SHARMAR VILLAGE SENIOR CARE COMMUNITY

A revisit survey was completed on 6/5/24 for all previous deficiencies cited on 4/1/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 6/5/24 for all previous deficiencies cited on 4/1/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO35270 was conducted on 4/1/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents/hazards. Resident #1 had a diagnosis of advanced Huntington's disease (inherited disease that causes degeneration of the nerve cells in the brain) and was identified as a fall risk. Interventions for Resident #1 included a low bed and a fall mat. Resident #1 needed the assistance of two staff for transfers. On the morning of 11/8/23, certified nurse aide (CNA) #1 was assisting Resident #1 to get ready for the day. CNA #1 had lifted the bed from a low position to a higher position and had removed the fall mat to prepare to transfer Resident #1. CNA #1 stepped away from Resident #1 with the bed in a high position and left the room to find assistance for the transfer. While CNA #1 was away from Resident #1, she fell out of bed and was found on the floor lying on her right arm with the right side of her face against the floor. Blood was visible around Resident #1's head. Resident #1 was sent out to the hospital and received sutures to her right temple and was noted to have a sacral fracture. Resident #1 passed away on 11/17/23. According to the death certificate the cause of death was decomposition following a mechanical fall. Findings include:I. Resident statusResident #1, age 67, was admitted on 1/15/21, readmitted on 11/1/21 and passed away on 11/17/23. According to the November 2023 computerized physician's order (CPO), diagnoses included Huntington's disease and abnormal involuntary movements. The 11/8/23 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) of zero out of 15. The assessment identified a diagnosis of a progressive neurological condition. Resident #1 was identified as receiving hospice care. II. Fall on 11/8/23The facility investigation dated 11/8/23 at 7:53 a.m. described the incident as, "The CNA was providing care to the resident. The CNA stepped out of the room to ask for assistance to transfer the resident. the resident rolled out of the bed sustaining injury. "The resident plan of care included an air mattress with winged overlay for sensory perception." The conclusion to the investigation documented, "The staff member did not have a history of this type of incident. Staff member was providing care services to the resident and left the room to get a second staff member to assist with the transfer- the resident had a recent medication change causing her to be more alert. "This is an educational opportunity to press the call light when extra assistance is needed and not to step out of the room."The fall investigation and progress note, dated 11/8/23 at 8:00 a.m., noted CNA #1 notified the nurse that the resident had fallen out of bed. The nurse immediately entered the room finding the resident lying on her right arm with the right side of her face against the floor. Upon examination, the nurse and the charge registered nurse (RN) found Resident #1 had a large hematoma to the right temple area which was bleeding. Her entire head was examined but no other injury was noted due to the blood and her hair. Her vital signs and neurological assessment were completed immediately. The area was cleaned immediately and pressure was applied to her right temple until the ambulance arrived. Her family and medical doctor (MD) were notified by the assistant director of nursing (ADON). III. Record reviewThe care plan, initiated 1/27/21 and revised 11/20/23, identified the resident required assistance with self-care deficits including dressing and impaired physical mobility secondary to Huntington's disease. Interventions included transfers with a Hoyer lift with two or more staff as she allowed. The anticoagulant care plan, initiated 1/27/21 and revised 10/10/22, identified a risk for bleeding related to the use of an antiplatelet. Interventions included to notify physician of any problems or concerns. The fall care plan, initiated on 11/9/23, identified the resident had an active history of falls related to weakness. Interventions included:-Assist with transfers/ambulation as needed.-Call light within reach when possible. Another fall care plan, initiated 1/27/21 and revised on 11/20/23, identified a history of falls. Interventions included:-Assist with transfers/ambulation as needed.-Keep call light in reach.-Notify physician of any changes in condition.-Resident to have a soft helmet on at all times while in bed and hard helmet on while out of bed.-Helmet for safety related to unsteady gait/balance related to Huntington's disease.-Winged mattress for sensory perception. Fall intervention related to overestimating when transferring in and out of bed.-Encourage floor mat next to bedside when the resident is laying in bed. The care plan, initiated 9/6/23 and revised 11/20/23, identified limited physical mobility related to Hintington's disease. Interventions included the resident was totally dependent on staff for locomotion. The care plan, initiated 1/27/21 and revised 11/20/23, identified a communication related to impaired cognition. Interventions included to ensure/provide a safe environment, call light in reach, adequate low glare light, bed in lowest position and wheels locked and to avoid isolation. She was admitted to hospice care on 1/27/23 for Huntington's Disease. The provider follow-up note dated 10/27/23 included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The progress note dated, 11/8/23 at 8:05 a.m., identified the facility called and notified the hospice provider of the fall with a hematoma on the right side of the head with difficulty controlling the bleeding. An order to send the resident to the emergency room (ER) for evaluation. The progress note dated, 11/8/23 at 8:22 a.m., included a message was left with the resident's daughter. The facility explained the resident had a fall with a head laceration to the right temple with bleeding. The progress note dated, 11/8/23 at 2:16 p.m., included the report from the hospital that the resident received six sutures to the head laceration and would need to keep pressure bandage on for at least the next 24 hours. The resident was found to have a sacral fracture. The hospice provider was notified about the update. The provider progress note dated, 11/9/23 at 1:53 a.m., included "Patient found resting comfortably in bed. She has head wrapped with pressure bandage due to a recent fall with head laceration. Was treated in emergency room and returned to the facility. Continues under hospice care."The provider follow-up note dated 11/10/23 included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The provider progress note, dated 11/10/23 at 4:15 a.m., included in part, "appears comfortable. Patient with sutured area on forehead."The interdisciplinary team (IDT) fall risk note, dated 11/10/23 at 8:31 a.m., included "Related to resident rolling out of bed on 11/8/23. Soft helmet while in bed and hard helmet when out of bed for safety related to weakness of body movements from disease process of Huntington's disease."The hospice note dated, 11/13/23 at 1:10 a.m., included the patient was in her bed in the low position. The note included discussion of status with risk of a brain bleed was possible. Interventions provided included fall precautions to include a low bed and call light in place. The hospice note, dated 11/14/23 (time unknown), included the nurse left the patient's room with the patient lying supine and helmet on, call