SILVER HEIGHTS SKILLED NURSING AND REHABILITATION

A revisit survey was completed on 1/12/24 for all previous deficiencies cited on 10/19/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/12/24 for all previous deficiencies cited on 10/19/23. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. The building is a one story wood framed structure, Type V (000) (VA), with no attic, and a partial basement used by staff only for maintenance. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic sprinklered system. The facility was surveyed on October 31, 2023 using the National Fire Protection Association (NFPA) Life Safety Code (2012) Chapter 19, Existing Health Care Occupancies; the NFPA Health Care Facilities Code (2012); and all referenced standards. The deficiencies cited were discussed with the Facilities Manager and the Director of Plant Operations during the exit conference conducted at the end of the on-site survey. The facility will be in compliance with the above stated requirements with the correction of the following deficiencies.

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1. Room 309, 207, 110, 405, 409, 410 do not resist the passage of smoke NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on 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:1. Penetrations in electrical room need to be filled 2. Smoke barrier by room 117 penetration needs to be filledNFPA 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 Maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire Drills: Missed 2nd shift 4th quarter and not more than 1 hour apartNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/16/2023 and 10/22/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A health survey with complaint #CO33849 was completed 10/16/23 to 10/19/23. No response necessary.

A recertification survey with complaint #CO33880 was completed on 10/16/23-10/19/23. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 10/16/23-10/19/23. No deficiencies were cited.

Based on interviews and record review, the facility failed to ensure one (#62) of one resident reviewed for verbal abuse out of 32 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #62 was kept free from verbal abuse and threats by a staff member. Findings include:I. Facility policy and procedureThe Abuse policy and procedure, undated, was provided by the nursing home administrator (NHA) on 10/16/23 at 10:30 a.m. It revealed, in pertinent part, "(Facility) does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or any other individuals."Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion."Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Resident abuse may be verbal, sexual, physical, involuntary seclusion, mental abuse, neglect and/or misappropriation of resident property."Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again."II. Resident #62 statusResident #62, age 80, was admitted and discharged on 10/4/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia. According to the 10/4/23 admission nursing notes, the resident had cognitive impairment related to a diagnosis of dementia. The resident required supervision with all activities of daily living. A. Record reviewThe 10/4/23 abuse investigation documented that at 6:00 p.m., registered nurse (RN) #5 received a report from the nurse from the previous shift. Resident #62 was sitting in a chair in the lobby, waiting for his son to come pick him up. RN #5 got into a verbal argument with Resident #62 and began threatening and yelling at the resident, saying "I ' m calling the police and you may not live until the police get here."RN #5 was removed from contact with Resident #62 and notified the director of nursing (DON). Licensed practical nurse (LPN) #1, who was interviewed on 10/4/23, said she had her medication cart down in the lobby to keep an eye on Resident #62, who was upset with being admitted to the facility. She said she was waiting for his son to arrive to take him home. Resident #62 was sitting quietly in the recliner chair. She said RN #5 entered the facility for his shift and she informed him why they were in the lobby. She began to give him a report of the day, when he started complaining that he did not need to put up with "this guy" all night long. She said Resident #62 got upset and said, "I can hear what you are saying, I know you are talking about me."She said RN #5 responded back to Resident #62 and said, "You ' re right, we are (expletive) talking about you. Not only that, I ' m going to call the police on you. Yeah, you want to (expletive) hit me man, go ahead and hit me. I ' m calling the police and you may not live until the police get here!"LPN #1 said she immediately told RN #5 to leave the area and get away from Resident #62. She said he continued swearing as he walked down the hallway, in front of other residents. Resident #62 was easily calmed down and forgot the incident by the time his son had arrived. B. Results of the facility's abuse investigationThe conclusion of the abuse investigation documented that RN #5 did not interact appropriately and verbally threatened Resident #62, which was confirmed by witnesses and video surveillance. RN #5 was removed from the area, his employment was terminated and his actions reported to the Board of Nursing. III. Staff interviewsThe NHA and DON were interviewed on 10/19/23 at 1:57 p.m. The DON said that she was called on the night of 10/4/23 when the incident with RN #5 and Resident #62 happened. She said she interviewed the staff on duty and watched back the video surveillance. She said it was clear that RN #5 was yelling at Resident #62 and had threatened him. The NHA said the facility immediately suspended RN #5 and then decided upon a final action of termination. The NHA said the facility was able to substantiate the verbal abuse by RN #5 toward Resident #62.

Based on record review and interviews, the facility failed to ensure a written notice of bed hold was provided to two (#51and #7) of two out of 32 sample residents at the time of hospitalization. Specifically, the facility failed to provide Resident #51 and Resident #7 a notice of bed hold upon a facility-initiated discharge from the facility to an acute care hospital. Findings include:I. Facility policy and procedureThe Bed Holds and Returns policy and procedure, revised March 2022, was provided by the nursing home administrator (NHA) on 10/19/23 at 5:30 p.m. It revealed in pertinent part, "All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a residents bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice:-well in advance of any transfer (in the admission packet); and-at the time of transfer (or, if the transfer was an emergency, within 24 hours)."The written information regarding bed-holds provided to the residents/representatives explains in detail:-the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility;-the reserve bed payment policy as indicated by the state plan (for Medicaid residents);-the facility policies regarding bed-hold periods;-the facility per diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and-the return policy."The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available."II. Resident #51 statusResident #51, age 72, was admitted on 12/13/22. According to the October 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease stage four and obstructive and reflux uropathy (obstructive urinary flow). The 10/11/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. He was independent with all activities of daily living. A. Record reviewThe 1/13/23 progress note revealed the resident had been sent to the emergency room for confusion and critical lab results. The 2/26/23 progress note revealed the resident had been sent to the emergency room for catheter replacement. The 3/30/23 progress note revealed the resident had been sent to the emergency room for catheter replacement. The 6/17/23 progress note revealed the resident had been sent to the emergency room for respiratory distress. The 9/21/23 progress note revealed the resident had been sent to the emergency room for high potassium levels. The 10/4/23 progress note revealed the resident had been sent to the hospital for fistula placement. The resident's medical record was reviewed on 10/18/23 at 10:15 a.m. It did not reveal documentation to indicate the resident had been provided a notice of bed hold for any of his discharges. The facility initiated a performance improvement plan (PIP) for bed hold consent on 9/29/23 after they had performed a mock survey and identified the error. -However, they failed to follow the plan on 10/4/23 for Resident #51 when he was sent to the hospital for surgery. III. Resident #7 statusResident #7, age 74, was admitted on 8/23/22. According to the October 2023 CPO, the diagnoses included cerebral infarction (area of dead brain tissue), malignant neoplasm of the prostate (cancer) and major depressive disorder. The 9/20/23 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. He needed extensive assistance with bed mobility, transferring, and personal hygiene. A. Record reviewThe 10/5/23 progress note revealed the resident had been sent to the hospital for 10 out of 10 pain in right femur area. The resident's medical record was reviewed on 10/18/23 at 10:30 a.m. It did not reveal documentation to indicate the resident had been provided a notice of bed hold for his discharge to the emergency room on 10/5/26. The facility initiated a performance improvement plan (PIP) for bed hold consent on 9/29/23 after they had performed a mock survey and identified the error. -However, they failed to follow the plan on 10/5/23 for Resident #7 when he was sent to the acute care hospital. B. Resident interviewResident #7 was interviewed on 10/16/23 at 10:56 a.m. He said he was not given a bed hold form other than when he was first admitted to the facility. IV. Staff interviewsThe director of nursing was interviewed on 10/19/23 at 1:53 p.m. She said the residents received a bed hold consent form upon admission to the facility. She said they should receive a bed hold consent when they were sent out to the hospital. The nursing home administrator (NHA) was interviewed on 10/19/23 at 4:30 p.m. She said the facility had completed a mock survey in September 2023 and identified the bed hold consent as an area that needed corrective action. They completed a PIP on 9/29/23. She said nursing staff was responsible for providing the residents or their responsible party with a notice of bed hold prior to the resident being transferred out of the facility. She said she had prepared a discharge packet that nursing staff used to ensure all of the required paperwork was completed. She said a copy of the notice of bed hold should be placed in the resident's medical record.

