QAPI committee. III. Facility policy and procedureThe Elopement/Unsafe Wandering policy, undated, was provided by the CR on 2/12/25 at 2:30 p.m. The policy read in pertinent part, "This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attending or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement. "Wandering is defined as random or repetitive locomotion and can either be goal directed or non-goal directed and aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization and/or any necessary supervision to do so. Residents with capabilities of ambulation and/or mobility in a wheelchair will have an unsafe wandering evaluation completed to determine risks for elopement and unsage wandering on admission and with observed behaviors of wandering or attempting to elope. "Residents with high risk factors identified on an elopement/wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and time frames. The care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wandering behavior. These interventions will address the individualized level of supervision needed to prevent elopement and unsafe wandering. Staff shall promptly report any resident who is trying to leave the premises, or is suspected of being missing, to the charge nurse or supervisor to evaluate the need for further interventions."If a resident is missing, it is a facility-wide emergency. The missing resident procedures will be initiated. Determine if the resident is out on an authorized leave or pass. If the resident was not authorized to leave, institute a search of the premises. If the resident is unaccounted for after a thorough search of the building and grounds, immediately notify the IDT team, the resident's legal representative or emergency contact, physician and law enforcement. "A review of the elopement incident by the IDT will include an investigation to determine safety of the environment and probable cause factors leading to the elopement. A summary of the investigation and recommendations will be documented in the resident's medical record."IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 12/27/22 and discharged to the hospital on 2/1/25. According to the February 2025 computerized physician orders (CPO), diagnoses included metabolic encephalopathy, frostbite, unspecified psychosis, convulsions, dementia and anxiety. The 12/22/24 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. The 2/1/25 discharge MDS assessment documented Resident #1 required set-up assistance for meals, dressing, personal hygiene and dressing. She was independent with all other activities of daily living (ADL). The assessment documented the resident wandered one to three days during the assessment period, experienced delusions and rejected care. B. Record review 1. Care plansResident #1's comprehensive care plan, initiated 4/19/24 and revised 6/24/24, documented Resident #1 was an elopement risk and exhibited wandering behaviors related toher impaired safety awareness and had two previous elopements. Pertinent interventions, initiated 6/18/24 and resolved 6/24/24, included one-to-one staff supervision and to document wandering behavior and attempted diversional interventions. Resident #1's dementia care plan, initiated 6/24/24 documented the resident was at risk for acute confusional episodes and had a history of elopements related to dementia with exit seeking behaviors. Pertinent interventions, initiated 6/24/24, included to document wandering behavior and attempted diversional interventions, completing one-to-one staff supervision or 15-minute checks as needed, reminding the resident where her room was and that it was divided by the curtain, identifying the resident's pattern of wandering - was it purposeful, aimless or escapist and intervening as appropriate and redirecting the resident as needed. Resident #1's care plan for ADLs, initiated 12/28/22, revealed she had a self-care performance deficit related to impaired mobility and cognition due to dementia. She refused medications, medical testing and labs, vital signs, assessments and showers. Pertinent interventions, initiated 12/30/22, included to converse with the resident while providing care, explaining all procedure and tasks before starting and providing the resident required set-up assistance to eat. 2. Elopement/wandering evaluationResident #1's 12/20/24 elopement/wandering evaluation documented she had a predisposing condition of mental illness, was disoriented and ambulated independently and/or with supervision. The evaluation further documented Resident #1 did not have a history of elopement and the resident had no history or current behavior of wandering within the look back period of the previous six months.-However, the resident's February 2025 CPO documented Resident #1 had a diagnosis of dementia, which was not indicated on the elopement/wandering evaluation (see interviews below). The resident's electronic medical record (EMR) documented wandering behaviors (in the last six months prior to the elopement/wandering evaluation) on 6/25/24 and 7/21/24, in which Resident #1 attempted to leave the facility and the wanderguard alarm was activated. 3. Treatment records and progress notesA review of Resident #1's February 2025 treatment administration record (TAR) revealed on the 2/1/25 to 2/2/25 overnight shifts from 6:00 p.m. to 6:00 a.m., LPN #1 documented that Resident #1 had zero exit seeking attempts. The TAR further documented Resident #1 was provided with non-pharmacological interventions for pain that included dim light, a quiet environment, relaxation and distraction. A review of Resident #1's EMR revealed the following documentation completed by CNA #1:-Resident #1's fall prevention intervention of a low bed in place was documented at 9:26 p.m. on 2/1/25 and 1:35 a.m. on 2/2/25;-Resident #1's snack was documented as accepted at 9:26 p.m. on 2/1/25; and,-Resident #1 was documented as being turned and repositioned at 9:27 p.m. on 2/1/25 and at 1:35 a.m. on 2/2/25.-However, Resident #1 was admitted to the hospital on 2/1/25 at 8:36 p.m. after being found downtown by police. -The facility failed to recognize Resident #1 was not in the building until after 6:00 a.m. the following morning (2/2/25). A 2/3/25 IDT note, written at 11:39 a.m. and related to Resident #1's elopement, documented it was noticed by the facility staff on 2/2/25 at approximately 6:10 a.m. that Resident #1 was not in the facility and the facility's elopement protocol was initiated. Resident #1 was located at a local hospital where she was admitted on 2/1/25 at 8:36 p.m. after being found by police downtown. It was discovered that the assigned LPN (LPN #1) and CNA (CNA #1) did not follow facility policy and procedure during their shift and were placed on suspension pending investigation. The resident had been accepted to a secure unit at another facility after her hospital discharge. C. Review of Resident #1's elopement incident on 2/1/25 On 2/12/25 at 2:30 p.m. the CR provided the investigation of Resident #1's elopement on 2/1/25. The investigation revealed the following:On 2/1/25 staff reported seeing Resident #1 in the hallways from 2:00 p.m. to 3:00 p.m. On 2/1/25 at 5:00 p.m. CNA #1 said Resident #1 was not in her room and to mark her down for the regular meal. On 2/1/25 at 6:00 p.m. Resident #1's dinner tray was delivered to her room. On 2/1/25 at 9:26 p.m. CNA #1 documented Resident #1 ate 100% (percent) of her meal. On 2/1/25 at 11:41 p.m. LPN #1 documented she had completed a pain evaluation for Resident #1 and that the resident had no exit seeking attempts for the 6:00 p.m. to 6:00 a.m. shift. On 2/2/25 at 6:00 a.m. CNA #2 arrived to the facility, took a report from the night shift CNA #1, and immediately went to the hall and answered the call lights. On 2/2/25 at 6:15 a.m. a bath aide told CNA #2 that Resident #1 was not in her room. Resident #1's roommate said she had not heard her roommate in the room since 5:30 p.m. the night before. On 2/2/25 at 6:20 a.m. CNA #2 reported to a nurse and LPN #1 she could not find Resident #1. LPN #1 told CNA #2 she saw Resident #1 walking down the hallway at 3:00 a.m. -However Resident #1 had already been admitted to the hospital on 2/1/25 at 8:36 p.m. On 2/2/25 at 6:30 a.m. CNA #2 called the ADON to report she was unable to find Resident #1. The staff were instructed to conduct a full facility check for the resident, including bathrooms, back hallways, the garden and surrounding outside areas. On 2/2/25 at 7:36 a.m. the IDT was alerted the resident was unable to be located. The DON arrived at the facility immediately after and conducted a second search of the facility and surrounding outside areas. At 8:10 a.m. the AC informed the IDT that Resident #1 had been located at a local hospital. At 8:20 a.m. the DON arrived back at the facility after looking for the resident in the surrounding area and a house wide resident count was conducted and all other residents were accounted for. An assessment was conducted of all exterior doors and door alarms and all were all functioning properly. An internal investigation was initiated by the DON and the NHA.LPN #1 was interviewed on 2/2/25 by the DON. LPN #1 stated she heard Resident #1 in her room around 3:00 a.m. when she was taking care of the resident's roommate. LPN #1 said she had not laid eyes on Resident #1 during her shift. LPN #1 explained that her documentation on Resident #1 on the overnight shift was just documentation on the resident's' usual' to explain Resident #1's pain evaluation and number of times the resident attempted to exit the facility. CNA #1 was interviewed on 2/2/25 by the DON. CNA #1 said she documented Resident #1's meal was 100% of the meal intake because Resident #1 did not like to be bothered when she was in her room. LPN #1 and CNA #1 were asked by the DON during the investigation to provide written statements for the events involving Resident #1 on 2/1/25 and 2/2/25, but they did not. V. Staff interviewsThe CR was interviewed on 2/12/25 at 2:35 p.m. The CR said the facility placed a wanderguard bracelet on Resident #1's wrist in June 2024 and she removed it multiple times until August 2024 and she refused multiple times to have the bracelet placed back on her wrist. The CR said Resident #1 was supposed to be on two-hour checks at the time of her elopement and staff were to check on her every two hours because she was refusing to have the wanderguard on. The CR said the facility thought it had to be around suppertime that the resident left the building through the front door because the front door closed at 6:00 p.m. Dietary aide (DA) #1 and DA #2 were interviewed together on 2/13/25 at 9:55 a.m. DA #1 said residents could exit the facility through the front door or through one of the dining rooms' side doors. DA #1 said the side doors of the dining room went to a lobby and were alarmed. DA #1 said if a resident had a wanderguard on and tried to exit through the side doors, the wanderguard alarm on the wall would sound. DA #1 said if the alarm sounded, there was a code that could be entered to turn the alarm off. DA #1 said residents could also use the dining room side door to go visit a friend in assisted living or get a coffee in the other dining room of the building. DA #1 said she was not at the facility when Resident #1 eloped but she knew of Resident #1. DA #1 said it seemed as though Resident #1 had days she wanted to leave the buildings more than others. DA #1 said she knew who the at-risk residents were in the building and monitored them in the dining room even if they were not attempting to leave through the side door. DA #2 said the dietary staff knew which residents should be redirected away from the dining room side door and the staff should check the elopement wanderguard book every day. The AC was interviewed on 2/13/25 at 10:20 a.m. The AC said was educated on the facility elopement policy after Resident #1's elopement from the facility. The AC said she came to the facility on the morning of 2/2/25 and called local hospitals. The AC said she discovered Resident #1 was in a local hospital during the first phone call she made. The AC said when elopements happened, the facility staff all had specific assignments. She said some staff contacted the hospital and other staff might contact the jails or homeless shelters. The AC said when she called the hospital, she provided specific resident information and the hospital was able to tell her Resident #1 was there. The AC said the facility staff might have to visit the homeless shelters in person because the homeless shelters did not typically provide information on who was there. The AC said if a resident had previously eloped, the facility would try to find that resident at their known or favorite place first. The social services assistant (SSA) was interviewed on 2/13/25 at 11:15 a.m. The SSA she was educated about Resident #1's elopement. The SSA said she had worked at the facility for a very long time and worked various positions in the facility that included the front desk of the assisted living (AL) facility connected to the nursing facility. The SSA said she knew which residents were at risk for elopement and those residents lived on the nursing side of the facility. The SSA said residents at risk for elopement were noted upon admission. She said she noted residents with a dementia diagnosis, even if that resident was not a high elopement risk and also looked out for those residents. The SSA said if a resident consented, the facility took a picture of the resident and included the resident's picture with their information in the elopement binder. The SSA said when she took her break she locked the front doors of the building so people could not enter from the outside, but residents were still able to exit. She said she locked the entrance doors with a key and on the inside of the door she hung a stop sign. The SSA said the stop sign was effective in deterring residents from exiting through the double doors. The SSA said if a resident who was an elopement risk started to or did exit the building through the AL side of the building, or if she was notified of a resident elopement, she immediately called to the nursing side of the facility. The SSA said she would try to reach the DON or other nursing supervisor to inform them of a potential elopement. The SSA said she would also inform the facility plant manager and then attempt to redirect the resident back inside the building. The SSA said she took her cell phone with her to update other staff by phone if she was successful or not in redirecting the resident. The SSA said the facility employed overnight staff that did laundry and while waiting for the laundry to finish, the overnight staff did security rounds outside the facility and checked entrances and doorways. LPN #2 was interviewed on 2/13/25 at 12:10 p.m. LPN #2 said if he was informed of a resident elopement, he would immediately lock his medication cart and start looking for the resident. LPN #2 said if he had to report a resident missing, it depended on the resident what he would report. LPN #2 said some residents were more independent and could sign themselves out of the facility. LPN #2 said if that was the case, he would check the sign out log to see where the resident signed out to go, and then inform the DON or the ADON if he thought the resident had been gone too long. LPN #2 said a resident that needed to be checked every two hours meant the resident needed to be checked at the start of his shift and every two hours after that. LPN #2 said he would, at minimum, put eyes on the resident and depending on the time of day, might ask the resident how they were doing and if they needed anything. LPN #2 said if a resident needed assistance with repositioning, he would have to physically assist the resident with the repositioning and needed to be able to see them directly. The CR, the DON and the NHA were interviewed together on 2/13/25 at 1:15 p.m. The DON said Resident #1 had a diagnosis of dementia. The DON said the dementia diagnosis should have been marked on Resident #1's elopement/wandering evaluation but it would not have increased Resident #1's risk category. The CR said Resident #1's elopement/wandering evaluation should have included the resident's wandering behaviors from the last six months. The CR said indicating those behaviors on the elopement/wandering evaluation placed the resident as high risk (instead of low) but her interventions would have still been the same. The CR said the resident was in the elopement binder at the front desk due to the resident's risk of elopement. The CR said the elopement/wandering evaluation reviewed as part of the plan of correction was correct. The DON said in IDT meetings, new resident admissions or readmissions were reviewed and one of the key parts of the resident admission assessment was the resident's elopement risk and what interventions were needed. The DON said if a resident was an elopement risk, the resident was included in the elopement binder, as were residents with a wanderguard. The DON said nursing staff, such as the DON or other designee, maintained the elopement binder. The DON said the primary failure revealed in the investigation of Resident #1's elopement was the staff working failed to check on Resident #1 as required. The DON said both LPN #1 and CNA #1 should have checked on Resident #1 every two hours. The DON said it was a standard of care the staff should know. The DON said she interviewed the staff who worked during Resident #1's elopement. The DON said said both LPN #1 and CNA #1 had just finished their overnight shift and were still present to look for Resident #1. The DON said LPN #1 had assisted looking for Resident #1 in the nearby neighborhood. The DON said when she received notice Resident #1 was admitted to the hospital, she asked LPN #1 to come back to the facility to interview her further. The NHA said the facility could not confirm for certain the resident was in the building at 5:00 p.m. when the dinner meal tickets were completed. The NHA said it was not unusual for Resident #1's tray to be dropped off in her room and Resident #1 was very independent. The DON said Resident #1 liked to keep her door closed often and did not like to be bothered. The DON said if the resident's door was closed, staff needed to just put eyes on the resident. The DON said LPN #1 and CNA #1 did not put eyes on Resident #1 in the time frame they should have. The DON said to conduct a resident search, the staff started first in the resident's room, and then checked the dining room, the second dining room, and started the other facility rooms, such as shower rooms. The DON said when she arrived at the facility the morning of 2/2/25, the staff had already done the facility search and she did a second room and facility search herself.

Plan of correction

The state did not require a plan of correction for this citation.

12/16/2024Complaint Survey · ID WXM111No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO38426 and #CO38557was conducted on 12/16/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

11/22/2024Revisit: Recertification Survey · ID B1Y622No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required. Tag Waived K-521.

Plan of correction

The state did not require a plan of correction for this citation.

10/16/2024Revisit: State Licensure Survey · ID 6TL212No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 10/16/24 for all previous deficiencies cited on 8/15/24. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

10/16/2024Revisit: Recertification Survey · ID B1Y612No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 10/16/24 for all previous deficiencies cited on 8/15/24. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

9/4/2024Recertification Survey · ID B1Y62111 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

The facility is a one-story, non-combustible, Type II (111), structure without a basement. A two-hour firewall separates The facility from the adjacent 10-story high-rise building. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinkled. The facility is licensed for 60 beds. This re-certification survey was conducted on September 3rd and 4th, 2024, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies". The deficiencies cited were discussed with the Executive Director, Life Safety Resource, and Maintenance Director during the survey and at the exit conference conducted at the end of the on-site survey.

Plan of correction

The state did not require a plan of correction for this citation.

0133Multiple Occupancies - Construction TypeS/S F▼

Findings

Through observation during the survey, it was determined that the facility failed to meet the Multiple Occupancies - Construction Type requirements in accordance with NFPA 101. This was evidenced by: 1) The doors from the Dining Room to the Service Kitchen are 90-minute rated. One door does not have the means to keep it latched and shut, diminishing the fire resistance rating. The Original Hardware was removed, and a deadbolt was added. 2) Numerous penetrations existed along the 2-hour-rated wall that appears to be the occupancy separation. The facility shall audit and correct any penetrations with a Fire Stop System. 3) The dining access panel has a 2-hour Fire Resistance Rating. It does not have a spring to automatically close the door, which is typically required per the access panel's listing. The access panel appears field-modified to allow plumbing valves to work. This wall is believed to be part of the 2-hour occupancy separation. 4) The 90-minute fire-rated door from the dining room near room 110 is broken and has been broken since January. This is part of what is believed to be an occupancy separation. Code Citations: 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 101: 19.1.3.5 Where separated occupancies provisions are used in accordance with either 19.1.3.3 or 19.1.3.4, the most stringent construction type shall be provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type shall be determined as follows: (1) The construction type and supporting construction of the health care occupancy shall be based on the story on which it is located in the building in accordance with the provisions of 19.1.6 and Table 19.1.6.1. (2)The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters of this Code. NFPA 80: 5.1.5.2.1 In cases where a field modification to a fire door or a fire door assembly is desired, the laboratory with which the product or component being modified is listed shall be contacted and a description of the modifications shall be presented to that laboratory. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Multiple occupancies – construction type 1) the doors from the dining room to the service kitchen are 90 min rated. One door does not have the means to keep latched and shut diminishing the fire resistance rating. The original hardware was removed, and a deadbolt was added. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted vender received and approved quote to replace existing hardware and install new door hardware that latches properly. Work was completed 10/4/2024 Monitoring: This door is a part of an existing preventable maintenance schedule and with new hardware installed will be maintained on that schedule to ensure functionality. Multiple occupancies – construction type 2) Numerous penetrations existed along the 2-hour rated wall that appears to be the occupancy separation the facility shall audit and correct any penetrations with a fire stop system. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: maintenance department will perform a whole house audit on the 2-hour rated wall and correct any penetrations with 3M fire block sealant on or before 9/23/2024. Monitoring: An inspection will ensue annually to visually inspect and correct any penetrations and or re-apply fire block to areas as needed because of fire stop systems age. Multiple occupancies – construction type 3) The dinning access panel has a 2-hour fire resistant rating. It does not have a spring to automatically close the door, which is typically required per access panels listing. The access panel appears to be field modified to allow plumbing valves to work. This wall is believed to be part of the 2-hour rated occupancy separation. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Facility got new fire rated access panel and modified Plumbing to make room for new panel. We then installed new panel to manufacturers instruction 9/23/2024 installed 9/24/2024 . Monitoring: there is no spring mechanism on the new panel from the manufacturer, but we will continue to monitor and ensure no other panels are field modified at the time of install or after Multiple occupancies – construction type 4) The 90- min fire rated door from the dinning room near room 110 is broken and has been since January. This is part of what is believed to be the occupancy separation. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted vender received and approved quote to replace existing broken 90 min fire rated door and replace it with a new 90 min fire rated door that is fully functional and tested to NFPA standards. Work was completed 10/4/2024Monitoring: This door is a part of an existing preventable maintenance schedule and with new door installed maintenance department will resume weekly monthly and annual testing and preventative maintenance on this door to insure functionality. Any issues found during monitoring will be corrected by maintenance department and taken before QAPI.

0271Discharge from ExitsS/S F▼

Findings

Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exit requirements in accordance with NFPA 101. This was evidenced by: 1) The east exit near the kitchen has a gate with a padlock and chain, and this door is the required means of egress. 2) The path of egress from S Hall was not clear and continuous to the public way. Obstructions included metal furniture, leaves and branches, garden hoses, and an elevation change in this area. Code Citations: NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. NFPA 101: 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1/4 in. (6.3 mm). Changes in elevation exceeding 1/4 in. (6.3 mm), but not exceeding 1/2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7. NFPA 101: 7.1.9 Impediments to Egress. Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress, unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23. NFPA 101: 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Discharge From Exits 1) The East exit near the kitchen has agate with a padlock and chain, and this door is the required means of egress. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: In addition to putting key labeled KG kitchen gate on med cart key rings we also installed a key on inside of door that egresses to gate and installed a key box on gate and clearly wrote code for all those on inside of gate to see so all staff can always have access to the key and have means to egress out of that gate if the circumstance may present itself. Staff education occurred on 9/25/24 by Maintenance Director19.2.2.2.6 Doors that are located in the means of egress and arepermitted to be locked under other provisions of 19.2.2.2.5 shall comply with all of the following:(1) Provisions shall be made for the rapid removal of occu-pants by means of one of the following:(a) Remote control of locks(b) Keying of all locks to keys carried by staff at all times (c) Other such reliable means available to the staff at alltimes(2) Only one locking device shall be permitted on each door.(3) More than one lock shall be permitted on each door, subject to approval of the authority having jurisdiction. Monitoring: A monthly task was created in our workorder system that will prompt us visually verify key is in box and confirm functionality of the key. Discharge From Exits 2) The path of egress from s hall was not clear and continuous to the public way. Obstructions include metal furniture, leaves and branches, garden hoses, and an elevation change in this area. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: The maintenance department cleared path of egress and moved furniture to a more appropriate place and a weekly task to audit all egress paths exiting the building. Monitoring: A monthly task was created in our workorder system that will prompt us to verify not only this egress, but all areas egresses are clear and continuous. We will do this for 12 months.

0291Emergency LightingS/S F▼

Findings

Through documentation review, it was determined that the facility failed to meet the Emergency Lighting requirements in accordance with NFPA 101. This was evidenced by: 1) Emergency light testing documentation only included "4th floor at nusres st, basement, electrical room by br, generator." No other areas were documentedCode Citations: NFPA 101: 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Emergency lighting 1) Emergency light testing documentation only included “4th floor at nurses st, basement electrical room by br, generator”. No other areas were documented. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance department has audited and updated work order that is currently generated with the appropriate locations automatically generated on the log and in the instructions. Monitoring: Maintenance department will continue to complete this task as it is currently scheduled. LSMR to audit this task every 60 days for 180 days.

0293Exit SignageS/S F▼

Findings

Through documentation review, it was determined that the facility failed to meet the Exit Signage requirements in accordance with NFPA 101. This was evidenced by: 1) Exit Light testing documentation was not provided for review. Code Citations: NFPA 101: 7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. NFPA 101: 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 the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Exit signage 1) Exit light testing documentation was not provided for review. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance department has audited and updated work order that is currently generated with the appropriate locations automatically generated on the log and in the instructions. Monitoring: Maintenance department will continue to complete this task as it is currently scheduled. LSMR to audit this task every 60 days for 180 days.

0324Cooking FacilitiesS/S E▼

Findings

Through documentation review, it was determined that the facility failed to meet the Cooking Facility requirements in accordance with NFPA 101, NFPA 96, and NFPA 17A. This was evidenced by: 1) Inspection report dated 05/24/2024 lists the following deficiencies: 1) System Due for hydro testing, to include testing of chemical tanks, replacement of chemical, replacement of hoses, replacement of actuation cartridges and testing of regulator. 2) Detection cable needs to be reconfigured. Code Citations: NFPA 101: 9.7.3.1 In any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1. NFPA 17A: 7.5.1 The following parts of wet chemical extinguishing systems shall be subjected to a hydrostatic pressure test at intervals not exceeding 12 years:(1) Wet chemical containers(2) Auxiliary pressure containers(3) Hose assembliesThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Cooking Facilities 1) The inspection report dated 05/24/2024 lists the following deficiencies 1) system due for hydro testing, to include testing of chemical tanks, replacement of chemical, replacement of hoses, replacement of actuation cartridge and testing of regulator. 2) Detection cable needs to be reconfigured. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted fire protection vender received and approved quote to replace chemical tanks, chemical hoses, actuation cartridge and testing of regulator as well as finding a solution for the detection cable needs to be reconfigured. Monitoring: Maintenance director has scheduled with the fire protection vender 9/27/2024 at 6pm.

0343Fire Alarm System - NotificationS/S F▼

Findings

Through observation during the survey and documentation review, it was determined that the facility failed to meet the Fire Alarm System Notification requirements in accordance with NFPA 101, and NFPA 72. This was evidenced by: 1) The latest Annual Inspection has the following deficiencies are listed on the report. 2) There are 14 speaker stropes that did not sound, only strobe worked. Code Citations: NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72: 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system. NFPA 72: 14.2.2.1* The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system. NFPA 72: 14.5.1 System equipment shall be maintained in accordance with the manufacturer ' s published instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Fire Alarm system notification 1) the latest annual inspection has the following deficiencies are listed on the report 2) There are 14 speaker strobes that did not sound, only strobe worked. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted fire protection vender received and approved quote to trace and fix the severed wires that were causing the 14 listed devices to not function properly. Monitoring: Maintenance director has scheduled with the fire protection vender 9/12/2024 to have work completed.

0345Fire Alarm System - Testing and MaintenanceS/S F▼

Findings

Through observation during the survey and documentation review, it was determined that the facility failed to meet the Fire Alarm System - Testing and Maintenance requirements in accordance with NFPA 101, and NFPA 72. This was evidenced by: 1) The latest Annual Inspection has the following deficiencies are listed on the report. 1) There are (4) batteries that failed and need to be replaced. 2) There are 14 speaker strobes that did not sound, only strobe worked. 3) There is 1 smoke that failed to activate. 4) there was 1 supervisory on the panel upon arrival and departure. See sprinkler report for details. 2) Through observation, it was determined that the batteries listed as failed in the report were still in use and had not been replaced. 3) Through observation it was determined that there were 2 supervisories and 2 troubles on the Fire Alarm Control Panel. 4) Through observation, it was determined that some smoke alarms in resident rooms are not correctly mounted. One smoke detector had tape on it to prevent smoke from entering the alarm. No documentation of maintenance for the smoke alarms was provided during the inspection. Code Citations: NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72: 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system. NFPA 72: 14.2.2.1* The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system. NFPA 72: 14.5.1 System equipment shall be maintained in accordance with the manufacturer ' s published instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Fire Alarm system testing and maintenance 1) The latest annual inspection has the following deficiencies are listed on the report. 1) There are (4) batteries that are failed and need to be replaced. 2) There are 14 speaker strobes that did not sound, only strobe worked 3) There is 1 smoke that failed to activate 4) there was 1 supervisory on the panel upon arrival and departure. See sprinkler report for details. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted fire protection vender received and approved quote to correct the (4) batteries that are failed, 14 speaker strobes that did not sound, 1 smoke that failed to activate, 1 supervisory on the panelMonitoring: Maintenance director has scheduled with the fire protection vender 9/23/2024-9/26/2024 to have work completed. Fire Alarm system testing and maintenance 2) Through observation it was determined that the batteries listed as failed in the report were still in use and had not been replaced. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted fire protection vender received and approved quote to correct the (4) batteries that are failed. Monitoring: Maintenance director has scheduled with the fire protection vender 9/12/2024 to have work completed. Fire Alarm system testing and maintenance 3) Through observation it was determined that there were 2 supervisory and 2 troubles on the fire alarm control panel. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director was undergoing a significant project on the fire system at the time as result the panel was reading these issues. After project completion administration confirmed and validated panel is now reading systems normal. Monitoring: now that panel is reading system normal maintenance will be monitoring daily Fire Alarm system testing and maintenance 4) Through observation it was determined that smoke alarms in resident rooms are not currently mounted one smoke detector had tape on it to prevent smoke from entering the alarm.no documentation of maintenance for smoke alarm was provided during the inspection. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Smoke detectors that were found to be not mounted properly have been corrected. The smoke alarm that was found to have tape on it and has been determined to be operational. Upon review of the inspection report rooms in the SNF occupation have been inspected. Monitoring: maintenance department will now conduct audits of SNF rooms monthly to confirm tracked via workorder system to ensure compliance.

0353Sprinkler System - Maintenance and TestingS/S F▼

Findings

Through observation during the survey and documentation review, it was determined that the facility failed to meet the Sprinkler System - Maintenance and Testing requirements in accordance with NFPA 101, and NFPA 25. This was evidenced by: 1) The latest Annual Inspection has the following deficiencies are listed on the report. 6" Fire Backflow Assembly failed due to "#2 Check valve not holding pressure, possible debris caught inside. Need to conduct internal inspection and possibly replace gasket." 2) Sprinkler heads throughout Breckenridge hall are not properly installed. Many appear to have had some movement, some are too high or to low. 3) Fire Sprinkler Hydraulic Design Information and Information Sign do not exist at the riser. Code Citations: NFPA 25: 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. NFPA 25: 4.1.4.2 *Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25: 4.7* Maintenance. Maintenance shall be performed to keep the system equipment operable or to make repairs. NFPA 25: 5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible. NFPA 25: 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Sprinkler system – maintenance and testing 1) The latest annual inspection has the following deficiencies are listed on the report. 6” fire back flow assembly failed due to #2 Check valve not holding pressure, possible debris caught inside. Need to conduct internal inspection and possibly replace gasket. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Back flow was repaired and re inspected and passed on 9/10/2024 by fire protection vender. Monitoring: Maintenance director will conduct an audit of all back flow inspection upon receiving and document and file report in life safety records. Sprinkler system – maintenance and testing 2) Sprinkler heads throughout Breckenridge Hall are not properly installed. Many appear to have had some movement; some are too high or too low. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted fire protection vender to correct the position of the sprinkler heads in question. fire protection company corrected this at no charge as the position of the heads was due to project work. Corrected 9/13/2024Monitoring: Maintenance department will ensure that outside licensed vendor completes quarterly and annual checks Sprinkler system – maintenance and testing 3) Fire sprinkler hydraulic design information and information sign do not exist at the riser. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures: Maintenance director contacted fire protection vender received and approved quote to backwards engineer sprinkler system to supply us with hydraulic calculation information. Monitoring: Maintenance department conduct a visual inspection annually

0354Sprinkler System - Out of ServiceS/S F▼

Findings

Through observation during the survey and documentation review, it was determined that the facility failed to meet the Sprinkler System- Out of Service requirements in accordance with NFPA 101, and NFPA 25. This was evidenced by: Upon arrival at the facility, a pickup truck with "Western States Fire Protection" on the side was parked near the main entrance to the facility. Near the bed of the pickup truck was black pipe, which was commonly used for sprinkler systems and tools for sprinkler pipe installation. I went to talk to the foreman, and I verified that the foreman was a licensed Sprinkler Fitter in the State of Colorado, and I confirmed that the Colorado Division of Fire Prevention and Control had issued a permit. During the document review through interview, it was determined that the sprinkler system had been out of service since January. The portion of the Sprinkler System that had failed was on the first floor of the building. Through document review on the dated of 09.02.2024, it was discovered that one staff member had signed the fire watch log for 5:00, 6:00, 7:00, 8:00, 9:00, 10:00, 11:00, 12:00, 1 PM, 2:00, 3:00, 4:00, 5:00, 6:00, 7:00, 8:00, 9:00, 10:00, 11:00, 12:00, 1:00. Through interview with the Maintenance Director, he stated that the local Fire Marshall allowed one hour interviews for the fire watch, it was discussed that the Colorado Division of Fire Prevention was never consulted for this change. Through interview it was discovered that someone is always at the nurses station, and stated from there you can see the entire building. The staff member is supposed to sign the fire watch log, but they typically do not so the maintenance directs his staff to sign the fire watch log. The maintenance director agreed and acknowledged that he has his staff sign documents for work they did not complete. Code Citations: 42 CFR 483.90(a)(8) When a sprinkler system is shut down for more than 10 hours, the LTC facility must: (i) Evacuate the building or portion of the building affected by the system outage until the system is back in service, or (ii) Establish a fire watch until the system is back in service. NFPA 101: 9.7.6 Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25: 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)* An approved fire watch (c)* Establishment of a temporary water supply (d)* Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (See Section 15.3.) (9) All necessary tools and materials have been assembled on the impairment site. NFPA 25: A.15.5.2(4)(b) A fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Sprinkler system – Out of service Upon arrival at the facility, a pickup truck with “Western states fire protection” on the side was parked near the main entrance to the facility. Near the bed of the truck was a black pipe, which is commonly used for sprinkle systems and tools for sprinkler pipe installation. I went to talk to the foreman and verified that the foreman was a licensed sprinkler fitter in the state of Colorado, and I confirmed the division of fire prevention and control had issued a permit. During the document review through interview, it was determined that the sprinkler system had been out of service since January. The portion of the Sprinkler System that had failed was on the first floor of the building. Through document review on the dated of 09.02.2024, it was discovered that one staff member had signed the fire watch log for 5:00, 6:00, 7:00, 8:00, 9:00, 10:00, 11:00, 12:00, 1 PM, 2:00, 3:00, 4:00, 5:00, 6:00, 7:00, 8:00, 9:00, 10:00, 11:00, 12:00, 1:00. Through interview with the Maintenance Director, he stated that the local Fire Marshall allowed one hour interviews for the fire watch, it was discussed that the Colorado Division of Fire Prevention was never consulted for this change. Through interview it was discovered that someone is always at the nurses station, and stated from there you can see the entire building. The staff member is supposed to sign the fire watch log, but they typically do not so the maintenance directs his staff to sign the fire watch log. The maintenance director agreed and acknowledged that he has his staff sign documents for work they did not complete. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures fire watch was corrected during survey and policy was updated as well as staff education and Inservice completed. maintenance director also brought this education to facility QAPI meeting to discuss corrective actions takenMonitoring: Maintenance director and administrator review fire watch policy on an annual Baisis or as needed will also monitor all active fire watch logs to ensure that fire watch maintains compliance throughout its entirety.