light in reach, and fall mat in place on the floor next to the bed. The facility investigation, dated 11/20/23 at 11:30 p.m., described the incident, "resident passed away peacefully with family at bedside under hospice care."The conclusion to the investigation documented, "the resident passed away peacefully. Resident was without brain injury from fall 8 (eight) days prior. Facility concluded resident expired due to Huntington's disease process."The death certificate for Resident #1 identified the date of death as 11/17/23. The cause of death was identified as decompensation following a mechanical fall, hypovolemia (low blood volume), and cephalohematoma (blood under the scalp from an injury). The death certificate was signed on 11/18/23. IV. InterviewsCNA #1 was interviewed on 4/1/24 at 1:05 p.m. CNA #1 said staff would check with their supervisor when they arrived to see which residents were fall risks and on fall precautions/interventions. He said if the resident had a fall mat they automatically knew there were fall interventions for the resident. He said every resident on fall precautions had a fall mat and repositioning pillows. He said if someone had a fall they were to notify the nurse immediately after making sure the resident was safe. He said if a resident required the assistance of two people, staff were to use the call light and wait for assistance and never to leave the resident unattended. He said if a resident had a fall after the nursing assessment they were to be monitored every 15 minutes. CNA #2 was interviewed on 4/1/24 at 1:10 p.m. CNA #2 said she would know who was a fall risk from the medical record on kiosks and the fall mats next to the bed. She said there were checklists that identified specific needs of the resident. She said the information in the kiosk had the resident specific fall interventions. She said if a resident were to fall she was to make sure the resident was safe and call for a nurse to assess. She said if she needed assistance from another staff member she was not to leave the resident alone but she was supposed to use the call light and wait for assistance. RN #1 was interviewed 4/1/24 on 1:15 p.m. RN #1 said the fall interventions for each resident were in the physician's orders. She said if a resident fell, the CNAs were to call her or any nurse and the nurse who completed the initial assessment would complete an assessment, fill out a fall risk assessment and notify the director of nursing (DON). She said if the injury was severe, she would send out the resident. The DON was interviewed on 4/1/24 at 1:35 p.m. The DON said the Resident #1 had fallen from the bed that was not in the low position and the fall mat was not in place when CNA #1 had stepped out to get assistance with the transfer. She said the resident had fallen and hit her head on the floor and sustained a laceration to the right temple. She said the facility sent her out to the ER and made notifications to the hospice provider, the family and the physician. She said the hospital reported to the facility the laceration needed six sutures and to keep the pressure dressing on for 24 hours. The DON said CNA #1 acknowledged she failed to follow facility protocol and left a resident identified as a fall risk unattended which resulted in the resident falling out of bed. She said the resident passed away eight days after her fall. She said after the fall, the facility provided education on assistance with transfers. She said the CNAs had access to the fall interventions on the Kardex (a tool utilized by staff for providing consistent care for residents) that could be accessed by the kiosk. The nursing home administrator (NHA) was interviewed on 4/1/24 at 2:45 p.m. The NHA said CNA #1 was terminated after the incident. The hospice executive director (HED) was interviewed on 4/1/24 at 4:45 p.m. The HED said hospice assessed the resident after notification of the fall and when the resident returned to the facility. She said the facility called hospice about the fall and bleeding and the ER transfer on 11/8/23. She said the resident had trauma to the right temple which required six sutures. She said the coroner's death certificate identified the cause of death as decomposition following a mechanical fall.

A survey prompted by complaint #CO35590 was completed 4/1/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents/hazards. Resident #1 had a diagnosis of advanced Huntington's disease (inherited disease that causes degeneration of the nerve cells in the brain) and was identified as a fall risk. Interventions for Resident #1 included a low bed and a fall mat. Resident #1 needed the assistance of two staff for transfers. On the morning of 11/8/23, certified nurse aide (CNA) #1 was assisting Resident #1 to get ready for the day. CNA #1 had lifted the bed from a low position to a higher position and had removed the fall mat to prepare to transfer Resident #1. CNA #1 stepped away from Resident #1 with the bed in a high position and left the room to find assistance for the transfer. While CNA #1 was away from Resident #1, she fell out of bed and was found on the floor lying on her right arm with the right side of her face against the floor. Blood was visible around Resident #1's head. Resident #1 was sent out to the hospital and received sutures to her right temple and was noted to have a sacral fracture. Resident #1 passed away on 11/17/23. According to the death certificate the cause of death was decomposition following a mechanical fall. Findings include:I. Resident statusResident #1, age 67, was admitted on 1/15/21, readmitted on 11/1/21 and passed away on 11/17/23. According to the November 2023 computerized physician's order (CPO), diagnoses included Huntington's disease and abnormal involuntary movements. The 11/8/23 facility assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) of zero out of 15. The assessment identified a diagnosis of a progressive neurological condition. Resident #1 was identified as receiving hospice care. II. Fall on 11/8/23The facility investigation dated 11/8/23 at 7:53 a.m. described the incident as, "The CNA was providing care to the resident. The CNA stepped out of the room to ask for assistance to transfer the resident. the resident rolled out of the bed sustaining injury. "The resident plan of care included an air mattress with winged overlay for sensory perception." The conclusion to the investigation documented, "The staff member did not have a history of this type of incident. Staff member was providing care services to the resident and left the room to get a second staff member to assist with the transfer- the resident had a recent medication change causing her to be more alert. "This is an educational opportunity to press the call light when extra assistance is needed and not to step out of the room."The fall investigation and progress note, dated 11/8/23 at 8:00 a.m., noted CNA #1 notified the nurse that the resident had fallen out of bed. The nurse immediately entered the room finding the resident lying on her right arm with the right side of her face against the floor. Upon examination, the nurse and the charge registered nurse (RN) found Resident #1 had a large hematoma to the right temple area which was bleeding. Her entire head was examined but no other injury was noted due to the blood and her hair. Her vital signs and neurological assessment were completed immediately. The area was cleaned immediately and pressure was applied to her right temple until the ambulance arrived. Her family and medical doctor (MD) were notified by the assistant director of nursing (ADON). III. Record reviewThe care plan, initiated 1/27/21 and revised 11/20/23, identified the resident required assistance with self-care deficits including dressing and impaired physical mobility secondary to Huntington's disease. Interventions included transfers with a Hoyer lift with two or more staff as she allowed. The anticoagulant care plan, initiated 1/27/21 and revised 10/10/22, identified a riskfor bleeding related to the use of an antiplatelet. Interventions included to notify physician of any problems or concerns. The fall care plan, initiated on 11/9/23, identified the resident had an active history of falls related to weakness. Interventions included:-Assist with transfers/ambulation as needed.