Based on observations, interviews, and record review, the facility failed to ensure two (#1 and #11) of four residents reviewed out of 32 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to:-Ensure Resident #1 and #11 received showers; and,-Ensure Resident #1 and Resident #11's care plan addressed shower refusals and preferences. Findings include: I. Facility policy and procedureThe Bath, Shower/Tub policy, revised Feburary 2018, was provided by the director of nursing (DON) on 10/18/23 at 5:13 p.m. It revealed in pertinent part, "The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin."II.. Resident #1A. Resident statusResident #1, under the age of 65, was admitted on 5/31/19. According to the September 2023 computerized physician orders (CPO) the diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (decreased movement of the right side following a stroke), cerebral palsy (weakness of the muscles), need of assistance with personal care and history of traumatic brain injury. The 8/4/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) with a score of nine out of 15. He required supervision of one person for bed mobility, toileting. He required supervision, set-up assistance for transfers, locomotion on and off the unit, eating. He required limited assistance of one person for dressing, personal hygiene. According to the MDS the resident did not have a shower in the review period. B. ObservationsOn 10/16/23 at 9:59 a.m. Resident #1 was in his room. His hair appeared wet and greasy. Resident #1 had a body odor. On 10/17/23 at 8:54 a.m. Resident #1 was in his room. His hair appeared wet and greasy. Resident #1 had a body odor. On 10/18/23 at 10:37 a.m. Resident #1 was in his room. His hair appeared wet and greasy. Resident #1 had a body odor. C. Record reviewThe director of nursing (DON) provided Resident #11's bathing log from 7/18/23 through 10/18/23 on 10/18/23. The July 2023 (7/18/23 to 7/31/23) shower documentation revealed Resident #1 refused a shower on 7/29/23.-It indicated Resident #1 did not receive a shower on six of six opportunities. The August 2023 shower documentation revealed Resident #1 received a shower on 8/9, 8/11 and 8/15/23. Resident #1 refused a shower on 8/19/23.-It indicated Resident #1 received a shower on three of 13 occasions. The September 2023 shower documentation revealed Resident #1 received a shower on 9/5 and 9/15/23. Resident #1 refused a shower on 9/4, 9/11, 9/13, 9/18, 9/20, 9/22, 9/25 and 9/27/23.-It indicated Resident #1 received a shower on two of 13 opportunities. The October 2023 (10/1/23 to 10/18/23) shower documentation revealed Resident #1 received a shower on 10/1, 10/2, 10/4, 10/6, 10/7, 10/8, 10/9, 10/12, 10/13, 10/15 and 10/16/23. -However, certified nurse aide (CNA) #8 was interviewed and said she did not provide Resident #1 a shower on 10/16/23 (see interviews below).-Review of the resident's medical record revealed there were no progress notes to indicate why the resident refused showers on multiple dates. A review of Resident #1's care plan did not indicate techniques to help encourage Resident #1 to bathe. III. Resident #11A. Resident statusResident #11, under the age of 65, was admitted on 3/21/13 and readmitted on 10/11/21. According to the October 2023 CPO the diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (decreased movement of the right side of the body following a stroke), epilepsy (seizure disorder), gastro-esophageal reflux disease (GERD) and mood disorder. The 9/29/23 MDS assessment revealed the resident had moderate cognitive impairments with BIMS of 12 out of 15. She required supervision with one person assistance for bed mobility. She required limited assistance of one person for transfers, dressing and personal hygiene. She required physical help limited to transfer only for bathing. B. ObservationsOn 10/16/23 at 2:25 p.m. Resident #11 was in the activity room. Resident #11 was wearing jeans and a red shirt. Resident #11 had a hat on. Resident #11's hair appeared greasy and wet. Resident #11 had body odor. On 10/16/23 at 1:20 p.m. Resident #11 was in the hallway wearing the same jeans and red shirt as 10/17/23. Resident #11 was wearing a hat and her hair was greasy and appeared wet. Resident #11 had body odor. C. Record reviewThe activities of daily living (ADL) care plan, initiated on 10/18/21 and revised on 6/3/22, revealed Resident #11 required assistance with some ADLs. Resident #11 became frustrated easily with communicating her need for assistance with ADLs at times. The interventions included in pertinent part: allowing and encouraging Resident #11 to make her decisions of care, allowing sufficient time for her to complete tasks independently and bathing per resident's current preference. The activities care plan, initiated on 10/18/21 and revised on 8/14/23, revealed Resident #11 preferred a shower with female assistance. Resident #11 needed encouragement and reassurance for showering. The director of nursing (DON) provided Resident #11's bathing log from 7/18/23 through 10/18/23 on 10/18/23. The July 2023 (7/18/23 to 7/31/23) shower documentation revealed Resident #11 refused a shower on 7/28/23. -It indicated Resident #11 was not provided a shower out of four opportunities. The August 2023 shower documentation revealed Resident #11 received a shower on 8/11, 8/16, 8/18 and 8/29/23. -It indicated Resident #11 was provided a shower on three of nine opportunities. The September 2023 shower documentation revealed Resident #11 received a shower on 9/4, 9/5, 9/12, 9/15, 9/19, 9/22 and 9/26/23. -It indicated Resident #11 was provided a shower on six of eight opportunities. The October 2023 (10/1/23 to 10/18/23) shower documentation revealed Resident #11 received a shower on 10/1, 10/2, 10/4, 10/5, 10/6, 10/8, 10/11, 10/13, 10/14 and 10/15/23.-It indicated Resident #11 was provided a shower on two of five opportunities. IV. Staff interviewsCNA #7 was interviewed on 10/18/23 at 4:01 p.m. CNA #7 said there were bath sheets in the nurses station that indicated each resident's preference for baths. CNA #7 said Resident #11 preferred to shower on Tuesday and Fridays on the evening shift. CNA #7 said Resident #1 preferred to shower Monday, Wednesday and Friday on the evening shift. CNA #8 was interviewed on 10/18/23 at 6:48 p.m. CNA #8 said she typically worked the evening shift. CNA #8 said Resident #11 occasionally refused showers. CNA #8 said Resident #11 responded well to a rewards system. CNA #8 said if Resident #11 refused a shower, she would reapproach the resident later and offer her a cigarette. CNA #8 said the cigarette helped encourage Resident #11 to shower. CNA #8 said Resident #1 occasionally refused showers. CNA #8 said she would attempt to help Resident #1 shower three times prior to documenting that he refused the shower. CNA #8 said she would also notify the nurse. CNA #8 said Resident #8 did not receive a shower on 10/16/23 or 10/17/23. Registered nurse (RN) #4 was interviewed on 10/19/23 at 10:55 a.m. RN #4 said CNAs were responsible for assisting residents with showers. RN #4 said a bath aide was scheduled on the day shift. RN #4 said the scheduled evening CNAs were responsible for assisting with showers on their assigned unit. RN #4 said the CNAs were responsible for notifying the nurse when a resident refused a shower. RN #4 said she was not aware that Resident #1 refused showers. RN #4 said Resident #11 had a history of refusing showers and is quite particular. RN #4 said Resident #11 preferred certain staff members to assist her with showers. The DON was interviewed on 10/19/23 at 1:19 p.m. The DON said the bath aides were responsible for assisting residents with showers. The DON said if a bath aide was not scheduled the CNAs were responsible for assisting residents with showers. The DON said the CNAs should attempt to encourage residents to shower three times prior to documenting the refusal. The DON said Resident #1 refused showers frequently. The DON said Resident #1 needed a lot of convincing to shower and preferred certain staff members. The DON said the residents care plan needed to be updated to include Resident #1's shower refusals and ways to encourage Resident #1 to shower. The DON said Resident #1 often had body odor. The DON said Resident #11 refused showers occasionally. The DON said Resident #11 preferred certain staff members to help her shower. The DON said Resident #11 often had body odor. The DON said Resident #11 responded well to positive reinforcement. The DON said Resident #11's care plan needed to be updated. The DON said the MDS documentation changed on 10/1/23. The DON said the CNAs could have been documenting showers incorrectly as there were a lot of changes. The DON acknowledged that CNA #8 said she did not provide Resident #1 a shower on 10/16/23, despite it being documented in the resident's medical record. The DON said she would provide education to the CNAs on proper shower documentation with the new changes that were implemented.

Based on interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#51) of two reviewed for change of condition out of 32 sample residents. Specifically, the facility failed to ensure:-A cardiology appointment was scheduled for Resident #51 with a diagnosis of heart failure; and,-The physician was notified when Resident #51 had chest pain. Findings include:I. Resident #51 status Resident #51, age 72, was admitted on 12/13/22. According to the October 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease stage four and obstructive and reflux uropathy (obstructive urinary flow). The 10/11/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview of mental status (BIMS) score of 13 out of 15. He was independent with all activities of daily living. A. Record reviewResident #51 was admitted to the hospital from the facility on 6/17/23 for shortness of breath and was discharged from the hospital back to the facility on 7/5/23. The hospital discharge instructions recommended a follow-up with cardiology due to a new diagnosis of heart failure with an ejection fraction of less than 40%. The discharge papers instructed the primary care physician (PCP) be notified of signs and symptoms of chest pain or shortness of breath. A nurse's note entered on 7/9/23 at 11:34 p.m. revealed the resident had dry heaves, sweating, nausea, sharp chest pain described as greater than 10 out 10 and shortness of breath. His vital signs were respirations of 26 (normal rate is 12 to 18), heart rate of 68, oxygen saturation of 93% out of 100% and blood pressure of 202/94 (normal range is less than 120 and less than 80). The note documented the nurse remained with the resident for 20 to 30 minutes and the chest pain had decreased to seven to eight out of 10 and the resident wanted to go bed. -There was not any documentation to show that the nurse notified the physician of the residents chest pain and shortness of breath. II. Staff interviewsThe director of nursing (DON) was interviewed on 10/18/23 at 5:25 p.m. She said she looked through all of the documentation on Resident #51's chart and could not locate where the physician was notified of the residents complaint of chest pain and shortness of breath. She said she would have called the physician if she were the nurse responsible for that resident that night. The physician was interviewed on 10/19/23 at 9:27 a.m. He said he does not recall being informed of any chest pain events in July 2023 for Resident #51. He said he would not want a nurse to make the decision without contacting a physician if a resident complained of chest pain. He said he would expect a phone call. The DON was interviewed again on 10/19/23 at 1:53 p.m. She said Resident #51 had not been seen by a cardiologist for an ischemic workup as recommended by the discharge instructions from his hospital stay that ended on 7/5/23 and the physicians note dated 7/6/23. She said the resident was not having a heart attack and he was seen by cardiology on 7/24/23 to be cleared for fistula surgery. She said he did not come back from hospital with a heart failure diagnosis and that he had atrial fibrillation from pneumonia and end-stage kidney failure. She said she did not believe the cardiac recommendations were for cardiac problems. -However, the hospital discharge instructions indicated the resident was to be seen by cardiology due to a new diagnosis of heart failure (see above). The assistant director of nursing (ADON) was interviewed on 10/19/23 at 5:27 p.m. She said she remembered the night that Resident #51 was outside dry heaving and complaining of chest pain. She said she did not call the doctor and she did not have a good reason for not doing so. She said she it was not in her scope of practice as a licensed practical nurse (LPN)to determine if the resident was having a heart attack and she would have expected her staff to call the physician for direction.