0355Portable Fire ExtinguishersS/S E▼

Findings

Through observation during the survey, it was determined that the facility failed to meet the Portable Fire Extinguishers requirements in accordance with NFPA 101, and NFPA 110. This was evidenced by: 1) The Fire Extinguisher in the IT closet's last monthly inspection was conducted on May of 2024. Corrected During Survey2) The Fire Extinguisher near the generator last monthly inspection was conducted on May of 2024. Corrected During Survey. Code Citations: NFPA 101: 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. NFPA 10: 9.7.4.1 * Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10: 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. NFPA 10: 7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. . Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Portable fire extinguishers 1) The fire extinguisher in the I.T. closet’s last monthly inspection was conducted in May of 2024. Corrected During survey. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures Maintenance director updated task in workorder system with specific locations and a pass or fail option that will generate monthly. Monitoring: Maintenance department to reinitiate monitoring fire extinguishers on a regular monthly basis and/or as needed Portable fire extinguishers 2) The fire extinguisher near the generator last monthly inspection was conducted in May of 2024. Corrected During survey. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures Maintenance director updated task in workorder system with specific locations and a pass or fail option that will generate monthly. Monitoring: Maintenance department to continue monitoring fire extinguishers on a regular monthly basis and/or as needed

0923Gas Equipment - Cylinder and Container StoragS/S E▼

Findings

Through observation during the survey, it was determined that the facility failed to meet the Gas Equipment – Cylinder and Container Storage requirements in accordance with NFPA 101, and NFPA 99. This was evidenced by: 1) During the tour of the facility fifteen liquid portable oxygen tanks were observed to be stored in an area that was open to the corridor, with no proper cabinet or fire resistance rating separating these units from the corridor. Code Citations: NFPA 99:11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1)Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hourNFPA 99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. NFPA 99: 11.7.3.2 Containers shall not be placed in the following areas: (1) Where they can be tipped over by the movement of a door (2) Where they interfere with foot traffic (3) Where they are subject to damage from falling objects (4) Where exposed to open flames and high-temperature devicesThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one smoke compartment. Deficient items were discussed during the survey and at the exit conference.

Plan of correction · submitted by the facility

Gas equipment -Cylinder and container storge 1) During the tour of the facility fifteen liquid portable oxygen tanks were observed to be stored in an area that was open to the corridor, with no proper cabinet or fire resistance rating separating these units from the corridor. Resident Specific: No residents Identified. But could affect all residents, staff, and visitors within the facility. Identification of others: Potential to affect occupants, who might include staff, residents and visitors in the facility. System and Measures maintenance department moved all portable 02 to the proper location during survey. In addition, they also added signage to the area in question and will perform weekly checks generated by workorder system. Monitoring: Maintenance department to continue monitoring on a weekly and as needed basis tracked by work order system.

8/15/2024Recertification Survey · ID B1Y61115 deficiencies▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A recertification survey was conducted from 8/12/24 to 8/15/24. Fifteen deficiencies were cited.

Findings · record 2 of 2

An Emergency Preparedness survey was conducted from 8/12/24 to 8/15/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0550Resident Rights/Exercise of RightsS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity for two (#4 and #5) of five residents reviewed out of 33 sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to:-Ensure staff knocked or announced themselves prior to entering Resident #4's room; and,-Ensure Resident #5 was provided with timely incontinence care when requested. Findings include:I. Facility policy and procedureThe Dignity and Respect policy, dated April 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part,"It is the policy of this facility that all residents be treated with kindness, dignity and respect."Residents will be appropriately dressed in clean clothes arranged comfortably on their persons, and be well groomed."Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by."Staff members shall knock before entering the residents' room."II. Resident #4A. Resident statusResident #4, age 82, was admitted on 2/22/16. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 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. She could hear adequately, was able to understand others and made herself understood. B. Resident observations and interviewOn 8/13/24 at 10:35 a.m. certified nurse aide (CNA) #1 entered Resident #4's room without knocking or announcing herself. CNA #1 walked into the room and delivered hot tea to Resident #4. Resident #4 said staff did not always knock. She said sometimes the staff came into her room and did not even speak to her. On 8/13/24 at 1:52 p.m. CNA #1 entered Resident #4's room without knocking. CNA #1 took the resident's lunch plate cover from the room and left without speaking to the resident or her roommate. On 8/15/24 at 1:21 p.m. CNA #2 entered Resident #4's room without knocking. She delivered the lunch tray to Resident #4's roommate, sat it on the bedside table and left without speaking to either resident. C. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 3:19 p.m. LPN #1 said staff should knock and announce themselves prior to entering a residents' room. She said staff should let the resident know who they were and what they were going to do. The director of nursing (DON) was interviewed on 8/15/24 at 5:45 p.m. The DON said staff should knock and announce themselves before entering a residents' room. III. Resident #5 A. Resident statusResident #5, age 68, was admitted on 9/13/22. According to the August 2024 CPO, diagnoses included type 2 diabetes mellitus, chronic respiratory failure, hypertension (high blood pressure), chronic obstructive pulmonary disease and bipolar disorder (a mental illness causing severe mood swings). The 7/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent on staff for transfers and toileting hygiene. She was frequently incontinent of urine. B. Resident observations and interviewOn 8/13/24 at 1:12 p.m. Resident #5 told an unidentified CNA that she needed her brief changed before she went to the music program that started at 2:00 p.m. Resident #5's husband assisted the resident to her room and turned the call light on. During a continuous observation on 8/13/24, beginning at 1:17 p.m. and ending at 1:40 p.m. the following was observed:At 1:17 p.m. CNA #5 went into Resident #5's room and turned off the call light. CNA #5 said she had to help another resident and would be back. At 1:28 p.m. CNA #5 was pushing a mechanical lift into another resident's room. At 1:30 p.m. CNA #2 was picking up lunch trays from two residents' rooms. At 1:40 p.m. Resident #5's husband came into the hall and told CNA #5 that the staff ran out of time and Resident #5 needed to go to the activity program. The resident's husband assisted Resident #5 to the activity program without having her brief changed. -Resident #5 had waited 28 minutes for CNA #5 to return to her room to provide her assistance. At 3:07 p.m. Resident #5 returned from the activity and went into her room. She turned on her call light. -Resident #5 had been in a wet brief for one hour and 55 minutes after informing a staff member she needed her brief changed. At 3:08 p.m. registered nurse (RN ) #2 went to Resident #5's room. RN #2 left, did not turn off the call light and retrieved the mechanical lift. CNA #2 and RN #2 took the mechanical lift into Resident #5's room. RN #2 said they were going to lay Resident #5 down and change her. Resident #5 was interviewed on 8/14/24 at 11:23 a.m. Resident #5 said she was upset when she did not get her brief changed before she went to the music program activity on 8/13/24. She said she was uncomfortable sitting in the wet brief during the program. C. Staff interviewsCNA #5 was interviewed on 8/15/24 at 3:42 p.m. CNA #5 said if a resident was incontinent, staff should check on them every two hours and change their brief if needed. CNA #5 said Resident #5 used her call light when she needed to be changed but sometimes she forgot so the staff needed to check on her. CNA #5 said it was important to change incontinent residents frequently to prevent skin breakdown. The DON was interviewed on 8/15/24 at 5:45 p.m. The DON said residents should be checked on for incontinence care at a minimum of every two hours. The DON said it was a priority for CNAs to change an incontinent resident before picking up room trays.

Plan of correction · submitted by the facility

TAG F 550 Resident Rights/Exercise of RightsCorrections-DON (director of nursing)/SSW (social services) spoke with Residents #4, #5 on or before 9/12/24. The resident’s care plans were updated to reflect preferences and resident’s daily care. Identification of others-The deficient practice had the potential to affect all residents. Systemic changes-DON/designee will educate staff on the facility’s dignity policy to include timely toileting assistance and ensure staff were knocking on doors prior to entering rooms on or before 9/12/24. Monitoring-DON/Designee will audit five random residents to ensure staff knocked or announce themselves prior to entering a resident room and interview and/or observe the residents for timely incontinence care (incontinence documentation will be reflected in POC record, a verbal audit will be initiated to residents to ensure compliance with knocking on doors, concerns will be documented on grievances.) Any concerns identified will be followed up with staff training. The audit will include Residents #4 and #5 (total of five residents) and will be completed two times a week x one month, and then weekly x two months or until compliance is achieved. QAPI-Data obtained, and issues and successes identified from audits, along with medical records will be reviewed and analyzed for trends and reported monthly to the Quality Assurance and Performance Improvement committee. QAPI will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure sustained compliance x three months.

0558Reasonable Accommodations Needs/PreferencesS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#8) of one resident reviewed out of 33 sample residents. Specifically, the facility failed to ensure Resident #8's call light was consistently accessible to her. Findings include:I. Facility policy and procedureThe Call Lights Accessibility and Timely Response policy and procedure, undated, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, "The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. "Call lights will directly relay to a staff member or centralized location to ensure appropriate response."All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light."All residents will be educated on how to call for help by using the resident call system."Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system."Staff will ensure the call light is within reach of the resident and secure, as needed."II. Resident #8 A. Resident statusResident #8, age 83, was admitted on 7/17/23. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia. The 7/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. She was dependent on staff assistance with toileting hygiene, upper and lower body dressing, putting on/taking off footwear, sitting to lying, lying to sitting on side of bed, sitting to standing, chair to bed/bed to chair transfers and toileting transfers. III. Resident interview and observationsResident #8 was interviewed on 8/12/24 at 3:30 p.m. Resident #8 said she did not know where her call light was.-Resident #8's call light was on the floor at the foot of her bed. On 8/13/24 at 9:35 a.m. an unidentified staff member entered Resident #8's room. The resident's call light was on the floor at the foot of her bed. At 9:41 a.m. the unidentified staff member exited Resident #8's room. The resident's call light was still on the floor.-The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. During a continuous observation on 8/13/24, beginning at 1:45 p.m. and ending at 4:52 p.m., the following was observed:At 1:45 p.m. an unidentified staff member entered Resident #8's room and closed the door. At 1:47 p.m. the unidentified staff member exited Resident #8's room and the call light was located on the floor at the foot of the resident's bed.-The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. At 2:29 p.m. an unidentified staff member entered the resident's room. Resident #8 was lying down in her bed and her call light was on the floor at the foot of her bed.-The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. At 4:12 p.m. an unidentified staff member entered the resident's room. The resident was lying down in bed and her call light was on the floor at the foot of her bed.-The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. At 4:48 p.m. an unidentified staff member entered Resident #8's room and closed the door. At 4:52 p.m. the unidentified staff member exited the room. The resident was lying in her bed and the call light was located on the floor at the foot of her bed.-The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. On 8/14/24 at 9:31 a.m. an unidentified staff member entered Resident #8's room. The resident was in bed lying down and her call light was located on the floor at the foot of her bed.-The unidentified staff member did not pick the call light up off of the floor and place it within reach of Resident #8 while in the resident's room. IV. Record reviewThe behavior care plan, revised 8/8/24, documented Resident #8 had the potential to demonstrate physical behaviors related to dementia with behaviors. She could become combative with cares and frequently refused her cares. The care plan indicated Resident #8 would frequently throw her call light on the floor after it had been clipped to her bed or clothing. The interventions included assessing and anticipating the resident's needs, food, thirst, toileting needs, comfort level, body positioning and pain, documenting observed behavior and attempted interventions and providing a guide away from source of distress when agitated, engaging calmly in conversation and, if response was aggressive, staff was to walk calmly away and approach later. The 10/26/23 progress note documented Resident #8 was in rehabilitation services for physical and occupational therapy. The note documented the staff would continue to focus on safety with bed mobility and training/education on use of call light. Due to memory issues, the resident had a decreased follow through with education and would benefit from repetitive training. The note documented the staff would continue to monitor for further needs and safety as appropriate. The 8/15/24 behavior note, documented during the survey, revealed Resident #8 continued to kick the call light on the floor after certified nurse aides (CNA) had placed it multiple times on the bed with a clip.-A review of Resident #8's electronic medical record (EMR) did not reveal any additional documentation regarding Resident #8 kicking her call light on the floor. V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 8/15/24 at 10:28 a.m. CNA #1 said the call light should always be within reach for all of the residents. She said if the call light was not within reach she would put it back where the resident could reach it. She said if the call light was on the floor she would not know when the resident needed assistance. She said the call light should never be on the floor. She said she was responsible for making sure the call light was within the resident's reach. She said if any of the staff saw the call light on the floor they needed to pick it up and make sure that it was within reach for the resident. CNA #1 said she did not know if Resident #8 could use her call light. CNA #1 said she checked on Resident #8 all the time. She said Resident #8 was a fall risk, so she checked on her more frequently. She said sometimes the residents did not press their call light, so she frequently checked in on the residents. Licensed practical nurse (LPN) #2 was interviewed on 8/15/24 at 11:28 a.m. LPN #2 said the call light should be placed somewhere the resident could reach it. She said if the call light was not within reach for the resident, she would let the resident know where the call light was located. LPN #2 said the call light should never be placed on the floor where it was out of reach for the resident. She said if the call light was on the floor or out of reach then the resident could not call for help and that could be a problem. She said any staff who went into Resident #8's room should have picked up her call light and put it within reach. LPN #2 said she was not sure if Resident #8 was able to use her call light. She said she thought Resident #8 might not have been able to use her call light due to her cognition. The director of nursing (DON) was interviewed on 8/15/24 at 6:02 p.m. The DON said the call light needed to be within reach when a resident was in bed and within reach while a resident was in a chair where the resident could reach it safely. She said if the call light was not within reach, the staff needed to move it so that it was within reach. She said the staff should be checking at least every hour to ensure the call light was within reach. She said the call light should never be on the floor. The DON said Resident #8 could use her call light but chose not to and would yell out for help instead. She said Resident #8 kicked the call light off her bed. She said the staff should be doing rounding and checking on those things to make sure the call light was within reach for all of the residents.

Plan of correction · submitted by the facility

TAG D 558 Reasonable AccommodationsCorrections-Specifically, the facility failed to ensure Resident #8's call light was consistently accessible to her. Resident #8’s care plan and preferences were revised on 9/12/24. Systemic changes-All residents can be affected by this deficient practice. Monitoring-All staff were educated to ensure call lights were within reach or placed on the bed if residents are not in the room by September 12, 2024. (visual observations and verbal interviews with residents will be initiated, concerns will be documented on grievance forms)The DON or designee will conduct random audit to ensure call lights are within reach of 3 residents to include resident # 8 three x a week x 4 weeks, then two a week x 4 weeks, then once a week x 4 weeks. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions. Compliance date 9/12/24

0561Self-DeterminationS/S E▼

Findings

VI. Resident #23A. Resident statusResident #23, age 71, was admitted on 1/30/24. According to the August 2024 CPO, diagnoses included hemiplegia and hemiparesis (impaired communication between the brain and muscles) and chronic systolic (congestive) heart failure. The 2/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was dependent on staff assistance for showering/bathing himself, lower body dressing, putting on/taking off footwear, lying to sitting, sitting to stand, chair to bed and bed to chair transferring and tub/shower transferring. B. Resident interviewResident #23 was interviewed on 8/14/24 at 8:49 a.m. Resident #23 said his roommate kept the television on all the time and it was loud. He said he could not hear his television and could not sleep due to the noise level. He said he talked to staff about the problem and was informed that if he filed a grievances then he would need to move to a different room. He said the facility staff did not provide any other solutions for the problem and told him he would have to deal with it. Resident #23 was interviewed on 8/15/24 at 11:55 a.m. Resident #23 said when his roommate had his television on loud then he would turn the volume up on his television so that he was able to hear. He said it was a constant problem that he dealt with every day. He said the facility staff did not offer to provide headphones or address the situation. C. Record reviewThe care plan for psychosocial needs, revised 5/13/24, revealed Resident #23 had the potential for psychosocial well-being problems related to a recent disagreement with another resident in the facility. Interventions included consulting with psychiatric services, which the resident declined, encouraging the resident to attend activities and meals in the dining room and social services to provide psychosocial check-ins as needed. A progress note dated 4/27/24 documented Resident #23 had a noise complaint made by the resident's roommate. The registered nurse (RN) went into Resident #23's room and asked him if he could turn down his music to a respectable level. Resident #23 proceeded to turn up his music. The resident's roommate then turned up his television louder than the music. Resident #23 was asked two more times by the assigned certified nurse aide (CNA) as well as the assigned RN to turn the music down and Resident #23 did not comply.-The nursing progress note did not document any interventions put into place to address the noise level concerns for either resident. D. Staff interviewsThe social services director (SSD) was interviewed on 8/15/24 at 3:32 p.m. The SSD said she was responsible for handling problems/concerns between residents but she said she got other staff/administrators involved when needed. The SSD said it was not the facility protocol to move someone to a different room when there was a problem/concern between roommates. She said moving someone was not the only solution and other interventions could be implemented. She said she could get the resident headphones to help with the noise complaint. She said she was not informed about the concern between the two roommates. The SSD said she would reeducate staff and let them know if there were any problems/concerns between roommates to notify social services. She said she would follow up with Resident #23 regarding his concern with the noise of his roommate's television. LPN #1 was interviewed on 8/15/24 at 5:06 p.m. LPN #1 said said Resident #23's roommate had brought up concerns about Resident #23's television noise. She said that before both residents got into bed she reminded both of them to be mindful of each other's environment. She said both residents were hard of hearing. LPN #1 said it had never been discussed that Resident #23 would have to move rooms. She said moving rooms was not a solution to the problem. She said if there were any threatening behaviors, that would warrant a room move but a noise complaint would not warrant a room move. She said she was not sure where Resident #23 would have gotten the information about needing to move. She said it was not standard practice to move someone for a noise complaint. CNA #4 was interviewed on 8/15/24 at 5:20 p.m. CNA #4 said he was aware of television volume concerns between Resident #23 and his roommate. He said he had gone into the room on occasions and turned down the volume. The SSD was interviewed a second time on 8/15/24 at 6:00 p.m. She said she spoke with Resident #23 and his roommate. She said she provided headphones to Resident #23's roommate. She said he was agreeable to use the headphones to solve the problem with the noise level of the television. The DON was interviewed on 8/15/24 at 6:48 p.m. The DON said Resident #23's roommate should have been offered headphones since he liked to listen to his television loudly. The DON said moving residents out of their room was not the process or protocol. She said staff should be mediators, help residents and involve social services when needed. Based on observations, record review and interviews, the facility failed to honor resident choices for four (#7, #59, #4 and #23) of six residents out of 33 sample residents. Specifically, the facility failed to:-Ensure Residents #59, #7 and #4 received bathing according to their comprehensive choice and plan of care; and,-Ensure Resident #23 was provided assistance to be able to hear his television when he had a conflict with his roommate. Findings include:I. Facility policy and procedureThe Resident Rights policy and procedure, revised April 2022, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:15 p.m. It revealed in pertinent part, "It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulatory agencies."To be treated with consideration, respect, and full recognition of his or her dignity and individuality."II. Resident #59A. Resident statusResident #59, age 72, was admitted on 7/11/24 and readmitted on 7/31/24. According to the August 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease. The 8/7/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required partial or moderate assistance with activities of daily living. B. Resident interviewResident #59 was interviewed on 8/13/24 at 10:07 a.m. He said had only received one shower since he had been admitted to the facility. He said he usually showered multiple times a week when he was home. He said he was only offered two showers per week when he was admitted. Resident #59 said he was frustrated because he was promised he would receive two showers per week and the facility had not honored that promise. C. Record reviewThe self-care deficit care plan, initiated on 7/12/24, documented Resident #59 had a self-care performance deficit due to a diagnosis of Parkinson's disease. It indicated that the resident required the assistance of one to two staff members for bathing. The July 2024 certified nurse aide (CNA) shower task documentation revealed Resident #59 did not receive bathing between his admission on 7/11/24 to 7/18/24, when the resident returned to the hospital. The documentation indicated the resident refused bathing on one occasion on 7/17/24.-Resident #59 should have received two showers during that one week timeframe in July 2024. The August 2024 CNA shower task documentation revealed Resident #59 received bathing once, on 8/4/24, between 8/1/24 to 8/15/24.-Resident #59 should have received four showers during the two week timeframe in August 2024. III. Resident #7A. Resident statusResident #7, age 88, was admitted on 9/6/22. According to the July 2024 CPO, diagnoses included heart failure, chronic respiratory failure with hypoxia, type 2 diabetes, unsteadiness on feet and pain in the left knee. The 7/13/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent upon staff for bathing assistance and partial to moderate assistance with toileting and dressing. B. Resident interviewResident #7 was interviewed on 8/12/24 at 2:51 p.m. Resident #7 said she was frustrated because she had not been receiving showers according to the established schedule. She said she was supposed to receive a shower on Mondays and Thursdays but she did not always get them. She said the facility had recently changed the shower aides schedule and ever since, she said she had not been receiving her showers. C. Record reviewThe Kardex (a tool utilized to enable staff to provide consistent care) documented Resident #7 should receive showers on Tuesday and Friday evenings. The resident required substantial to maximum assistance of staff for bathing.-However, according to Resident #7, her showers were supposed to be on Mondays and Thursdays (see resident interview above). The June 2024 CNA shower task documentation revealed Resident #7 only received a shower on four occasions (6/3/24, 6/6/24, 6/13/24 and 6/27/24) out of eight opportunities, missing four showers. The July 2024 shower documentation revealed Resident #7 only received a shower on five occasions (7/4/24, 7/8/24, 7/11/24, 7/22/24 and 7/29/24) out of nine opportunities, missing four showers. The August 2024 shower documentation, from 8/1/24 to 8/15/24, revealed Resident #7 only received a shower on two occasions (8/5/24 and 8/12/24) out of four opportunities, missing two showers. IV. Resident #4A. Resident statusResident #4, age 82, was admitted on 2/22/16. According to the August 2024 CPO, diagnoses included type 2 mellitus diabetes with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She could hear adequately, was able to understand others and made herself understood. Resident #4 was dependent on staff for bathing and did not reject care during the assessment period. B. Resident interviewResident #4 was interviewed on 8/15/24 at 9:17 a.m. Resident #4 said a CNA offered her a shower on 8/14/24 but she declined due to her recent surgery. She said the CNA did not offer her a bed bath. C. Record reviewThe activities of daily living (ADL) care plan, initiated 10/17/18, indicated Resident #4 required substantial assistance with bathing and two-person assistance to transfer her into a shower chair. Resident #4 preferred showers. The behavior care plan, initiated 8/29/17, revealed Resident #4 would refuse showers at times. Interventions included leaving and returning five to10 minutes later and offering care again. The CNA task shower documentation in Resident #4's electronic medical record (EMR) revealed Resident #4 was to have a shower every Wednesday. The CNA shower task documentation was reviewed from 4/1/24 through 8/14/24. The documentation revealed the following:-Resident #4 received a shower on two out of four Wednesdays in April 2024; -Resident #4 received a shower on two out of five Wednesdays in May 2024; -Resident #4 received a shower on two out of four Wednesdays in June 2024; -Resident #4 received a shower on three out of five Wednesdays in July 2024; and, -Resident #4 received a shower on one out of two Wednesdays in August 2024.-From 4/1/24 through 8/14/24, Resident #4 received 10 showers out of 20 opportunities for a shower. The CNA shower task documentation further revealed Resident #4 refused her shower five times and there was no documentation regarding whether or not a shower occurred on five occasions from 4/1/24 through 8/14/24. -Review of Resident #4's nurse progress notes revealed no documentation from 4/1/24 through 8/14/24 to indicate the resident refused her shower on the five dates the documentation was left blank, the reason for the five shower refusals or if the resident was reapproached at a later time when she refused her shower. V. Staff interviewsCNA #6 was interviewed on 8/15/24 at 3:53 p.m. CNA #6 said she offered Resident #4 a shower on 8/14/24 but Resident #4 declined. CNA #6 said she forgot to chart the refusal for 8/14/24 and that was why the charting was blank. CNA #6 said Resident #4 preferred a shower one time per week. She said sometimes she did not feel good and did not want a shower. CNA #6 said if the resident refused her shower, she would offer one the next day or on Saturdays. CNA #3 was interviewed on 8/15/24 at 5:20 p.m. CNA #3 said the facility used to have two shower aides but currently only had one. She said the facility had recently changed their hours from eight hour shifts five days per week to 10 hour shifts three days per week. She said she found the schedule change made it very difficult to provide showers to all the residents. CNA #3 said the shower aides were the staff members who provided showers to the residents. She said the floor CNAs did not provide showers. She said the other shower aide was injured so she had been the only shower aide for the past few weeks. CNA #3 said she tried her best to get to all of the residents' showers but sometimes she was not successful. The director of nursing (DON), the NHA and the clinical consultant (CC) were interviewed on 8/15/24 at 5:44 p.m. The DON said the facility employed two shower aides to provide all the resident showers throughout the facility. She said she had recently changed the shower aide schedule from eight hours five days per week to three days per week for 10 hours per day. She said she changed the shower aide schedules to address the staffing needs. The DON said the shower aides should document which residents did not receive a shower and provide that list to the nurse at the end of their shift. She said if a resident did not receive a shower, that resident should receive a shower the next day. The DON said she was aware the showers were not being completed according to the shower schedule. She said the shower schedule was a work in progress. The NHA said the facility would look at the shower aide schedule again to see if another alteration needed to be made to ensure residents were receiving their showers per their preferences.

Plan of correction · submitted by the facility

TAG E 561 D Self - Determination I. CORRECTIVE ACTION:Residents # 59, Resident # 7, and Resident #4 have been re-interviewed for their bathing preference and their care plan has been updated. Resident #23 was provided headphones and can listen to his television. II. IDNETIFICATION OF OTHERS:A full house shower preference audit was completed by 9/12/24. All resident’s bathing schedules were updated to include their preferences and care plans were updatedA full house television audit was completed by 9/12/24. Care plans were updated with the resident's preference and/or accommodation. SYSTEMIC CHANGES:Weekly ambassadors’ rounds will be conducted by IDT/designee to include asking if they are being showered according to their preference, if they can hear their TV when they watch TV in their room; and if they have any conflict with their roommate. (concerns will be documented on grievance forms)At all care conferences IDT will ask specifically if they are pleased with their current bathing schedule and method of bathing. If there are changes, the residents’ preferences, and care plan will be updated. Residents will be asked if they can hear their tv and if they have any conflict with their roommate, if there are any concerns a grievance will be initiated. All new admissions will be interviewed about bathing preference and the care plan will be updated reflecting their preference. Nursing staff will be educated on how to access the kardex for preference and bathing schedules. DON/designee will conduct a shower audit 3 times per week for 4 weeks then 2 times a week times 4 weeks and one time week x 4 weeks to ensure compliance is sustained. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0565Resident/Family Group and ResponseS/S E▼

Findings

Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances about a variety of concerns, including grievances not being answered in a timely manner, staffing shortages with provision of timely care and responding to resident call lights. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, revised August 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:14 p.m. It read in pertinent part, "It is the policy of this facility to establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, other concerns regarding their facility stay and make prompt efforts to resolve grievances the resident may have."The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested and coordinating with state and federal agencies as necessary."The grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated."The grievance official or designee responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution."II. Resident group interviewSix alert and oriented residents (#23, #17, #22, #52, #1 and #3) who regularly attended the resident council meetings were interviewed on 8/14/24 at 10:08 a.m. The residents were identified as alert and oriented through facility and assessment. The group of residents said they had turned in grievances and the staff did not get back to them regarding the concerns. The residents said they were unhappy with the staff shortages, especially the certified nurse aides (CNA). The group of residents said the facility needed more staff, especially during the hours of 2:00 p.m. to 10:00 p.m. and on the weekends. The group of residents said most days they only had one CNA working the hallways. Resident #22 said he was told that the facility did not use agency staff. The group of residents all discussed how long they had had to wait for call lights to be answered by staff. The group of residents said when they turned on their call lights, staff should be coming into their rooms to find out what was going on. The group of residents said most days the staff just walked by and ignored their call lights. Resident #23 and Resident #17 said they had had a couple of accidents where they had an incontinence episode because the staff did not answer their call light in a timely manner. The group of residents said they had had to wait 20 to 30 minutes before staff would respond to their call lights. The group of residents said the facility needed extra CNAs to walk the halls and help the residents. III. Additional resident interviewsResident #7, who was cognitively intact based on facility assessment, was interviewed on 8/12/24 at 2:51 p.m. Resident #7 said it took a long time for call lights to be answered at the facility. She said when she activated her call light, the staff would talk to her roommate first, even though she was the one who had activated the call light. She said it took even longer for the staff to attend to her needs because of that. Resident #7 said the staff would often enter her room, turn off her call light, ask her what she wanted and then say they would return. However, she said staff would not come back. She said she felt like the staff did not care about the residents. She said there had been a lot of recent turnover with the nursing staff and the new staff did not care like the other staff had. Resident #7 said she had expressed her concerns to the nursing staff during care conferences and her family had brought it up to management staff. She said the facility staff had not followed up on her concerns and she felt they were not being addressed. Resident #14, who was cognitively intact based on facility assessment, was interviewed on 8/12/24 at 3:21 p.m. Resident #14 said she let the facility staff know her concerns constantly but felt they did not care and her concerns were not addressed. She said an example was the call lights. She said it would take between 30 minutes to over an hour to get the call light answered, especially on the weekends. She said she had sat in her dirty brief for over an hour at times waiting for someone to come in and provide her assistance. Resident #14 said she had expressed her concerns to the director of nursing (DON) on multiple occasions, however, she said the problems never got any better. She said she did not think the DON liked her very much and would disregard any of her concerns. Resident #14 said there had been a lot of nursing staff turnover recently and she felt the environment at the facility was not a caring environment. Resident #14 said, that morning (8/12/24), the nursing staff did not wake her up in time for breakfast. She said by the time she woke up, the CNA told her breakfast was over and she could not have anything. She said she ate cereal and a banana every morning for breakfast. She said her favorite CNA, who was working another hallway, entered her room around 10:15 a.m. to see how she was doing. She said that CNA, after being told the resident did not have breakfast, went to the kitchen and got her cereal and a banana. She said this particular CNA was rare and was one of the only staff members who truly cared about the residents. Resident #14 said she had written up a lot of grievances. She said she turned them into the nursing staff or the DON and then would not hear any follow up. She said her concerns were never addressed. Resident #36, who was cognitively intact based on facility assessment, was interviewed on 8/13/24 at 9:38 a.m. Resident #36 said he felt the nursing staff at the facility did not care about the residents. He said when he would voice a concern, he felt like it "fell on deaf ears." He said he had expressed his concerns a lot and did not feel like the facility tried to resolve them. Resident #36 said he had expressed on multiple occasions his frustration with his medications being administered late. He said the nursing staff would answer his call light and say they would be back but then not return. He said he would often find the staff sitting in the computer room on their cell phones and call lights would be going off in the hallway. Resident #59, who was cognitively intact based on facility assessment, was interviewed on 8/13/24 at 10:07 a.m. Resident #59 said the facility took a long time to answer the call lights. He said sometimes he would wait for longer than 30 minutes. He said he had expressed his frustration to the therapy department and the nursing staff. Resident #59 said he had been living with Parkinson's disease for a long time. He said a side effect of the disease that he dealt with every day was hand tremors. Resident #59 said he had never experienced this bad of hand tremors. He said the facility had not been administering his medication appropriately. Resident #59 said his hand tremors had been worse since he was admitted to the facility. He said he had expressed his frustration to the nursing staff. He said the facility had never followed up with him regarding his concerns. Cross reference F760: the facility failed to ensure Resident #59's Parkinson's medications were administered according to the manufacturer's guidelines. IV. Staff interviewsCNA #1 was interviewed on 8/15/24 at 11:08 a.m. CNA #1 said she had worked in the facility for a long time. She said when a resident voiced a concern, if she was able to handle it herself, she would, otherwise she said she would tell the nurse on duty. She said she was aware the facility had a grievance policy, however, she was not sure what it entailed. CNA #1 said she had never filled out a grievance form for a resident. The social services director (SSD) and the social services consultant (SSC) were interviewed together on 8/15/24 at 3:02 p.m. The SSD said the social services department was responsible for reviewing the grievances, distributing them to the appropriate department and ensuring follow-up occurred with the resident. She said each department was responsible for addressing the grievance with the resident. The SSD said the amount of grievances received had gone up in the last three months. She said she had not seen an improvement yet, but was working to make sure the grievances were addressed timely for the residents. The SSD said she had received a lot of grievances related to call light response times, especially on the weekends. She said the grievances documented that residents were waiting a long time for call lights to be answered. She said the residents had voiced concerns over call light wait times during meals. The SSD said she did not know what the response was for the call light grievances or if the residents were satisfied with the response. The SSD said the facility had implemented ambassador rounds for all the department heads. She said the department head was responsible for meeting with their list of assigned residents three times per week and turning in a form every Friday about the resident rounds. The SSD said the ambassador rounds did not formally follow up with written grievances for any concerns. She said she was not aware of what happened to any resident concerns documented on the ambassador round forms. Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 5:06 p.m. LPN #1 said she had never filled out a grievance form for a resident. She said she knew the grievance form went through a chain of command but did not know what department received the grievance forms. She said she did not know the facility's policy for grievances. She said she thought grievances should be addressed within 24 to 48 hours. The director of nursing (DON), the NHA and the clinical consultant (CC) were interviewed together on 8/15/24 at 5:44 p.m. The DON said grievances were filed through the ambassador rounds, from an individual resident or from the resident council meeting. She said any staff member who was told a concern by a resident should fill out a grievance form and turn it into the social services department. The DON said each grievance should be investigated within 72 hours of the form being completed. She said each grievance should have a plan developed to address the concern and follow up with the resident to ensure their satisfaction. The DON said the residents had voiced their concerns over call light response times. She said she felt like the residents only wanted their favorite CNAs to answer the call light and would not allow other staff to assist them. The NHA said she had recently implemented the ambassador rounds to assist with resident concerns. The DON said she felt the residents saying they felt some of the staff did not care was unfair because she had tried to change the culture of the facility. However, she said she could not point to anything specific she had done to change the culture. The NHA was interviewed again on 8/15/24 at 7:08 p.m. The NHA said the ambassador rounds were non-existent when she first started at the facility a couple of months prior. She said the department heads had not completed grievance forms for resident concerns that they were documenting on the ambassador rounds. She said that was an oversight in direction that she would fix. The NHA saidshe felt that receiving grievances was not a bad thing, but pointed to areas where the facility could improve. She said she thought the rest of the department heads did not feel the same way. She said she was trying to change that mindset. The NHA said she thought the culture at the facility needed a change but she was not sure what that change would entail just yet. She said she had been trying to come up with different ideas for the staff to change their mindset. The NHA said all grievances should be followed up on to ensure the facility staff were doing everything they could to do right by the residents.