-Call light within reach when possible. Another fall care plan, initiated 1/27/21 and revised on 11/20/23, identified a history of falls. Interventions included:-Assist with transfers/ambulation as needed.-Keep call light in reach.-Notify physician of any changes in condition.-Resident to have a soft helmet on at all times while in bed and hard helmet on while out of bed.-Helmet for safety related to unsteady gait/balance related to Huntington's disease.-Winged mattress for sensory perception. Fall intervention related to overestimating when transferring in and out of bed.-Encourage floor mat next to bedside when the resident is laying in bed. The care plan, initiated 9/6/23 and revised 11/20/23, identified limited physical mobility related to Huntington's disease. Interventions included the resident was totally dependent on staff for locomotion. The care plan, initiated 1/27/21 and revised 11/20/23, identified a communication related to impaired cognition. Interventions included to ensure/provide a safe environment, call light in reach, adequate low glare light, bed in lowest position and wheels locked and to avoid isolation. She was admitted to hospice care on 1/27/23 for Huntington's Disease. The provider follow-up note dated 10/27/23 included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The progress note dated, 11/8/23 at 8:05 a.m., identified the facility called and notified the hospice provider of the fall with a hematoma on the right side of the head with difficulty controlling the bleeding. An order to send the resident to the emergency room (ER) for evaluation. The progress note dated, 11/8/23 at 8:22 a.m., included a message was left with the resident's daughter. The facility explained the resident had a fall with a head laceration to the right temple with bleeding. The progress note dated, 11/8/23 at 2:16 p.m., included the report from the hospital that the resident received six sutures to the head laceration and would need to keep pressure bandage on for at least the next 24 hours. The resident was found to have a sacral fracture. The hospice provider was notified about the update. The provider progress note dated, 11/9/23 at 1:53 a.m., included "Patient found resting comfortably in bed. She has head wrapped with pressure bandage due to a recent fall with head laceration. Was treated in emergency room and returned to the facility. Continues under hospice care."The provider follow-up note dated 11/10/23 included history of falls: continue with helmet when out of bed and fall mat at bedside for safety. The provider progress note, dated 11/10/23 at 4:15 a.m., included in part, "appears comfortable. Patient with sutured area on forehead."The interdisciplinary team (IDT) fall risk note, dated 11/10/23 at 8:31 a.m., included "Related to resident rolling out of bed on 11/8/23. Soft helmet while in bed and hard helmet when out of bed for safety related to weakness of body movements from disease process of Huntington's disease."The hospice note dated, 11/13/23 at 1:10 a.m., included the patient was in her bed in the low position. The note included discussion of status with risk of a brain bleed was possible. Interventions provided included fall precautions to include a low bed and call light in place. The hospice note, dated 11/14/23 (time unknown), included the nurse left the patient's room with the patient lying supine and helmet on, call light in reach, and fall mat in place on the floor next to the bed. The facility investigation, dated 11/20/23 at 11:30 p.m., described the incident, "resident passed away peacefully with family at bedside under hospice care."The conclusion to the investigation documented, "the resident passed away peacefully. Resident was without brain injury from fall 8 (eight) days prior. Facility concluded resident expired due to Huntington's disease process."The death certificate for Resident #1 identified the date of death as 11/17/23. The cause of death was identified as decompensation following a mechanical fall, hypovolemia (low blood volume), and cephalohematoma (blood under the scalp from an injury). The death certificate was signed on 11/18/23. IV. InterviewsCNA #1 was interviewed on 4/1/24 at 1:05 p.m. CNA #1 said staff would check with their supervisor when they arrived to see which residents were fall risks and on fall precautions/interventions. He said if the resident had a fall mat they automatically knew there were fall interventions for the resident. He said every resident on fall precautions had a fall mat and repositioning pillows. He said if someone had a fall they were to notify the nurse immediately after making sure the resident was safe. He said if a resident required the assistance of two people, staff were to use the call light and wait for assistance and never to leave the resident unattended. He said if a resident had a fall after the nursing assessment they were to be monitored every 15 minutes. CNA #2 was interviewed on 4/1/24 at 1:10 p.m. CNA #2 said she would know who was a fall risk from the medical record on kiosks and the fall mats next to the bed. She said there were checklists that identified specific needs of the resident. She said the information in the kiosk had the resident specific fall interventions. She said if a resident were to fall she was to make sure the resident was safe and call for a nurse to assess. She said if she needed assistance from another staff member she was not to leave the resident alone but she was supposed to use the call light and wait for assistance. RN #1 was interviewed 4/1/24 on 1:15 p.m. RN #1 said the fall interventions for each resident were in the physician's orders. She said if a resident fell, the CNAs were to call her or any nurse and the nurse who completed the initial assessment would complete an assessment, fill out a fall risk assessment and notify the director of nursing (DON). She said if the injury was severe, she would send out the resident. The DON was interviewed on 4/1/24 at 1:35 p.m. The DON said the Resident #1 had fallen from the bed that was not in the low position and the fall mat was not in place when CNA #1 had stepped out to get assistance with the transfer. She said the resident had fallen and hit her head on the floor and sustained a laceration to the right temple. She said the facility sent her out to the ER and made notifications to the hospice provider, the family and the physician. She said the hospital reported to the facility the laceration needed six sutures and to keep the pressure dressing on for 24 hours. The DON said CNA #1 acknowledged she failed to follow facility protocol and left a resident identified as a fall risk unattended which resulted in the resident falling out of bed. She said the resident passed away eight days after her fall. She said after the fall, the facility provided education on assistance with transfers. She said the CNAs had access to the fall interventions on the Kardex (a tool utilized by staff for providing consistent care for residents) that could be accessed by the kiosk. The nursing home administrator (NHA) was interviewed on 4/1/24 at 2:45 p.m. The NHA said CNA #1 was terminated after the incident. The hospice executive director (HED) was interviewed on 4/1/24 at 4:45 p.m. The HED said hospice assessed the resident after notification of the fall and when the resident returned to the facility. She said the facility called hospice about the fall and bleeding and the ER transfer on 11/8/23. She said the resident had trauma to the right temple which required six sutures. She said the coroner's death certificate identified the cause of death as decomposition following a mechanical fall.