Based on observations, record review and interviews, the facility failed to ensure one (#14) of eight out of 32 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure Resident #14 received the supervision he required to prevent falls. Findings include:I. Resident #14Resident #14, age under 65, was admitted on 8/3/22. According to the October 2023 computerized physician orders (CPO), the diagnoses included Huntington's Disease, Parkinson's disease, vascular dementia without behavioral disturbance, chorea (a neurological disorder characterized by spasmodic involuntary movements of the limbs or facial muscles), muscle weakness, depression, repeated falls, lack of coordination, functional urinary incontinence and unsteadiness on feet. The 9/29/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. He required extensive assistance of one person with bed mobility, transfers, eating and personal hygiene and total dependence of one person with toileting and dressing. It indicated the resident had two or more falls since the prior assessment. A. Resident interview and observations Resident #14 was interviewed on 10/16/23 at 1:45 p.m. He said he had experienced a lot of falls. He said at first he had a difficult time accepting he could not do certain things, but that lately his falls were because the facility staff took a long time to help him. He said he needed help with almost everything. On 10/16/23 at 3:22 p.m. Resident #14 could be heard calling out for help from the hallway before rounding the corner to the nursing station. Two staff members were observed sitting in the nursing station, looking down at their cell phones. Resident #14's room was directly across from the nursing station and could be heard calling out for help. The call light was activated. Resident #14 was observed on the floor, with his left leg tangled in the wheelchair with a urine puddle on the ground. Upon notifying an unidentified staff member that Resident #14 was on the ground, tangled in his wheelchair, the staff member said, "um ok." She finished looking at something on her cell phone, placed her cell phone down and entered the resident's room. She said to the resident she needed to get gloves and other items and would be back to help him off the ground. She returned with a nurse to assist. On 10/17/23 at 1:31 p.m. Resident #14's call light had been activated, along with two other call lights. Resident #14 was observed calling out for help. Staff members were observed sitting at the nursing station, not getting up to attend to any of the call lights. Activity assistant (AA) #1 was observed entering each of the rooms of the activated call lights. AA #1 informed licensed practical nurse (LPN) #3 that three call lights had been activated, staff were sitting in the nursing station and all three residents required incontinence care. B. Record review The cognitive care plan, initiated on 7/24/23 and revised on 10/13/23, documented the resident had impaired cognitive function related to a diagnosis of dementia. The interventions included administering medications as ordered, asking yes or no questions to determine the resident's needs, communicating with the resident regarding his capabilities and needs and keeping the resident's routine consistent to decrease confusion. The communication care plan, initiated on 8/15/22 and revised on 10/13/23, documented that the resident had potential for complications due to impaired communication exhibited by unclear speech and difficult to understand. The resident had effects of chorea on vocalization. The interventions included allowing the resident time to respond, express himself and understand others; asking the resident for clarification as needed; providing the resident with appropriate adaptive equipment and observing any changes to his communication. The activities of daily living (ADL) care plan, initiated on 8/15/22 and revised on 2/21/23, documented that the resident had severe chorea that impacted his ability for self-care. He was able to feed himself with finger foods, but was unable to use utensils safety or effectively. It indicated the resident had impaired vision, was forgetful and his speech was unclear at times. The interventions included offering and assisting the resident with transfers and bed mobility; and offering and providing assistance with grooming, oral/dental care, personal hygiene, meals and incontinence care. The fall risk care plan, initiated on 8/15/22 and revised on 4/21/23, documented that the resident was at risk for injuries from falls due to decreased coordination and a history of falls. The resident had uncontrolled tremors. It indicated that the resident chose to transfer without assistance. The interventions included providing safety devices, assistive equipment, dycem under the cushion to prevent slipping, therapy for transfer training; providing verbal reminders not to transfer without assistance; encouraging the resident to call for help when needed; keeping the call light within reach and responding promptly; providing a low bed for safety; providing anti-rollbacks for the wheelchair; and removing the foot pedals from the wheelchair. 1. Fall incident 2/13/23 According to the 2/13/23 interdisciplinary (IDT) team fall committee progress note, the resident sustained an unwitnessed fall while self-transferring from the recliner to his wheelchair to go to dinner. The resident lost his balance and fell to the ground. The resident sustained a laceration to the top of the right side of his head. There was minimal bleeding and no swelling noted. The interventions included offering the resident a helmet for safety and continuing to encourage the resident to ask for assistance with transfers. 2. Fall incident 3/3/23 The 3/3/34 nursing progress note documented the resident was found on the floor twice, within a few minutes of each other. The resident was unable to verbalize what caused the fall. The resident did not sustain any injuries. -It did not include any new interventions. 3. Fall incident 4/3/23 The 4/3/23 nursing progress note documented that at 1:00 p.m., the resident was seen by staff and another resident transferring himself from the wheelchair to the recliner. He made it to the arm of the chair and slid to the floor. He said he did not hit his head. The resident did not sustain any injuries. The interventions included reminding the resident to call for help when he is ready to transfer back to his wheelchair. The 4/4/23 post fall evaluation documented to continually encourage the resident to ask for assistance and that the current interventions were in place to promote safety when the resident falls rather than reducing falls. It indicated that the resident's falls were unavoidable. The 4/5/23 nurse practitioner progress note documented the falls with the resident were unfortunately unavoidable due to his diagnosis of Huntington's disease and severe chorea movements. -However, according to the observations, the resident not only vocalized needing assistance but had also activated his call light with staff close by at the nursing station. The staff did not respond to the call light or the yelling out for help until prompted. The resident was on the floor with evidence of an incontinence episode. 4. Fall incident 4/20/23 The 4/20/23 nursing progress notes documented the nurse was notified that the resident landed on his bottom during a self-transfer from the wheelchair to the recliner in the front lobby, lost his footing and fell. The resident did not sustain an injury. -It did not include any additional interventions. The 4/21/23 IDT fall committee progress note documented the resident was educated again on asking for help when transferring. 5. Fall incident 5/7/23 The 5/7/23 nursing progress note documented that the resident was found on the floor. He said he was transferring himself from the wheelchair to the bed and slid off his chair. The resident did not sustain any injuries. The interventions included frequent visual monitoring for the resident's needs and safety and ensuring the call light is within reach at all times. -However based on the observations, the resident's needs were not addressed timely after the resident had activated his call light and called out for help. 6. Fall incident 7/11/23 The 7/11/23 nursing progress note documented that the resident was on the phone, talking excitedly, and popped out of his wheelchair and landed on the floor. The resident did not sustain an injury. -No new interventions were in place. 7. Fall incident 8/13/23 The 8/13/23 nursing progress note documented at 1:00 p.m. the resident was found sitting on the floor in front of his wheelchair. The resident said he tried to transfer himself and landed on the ground. The resident did not sustain an injury. The resident was strongly encouraged to always call when he would like to be transferred. 8. Fall incident 9/6/23 The 9/6/23 nursing progress note documented the resident was found on the floor, on his buttocks with his legs extended in front of him, with the wheelchair facing the opposite direction. The certified nurse aide (CNA) said she was assisting the resident at the sink prior to bed. She attempted to help the resident sit back in the wheelchair, but because of the foot pedals, the wheelchair moved backwards. The resident was lowered to the floor by the CNA. 9. Fall incident 9/24/23 The 9/24/23 situation, background, assessment and recommendations (SBAR) documented that the resident sustained a fall. -It did not provide any additional details. The 9/25/23 IDT fall committee progress note documented the resident was found on the floor next to his bed, reaching for his IPad. The resident did not sustain an injury. The intervention included therapy evaluating the resident's room. 10. Fall incident 10/15/23 The 10/15/23 nursing progress note documented that the resident fell from the low bed to the floor and then crawled out to the doorway. The resident was assisted with incontinence care upon his request. The resident did not sustain an injury. 11. Fall incident 10/16/23 The 10/16/23 nursing progress note documented that the CNA told the nurse that the resident was found on the floor, in his room, in front of his wheelchair. The resident was soiled with urine. The resident said he slipped from the cushion on his wheelchair because of the urine. The resident did not sustain an injury. II. Staff interviews CNA #2 was interviewed on 10/19/23 at 11:30 a.m. She said Resident #14 required assistance with all ADLs. She said the resident was incontinent and required assistance with incontinence care. She said the resident was able to activate his call light when it was within reach, but that sometimes he would call out for assistance. She said the resident had a difficult time communicating and was difficult to understand at times. She said Resident #14 had sustained a lot of falls. She said the resident usually fell because he wanted to get up out of bed or needed incontinence care and he did not want to wait any longer. She said it depended on the day and what was happening if she was able to assist him timely. She said the resident often did not like to wait for an extended period of time and would attempt to transfer himself. She said she did not think the involuntary movements from his disease were the cause of most of his falls. The director of nursing (DON) was interviewed on 10/19/23 at 1:57 p.m. She said Resident #14 required total assistance with ADLs. She said he had sustained a lot of falls. She said the resident had difficulty accepting the change in his level of care and would self-transfer, which caused the falls. She said the resident was able to activate his call light and would sometimes yell out for help. She said the resident was in the room directly across from the nursing station so staff could assist the resident quickly. The DON said she was not aware of the two observations made on 10/16/23 and 10/17/23, during the survey process. She said the staff should not be sitting in the nursing station on their cell phones. She said if they had down time, then they should be rounding and checking on the residents. She said the staff were aware that Resident #14 would yell for assistance and that should have alerted them to check on him.