Plan of correction · submitted by the facility

0565 S/S E Resident/Family Group Response I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: Specifically, the facility failed to make prompt efforts to resolve resident grievances about a variety of concerns, including grievances not being answered in a timely manner, staffing shortages with provision of timely care and responding to resident call lights. DON/designee specifically followed up with residents #1, #3, #17, #22, #23 & #52 to ensure their grievances filed were followed up with. All residents had the potential to be affected. Interviewable residents will be solicited to and asked if they have any grievances filed. Any grievances will be noted on grievance forms and solutions sought accordingly. Any resident who can not articulate their potential grievances, their responsible party will be sought, and any grievances voiced will be noted on grievance forms and solutions sought, residents will be collaborated with to ensure they are agreeable to resolution by September 12,2024 All residents were invited to a resident council meeting focusing on the ‘Grievance system“, informing them of who to solicit, and follow up with, and who to seek out in the event the grievance wasn’t addressed. The Social Services Director was provided education by the administrator, regarding the grievance policy, timing for response to grievance and the use of the grievance log on or before 9/12/24. The IDT team was provided education by the Administrator with regards to the IDT’s involvement in the grievance process to include the delegation of responsibility regarding grievances that concern their departments and ensure the grievance was addressed by the correct department and are all IDT members familiar with the resolution on or before 9/12/24 All staff were provided specific education related to the grievance process to include staff response when a resident voiced a grievance to any department. The Administrator/designee will audit all grievances 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for 3 months to ensure solutions were sought and within the decided upon timeframe. (verbal interviews with residents will be initiated to ensure satisfaction with resolution and will be documented on grievance forms)All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0584Safe/Clean/Comfortable/Homelike EnvironmentS/S E▼

Findings

Based on observations and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents. Specifically, the facility failed to ensure resident rooms, bathrooms and hallways received necessary maintenance repairs. Findings include:I. Observations and resident interviewsOn 8/12/24 at 10:24 a.m. the corner edge of the sink in room #124 was chipped. The left side of the sink had a chipped piece missing. The side wood panel to the sink was chipped on the right side. On 8/12/24 at 1:14 p.m. the dresser next to the bed in room #122 was missing both of the drawer fronts that had handles to open the drawers. The drawer front to the bottom drawer The resident who resided in room #122 reported that the dresser drawer had been broken for a while. On 8/12/24 at 3:20 p.m. room #111's window curtain on the left side was disconnected from five hooks. A family member of the resident who resided in room #111 said the curtain had been disconnected for two weeks. On 8/14/24 at 2:30 p.m. the door going into the dining room down across from room #101 had missing baseboards and trim around all of the edges of the door. On 8/14/24 at 2:32 p.m. one ceiling tile in room #112 had a brown water stain on it. In the bathroom of room #112, behind the toilet, there was a part of the wall that had been patched and needed to be painted. On 8/14/24 at 2:33 p.m. room #119 had two ceiling tiles that were discolored and brown. In the bathroom in room #119, the wall behind the toilet had a part of the wall that had been patched and needed to be painted. The bathroom wall on the left side as one exited the bathroom was chipped. The side panel on the sink was chipped. One of the dresser drawers that were built into the wall in room #119 were chipped on the left side. In room #119, one of the residents who resided in the room had a fan that was attached to the wall by the head of the bed that was coming off the wall. The resident said she was afraid the fan was going to come off the wall and hit her in the head. The same resident's light fixture at the head of the bed in room #119 was missing the light cover. On 8/14/24 at 2:35 p.m. room #S2 had two ceiling tiles that were stained brown. On 8/14/24 at 2:36 p.m. room #S1 had one ceiling tile with a white circular stain. On 8/14/24 at 2:37 p.m. the hallway between room #S2 and room #S1 had three stained ceiling tiles that were brown. On 8/14/24 at 2:38 p.m. the floor down the Silverthorn unit was removed and covered up with flooring paper and tape. On 8/14/24 at 2:40 p.m. at the main entrance of the facility there were six ceiling tiles that had brown stains on them. On 8/15/24 at 4:03 p.m. the ceiling in the Breckenridge hallway shower room had approximately five inches of paint that was peeling off by the toilet. The wall by the sink in the Breckenridge shower room was patched but needed to be painted. II. Staff interviewsAn environmental tour was conducted on 8/15/24 at 4:17 p.m. with the maintenance director (MTD) and the above concerns were observed. The MTD said staff should be putting in work orders when they noticed something was broken. He said the facility utilized an electronic work system to track needed repairs. He said the facility staff also verbally let him know what needed to be repaired. He said the receptionist or the maintenance staff put the work orders into the electronic work system. He said most of the facility staff did not have access to the electronic work system. He said all of the maintenance staff knew how to put a work order into the electronic work system. The MTD said he did a walk through with new employees to show them the facility. He said he did a morning walk through every day he was working. He said the walk through usually took him 30 to 40 minutes to complete. He said he would do a walk through by himself or with two of his technicians that worked with him. He said he would take notes on what needed to be repaired. He said every Monday and Wednesday he did a building inspection where he checked the water temperature, air temperature and fans in the bathroom. The MTD said if he found any issues during the building inspection he would let the nursing home administrator (NHA) know. He said the NHA did a walk through the building with him once a week. He said the last time he did a walk through with the NHA was on Monday 8/12/24. He said they noticed the ceiling tiles were stained and needed to be repaired. He said he replaced the ceiling tiles three to four times a year. The MTD said when there was an empty resident room his staff would do a whole remodel and find out what needed to be fixed and repaired before another resident was admitted to the room. The MTD said work orders could take a while to get approved depending on how much it cost to fix the issue. He said anything that cost over 2500 dollars had to be approved by the NHA and the corporate office prior to him fixing it. He said the approval process could take one week, three weeks or even one month.. He said if he was working on a big project he needed to get two separate quotes from contractors and then the corporate office decided who they were going to use. He said he had gotten one quote for the floor down the S hallway and was waiting on another quote before he could send it off for approval. He said he did not know how long it would be before the floor would be replaced down the S hallway.

Plan of correction · submitted by the facility

Tag 0584 S/S - E Safe/Clean/Comfortable/Homelike EnvironmentI. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: Specifically, the facility failed to ensure resident rooms, bathrooms and hallways received necessary maintenance repairs. Any areas identified were corrected on or before 9/12/24. All maintenance staff were educated on maintaining All fans, clean ceiling tiles, wall repairs, chipped paint were fixed timely. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: All rooms in the center have the potential to be at risk for the deficient practice Environmental rounds were completed-including paint needs, ceiling tiles, unsecured cable cord, and cleanliness. All rooms with these deficient practices will be repaired/cleaned by 9/12/24. Maintenance supervisor/designee will educate all employees to report any issue with flooring and cable cords immediately to the maintenance department per the maintenance reporting system, (tels). All staff will be educated on the policy and procedure on the facility policy for Accidents/hazards and Supervision on or before 9/12/24. IV. HOW THE FACILITY PLANS TO MONITOR PERFORMANCE TO MAKE SURE THE SOLUTIONS ARE SUSTAINED The maintenance team will conduct environmental rounds, corrections will be placed in TELs as a work order any continued concerns will be documented on a grievance. Three times a week for 4 weeks then twice a week for 4 weeks then weekly x 4 weeks to ensure there are no environmental hazards or repairs needed resident rooms. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0585GrievancesS/S D▼

Findings

Based on record review and interviews, the facility failed to ensure one (#4) of three residents out of 33 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #4's grievance, which he had communicated to staff on multiple occasions, regarding the resident's care. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, revised August 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:14 p.m. It read in pertinent part, "It is the policy of this facility to establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, other concerns regarding their facility stay and make prompt efforts to resolve grievances the resident may have."The facility's grievance official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident, if requested and coordinating with state and federal agencies as necessary."The grievance official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated."The grievance official or designee responds to the individual expressing the concern within three working days of the initial concern to acknowledge receipt and describe steps taken toward resolution."II. Resident #4A. Resident statusResident #4, age 82, was admitted on 2/22/16. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 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. She could hear adequately, was able to understand others and made herself understood. B. Resident interviewResident #4 was interviewed on 8/13/24 at 10:33 a.m. Resident #4 said she filed a grievance right before she went to the hospital on 8/5/24. Resident #4 said a certified nurse aide (CNA) was unfamiliar with her care and did not know how to transfer her with the sit to stand mechanical lift. Resident #4 said the CNA left the room to get another staff member to help her and was gone for 30 minutes. When the CNA returned, Resident #4 said she was upset because she had waited so long. She said the CNA argued with her and spoke in a disrespectful manner. Resident #4 said she wrote out a grievance and gave it to her regular CNA to give to the NHA.C. Record reviewA nursing progress note, dated 8/3/24 at 3:46 p.m., documented Resident #4 said a CNA was incompetent to care for her. -The progress note did not indicate a grievance was filed by the resident. On 8/14/24 at 4:30 p.m. the NHA provided a grievance form dated 4/5/24, regarding call light times. The facility follow-up was educating staff and monitoring of call light times. On 8/15/24 at 5:45 p.m. the NHA provided an additional grievance form, dated 8/5/24 which noted an investigation was started upon review of a progress note from 8/3/24 related to Resident #4. The follow-up action on the grievance form indicated Resident #4 was spoken to regarding the importance of skin hygiene and teaching new CNAs her preferences for care. -The grievance did not address Resident #4's concern of the CNA arguing with her and speaking to her in a disrespectful manner. The resident's name was not on the grievance form and the section for the resident's concern was blank. III. Staff interviewsThe director of nursing (DON) was interviewed on 8/15/24 at 5:45 p.m. The DON said grievances came through staff rounding with the residents, individual resident concerns and through reports from a CNA or other staff member. She said grievances had to be followed up on by the manager of the department the concern pertained to within three days. She said the grievance was supposed to have some sort of resolution that was satisfactory for the resident. The DON said Resident #4 had a history of self-sabotaging and not allowing care if she thought the CNA did not know how to care for her. The DON said the resident would say the staff were incompetent. She said Resident #4 did not tell the staff how she wanted them to care for her. The DON said they had tried to train other staff how to care for Resident #4 but she still preferred only certain staff.

Plan of correction · submitted by the facility

F 585 Grievances I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: DON/designee re-interviewed resident # 4 to reestablish preference, previously identified care concerns and updated the resident’s care plan per resident's preferences. All interviewable residents will be solicited to and asked if they have any grievances. Any grievances will be noted on grievance forms and solutions sought accordingly. Any resident who cannot articulate their potential grievances, their responsible party will be sought, and any grievances voiced will be noted on grievance forms and solutions sought, residents will be collaborated with to ensure they are agreeable to resolution on or before 9/12/24 All residents were invited to a resident council meeting focusing on the ‘Grievance system“, informing them of who to solicit, and follow up with, and who to seek out in the event the grievance was not addressed. The Social Services Director was provided education by the administrator, regarding the grievance policy, timing of response to grievance and the use of the grievance log on or before 9/12/24. The IDT team was provided education by the Administrator with regards to the IDT’s involvement in the grievance process, the delegation of responsibility regarding grievances that concern their departments, if the grievance was addressed by the correct department, and are all IDT members familiar with the resolution on or before 9/12/24 All staff were provided with education on the grievance process, specifically their response when a resident voiced a grievance to them. The Administrator/designee will audit all grievances 3x weekly x 4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for 3 months to ensure solutions were sought and within the decided upon timeframe. (verbal interviews with residents will be initiated, to ensure satisfaction with resolution, concerns will be documented on grievance forms)All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0658Services Provided Meet Professional StandardsS/S D▼

Findings

Based on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for one (#4) of one resident reviewed out of 33 sample residents. Specifically, the facility failed to ensure medications were not left at Resident #4's bedside. Findings include:I. Facility policy and procedure The Medication Administration policy, dated January 2023, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part,"Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so."Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center."Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's interdisciplinary team (IDT), and in accordance with procedures for self-administration of medications and state regulations."The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the medication administration record (MAR), and action is taken as appropriate."II. Resident #4A. Resident statusResident #4, age 82, was admitted on 2/22/16. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failure, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. The 7/13/24 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. She could hear adequately, was able to understand others and made herself understood. She was independent with eating and drinking. B. Observations and interviewOn 8/15/24 at 9:17 a.m. Resident #4 was in bed in her room. There were two cups of pills on her bedside table. One cup contained seven pills and the other cup contained two pills, one of the pills was broken in half. Resident #4 said she asked for fresh ice water to take her seven pills this morning but no one had brought her any so she was unable to take her medications. Resident #4 said the cup containing two pills was from last night (8/14/24). Resident #4 said the night nurse delivered the pills to her but did not return to see if she had taken the medications. C. Record reviewThe self-administration of medication evaluation, completed on 8/12/24 (during the survey), revealed Resident #4 was able to self-administer medication.-A review of Resident #4's electronic medical record (EMR) did not reveal a physician's order for the resident to self-administer oral medications. -A review of Resident #4's comprehensive care plan did not reveal documentation regarding the resident's ability to self-administer medications. A review of the August 2024 medication administration record (MAR) indicated licensed practical nurse (LPN) #3 administered cetirizine HCl 5 milligrams (mg) and calcium carbonate with vitamin D 600 mg-400 mg at 11:04 p.m. on 8/14/24. D. Staff interviewsLPN #1 was interviewed on 8/15/24 at 9:17 a.m. LPN #1 said she delivered medications to Resident #4 that morning (8/15/24). LPN #1 said the nurses left Resident #4's medication at her bedside and she took her medication when she was ready. LPN #1 said she checked in with the resident about two hours after she gave the resident the medication cup to see if the resident had taken the medication. LPN #1 said Resident #4 did not ask for fresh ice water when she delivered her medication that morning. LPN #1 said she only delivered one medication cup containing seven pills. LPN #1 said she did not see the other medication cup containing two pills when she delivered Resident #4's morning medications but she said the medications must have been from the previous night. LPN #1 said she would document that the resident did not take the two pills and dispose of the medications. LPN #1 said she would get fresh ice water for Resident #4 and make sure she took her morning medications. The director of nursing (DON) was interviewed on 8/15/24 at 6:23 p.m. The DON said medications could be left at the bedside if a resident was independent and had been assessed to safely self-administer their medications. The DON said if the nurse left medications at the bedside, the nurse should go back and check with the resident before the end of their shift to make sure the resident took the medications. E. Facility follow upOn 8/15/24 at 5:45 p.m. the DON provided a copy of a counseling notice, dated 8/15/24 (during the survey), for LPN #3. The notice indicated LPN #3 received a written warning via telephone for documenting medications as administered on the evening of 8/14/24 without verifying the medication was taken by the resident. The counseling notice was signed by the DON.

Plan of correction · submitted by the facility

658 Services Provided to Meet Professional StandardsResident #4’s physician was notified that the resident frequently preferred to have her meds left at bedside. All Residents including Resident #4 were educated on the need to take their medications when delivered. An audit of the MAR (medication administration record) will be conducted identifying all medication refusals identifying why the medication was refused after speaking with the resident notify the physician and document any changes to the regimen or note any new orders received to be completed by 9/12/24. The DON/designee will complete education with all nursing staff to include medication administration policies and procedures (not leaving medication at bedside, ensuring a resident who has orders to self-administer medications and are properly care planned) on or before 9/12/24 The DON/designee will conduct an audit of refused medication entries to ensure any medication not given will have an accompanying note stating why the medication was refused and with evidence that physician was informed, (documentation to be made in residents electronic record, to include notification to physician, any new orders received) 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for a total of 3 months to ensure that these solutions are sustained. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions. The DON/designee will observe 5 resident rooms during med pass to ensure medications are not left at bedside, 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for 3 months to ensure these solutions are sustained. All outcomes from audits and observations will be analyzed and reviewed at QAPI to establish further solutions.

0660Discharge Planning ProcessS/S D▼

Findings

Based on record review and interviews, the facility failed to develop and implement effective discharge planning for one (#59) of two residents reviewed for discharge planning out of 33 sample residents. Specifically, the facility failed to develop and implement a collaborative discharge plan that involved Resident #59's discharge goals. Findings include:I. Resident #59A. Resident statusResident #59, age 72, was admitted on 7/11/24 and readmitted on 7/31/24. According to the August 2024 computerized physician orders (CPO), the diagnoses included Parkinson's disease. The 8/7/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required partial or moderate assistance with activities of daily living. B. Resident interviewResident #59 was interviewed on 8/13/24 at 10:07 a.m. Resident #59 said he was admitted to the facility for short-term rehabilitation. He said his goal was to move back to the community. He said his previous living arrangement was with a family member who had passed away and he was not sure if he was able to return. Resident #59 said the facility staff had not asked him what his discharge plan goal was except for when he was first admitted. He said he did not feel like anyone was working toward a goal of him discharging but were instead planning on him staying at the facility under long-term care services. Resident #59 said he was aware of his limitations with Parkinson's disease, but he wanted to be as independent as possible for as long as possible, which included his living situation. He said facility staff had not developed goals with him for discharge or provided him different options for when he would return to the community. Resident #59 said he did not want to stay at the facility for long-term care. He said he had never told the facility staff he wanted to stay, but he felt that they were planning to do whatever they wanted without consulting him. C. Record reviewThe 8/8/24 social services assessment documented the resident previously lived alone with a family member who had passed away. It indicated that a family member was the resident's only support, however, the resident was still in touch with his brother-in-law. The social services assessment documented the resident had a discharge plan of long-term care placement at the facility.-The assessment did not document the resident's wish to return to his previous living situation, nor did it provide any documentation or follow-up with the brother-in-law to determine if the resident living with the brother-in-law was a viable option.-A review of the resident's comprehensive care plan did not reveal documentation that a care plan had been developed with the resident's discharge goals and any interventions to assist the resident in achieving those goals.-A review of the resident's electronic medical record (EMR) did not reveal documentation that active discharge planning had been conducted for Resident #59. II. Staff interviews The social services director (SSD) and the social services consultant (SSC) were interviewed on 8/15/24 at 3:02 p.m. The SSD said social services was responsible for discharge planning. The SSC said discharge planning was fluid and should begin at the resident's admission and continue throughout their stay at the facility. She said the comprehensive care plan should include the resident's discharge goals and interventions to assist the resident to achieve those goals. The SSD said the discharge goals were obtained during the initial social services assessment when the resident was admitted to the facility. She said from there, the comprehensive care plan would be developed within the first seven days of the residents' admission. The SSC said the least restrictive goal was the initial plan and development of that plan would lead to achievement or alteration of the goals. The SSD said Resident #59 planned to remain at the facility for long-term care. She said she had documented that on the social services assessment. She said she did not know the resident wanted to return to his previous living arrangement or a possible assisted living. She said she had not provided Resident #59 with any discharge alternatives other than long-term care. The SSD confirmed she had not developed a discharge care plan within the comprehensive plan of care. She said that should have been developed immediately following the completion of the social services assessment. The SSD said she would meet with Resident #59 and provide him with alternative discharge options and a list of different assisted living communities. She said she would develop his discharge plan and interventions to reach his goals. The SSD was interviewed again on 8/15/24 at 5:11 p.m. The SSD said she went to Resident #59's room to speak about his discharge goals, however the resident said he had a migraine and asked if she could visit later. She said she set up a care conference to discuss his discharge goals for the following week.

Plan of correction · submitted by the facility

F660-Discharge PlanningCorrections-Specifically, the facility failed to develop and implement a collaborative discharge plan that involved Resident #59's discharge goals. Resident #59 was re-interviewed regarding his discharge goals and his care plan was updated. Identification of others-All Short-term residents had the potential to be affected. Systemic Changes-The IDT (interdisciplinary team) was provided related to developing and implementing effective discharge planning for all short-term residents. The IDT education will be completed on or before 9/12/24. Monitoring-SS/designee will conduct an audit of 3 residents slated to discharge to ensure their discharge goal is met, (documentation of these efforts will be indicated in the residents record) 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for a total of 3 months to ensure that solutions were sought and within the decided timeframe. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0677ADL Care Provided for Dependent ResidentsS/S E▼

Findings

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#18, #45 and #5) of three residents reviewed for assistance with ADLs out of 33 sample residents. Specifically, the facility failed to:-Ensure Resident #18 and #45's fingernails were trimmed and clean; and,-Ensure Resident #5 received staff assistance with getting dressed. Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADLs) policy and procedure, dated October 2022 was received by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, "The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable."Care and services will be provided for the following activities of daily living, bathing, dressing, grooming and oral care."The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment."A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene."The facility will maintain individual objectives of the care plan and periodic review and evaluation."II. Resident #18A. Resident statusResident #18, age 78, was admitted on 5/19/22. According to the August 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease stage four and dementia. The 8/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required set up or clean up assistance with eating, oral hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear and personal hygiene. B. Observations and resident interviewResident #18 was interviewed on 8/12/24 at 10:30 a.m. Resident #18 said his fingernails were long and the staff did not cut them when he received his showers. He said he wanted his fingernails cut. He said he did not know the last time his fingernails were trimmed. Resident #18's fingernails extended past the tip of his fingers and had brown matter underneath them. He had fingernail clippers on his dresser and he said they were too small and did not work for him. C. Record reviewThe ADLs care plan, revised on 6/1/23, documented Resident #18 had an ADL self care performance deficit related to impaired mobility/cognition due to dementia, chronic renal failure with hypoxia. Interventions included conversing with the resident while providing care, explaining all procedures/tasks before starting, praising all efforts at self-care and encouraging the resident to discuss feelings about self-care deficits.-The care plan did not include information regarding the resident's nail care.-A review of the certified nurse aide (CNA) task documentation for nail care (reviewed from 7/12/24 to 8/15/24) revealed there was no documentation indicating the resident had received nail care during that time period. III. Resident #45A. Resident statusResident #45, age 76, was admitted on 6/1/24. According to the August 2024 CPO, diagnoses included Alzheimer's disease, dementia and stage four chronic kidney disease. The 7/3/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. He was dependent on staff assistance with toileting hygiene, showering/bathing, upper and lower body dressing and putting on/taking off footwear. He required set up or clean-up assistance with personal hygiene. B. Observation and resident interviewResident #45 was interviewed on 8/12/24 at 1:17 p.m. Resident #45 said his fingernails were long and had not been trimmed since his admission. He said staff had never offered to trim his nails. He said he would like his fingernails to be trimmed. Resident #45's fingernails extended past the tip of his fingers and he had brown matter underneath all of his nails. C. Record reviewThe ADL care plan, revised 6/24/24, documented Resident #45 had an ADL self care performance deficit. Interventions included encouraging the resident to discuss feelings about self-care deficits, encouraging the resident to participate to the fullest extent possible with each interaction and providing maximum assistance of one to two people for personal hygiene.-The care plan did not include information regarding the resident's nail care.-A review of the CNA task documentation for nail care (reviewed from 7/12/24 to 8/15/24) revealed there was no documentation indicating the resident had received nail care during that time period. D. Staff interviewsCNA #1 was interviewed on 8/15/24 at 10:34 a.m. CNA #1 said the CNAs and shower aides were responsible for cutting the residents ' fingernails. She said the residents' fingernails should be cut once a week or every other week. She said the best time to cut the residents ' fingernails was during their showers. She said she did not know the last time Resident #18 and Resident #45 had their fingernails trimmed. CNA #1 said Resident #18's and Resident #45's fingernails needed to be cut. She said she did not know why both residents had not had their fingernails cut recently. She said both of the residents should have had their fingernails cut before they got that long. Licensed practical nurse (LPN) #2 was interviewed on 8/15/24 at 11:33 a.m. LPN #2 said if the resident was not diabetic that the CNAs could cut the residents' fingernails. She said if the resident was diabetic then the nurses were responsible for cutting the residents' fingernails. She said she did not know how often the residents' fingernails should be cut. She said the best time for the residents to have their fingernails cut was when they were taking a shower. LPN #2 said Resident #45 could not cut his own fingernails because he had vision impairments. She said Resident #18 was not able to cut his own fingernails. She said all of the residents should have received assistance cutting their nails and should not cut them on their own. She said did not know when the last time Resident #18 and Resident #45 had their fingernails cut. She said both residents should have had their fingernails cut. She said she did not know why both residents' fingernails were not cut. The director of nursing (DON) was interviewed on 8/15/24 at 6:44 p.m. The DON said the CNAs, shower aides and nurses could cut the residents' fingernails. She said if the resident was diabetic a nurse needed to cut the fingernails. She said residents' fingernails should be cut when they were long, sharp or dirty and when they requested it. She said during shower times the residents' fingernails should be checked and cut if needed. The DON said she did not know when the last time Resident #18 and Resident #45 had their fingernails cut. She said she would provide education to the staff about checking and cutting fingernails. IV. Resident #5A. Resident statusResident #5, age 68, was admitted on 9/13/22. According to the August 2024 computerized CPO, diagnoses included type 2 diabetes mellitus, chronic respiratory failure, hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems) and bipolar disorder (a mental illness causing severe mood swings). The 7/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent on staff for transfers, dressing and toileting hygiene. The 4/24/24 MDS assessment indicated it was very important for Resident #5 to choose which clothes to wear. B. Resident observations and interviewOn 8/14/24 at 11:22 a.m. Resident #5 was sitting in her wheelchair in her room wearing a hospital gown. Resident #5 said the staff did not have time to get her dressed this morning (8/14/24) and she went to the dining room for breakfast in a hospital gown. Resident #5 said she usually got dressed in her clothes in the morning, which was what she preferred to do. She said she would go to lunch in her hospital gown because it was too much trouble to get dressed now that she was up. At 12:34 p.m. Resident #5 was sitting in her wheelchair in the dining room for lunch wearing a hospital gown. C. Record reviewThe activities of daily living (ADL) care plan, initiated 2/14/24, revealed Resident #5 required substantial assistance from one staff member to get dressed and she preferred to go to the dining room for meals. -The care plan did not indicate she preferred to wear a hospital gown when out of bed.-The CNA documentation (8/1/24 to 8/14/24) did not indicate the resident refused to get dressed on 8/14/24. D. Staff interviewsThe DON was interviewed on 8/15/24 at 6:13 p.m. The DON said residents should be given a choice of what they wanted to wear each day. She said residents should receive assistance getting dressed in personal clothing unless it was their preference not to. The DON said she did not know why Resident #5 was not dressed in the clothes she preferred to wear on 8/14/24.