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

A revisit survey was completed on 10/11/23 for all previous deficiencies cited on 8/14/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 10/11/23 for all previous deficiencies cited on 8/14/23. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/18/2023 and 09/24/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (000), wood framed structure. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler systems. The facility 's fire sprinkler system is a wet pipe system that contains an anti-freeze loop with a propylene glycol solution and protects the front and back porch only. The facility was constructed in 1989. Also located on the property is an Assisted Living Facility that is separated from the Long Term Care Facility by a two-hour fire rated wall. The 64 bed facility was surveyed on August 30, 2023 using the National Fire Protection Association, (NFPA) Life Safety Code (2012) chapter 19, Existing Health Care Occupancies. An exit conference was conducted with the Executive Director and Physical Plant Manager at the end on-site survey.

Based on observation it was determined the facility failed to maintain Alcohol Based hAND RUB dispensers in accordance with NFPA 101. Alcohol Based Hand Rub Dispenser over plug by room 2819.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:(8) Dispensers shall not be installed in the following locations:(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source(b)To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source(c)Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition sourceThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101. Room door do not resist the passage of smoke room numbers (30,28,25,23,20,14,17,15,9,11)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:Penetration in fire barrier by nurses stationNFPA 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 and administrator at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

A licensure survey was completed on 7/19/23 to 8/14/23. Three deficiencies were cited.

Based on record review and interviews, the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to unavailable and missed medications during the survey on 7/24/23 to 8/14/23. Due to the missed medications, it caused distress and decline to Resident #7 and Resident #25. Findings include:I. Facility policyThe Quality Assessment Performance Improvement Plan, dated 4/3/23, was provided by the nursing home administrator (NHA) on 7/24/23 at 1:00 p.m. It revealed in pertinent part, "Our facility's QAPI plan serves as guide for our overall quality improvement program and initiatives. The decision making within the facility will be driven by quality assurance performance improvement principles. These decisions will assist in promoting quality of care and quality of life of residents. In addition, these principles will lead to an emphasis on resident choice, person directed care and resident transitions. Any system that affects the satisfaction of residents, families and associates will be considered an area of opportunity. This will include systems affecting the quality of care, quality of life and safety of residents."Our QAPI efforts and activities across departments in order to better work together in assuring that areas of concern are being addressed and services are continually improved."The facility provides care and services to residents across the continuum of care. Because these services have an impact on the clinical care of the resident, all departments will be involved in QAPI efforts to continuously improve the clinical care provided. QAPI efforts will also incorporate healthcare partners in order to provide safe, effective care transitions to the residents we serve. These efforts are established in order to continuously improve our services."The QAPI program at this facility is comprehensive, data-driven and involves the full range of care and services offered, including the full range of departments. QAPI principles are utilized in order to align business and clinical care decisions within the facility in order to provide residents with individualized care to meet their specific goals." II. Cross-reference citation Cross-reference F760: The facility failed to ensure Resident #7 had medication available to include vital medications and Resident #25 received all medications as ordered by the medical provider. The facility failed to ensure medications were available for Resident #7 on several occasions including during the recertification process. The facility failed to administer medications to Resident #25, citing the resident was sleeping but failed to notify the providers of the several missed doses. The facility's failure to ensure Residents #7 and #25 received their medications as ordered contributed to Resident #7 experiencing increasing distress (fear, anxiety, behavioral symptoms) and Resident #25 experiencing signs of distress (agitation, behavioral symptoms). The facility's failure to develop, implement, and monitor medication administration processes to prevent repeated, significant medication errors contributed actual decline in Resident #7 and #25's quality of life and created the potential for serious physical and psychosocial harm if the situation was not immediately corrected. III. InterviewsThe director of nursing (DON) and the NHA were interviewed on 8/14/23 at 11:40 a.m. The DON said the missed medications for Resident #7 due to unavailability was investigated and narrowed down to one nurse. She said education was provided by the facility to include the DON and the facility reaching out to the pharmacy consultant to help with education as well. When the facility discovered themedication was still not being administered due to unavailability for Resident #7, they terminated the nurse on 7/11/23. She said she was aware the issue was still occurring during the recertification survey. The DON said the facility knew of non-compliance with the medication pass and educated the nurses on the importance of the medication and the process of ordering medications to prevent running out of the medication. The DON said she did not consider the medications for Resident #25 missed doses. She said the resident had the right to sleep. She said when the nurse documented sleeping it was considered acceptable documentation. She said the doses not given when the resident was sleeping were not communicated with the provider. The DON said as of 8/14/23, the facility was current on notification to providers of missed medications. The DON said the plan going forward was she would implement ordering medications that qualified for auto-refill and until it happened she or a designee would check the medication carts weekly to ensure a minimum of a seven day supply to help prevent future missed doses due to unavailability. She said there would be a review of residents who sleep during medication administration times and contact providers to discuss the medication orders.