Based on observations, staff interviews, and record review, the facility failed to consistently provide urostomy care, treatment and services to minimize the risk of urinary tract infections for one (#7) of two residents reviewed for urinary devices out of 32 sample residents. Specifically, the facility failed to ensure Resident #7 had orders for urostomy care. Findings include:I. Professional referenceAccording to the American Cancer Society (10/16/19) at https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/urostomy/management.html accessed on 10/30/23, it read in pertinent part, "During the day most people need to empty the pouch about as often as they used the bathroom before they had urostomy surgery or other bladder problems-for many people, this might mean every 2 to 4 hours, or more often if you drink a lot of fluids. "Different pouching systems are made to last different lengths of time. Some are changed every day, some every 3 days or so, and some just once a week. It depends on type of pouch you use."Your pouch should be changed on a schedule that fits your routine. And it's best to have a regular changing schedule so problems don't develop. In other words, don't wait for it to leak to change it. "Before changing your pouch, clean your hands well and put all your supplies on a clean surface. Clean pouches decrease the chances of germs (bacteria) getting into your urinary system. Bacteria can multiply quickly even in the tiniest drop of urine. These germs may travel up the ureters and cause a kidney infection. Bacteria can also cause foul-smelling urine. II. Resident #7A. Resident statusResident #7, age 74, was admitted on 8/23/23. According to the October 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm of the prostate (prostate cancer), chronic kidney disease and unspecified injury of the right kidney. The 9/20/23 admission minimum data set (MDS) assessment revealed the resident had intact cognition and scored a 15 out of 15 on the brief interview for mental status (BIMS). The resident showed no signs of delusions or psychosis and had no aggressive behaviors. The resident did not reject care or assistance. The resident upon admission was able to complete some activities of daily living independently and some with only set up assistance from staff. The resident needed extensive assistance from staff for bed mobility, transferring, toileting, dressing and with personal hygiene. The resident was continent of bowel and preferred to use a bedpan. The resident had a urostomy and was not placed on a toileting program. B. Resident observationResident #7 was observed on 10/16/23 at 10:56 a.m. The resident had a urostomy connected to a foley bag. C. Record reviewReview of the resident's medical record revealed the resident was admitted on 8/23/23 with a urostomy (ileal conduit in right upper quadrant with catheter drainage bag). At the time of admission there were not any orders entered for care of the stoma or urostomy. Review of the resident's October 2023 physician's orders, medication and treatment administration record (MAR/TAR) and comprehensive care plan revealed:-No orders for routine stoma or urostomy care, maintenance or monitoring of the resident urostomy, and;-No documentation of urostomy care provided. A nursing progress note, dated 8/25/23 at 5:15 a.m., revealed the urostomy was leaking and was changed with the last remaining urostomy bag. The care plan, initiated on 8/29/23 and revised on 9/20/23, had a focus for the urostomy and listed goals of no signs or symptoms or urinary infection and free from catheter-related trauma. The interventions listed were to monitor/document for pain/discomfort due to catheter and monitor/record/report to physician signs and symptoms of a urinary tract infection such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. III. Staff interviewThe director of nursing (DON) was interviewed on 10/19/23 at 1:53 p.m. The DON said orders for urostomies should be entered upon admission to the facility and should include orders for the care. Licensed practical nurse (LPN) #3 was interviewed on 10/18/23 at 2:19 p.m. She said orders should be placed upon admission for residents with urinary devices. She said the orders should include the care and maintenance of those devices.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for five of eight staff reviewed. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #4, CNA #2, CNA #5, CNA #6 and activities aide (AA) #1. Findings include:I. Record reviewA request for CNA #4 (hired 1/20/21), CNA #2 (hired 9/22/2020), CNA #5 (hired 11/23/16), CNA #6 (hired 11/11/21) and AA #1 (hired 10/8/21) annual performance review on 10/19/23. -The human resources director (HRD) said CNA #4, CNA #2, CNA #5, CNA #6 and AA #1 did not have an annual performance review. AA #1 was a CNA and worked as a bath aide (see interview). CNA #4, CNA #2, CNA #5, CNA #6 and AA #1 had not completed annual inservice education based on the outcome of their reviews. II. Staff interviewsAA #1 was interviewed on 10/16/23 at 10:04 a.m. AA #1 said she was a CNA and worked as a bath aide once a week. The director of nursing (DON) was interviewed on 10/19/23 at 1:10 p.m. The DON said staff training was done via a website. The DON said the facility was not completing annual reviews for CNAs. The staffing coordinator (SC) was interviewed on 10/19/23 at 2:06 p.m. The SC said she was responsible for helping ensure all CNAs received annual training. The SC said the facility used to complete annual competencies, but no longer completed them regularly. The SC said she was unsure why the facility no longer did annual competencies. The SC said it was important to complete annual competencies to help determine what training the staff needed. The HRD was interviewed on 10/19/23 at 4:23 p.m. The HRD said annual competencies have not been completed. The NHA and the DON were interviewed on 10/19/23 at 4:50 p.m. The DON said annual competencies have not been completed. The NHA said annual competencies needed to be completed and they would start completing them.

Based on observations and interviews, the facility failed to ensure two out of three medication carts stored medications in accordance with accepted professional standards. Specifically, the facility failed to ensure the medication carts were locked when the nurse was not at the cart or in direct line of sight. Findings include: I. Facility policy and procedure The Medication Storage policy and procedure was requested on 10/19/23 from the nursing home administrator (NHA), however, it was not provided. II. ObservationsOn 10/16/23 at 9:41 a.m. the medication cart was left unlocked while licensed practical nurse (LPN) #1 went into a residents room. She was not in direct line of sight of the cart which was across and up the hall from the room she entered and there were not any licensed nursing staff observed within direct line of sight. Residents were walking in the hall and one unidentified male resident frequently waited at the cart requesting medication. LPN #1 returned to the cart four minutes later and realized she left the cart unlocked. She put her keys back in her pocket and continued to prepare another medication. At 10:24 a.m. the medication cart in the main room on the 300 hall was unlocked and there were not any licensed nursing staff observed within direct line of sight. Several residents were in the hall including a female resident who was known to wander. After two minutes, registered nurse (RN) #1 opened the door from inside a residents room. She was notified that the medication cart was unlocked and she proceeded to lock it. At 1:41 p.m. the medication cart on the 300 hall was unlocked and there were not any licensed nursing staff observed within direct line of sight. A male resident was wandering in the hall during this time. RN #1 was assigned to the medication cart, however she could not be located. III. Staff interviewsRN #1 was interviewed on 10/16/23 at 10:26 a.m. She said the medication cart should not ever be left unlocked. She said it the nursing staff kept the medication cart locked when unattended and out of direct line of sight. She said she could not believe she forgot to lock the cart because she never usually leaves the medication cart unlocked. LPN #3 was interviewed on 10/18/23 at 2:19 p.m. She said the medication carts should always be locked. She said the facility was home to many residents with memory deficits and wandering behaviors. She said the danger of an unlocked medication cart was that the residents could get into medications that were not safe for them and take something they should not. This could lead to possible overdose or harm, even if it was an over-the-counter medication. The director of nursing (DON) was interviewed on 10/19/23 at 1:53 p.m. The DON said medication carts should be locked at all times. She said it was not acceptable for staff to leave them unlocked. She said the facility was home to many dementia residents so if the medication carts were left unlocked those residents could get into medications that were not meant for them.