Plan of correction · submitted by the facility

TAG E 677 Activities of Daily Living (ADLs)/Mntn Abilities I. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE: Corrections- Resident # 18 nails trimmed. Resident # 45 nails trimmed. Resident #5 assistance level was reviewed and IDT to ensure the appropriate level was reflected on the care plan. II. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE: All residents could be affected by the deficient practice. Identification of others-DON/Designee completed a full house audit to ensure all residents nails were cleaned and trimmed, and residents dressed for the day on or before 9/12/24. Nursing staff were provided with education on the facility’s policy and procedure related to activities of daily living and ensure residents are well groomed on or before 9/12/24. DON/designee will conduct a random ADL audit to include nail care and dressing to include observation. Verbal interviews to residents to include preference of clothing and nail trimming documentation in electronic record. 3x week x 4 weeks then 2x week x 4 weeks then weekly x 4 weeks to ensure compliance is sustained. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0684Quality of CareS/S G▼

Findings

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#4) of two residents reviewed out of 33 sample residents. Resident #4 was admitted on 2/22/16 for long term care with diagnoses of type 2 diabetes with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failures, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. On 7/12/24 Resident #4 struck her right lower leg on the side of her metal bed frame when she was maneuvering her electric wheelchair near her bed, causing a hematoma (bruise) to her leg. The resident reported the injury was very painful. On 7/15/24 the facility obtained an x-ray of the resident's right lower extremity, which was negative. The facility failed to consistently document observations of the resident's injury. On 7/22/24 the resident reported increased pain and swelling, the nurse practitioner (NP) ordered ice three times a day to the area. On 7/29/24 the wound doctor (WD) visited the resident for a different wound. The WD did not see or assess the resident's wound to her right lower extremity. Due to the facility's failure to consistently monitor and document the status of the resident's wound, the resident was sent to the emergency department on 8/5/24 for increased swelling and pain. At the hospital, Resident #4 was diagnosed with cellulitis to the right lower extremity and she had an increased white blood cell count. The resident had surgery to drain and clean out the right leg wound which had become infected and required treatment with intravenous (IV) antibiotics. Findings include:I. Facility policy and procedureThe Skin and Wound Monitoring policy, dated January 2022, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part,"A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whetherpresent on admission or developed after admission, which exists on the resident. Thisassessment/evaluation should include but not be limited to: measuring the skin injury; staging the skin injury (when the cause is pressure); describing the nature of the injury (pressure, stasis, surgical incision); describing the location of the skin alteration; describing the characteristics of the skin alteration; describing the progress with healing, and any barriers to healing which may exist; and, identifying any possible complications or signs/symptoms consistent with the possibility of infection."Weekly skin checks will be conducted by a licensed nurse. All residents will have a head to toe skin check performed at least weekly by a licensed nurse. The licensed nurse should document the findings."II. Resident #4A. Resident statusResident #4, age 82, was admitted on 2/22/16. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy, chronic kidney disease, heart failure, chronic obstructive pulmonary disease , major depressive disorder and anxiety. The 7/13/24 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. She could hear adequately, was able to understand others and made herself understood. B. Resident interviewResident #4 was interviewed on 8/13/24 at 10:33 a.m. Resident #4 said she returned from the hospital yesterday (8/12/24). She said she had an infection in her leg that required surgery. Resident #4 said about a month ago (July 2024), she hit her leg on her bed frame when she was trying to maneuver her electric wheelchair in her room. She said there were no staff around and she was trying to get to her call light, which was on the floor. She said her leg started swelling and hurting right away. Resident #4 said an x-ray was done a couple of days later and there was no fracture so the staff stopped monitoring her leg. Resident #4 said the swelling continued to worsen and the area became warm and painful. Resident #4 said she was told by the nurses she just needed to ice the area to decrease the swelling. Resident #4 said after a few weeks, a red bump formed on top of the swollen area of her leg. She said when this occurred, the nurse called the doctor and was concerned about a blood clot. She said when her leg started draining, the facility decided to send her to the hospital. C. Record review The 7/12/24 incident report, completed by the director of nursing (DON), revealed Resident #4 hit her right leg on the metal part of her bed frame while maneuvering her electric wheelchair in her room. The report documented she obtained a large hematoma with red, blue and purple discoloration. The resident reported the leg was very painful. The DON applied ice to the area and instructed the resident to elevate her leg in the recliner. The physician was notified. The 7/15/14 interdisciplinary team (IDT) progress note indicated x-rays were obtained of the resident's right leg which were negative for a fracture. The note documented the IDT recommended therapy to evaluate the resident's environment and assess the resident's electric wheelchair for safety. According to the nurse progress notes, alert charting (charting done when a resident's condition needs to be monitored) was initiated after the incident on 7/12/24. -However, there were no progress notes documented on 7/13/24 or 7/14/24 to indicate the injury was assessed or was being monitored. The 7/15/2024 alert charting indicated it was the third day of the skin alteration to the resident's right lateral (outside) lower extremity. The area had a dark purple discoloration to the mid-outer calf with an indentation to skin proximal to the ankle with a possible hematoma above the indentation. The resident reported the area was tender to soft touch. An x-ray was completed that morning and the results were pending. The 7/16/24 alert charting indicated it was the fourth day of the skin alteration to the right lateral lower extremity. The area was dark purple discoloration to the mid-outer calf. There was an indentation to the skin proximal to the ankle with a possible hematoma above the indentation. The resident reported the area was tender to soft touch. The x-ray results were negative for fractures. The 7/17/24 alert charting indicated the resident had a skin alteration of a left calf hematoma due to hitting her leg on her bed frame while in an electric wheelchair. The nurses were monitoring for signs and symptoms of infection, pain to sight, or complications every shift for the hematoma to the left lower extremity for three days. There were no signs or symptoms of infection to the resident's left calf. The resident did not have complaints of pain. -However, the resident sustained an injury to her right leg, not the left leg (see record review above and DON interview below).-A review of the resident's electronic medical record (EMR) did not reveal any documentation from 7/18/24 to 7/21/24 regarding the status of the resident's right leg injury. The 7/22/24 nursing progress note documented the nurse practitioner (NP) was notified of increased swelling in Resident #4's right lower leg. The 7/23/24 NP progress revealed the NP visited Resident #4 at the facility. The NP note documented Resident #4 said her leg had decreased in swelling since 7/22/24 but she still had discomfort to the touch. The NP ordered ice to the area three times a day for three days, to encourage elevation and continue to monitor the area.-A review of the residents EMR did not reveal any additional nursing documentation to indicate the staff were monitoring the status of Resident #4's leg from 7/23/24 to 8/4/24. The 7/29/24 wound doctor (WD) progress note documented the WD visited Resident #4 for continued monitoring of a wound in her groin area. -The WD note did not document that the WD examined the resident's injury to her right lower extremity. The 8/5/24 nursing progress note, documented at 8:24 a.m., indicated a phone call was received from the NP with orders for a Doppler (an ultrasound test showing blood flow), to start Keflex (an antibiotic) for possible cellulitis (skin infection) and tramadol (an oral pain medication) for the resident's pain in her leg. The 8/5/24 nursing progress note, documented at 9:31 a.m., indicated the nurse placed a call to Resident #4's physician at 6:40 a.m. regarding the pain to her right lower leg approximately at the mid-calf. The area was red, warm and slightly elevated. The nurse requested a Doppler to rule out deep venous thrombosis (DVT - a blood clot). The 8/5/24 nursing progress note, documented at 1:39 p.m., indicated there was no evidence of a DVT in the resident's right lower extremity according to the Doppler test. The 8/5/24 nursing progress note, documented at 3:00 p.m., indicated the NP was called and notified the hematoma on Resident #4's right lower extremity had opened and was draining. The 8/5/24 nursing progress note, documented at 4:52 p.m., indicated Resident #4 was sent to the hospital emergency department for possible incision and drainage of a right lower extremity hematoma with bloody drainage and a foul smell. The 8/5/24 nursing progress note, documented at 5:28 p.m., revealed Resident #4 left the facility by emergency transport. The 8/5/24 hospital admission record revealed Resident #4 was diagnosed with cellulitis of the right lower limb, a cutaneous (on the skin) abscess of the right lower limb, local infection of the skin and subcutaneous (under the skin) tissue and an elevated white blood cell count of 13.6 (normal range is 4 to 11). The hospital physician's note indicated, upon admission, Resident #4 had a large area of fluctuant (fluid filled) swelling over the anterior pretibial (front of shin bone) space of the right lower leg. It was tender to palpation (touch). There was erythema (redness) with increased skin temperature. The area measured 14 centimeters (cm) length by 10 cm width by two cm depth. There was bloody, malodorous (foul smelling) and copious (large amounts) drainage. Resident #4 was complaining of pain to the right lower extremity which she rated at an 8 out of 10 and described as sharp in nature. The resident said she had been feeling poorly over the last several days. The hospital documentation indicated Resident #4 had surgery overnight for the wound incision and drainage, which was completed at 12:44 a.m. on 8/6/24. She was started on IV antibiotics. The resident returned to the operating room on 8/7/24 for removal of packing, wound re-evaluation and excisional debridement (cutting away of dead tissue) of the wound cavity and repacking. The culture of the wound determined it was infected with multi-drug resistant Escherichia coli (a common bacteria normally found in feces that can infect wounds). On 8/9/24, Resident #4 returned to the operating room for a wound washout and complex wound closure with drain placement. The wound size was 8 cm length by 7 cm width by 2 cm depth. III. Staff interviewsThe NP was interviewed on 8/16/24 at 3:07 p.m. The NP said she was aware of the injury on Resident #4's leg. The NP said she received a phone call on 7/22/24 from the facility regarding increased swelling in the resident's leg. The NP said she visited Resident #4 on 7/23/24. The NP said the leg did not show signs of infection at that time and she ordered ice to the area. The NP said she received another phone call from the facility on 7/30/24 regarding Resident #4 having increased pain in her leg. She said the resident did not want to take narcotics so she did not order any new medication. The NP said the nurses at the facility should have been monitoring the injury daily and documenting the status. The DON was interviewed on 8/15/24 at 6:36 p.m. The DON said the nurses should have continued to monitor Resident #4's leg until the injury was resolved. The DON said the NP did see Resident #4 on 7/23/24 and ordered ice to the area. The DON said the nurses should have documented their observations of the wound. The DON said there were no signs or symptoms of infection until right before the resident's hospitalization but this was not documented (see record review above). IV. Facility follow-upA chart review was received from the NHA on 8/19/24 at 10:37 a.m. (after the survey). The review was performed by the medical director (MD). The MD confirmed Resident #4 was visited by the wound doctor on 7/29/24 who said he remembered seeing a lesion on the right lower leg but he did not include this observation in his progress note. The MD confirmed that Resident #4 was hospitalized for an infected hematoma on the right lower leg resulting from trauma occurring at the nursing facility.

Plan of correction · submitted by the facility

G 684 Quality of CareResident #4 record was reviewed, and care plan, was updated to include monitoring of her current change in condition. Resident returned to facility, upon readmission nurse completed follow up related to all concerns. All have been addressed to the resident's satisfaction. A facility wide skin sweep was conducted to ensure any areas of skin alteration were identified with immediate interventions to include monitoring and treatments as appropriate; care plans updated and change of condition monitoring initiated on or before 9//12/24. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: All nursing staff were provided with education on skin management and the process for new skin alterations including change of condition, risk management, obtaining orders for treatment/monitoring on or before 9/12/24. DON/designee will perform an audit of 5 skin evaluations to include resident #4 ( for skin alterations including edema in the residents clinical record, In the event of new skin alteration a change of condition and risk management will be initiated and completed including alerting the MD and following orders given, initiating interventions as appropriate and monitoring until resolved) 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for a total of 3 months to ensure that these solutions are sustained. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0692Nutrition/Hydration Status MaintenanceS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure one (#39) of one resident out of 33 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically the facility failed to provide Resident #39 meal set-up assistance and implement nutritional interventions to prevent weight loss. Findings include:I. Facility policy and procedureThe activities of daily living (ADL) policy, dated 2022, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, "Care and services will be provided for the following activities of daily living eating to include meals and snacks."A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene."II. Resident #39A. Resident statusResident #39, age 83, was admitted on 1/19/22. According to the August 2024 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, type 2 diabetes mellitus, atherosclerotic heart disease (a build-up plaque in the arteries, restricting blood blow), lack of coordination, unspecified protein-calorie malnutrition, frontotemporal neurocognitive disorder (damage to the frontal and temporal lobes of the brain) and vitamin B-12 deficiency anemia. The 7/6/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. Resident #39 was able to feed himself with set-up assistance and was prescribed a mechanically altered diet. B. ObservationsDuring a continuous observation on 8/14/24, beginning at 11:55 a.m. and ending at 1:12 p.m., Resident #39 was sitting at a table in the dining room, drinking a beverage from a regular glass. At 12:29 p.m. Resident #39's food was delivered. An unidentified staff member set the resident's plate above his beverage, which was sitting directly in front of the resident. He was not served a dessert.-The unidentified staff member did not hand the resident a utensil, napkin or ensure his plate was set directly in front of him. Resident #39 picked up his fork and began eating his pureed food, reaching over his beverage. The resident dropped some food into his drink and attempted to fish it out with the fork. Resident #39 repeatedly put his fork in his drink. Resident #39 picked up the glass and drank some of his beverage and set the glass back in front of his plate. He continued reaching over the glass to eat his food. The registered dietitian (RD) was standing nearby observing residents and looking at her cellular phone. -The RD did not assist the resident with setting up his plate in a location where he could reach all of his food. At 12:35 p.m. Resident #39 dropped some pureed food from his fork onto the table. The resident attempted to pick the food up with his fork and eat it. He was attempting to reach the food on the far side of his plate, however he was unable to reach it, therefore the resident was only able to get small amounts of food on his fork. At 12:46 p.m. Resident #39 was attempting to get food out of his drink with his fork. He became distracted by another resident at his table and stopped eating. -The staff in the dining room did not notice or provide Resident #39 cueing to continue eating. At 12:53 p.m. Resident #39 leaned forward in his wheelchair to reach for the food on the far side of his plate but only got a small amount on his fork. The RD walked by but did not stop to assist him. Registered nurse (RN) #2 came into the dining room and looked over Resident #39's shoulder but did not offer to assist him. At 12:57 p.m. Resident #39 put down his fork and picked up his spoon. He leaned forward and reached for some more of the food on the far side of his plate. He continued this until he ate all the food within his reach,leaving the food that was around the far edge of the plate. The resident did not receive any dessert. At 1:06 p.m. the RD stopped at the table and talked to Resident #39's table mate. She did not offer to move Resident #39's plate closer to him. Resident #39 continued to lean forward in his wheelchair, reaching over his glass with his spoon. He was unable to reach more food and put the empty spoon into his mouth. At 1:12 p.m. certified nurse aide (CNA) #5, asked Resident #39 if he was going to eat anymore. She did not move his plate closer to him or move his glass out of the way so he could reach more food. Resident #39 did not respond to CNA #5. CNA #5 took his plate away. The plate had food remaining around the far edge from the 9:00 o'clock position to the 12:00 o'clock position. He had eaten approximately 75% of his meal. He did not receive a dessert. -The resident was observed attempting to eat without assistance for 41 minutes and did not eat 100% of his meal. On 8/15/24 at 12:21 p.m. Resident #39 was observed eating lunch in the dining room with his plate directly in front of him. He had finished 100% of the meal and dessert. He continued putting the spoon on his plate and into his mouth, but there was no food left on the plate. The RD approached Resident #39 and asked him if he wanted more to eat. She brought another plate of food to him and he continued eating. C. Record reviewThe self-care deficit care plan, initiated 1/20/22, documented Resident #39 had a self-care performance deficit related to impaired cognition and mobility due to dementia. The pertinent intervention included providing set-up to supervision assistance with eating. The nutritional care plan, revised on 7/31/24, documented Resident #39 had a nutritional problem related to diagnoses of dementia, dysphagia, protein calorie malnutrition and moderate cognitive impairment. He was at risk of malnutrition per the mini nutritional assessment (MNA) score and had a history of difficulty swallowing. The pertinent interventions included a nosey cup (specialized cup to aid with swallowing), mechanically altered meal with thickened liquids, providing assistance with meals as needed and large portions per resident request. -The care plan did not specify how much assistance Resident #39 needed with meals. -There were no new nutrition interventions added to the care plan since 12/20/23, including since his recent weight loss (see weights below). According to the August 2024 CPO, the resident had a physician's order for a consistent carbohydrate (CCHO) diet, pureed texture with honey thick liquids, ordered 7/3/24. An evening snack was ordered on 10/24/22. -Review of the resident's electronic medical record (EMR) did not reveal any additional nutritional interventions that were implemented. The nutrition evaluation, dated 7/3/24, indicated Resident #39 was independent with eating, he was alert and oriented and was able to make his needs known. It indicated his usual meal intakes were 75-100%, his weight was stable and there were no new recommendations.-The resident's EMR did not reveal any further documentation from the RD regarding his weight trending downward and the 6.36% weight loss in just under four months (see weights below). Resident #39's weights were documented as follows:-On 4/11/24, the resident weighed 154.0 pounds (lbs);-On 5/2/24, the resident weighed 151.8 lbs;-On 6/5/24, the resident weighed 151.3 lbs;-On 7/17/24, the resident weighed 148.0 lbs (6 lb weight loss, 3.9%); and,-On 8/1/24, the resident weighed 144.2 lbs (9.8 lb weight loss, 6.36%). Resident #39's documented weights revealed a gradual weight loss over the past four months with a total loss of 9.8 lbs. Review of the CNA charting (from 7/17/24 to 8/13/24) revealed Resident #39 had accepted an evening snack eight times in the past 28 days. Review of the CNA charting (from 7/1/24 to 8/14/24) revealed Resident #39 had a decrease in meal intakes beginning on 7/1/24. The meal intake documentation wasas follows: -From 7/1/24 to 7/16/24, Resident #39 consumed an average of 76-100% of his meals 34% of the time; -From 7/17/24 to 7/31/24, Resident #39 consumed an average of 76-100% of his meals 26% of the time; and,-From 8/1/24 to 8/14/24, Resident #39 consumed an average of 76-100% of his meals 11% of the time. III. Staff interviewsCNA #7 was interviewed on 8/15/24 at 2:00 p.m. CNA #7 said plates should be set directly in front of the residents so the residents could reach their meal. She said for residents who required set-up assistance, she would place the utensil in their hand and make sure they started eating. CNA #7 said the residents should be positioned correctly in their chairs. She said this was important to ensure the residents got adequate nutrition and did not choke. CNA #7 said Resident #39 required set-up assistance. She said she would hand him the spoon and make sure he started eating. The RD was interviewed on 8/15/24 2:15 p.m. The RD said if a resident required set-up assistance with meals, the staff should unwrap their silverware, hand them the napkin, cut up the food and offer the resident condiments. She said the amount of assistance needed varied with each resident. The RD said Resident #39 required set-up assistance. She said the facility staff needed to get his plate set up in front of him and monitor him in case he needed further assistance throughout the meal. The RD said Resident #39 had a steady weight decline over the past four months. She said it had not triggered on her radar yet, because it was not considered significant. She said additional nutritional interventions had not yet been put into place for the weight loss. She said she would recommend for Resident #39 to have double portions at every meal and she would add him to the nutrition at risk committee for review.

Plan of correction · submitted by the facility

TAG D 692 Nutrition / Hydration I. CORRECTION Resident #39 was observed during three meals to ensure he was properly set up for his meals and had proper adaptive equipment. completed by 9/12/24 II. IDENTIFICATION OF OTHERS All residents have the potential to be affected by this deficient practice A facility wide audit / (Observations) was conducted to determine if residents were receiving proper meal set up. No other residents were identified. All staff were educated on the need to set residents up for meals to include sitting up, food cut up as allowed, drink accessibility and silverware unrolled for safety and preference on or before 9/12/24. IV. MONITORING Dietary manager/RD (registered dietitian) will conduct a random audit (Observation of meals assistance to include residents are set up appropriately with utensils and or adaptive equipment, residents can reach food and fluids, and proper assistance during meals) 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for 3 months to ensure solutions were sought and within the decided upon timeframe. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0760Residents are Free of Significant Med ErrorsS/S D▼

Findings

Based on record review and interviews, the facility failed to ensure one (#59) of one resident out of 33 sample residents was free of significant medication errors. Specifically, the facility failed to ensure Resident #59 was administered medication in regular intervals for Parkinson's disease according to the manufacturer recommendations, which resulted in the resident experiencing increased tremors, a symptom of his Parkinson's disease. Findings include:I. Professional referencesAccording to the carbidopa/levodopa dosing instructions, retrieved from https://www.goodrx.com/carbidopa-levodopa/dosage on 8/14/24, "A combination of two medications: carbidopa and levodopa. Levodopa replaces dopamine, which improves symptoms of Parkinson's disease. And carbidopa helps levodopa stick around longer in the body."If you miss a dose of carbidopa/levodopa, take the medication as soon as you remember. But if you remember when you're already close to taking your next dose, skip the missed one."Don't take more than one carbidopa/levodopa dose at a time. Doubling up on doses can be dangerous and lead to more side effects, such as movement problems and mood changes."Taking too much carbidopa/levodopa can be dangerous and increase your risk of side effects. These side effects may include low blood pressure, a fast heartbeat and confusion."According to carbidopa-levodopa dosing guidelines, retrieved from https://www.drugs.com/medical-answers/carbidopa-levodopa-3562239/ on 8/14/24, "It is important to adhere to the schedule closely, and it is recommended that you take the medication at the same time each day."It may be best to take your first daily dose one to two hours before eating your first meal of the day."Taking carbidopa and levodopa soon after eating a meal that is high in fat and calories can elongate the time it takes for your body to absorb the medication and feel its effects. Eating lots of protein or acidic foods with the medication may also delay the onset of the medication's effects."The short-acting (immediate-release) formulation of carbidopa/levodopa takes effect within about 20 to 50 minutes."II. Facility policy and procedureThe Medication Administration Times policy, undated, was provided by the nursing home administrator (NHA) on 8/12/24 at 12:00 p.m. It documented, "The facility medication administration times are: 7:00 a.m. to 10:00 a.m., 11:00 a.m. to 2:00 p.m., 3:00 p.m. to 6:00 p.m. and 7:00 p.m. to 10:00 p.m."III. Resident #59A. Resident statusResident #59, age 72, was admitted on 7/11/24 and readmitted on 7/31/24. According to the August 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease. The 8/7/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required partial or moderate assistance with activities of daily living (ADL). B. Resident interview and observationsResident #59 was interviewed on 8/13/24 at 10:07 a.m. Resident #59 said he had been living with Parkinson's disease for a long time. He said a side effect of the disease that he dealt with every day was hand tremors. Resident #59 said he had never experienced this bad of hand tremors. He said the facility had not been administering his medication appropriately. He said he still had not received his morning medications that day (8/13/24). He said he had to stop his physical therapy that morning (8/13/24) because his hand tremors were so bad that it was difficult to walk with the walker. Resident #59 said his hand tremors had been worse since he was admitted to the facility. He said the facility was not administering his medications at the appropriate times and it was making his hand tremors worse. He said the facility would administer the medications after he ate. He said his Parkinson's medication should be administered an hour before he ate a meal. Resident #59 was observed sitting in his bed, with his legs over the side and feet on the ground. His hand tremors were significant. The resident was unable to still his hands. On 8/14/24 at 9:40 a.m. registered nurse (RN) #3 was observed administering Resident #59's medications.. RN #3 handed Resident #59 a cup of water to rinse his mouth after an inhaler. Resident #59 had significant hand tremors and spilled the cup of water onto his shirt. RN #3 offered to assist the resident with the water. Resident #59 agreed. RN #3 said she needed to go to the medication cart to get Resident #59 a straw since his tremors were so significant. As RN #3 was administering Resident #59's medication, the physical therapy assistant (PTA) entered the resident's room. Resident #59 said he was not able to participate in therapy for at least 30 minutes, until the medication had time to take effect and his tremors would reduce. The PTA left the room and said she would return later in the day. C. Record reviewThe Parkinson's disease care plan, initiated on 7/11/24 and revised on 7/12/24, documented Resident #59 was on anti-Parkinson therapy. The interventions included administering the medications as ordered. The August 2024CPO documented the following physician's order:Carbidopa-Levodopa 25-100 mg (milligrams), give two tablets by mouth four times a day for Parkinson's disease, ordered 7/31/24. The August 2024 medication administration record (MAR) documented the administration times for Resident #59's carbidopa-levodopa medication were as follows: in the morning, mid-day, evening 1 and evening 2.-The medication was not scheduled to be administered at a specific time. The August 2024 MAR detailed the following administrations of the carbidopa-levodopa medication:On 8/1/24, the medication was administered at 9:15 a.m., 11:50 a.m. (two hours and 35 minutes after the last dose), 3:56 p.m. (four hours and six minutes after the last dose) and 8:19 p.m. (four hours and 35 minutes after the last dose). On 8/2/24, the medication was administered at 10:18 a.m., 2:15 p.m. (four hours and three minutes after the last dose), 3:35 p.m. (one hour and 20 minutes after the last dose) and 11:12 p.m. (seven hours and 37 minutes after the last dose). On 8/3/24, the medication was administered at 8:25 a.m., 11:46 a.m. (three hours and 11 minutes after the last dose), 3:17 p.m. (three hours and 31 minutes after the last dose) and 11:52 p.m. (seven hours and 35 minutes after the last dose). On 8/4/24, the medication was administered at 8:59 a.m., 12:15 p.m. (three hours and 16 minutes after the last dose), 3:28 p.m. (three hours and 13 minutes after the last dose) and 8:58 p.m. (five hours and 30 minutes after the last dose). On 8/5/24, the medication was administered at 8:37 a.m., 12:05 p.m. (three hours and 28 minutes after the last dose), 3:51 p.m. (three hours and 46 minutes after the last dose) and 7:37 p.m. (three hours and 46 minutes after the last dose). On 8/6/24, the medication was administered at 10:15 a.m., 3:05 p.m. (four hours and 50 minutes after the last dose), 4:36 p.m. (one hour and 31 minutes after the last dose) and 7:54 p.m. (three hours and 18 minutes after the last dose). On 8/7/24, the medication was administered at 9:50 a.m., 1:52 p.m. (three hours and 2 minutes after the last dose), 4:45 p.m. (two hours and 53 minutes after the last dose) and 7:46 p.m. (three hours and one minute after the last dose). On 8/8/24, the medication was administered at 8:53 a.m., 1:37 p.m. (four hours and 16 minutes after the last dose), 3:50 p.m. (two hours and 13 minutes after the last dose) and 8:21 p.m. (four hours and 29 minutes after the last dose). On 8/9/24, the medication was administered at 10:21 a.m., 2:17 p.m. (three hours and 56 minutes after the last dose), 5:39 p.m. (three hours and 22 minutes after the last dose) and 8:26 p.m. (two hours and 47 minutes after the last dose). On 8/10/24, the medication was administered at 8:37 a.m., 12:42 p.m. (four hours and five minutes after the last dose), 3:17 p.m. (two hours and 25 minutes after the last dose) and 7:47 p.m. (four hours and 30 minutes after the last dose). On 8/11/24, the medication was administered at 8:29 a.m., 12:34 p.m. (four hours and five minutes after the last dose), 4:17 p.m. (three hours and 43 minutes after the last dose) and 9:12 p.m. (four hours and 55 minutes after the last dose). On 8/12/24, the medication was administered at 9:43 a.m., 11:37 a.m. (one hour and 44 minutes after the last dose), 2:37 p.m. (three hours after the last dose) and 7:23 p.m. (four hours and 46 minutes after the last dose). On 8/13/24, the medication was administered at 10:07 a.m., 12:07 p.m. (two hours after the last dose), 3:26 p.m. (three hours and 19 minutes after the last dose) and 10:25 p.m. (seven hours after the last dose). The August 2024 MAR, from 8/1/24 to 8/13/24, indicated the following:-The medication was administered late, according to the facility medication administration times, on five occasions;-The medication was given in less than four hour intervals on 26 occasions;-The medication was given over a four hour interval on 12 occasions; and,-The medication was not administered consistently at the same time every day (see professional references above and pharmacist interview below). IV. Staff interviewsRN #3 was interviewed on 8/14/24 at 9:40 a.m. RN #3 said the facility had scheduled administration time frames of 7:00 a.m. to 10:00 a.m. for morning medications, 11:00 a.m. to 2:00 p.m. for mid-day medications, 3:00 p.m. to 6:00 p.m. for evening medications and 7:00 p.m. to 10:00 p.m. for nocturnal medications. She said medications should be administered during those time frames. RN #3 said Resident #59 had a diagnosis of Parkinson's disease. She said she had observed Resident #59 with significant hand tremors since his admission to the facility. RN #3 said Resident #59 was administered the carbidopa-levodopa medication due to the resident's diagnosis of Parkinson's disease. She said she administered the medications in the time frame indicated. She said she did not know if the medication should be administered at the same time every day or in a specific interval. She said she administered the medication when she was able. RN #3 said if the medication was administered outside the facility's designated time frame it was considered late and that was a medication error. The pharmacist (PH) was interviewed on 8/15/24 at 10:37 a.m. The PH said Resident #59 had a diagnosis of Parkinson's disease and was prescribed carbidopa-levodopa medication to alleviate the symptoms of the disease. She said the symptoms of Parkinson's disease could include hand tremors. The PH said the facility had medication administration time intervals to administer medications. She said the intervals established at the facility were 7:00 a.m. to 10:00 a.m. for morning medications, 11:00 a.m. to 2:00 p.m. for mid-day medications, 3:00 p.m. to 6:00 p.m. for evening medications, and 7:00 p.m. to 10:00 p.m. for nocturnal medications. The PH said that carbidopa-levodopa should be administered in regular intervals and at the same time every day to promote consistent blood levels, ideally in four hour intervals. She said there should be several hours in between each dose. She said Resident #59 could experience a variation in side effects of Parkinson's disease if the medication was not given according to the administration guidelines. The PH said the facility was not administering Resident #59's carbidopa-levodopa medication appropriately. She said the facility should have scheduled the medication at a specific time to ensure the resident received the medication at the appropriate intervals in order to provide him with the appropriate blood levels of the medications to help with the side effects of his Parkinson's disease. The PH said it was possible for Resident #59 to experience an increase in hand tremors because the medication was not being administered in the appropriate intervals. The PH said she would contact the facility immediately and ensure the medication was scheduled at the same time every day and within four hour intervals. The PTA was interviewed on 8/15/24 at 12:35 p.m. The PTA said she had worked with Resident #59. She said Resident #59 had significant hand tremors. She said Resident #59 had experienced an increase in his hand tremors on 8/14/24 and she had to provide him with additional assistance. The PTA said Resident #59 got really frustrated when his hand tremors increased. She said she was the therapist that entered the room when the resident was taking his medications. She said she witnessed him spilling the water down the front of his shirt because of his hand tremors. She said Resident #59 was usually able to drink by himself. The director of nursing (DON), the NHA and the clinical consultant (CC) were interviewed on 8/15/24 at 5:44 p.m. The DON said the facility had designated medication administration times of 7:00 a.m. to 10:00 a.m. for morning medications, 11:00 a.m. to 2:00 p.m. for mid-day medications, 3:00 p.m. to 6:00 p.m. for evening medications, and 7:00 p.m. to 10:00 p.m. for nocturnal medications. She said medications not administered during those time frames were considered late and a medication error. The DON said Resident #59 had a diagnosis of Parkinson's disease and had significant hand tremors. She said carbidopa-levodopa should be administered at the same time every day and within four hour intervals. She said this was important to make sure blood levels were at the appropriate level to ensure the medication was effective. The DON said Resident #59 was not being administered the carbidopa-levodopa medication according to the administration guidelines for the medication. She said she spoke with the PH and they scheduled the medication to be administered at specific times that day (8/15/24).

Plan of correction · submitted by the facility

760 Residents Are Free of Significant Med ErrorsI. CORRECTIVE ACTION FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICEThe facility updated resident #59’s orders on 8/15/24 to be given at specific times 8am, 12pm, 4pm, and 8pm. One other resident was identified for time specific medication their administration times were updated to 8am, 12pm, 4pm, and 8pm. Nurses were provided education on the facility’s medication administration policy; if there was a delay in the resident receiving medication the physician must be notified, and a note must be placed in the electronic record on or before 9/12/2024. DON/designee will perform an audit to include observation of medication administration (to include medications ordered at a specific time to ensure that they are given an hour before or an hour after recommended times, if medication given outside of recommended times the provider should be notified and documentation to be completed in electronic record.) 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for 3 months to ensure these solutions are sustained. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0761Label/Store Drugs and BiologicalsS/S E▼

Findings

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of three medication carts and one of one medication storage rooms. Specifically, the facility failed to:-Ensure controlled medications were securely stored under double lock; -Ensure expired medications were removed from the medication carts and the medication storage room; and,-Ensure medications were labeled with an expiration date. Findings include:I. Professional referenceThe United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 8/19/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, "Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it."II. Facility policy and procedureThe Storage of Medication policy, dated January 2024, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part,"Controlled medications should be stored separately from non-controlled medications. The access system (key, security codes) used to lock controlled medications, cannot be the same access system used to obtain the non-controlled medications."Outdated, contaminated, discontinued or deteriorated medications are immediately removed from stock and disposed of according to procedures for medication disposal."III. ObservationsOn 8/14/24 at 4:35 p.m. the medication storage room was observed with the director of nursing (DON). The following items were found:-Four one ounce (oz) tubes of bacitracin ointment (first aid antibiotic) that expired in March 2024. The following personal medications were found in a plastic grocery bag in the medication room. The DON said a resident brought them in from home upon admission. -One three oz tube of Theragesic cream (pain relieving cream) that expired in December 2018;-One 1.8 oz tube of hemorrhoid cream that expired in July 2020;-One 5.5 oz tube of Neosporin ointment (first aid antibiotic) that expired in November 2014;-One 3.8 oz bottle of lidocaine hemorrhoid spray that expired in October 2023;-One bottle of Lexapro 10 milligrams (mg) (antidepressant medication) that expired on 6/1/24;-One bottle of hydrochlorothiazide 25 mg (diuretic medication) that expired on 5/17/24; and,-One bottle of lorazepam 0.5 mg, (a controlled anti anxiety medication) containing two tablets, that was not in a locked cabinet. On 8/15/24 at 1:00 p.m. the Aspen hall medication cart was observed with licensed practical nurse (LPN) #1. The following item was found:-One bottle of Pro-Stat (liquid protein supplement) 30 oz that expired on 7/31/24. On 8/15/24 at 1:44 p.m. the Silverstone hall medication cart was observed with registered nurse (RN) #1. The following items were found:-Three bottles of magic mouthwash with no expiration date on the pharmacy label; and,-One bottle of Systane lubricant dry eye relief 1.5 oz that expired in July 2024. IV. Staff interviewsLPN #1 was interviewed on 8/15/24 at 1:00 p.m. LPN #1 said the night shift nurse checked the medication carts for expired medications, cleaned the carts and checked for loose pills. She said if a medication was expired, the night shift nurse removed it from the cart and placed it in the designated area in the medication room for expired medications. The DON was interviewed on 8/14/2024 at 4:45 p.m. The DON said if a resident brought medications from home, the medications should be reviewed with the doctor to determine if the resident was still taking them. She said if the medication had been discontinued or changed, the resident's family should take the medications home. The DON said medications brought from home should be checked for expiration dates. The DON said controlled medication should be secured under a double lock.