Based on record review, observations, and interviews, the facility failed to ensure two (#1 and #7) of five residents received services and assistance to prevent a reduction in range of motion out of 23 sample residents. According to diagnoses on admission, Resident #1 did not admit to the facility with a contracture to her left hand but based on observations and interviews on 7/24-7/26/23, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her left hand. Further, the facility failed to provide the resident occupational therapy (OT) as ordered after the identification of a possible ligament injury to the left wrist on 1/16/23. The facility's failure to provide services to maintain the resident's mobility contributed to a decline in the mobility of the resident's left wrist and hand. Resident #7 was ordered assistance with hand splinting from the facility staff post surgical revision of her left hand. Interview and record review revealed the facility failed to ensure the resident was receiving assistance as ordered 3/14/23, 3/16/23, 3/25/23, 4/4/23, and 5/4/23, to maintain mobility or decrease further loss of range of motion of the resident's left hand. Findings include:I. Resident #1A. Resident status Resident #1, age 88, was admitted to the facility on 7/16/21. According to the July 2023 computerized physician's orders (CPO), diagnoses included diabetes type II, dementia with agitation and disorders of bone density and bone structure. The 6/23/23 facility assessment showed the resident had significant cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive one-two person physical assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. The resident had no functional limitations in range of motion of her upper or lower extremities. She was enrolled in hospice and had not received any therapy or restorative services during the assessment look back period. -No diagnosis of arthritis or cellulitis (bacterial infection to the skin) was indicated. B. Resident observationsThe resident was observed on 7/24/23 at 10:48 a.m. inside the activity room. The fingers on resident's left hand were curled and while participating in a balloon catch activity, the resident was unable to open her left hand at all. Resident #1 was observed on 7/25/23 at 12:15 p.m. in the lunchroom. The resident was attempting to adjust the front of her shirt with her left hand but she was only able to pinch the material with her thumb. Her left hand remained curled into a fist. Resident #1 was observed on 7/26/23 at 12:16 p.m. in the lunchroom. She was able to feed herself using her right hand but was not able to use her left hand. Her left hand rested on her lap, fingers curled in a fist position. C. Record reviewThe comprehensive care plan initiated on 7/21/21 revealed the resident had a history of cellulitis in her left hand. Interventions were to assist the resident to the bathroom as needed, offer non medicinal means of pain relief, encourage the resident to comply with recommended interventions to help prevent skin breakdown, and notify the medical director or hospice of any skin breakdown. The resident had decreased range of motion with interventions to keep the call light within reach and keep frequently used items in reach. -The care plan did not indicate the reason, the location of, or the extent of the resident's decreased range of motion. The CPO reviewed from 7/17/22-7/26/23 revealed:-X-ray of left wrist due to red, swollen and warm-ordered on 7/17/22.-Keflex 500 milligram (MG])- give one tablet by mouth four times a day for cellulitis for five days-ordered on 7/18/22.-Voltaren gel 1%- apply to left wrist topically two times a day for joint pain and swelling for two weeks-ordered on 9/6/22.-Keflex 500 MG- give one tablet by mouth four times a day for cellulitis in the left hand for five days-ordered on 9/3/22.-Voltaren gel 1%- apply to left wrist topically two times a day for arthritic pain for two months-ordered on 9/27/22.-Aspercreme lotion 10%- apply to left wrist topically every eight hours as needed for pain- ordered on 10/28/22.-Occupational therapy (OT) to evaluate and treat for decreased range of motion and use of left upper extremities-ordered on 10/24/22 and discontinued 12/5/22.-OT to continue with therapy three times a week for thirty days related to wheelchair management, self-care training, therapeutic activities, therapeutic exercises and manual techniques due to lack of coordination and muscle weakness dated 10/26/22 and discontinued 2/6/23.-Restorative therapy for active assistive range of motion with rod; shoulder and elbow flex extension three times weekly or as tolerated- ordered 1/4/23 and discontinued 3/15/23.-X-ray of left hand and fingers for swelling and pain-ordered on 1/11/23.-Voltaren gel 1%- apply to left hand and knuckles topically two times a day for pain- ordered on 1/11/23.-OT to evaluate and treat diagnosis of left wrist scapholunate (small bones in the wrist) ligament injury- ordered on 1/16/23.-Voltaren gel 1%- apply to left hand and knuckles topically every six hours as needed for pain- ordered on 1/20/23.-No further orders were located pertaining to the resident's left wrist or hand. Physician visit notes dated from 9/27/22 to 1/17/23 revealed: -Physician visit note dated 9/27/22 revealed the reason for the appointment was for a swollen left wrist and left hand. The resident was able to hold objects in her left hand and still maintained range of motion. Voltaren gel was continued daily for joint arthropathy (disease of the joint). -Physician visit note dated 10/21/22 revealed the reason for the appointment was due to an abnormal reduction of circulating white blood cells. During the visit, the physician noted the nurses reported the resident was displaying signs of pain and discomfort with no recent falls or specific areas of concern identified. The resident was unable to describe the pain. The resident was still able to move all four extremities however, chronic arthritic changes were noted by the physician.