Based on observations, record review and staff 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. Specifically, the facility failed to ensure control measures for monitoring and preventing Legionella and waterborne pathogens growth were included in the facility's water management plan. Findings include:I. Professional referenceThe Center for Disease Control and Prevention (CDC) recommendations for Legionella, last reviewed on 3/25/21, was retrieved on 10/22/23 at https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html under Heathcare Water Mangement read in pertinent part: "Healthcare facilities, such as hospitals and nursing homes, usually serve the populations at highest risk for Legionnaires' disease. These include older people and those who have certain risk factors, such as being a current or former smoker, having a chronic disease, or having a weakened immune system. Also, healthcare facilities can have large complex water systems that promote Legionella (the bacterium that causes legionnaires' disease) growth if not properly maintained. For these reasons, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) consider it essential that hospitals and nursing homes have a water management program that is effective in limiting legionella and other opportunistic pathogens of premise plumbing (waterborne pathogens, for short) from growing and spreading in their facility. "Legionella and other waterborne pathogens occur naturally in the environment, in bodies of water like lakes, rivers, and streams. Although municipalities treat their water with disinfectants like chlorine that can kill these pathogens, a number of factors may allow these pathogens to enter a building's water distribution system, such as construction (including renovations and installation of new equipment). Vibrations and changes in water pressure can dislodge biofilm and release legionella or other waterborne pathogens. Biofilm is a slimy layer in pipes in which pathogens can live; it can give pathogens a safe harbor from disinfectants."Water management programs identify hazardous conditions and take steps to minimize the growth and spread of legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review."In general, the principles of effective water management include:-Maintaining water temperatures outside the ideal range for legionella growth (77-113 Fahrenheit).-Preventing water stagnation.-Ensuring adequate disinfection.-Maintaining premise plumbing, equipment, and fixtures to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for legionella."Members of a building water management program team work together to:-Identify ways to minimize growth and spread of legionella and other waterborne pathogens.-Conduct routine checks of control measures to monitor areas at risk.-Take corrective action if a problem is found."Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions. Programs should include predetermined responses to correct hazardous conditions if the team detects them."II. Facility policy and procedureThe Legionella Water Management Program policy and procedure, undated, was provided by the nursing home administrator (NHA) on 10/17/23 at 3:00 p.m. It revealed in pertinent part, "Legionalla an grow in many parts of of the building water systems that are continually wet, and certain devices can then spread contaminated water droplets. Examples include but are not restricted to: water heaters, water filters, electronic and manual faucets, showerheads and hoses, ice machines, pipes, valves and fittings, cooling towers, medical devices (such as CPAP machines) and evaporative coolers."If a control limit is not being met, you need to take corrective actions to get the conditions back to within an acceptable range. If three is any time there is a suspected case of Legionnaires disease associated with your building you should decontaminate the building water system if necessary and review the water management program and review it if necessary. Control measures and limits will be established for each control point. You will need to monitor to ensure your control measures are performing as designed. "A list of interventions known to eliminate legionella: prevention is the best intervention, ten to one bleach solution, heating water to above 160 degrees and water movement (stagnant water allows Legionalla to grow)."-The interventions included in the Legionella Water Management Program did not include additional details on how or where to administer and monitor a ten to one bleach solution, how to monitor heating water to above 160 degrees fahrenheit at the source and throughout the flow of water through the facility or how to determine the effectiveness of these interventions. The Legionella Water Management Program did not include specific facility locations monitored such as water heaters, water filters, electronic and manual faucets, showerheads and hoses, ice machines, pipes, valves and fittings, cooling towers, medical devices (such as CPAP machines) and evaporative coolers. III. Record reviewThe weekly water systems testing and monitoring spreadsheet was provided by the NHA on 10/19/23 at 10:20 a.m. The spreadsheet documented monthly and weekly monitoring from 10/1/22 to 10/31/23. The monthly monitoring included an inspection of the eyewash stations. The weekly monitoring included testing and monitoring of the water management plan for Legionella with a corresponding completion date.-The water systems testing and monitoring spreadsheet did not include specific locations monitored in the facility such as water heaters, water filters, electronic and manual faucets, showerheads and hoses, ice machines, pipes, valves and fittings, cooling towers, medical devices (such as CPAP machines) and evaporative coolers. The spreadsheet did not indicate how many eyewash stations were inspected. IV. Staff interviewsThe NHA, the maintenance supervisor and regional maintenance supervisor (RMS) were interviewed on 10/19/23 at 10:00 a.m. The RMS said there was a document in the electronic building and asset management system that contained specifics on which facility locations to monitor. The RMS said the water management plan was for the facilities in their corporation, but each facility might have different items or locations specifically to monitor. The RMS said he could enter the specific facility locations to monitor into the electronic building and asset management system and add to the water management binder the steps to take if the facility had to turn up the temperature on boilers. The MS said the facility halls had separate boilers and one boiler could be adjusted if a single hall was found to have an issue. The MS said water for certain sections can be closed off to control which hallway was monitored. The NHA said if if there was possible contamination the facility water temperature could be increased. The NHA said if the water temperature was increased, the facility would implement the same plan used when the facility previously repaired facility pipes. The residents did not use the water and staff were notified of the changes. The NHA said the unused resident room on the other side of the building were part of the facility monitoring and the goal was to someday use those rooms again. The RMS said the MS checked sections of pipes that were rarely or not used, swamp coolers and the shower room on the closed hall for any signs of Legionella. The RMS if there were signs of Legionella contaminationwhen the facility tested then Ecolab conducted tests at the facility. V. Facility follow-upThe RMS added specific facility locations in addtion to the eyewash stations that were monitored to the electronic building and asset management system on 10/19/23 at 11:00 a.m.

A licensure survey was completed on 10/16/23 to 10/19/23. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure compliance with the Colorado Adult Protective Services Data System (CAPS) check requirements for seven employees. Specifically, the facility failed to ensure an employee CAPS check for activities assistant (AA) #1, maintenance supervisor (MS), AA #2, licensed practical nurse (LPN) #3, cook #1, certified nurse aide (CNA) #4 and cook #2 was completed prior to working with residents. Findings include:I. Professional referenceThe Colorado Adult Protective Services Caps Check Unit, Statute and Rule Requirements1/21/22, retrieved from https://ccu.colorado.gov/statute-and-rule-requirements retrieved on 10/23/23 revealed in pertinent part:"Employers who are required to request a CAPS Check prior to hiring an employee, including a contractor, who will be providing direct care to at-risk adults include the following agency types."Agencies licensed by the Colorado Department of Public Health and Environment under Title 25 and listed below are required to request CAPS Checks:"Any licensed health facility including those wholly owned and operated by any governmental unit."More specifically, these agencies include nursing homes."II. Record review The human resources director (HRD) provided a list of all staff members with their hire date and a copy AA #1, MS, AA #2, LPN #3, cook #1, CNA #4 and cook #2's CAPS checks on 10/19/23. AA #1 was rehired on 8/2/22. She had a previous CAPS check from her previous employment at the facility but there was not one completed when she was rehired. The MS was hired on 9/21/22 and his CAPS check was completed on 9/27/22. AA #2 was hired on 5/1/23 and her CAPS check was completed on 6/5/23. LPN #3 was hired on 1/9/23 and her CAPS check was completed on 1/25/23. CNA #4 was hired on 1/20/21 and did not have a completed CAPS check. Cook #2 was hired on 6/24/21 and did not have a completed CAPS check. IV. Staff interviewsAA #1 was interviewed on10/16/23 at 10:04 a.m. AA #1 said she was a CNA and worked as a bath aide once a week. The HRD was interviewed on 10/19/23 at 3:56 p.m. The HRD said AA #1 CAPS checks was completed on 11/10/21 during her previous employment. The HRD said AA #1 was rehired on 8/2/22 and immediately started working with residents. The HRD said a CAPS check was not completed upon rehired for AA #1. The HRD said the MS was hired on 9/21/22 and began working with residents on 9/21/22. The HRD said the MS CAPS check was not completed until 9/27/22. The HRD said AA #2 was hired on 5/1/23 and began working with residents on 5/4/23. The HRD said AA #2's CAPS check was not completed until 6/5/23. The HRD said LPN #3 was hired on 1/9/23 and began working with residents on 1/11/23. The HRD said LPN #3's CAPS check was not completed until 1/25/23. The HRD said cook #1 was hired on 5/4/23 and began working around residents on 5/29/23. The HRD said cook #1's CAPS check was not completed until 5/30/23. The HRD said CNA #4 and cook #2 did not have a completed CAPS check. The HRD said she was going to submit CAPS checks for CNA #4 and cook #2 on 10/19/23 (during the survey). The HRD said staff did not need to have a completed CAPS check to begin working around residents. The HRD said as long as the CAPS check was in process, staff could work on the floor. The NHA was interviewed on 10/19/23 at 4:12 p.m. The NHA said all staff in all departments needed to have a completed CAPS check prior to their first shift on the floor. The NHA said CNA #4 and cook #2 did not have completed CAPS checks. The NHA said the HRD submitted CAPS checks for CNA #4 and cook #2 on 10/19/23. The NHA said CNA #4 and cook #2 were taken off the schedule until the CAPS checks were completed. The NHA said CAPS checks needed to be completed upon rehire.

A complaint survey, prompted by #CO32680 and #CO32688 was conducted on 7/11/23. No deficiencies were cited.

A revisit survey was completed on 6/29/23 for all previous deficiencies cited on 4/26/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO31794 was conducted on 4/25/23 and 4/26/23. One deficiency was cited.