Plan of correction · submitted by the facility

F761Corrections-The expired medications that were found in the medication room and on the medication carts, were removed. Identification of others-The deficient practice had the potential to affect all residents. Systemic changes-DON/designee will complete education with all nursing staff to include medication storage policies and procedures (removing/discarding expired medication from the medication room and medication carts), on or before 9/12/24. Monitoring-DON/designee will complete audit of medication rooms for expired, undated medications, and to ensure mediations are properly labeled. on or before 9/12/24, then auditing of the medication room and medication carts will be completed 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for a total of 3 months to ensure that these solutions are sustained. Findings will be documented on the weekly audit toolsAll outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0791Routine/Emergency Dental Srvcs in NFsS/S D▼

Findings

Based on record review and interviews,, the facility failed to assist residents in obtaining routine or emergency dental services, as needed for two (#23 and #18) of four residents reviewed for dental services out of 33 sample residents. Specifically, the facility failed to ensure:-Dental services were offered to Resident #23; and,-Resident #18 was provided dentures in a timely manner. Findings include:I. Facility policy and procedureThe Dental Services policy and procedure, dated January 2020, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part, "It is the policy of this facility, in accordance with residents' needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care."The dental needs of each resident are identified through the physical assessment and minimum date set (MDS) assessment processes and are addressed in each resident's plan of care.-Oral/dental status shall be documented according to assessment findings.-Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care."The social services director (SSD) maintains contact information for providers of dental services that are available to facility residents at a nominal cost."The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location."All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record."II. Resident #57A. Resident statusResident #23, age 71, was admitted on 1/30/24. According to the August 2024 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (impaired communication between the brain and muscles) and chronic systolic (congestive) heart failure. The 2/2/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was dependent on staff assistance with showering/bathing himself, lower body dressing, putting on/taking off footwear, lying to sitting, sitting to stand, chair/bed and bed/chair transferring and tub/shower transferring. The MDS assessment indicated the resident had no dental issues.-However, the resident had broken teeth (see resident observation and interview below). B. Resident interview and observationResident #23 was interviewed on 8/12/24 at 10:30 a.m. Resident #23 said he had not seen the dentist since he was admitted to the facility. He said he would like to see the dentist because he would like his teeth to be fixed. An observation of Resident #23's mouth revealed the resident had a couple of broken teeth. C. Record reviewThe nutrition care plan, revised 7/31/24, documented Resident #23 had potential nutritional problem related to urinary tract infection (UTI), congestive heart failure (CHF), failure to thrive, seizure disorder, acute on chronic respiratory failure, diabetes, edema and diuretic treatment, obesity per body mass index (BMI), poor dentition but resident declined diet texture downgrade, dietary noncompliance and fluid related significant weight gain. Interventions included diet as ordered by physician (regular, regular, thin), food preferences (chicken, beef, peanut butter) and honoring resident rights to make personal dietary choices and provide dietary education as needed. Review of the August 2024 CPO revealed the following physician's order:Resident may have doctor of dental surgery (DDS), ophthalmology, audio and podiatry care as needed, ordered 1/30/24. A 1/31/24 social services note documented the social worker met with Resident #23 and no immediate concerns were noted per the resident regarding vision or dental needs. However, Resident #23 told the social worker he should see a dentist at some point. The social worker would continue to follow and assist the resident as needed.a 4/30/24 social service quarterly note documented vision, dental, and hearing were not a concern for Resident #23 but he was open to getting dentures. The social worker would continue to follow and assist the resident as needed. III. Resident #18A. Resident statusResident #18, age 78, was admitted on 5/19/22. According to the August 2024 CPO, diagnoses included chronic kidney disease stage four and dementia. The 4/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup or clean up assistance with eating, oral hygiene, showering/bathing himself, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS assessment revealed Resident #18 had no natural teeth or tooth fragments (edentulous). B. Resident interviewResident #18 was interviewed on 8/12/24 at 10:27 a.m. Resident #18 said he had no teeth and was promised a year ago (in 2023) the facility would help him get some dentures. He said he saw the dentist at the facility but still had not received dentures. The resident said he would like to get dentures. C. Record reviewThe care plan for dentition, revised 6/7/22, documented Resident #18 had the potential for impaired dentition as he was edentulous and did not have dentures because he had lost them. Interventions included coordinating arrangements for dental care, transportation as needed/as ordered, monitoring/documenting/reporting to the medical doctor (MD) as needed (PRN) signs/symptoms of oral/dental problems needing attention, teeth missing, loose, broken, eroded, or decayed and providing mouth care as per activities of daily living (ADL) personal hygiene. Review of the August 2024 CPO revealed the following physician's order: Resident may have doctor of dental surgery (DDS), ophthalmology, audio and podiatry care as needed, ordered 5/19/22. A dental note dated 8/23/23 documented Resident #18 was seen by the dentist. The dentist documented a pre-authorization would be obtained for full upper and full lower dentures. The resident would have dental impressions for full upper and lower dentures taken on his next dental visit. A quarterly social services assessment, dated 11/1/23, documented Resident #18 was up to date with his vision and dental care. The social worker would continue to follow and assist the resident with support. A quarterly social services assessment, dated 2/2/24, failed to reveal documentation that Resident #18 had been offered dental care services. A quarterly social services assessment, dated 4/24/24, failed to reveal documentation that Resident #18 had been offered dental care services..A quarterly social services assessment, dated 7/24/24, failed to reveal documentation that Resident #18 had been offered dental care services. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 8/15/24 at 10:08 a.m. CNA #1said she did not know the process for follow up visits or recommendations from the dentist. She said she would give any information to management. She said Resident #18 had his natural teeth. She said Resident #18 had no concerns with his food and he was independent with all his meals. She said Resident #18 had not voiced any concerns about his teeth.-However, Resident #18 did not have any natural teeth (see record review and resident interview above). CNA #1 said if a resident reported any oral/dental pain or lost or damaged dentures she would notify the nurse. Licensed practical nurse (LPN) #2 was interviewed on 8/15/24 at 11:35 a.m. LPN #2 said if a resident reported having any problems with their teeth she would notify the assistant director of nursing (ADON) and see about getting a dental appointment made for the resident. She said if a resident reported any oral/dental changes she would report it to the ADON so that they could make a dental appointment. LPN #2 said the dentist came to the facility and was there every few months. She said Resident #18had seen the dentist but she did not know when he was last seen. She said she would have to follow up with the ADON.The social service director (SSD) was interviewed on 8/15/24 at 3:10 p.m. The SSD said she was in charge of arranging ancillary services, including dental services for the residents. She said if residents requested to be seen by the dentist then they would be seen. She said seeing the dentist was offered upon admission. She said she let the residents know what services were offered. She said the dentist came to the facility to see residents. She said she did not know that Resident #23 and Resident #18 needed to be seen by the dentist. She said she had no idea when Resident #18 or Resident #23 were last seen by the dentist. She said the facility had not been getting the records from the dentist and had requested the records for the last three months. The SSD said the dentist was at the facility in July 2024 and the dental hygienist would be coming in September 2024. She said the dentist and the dental hygienist alternated visits with each other and came to the facility every other month. She said ancillary services were offered every three months in care conferences. The SSD said residents could also request to be placed on a list to be seen the next time the dentist or the dental hygienist were in the facility. The SSD said residents should be seen by the dentist annually for dental care and every six months for hygiene care. She said residents could be seen more frequently or less frequently depending on their dental needs and the recommendations of the dental provider. The SSD said Resident #18 was on the list to be seen in September 2024. She said Resident #18 was last seen by the dentist on 8/23/23. She said she did not know if Resident #18 had received dentures or if anyone had followed up with him about the dentures since his last visit in August 2024. She said she would follow up on the services for Resident #18. The SSD said if Resident #23 had requested to be seen by the dentist he should have been seen. She said upon admission residents were offered to be seen by the dentist. She said she did not know Resident #23 wanted to be seen by the dentist. She said she did not know if he had ever been seen by the dentist. She said she would be following up with the resident about dental services and get him on the list to be seen.

Plan of correction · submitted by the facility

Corrections- Specifically, the facility failed to ensure: -Dental services were offered to Resident #23;-Resident #18 was provided a dental appointment to begin process for dentures 9/18/23An appointment was made for the resident # 23 to see the dentist on 9/18/24. Identification of others-SSW/Designee performed a full house audit of all for all ancillary services including dental services was completed by 9/12/24Systemic Changes-Social Services was educated on the need for residents to be assessed by the dentist when a resident admits to the facility and if any dental issues arise on or before 9/12/24. Monitoring-SSW/Designee will audit all new residents and random check of other residents to ensure no dental needs are not being met and any outside referrals are needed to be made are done. (Documentation in clinical record) Auditing will be completed 3 times a week x4 weeks, then 2 times a week x 4 weeks, then 1x weekly x4 weeks for a total of 3 months to ensure that these solutions are sustained. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

0880Infection Prevention & ControlS/S D▼

Findings

Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of three units. Specifically, the facility failed to:-Ensure housekeeping staff disinfected high touch surfaces (call lights, door handle and light switches) in resident rooms;-Ensure surface disinfectant dwell times (the amount of time a disinfectant needs to remain wet on a surface to effectively kill germs) were followed; -Ensure areas were cleaned from clean areas to dirty areas; and,-Ensure hand hygiene was performed appropriately during the cleaning of residents' rooms. Findings include:I. Professional referenceAccording to The Centers for Disease Control (CDC) Environment Cleaning Procedures (3/19/24), retrieved on 8/20/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include:-bedrails;-IV (intravenous) poles;-sink handles;-bedside tables;-counters;-edges of privacy curtains;-patient monitoring equipment (keyboards, control panels);-call bells; and,-door knobs."Proceed From Cleaner to DirtierProceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include:-During terminal cleaning, clean low-touch surfaces before high-touch surfaces;-Clean patient areas (patient zones) before patient toilets; and,-Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone."II. Manufacturer's recommendationsThe Ecolab product specification document for Peroxide multi-surface cleaner and disinfectant was provided by the housekeeping manager (HM) on 8/15/24 at 5:15 p.m. It read in pertinent part:"Treated surfaces must stay wet for 90 seconds for use as a sanitizer. For bactericidal or virucidal use, the solution should stay wet on the surface for five minutes before wiping." III. Facility policyThe Room and Bathroom Cleaning policy, not dated, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part,"It is the policy of this facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare-associated infections (HAI)."Employees are required to use standard precautions when handling body fluids, excretions, secretions and contaminated equipment or environmental surfaces. Standard precautions refers to infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status and includes hand hygiene, use of gloves, gown, mask, eye protection or face shield."Working from clean areas to dirty areas:-Remove soiled linen from floor, wipe up any spills and remove waste;-Clean door handle, frame and light switch;-Clean wall attachments (if applicable);-Clean inside and outside the sink, sink faucets and mirror. Wipe plumbing under the sink. Apply disinfectant to interior of sink and allow sufficient contact time with disinfectant according to manufacturer's recommendation. Rinse sink and dry fixtures;-Clean all dispensers and frames;-Clean call bell and cord;-Clean support railings, ledges and shelves;-Clean shower/tub faucets, walls and railing, scrubbing as required to remove soap scum. Inspect grout for mold, apply disinfectant to interior surfaces of shower/tub, including soap dish, faucets and shower head. Allow sufficient contact time for disinfectant according to manufacturer's recommendations. Rinse and wipe dry. Inspect shower curtain and replace as required; and,-Clean entire toilet including handle and underside of flush rim. Apply disinfectant and allow sufficient contact time according to manufacturer's recommendations." IV. ObservationsOn 8/15/23 at 9:55 a.m. housekeeper (HSK) #1 was observed cleaning a double occupancy room on the Breckenridge unit. HSK #1 entered the resident room without donning gloves. She took the disinfectant cleaner into the bathroom and sprayed the toilet and grab bars with the disinfectant. She said she let the disinfectant remain on the surface for five minutes. HSK #1 got her broom and dustpan from her cart. She emptied the trash (without wearing gloves) then swept the floor on side two of the room with the broom, swept under the bed and around the resident's wheelchair, then moved the recliner and swept behind it. HSK #1 proceeded to side one of the room and swept the floor. HSK #1 put a glove onto her right hand. She took a rag in her gloved hand, wiped the toilet from the top of the tank to the seat and base and wiped the floor area around the toilet. She put the dirty rag into her left, ungloved hand, took the toilet cleaning brush with her gloved hand and cleaned the inside of the toilet. HSK #1 got a clean rag and wiped the bathroom grab bars without changing her glove or performing hand hygiene. She removed the glove, obtained a mop and mopped the bathroom floor. -HSK #1 did not perform hand hygiene after removing the glove. HSK #1 obtained a clean rag from her cart (without performing hand hygiene) and went back to side two of the room. HSK #1, without performing hand hygiene or applying a new pair of gloves, used the disinfectant cleaner to spray the windowsill and wiped it with her rag immediately. She sprayed and cleaned the sink area, wiping off the disinfectant immediately. -HSK #1 did not allow the disinfectant to remain wet on the surfaces for the manufacturer recommended dwell time. HSK #1 put the dirty rag she used to clean the windowsill and sink area over her shoulder and mopped the floor under the window, under the bed and towards side one of the room. She cleaned the television and stand. -HSK #1 did not clean the high touch surfaces in the room, such as the call light cord, over the bed table, door handles or light switches. HSK #1 took the mop with the same mop head and mopped the floor on side one of the room. -HSK #1 did not perform hand hygiene before moving to side one of the room. HSK #1 sprayed the disinfectant cleanser on the over the bed table and wiped it off immediately. She sprayed the sink area with disinfectant and wiped it off immediately. She cleaned the television stand. -HSK #1 did not allow the disinfectant to remain wet on the surfaces for the manufacturer recommended dwell time. HSK #1 finished cleaning the room by mopping the entryway and partially into the hall. HSK #1 removed the dirty mop head but did not perform hand hygiene prior to moving to clean the next room. At 10:18 a.m. HSK #1 moved her cart in front of a single occupancy room on the Breckenridge unit to begin cleaning that room.-HSK #1 did not perform hand hygiene or don a pair of gloves prior to entering the room and picking up trash from the floor. Without performing hand hygiene, HSK #1 proceeded to straighten items on the resident's nightstand and over the bed table. HSK #1 emptied the trash from the bathroom and took all the trash to the housekeeping cart in the hallway. She obtained a rag, toilet cleaner spray and brush. Without performing hand hygiene, HSK #1 put a glove on her right hand and sprayed the entire toilet, grab bars, shower chair and pull down seat in the shower with disinfectant cleaner. She said she would sweep the bedroom floor while the disinfectant sat on the surfaces for five minutes. HSK #1 took the broom and swept under the bed, around the room, under the sink area, and the entry area in front of the bathroom. She swept the bathroom and the rest of the entry area and out into the hall. She returned the broom to the cart, removed the glove and sanitized her hands. HSK #1 donned a glove on her right hand, took a clean rag and cleaned the toilet from top to bottom with her gloved hand. She used a clean rag and cleaned the hand rails by the toilet with the same glove on her right hand. She wiped the shower hand rails, shower chair and fold down seat in the shower. HSK #1 did not clean the shower walls or the shower floor. HSK #1 left the room to fill her mop with disinfectant. When she returned, she mopped part of the bathroom then cleaned the toilet with the toilet brush without donning gloves on either hand. She mopped the remainder of the bathroom. -HSK #1 did not perform hand hygiene after cleaning the toilet. She went to the bedroom and cleared personal items off of the counter around the sink. She sprayed the counter and sink with disinfectant cleaner and wiped it off immediately with a clean rag.-HSK #1 did not allow the disinfectant to remain wet on the surfaces for the manufacturer recommended dwell time. HSK #1 moved the resident's personal items (briefs, hanger, and hospital bags containing wipes) from a side table into the closet. She sprayed and wiped the side table with disinfectant cleaner. -HSK #1 did not perform hand hygiene after cleaning the toilet and prior to touching the resident's personal belongings. HSK #1 obtained her mop with a clean mop head and started mopping the floor under the bed. She picked up the telephone (without performing hand hygiene) to move the cords out of the way of her mop. She mopped under and around the furniture and then out of the room. -HSK #1 did not wipe down high touch surfaces such as the call light, door knobs or light switches. -HSK #1 did not clean the telephone after touching it with dirty hands. V. Staff interviewsHSK #1 was interviewed on 8/15/24 at 10:37 a.m. HSK #1 said she only needed to wear gloves when cleaning the bathroom. She said she sanitized her hands when taking her gloves off. She said she cleaned the bathroom first and then the rest of the room. -However, HSK #1 was observed cleaning the bathroom in both rooms prior to cleaning the residents' rooms and did not perform appropriate hand hygiene during the room cleanings (see observations above). The infection preventionist (IP) was interviewed on 8/15/24 at 4:08 p.m. The IP said housekeepers should clean resident rooms from the cleanest part to the dirtiest part. She said bathrooms should be cleaned last. The IP said housekeepers should wear gloves when cleaning resident rooms and they should treat each side of the room separately. The IP said high touch surfaces should be cleaned at least daily. The HM was interviewed on 8/15/24 at 4:47 p.m. The HM said when cleaning residents' rooms, the housekeepers should spray disinfectant cleaner on high touch surfaces and let it sit for five minutes to kill all bacteria and viruses. The HM said the housekeepers were taught to clean from the cleanest surface to the dirtiest surfaces. He said they should use different rags for each side of the room in double occupancy rooms but could use the same mop for both sides. The HM said housekeepers should change gloves between each side of a double room and clean the bathroom last. He said the housekeepers should perform hand hygiene in between each side of the room. The HM said for rooms with showers, the showers should be cleaned daily.

Plan of correction · submitted by the facility

Corrections-Housekeeper #1 was immediately educated on proper room cleaning, infection control practices with hand hygiene, including disinfectant dwell times PPE (personal protective equipment) use. Identification of others-The deficient practice had the potential to affect all residents. Systemic Changes-IP (infection preventionist)/designee will educate all housekeeping staff on proper room cleaning, infection control practices including hand hygiene, disinfectant dwell times and PPE on or before 9/12/2024. Monitoring- Housekeeping Supervisor/Designee will audit and observed housekeeping staff to ensure they are following facility protocols regarding room cleaning 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for 3 months to ensure solutions were sought and within the decided upon timeframe. documentation will be on the weekly audit tools. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

8/15/2024State Licensure Survey · ID 6TL2111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure survey was completed on 8/12/24 to 8/15/24. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0701Resident Care - Overall Care of the Residents▼

Findings

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#4) of two residents reviewed out of 33 sample residents. Resident #4 was admitted on 2/22/16 for long term care with diagnoses of type 2 diabetes with diabetic peripheral angiopathy (narrowing of the arteries decreasing blood flow), chronic kidney disease, heart failures, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), major depressive disorder and anxiety. On 7/12/24 Resident #4 struck her right lower leg on the side of her metal bed frame when she was maneuvering her electric wheelchair near her bed, causing a hematoma (bruise) to her leg. The resident reported the injury was very painful. On 7/15/24 the facility obtained an x-ray of the resident's right lower extremity, which was negative. The facility failed to consistently document observations of the resident's injury. On 7/22/24 the resident reported increased pain and swelling, the nurse practitioner (NP) ordered ice three times a day to the area. On 7/29/24 the wound doctor (WD) visited the resident for a different wound. The WD did not see or assess the resident's wound to her right lower extremity. Due to the facility's failure to consistently monitor and document the status of the resident's wound, the resident was sent to the emergency department on 8/5/24 for increased swelling and pain. At the hospital, Resident #4 was diagnosed with cellulitis to the right lower extremity and she had an increased white blood cell count. The resident had surgery to drain and clean out the right leg wound which had become infected and required treatment with intravenous (IV) antibiotics. Findings include:I. Facility policy and procedureThe Skin and Wound Monitoring policy, dated January 2022, was provided by the nursing home administrator (NHA) on 8/15/24 at 9:12 p.m. It read in pertinent part,"A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whetherpresent on admission or developed after admission, which exists on the resident. Thisassessment/evaluation should include but not be limited to: measuring the skin injury; staging the skin injury (when the cause is pressure); describing the nature of the injury (pressure, stasis, surgical incision); describing the location of the skin alteration; describing the characteristics of the skin alteration; describing the progress with healing, and any barriers to healing which may exist; and, identifying any possible complications or signs/symptoms consistent with the possibility of infection."Weekly skin checks will be conducted by a licensed nurse. All residents will have a head to toe skin check performed at least weekly by a licensed nurse. The licensed nurse should document the findings."II. Resident #4A. Resident statusResident #4, age 82, was admitted on 2/22/16. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic peripheral angiopathy, chronic kidney disease, heart failure, chronic obstructive pulmonary disease , major depressive disorder and anxiety. The 7/13/24 facility assessment revealed the resident was cognitively intact. She could hear adequately, was able to understand others and made herself understood. B. Resident interviewResident #4 was interviewed on 8/13/24 at 10:33 a.m. Resident #4 said she returned from the hospital yesterday (8/12/24). She said she had an infection in her leg that required surgery. Resident #4 said about a month ago (July 2024), she hit her leg on her bed frame when she was trying to maneuver her electric wheelchair in her room. She said there were no staff around and she was trying to get to her call light, which was on the floor. She said her leg started swelling and hurting right away. Resident #4 said an x-ray was done a couple of days later and there was no fracture so the staff stopped monitoring her leg. Resident #4 said the swelling continued to worsen and the area became warm and painful. Resident #4 said she was told by the nurses she just needed to ice the area to decrease the swelling. Resident #4 said after a few weeks, a red bump formed on top of the swollen area of her leg. She said when this occurred, the nurse called the doctor and was concerned about a blood clot. She said when her leg started draining, the facility decided to send her to the hospital. C. Record review The 7/12/24 incident report, completed by the director of nursing (DON), revealed Resident #4 hit her right leg on the metal part of her bed frame while maneuvering her electric wheelchair in her room. The report documented she obtained a large hematoma with red, blue and purple discoloration. The resident reported the leg was very painful. The DON applied ice to the area and instructed the resident to elevate her leg in the recliner. The physician was notified. The 7/15/14 interdisciplinary team (IDT) progress note indicated x-rays were obtained of the resident's right leg which were negative for a fracture. The note documented the IDT recommended therapy to evaluate the resident's environment and assess the resident's electric wheelchair for safety. According to the nurse progress notes, alert charting (charting done when a resident's condition needs to be monitored) was initiated after the incident on 7/12/24. -However, there were no progress notes documented on 7/13/24 or 7/14/24 to indicate the injury was assessed or was being monitored. The 7/15/2024 alert charting indicated it was the third day of the skin alteration to the resident's right lateral (outside) lower extremity. The area had a dark purple discoloration to the mid-outer calf with an indentation to skin proximal to the ankle with a possible hematoma above the indentation. The resident reported the area was tender to soft touch. An x-ray was completed that morning and the results were pending. The 7/16/24 alert charting indicated it was the fourth day of the skin alteration to the right lateral lower extremity. The area was dark purple discoloration to the mid-outer calf. There was an indentation to the skin proximal to the ankle with a possible hematoma above the indentation. The resident reported the area was tender to soft touch. The x-ray results were negative for fractures. The 7/17/24 alert charting indicated the resident had a skin alteration of a left calf hematoma due to hitting her leg on her bed frame while in an electric wheelchair. The nurses were monitoring for signs and symptoms of infection, pain to sight, or complications every shift for the hematoma to the left lower extremity for three days. There were no signs or symptoms of infection to the resident's left calf. The resident did not have complaints of pain. -However, the resident sustained an injury to her right leg, not the left leg (see record review above and DON interview below).-A review of the resident's electronic medical record (EMR) did not reveal any documentation from 7/18/24 to 7/21/24 regarding the status of the resident's right leg injury. The 7/22/24 nursing progress note documented the nurse practitioner (NP) was notified of increased swelling in Resident #4's right lower leg. The 7/23/24 NP progress revealed the NP visited Resident #4 at the facility. The NP note documented Resident #4 said her leg had decreased in swelling since 7/22/24 but she still had discomfort to the touch. The NP ordered ice to the area three times a day for three days, to encourage elevation and continue to monitor the area.-A review of the residents EMR did not reveal any additional nursing documentation to indicate the staff were monitoring the status of Resident #4's leg from 7/23/24 to 8/4/24. The 7/29/24 wound doctor (WD) progress note documented the WD visited Resident #4 for continued monitoring of a wound in her groin area. -The WD note did not document that the WD examined the resident's injury to her right lower extremity. The 8/5/24 nursing progress note, documented at 8:24 a.m., indicated a phone call was received from the NP with orders for a Doppler (an ultrasound test showing blood flow), to start Keflex (an antibiotic) for possible cellulitis (skin infection) and tramadol (an oral pain medication) for the resident's pain in her leg. The 8/5/24 nursing progress note, documented at 9:31 a.m., indicated the nurse placed a call to Resident #4's physician at 6:40 a.m. regarding the pain to her right lower leg approximately at the mid-calf. The area was red, warm and slightly elevated. The nurse requested a Doppler to rule out deep venous thrombosis (DVT - a blood clot). The 8/5/24 nursing progress note, documented at 1:39 p.m., indicated there was no evidence of a DVT in the resident's right lower extremity according to the Doppler test. The 8/5/24 nursing progress note, documented at 3:00 p.m., indicated the NP was called and notified the hematoma on Resident #4's right lower extremity had opened and was draining. The 8/5/24 nursing progress note, documented at 4:52 p.m., indicated Resident #4 was sent to the hospital emergency department for possible incision and drainage of a right lower extremity hematoma with bloody drainage and a foul smell. The 8/5/24 nursing progress note, documented at 5:28 p.m., revealed Resident #4 left the facility by emergency transport. The 8/5/24 hospital admission record revealed Resident #4 was diagnosed with cellulitis of the right lower limb, a cutaneous (on the skin) abscess of the right lower limb, local infection of the skin and subcutaneous (under the skin) tissue and an elevated white blood cell count of 13.6 (normal range is 4 to 11). The hospital physician's note indicated, upon admission, Resident #4 had a large area of fluctuant (fluid filled) swelling over the anterior pretibial (front of shin bone) space of the right lower leg. It was tender to palpation (touch). There was erythema (redness) with increased skin temperature. The area measured 14 centimeters (cm) length by 10 cm width by two cm depth. There was bloody, malodorous (foul smelling) and copious (large amounts) drainage. Resident #4 was complaining of pain to the right lower extremity which she rated at an 8 out of 10 and described as sharp in nature. The resident said she had been feeling poorly over the last several days. The hospital documentation indicated Resident #4 had surgery overnight for the wound incision and drainage, which was completed at 12:44 a.m. on 8/6/24. She was started on IV antibiotics. The resident returned to the operating room on 8/7/24 for removal of packing, wound re-evaluation and excisional debridement (cutting away of dead tissue) of the wound cavity and repacking. The culture of the wound determined it was infected with multi-drug resistant Escherichia coli (a common bacteria normally found in feces that can infect wounds). On 8/9/24, Resident #4 returned to the operating room for a wound washout and complex wound closure with drain placement. The wound size was 8 cm length by 7 cm width by 2 cm depth. III. Staff interviewsThe NP was interviewed on 8/16/24 at 3:07 p.m. The NP said she was aware of the injury on Resident #4's leg. The NP said she received a phone call on 7/22/24 from the facility regarding increased swelling in the resident's leg. The NP said she visited Resident #4 on 7/23/24. The NP said the leg did not show signs of infection at that time and she ordered ice to the area. The NP said she received another phone call from the facility on 7/30/24 regarding Resident #4 having increased pain in her leg. She said the resident did not want to take narcotics so she did not order any new medication. The NP said the nurses at the facility should have been monitoring the injury daily and documenting the status. The DON was interviewed on 8/15/24 at 6:36 p.m. The DON said the nurses should have continued to monitor Resident #4's leg until the injury was resolved. The DON said the NP did see Resident #4 on 7/23/24 and ordered ice to the area. The DON said the nurses should have documented their observations of the wound. The DON said there were no signs or symptoms of infection until right before the resident's hospitalization but this was not documented (see record review above). IV. Facility follow-upA chart review was received from the NHA on 8/19/24 at 10:37 a.m. (after the survey). The review was performed by the medical director (MD). The MD confirmed Resident #4 was visited by the wound doctor on 7/29/24 who said he remembered seeing a lesion on the right lower leg but he did not include this observation in his progress note. The MD confirmed that Resident #4 was hospitalized for an infected hematoma on the right lower leg resulting from trauma occurring at the nursing facility.

Plan of correction · submitted by the facility

701 Overall Care of residents Resident #4 record was reviewed, and care plan, was updated to include monitoring of her current change in condition. Resident returned to facility, upon readmission nurse completed follow up related to all concerns. All have been addressed to the resident's satisfaction. A facility wide skin sweep was conducted to ensure any areas of skin alteration were identified with immediate interventions to include monitoring and treatments as appropriate; care plans updated and change of condition monitoring initiated on or before 9//12/24. III. MEASURES OR SYSTEMIC CHANGES MADE TO ENSURE THE DEFICIENT PRACTICE WILL NOT OCCUR AGAIN: All nursing staff were provided with education on skin management and the process for new skin alterations including change of condition, risk management, obtaining orders for treatment/monitoring on or before 9/12/24. DON (director of nursing)/designee will perform an audit of 5 skin evaluations to include resident #4 (for skin alterations including edema in the residents clinical record, In the event of new skin alteration a change of condition and risk management will be initiated and completed including alerting the MD and following orders given, initiating interventions as appropriate and monitoring until resolved) 3x weekly x4 weeks, then 2x weekly x4 weeks, then weekly x4 weeks for a total of 3 months to ensure that these solutions are sustained. All outcomes from audits and observations will be analyzed for trends and be reported to QAPI committee to establish further solutions.