-Physician visit note dated 1/11/23 revealed the reason for the appointment was left hand pain and swelling. The resident presented with acute pain, redness and swelling to her left hand and knuckles. She had a history of arthritis in her left wrist. An x-ray of the left hand was ordered to rule out any possible injuries and a topical gel was provided for relief of pain and swelling.-Physician visit note dated 1/12/23 revealed the reason for the appointment was left hand pain and swelling. The swelling had improved but the joints remained tender to the touch. At this time, the note documented the resident was l able to open her left hand and perform a range of motion activities but with discomfort.-Physician visit note dated 1/16/23 revealed the reason for the appointment was left hand pain and x-ray results. The x-rays revealed soft tissue swelling and arthritic changes of the hand with a suspected injury to the ligaments in the small bones of the resident's left wrist. The swelling had resolved but the resident was still displaying discomfort with her range of motion in the left wrist. A referral was recommended for OT to treat and evaluate the ligament injury. Review of therapy notes revealed:An OT therapist plan of care notes dated 11/23/22 revealed the resident was being seen for cellulitis of the left upper limb. The resident's level of functioning was bilateral upper extremity functional activity tolerance with moderate cues for left upper extremity use, no reported pain. The goal was for the resident to be able to feed herself with finger foods and use a cup to drink with stand by assistance from a therapist. The underlying impairments documented were decreased strength and range of motion in the left upper extremity requiring moderate assistance from staff. The OT therapist discharge notes dated 12/22/2 revealed the resident was able to feed herself with finger foods and use a cup to drink with verbal cues provided by staff. The goal of increasing strength and range of motion in the left upper extremity was not met due to resident pain. Record review failed to reveal a comprehensive assessment of the resident's range of motion by physical or occupational therapy since the resident's admission in July 2021, since resolution of her left wrist cellulitis in the fall of 2022, or since x-rays revealed ligament damage in 1/16/23. Further, record review revealed no evaluation or treatment recommendations from OT following the physician order on 1/16/23 for a referral to OT to treat and evaluate the ligament injury. Progress notes dated from 1/17/23 to 7/27/23 revealed the resident received restorative services to maintain mobility; however, there was no documentation regarding exercises for or the resident's mobility of her left wrist and hand. -Restorative therapy note dated 1/19/23 revealed the restorative therapist was working with the resident three times a week on upper body exercises to build up strength.-Restorative therapy note dated 1/26/23 revealed the resident was stable with restorative. She did refuse to participate at times but the restorative therapist would continue to encourage her to participate.-Restorative program note dated 2/2/23 revealed the resident remained stable with the restorative therapist's encouragement.-Restorative therapy note dated 2/10/23 revealed the resident continued with the restorative program and was totally physically dependent on the restorative therapist to perform all exercises.-Restorative therapy note dated 2/14/23 revealed the resident continued with the restorative program to work on upper body range of motion to prevent decline.-Restorative therapy note dated to 2/16/23 revealed the resident continued to refuse to participate at times and required restorative therapist encouragement.-Restorative therapy note dated 2/23/23 revealed the resident continued to work with the restorative therapist three times a week. She continued to receive encouragement to participate.-Restorative therapy note dated 3/2/23 revealed no changes to the resident's exercise program and she required total physical assistance from the restorative therapist to participate.-Nursing note dated 3/30/23 revealed the resident had been newly admitted to hospice services for a diagnosis of Alzheimer's disease.-There were no notes located after 3/22/23 referring to the status or treatment of the resident's left wrist and hand arthritis. D. Interviews and observationCNA #9 was interviewed on 7/26/23 at 9:45 a.m. She stated Resident #1 had a contracture to her left hand and she did not have a brace or hand splint. CNA #9 stated she did not know if occupational therapy or restorative therapy were working with Resident #1. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He said occupational therapy had worked with Resident #1 from 10/25/22 to 12/22/22. One of the goals was to strengthen the left upper extremity. Resident #1 had an incomplete range of motion in the left hand but it was not contractured at that time. He was not aware of the recommended referral from the physician on1/16/23. (See above)The facility coordinator was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said she had not worked with Resident #1 since she enrolled in hospice services on 3/30/23. Restorative had worked with her on upper extremity strength and range of motion. She could not recall if Resident #1 had a contracture in her left hand when she was discharged from restorative therapy services in March. The hospice aide (HA) was interviewed on 7/27/23 at 12:30 p.m. She was taking Resident #1 down the hallway and attempted to open the resident's left hand during the interview. The resident was unable to open any of her fingers without the HA's assistance and without grimacing and showing signs of pain. The HA stated it was very painful for the resident to try to open the left hand when she tried to clean the inside of the hand during showers. She said the hand was always closed when she came to see the resident and she had not seen any intervention in place to manage the contracture. The director of nursing (DON) was interviewed on 7/27/23 at 1:40 p.m. The DON was unaware Resident #1 had a contraction to her left hand, did not know what treatment the resident was receiving and did not know the status of her range of motion. The hospice clinical director (HCD) was interviewed via