Based on observations and interviews, the facility failed to maintain a clean, comfortable, homelike environment in resident rooms in three of four units. Specifically, the facility failed to ensure resident rooms were clean, comfortable and in good repair. Findings include: I. Observations and resident interviews Observations in resident rooms identified the floors were stained and in poor repair. An interview with the nursing home administrator (NHA, see below) identified the facility had plans and were in the process of replacing the floors; however, observations identified the rooms and bathrooms were not thoroughly cleaned. Room #307 floor surface was sticky beside the resident's bed on 4/25/23 at 4:57 p.m. There were no visible spills located on the floor where it was sticky. According to the resident, housekeeping had already cleaned her room for the day. Room #202 was observed at 5:08 p.m. There was a dark streak on the floor that could be rubbed off. The floor had food debris, two tissues and a packet of wipes. There was an empty lidded styrofoam cup on the floor in front of a dresser. According to the resident, the room was already cleaned for the day. The resident in room #203 was interviewed on 4/25/23 at 5:12 p.m. She said a while ago the toilet broke in her bathroom and it had to be replaced. She said now the tile in front of the toilet was broken and looked dirty around it. Observations on the bathroom showed dark stains on the floor, a tile depression was in front of the toilet. The grout around the toilet was yellow, dark brown and rust colored. The floor on sides and behind the toilet had not been swept or mopped with visible dust and debris on the surface of the floor. There was thick, sticky and dark debris all along the floorboards of the bathroom. The resident said housekeeping comes in daily and has already cleaned the bathroom. The resident said she had asked maintenance to address the tile in the room. A strong urine odor was observed at the entrance of the 100 hall at 5:32 p.m. The odor smell came from room #117. There was not a resident in room #117 at the time of the odor. Review of the bathroom identified there was not a pull string attached to the call light to notify staff if a resident needed assistance in the bathroom. Resident #4 was interviewed on 4/25/23 at 5:36 p.m. She said when housekeeping cleaned her room, they did not do a thorough job. She said the floors were often left sticky. She said spills have been left on the floor for a couple of days before someone cleaned them up. In the bathroom of a female room, room #105, two empty urinals laid on their sides, on the floor behind the toilet at 5:40 p.m. The resident in room #107 was interviewed on 4/25/23 at 5:44 p.m. He said he sometimes had to ask the housekeepers to clean his floor. He said they would sweep and mop the floor but would just push all the dirt to the sides of the room. Observation of the bathroom in room #107 identified a dirty washcloth on the floor and visible grit like debris all over the surface of the floor. Resident #11 was interviewed on 4/26/23 at 9:30 a.m. She said she no longer resided at the facility but was a resident at the facility in December 2022 and January 2023. She said the facility did not do a thorough job cleaning her room, making her stay at the facility uncomfortable. She said spills were left unattended and cob webs were left in the corners of the room. She said the staff did not deep clean her room and the housekeepers would not move items on the floor to clean under them. She said the bathroom toilet had a black ring around it on the floor and the grout was very dirty. The former resident said staff would not properly clean her commode. She said the facility routinely smelled of bodily odors. The resident in room #202 was interviewed on 4/26/23 at 11:43 a.m. She said housekeeping mopped her room but it was still dirty. She said the housekeepers swept when she ate her meals in her room and kicked up dust in the air. She said they did not clean her bathroom well and pointed out smears of a brown substance on the wall of the bathroom. She said her roommate was incontinent so staff sprayed a fragrance in the room but she said she was sensitive to the perfumed smell. The resident pointed to the call light button in her bathroom, she said the cord to the call light was missing so she had to hit the button with her shoe if she needed assistance. Additional observations in the bathroom of room #202 identified a urinal on the back of the top of the toilet used by female residents that had not been cleaned. The surface of floor boards had visible debris on them all around the bathroom. There was a thick, dark and sticky substance in front of the floor boards in the bathroom. The floor behind the toilet had not been cleaned. The floor in the front bed of the resident had visible food crumbs on the floor and the same styrofoam lid cup. The cup was in the same place as the day before, in front of the small dresser. The resident in room #303 was interviewed on 4/26/23 at 11:45 a.m. He said his bed was not made this morning and he had been waiting all morning. The bed did not have sheets or a blanket on it. Room #203 was observed again on 4/26/23 at 11:50 a.m. A thick dark sticky substance remained around the baseboards in the bathroom. Room #203 was observed again on 4/26/23 at 12:05 p.m. In the middle of the room was purple jelly like substance stuck to the floor in the middle of the room. There was a torn box and two broken cookies on the floor under the bed of the resident. There was visible debris and torn pieces of tissue in the middle of the room and in front of the bed. Housekeeper (HK) #1 was observed cleaning room #109 on 4/26/23 at 12:25 p.m. Resident #7 ate her lunch as HK #1 finished the room cleaning at 12:29 p.m. Observation of the room identified debris on all long floor boards in the bathroom and in the room. The floorboards had dust and a sticky substance still on them. The beds in the room did not have sheets on them. Room #107 was observed again at 12:44 p.m. The resident said he was a veteran and his room was not cleaned to his standards and sometimes would grab whatever cloth he could find and get on hands and knees and wipe down the floor himself. The resident pointed out debris in front of his chair and got on his hands and knees and wiped the floor. The resident said there was a mop room across from his room that often smelled. The resident attempted to open the door to the mop room but it was locked. He said the odor came from the room sometimes even when the doors were shut. The resident in room #209 was interviewed on 4/26/23 at 1:20 p.m. She said she felt housekeeping did not clean her room well. She said she has been gone all day out of her room at times and the room remained in the same condition. She said sometimes she dropped items on the floor by accident and could not pick the item up herself. She said when she returned to her room at the end of the day, the items were not picked up and the floor looked just as unclean when she left it with crumbs remaining on the floor. She said she did not feel comfortable in her room when it was not cleaned well. She said staff did not always clean her toilet so she brought cleaning supplies and would often clean the toilet herself. She said there was also dust on the vent in the bathroom. Observations of the ceiling vent revealed significant dust on the cover of the vent and strands of dust attached to the vest swaying with motion of the air. Two housekeepers, HK #1 and HK #2 were observed cleaning room #304 at 2:46 p.m. At 2:53 p.m. the housekeepers finished cleaning the floor. Review of the room after the housekeeper cleaned the room identified visual debris that was left on the floor in the bathroom. Behind the toilet was dusty and a resident's personal hygiene product laid on its side in the corner behind the toilet. Room #303 was observed at 2:54 p.m. The bed remained unmade without sheets and blankets. HK #1 and HK #2 entered room #310 at 2:53 p.m. and finished at 3:00 p.m. Room #310 was observed at 3:06 p.m. There was visible debris in front of the bed, dresser and around the bathroom floor boards. The bathroom had a raised black gum like substance on the floor and the bathroom had a strong smell of urine. The housekeeper finished cleaning room #307 at 3:10 p.m. The room was observed after it was cleaned. The observation identified two bottles of soda that were left on the floor next to the bed after the room was cleaned. The head of the bed was raised up, revealing a mustard bottle, a bottle of lotion, a bottle of deodorant, and a plastic container remained on the floor between the bed, wall and dresser. Cookie crumbs and torn tissue observed during the morning were identified and pushed off to the side of the room near the wall by the bathroom door. The toilet in the bathroom had spots of dried urine on the backside of the toilet seat and hair was observed on the side of the toilet bowl. II. Resident group interviewResident group interview was conducted on 4/26/23 at 10:30 a.m. The group interview consisted of five residents (#12, #13, #15, #14 and #19) the facility assessed as interviewable. According to the group, there was sometimes a body odor/bodily fluids smell in the facility but the open windows helped with smell. A resident said his roommate made a mess on the surface of the toilet but it was sometimes not taken care of till housekeeping cleans it up the following day. He said he complained to the SSD and he was told that he would be able to switch to another room soon. III. Record reviewResident council minutes were provided on 4/25/23 at 4:50 p.m. The January 2023 resident council meeting. The minutes read the NHA informed residents that over the last couple of months, concerns with water leaks and wipes were clogging up the pipes via the toilet. During the meeting, residents were asked not to flush wipes, or pour juice, cereal, and denture adhesive down the sink because it creates clogs in the pipes. According to the January 2023 minutes, a resident during the 1/10/23 council stated that accidents/messes occur after housekeeping leaves the facility, the messes were left till the housekeepers clean it up the following day. The NHA informed the residents that if something needed to be cleaned, staff should take care of it. The February 2023 minutes identified water leaks were resolved and clogs in pipes have improved. According to the February 2023 minutes the concern related to messes left for housekeeping were resolved. The April 2023 minutes were provided by the facility on 4/26/23. The minutes identified that the majority of residents said the hallways have had an increase in odor.-No other environmental concerns were identified in the resident council minutes. A 1/4/23 nursing/certified nurse aide (CNA) staff meeting agenda was provided by the NHA on 4/26/23 at 5:42 p.m. On the agenda was a written notation that read "Night shift housekeeping." According to the NHA, the notation was related to reminding staff to clean up messes/spills when they were identified and not wait for housekeeping to clean up the next day. The NHA provided the housekeeping cleaning audit on 4/26/23 at 5:42 p.m. The audit confirmed three rooms were reviewed for cleanliness weekly between 2/16/23 and 4/21/23. The audit read:-"Did the housekeeper clean high touch surfaces;-Did the housekeeper clean the room from clean to dirty;-Did the housekeeper clean the bathroom after the room;-Did the housekeeper clean the bathroom room from clean to dirty; and,-Did the housekeeper remove their gloves and utilize hand sanitation after cleaning each area?"-According to the audits, there were no concerns with the cleaning of high touch surfaces, or order of cleaning (clean to dirty), including in the bathroom, and hand hygiene was done after cleaning. The audit did not specifically identify the cleanliness of the floors, toilets/commodes, or odors. -Observations and resident interviews (see above) identified current issues with room cleanliness. IV. Staff interviewThe NHA was interviewed on 4/25/23 at 5:15 p.m. The NHA pointed at the stained floor and said the facility was working on aesthetically improving the facility. She said the flooring was old and the facility was in the process of stripping the floors and painting the walls but temporarily put the improvements on hold till next week. The NHA was interviewed on 4/26/23 at 3:25 p.m. with the administrator in training (AIT). The NHA said the housekeeping supervisor was not at the facility at the time of the interview and he was contracted by the facility from October 2022. She said the maintenance director oversaw the housekeeping but he was new to long term care. She said HK #1 had some language barriers with interacting with residents but she was the most senior of the other housekeepers and helped direct the other housekeepers. The NHA said the facility has had difficulty recruiting housekeeping staff and for a while they only had one housekeeper. The NHA said staff has been educated to clean up spills and messes that occur when the housekeepers were not on duty. She said the facility had added a third housekeeper to focus on facility disinfection. She said they were currently conducting audits in rooms related to housekeeping. She said they randomly choose three rooms a week to watch housekeepers clean rooms. The NHA said over the last few months they have made a lot of improvements but it was still a work in progress. The NHA said the facility has had plumbing issues and the mop room was currently not being used because the water would not drain. She said the facility was getting estimates on fixing the drainage issue. She said some of the facility odors were pipe related and some odors were related to residents resistant to having their briefs changed which was care planned and staff were continuing to work with those residents. She said the facility had replaced flooring and completed wall work on rooms that were identified to have concerning issues with odor and in need of repair. The AIT said if a resident informed the facility of a concern such as the environment or housekeeping, a grievance/action plan would be created and given to the department head to follow up with. The NHA would then determine if the plan of action was working. She said if the concern was identified in the resident council, the action plan would be shared with the resident council members and they would decide if the concern was resolved. The NHA said there was a housekeeping concern identified by a resident in January 2023 related to concerns with the roommate and the room needed repair. The resident was discharged before the following resident council but before he was happy the staff was going to receive additional education of facility cleanliness and he was happy he was provided a different room. She said the resident council determined the concern was resolved. The social service director was interviewed on 4/26/23 at 5:40 p.m. The SSD reviewed recent grievances/action plans related to the facility environment. The SSD said an action plan was submitted on 4/26/23 related to facility odors and in process for resolution. The NHA was interviewed again on 4/26/23 at 7:03 p.m. with the corporate consultant (CC). The NHA said next week the facility was going to start painting empty resident rooms on the 100 and 200 hall and would try to complete two rooms at a time. She said the facility would focus on the floor boards in the resident rooms. The NHA said she recently had a resident cry because he was so happy after his floor was waxed and his walls were painted. The CC said in December 2022, they had much more concerns with cleanliness and repair of the environment. The NHA said in the eight months that she had been at the facility, there had been a remarkable improvement in the environment and the work they have done. The NHA said the facility would retrain the housekeeping staff. She said the housekeeper needed to focus on the details when cleaning a room. The NHA said the housekeeper tried hard but moving forward, the facility would focus more on oversight of the room cleaning/cleanliness. She said the facility would continue to audit rooms but the audits would include more random and spot checks after the housekeepers clean the room to determine if they did a thorough cleaning. The NHA said the facility would identify which rooms the floors needed waxing and which ones needed to be completely replaced. The NHA said staff was determined to make the facility more homelike for the residents. She said all the residents at the facility deserve a clean and comfortable home.