5/15/2024Revisit: Complaint Survey · ID 92FT12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 5/15/24 for all previous deficiencies cited on 4/11/24. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

5/15/2024Revisit: Licensure Complaint Survey · ID VB8712No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 5/15/24 for all previous deficiencies cited on 4/11/24. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/11/2024Complaint Survey · ID 92FT111 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO34280, #CO35502 and Incident #35470 was conducted on 4/8/24 to 4/11/24. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0689Free of Accident Hazards/Supervision/DevicesS/S J▼

Findings

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting three (#1, #2, and #3) out of five residents. Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 9/8/22) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen who smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. While the facility revised the smoking policy after the incident on 3/27/24, record review and observations revealed the revisions were inadequate and ineffective. Smoking and oxygen use were not adequately addressed with residents who smoked and on 4/9/24, observations revealed supervised smoker Resident #1 with a cigarette on his bedside table that had been smoked, with three-quarters to one-half left. The facility's failure to implement interventions to ensure resident safety from smoking accidents before and after 3/27/24 created a situation with the likelihood of serious harm. Resident #1, who had severe cognitive impairment, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 1/1/23) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility and related to resident oxygen use and smoking. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen that smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. Resident #1, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. While the facility smoking policy was amended on 3/27/24 to provide that the smoking products of residents who required supervision to smoke would be kept secured in either the medication room or nurses' cart, on 4/9/24, Resident #1 was found with a cigarette on his bedside table. It had been lit and three-quarters to one-half remained. B. Imposition of Immediate Jeopardy On 4/9/24 at 3:35 p.m., the Colorado Department of Public Health and Environment (CDPHE) informed the nursing home administrator (NHA) that the facility's failure to implement safe smoking interventions for residents who smoked and to implement effective interventions to prevent injury from cigarettes to Resident #1, created a situation of immediate jeopardy with the potential for serious resident harm. C. Facility Response On 4/10/24 at 3:42 p.m., the facility submitted the following plan (draft #4) to remove the immediate jeopardy. The plan read:"Removal of Immediacy Plan: Unsafe SmokingDate/Time Presented to Surveyors: 4/10/24 at 3:35 p.m. Identified here are the steps and immediate action(s) (name of facility) will take to address the reported non-compliance, keep residents safe and free from serious harm or death, and prevent serious harm from occurring or recurring. 1. Resident #1 was identified as a supervised smoker on 03/19/2024. On 3/27/24 Resident #1 was given a cigarette and lighter by a RN while in the building. The CNA supervising did not ensure oxygen was removed prior to Resident #1 lighting cigarette which in turn led to oxygen from cannula igniting. CNA immediately following turned oxygen off. The smoking UDA was updated to include questions referring to oxygen use on 4/9/24. Items added:-Can the resident light their own cigarette?-Does the resident utilize oxygen?-Is the resident able to manage oxygen safety, remove and store for safe smoking practices,-Observe the resident smoking in designated smoking area,-Is the resident able to safely light smoking materials, hold smoking materials safely and dispose of smoking materials appropriately,-Has the resident been educated on safe smoking practices?On 4/10/24 an additional smoke detector was placed in residents (Resident #1's) bathroom. 2. Director of nurses (DON)/Designee and Clinical Resource completed a full house audit of all smoking evaluation(s) by 4/9/24 and updated all residents' care plans. Facility placed an updated smoking list out at the units on 4/9/24. DON to complete additional full house audit of all smokers starting on 4/9/24 to identify need for supervision or adaptive equipment, facility will review all residents BIMS score, and update a smoking assessment (completed 4/9/24). Any resident who smokes with a BIMS (brief interview of mental status) of 12 or below will be placed on supervised smoking (Resident #1 identified). Smoking policy updated on 4/9/24 to reflect the change. Administrator or designee to review updated smoking Policy with all residents who smoke on 4/9/24 or their representative. 3. All Staff/All residents who smoke to be educated on updated Smoking Policy to address the following:-Use of oxygen,-Who is Supervised and Unsupervised,- How to properly supervise smokers-Supervised smoking times-Proper adaptive equipment available and locations,-Proper smoking equipment indicated in smoking area such as blankets/extinguisher,g-Cleanliness of smoking area, and-Monitoring for proper disposal of cigarette butts.-Safety education was provided to residents regarding our smoking policy and-Use of oxygen to ensure that they remove oxygen prior to going out to smoke.-Smoking materials need to be safely stored out of sight of other residents.-No cigarettes or lighters [will] be given to other residents. 4. Staff education to be completed by Administrator, Nurse Manager, SDC (staff development coordinator), Social Worker, or Activity Director. This education will be provided to all staff/residents who smoke by 4/10/24, any staff that is not able to come in for education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. 5. On 4/9/24 Resident #1 was found to have a cigarette butt on his bedside table. All staff will be educated on Proper Supervision of smokers to include disposing of any non smoked tobacco product in proper receptacle before re-entering building. A facility audit was implemented on 4/10/2024 to include observations of any smoking materials in resident rooms or on their person. An order was initiated to monitor the residents' room for smoking items every shift. If any are found, remove and provide education to the resident on facility smoking policy and safety. This education will be completed by 4/10/24 any staff that is not able to come in for training education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. This education will be provided by DON/NHA/Designee. Monitoring:DON/Designee will audit all new admissions for smoking preference, complete a smoking evaluation (to include oxygen use and if they are to be supervised or unsupervised) and update the care plan with current interventions. Assessment and care plan to be completed within 24 hours. Smoking assessments will be completed by ADON (assistant director of nursing) or designee. DON/Designee to review all those residents who smoke weekly and document if they continue to follow safe smoking rules, or if there are changes needed to their care plan. Specifically, for Resident #1 daily audits of resident's room and on his person to ensure he has not brought in any smoking materials from the smoking area. Maintenance to monitor smoking area daily for cigarette butts, safety blankets, and No Oxygen use signs x 12-weeks or until compliance is achieved, any issues identified will be discussed in monthly QAPI (quality assurance performance improvement). These audits will continue for 12-weeks until compliance is achieved, any issues identified will be discussed in monthly QAPI. 6. "NO OXYGEN WITHIN 10 FEET" signage ordered for designated smoking area to arrive 4/12/24." D. Removal of immediate jeopardy On 4/10/24 at 4:00 p.m., CDPHE notified the NHA that the immediate jeopardy was removed based on observations that the facility was taking steps to begin implementation of the above correction action plan. However, based on observations, interviews, and record review, the deficient practice remained at a G level, actual harm that is isolated. II. Resident #1 - smoking incident 3/27/24 A. Resident #1 Resident #1, age 70, was admitted on 2/13/24. According to the 4/10/24 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, emphysema, dementia, and acute respiratory failure with hypoxia (insufficient oxygen to the body tissues). The 2/19/24 minimum data assessment (MDS) showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. A 3/23/24 MDS documented the resident had moderately impaired decision-making skills, had poor cues, and required supervision. Per the MDS, he used oxygen. Per the resident's care plan, oxygen was to be administered as ordered by the physician. B. Smoking status Review of Resident #1's care plan, initiated on 3/6/24 for smoking, revealed he had a history of smoking in his room. Pertinent interventions included smoking materials to be kept at the nurses' station or other designated areas. The cigarettes/lighter were to be kept with the nurse and the resident was to ask for them. Review of a resident safe smoking evaluation completed on 3/19/24 at 3:31 p.m. revealed the resident, who smoked five times a day, was determined to be unsafe to smoke without supervision due to increased confusion and cognitive loss. Review of a smoking evaluation completed on 3/27/24 at 2:47 p.m. (prior to the smoking incident the same day) revealed the resident, who now smoked six times a day, remained unsafe with smoking independently. He had cognitive loss and fell forward while standing. The clinical resource nurse assisted the resident in removing his oxygen before attempting to stand from his wheelchair and walk to the designated smoking area. There, he was able to light his cigarette and flick the ashes away from his body but was unable to extinguish his cigarette butt into the receptacle. Failure: There was no evidence the resident's care plan was updated on 3/19/24 to document the resident's status as a supervised smoker. Further, there was no evidence the IDT considered additional safety interventions to instruct staff on how to assist the resident in smoking safely. There was no evidence the resident was educated regarding what staff expected of him as a supervised smoker to ensure his and other residents' safety when smoking. C. Smoking incident on 3/27/24 1. Nurses' notes A review of nurses' notes from 3/27/24 at 3:45 p.m. revealed Resident #1 was assisted to smoke outside by the CNA. The resident was walking ahead of the CNA when he lit his cigarette. The CNA turned off the resident's oxygen and removed the nasal cannula from his face. The resident was noted to have seared facial hair and nose pain. The resident was transferred to the emergency department for evaluation and a review of Resident #1's emergency department records revealed a diagnosis of mild first-degree burns to the face. 2. NHA interview The NHA interviewed on 4/8/24 at 5:34 p.m., said she completed an investigation following the resident's smoking incident. The NHA said the investigation revealed Resident #1 was observed walking outside with CNA #1. RN #1 had given the cigarette and lighter to the resident, rather than to the CNA. CNA #1 said she was assisting the resident outside; he was moving swiftly with his front wheel walker and had his oxygen on. Before she could remove the oxygen and turn it off, the resident lit the cigarette. The NHA said the resident had singed his mustache and the hair to the left side of his face along with the oxygen tubing. She said the resident's primary physician was in the building and had him assessed. The primary physician had him sent to the emergency department for further evaluation as the resident complained of burning in his nose. III. Facility failures contributing to the smoking incident on 3/27/24. 1. Facility failure to review and revise the facility smoking policy and resident safe smoking evaluations, and obtain smoking agreements that addressed oversight and safety interventions after the facility transitioned to a smoking facility, allowing smoking on campus and supervised smoking. On 4/8/24 at 5:34 p.m., the social services director (SSD) and NHA were interviewed. The SSD said before March 2024, the facility was a non-smoking facility, which meant residents who chose to smoke had to smoke cigarettes off campus. She said in March 2024 (a definite date was not provided), the facility became a facility that would allow smoking on campus and there could be supervised smoking. On 4/9/24 at 12:38 p.m., the NHA provided the facility smoking policy and smoking evaluation in effect after the transition to a smoking facility and before the incident with Resident #1 on 3/27/24. a. Smoking Policy The policy, last revised 9/8/22 read that its purpose was to address the wishes of both smoking and nonsmoking residents without compromising the safety of either. Procedures read in part: -The facility does not allow smoking of any kind to occur within the facility. Designated smoking areas outside the building are available for this purpose. -Upon admission, residents who desire to smoke will be assessed for their ability to do so safely. Until the completion of the initial smoking safety evaluation residents will be on supervised smoking. Supervised smoking will be offered during designated smoking times and last no more than 20 minutes. -If IDT (interdisciplinary team) determines that the resident is unable to safely store their smoking materials or require supervision to smoke safely, smoking products will be kept secured in either medication room or nurses cart. -Upon quarterly review by the IDT, or any time a significant change of condition occurs, smoking residents will be re-evaluated as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility smoking policy. Failure: There was no evidence the smoking policy had been reviewed and revised to address the safety risks associated with the facility's transition to a smoking facility and the plan to allow smoking on campus and supervised smoking. The policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. The NHA was interviewed on 4/9/24 at 12:38 p.m. She said residents who are supervised smokers should not be handed their cigarettes or their lighter. Rather, the smoking material needed to be handed to the staff member responsible for assisting the resident outdoors, and oxygen needed to be removed before exiting the facility. -However, these safety interventions were not part of the facility's smoking policy. b. Resident safe smoking evaluation The evaluation asked all residents who smoked the following questions. 1. Cognition- Resident has cognitive loss?2. Vision- Has a visual deficit?3. Dexterity- Has a dexterity problem (e.g tremors, paresis, etc)?4. Balance- Falls forward? Falls leans sideways?5. Smoking frequency- How many times does the resident smoke per day?6. Safety- Can resident light own cigarette? Resident need for adaptive clothing, device or assistance? Plan of care is used to assure resident is safe while smoking. Failure: The evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. c. Smoking agreement The facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. 1. Review of Resident #1's record (see above) revealed his care plan read to administer oxygen as ordered and smoking evaluations revealed he was a supervised smoker. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before his smoking incident on 3/27/24. 2. Review of the record for Resident #2, admitted on 12/26/23, revealed orders on 1/15/23 that included use of oxygen at 3 liters per minute via nasal cannula, to keep her oxygen saturation at or above 90%. Smoking evaluations revealed she was an independent smoker. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 3. Review of the record for Resident #3, admitted on 8/29/23, revealed a progress note dated 9/4/23 that read the resident was oxygen at 2 liters per minute continuously. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 2. Facility failure to educate staff regarding the transition to a smoking facility and the oversight and necessary safety interventions when allowing smoking on campus and supervised smoking. The assistant director of nursing (ADON) was interviewed on 4/11/24 at approximately 11:00 a.m. The ADON said staff were not provided training on the smoking program before the building transitioned to a smoking facility. She said it was just "rolled out." She said after the incident on 3/27/24 with Resident #1, the staff were provided education on the facility smoking program. IV. Continued facility failures after 3/27/24 A. NHA interview The NHA was interviewed on 4/8/24 at 5:34 p.m. She said she immediately provided education to CNA #1 and RN #1 after the incident on 3/27/24. A review of the education revealed it read in pertinent part: -Residents who are supervised smoking should not be handed their stored smoking material. Smoking materials should be handed to the staff member responsible for assisting residents outside for a supervised smoke.-When assisting residents outside for supervised smoking, if residents are noted to be on oxygen, staff is to remove the portable concentrator prior to exiting the facility and prior to handing over the residents smoking materials or assisting with lighting cigarettes. The NHA further stated she then provided training to all staff regarding the smoking policy, which she revised after the incident on 3/27/24, and about safety issues with oxygen. All residents were assessed and all the residents signed a smoking agreement that included the rules of the facility. 1. Smoking policy Review of the facility's revised smoking policy revealed the substantive changes from the 9/8/22 revisions (see above) included the removal of the frequency of smoking for residents that required staff supervision. However, as noted above, the policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. Safety interventions disclosed in the NHA's 4/9/24 interview regarding when to hand cigarettes to the supervised resident were not part of the smoking policy. 2. Resident safety smoking evaluation However. as noted above, the resident safety evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. 3. Smoking agreement However, as noted above, the facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. While smoking agreements were signed by Resident #1, #2, and #3 on 3/29/24, two days after the 3/27/24 incident, the agreements were incomplete. Resident #1's agreement read, "all smoking supplies will be kept out of sight within rooms." However, as a supervised smoker, per the smoking policy, smoking products were to be kept secured in either the medication room or nurses' cart. Finally, a review of Resident #1, #2's, and #3's smoking agreement revealed they failed to include specific safety interventions, such as the residents agreeing to remove the nasal cannula before leaving the facility or lighting a cigarette. V. Observations confirmed continued noncompliance with oversight and implementation of safety interventions. Record review revealed the facility updated Resident #1's care plan on 3/28/24 to read Resident #1 was to be provided 1:1 observation while smoking. And, on 4/5/24, a new care plan related to smoking read that a smoke detector was in place in the resident's room and staff was to ensure the resident was escorted to the designated smoking area by staff. However, on 4/9/24 at 9:50 a.m., Resident #1 was observed lying in bed with oxygen on and being administered via a nasal cannula. The resident had a bedside table near his bed. On the bedside table was a cigarette that had been previously lit. Three-quarters to one-half of the cigarette remained. The assistant director of nurses (ADON) was notified at 9:52 a.m. and she removed the cigarette. The ADON told the resident that the cigarette was being removed and the resident responded that it was his cigarette. The ADON told the resident that he was not allowed to keep cigarettes. The ADON said the cigarette would be put with the others in his medication cart. VI. Action taken on 4/9/24 after notification of immediate jeopardy The smoking policy was reviewed and updated on 4/9/24. The changes to the policy were in pertinent part: "Smoking times for supervised smokers: 6:00, 9:30, 11:30, 1:30, 3:30, 6:00, 8:30. If the IDT determines that the resident is unable to safely store their smoking materials or [to] require supervision to smoke safely, smoking products will be kept secured in either the medication room or nurses cart. If a resident is deemed an independent smoker, they may keep their smoking supplies in their rooms as long as they kept out of site. If a resident is on oxygen, the tank must be left inside the building and not taken outside to the designated smoking area. For independent residents, cigarettes will not be lit until they are within the designated smoking area. For supervised smokers, once within the designated smoking area, the resident may be given their cigarette and the supervisor will light the cigarette. The lighter is not to be given to the resident. Upon completion of the smoking task, the supervisor will ensure that the cigarette has been put out and the remaining cigarette will be placed inside the cigarette butt receptacle. No partially smoked cigarettes are to be kept. No smoking supplies will be allowed to stay with the supervised smoker. Any resident with a brief interview for mental status (BIMS) score of 12 and below and/or demonstrates the inability to perform safe smoking practices will be placed on supervised smoking. No resident is to give cigarettes or lighters to other residents."

Plan of correction · submitted by the facility

Resident Specific: Resident #1 had smoking assessment completed to identify resident’s abilities, practices, and circumstances that may contribute to resident exhibiting unsafe smoking practices on 03/27/2024. During the assessment completed on 3/27/24 it was identified Resident #1 required assistance to smoke as he could not manage his oxygen safely. Resident #1’s smoking assessment and care plan was updated on 04/10/2024. Education was provided to Resident #1 and all staff to ensure safe smoking practices are followed this was completed on 4/17/24. Identification of Others: All residents who smoke are at risk. ADON/ Designee completed an audit of all residents who currently smoke, updated the smoking assessment and care plan by 04/10/2024. There were four other residents who independently smoke that were identified in the full house audit. The updated smoking assessment included education to all residents who smoke and if they can manage oxygen safely. Systems and measures: The facility updated Smoking Policy on 04/10/2024. DON/ Designee completed education to all staff regarding the updated Smoking Policy and reviewed residents who are on supervised smoking program and how to identify and report changes in a residents safe smoking ability. Education also included safe smoking practices such as proper disposal of smoking materials and proper storage of smoking materials. All education to be completed by 04/17/2024. DON/ Designee to educate staff who complete smoking assessments on the importance of accurately assessing and documenting residents safe smoking ability by 04/17/2024. Any staff who were unable to attend the education in person would be educated prior to start of next scheduled shift. Education will be completed upon new hire and annually. The no oxygen in use was added to the designated smoking area on 04/12/2024. All residents were educated not to share smoking materials with others (included in the smoking policy) on 04/09/2024. Signage was placed at the entrance of the facility to include where the designated smoking area is located, and the smoking policy placed at the visitor sign in location for review. Monitoring: DON/ Designee will audit all new admissions for the following: if the resident would like to smoke and the completion of the smoking assessment and resident specific care plan initiation. DON/ designee will observe current smokers weekly in designated smoking area for safe smoking practices. Weekly, for no less 12-week, DON/Designee will audit/monitor compliance with ensuring residents are free from avoidable smoking injuries: When monitoring audits demonstrate consistent implementation, tracking, and satisfactory compliance with keeping residents free from unavoidable smoking injuries for 12-weeks. Will review audits in QAPI monthly to discuss audits and identify where system is successful, and any areas identified that need improvement for three months. Correction Date04/17/2024

4/11/2024Licensure Complaint Survey · ID VB87111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A survey prompted by complaint #CO35798 was completed on 4/8/24 to 4/11/24. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0704Res Care - Accident Prevention and Attention▼

Findings

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible, affecting three (#1, #2, and #3) out of five residents. Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 9/8/22) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen who smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. While the facility revised the smoking policy after the incident on 3/27/24, record review and observations revealed the revisions were inadequate and ineffective. Smoking and oxygen use were not adequately addressed with residents who smoked and on 4/9/24, observations revealed supervised smoker Resident #1 with a cigarette on his bedside table that had been smoked, with three-quarters to one-half left. The facility's failure to implement interventions to ensure resident safety from smoking accidents before and after 3/27/24 created a situation with the likelihood of serious harm. Resident #1, who had severe cognitive impairment, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. Findings include: I. Smoking facility failures Interviews with leadership revealed the facility had transitioned in March 2024 from a non-smoking to a smoking facility. However, a review of the facility's smoking policy (revision date 1/1/23) and the resident smoking safety evaluation in effect in March 2024, revealed they were not reviewed and revised and failed to address oversight and safety interventions for staff to implement as a smoking facility and related to resident oxygen use and smoking. Further, there were no resident smoking agreements since the transition. None of these documents included adequate consideration of the risks and the procedures to ensure the safety of residents with an order for oxygen that smoked. Interviews with leadership revealed staff had not received training on smoking safety when the facility transitioned to a smoking facility. And, on 3/27/24, Resident #1, a supervised smoker due to his increased confusion and change in safe smoking practices, was given a cigarette and a lighter by the registered nurse (RN) while in the building and walked ahead of the certified nurse aide (CNA) supervising him to the designated smoking area. The resident had his oxygen on, and his nasal cannula in place when he stepped outside the door and lit his cigarette. The oxygen from the cannula ignited immediately. The CNA who followed the resident immediately turned off the resident's oxygen and removed the cannula. Resident #1, sustained first-degree burns to the neck, head, and face after lighting a cigarette on 3/27/24, while wearing oxygen administered via nasal cannula. While the facility smoking policy was amended on 3/27/24 to provide that the smoking products of residents who required supervision to smoke would be kept secured in either the medication room or nurses' cart, on 4/9/24, Resident #1 was found with a cigarette on his bedside table. It had been lit and three-quarters to one-half remained. On 4/9/24 at 3:35 p.m., the Colorado Department of Public Health and Environment (CDPHE) informed the nursing home administrator (NHA) that the facility's failure to implement safe smoking interventions for residents who smoked and to implement effective interventions to prevent injury from cigarettes to Resident #1, created a situation with the potential for serious resident harm. On 4/10/24 at 3:42 p.m., the facility submitted the following plan (draft #4):"Removal of Immediacy Plan: Unsafe SmokingDate/Time Presented to Surveyors: 4/10/24 at 3:35 p.m. Identified here are the steps and immediate action(s) (name of facility) will take to address the reported non-compliance, keep residents safe and free from serious harm or death, and prevent serious harm from occurring or recurring. 1. Resident #1 was identified as a supervised smoker on 03/19/2024. On 3/27/24 Resident #1 was given a cigarette and lighter by a RN while in the building. The CNA supervising did not ensure oxygen was removed prior to Resident #1 lighting cigarette which in turn led to oxygen from cannula igniting. CNA immediately following turned oxygen off. The smoking UDA was updated to include questions referring to oxygen use on 4/9/24. Items added:-Can the resident light their own cigarette?-Does the resident utilize oxygen?-Is the resident able to manage oxygen safety, remove and store for safe smoking practices,-Observe the resident smoking in designated smoking area,-Is the resident able to safely light smoking materials, hold smoking materials safely and dispose of smoking materials appropriately,-Has the resident been educated on safe smoking practices?On 4/10/24 an additional smoke detector was placed in residents (Resident #1's) bathroom. 2. Director of nurses (DON)/Designee and Clinical Resource completed a full house audit of all smoking evaluation(s) by 4/9/24 and updated all residents' care plans. Facility placed an updated smoking list out at the units on 4/9/24. DON to complete additional full house audit of all smokers starting on 4/9/24 to identify need for supervision or adaptive equipment, facility will review all residents BIMS score, and update a smoking assessment (completed 4/9/24). Any resident who smokes with a BIMS (brief interview of mental status) of 12 or below will be placed on supervised smoking (Resident #1 identified). Smoking policy updated on 4/9/24 to reflect the change. Administrator or designee to review updated smoking Policy with all residents who smoke on 4/9/24 or their representative. 3. All Staff/All residents who smoke to be educated on updated Smoking Policy to address the following:-Use of oxygen,-Who is Supervised and Unsupervised,- How to properly supervise smokers-Supervised smoking times-Proper adaptive equipment available and locations,-Proper smoking equipment indicated in smoking area such as blankets/extinguisher,g-Cleanliness of smoking area, and-Monitoring for proper disposal of cigarette butts.-Safety education was provided to residents regarding our smoking policy and-Use of oxygen to ensure that they remove oxygen prior to going out to smoke.-Smoking materials need to be safely stored out of sight of other residents.-No cigarettes or lighters [will] be given to other residents. 4. Staff education to be completed by Administrator, Nurse Manager, SDC (staff development coordinator), Social Worker, or Activity Director. This education will be provided to all staff/residents who smoke by 4/10/24, any staff that is not able to come in for education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. 5. On 4/9/24 Resident #1 was found to have a cigarette butt on his bedside table. All staff will be educated on Proper Supervision of smokers to include disposing of any non smoked tobacco product in proper receptacle before re-entering building. A facility audit was implemented on 4/10/2024 to include observations of any smoking materials in resident rooms or on their person. An order was initiated to monitor the residents' room for smoking items every shift. If any are found, remove and provide education to the resident on facility smoking policy and safety. This education will be completed by 4/10/24 any staff that is not able to come in for training education will be educated over the phone and will be reviewed with Administrator prior to start of next scheduled shift. This education will be provided by DON/NHA/Designee. Monitoring:DON/Designee will audit all new admissions for smoking preference, complete a smoking evaluation (to include oxygen use and if they are to be supervised or unsupervised) and update the care plan with current interventions. Assessment and care plan to be completed within 24 hours. Smoking assessments will be completed by ADON (assistant director of nursing) or designee. DON/Designee to review all those residents who smoke weekly and document if they continue to follow safe smoking rules, or if there are changes needed to their care plan. Specifically, for Resident #1 daily audits of resident's room and on his person to ensure he has not brought in any smoking materials from the smoking area. Maintenance to monitor smoking area daily for cigarette butts, safety blankets, and No Oxygen use signs x 12-weeks or until compliance is achieved, any issues identified will be discussed in monthly QAPI (quality assurance performance improvement). These audits will continue for 12-weeks until compliance is achieved, any issues identified will be discussed in monthly QAPI. 6. "NO OXYGEN WITHIN 10 FEET" signage ordered for designated smoking area to arrive 4/12/24." On 4/10/24 at 4:00 p.m., CDPHE notified the NHA that the above plan was accepted. II. Resident #1 - smoking incident 3/27/24 A. Resident #1 Resident #1, age 70, was admitted on 2/13/24. According to the 4/10/24 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, emphysema, dementia, and acute respiratory failure with hypoxia (insufficient oxygen to the body tissues). The 2/19/24 facility assessment showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. A 3/23/24 facility assessment documented the resident had moderately impaired decision-making skills, had poor cues, and required supervision. Per the facility assessment, he used oxygen. Per the resident's care plan, oxygen was to be administered as ordered by the physician. B. Smoking status Review of Resident #1's care plan, initiated on 3/6/24 for smoking, revealed he had a history of smoking in his room. Pertinent interventions included smoking materials to be kept at the nurses' station or other designated areas. The cigarettes/lighter were to be kept with the nurse and the resident was to ask for them. Review of a resident safe smoking evaluation completed on 3/19/24 at 3:31 p.m. revealed the resident, who smoked five times a day, was determined to be unsafe to smoke without supervision due to increased confusion and cognitive loss. Review of a smoking evaluation completed on 3/27/24 at 2:47 p.m. (prior to the smoking incident the same day) revealed the resident, who now smoked six times a day, remained unsafe with smoking independently. He had cognitive loss and fell forward while standing. The clinical resource nurse assisted the resident in removing his oxygen before attempting to stand from his wheelchair and walk to the designated smoking area. There, he was able to light his cigarette and flick the ashes away from his body but was unable to extinguish his cigarette butt into the receptacle. Failure: There was no evidence the resident's care plan was updated on 3/19/24 to document the resident's status as a supervised smoker. Further, there was no evidence the IDT considered additional safety interventions to instruct staff on how to assist the resident in smoking safely. There was no evidence the resident was educated regarding what staff expected of him as a supervised smoker to ensure his and other residents' safety when smoking. C. Smoking incident on 3/27/24 1. Nurses' notes A review of nurses' notes from 3/27/24 at 3:45 p.m. revealed Resident #1 was assisted to smoke outside by the CNA. The resident was walking ahead of the CNA when he lit his cigarette. The CNA turned off the resident's oxygen and removed the nasal cannula from his face. The resident was noted to have seared facial hair and nose pain. The resident was transferred to the emergency department for evaluation and a review of Resident #1's emergency department records revealed a diagnosis of mild first-degree burns to the face. 2. NHA interview The NHA interviewed on 4/8/24 at 5:34 p.m., said she completed an investigation following the resident's smoking incident. The NHA said the investigation revealed Resident #1 was observed walking outside with CNA #1. RN #1 had given the cigarette and lighter to the resident, rather than to the CNA. CNA #1 said she was assisting the resident outside; he was moving swiftly with his front wheel walker and had his oxygen on. Before she could remove the oxygen and turn it off, the resident lit the cigarette. The NHA said the resident had singed his mustache and the hair to the left side of his face along with the oxygen tubing. She said the resident's primary physician was in the building and had him assessed. The primary physician had him sent to the emergency department for further evaluation as the resident complained of burning in his nose. III. Facility failures contributing to the smoking incident on 3/27/24. 1. Facility failure to review and revise the facility smoking policy and resident safe smoking evaluations, and obtain smoking agreements that addressed oversight and safety interventions after the facility transitioned to a smoking facility, allowing smoking on campus and supervised smoking. On 4/8/24 at 5:34 p.m., the social services director (SSD) and NHA were interviewed. The SSD said before March 2024, the facility was a non-smoking facility, which meant residents who chose to smoke had to smoke cigarettes off campus. She said in March 2024 (a definite date was not provided), the facility became a facility that would allow smoking on campus and there could be supervised smoking. On 4/9/24 at 12:38 p.m., the NHA provided the facility smoking policy and smoking evaluation in effect after the transition to a smoking facility and before the incident with Resident #1 on 3/27/24. a. Smoking Policy The policy, last revised 9/8/22 read that its purpose was to address the wishes of both smoking and nonsmoking residents without compromising the safety of either. Procedures read in part: -The facility does not allow smoking of any kind to occur within the facility. Designated smoking areas outside the building are available for this purpose. -Upon admission, residents who desire to smoke will be assessed for their ability to do so safely. Until the completion of the initial smoking safety evaluation residents will be on supervised smoking. Supervised smoking will be offered during designated smoking times and last no more than 20 minutes. -If IDT (interdisciplinary team) determines that the resident is unable to safely store their smoking materials or require supervision to smoke safely, smoking products will be kept secured in either medication room or nurses cart. -Upon quarterlyreview by the IDT, or any time a significant change of condition occurs, smoking residents will be re-evaluated as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility smoking policy. Failure: There was no evidence the smoking policy had been reviewed and revised to address the safety risks associated with the facility's transition to a smoking facility and the plan to allow smoking on campus and supervised smoking. The policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. The NHA was interviewed on 4/9/24 at 12:38 p.m. She said residents who are supervised smokers should not be handed their cigarettes or their lighter. Rather, the smoking material needed to be handed to the staff member responsible for assisting the resident outdoors, and oxygen needed to be removed before exiting the facility. -However, these safety interventions were not part of the facility's smoking policy. b. Resident safe smoking evaluation The evaluation asked all residents who smoked the following questions. 1. Cognition- Resident has cognitive loss?2. Vision- Has a visual deficit?3. Dexterity- Has a dexterity problem (e.g tremors, paresis, etc)?4. Balance- Falls forward? Falls leans sideways?5. Smoking frequency- How many times does the resident smoke per day?6. Safety- Can resident light own cigarette? Resident need for adaptive clothing, device or assistance? Plan of care is used to assure resident is safe while smoking. Failure: The evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. c. Smoking agreement The facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. 1. Review of Resident #1's record (see above) revealed his care plan read to administer oxygen as ordered and smoking evaluations revealed he was a supervised smoker. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before his smoking incident on 3/27/24. 2. Review of the record for Resident #2, admitted on 12/26/23, revealed orders on 1/15/23 that included use of oxygen at 3 liters per minute via nasal cannula, to keep her oxygen saturation at or above 90%. Smoking evaluations revealed she was an independent smoker. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 3. Review of the record for Resident #3, admitted on 8/29/23, revealed a progress note dated 9/4/23 that read the resident was oxygen at 2 liters per minute continuously. Smoking evaluations revealed she had no dexterity problems, could light her own cigarette, and had no need for adaptive clothing, devices, or supervision. Failure: Record review revealed no smoking agreements signed after the facility transitioned to a smoking facility and before the smoking incident involving Resident #1 on 3/27/24. Further, there was no evidence the resident was educated on the facility's smoking policy. 2. Facility failure to educate staff regarding the transition to a smoking facility and the oversight and necessary safety interventions when allowing smoking on campus and supervised smoking. The assistant director of nursing (ADON) was interviewed on 4/11/24 at approximately 11:00 a.m. The ADON said staff were not provided training on the smoking program before the building transitioned to a smoking facility. She said it was just "rolled out." She said after the incident on 3/27/24 with Resident #1, the staff were provided education on the facility smoking program. IV. Continued facility failures after 3/27/24 A. NHA interview The NHA was interviewed on 4/8/24 at 5:34 p.m. She said she immediately provided education to CNA #1 and RN #1 after the incident on 3/27/24. A review of the education revealed it read in pertinent part: -Residents who are supervised smoking should not be handed their stored smoking material. Smoking materials should be handed to the staff member responsible for assisting residents outside for a supervised smoke.-When assisting residents outside for supervised smoking, if residents are noted to be on oxygen, staff is to remove the portable concentrator prior to exiting the facility and prior to handing over the residents smoking materials or assisting with lighting cigarettes. The NHA further stated she then provided training to all staff regarding the smoking policy, which she revised after the incident on 3/27/24, and about safety issues with oxygen. All residents were assessed and all the residents signed a smoking agreement that included the rules of the facility. 1. Smoking policy Review of the facility's revised smoking policy revealed the substantive changes from the 9/8/22 revisions (see above) included the removal of the frequency of smoking for residents that required staff supervision. However, as noted above, the policy failed to include adequate consideration of the risks and the procedures necessary to ensure the safety of residents with an order for oxygen who smoked. Safety interventions disclosed in the NHA's 4/9/24 interview regarding when to hand cigarettes to the supervised resident were not part of the smoking policy. 2. Resident safety smoking evaluation However. as noted above, the resident safety evaluation failed to include any questions regarding oxygen use and, if the resident, whether an independent or supervised smoker, understood the safety considerations of oxygen use and smoking. 3. Smoking agreement However, as noted above, the facility failed to provide evidence that residents signed smoking agreements after the facility transitioned to a smoking facility in March 2024 and before Resident #1's smoking incident on 3/27/24. While smoking agreements were signed by Resident #1, #2, and #3 on 3/29/24, two days after the 3/27/24 incident, the agreements were incomplete. Resident #1's agreement read, "all smoking supplies will be kept out of sight within rooms." However, as a supervised smoker, per the smoking policy, smoking products were to be kept secured in either the medication room or nurses' cart. Finally, a review of Resident #1, #2's, and #3's smoking agreement revealed they failed to include specific safety interventions, such as the residents agreeing to remove the nasal cannula before leaving the facility or lighting a cigarette. V. Observations confirmed continued noncompliance with oversight and implementation of safety interventions. Record review revealed the facility updated Resident #1's care plan on 3/28/24 to read Resident #1 was to be provided 1:1 observation while smoking. And, on 4/5/24, a new care plan related to smoking read that a smoke detector was in place in the resident's room and staff was to ensure the resident was escorted to the designated smoking area by staff. However, on 4/9/24 at 9:50 a.m., Resident #1 was observed lying in bed with oxygen on and being administered via a nasal cannula. The resident had a bedside table near his bed. On the bedside table was a cigarette that had been previously lit. Three-quarters to one-half of the cigarette remained. The assistant director of nurses (ADON) was notified at 9:52 a.m. and she removed the cigarette. The ADON told the resident that the cigarette was being removed and the resident responded that it was his cigarette. The ADON told the resident that he was not allowed to keep cigarettes. The ADON said the cigarette would be put with the others in his medication cart. VI. Action taken on 4/9/24 after notification of the situation The smoking policy was reviewed and updated on 4/9/24. The changes to the policy were in pertinent part: "Smoking times for supervised smokers: 6:00, 9:30, 11:30, 1:30, 3:30, 6:00, 8:30. If the IDT determines that the resident is unable to safely store their smoking materials or [to] require supervision to smoke safely, smoking products will be kept secured in either the medication room or nurses cart. If a resident is deemed an independent smoker, they may keep their smoking supplies in their rooms as long as they kept out of site. If a resident is on oxygen, the tank must be left inside the building and not taken outside to the designated smoking area. For independent residents, cigarettes will not be lit until they are within the designated smoking area. For supervised smokers, once within the designated smoking area, the resident may be given their cigarette and the supervisor will light the cigarette. The lighter is not to be given to the resident. Upon completion of the smoking task, the supervisor will ensure that the cigarette has been put out and the remaining cigarette will be placed inside the cigarette butt receptacle. No partially smoked cigarettes are to be kept. No smoking supplies will be allowed to stay with the supervised smoker. Any resident with a brief interview for mental status (BIMS) score of 12 and below and/or demonstrates the inability to perform safe smoking practices will be placed on supervised smoking. No resident is to give cigarettes or lighters to other residents."