phone on 7/27/23 at 1:21 p.m. She stated she did not see anything in the resident's hospice records regarding her left hand. If there was a decline related condition, like a hand contracture, it would be documented in the hospice records if it occurred while the resident was on hospice services. II. Resident #7A. Resident status Resident #7, age 71,was admitted to the facility on 5/5/21. According to the July 2023 CPO, diagnoses included diabetes type II, contracture of the left hand (dated 4/2/23), fibromyalgia, bipolar disorder, chronic pain syndrome and injury of extensor muscle, fascia and tendon of left ring finger (dated 2/21/23). The 5/10/23 facility assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive two person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She required total assistance for bathing and locomotion. The resident had not received any orthopedic surgery to repair bones, tendons, or ligaments in hand. The resident had an upper extremity impairment on one side limiting range of motion. The resident received occupational and physical therapy three times in the seven day lookback period. B. Resident observation and interviewResident #7 was interviewed on 7/26/23 at 9:30 a.m. She stated she had surgery on her left hand in January 2023 and was supposed to be doing therapy but therapy did not help her learn how to put a hand splint on and off on her own. She said she needed the staff's help but they did not do it for her except for maybe one time a week. Her splint was observed on her table next to her TV.Resident #7 was observed on 7/26/23 at 9:30 a.m. Two of the fingers on her left hand appeared bent over and the resident, when asked, was not able to open them. C. Record reviewThe comprehensive care plan revised on 6/21/23 revealed the resident had a surgical repair of the left ring finger related to trigger finger type stiffening. Interventions included applying topical treatments as ordered and administering medication as ordered. The resident required assistance with self-care deficits related to a trigger finger surgical procedure due to tendon pain and to help decrease contracture like range of motion. Interventions were for staff to provide a level of assistance as required and to set up items needed within the residence reach. -The care plan did not include the use of a hand splint. The CPO reviewed from 12/1/22 to 7/26/23 revealed:-Surgical revision appointment for left hand on 12/7/22 at joint clinic- ordered on 12/1/22. -Post operative instructions from the surgical center to keep the operative hand elevated and watch for signs of infection- ordered 12/7/22.-X-ray to left wrist for pain- ordered on 1/30/23.-Physical and occupational therapy to evaluate and treat with no directions specified for order- ordered on 2/4/23 and discontinued 3/6/23.-Order from physician requesting occupational therapy (OT) for hand activities of daily living needs-ordered on 3/10/23 and discontinued on 7/3/23.-Physical therapy (PT) to evaluate and treat five times a week for twelve weeks for therapeutic activities, therapeutic exercises, neuromuscular reeducation related to muscle wasting- ordered on 2/8/23 and discontinued 6/15/23.-Order for OT for hand activities of daily living needs- ordered on 3/10/23 and discontinued on 7/3/23.-Order for splint replacement: remove to let resident move finger and retape each shift- ordered on 3/16/23 and discontinued 3/25/23.-Order for splint replacement: remove to let resident move finger and retape tape each shift- ordered on 3/25/23 and discontinued 5/4/23.-Occupational therapy for the resident to continue with occupational therapy services for 12 visits in 30 days for self-care, wheelchair management, and splinting- ordered on 4/4/23 and discontinued 5/4/23. -Physician order to use left hand brace (splint) 2 hours a day- ordered on 5/4/23 with no end date.-Occupational therapy order to evaluate and treat for left hand trigger finger ordered on 7/24/23.-Occupational therapy for the resident to be seen three times a week for four weeks for diagnosis of self-care, wheelchair assessment, and short arm splint- ordered on 7/24/23. Physician records reviewed from 3/14/23 to 7/26/23 revealed:-Physicians order dated 3/14/23 from the bone and joint clinic for physical therapy two to three times per week for four to six weeks. Finger splint to be applied to the left ring finger to aid in extension related to deformity of left ring finger.-Physician follow-up note dated 3/14/23 revealed the resident had seen the hand surgeon that day and was placed on a finger splint with instructions to tighten with tape daily to help with contracture of 4th digit. -The certified nurse aide (CNA) facility tasks for July 2023 did not reveal instructions to assist the resident with putting on or removing a hand splint. Further, review of the resident's treatment records did not document the implementation of current splint orders. Restorative progress notes revealed one note, dated 6/30/23, that read the restorative CNA washed the resident's left hand and was able to put her hand splint on for one to two hours. D. Staff interviews Registered nurse (RN) #1 was interviewed on 7/26/23 at 9:10 a.m. She said Resident #7 had a contracture to her left hand and had a hand splint staff were to assist her with. CNA #9 was interviewed on 7/26/23 at 9:45 a.m. CNA #9 did know if Resident #7 had a hand brace or splint. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He stated the therapy department had just met with Resident #7 to initiate occupational therapy for her left hand at her request. He stated she had a hand brace but she was incapable of using it without staff assistance. The FC was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said Resident #7 was receiving restorative therapy services from 5/25/23 until 7/3/23. Restorative was working with the resident on range of motion to promote extension of fingers on the left hand. She was working with Resident #7 on putting on a hand splint. The DON was interviewed on 7/27/23 at 1:40 p.m. She said was aware Resident #7 had a contracture in her left hand but did not know if there was a splint ordered for the resident to wear.