A complaint survey, prompted by #CO31139 and #CO31121 was conducted on 3/7/23 to 3/9/23. No deficiencies were cited.

A revisit to the 1/13/2023 survey was completed on 3/2/2023. The facility was in compliance with the regulations surveyed.

A focused infection control survey with complaints #CO30478, #CO30479, #CO30480, #CO30481, and #CO30482 were conducted on 1/9/23 to 1/13/23. Two deficiecies were cited.

An Emergency Preparedness focused infection control survey was conducted 1/9/23 to 1/13/22. No deficiencies were cited.

Based on record review and interviews, the facility failed to provide necessary assistance with activities of daily living (ADLs) for three (#5, #3, and #7) out of nine sample residents to maintain personal hygiene. Specifically, the facility failed to provide residents showers and bathing services according to the schedule and resident preferences for Resident #5, #3 and #7. Findings include:I. Facility policy and procedureThe Bath, Shower/Tub policy, dated February 2018, was provided by the nursing home administrator (NHA) on 1/13/23 at 1:00 p.m. It read in pertinent part:-"The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident ' s skin."-The remainder of the policy was a step by step instruction on how to provide a shower, bath or bed bath, not related to timing, schedules, or preferences. II. Resident #5A. Resident statusResident #5, age under 65, was admitted on 4/29/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included critical illness myopathy (significant slowing of muscle conductivity), unspecified dementia, acute kidney failure, diabetes mellitus, severe protein calorie malnutrition, and ischemic cardiomyopathy (heart can no longer pump enough blood to the body). The 12/16/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one or two staff members with her activities of daily living and mobility. She required extensive assistance of two staff with bathing. B. Resident interviewResident #5 was interviewed on 1/12/23 at 1:05 p.m. She stated up until the previous Saturday (1/7/23), she had not had a true shower provided by facility staff for 90 days. She stated her husband assisted her with a bed bath most days, though she really wanted consistent full showers provided by facility staff. She stated the staff rarely offered her showers and when she asked for them, they told her they could not give her one or told her they would "try" and never did. C. Record reviewResident #5 ' s bathing records were reviewed from October 2022 to the present and revealed the resident was scheduled for three showers per week on Tuesdays, Thursdays, and Saturdays on the day shift. In October 2022, Resident #5 was documented to have received showers on 10/11/22 and 10/15/22 and documented to have refused bathing on 10/18/22 and 10/22/22. Scheduled showers were not given on 10/1/22, 10/4/22, 10/6/22, 10/8/22, 10/13/22, 10/20/22, 10/25/22, 10/27/22, and 10/29/22. The resident missed nine scheduled showers in October 2022. In November 2022, Resident #5 was documented to have received showers on 11/1/22 and refused on 11/8/22 and 11/15/22. Scheduled showers were not given on 11/3/22, 11/5/22, 11/10/22, 11/12/22, 11/17/22, 11/19/22, 11/22/22, 11/24/22, 11/26/22, and 11/29/22. The resident missed 10 scheduled showers in November 2022. In December 2022, Resident #5 was documented to have received showers on 12/1/22 and refused on 12/20/22. Scheduled showers were not given on 12/3/22, 12/6/22, 12/8/22, 12/13/22, 12/15/22, 12/17/22, 12/22/22, 12/24/22, 12/27/22, 12/29/22, and 12/31/22. The resident missed 11 scheduled showers in December 2022. At the time of the onsite investigation (between 1/9/23 and 1/13/23), the resident had no documented showers for the month of January 2023 and had missed showers on 1/3/23, 1/5/23, 1/7/23, 1/10/23, and 1/12/23. The resident had missed all five scheduled showers for the month of January 2023. III. Resident #3A. Resident statusResident #3, age under 65, was admitted on 8/20/21. According to the January 2023 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis following cerebral infarction (muscle weakness or partial paralysis), unsteadiness on feet, history of transient ischemic attack (mini stroke), mesothelioma of peritoneum (buildup offluid in the abdominal cavity and thickening of abdominal lining), acute embolism and thrombosis (blockage of an artery) of left lower leg, asthma, and central pain syndrome. The 11/16/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one staff member with mobility and ADLs including bathing. B. Resident interviewResident #3 was interviewed on 1/10/23 at 11:15 a.m. She had just gotten out of the shower and she stated the staff missed her showers "all the time" and she wanted them to keep to the schedule. She stated when she missed showers she always complained to the staff. She stated the staff would tell her they did not have enough staff or enough time, but she thought that was a lie. C. Record reviewResident #3 ' s bathing records were reviewed from October 2022 to present. The resident was scheduled to receive showers twice a week on Tuesday and Saturday day shifts. In October 2022, the resident did receive a shower on 10/11/22, 10/15/22, 10/18/22, 10/22/22, 10/25/22, and 10/29/22, though did not receive scheduled showers on 10/1/22, 10/4/22, or 10/8/22. She missed three scheduled showers in October 2022. In November 2022, she received showers on 11/1/22, 11/9/22, 11/19/22, and 11/25/22. She was documented to refuse showers on 11/8/22 and 11/22/22. She missed showers on 11/5/22, 11/12/22, 11/26/22, and 11/29/22. She missed six scheduled showers in November 2022. In December 2022, she received showers on 12/8/22, 12/13/22, 12/20/22, 12/24/22, and 12/31/22. She missed showers on 12/3/22, 12/6/22, 12/10/22, 12/17/22, and 12/27/22. She missed five scheduled showers in December 2022. In January 2023, the resident received showers on 1/7/23 and 1/10/23. She missed the scheduled shower on 1/3/23. She has missed one scheduled shower so far in January 2023. IV. Resident #7A. Resident statusResident #7, age 73, was admitted on 7/13/13. According to the January 2023 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis following cerebral infarction, benign prostatic hyperplasia (prostate gland enlargement), cerebral infarction, venous insufficiency, osteoarthritis, and contracture of right hand. The 11/25/22 MDS assessment revealed the resident was cognitively impaired with a staff interview for mental status that revealed the resident was rarely or never understood, had long and short term memory problems, and impaired decision making skills. He required extensive assistance of two staff members with mobility and transfers and was totally dependent on one to two staff members with activities of daily living. The assessment indicated no bathing activities had occurred.-Resident #7 and family members were unable to be interviewed during the survey. B. Record reviewResident #7 ' s bathing records were reviewed from October 2022 to present. The resident was scheduled to receive two showers per week on Sunday and Wednesday evening shifts. In October 2022, the resident was documented to have received showers on 10/9/22, 10/12/22 and was documented to refuse showers on 10/5/22, 10/19/22, and 10/23/22. The resident ' s scheduled showers were not given on 10/2/22, 10/16/22, 10/26/22, and 10/30/22. The resident missed four scheduled showers in October 2022. In November 2022, the resident was documented to have refused showers on 11/13/22, 11/16/22, and 11/20/22. The resident ' s scheduled showers were missed on 11/2/22, 11/6/22, 11/9/22, 11/23/22, 11/27/22, and 11/30/22. The resident missed six scheduled showers in November 2022. As needed bathing records revealed the resident received a shower on 11/3/22 during the day shift which was not according to the schedule. In December 2022, the resident was documented to have received showers on 12/8/22 and 12/14/22 and to have refused a shower on 12/4/22. The resident missed scheduled showers on 12/7/22, 12/18/22, 12/21/22, 12/25/22, and 12/28/22. The resident missed five scheduled showers in December 2022. In January 2023, the resident was documented to have received showers on 1/8/23 and 1/11/23 and refused on 1/4/23. The resident missed a scheduled shower on 1/1/23.-Review of the resident ' s progress and nursing notes revealed no notes related to refusals of showers or re-approach attempts to convince the resident to shower. There was also no description of how the resident refused showers due to the fact the resident was rarely or never understood. V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 1/12/23 at 11:07 a.m. She stated resident showers were very difficult to complete according to schedule on day shift. She stated there were many showers scheduled on day shift each day and the night shift staff were also often unable to complete their showers according to schedule, so day shift would frequently have to make up showers that were missed on night shift. She stated residents became frustrated with missing showers. Licensed practical nurse (LPN) #1 was interviewed on 1/12/23 at 1:20 p.m. She stated all residents should get at least two showers per week as scheduled, unless the resident preferred only one. She stated residents did not always get their showers as scheduled due to so many showers scheduled during the day. CNA #2 was interviewed on 1/13/23 at 9:12 a.m. She stated the problem with completing resident showers according to the schedule was there were so many day shift showers on the schedule and not enough usable shower rooms. She stated it was very difficult to get 15 to 22 scheduled showers done on day shift with no shower aide and only two shower rooms and all other CNA duties to complete. LPN #3 was interviewed on 1/13/23 at 9:30 a.m. She stated the night shift had trouble completing scheduled showers which frequently needed to be made up on day shift. She stated the facility used to have a bath aide to complete the scheduled showers so floor staff could stay with the residents who did not need showers. She stated it was a struggle to complete all of the scheduled showers during the day. The NHA and the director of nursing (DON) were interviewed on 1/13/23 at 12:45 p.m. They stated bathing has been an area they had been working on in the facility for some time. They stated they had a performance improvement plan in the works since 12/20/22 which focused on preferences, sticking to the schedule and documentation. They stated they had been discussing and considering adding a bath aide back to the schedule. They stated there were definitely issues with showers being completed in the facility, though there was also an issue with documenting showers given.