Plan of correction · submitted by the facility

9/5/2023Complaint Survey · ID KI9M11No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey prompted by #CO33477 was conducted on 9/5/23. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

7/19/2023Revisit: Recertification Survey · ID CBL522No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

3/29/2023Revisit: Complaint, Recertification Survey · ID CBL512No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 3/29/23 for all previous deficiencies cited on 2/16/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

3/29/2023Revisit: State Licensure Survey · ID V2ND12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 03/29/2023 for all previous deficiencies cited on 2/16/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

3/14/2023Recertification Survey · ID CBL5215 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

INITIAL COMMENTS (Prefix Tag #000) 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-story, non-combustible, Type II (111), structure without a basement. The facility is separated from the adjacent 10-story high-rise building by a two-hour firewall. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility is licensed for 60 beds. this re-certification survey conducted on March 14, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

Plan of correction

The state did not require a plan of correction for this citation.

0293Exit SignageS/S E▼

Findings

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency. Exit signs need to be UL listedExit sign need to added to break room NFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Plan of correction · submitted by the facility

Resident Specific: No residents Identified. But could affect all residents within the smoke compartment. Identification of others: Potential to affect occupants, who might include staff, residents, and visitors throughout the facility if an exit cannot be identified during an emergency. System and Measures:Exit sign was missing from Break room, and UL listed. Sign was purchased and installed in Break room. Monitoring:Maintenance staff will check this door with their weekly exit signage check on TELs. In compliance on 5/14/23

0324Cooking FacilitiesS/S D▼

Findings

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. Kitchen stove and cooking equipment missing wheel blocking and/or a means to ensure the appliance is returned to its design location. Suppression nozzles need to be adjusted over cooking areaNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

Plan of correction · submitted by the facility

Resident Specific: No residents Identified. But could affect all residents within the smoke compartment. Identification of others: Potential to affect occupants, who might include staff, residents and visitors within the entire facility. System and Measures:Wheel chocks were found to be missing from the kitchen stove. We ordered wheel chocks and called Western states fire to change the kitchen suppression heads around. Monitoring:Will educate kitchen staff that the kitchen stove needs to slide back into wheel chocks after every cleaning, and will have Western states continue to monitor Kitchen nozzle placement above cooking equipment.

0351Sprinkler System - InstallationS/S D▼

Findings

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 101Sprinkler Heads closer than 3 feet in old bathroom NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Plan of correction · submitted by the facility

Resident Specific: No residents Identified. Potential to affect occupants, who might include staff, residents, and visitors in that smoke compartment. Identification of others: Potential to affect occupants, who might include staff, residents, and visitors within the entire facilitySystem and Measures:Sprinkler heads are too close in old bathroom, called Western states in, to remove redundant sprinkler head. Monitoring: Going forward we will notate heads closer than 3 feet in our weekly TELS inspection for sprinkler heads if we run into sprinkler heads closer than 3 feet. Then report them to our fire protection company for correction.

0372Subdivision of Building Spaces - Smoke BarrieS/S F▼

Findings

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:Fire Wall by ALR dining room need to be fire caulkedFire Wall by by room S-1 need to be fire caulkedMechanical room penetrations need to be fire caulked Electrical room penetrations need to be fire caulkedNFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Plan of correction · submitted by the facility

Resident Specific: No residents Identified. But could affect all residents within the smoke compartment. Identification of others: Potential to affect occupants, who might include staff, residents, and visitors within the entire facility. System and Measures: Was found that proper Fire caulk was not used in our:Dining room, Fire wall by S-1, Mechanical room, and electrical room. Maintenance team went back over all these penetrations took care of inappropriate barrier and applied proper fire caulked. Monitoring:Maintenance will check for penetrations monthly through TELS to keep up on any new barrier penetrations.

0521HVACS/S F▼

Findings

Based on record review and staff interview during the survey, the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. No records or documentation for fire/smoke damper 4-year inspection and maintenance was completed. NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 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 at the exit conference.

Plan of correction · submitted by the facility

Resident Specific: No residents Identified. Potential to affect occupants, who might include staff, residents, and visitors in that smoke compartment. Identification of others: Potential to affect occupants, who might include staff, residents, and visitors within the entire facility. System and Measures:No Damper inspection was found during time of inspection, we reached out to fire protection vendors to get this accomplished. Monitoring:We will keep up with the 4 year schedule on Damper inspections going forward.

2/16/2023Complaint, Recertification Survey · ID CBL5113 deficiencies▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A recertification survey with complaint #CO30704 was conducted on 2/13/23-2/16/23. Three deficiencies were cited.

Findings · record 2 of 2

An Emergency Preparedness survey was conducted from 2/13/22 to 2/16/22. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0582Medicaid/Medicare Coverage/Liability NoticeS/S B▼

Findings

Based on record review and interviews, the facility failed to inform two (#24 and #41) of three out of 23 sample residents reviewed for liability notices and appeal rights changes in their services covered by Medicare. Specifically, the residents were not provided with completed skilled nursing facility-advanced beneficiary notice after Medicare coverage ended and the residents remained in the facility. Findings include:I. Facility policyThe Advanced Beneficiary Notice of Noncoverage (ABN) policy, revised March 2018, was provided by the social services director (SSD) on 2/16/23 at 3:00 p.m. It read in pertinent part: "The ABN was used for beneficiaries in original (fee for service) Medicare when the facility believed that Medicare was not likely to cover the services described in the ABN. Form CMS-10055(2018) was used to satisfy the SNF Part A ABN requirement. The ABN must be issued before the provision of services described in the ABN. The ABN must be verbally reviewed with the beneficiary of his/her representative and any questions raised during that review must be answered before it is signed. Once all the blanks were completed and the form was signed, a copy was given to the beneficiary or representative."II. Facility failureResident #24 The medical record showed Resident #24 had been discharged from Medicare part A services on 1/25/23. The resident continued to live in the facility. The Notice of Medicare Provider Non-Coverage (NOMNC) had been issued to the resident as well as the ABN. Both forms were signed on 1/23/23. However, no options were chosen. There were three options to choose from. -Option 1. I want skilled services and want Medicare billed.-Option 2. I want skilled services but don't bill Medicare.-Option 3. I don't want the skilled services. Resident #41The medical record showed Resident #41 had been discharged from Medicare part A services on 1/14/23. The resident continued to live in the facility. The NOMNC had been issued to the resident as well as the ABN. Both forms were signed on 1/11/23. However, no options were chosen. III. Staff interviewsThe SSD was interviewed on 2/16/23 at 9:20 a.m. She said she gave the two forms to the resident to sign. She said when she was trained, she was told she was not allowed to pick the options for the resident. She said the ABN form was for residents who were staying in the facility past their covered days. She said she gave the resident the form to review and sign. She said she knew the residents' wishes by which option they chose. She said she did not know she needed to make sure the resident picked an option. She acknowledged that an option should be chosen. She said going forward she would ask medical records to review the form for completion prior to scanning it into the medical record to double check that the option had been chosen. The director of nursing (DON) was interviewed on 2/16/23 at 9:31 a.m. She said she was not familiar with the NOMNC and ABN forms but believed the forms should be completely filled out to know the residents wishes.

Plan of correction · submitted by the facility

F582Resident Specific: Resident #24 and #41 have been identified and currently reside at the facility. Residents #24 and #41 were informed of payment status as of resident’s last covered day and signature of notification was obtained. Review of options completed and updatedIdentification of others: The facility has determined that residents that have been issued a NOMNOC and staying here long term care will be issued a ABN and the options on the ABN will be marked and signed by resident or resident representative. This will be audited by Medical Records or designee for 3 months. System and Measures: The administrator educated the following personnel on the facility’s Advance Beneficiary Notices policy: Business Office Manager, Social Services Director, MDS coordinator, Director of Nursing, Director of Therapy, and Unit Managers. This required a in service. These actions were completed on 03/10/23. Monitoring:The Social Service Director, or designee will complete and review the ABN with resident or resident representative and check options and signature of any resident who will be staying long term care for 3 months to verify that notices were issued and completed appropriately. This will be put on a audit form, which will be audited by Medical Records and will be monitored at the monthly Quality Assurance meeting for 3 months at 100% compliance. Corrective action completion date: 03/10/2023

0689Free of Accident Hazards/Supervision/DevicesS/S G▼

Findings

Based on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#6) of two residents reviewed for falls out of 23 sample residents. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living as documented in her 10/19/22 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light due to severely impaired cognition. Due to the facility's failures, lack of appropriate supervision and effective interventions resulted in four falls. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent falls for Resident #6, with a fall on 12/26/22 that resulted in major injury with right distal and proximal femur (hip) fractures and surgery, and required hospitalization for eight days. Findings include: I. Resident status Resident #6, age 86, was admitted on 10/16/22 and readmitted on 1/3/23. According to the February 2023 clinical physician orders (CPO), diagnoses included encounter for other orthopedic aftercare, fracture of unspecified part of neck of right femur, displaced spiral fracture of shaft of right femur, pain in right leg and history of falling. The 10/19/22 MDS assessment revealed the resident's cognition was moderately impaired with BIMS score 10 out of 15. No behaviors or rejection of care were noted. She required extensive assistance of two staff with bed mobility, she was totally dependent on two staff with transfers, required limited assistance with dressing, and was independent with eating. The 1/6/23 minimum data set (MDS) assessment revealed intact cognition with a brief interview for mental status (BIMS) score 15 out of 15. No rejection of care was noted. She required limited assistance with bed mobility, dressing, toilet use and personal hygiene, supervision of two staff with transfers and supervision with eating. The resident was frequently incontinent of urine. The resident had a fall with a fracture prior to admission. Medication she was administered included an anticoagulant, antidepressant and opioid. II. Record review Care Plan: The resident's records were reviewed on 2/15/23 and revealed the comprehensive person-centered care plan was canceled on 12/30/22. The facility failed to timely develop a care plan addressing falls risk for Resident #6 who was readmitted on 1/3/23. Interdisciplinary notes: On 10/18/22 a social worker documented in part: "New admit following a fall with fracture of her hip. Patient is a resident here at (facility) on the AL (assisted living) floor. She is hopeful to return back after she completes her therapy. (Resident) was administered a BIMS (Brief Interview for Mental Status) by Speech Therapy where she scored 10 indicating moderate impairments with cognitive functioning. She has a dx (diagnosis) of cognitive communication deficits as well as aphasia. She is very much aware that at times she is forgetful and has word finding difficulties. It is obvious that she has been counseled because several times during the interview with SS (social services) she told herself to slow down when she was communicating. SS (social services department) will continue to follow with IDT (interdisciplinary team) members and assist as needed with discharge planning and providing assistance with any necessary adjustment concerns." On 10/19/22 a registered nurse documented, in part: "Barriers to safe and effective discharge: assist with ADL (activities of daily living) cares and cognition. TTWB to RLE (toe touch weight bearing to right lower extremity); max x 2 (maximum assistance of two staff) for transfers; noted with delusions and confusion on readmit. IDT (interdisciplinary team) plans for this week: continue therapy services for swallowing, dressing, grooming/hygiene, transfers and strength. Additional Information: nursing for pain/medication management, obtaining and monitoring vitals/labs; assist with ADL (activities of daily living) cares." -The interdisciplinary team plan did not include resident's risk for falls. Falls with no major injuries: On 10/25/22 at 1:00 p.m. a nurse documented in part: "This nurse notified that pt (patient) had fallen. When entering the room she was sitting on the floor, leaning against her bed frame. She stated she was trying to get in bed by herself. A therapist was walking by and assisted her the rest of the way to the ground. She states she did not hit her head. Assessed pt (patient) for injury, none noted. Assisted pt (patient) into bed x3 (with three) staff members and a gait belt. Pt is able to move all extremities, equal hand grasps, pupils are equal and reactive. PCP (primary care physician) and DON (director of nursing) notified." On 10/27/22 the DON documented, in part: "Fall committee IDT (interdisciplinary team) follow up for fall on 10/25/2022. Predisposing factors: weakness, ORIF (open reduction internal fixation) of right hip, lack of safety awareness, cognitive deficit, hx (history) of falling. Interventions: Resident is being followed by therapy services for post right hip ORIF for safety awareness, endurance and strengthening as well as ambulation and transfers. Therapy to eval (evaluate) for visual reminders to ask for assistance." On 10/28/22 the director of rehabilitation (DOR) documented: "Pt (patient) is receiving therapy services focusing on strength, balance, safety. Pt (patient) cognitively impaired following her surgery and requires verbal and visual reminders to not transfer herself. Sign placed as a reminder to call for help." On 11/1/22 a nurse documented in part: "Pt (patient) out to see ortho (orthopedic physician) today. Continue TTWB x2 (toe touch weight bearing for two) weeks. F/U (follow up) in 1 (one) month. WBAT (weight bearing as tolerated) on 11/15/22." On 11/26/22 at 1:00 a.m., a nurse documented: "CNA (certified nurse aide) came to this nurse stating resident on floor in room. Upon entering room resident sitting on buttocks next to bed, facing door to hall, denies hitting head, c/o (complains of) pain in buttocks and RLE (right lower extremity), no visible injuries upon assessment, stated 'my brief was wet, I was going to the commode.' Denies injuries and hitting head, c/o (complained of) pain in buttocks, states 'I'm fine, the floor is just hard.' Resident placed back into bed x3 (with three) staff assist. Vital signs taken, assessment completed, neuro checks initiated, all responsible parties notified." On 11/28/22 a nurse documented, in part: "Fall committee IDT (interdisciplinary team)"Follow up for fall on 11/26/2022. Predisposing factors: history of falling, muscle weakness, lack of coordination, right femur fx (fracture). Interventions: educate staff to keep w/c (wheelchair) closer to the bed, therapy to evaluate room layout." On 11/29/22 the DOR documented: "Pt (patient) sustained a fall without injury when attempting to transfer herself to the bedside commode when was paced at the foot of the bed. Pt (patient) is progressing in therapy and felt she was able to perform the transfer. Recommend that the BSC (bedside commode) placed at bedside to lessen distance for transfer and to improve successful transfer." Falls with injuries: On 12/16/22 at 10:15 a.m., a nurse documented: "CNA notified this nurse that resident was found on floor. This nurse entered resident's room and visualized resident sitting on floor next to bedside commode. Resident was holding right knee and complaining of pain to right knee and elbow. Resident stated she was sitting at the edge of her bed and attempted to adjust her commode and slid off the bed onto right knee and elbow. Resident noted with abrasion and swelling to right knee, bruising and abrasion to right elbow. Neuro sheet started, neuros WNL (within normal limits), vitals WNL (within normal limits). Resident assisted back to bed and educated on use of call light for assistance. NP (nurse practitioner) notified and ordered STAT (immediate) x-ray of right knee, right hip, and right elbow. Resident's daughter notified." On 12/16/22 a nurse documented in part: "X-ray results received. Results reviewed with (physician), new order for NWB (no weight bearing) to RLE (right lower extremity) until f/u (follow up) ortho apt (orthopedic appointment). " On 12/17/22 a nurse documented: "Resident returned from ED (emergency department), transferred by (ambulance). CT (computed tomography) pelvis and x-ray R (right) femur completed, no significant findings noted. No new orders." On 12/19/22 the DON documented, in part: "Incident committee IDT (interdisciplinary team). Follow up for fall on 12/16/2022. Injuries: Abrasion to right elbow and right knee. Bruise to right elbow. Predisposing factors: History of falls, muscle weakness, unsteady gait, impulsiveness. Interventions: Will speak with resident about moving rooms closer to the nurses' station." On 12/20/22 the DOR documented: "Pt (patient) is receiving therapy services. Pt (patient) has a bedside commode due to her not wanting to use her regular shared room bathroom. Pt (patient) often attempts to transfer herself to the commode despite education to always call for assistance. Pt (patient) is impulsive and would benefit from moving closer to the nursing station for increased level of supervision. Therapy working on safety with transfers and bedside commode use." On 12/26/22 at 5:07 p.m., the DON documented: "Called to residents room by cna (certified nurse assistant) as resident had fallen. When resident asked what happened she stated 'I was trying to get from here to there' pointing from the commode to the recliner. RN (registered nurse) assessment: Resident noted sitting on the floor with her back against her recliner. Right leg externally rotated and resident screamed out in pain with slight touch to the area. She is able to wiggle her toes, but unable to move extremity. (Ambulance) called for emergent transfer to hospital for further evaluation. MD (physician) and daughter notified."The 12/26/22 x-ray report from the hospital revealed in part: "Displaced angulated spiral/oblique fracture near the distal third of the right femoral shaft; proximal right femur subtrochanteric fracture surgically addressed with orthopedic metallic fixation hardware, near normal anatomic alignment; persistent right superior and inferior pubic rami fracture deformities. "Patient presents with mechanical fall and obvious right leg deformity. Orthopedic surgery recommended placing patient in Buck's traction (device/traction to restore normal bone alignment and length) which was performed in the emergency department and she will be admitted for ongoing pain control and operative intervention. " On 12/27/22 the DON documented, in part: "Incident committee IDT. Follow up for fall on 12/26/2022. Injuries: right hip with external rotation. Predisposing factors: History of falls, muscle weakness, unsteady gait, impulsiveness. Interventions: Resident sent to ED (emergency department) for further evaluation." On 12/28/22 the DOR documented: "Pt (patient) sustained a fall attempting again to transfer herself. Pt (patient) is currently in the hospital and will be evaluated by therapy upon her return." On 1/4/23 the DON documented, in part: "Fall Committee Follow-up for fall on 12-26-22. Resident returned to the facility on 1/3/23. Resident's room moved closer to the nurses' station by the door for better observation. Resident with PT & OT (physical therapy and occupational therapy) services in place." On 1/11/23 the DON documented, in part: "Deep dive into frequent faller with fish bone diagram for root cause analysis review. Care plan reviewed and updated, as indicated. New interventions include perimeter mattress for safety awareness. Resident also placed on frequent toileting schedule during the day. Consent obtained from POA (power of attorney) for perimeter mattress and aware of clinical situation." III. Staff interviews The clinical resource registered nurse (CRRN) was interviewed on 2/16/23 at 8:45 a.m. She said Resident #6's care plan was canceled during her stay in the hospital. She said the comprehensive care plan was not reinstated and updated since the resident returned to the facility on 1/3/23 (over a month previous). Certified nurse aide (CNA) #2 was interviewed on 2/16/23 at 8:55 a.m. She said she was aware of the resident's risk for falls. She said after return to the facility Resident #6 was moved to a room close to the nurses' station and had not had any falls since. She said the resident did not have or use a bedside commode and the nursing staff was checking on her frequently. She said the staff offered toileting to the resident every two hours and was taking her to use the bathroom in the shower room across the hallway. She said most of the time the resident did not remember to use her call light. The DON, the DOR and the CRRN were interviewed on 2/16/23 at 11:40 a.m. The DOR said after the resident's fall on 10/25/22, the therapy team focused on visual reminders to ask for assistance and signs were placed on the resident's walker. The DOR said prior to the fall on 11/26/22, while transferring to the commode, Resident #6's weight bearing status was upgraded to as tolerated, she required supervision with bed mobility and contact guard assistance from staff with transfers. The DON said staff education was provided and the resident's wheelchair was to be kept close to her bed. The DOR said after the resident's fall on 12/16/22, staff tried to remove the commode and the resident did not allow it. The resident declined to move closer to the nurses' station previous to when she was moved closer.-There were no notes in Resident #6 records about the resident declining to move closer to the nurses' station. The DON said before the fall with injury, the resident refused to use the bathroom in her room as it was difficult for her to get to the toilet, therefore the bedside commode was an option at the time. She said the interdisciplinary team did not consider removing the bedside commode from the resident's room and staff could take the resident to a bathroom in the shower room. IV. Facility follow-up On 2/16/23 at 11:30 a.m., the CRRN provided a copy of the resident's new and updated comprehensive care plan. On 2/16/23 at 11:35 a.m., the DON provided a copy of all facility staff training on falls prevention and the Performance Improvement Plan (PIP). The PIP was dated 1/10/23 and read, "She admitted to facility with fracture, and has severe osteopenia (loss of bone mineral density) and osteoarthritis to bilateral knees. She is noncompliant with using call light. She will be placed on toileting program while awake and we will place her on concave mattress (a mattress with concave sides)."-The above noted interventions were in place for the resident. On 2/16/23 at 4:42 p.m., the CRRN provided a copy of the 12/26/22 hospital record, read in part: "Patient had a hip fracture with hip nail placed 2 and half months ago and is unclear if she refractured this area or if it has not fully healed yet."

Plan of correction · submitted by the facility

F689Resident specific: Resident #6 identified and currently reside at the facility. Fall risk assessment was completed for Resident #6. Care plan has been updated for resident #6. The revised assessment and care plan was reviewed with staff involved in the care of resident #6. Identification of others: The nursing management team reviewed the MDS assessment for all residents who have been identified as having potential risk for falls. Fall risk assessments are complete and interventions currently in place are appropriate. System and Measures: Director of Nursing or designee will in-service all licensed nursing staff on the facility policy for Accidents and Supervision. This sign in service will be completed by 3/10/23. All residents falls/accidents will be reviewed daily by the nursing management team to ensure appropriate implementation of fall interventions including updating the plan of care. Monitoring: The nursing management team will review each incident report upon occurrence to ensure appropriate interventions are implemented and updated plan of care is complete. The Director of Nursing or designee will audit 3 incidents/falls x 3-week x 12 weeks to ensure appropriate interventions have been put in place to reduce the risk of resident falls/accidents and that care plans have been updated to reflect these interventions. The results of these audits will be reported to the Quality assurance committee for review and recommendation. The quality Assurance committee will determine further auditing needs. Correction action completion 3/10/23

0849Hospice ServicesS/S D▼

Findings

Based on record review and interviews, the facility failed to communicate and collaborate with the hospice provider to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (#8) out of two residents reviewed for hospice care of 23 sample residents. Specifically, the facility failed to for Resident #8:-Collaborate with the hospice provider to develop a coordinated plan of care; and,-Ensure adequate communication and documentation between the facility and the hospice provider occurred. Findings include:I. Facility policyThe Coordination of Hospice Services policy, dated 2022, was provided by the director of nursing (DON) 2/22/23 at 10:30 a.m. The policy read in pertinent part:"When a resident chooses to receive hospice care and services the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being;"The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician and resident's representative;"The plan of care will identify the care and services that each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care.a. The hospice provider retains primary responsibility for the provision of hospice care and services that are necessary for the care of the resident's terminal illness and related conditions.b. The facility retains primary responsibility for implementing those aspects of care that are not related to the duties of the hospice;"The plan of care will identify the care and services that each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care.a. The hospice provider retains primary responsibility for the provision of hospice care and services that are necessary for the care of the resident's terminal illness and related conditions.b. The facility retains primary responsibility for implementing those aspects of care that are not related to the duties of the hospice;"The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities;"The plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary;"The facility will monitor medical supplies to ensure they are provided by hospice as indicated in the plan of care for palliation and management of the terminal illness;"All residents receiving hospice will continue to receive the same facility services as residents who have not elected hospice. This includes, but is not limited to the following: ongoing comprehensive and quarterly assessments, personal care/support with activities of daily living, medication administration, physician visits, medication regimen review, social services and activities programming, nutritional support and services, and ongoing monitoring of resident conditions;"The facility will immediately contact and communicate with the hospice staff,attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations."II. Resident statusResident #8, age 66, was admitted on 12/14/22. She was admitted to hospice care at the facility on 1/1/23. The February 2023 computerized physicians orders (CPO) diagnoses included chronic obstructive pulmonary disease, morbid obesity, acute and chronic respiratory failure, diabetes mellitus, and essential hypertension. The minimum data set (MDS) assessment dated 12/27/22 revealed the resident had a moderate cognitive impairment with a score of 10 out of 15 on the brief interview for mental status (BIMS) assessment. The resident required extensive assistance from two or more staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. III. Record reviewThe resident's care plan focus for hospice care was updated on 1/11/23. A new goal was initiated for the resident to have all needs met without discomfort and will be provided with extra support by staff. Interventions identified for goal achievement included:-Attempt to meet resident's needs quickly with a compassionate and caring demeanor;-Encourage to express feeling and concerns as necessary;-Resident may need more assistance/encouragement/support with problems solving as she declines;-Refer/order consult:pastoral care, social services, home health care, psychiatry.-The care plan did not delineate care provided from the hospice care team. -The resident's hospice record at the facility included progress notes and care plan from the hospice provider. A review of the hospice documentation revealed the resident had reported concerns to the hospice provider and the hospice nurse; however, there was no collaboration with the hospice provider or the facility staff to ensure the resident concerns were addressed in a timely manner. Resident documented concerns The resident reported to the hospice provider on 12/22/22 and 12/27/22 that she wished to have her hair cut and styled. The hospice documentation revealed the hospice health aide recommended the spouse arrange to have an outside hairstylist come to the facility. The hospice documentation and facility documentation did not reveal collaboration or follow-up for the residents request to have her hair cut and styled. The resident reported to the hospice nurse on 1/5/23 she wanted to speak with the hospice physician about her hospice diagnosis because she wanted information about her hospice diagnosis. The resident reported to the hospice nurse that she wanted a second opinion regarding her need to be on hospice. The hospice nurse documented she educated the resident that hospice service was a benefit and an option and the resident could revoke hospice service. The hospice documentation and facility documentation did not reveal collaboration or arrangements for the resident to speak with a physician or obtain a second option regarding hospice. On 1/3/23 the resident's appointment with her attending pulmonary specialist was canceled by the facility because she was receiving hospice care. IV. InterviewsRegistered nurse (RN) #1 was interviewed on 2/14/23 at 10:30 a.m. RN #1 stated the hospice nurse would access the binder and file the hospice paperwork during a visit to the facility. The RN was unsure if the paperwork was reviewed with facility staff. The RN stated sometimes the hospice nurse would update the facility staff on resident status but she was unsure of the hospice providers schedules and the process and time frames for the facility to update the hospice provider of resident's concerns. The DON was interviewed on 2/14/23 at 1:22 p.m. She stated the facility has a contract in place with the hospice provider for Resident #8. The DON stated the hospice provider and facility staff communicated and collaborated on the status of the resident. The DON stated the communications have occurred by email or person-to-person and active communications were important to meet the needs of residents that received hospice care. The DON was unaware Resident #8 had expressed concerns to the hospice nurse that had not been resolved. The DON said she would meet with the resident and spouse on their concerns reported to the hospice provider. V. Facility follow-up The DON interviewed the resident and her spouse on 2/14/23 (after being identified on survey). The resident reported to the DON that she told the hospice nurse she was unable to have her hair cut and styled at the facility because the salon was upstairs and she could not get upstairs because she was unable to get out of bed and her dependence on oxygen. The DONinformed the resident the facility has hi-flow oxygen portables that can be provided so that she can access the hair salon. The resident was agreeable to be scheduled for hair services the next available appointment.

Plan of correction · submitted by the facility

POCF849Resident Specific: Resident #8 has been identified and currently resides at the facility. Social Services Director met with resident #8, no issues have been identified, care plans have been reviewed and updated. Identification of others: All hospice residents have the potential to be affected by the alleged deficient practice. The Director of Nursing or designee will audit all Hospice residents and ensure all documentation/notes/ care plans are all current and where facility staff have access to them. This audit will be completed by 3/10/23. System and Measures: A. The administrator and Director of Nursing will meet with the Hospice Director on policy, regulations, and expectations of the facility and Hospice partnership regarding communication/ timely notes/ care plans being at the facility and accessible to facility staff. This will be completed by 3/10/23B. The Hospice administrator will educate Hospice staff on the contractual agreement to have communication/timely notes/care plans up to date and done timely and left where facility staff have access to them. This will require a sign in-service and will be completed by 3/10/23Monitoring:The Director of Nursing or designee will audit all hospice residents for the above mentioned in (B) weekly for four weeks and then monthly for 3 months and bring information to the QA committee for recommendation to stop or continue audit. Daily clinical meeting will address all hospice visits occurring and ensure documentation is accessible and communicated timely to facility staff. This will be ongoing. The results of these audits will be reported to the Quality Assurance Committee for review and recommendation. The Quality Assurance committee will determine further auditing needs. Corrective action completion date: 3/10/23

2/16/2023State Licensure Survey · ID V2ND111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure survey was completed on 2/13/23 to 2/16/23. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0704Res Care - Accident Prevention and Attention▼