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and infection for one out of three halls. Specifically, the facility failed to:-Ensure housekeeping staff cleaned high-touch surfaces in resident rooms; and,-Ensure housekeeping staff followed the appropriate procedure when cleaning resident rooms and bathrooms. Findings include:I. Professional standardsThe Centers for Disease Control and Prevention (2020) Preparing for COVID-19 in Nursing Homes, updated 11/15/21, retrieved on 1/17/23 from: https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html/, revealed in part: "For environmental cleaning and disinfection: develop a schedule for regular cleaning and disinfection of shared equipment, frequently touch surfaces in resident rooms and common areas." "Clean high-touch surfaces at least once a day or as often as determined is necessary. Examples of high-touch surfaces include: pens, counters, shopping carts, tables, doorknobs, light switches, handles, stair rails, elevator buttons, desks, keyboards, phones, toilets, faucets, and sinks."II. Facility PolicyThe COVID-19 Cleaning and Disinfecting policy, dated September 2022, was provided by the nursing home administrator (NHA) on 1/9/23 at 12:16 p.m. It read in pertinent part, "High touch surfaces (light switches, door knobs, handles, desks, phones, toilets, faucets, sinks, bedside tables, call lights) and equipment are cleaned at least daily." III. ObservationsOn 1/10/23 at 1:02 p.m., housekeeper (HK) #1 was observed preparing to enter room 302. He used alcohol based hand rub (ABHR) and donned gloves. He entered the room and emptied the trash and placed a new trash bag. He placed the trash on the housekeeping cart and removed a rag from the disinfectant. He used the rag to wipe the sink and inside of the sink. He placed the soiled rag in the bag on the cart and removed a clean rag from the disinfectant and the toilet brush. He knocked on the bathroom which was occupied. He placed the rag and the toilet brush back on the cart and removed a soaked mop pad from the floor solution, placed it on the floor, and placed the mop handle on top of the mop pad. He mopped the room to the door. He removed the mop pad and placed the handle back onto the cart. He removed his gloves, used ABHR, and placed a wet floor sign in the doorway. -HK#1 failed to clean and disinfect high touch areas such as door knobs, light switches, closet handles, night stand, overbed table, call light, television remote, and bed controller. He failed to recheck the bathroom to see if it was still occupied. He failed to clean the faucet or the shelf above the sink which was in the bedroom. At 1:07 p.m., HK #1 was observed preparing to enter room 303. He used ABHR and donned gloves. He entered the room and emptied the trash and placed a new trash bag. He placed the trash on the housekeeping cart and removed a rag from the disinfectant. He used the rag to wipe the sink and inside of the sink. He removed a broom from the cart and swept in front of bed A. He swept the debris to the door and used a dustpan to pick up the debris. He placed the broom and dustpan back onto the cart. Bed B had his privacy curtain pulled around his bed. He knocked on the bathroom door which was occupied (that was shared). He removed a mop pad and the mop handle from the cart. He mopped in front of Bed A's bed, in front of the sink, and to the door. He removed the mop pad and placed the mop handle back on the cart. He removed a soaked mop pad from the floor solution, placed it on the floor, and placed the mop handle on top of the mop pad. He mopped the room to the door. He removed the mop pad and placed the handle back onto the cart. He removed his gloves, used ABHR, and placed a wet floor sign in the doorway.-HK #1 failed to clean and disinfect high touch areas such as door knobs, light switches, closet handles, night stand, overbed table, call light, television remote, and bed controller. He failed to recheck the bathroom to see if it was still occupied. He failed to clean the sink, the faucet, and the shelf above the sink in the bedroom. He failed to clean the floor in front of bed B.At 1:12 p.m., HK #1 was observed preparing to enter room 309. He used ABHR and donned gloves. He entered the room and emptied the trash and placed a new trash bag. He placed the trash on the housekeeping cart and removed the broom and dustpan from the cart. He swept the room and used the dustpan to pick up the debris at the door. He removed a soaked mop pad from the floor solution, placed it on the floor, and placed the mop handle on top of the mop pad. He mopped the room to the door. He removed the mop pad and placed the handle back onto the cart. He removed a soaked mop pad from the floor solution, placed it on the floor, and placed the mop handle on top of the mop pad. He mopped the room to the door. He removed the mop pad and placed the handle back onto the cart. He removed his gloves, used ABHR, and placed a wet floor sign in the doorway.-HK #1 failed to clean and disinfect high touch areas such as door knobs, light switches, closet handles, night stand, overbed table, call light, television remote, and bed controller. He failed to clean the bathroom. He failed to clean the sink, the faucet, and the shelf above the sink in the room in the bedroom. At 1:16 p.m., HK #1 was observed preparing to enter room 304. He used ABHR and donned gloves. He entered the room and emptied the trash and placed a new trash bag in the trash can. He placed the trash on the housekeeping cart and removed a rag from the disinfectant and the toilet brush. He knocked on the bathroom door. He entered the bathroom and lifted the toilet seat. He used the toilet brush to clean the toilet bowl. He used the rag to clean under the seat, the seat, and then the rim. He placed the soiled rag and the toilet brush onto the cart. He removed his gloves and used ABHR. He removed the mop pad from the solution from the solution and placed it on the floor. He placed the mop handle onto the pad and mopped the room to the door. He removed the mop pad from the handle and placed both items onto the cart. He removed a clean rag from the disinfectant and cleaned the sink and inside of the sink. He placed a wet floor sign in the doorway, removed his gloves and used ABHR. -HK #1 failed to clean and disinfect high touch areas such as door knobs, light switches, closet handles, night stand, overbed table, call light, television remote, and bed controller. He failed to clean the faucet, and the shelf above the sink which was in the room. He failed to sweep and mop the bathroom. He failed to clean the toilet from top to bottom and clean to dirty. IV. Staff interviewsHK#1 was interviewed on 1/10/23 at 1:34 p.m. through an interpreter. He said he worked for a contract company that was used by the facility. He said he was trained to empty the trash, sweep and mop the residents room, clean the sink, and clean the toilet. He said when cleaning a resident room, he would knock on the bathroom door. He said if the bathroom was occupied he would continue on and clean the next room. He said he was supposed to go back to the previous room and check to see if the bathroom was empty. He acknowledged he did not return to the previous room to clean the bathroom. He said he did not receive any training from the facility. The housekeeping manager (HKM) was interviewed on 1/10/23 at 1:38 p.m. He said the housekeepers were trained to empty the trash, sweep and mop the residents room, clean the sink, and clean the toilet. He said if the bathroom was occupied, the HK was expected to move onto the next room and return to the previous room to clean the bathroom. He said he would have to speak to the administration about cleaning high touch areas and other items in the room. The housekeeping supervisor (HKS) was interviewed on 1/10/23 at 2:00 p.m. He said the housekeepers were trained by the company they worked for. He said the housekeepers should clean the bathroom, windows, blinds, sweep, mop, clean the sink and toilet. He said they should be cleaning high touch areas as well. He said if the bathroom was occupied, the HK should return to the residents room to clean the bathroom. He said he had discussed the proper technique for cleaning the residents rooms with the HKM. He said the HKM then translated the information to the housekeepers. He said he thought it had been taken care of, but apparently not, if the rooms were still not being cleaned properly. He said he did not do any training with the housekeepers since they were a third party contractor. He said he would immediately speak with the HKM and let him know his expectations and give him a checklist of items that need to be cleaned daily. The infection preventionist (IP) was interviewed on 1/10/23 at 2:37 p.m. She said the facility was using a contract company to clean the facility. She said the housekeepers were brand new and still training to clean a nursing facility. She said all resident rooms should be cleaned daily. She said the housekeepers should be cleaning high touch surfaces, sink, faucet, bedside tables, overbed tables, bathroom and anything touched frequently. She said the facility did not do training with the contract company, but worked with them on what they need to educate their staff on. She said the housekeepers should return to bathrooms that were occupied and clean them. She said the bathroom should be swept and mopped as well as the room. She said the toilet should be cleaned from top to bottom and clean to dirty. She said she did not know if the housekeepers were trained on proper cleaning techniques or what needed to be cleaned. She said it was very important to clean the rooms properly to avoid cross contamination. The nursing home administrator (NHA) was interviewed on 1/11/23 at 10:28 a.m. She said the housekeeping crew started working in the facility at the end of October 2022. She said the contract company was new at cleaning nursing facilities. She said the HKM was out for surgery and she was waiting for him to return to train the housekeepers. She said it was the housekeeping company's first experience cleaning nursing facilities and they were still learning. She said the facility would start training with the housekeepers the following week when the HKM returned. She said they would make sure the training was available in Spanish as well as English.