Findings

Based on interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#6) of two residents reviewed for falls out of 23 sample residents. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living as documented in her 10/19/22 facility assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she could not initiate staff assistance by using her call light due to severely impaired cognition. Due to the facility's failures, lack of appropriate supervision and effective interventions resulted in four falls. Furthermore, the facility failed to ensure adequate supervision and effective interventions were in place to prevent falls for Resident #6, with a fall on 12/26/22 that resulted in major injury with right distal and proximal femur (hip) fractures and surgery, and required hospitalization for eight days. Findings include: I. Resident status Resident #6, age 86, was admitted on 10/16/22 and readmitted on 1/3/23. According to the February 2023 clinical physician orders (CPO), diagnoses included encounter for other orthopedic aftercare, fracture of unspecified part of neck of right femur, displaced spiral fracture of shaft of right femur, pain in right leg and history of falling. The 10/19/22 facility assessment revealed the resident's cognition was moderately impaired with BIMS score 10 out of 15. No behaviors or rejection of care were noted. She required extensive assistance of two staff with bed mobility, she was totally dependent on two staff with transfers, required limited assistance with dressing, and was independent with eating. The 1/6/23 facility assessment revealed intact cognition with a brief interview for mental status (BIMS) score 15 out of 15. No rejection of care was noted. She required limited assistance with bed mobility, dressing, toilet use and personal hygiene, supervision of two staff with transfers and supervision with eating. The resident was frequently incontinent of urine. The resident had a fall with a fracture prior to admission. Medication she was administered included an anticoagulant, antidepressant and opioid. II. Record review Care Plan: The resident's records were reviewed on 2/15/23 and revealed the comprehensive person-centered care plan was canceled on 12/30/22. The facility failed to timely develop a care plan addressing falls risk for Resident #6 who was readmitted on 1/3/23. Interdisciplinary notes: On 10/18/22 a social worker documented in part: "New admit following a fall with fracture of her hip. Patient is a resident here at (facility) on the AL (assisted living) floor. She is hopeful to return back after she completes her therapy. (Resident) was administered a BIMS (Brief Interview for Mental Status) by Speech Therapy where she scored 10 indicating moderate impairments with cognitive functioning. She has a dx (diagnosis) of cognitive communication deficits as well as aphasia. She is very much aware that at times she is forgetful and has word finding difficulties. It is obvious that she has been counseled because several times during the interview with SS (social services) she told herself to slow down when she was communicating. SS (social services department) will continue to follow with IDT (interdisciplinary team) members and assist as needed with discharge planning and providing assistance with any necessary adjustment concerns." On 10/19/22 a registered nurse documented, in part: "Barriers to safe and effective discharge: assist with ADL (activities of daily living) cares and cognition. TTWB to RLE (toe touch weight bearing to right lower extremity); max x 2 (maximum assistance of two staff) for transfers; noted with delusions and confusion on readmit. IDT (interdisciplinary team) plans for this week: continue therapy services for swallowing, dressing, grooming/hygiene, transfers and strength. Additional Information: nursing for pain/medication management, obtaining and monitoring vitals/labs; assist with ADL (activities of daily living) cares." -The interdisciplinary team plan did not include resident's risk for falls. Falls with no major injuries: On 10/25/22 at 1:00 p.m. a nurse documented in part: "This nurse notified that pt (patient) had fallen. When entering the room she was sitting on the floor, leaning against her bed frame. She stated she was trying to get in bed by herself. A therapist was walking by and assisted her the rest of the way to the ground. She states she did not hit her head. Assessed pt (patient) for injury, none noted. Assisted pt (patient) into bed x3 (with three) staff members and a gait belt. Pt is able to move all extremities, equal hand grasps, pupils are equal and reactive. PCP (primary care physician) and DON (director of nursing) notified." On 10/27/22 the DON documented, in part: "Fall committee IDT (interdisciplinary team) follow up for fall on 10/25/2022. Predisposing factors: weakness, ORIF (open reduction internal fixation) of right hip, lack of safety awareness, cognitive deficit, hx (history) of falling. Interventions: Resident is being followed by therapy services for post right hip ORIF for safety awareness, endurance and strengthening as well as ambulation and transfers. Therapy to eval (evaluate) for visual reminders to ask for assistance." On 10/28/22 the director of rehabilitation (DOR) documented: "Pt (patient) is receiving therapy services focusing on strength, balance, safety. Pt (patient) cognitively impaired following her surgery and requires verbal and visual reminders to not transfer herself. Sign placed as a reminder to call for help." On 11/1/22 a nurse documented in part: "Pt (patient) out to see ortho (orthopedic physician) today. Continue TTWB x2 (toe touch weight bearing for two) weeks. F/U (follow up) in 1 (one) month. WBAT (weight bearing as tolerated) on 11/15/22." On 11/26/22 at 1:00 a.m., a nurse documented: "CNA (certified nurse aide) came to this nurse stating resident on floor in room. Upon entering room resident sitting on buttocks next to bed, facing door to hall, denies hitting head, c/o (complains of) pain in buttocks and RLE (right lower extremity), no visible injuries upon assessment, stated 'my brief was wet, I was going to the commode.' Denies injuries and hitting head, c/o (complained of) pain in buttocks, states 'I'm fine, the floor is just hard.' Resident placed back into bed x3 (with three) staff assist. Vital signs taken, assessment completed, neuro checks initiated, all responsible parties notified." On 11/28/22 a nurse documented, in part: "Fall committee IDT (interdisciplinary team)"Follow up for fall on 11/26/2022. Predisposing factors: history of falling, muscle weakness, lack of coordination, right femur fx (fracture). Interventions: educate staff to keep w/c (wheelchair) closer to the bed, therapy to evaluate room layout." On 11/29/22 the DOR documented: "Pt (patient) sustained a fall without injury when attempting to transfer herself to the bedside commode when was paced at the foot of the bed. Pt (patient) is progressing in therapy and felt she was able to perform the transfer. Recommend that the BSC (bedside commode) placed at bedside to lessen distance for transfer and to improve successful transfer." Falls with injuries: On 12/16/22 at 10:15 a.m., a nurse documented: "CNA notified this nurse that resident was found on floor. This nurse entered resident's room and visualized resident sitting on floor next to bedside commode. Resident was holding right knee and complaining of pain to right knee and elbow. Resident stated she was sitting at the edge of her bed and attempted to adjust her commode and slid off the bed onto right knee and elbow. Resident noted with abrasion and swelling to right knee, bruising and abrasion to right elbow. Neuro sheet started, neuros WNL (within normal limits), vitals WNL (within normal limits). Resident assisted back to bed and educated on use of call light for assistance. NP (nurse practitioner) notified and ordered STAT (immediate) x-ray of right knee, right hip, and right elbow. Resident's daughter notified." On 12/16/22 a nurse documented in part: "X-ray results received. Results reviewed with (physician), new order for NWB (no weight bearing) to RLE (right lower extremity) until f/u (follow up) ortho apt (orthopedic appointment). " On 12/17/22 a nurse documented: "Resident returned from ED (emergency department), transferred by (ambulance). CT (computed tomography) pelvis and x-ray R (right) femur completed, no significant findings noted. No new orders." On 12/19/22 the DON documented, in part: "Incident committee IDT (interdisciplinary team). Follow up for fall on 12/16/2022. Injuries: Abrasion to right elbow and right knee. Bruise to right elbow. Predisposing factors: History of falls, muscle weakness, unsteady gait, impulsiveness. Interventions: Will speak with resident about moving rooms closer to the nurses' station." On 12/20/22 the DOR documented: "Pt (patient) is receiving therapy services. Pt (patient) has a bedside commode due to her not wanting to use her regular shared room bathroom. Pt (patient) often attempts to transfer herself to the commode despite education to always call for assistance. Pt (patient) is impulsive and would benefit from moving closer to the nursing station for increased level of supervision. Therapy working on safety with transfers and bedside commode use." On 12/26/22 at 5:07 p.m., the DON documented: "Called to residents room by cna (certified nurse assistant) as resident had fallen. When resident asked what happened she stated 'I was trying to get from here to there' pointing from the commode to the recliner. RN (registered nurse) assessment: Resident noted sitting on the floor with her back against her recliner. Right leg externally rotated and resident screamed out in pain with slight touch to the area. She is able to wiggle her toes, but unable to move extremity. (Ambulance) called for emergent transfer to hospital for further evaluation. MD (physician) and daughter notified."The 12/26/22 x-ray report from the hospital revealed in part: "Displaced angulated spiral/oblique fracture near the distal third of the right femoral shaft; proximal right femur subtrochanteric fracture surgically addressed with orthopedic metallic fixation hardware, near normal anatomic alignment; persistent right superior and inferior pubic rami fracture deformities. "Patient presents with mechanical fall and obvious right leg deformity. Orthopedic surgery recommended placing patient in Buck's traction (device/traction to restore normal bone alignment and length) which was performed in the emergency department and she will be admitted for ongoing pain control and operative intervention. " On 12/27/22 the DON documented, in part: "Incident committee IDT. Follow up for fall on 12/26/2022. Injuries: right hip with external rotation. Predisposing factors: History of falls, muscle weakness, unsteady gait, impulsiveness. Interventions: Resident sent to ED (emergency department) for further evaluation." On 12/28/22 the DOR documented: "Pt (patient) sustained a fall attempting again to transfer herself. Pt (patient) is currently in the hospital and will be evaluated by therapy upon her return." On 1/4/23 the DON documented, in part: "Fall Committee Follow-up for fall on 12-26-22. Resident returned to the facility on 1/3/23. Resident's room moved closer to the nurses' station by the door for better observation. Resident with PT & OT (physical therapy and occupational therapy) services in place." On 1/11/23 the DON documented, in part: "Deep dive into frequent faller with fish bone diagram for root cause analysis review. Care plan reviewed and updated,as indicated. New interventions include perimeter mattress for safety awareness. Resident also placed on frequent toileting schedule during the day. Consent obtained from POA (power of attorney) for perimeter mattress and aware of clinical situation." III. Staff interviews The clinical resource registered nurse (CRRN) was interviewed on 2/16/23 at 8:45 a.m. She said Resident #6's care plan was canceled during her stay in the hospital. She said the comprehensive care plan was not reinstated and updated since the resident returned to the facility on 1/3/23 (over a month previous). Certified nurse aide (CNA) #2 was interviewed on 2/16/23 at 8:55 a.m. She said she was aware of the resident's risk for falls. She said after return to the facility Resident #6 was moved to a room close to the nurses' station and had not had any falls since. She said the resident did not have or use a bedside commode and the nursing staff was checking on her frequently. She said the staff offered toileting to the resident every two hours and was taking her to use the bathroom in the shower room across the hallway. She said most of the time the resident did not remember to use her call light. The DON, the DOR and the CRRN were interviewed on 2/16/23 at 11:40 a.m. The DOR said after the resident's fall on 10/25/22, the therapy team focused on visual reminders to ask for assistance and signs were placed on the resident's walker. The DOR said prior to the fall on 11/26/22, while transferring to the commode, Resident #6's weight bearing status was upgraded to as tolerated, she required supervision with bed mobility and contact guard assistance from staff with transfers. The DON said staff education was provided and the resident's wheelchair was to be kept close to her bed. The DOR said after the resident's fall on 12/16/22, staff tried to remove the commode and the resident did not allow it. The resident declined to move closer to the nurses' station previous to when she was moved closer.-There were no notes in Resident #6 records about the resident declining to move closer to the nurses' station. The DON said before the fall with injury, the resident refused to use the bathroom in her room as it was difficult for her to get to the toilet, therefore the bedside commode was an option at the time. She said the interdisciplinary team did not consider removing the bedside commode from the resident's room and staff could take the resident to a bathroom in the shower room. IV. Facility follow-up On 2/16/23 at 11:30 a.m., the CRRN provided a copy of the resident's new and updated comprehensive care plan. On 2/16/23 at 11:35 a.m., the DON provided a copy of all facility staff training on falls prevention and the Performance Improvement Plan (PIP). The PIP was dated 1/10/23 and read, "She admitted to facility with fracture, and has severe osteopenia (loss of bone mineral density) and osteoarthritis to bilateral knees. She is noncompliant with using call light. She will be placed on toileting program while awake and we will place her on concave mattress (a mattress with concave sides)."-The above noted interventions were in place for the resident. On 2/16/23 at 4:42 p.m., the CRRN provided a copy of the 12/26/22 hospital record, read in part: "Patient had a hip fracture with hip nail placed 2 and half months ago and is unclear if she refractured this area or if it has not fully healed yet."

Plan of correction · submitted by the facility

704Resident specific: Resident #6 identified and currently reside at the facility. Fall risk assessment was completed for Resident #6. Care plan has been updated for resident #6. The revised assessment and care plan was reviewed with staff involved in the care of resident #6. Identification of others: The nursing management team reviewed the MDS assessment for all residents who have been identified as having potential risk for falls. Fall risk assessments are complete and interventions currently in place are appropriate. System and Measures: Director of Nursing or designee will in-service all licensed nursing staff on the facility policy for Accidents and Supervision. This sign in service will be completed by 3/10/23. All residents falls/accidents will be reviewed daily by the nursing management team to ensure appropriate implementation of fall interventions including updating the plan of care. Monitoring: The nursing management team will review each incident report upon occurrence to ensure appropriate interventions are implemented and updated plan of care is complete. The Director of Nursing or designee will audit 3 incidents/falls x 3-week x 12 weeks to ensure appropriate interventions have been put in place to reduce the risk of resident falls/accidents and that care plans have been updated to reflect these interventions. The results of these audits will be reported to the Quality assurance committee for review and recommendation. The quality Assurance committee will determine further auditing needs. Correction action completion 3/10/23

Reportable Occurrences

37 records

4/23/2026Brain Injury · ID 26020582006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/23/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a brain injury event. While ambulating outside with staff (1), client (A) tripped and fell hitting their head on the concrete, which resulted in facial and head injuries. Nursing provided first aid treatment until emergency services transported client (A) to the hospital for further evaluation. Diagnostic test results revealed a brain bleed and wrist fracture. During the course of the investigation, the healthcare entity conducted a post fall review, record review and interviews. Management checked the outdoor area for safety hazards. Once medically treated and stable, client (A) returned and staff reassessed client (A)'s mobility and fall safety needs. Through interviews, staff indicated they were following safety precautions when this unfortunate incident happened. The facility concluded the fall was accidental related to uneven natural surfaces in an outdoor area. A brain injury event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/11/2026 · released to the public 6/18/2026.

4/6/2026Misappropriation of Property · ID 26020582005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/7/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Reportedly, client (A)'s family requested $100 to cover the cost of an insurance policy. When client (A) declined, the family member stated they would keep client (A)'s identification card in their possession until client (A) paid. During the course of the investigation, the healthcare entity instructed the business office not to disburse any funds to the family. Management notified the police, Adult Protective Services, and conducted interviews. The family member brought client (A)'s identification cards to the facility for safekeeping. With additional interviews, the facility concluded the family member had been assisting the client appropriately and unfortunately, with client (A)'s cognitive impairment, they did not recall prior transactions or conversations. An outside investigation was ongoing. However, at a facility level, the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/26/2026 · released to the public 7/3/2026.

3/22/2026Brain Injury · ID 26020582004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/23/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a brain injury event. Staff observed client (A) on the floor with facial injuries. Client (A) was transported to the hospital for further evaluation. Diagnostic test results showed a brain bleed. During the course of the investigation, the healthcare entity conducted a post fall review, record review and interviews. Client (A) refused treatment in the hospital and returned under comfort care services. Staff reassessed client (A)'s safety needs and updated the fall care plan. Staff could not determine what caused the fall, as it was unwitnessed. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/28/2026 · released to the public 5/5/2026.

3/15/2026Neglect · ID 26020582003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/13/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. The police arrived to the facility to investigate client (A)'s concern that staff had not administered their pain medication since admission. During the course of the investigation, the healthcare entity conducted record reviews and interviews. Medication records revealed client (A) received the prescribed pain medications per physician orders and client (A) had not expressed concerns about pain management. No other clients reported having any concerns about not receiving their medications. Staff requested a reassessment regarding pain management for client (A), and orders were updated. The allegation of neglect could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/22/2026 · released to the public 5/29/2026.

2/16/2026Sexual Abuse · ID 26020582002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. The client reported they were sexually assaulted by two unknown assailants. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, and conducted interviews. The client, who had a history of delusions, gave varying accounts of when and where the sexual assault occurred. Upon assessment, the client did not have any injuries or signs of trauma related to the allegation. The client had recently experienced a fall and was diagnosed with a urinary tract infection, which may have triggered reminders of past traumatic experiences. The facility found no evidence to support the allegations. The facility offered behavioral health services and increased behavioral monitoring. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/5/2026 · released to the public 6/12/2026.

10/31/2025Physical Abuse · ID 25020582013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/4/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, the client was placed in a choke hold by two staff members. During the course of the investigation, the healthcare entity suspended staff, notified law enforcement, assessed the client, and conducted interviews. The client initially denied being harmed by anyone, later reported being choked, gave varying descriptions of alleged assailants, and could not provide any details about the alleged event. An assessment showed bruising to the knees which had previously been documented, and no other injuries. Staff denied the allegations and reported no concerns when they provided care to the client. The facility started a two person care model and educated staff. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/11/2026 · released to the public 3/18/2026.

8/22/2025Neglect · ID 25020582012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 08/22/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. After the client was transferred to the hospital due to change of condition, the hospital alleged neglect due to urine soaked brief and wet gown. During the course of the investigation, the healthcare entity suspended staff, reviewed medical documentation, and conducted interviews. Staff interviews revealed the client had received incontinence care and clothing change multiple times on the day of being transferred to the hospital. Medical record review indicated the client was on medications that increased incontinence frequency and received support accordingly. The client declined to return to the facility. The facility completed an audit of all clients to identify if there were any unmet incontinence support needs. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was/was not submitted within the required timeframe.

Publication

Sent to facility 12/16/2025 · released to the public 12/23/2025.

6/23/2025Physical Abuse · ID 25020582009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/23/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed the wheelchair wheels of two clients become tangled, client (A) became startled and reached out their arm behind them, striking client (B) in the mouth. During the course of the investigation, the healthcare entity separated the client prior to notifying law enforcement, completed an assessment, and conducted interviews. Client (B) sustained an abrasion to the lip requiring first aid treatment. Due to cognitive impairment, neither client could recall the event. The facility educated staff, modified client (A)’s wheelchair to enhance spatial awareness, and started line of sight in public areas for client (A). The facility determined the event to be an isolated event related to an accidental bump with no identified intent to harm anyone. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/30/2025 · released to the public 10/7/2025.

6/11/2025Neglect · ID 25020582010Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/18/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. Reportedly, one month prior to the report being made, staff left their shift without getting the client up for the day. During the course of the investigation, the healthcare entity conducted interviews with all clients in the facility and reviewed medical records. The client indicated the event was a single instance of receiving assistance later than their preferred time, which was corrected after the cognitively intact client notified staff. The client was unharmed and reported no ongoing concerns. Record review indicated the facility was notified of preferred time to get up one month ago and made adjustments accordingly. The facility educated staff. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 10/31/2025 · released to the public 11/7/2025.

2/1/2025Missing Person · ID 25020582006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/2/25, the healthcare entity investigated a reportable event of an at-risk missing client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please referencehttps://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/13/25, YJM411. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/29/2025 · released to the public 5/6/2025.

1/7/2025Physical Abuse · ID 25020582005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/7/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity conducted interviews, reviewed the client’s chart, placed her on frequent checks, and had all visitors show verification of identity with approved visitation only. The client’s husband reported to police that the client incurred a black eye a couple of months prior, and he did not know where it came from. The client was assessed with no injuries and the chart showed no documentation of the client ever having a black eye. Staff also stated the client never had a black eye and the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/24/2025 · released to the public 5/1/2025.

1/3/2025Missing Person · ID 25020582003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/3/25, the healthcare entity investigated a reportable event of a missing person. The client signed out and did not return within 8 hours. During the course of the investigation, the healthcare entity notified law enforcement, called the client and their relatives. The client returned 9 hours later with elevated blood pressure and skin alterations that required monitoring. Reportedly, the client fell asleep at a friend's home and didn’t hear their phone. The facility provided education to the client. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/13/25, Event ID YJM411.

Publication

Sent to facility 5/28/2025 · released to the public 6/4/2025.

1/3/2025Missing Person · ID 25020582004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/3/25, the healthcare entity investigated a reportable event of a missing person. The client signed out and did not return within 8 hours. During the course of the investigation, the healthcare entity notified law enforcement, called the client and their relatives. The client returned 9 hours later with elevated blood pressure that required monitoring. Reportedly, the client fell asleep at a friend's home and didn’t hear their phone. The facility provided education. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/13/25, Event ID# YJM411.

Publication

Sent to facility 6/18/2025 · released to the public 6/25/2025.

12/26/2024Misappropriation of Property · ID 24020582034Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 12/26/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation, the healthcare entity conducted a search of the client’s room finding $62 after the client reported $160 missing from her room. The client stated the last time she saw the money was when her sister visited but she didn’t want staff to call her, and she did not believe that her roommate would have stolen any money from her. The event was not substantiated, and the client obtained a lock box for her valuables. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/8/2025 · released to the public 4/15/2025.

12/23/2024Neglect · ID 24020582033Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/23/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. Reportedly, client (B) said staff told her to stop pressing her call light so much and one night, staff allegedly took her call light and hid it. Client (B) reported being scared and was upset. During the course of the investigation, the healthcare entity suspended staff, conducted interviews and started safety checks. Management ensured client call lights were within reach and accessible. No other clients reported having any concerns about their call lights or staff neglect. Additional measures were put in place to help provide emotional support to client (B). Staff returned to work, and the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/10/2025 · released to the public 7/17/2025.

12/13/2024Neglect · ID 24020582031Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/13/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. Reportedly, the police opened an investigation of staff neglect for at-risk client (B). Client (B) had recently been transferred to the hospital for an evaluation of an altered mental status. Hospital staff noted feces on and in client (B)’s catheter upon admission to their facility. During the course of the investigation, the healthcare entity conducted a medical chart review and interviews. The facility indicated the client could have experienced an incontinence episode leading to the findings, but management concluded staff offered and provided care. However, the facility identified a system process gap regarding physician orders with catheter bag changes. Once client (B) returned, staff reviewed all physician orders and plan of care regarding catheter care. No other client concerns were identified. Despite the findings, the facility concluded that the allegation of neglect could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/10/2025 · released to the public 7/17/2025.

11/18/2024Misappropriation of Property · ID 24020582029Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 11/18/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. A cell phone and purse were reported missing from the belongings of the recently deceased client. Reportedly, the facility gave the deceased client’s property to the family and a cell phone and purse were missing from the belongings. During the course of the investigation, the healthcare entity conducted a search, conducted interviews, and offered to replace the items. The facility was unable to determine if the items were lost or stolen. The facility implemented a new process for securing the personal property of deceased clients. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/26/2025 · released to the public 7/3/2025.

11/13/2024Verbal Abuse · ID 24020582026Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 11/13/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Reportedly, during a group activity client (A) made a threatening statement towards client (B). During the course of the investigation, the healthcare entity separated the clients prior to reporting to law enforcement, increased monitoring, and conducted interviews. Client (A) denied the allegation. Although client (B) did not report fear, they would not attend group activities in an effort to avoid client (A). Facility policy indicated that a staff member should have been present for the group activity but was not. The facility will ensure staff are present in common areas for group activities. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/26/2025 · released to the public 7/3/2025.

11/8/2024Sexual Abuse · ID 24020582024Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/8/24, the healthcare entity investigated a reportable event of sexual abuse of a client. Staff observed client (A) touch client (B) on the breast. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, completed an assessment, and conducted interviews. Client (B) attempted to push the other client's hand off of her breast, but was not successful until staff intervened. Client (A) touched client (B) without permission, client (A) reported that they could not recall the event. Client (B) was uninjured. The facility provided staff education, referrals to therapy and increased safety monitoring. The event was substantiated. On the same day, client (A) was involved in another allegation of sexual abuse with a different client, please see Case ID 24020582025 for additional information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 4/23/25, Event ID M7GO11.

Publication

Sent to facility 6/11/2025 · released to the public 6/18/2025.

11/8/2024Sexual Abuse · ID 24020582025Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 11/8/24, the healthcare entity investigated a reportable event of sexual abuse of a client. Staff observed client (A) touch client (B) on the breast. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, completed an assessment, and conducted interviews. Client (B) attempted to push the other client’s hand off of her breast, but was unsuccessful until staff intervened. Client (B) was not injured. Client (A) did not recall the incident. The facility provided staff education, referrals to therapy and increased safety monitoring. The event was substantiated. On the same day, client (A) was involved an another allegation of sexual abuse with a different client, please see case ID 24020582024 for additional information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 4/23/25, Event ID M7GO11.

Publication

Sent to facility 6/11/2025 · released to the public 6/18/2025.

10/30/2024Physical Abuse · ID 24020582023Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 10/31/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, during incontinence care the staff was rough with the client, causing the client pain. During the course of the investigation, the healthcare entity suspended staff, reported to law enforcement, completed an assessment, and conducted interviews. During the assessment, the client reported pain, the provider was notified, and adjustments to medication administration times were made. Medication adjustments resulted in the client's chronic pain being managed and controlled. After the medication adjustments the client reported that the staff was not rough with them and they enjoy working with the staff. The facility’s investigation revealed that the client was experiencing chronic pain and not pain caused by the staff. The facility provided education to staff. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/9/2025 · released to the public 6/16/2025.

10/13/2024Missing Person · ID 24020582021Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 10/13/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing person. During the course of the investigation, the healthcare entity conducted a search of the facility and called hospitals, jails, and shelters. Client (A) indicated intent to leave for the night and left the facility without signing out. Client (A) returned to the facility 18 hours later and was uninjured. Client (A) was re-educated on the sign out process. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/9/2025 · released to the public 5/16/2025.

7/1/2024Physical Abuse · ID 24020582019Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 8/12/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity suspended a hospice employee after a client alleged he was hit by the staff member a while ago, but only now notifying the facility of the event. The client reported an altered allegation after police arrived that indicated the event never happened. The hospice employee denied the allegations made against her. The hospice employee was allowed to return to the facility after receiving retraining on allowing clients time to process information when care was provided. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/28/2025 · released to the public 3/7/2025.

6/5/2024Verbal Abuse · ID 24020582016Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/5/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported verbal abuse of a client. During the course of the investigation, the healthcare entity determined the client was fearful of his roommate after the client was found by his roommate on his roommate's side of the room and threats were directed towards him. The clients were separated and the client was moved to a different room and offered therapy. The client’s roommate had his care plan updated after the event. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/13/2025 · released to the public 2/20/2025.

5/19/2024Physical Abuse · ID 24020582015Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/19/2024, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client by the client’s spouse after staff witnessed the spouse hit the client's arm with a spoon and restrained his/her arm while reaching for something. During the course of the investigation, the healthcare entity conducted frequent checks while the spouse was in the facility, transitioning to one to one observation, and provided caregiver education to the spouse about managing the client's disease. The client’s skin was checked with no injuries, and s/he reported no fear of his/her spouse. The spouse stated s/he would never hurt the client and was appreciative and open to the education provided by the facility. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 3/10/2025 · released to the public 3/17/2025.

4/28/2024Sexual Abuse · ID 24020582013Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The agency/facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.

Publication

Sent to facility 2/6/2025 · released to the public 2/13/2025.

1/24/2024Physical Abuse · ID 24020582009Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE:On 1/25/24 a resident reported over the last couple nights CNA (1) had been rough and aggressive with him. On occasion when s/he placed the urinal it hurt and when they said something about it she seemed to dismiss it. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, physician, family and ombudsman. CNA (1) was suspended pending investigation completion and the resident was provided with frequent checks and psychosocial monitoring. The facility nurse assessed the resident. Although no injuries were found, it was noted the resident indicated fear of CNA (1). The resident stated, when CNA (1) places the urinal s/he says "Go." When this happens he has a hard time actually urinating, making him hesitant to ask her for help. CNA (1) stated that s/he may have been frustrated because it was a very busy night, but at no time did s/he act frustrated with the resident. S/he stated that s/he was professional every time s/he went into the room. Other residents and staff members were interviewed with no concerns noted. The facility concluded the allegation of physical abuse occurred and CNA (1) did not treat the resident with dignity and respect. The facility implemented two staff to work with the resident for all cares. CNA (1) resigned from the facility and all staff were trained on abuse, neglect and customer service. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the facility. This public summary is based on information provided by the facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the facility, this occurrence will be reviewed. The facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.

Publication

Sent to facility 11/21/2024 · released to the public 11/28/2024.

1/22/2024Neglect · ID 24020582008Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS:On 1/22/24 a resident alleged certified nurse aide (CNA) (1) did not provide them care as needed during their shift. Specifically, CNA (1) assisted the resident onto the toilet then left the room for privacy. When the resident finished s/he pulled her call light cord and waited about five minutes before s/he self-transferred from the toilet to their wheelchair then turned off their call light. In addition, CNA (1) did not come to their room to help them get ready and into bed as s/he usually did. The resident did not not recall CNA (1) returning to their room the rest of the day. CNA (2) who started their shift at 10:00 pm got the resident into bed. The resident was not fearful of CNA (1) but would prefer to not have them care for her anymore. From the facility’s investigation, it was found, the CNA (1) did not follow up with the resident and did not provide cares. CNA (1) was terminated. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the facility, this occurrence event will be reviewed by the State Agency. The facility complied with licensing standards for conducting an internal investigation of this Occurrence event and submitting a report of the findings to the Department. However, the licensing standard for timely reporting was not met.

Publication

Sent to facility 11/20/2024 · released to the public 11/27/2024.

1/21/2024Neglect · ID 24020582007Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS:On 1/22/24 a resident alleged the night before a certified nurses aide (CNA) entered their room, turned off the call light and walked out without providing care. The CNA never returned. The resident also reported some staff act like they do not want to change them when s/he is wet. There were no reported adverse findings to the resident's skin. The resident did not know the names and could not describe the CNA. From the facility’s investigation, it was found, staff were turning the call light off before care was completed. To help prevent a recurrence, the resident was put on a toileting schedule. The call light will not get turned off until the task is complete and a resident should not be made to feel as if the task they are requesting is a bother. In addition, all staff were provided education on customer service and the process and expectations to follow when responding to call lights. Staff voiced their understanding of the expectations. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/20/2024 · released to the public 11/27/2024.

1/9/2024Neglect · ID 24020582001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE:On 1/9/24, Adult Protective Services (APS) arrived at the facility to investigate an allegation made by resident (A) regarding they did not receive treatment for difficulty breathing and the facility not having supplies. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family, ombudsman and physician. Resident (A) stated by the facility not having supplies it was preventing them from getting up and into their wheelchair. Resident (A) was immediately assessed without any concerns or negative findings. All documentation was reviewed and did not show resident (A) complained of or had any breathing concerns based on x-ray and other tests that were completed. Resident (A) discharged to their home during the investigation without further concerns. The facility investigation concluded no neglect was substantiated. There were supplies available that all staff had access to. Resident (A) had a preference on what type of supplies s/he used at home versus the type utilized in the facility. To help prevent a recurrence, at the all staff meeting staff were educated to review supplies residents need and keep their rooms stocked with the items. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

12/27/2023Verbal Abuse · ID 23020582013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/27/23, female resident (B) alleged male resident (A) told her that he had a big knife in his pocket and was not afraid to use it. Staff ensured resident (A) did not have any weapons in his possession or access to any knives. Emotional support was provided to resident (B). Safety measures were put in place to deter resident (A)’s wandering. He reported having no recall of making this comment. The facility indicated resident (A) did not have a history of making threats. The allegation of verbal abuse could not be substantiated. Frequent safety checks were in place for the residents. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

12/26/2023Neglect · ID 23020582012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/26/23, after a resident had been transferred to the hospital, hospital staff noted a high blood sugar reading. The resident alleged facility staff did not administer his insulin and that he did not receive proper Foley catheter care. The resident returned the following day after receiving additional insulin coverage and wound care treatments to his chronic wounds. No infections were identified. Review of facility records indicated he received his insulin per physician orders. Wound care treatments were completed per physician orders. After his return, the physician changed the resident’s insulin orders. The facility investigation concluded an allegation of neglect could not be substantiated. The following day, he suffered a cardiac arrest and was transferred back to the hospital where he later passed. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

12/21/2023Physical Abuse · ID 23020582010Reported on time: Yes▼

Occurrence summary

Summary of Findings:On 12/21/23, resident (B) alleged resident (A) yelled at her and hit her in the stomach to the site of their ostomy bag. She reported being fearful of resident (A). The two residents were roommates. Management reported resident (B)’s conversations about what allegedly occurred fluctuated and was confusing. Resident (A) denied the allegations. No visible injuries were observed on resident (B). The facility was unable to substantiate an allegation of physical or verbal abuse. Resident (B) was moved to another room per her request. Staff started 15-minute safety checks and continued to support the individuals per their care plans. Department Findings:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/20/2024 · released to the public 11/27/2024.

12/15/2023Misappropriation of Property · ID 23020582009Reported on time: Yes▼

Occurrence summary

Summary of Findings:On 12/18/23, resident (B) reported five rings were missing from her room. She recalled the items were in a cup on her bedside table and alleged a staff member stole them. They were last seen on 12/15/23. Staff indicated they have only seen the resident wear one ring. As a precautionary measure, management suspended staff (1) pending investigation. Managers helped search for the rings, but none were found. The facility was not able to determine what happened to the rings. A decision was made to compensate resident (B) for the missing rings. Resident (B) was encouraged to keep any valuable items with a family member outside of the facility. Staff (1) returned to work and management requested staff continue providing care in pairs. Department Findings:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/18/2024 · released to the public 11/25/2024.

12/9/2023Physical Abuse · ID 23020582008Reported on time: Yes▼

Occurrence summary

Summary of Findings:On 12/9/23, there was a report of male resident (A) being agitated when he picked up a garbage can and threw it in the direction of female resident (B) hitting her on the face. Resident (B) screamed and yelled profanities at resident (A). Staff intervened to separate the residents and notified the police. A nurse assessed resident (B) and found no visible injuries. She had no current complaint of pain. Resident (A) was transferred to the hospital for an evaluation and did not return. The facility investigation concluded resident (A) physically reacted when becoming angry, which placed other residents at risk for harm. Department Findings:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency.

9/22/2023Neglect · ID 23020582005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 9/22/23, while a resident was hospitalized, the facility became aware of a neglect allegation regarding the resident. Hospital staff reported concerns about the care and treatment of the resident’s fractures. On 9/20/23, the resident had been transferred to the hospital for an evaluation of a respiratory change of condition and at that time, a known fracture. Per the facility, staff had been working on obtaining an orthopedic appointment for the resident prior to the hospital transfer. One nurse indicated they communicated with the hospital and solicited the help of the hospital staff with getting a referral to an orthopedist. AGENCY/FACILITY ACTION: The facility conducted an internal investigation and notified the physician and family/guardian. Facility records showed the resident’s fracture occurred on 8/18/23, when she accidentally ran into a dresser. The facility physician evaluated the resident post event and noted she suffered non-displaced fractures of the lower tibia. Per physician guidance and orders, precautions were implemented for non-weight bear status until she could be evaluated by an orthopedist in an out-patient setting. The plan of care was discussed with the resident at the time. When reviewing the timeline of nursing attempts to set up an ortho consult between August and the date of the resident’s hospitalization in September, records showed staff attempted to schedule an orthopedic consult. Noted delays occurred on the side of the facility and in between responses with clinics. Records showed instances of miscommunication and delayed clerical requests between both parties. In addition, some of the clinics reported they could not accommodate the resident. The facility recognized the resident experienced a delay in seeing an orthopedic surgeon for her fracture. However, the allegation of staff neglect was unsubstantiated as staff attempted to obtain an appointment and a conservative treatment plan for the fracture had been in place. While in the hospital, the resident received an orthopedic consult, which included the placement of a leg splint and continuation of non-weight bearing status. The resident returned to the facility on 9/22/23 with the precautions in place. Pain medications were in place and therapy evaluated the resident’s mobility needs. When speaking with the resident, she denied any concerns of abuse or neglect by facility staff. The facility initiated an audit to ensure all referrals and appointments were scheduled and/or being followed up appropriately. Following the findings, the facility implemented a new appointment binder to help with better monitoring and staff follow-up. Facility staff received training on the scheduling process and expectations with follow up. A manager planned to audit the process to ensure compliance. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 7/3/2024 · released to the public 7/10/2024.

9/19/2023Brain Injury · ID 23020582004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 9/19/23, staff discovered a resident on the floor with a bleeding laceration to the back of his scalp. First aid treatment was provided. Neurological checks were initiated and within baseline for this resident. No other apparent injuries noted. Staff reported his protective head helmet was not in place. He reported getting up to use the restroom, slipped, and fell. There was water noted on the floor and he did not call for staff assistance. A decision was made to transfer the resident to the hospital for an evaluation. CT scan results showed an acute on chronic brain bleed. AGENCY/FACILITY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman, and physician. After being medically cleared, he returned to the facility. Nursing reassessed him and reported no changes to his baseline of function. Therapy services were ordered and fall prevention interventions were resumed. Per his admission fall risk assessment, he was identified to be at-risk for falls. Fall prevention measures had been implemented and in place, but staff reported he continued to demonstrate impulsivity and poor safety awareness due to his impaired cognition. One staff member reported they were in the room five minutes earlier and asked him to put his helmet back on his head. He started placing the helmet on his head when the staff member left with a plan to return within a few minutes. The source of the water on the floor could not be determined. The facility concluded the resident had an unfortunate fall in the room with injury. Education was provided to staff on safety specific interventions for this resident and to always be mindful of environmental surroundings. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is reported to be accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the State Agency.

Publication

Sent to facility 4/23/2024 · released to the public 4/30/2024.