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

A recertification survey with complaint #CO32973 and #CO33284 was completed on 7/24/23 to 8/14/23. Thirteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 7/24/23 to 8/14/23. No deficiencies were cited.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to:-Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the assisted dining room; and,-Ensure staff knocked before entering resident rooms. Findings include:I. Facility policy and procedureThe Resident Rights policy and procedure, dated September 2016, provided by the nursing home administrator (NHA) on 7/26/23 at 5:53 p.m., it read in pertinent part:"The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, the right to receive adequate and appropriate health care consistent with established and recognized practice standards within the facility and within Health Department regulations, and the facility will protect and promote the exercise of rights for each resident."II. Meals served timely A. Posted mealtimesThe posted meal times for the main dining room were scheduled to begin breakfast at 7:30 a.m., lunch at 11:30 a.m. and dinner at 4:30 p.m. B. Resident observations/interviewsOn 7/26/23 at 12:16 p.m., Resident #30 was observed self-propelling out of the dining room. Resident #30 was approached by the activity director and asked where she was going. Resident #30 said, "I am tired of waiting and I am going back to my room." The AD asked Resident #30 if she wanted to some ice-cream and placed her back at her table and provided Resident #30 with a small bowl of ice cream. Resident #30's meal was served to her at 12:23 p.m. Resident #2 was interviewed on 7/26/23 at 2:40 p.m. Resident #2 said she was legally blind and she had difficulty eating her meals. She said, "I need help with my meals but there was not enough staff in the dining room to help me with my meals and she said it takes a long time to get my meal."C. Additional observations7/25/23-At 11:10 a.m. There were 14 residents sitting in the assisted dining room. All of the residents' were seated in wheelchairs.-At 11:12 a.m. Resident #23 and Resident #38 were sitting in their wheelchairs sleeping. -At 11:39 a.m. A resident's daughter entered the assisted dining room and sat next to her mother.-At 11:45 a.m. Two female residents were observed sleeping.-At 11:47 a.m. A female resident removed her clothing protector.-At 11:52 a.m. Resident #23 and Resident #38 were sleeping in their wheelchairs.-At 11:53 a.m. The daughter was served her mother's meal and proceeded to assist her with eating the meal. -At 12:07 p.m. Resident #23 was served her meal.-At 12:13 p.m. Resident #38 was served her meal. A certified nurse aide (CNA) was observed trying to wake up Resident #38 so she could assist her.-At 12:20 p.m. The last meal was served to residents in the assisted dining room. 7/26/23-At 11:13 a.m. There were eight residents observed sitting in the assisted dining room.-At 11:20 a.m. One resident was assisted into the dining room and placed at the table. -At 11:15 a.m. Two more residents were assisted into the dining room and their wheelchairs and placed at their table.-At 11:38 a.m. A total of 13 residents were seated in their wheelchairs in the assisted dining room.-At 11:40 a.m. One more resident was assisted into the dining room.-At 11:50 a.m. Four residents were served their meals.-At 11:55 a.m. 10 residents were still waiting for their meals. -At 12:06 p.m. The fifth tray was served in the assisted dining room. -At 12:09 p.m. The sixth tray was served in the assisted dining room. -At 12:13 p.m. There were eight residents still waiting for their meals.-At 12:22 p.m. A female resident was served her meal and a CNA asked if she wanted pepper and salt on her meal. The resident replied, "I just want to eat."-At 12:24 p.m. The last meal was served. C. Staff interviewThe nursing home administrator (NHA) was interviewed on 7/27/23 at 10:40 a.m. She was told of the observations above. She said residents should not have to wait longer than 20 minutes for their meals. She said the resident's room trays were served first and then the assisted residents were served their meals and then residents in the main dining room. She said the residents should have been served in a timely manner. Cook (CK) #2 was interviewed on 7/27/23 at 11:30 a.m. She said staff would serve the room trays first and then the assisted dining room would be served next and then the main dining room last. . She said most of the time it went well but if there was a problem it would delay the serving process. II. Failure to knock on doors before enteringA. ObservationsOn 7/24/23 at 10:00 a.m., the housekeeper (HSK) entered room #6 without knocking or waiting to be invited in. The resident was seated in her recliner next to the window and her roommate was sleeping in the bed next to the door entrance. The HSK proceeded to clean the room. The HSK repeated the same process for room #2, #3 and #4.-At 10:05 a.m., licensed practical nurse (LPN) #1 entered room #11 without knocking or waiting to be invited in. The resident was in the restroom when LPN #1 walked in. LPN #1 then turned and left the room.-At 10:15 a.m., LPN #1 entered room #4 without knocking or waiting to be invited in, walked across the room and appeared to be standing next to the resident's bed. The resident was lying in bed in her room and was awake looking forward. LPN #1 did not speak to the resident or acknowledge her in any way, then turned and exited the room.-At 11:23 a.m., certified nurse aide (CNA) #3 entered room #2 without knocking or waiting to be invited in. CNA #3 exited the resident's room. -At 1:54 p.m. LPN #1 walked into room #8. She was sleeping in her bed across the room next to the window. LPN #1 then turned and left the room. B. Resident interviewResident #13 was interviewed on 7/24/23 at 11:18 a.m. He said he preferred that staff knock on the door to her room before they entered and stated, "It's the rule." She said the housekeeping and nursing staff never knocked upon entering his room. Resident #145 was interviewed on 7/24/23 at 3:18 p.m. She said staff never knock prior to entering her room. She said they just walked right in. C. Staff interviewsLPN #1 was interviewed on 7/25/23 at 2:21 p.m. LPN #1 was told of observations above. She said, "I don't have to knock if I am in line of sight of the resident."CNA #8 was interviewed on 7/25/23 at 4:50 p.m. She said staff should always knock and announce themselves and wait for them to answer before going into a resident's room. The director of nurses (DON) was interviewed on 7/26/23 at 1:39 p.m. She said all staff should knock prior to entering residents' rooms in order to maintain their dignity. She said staff were provided this education upon hire during their general orientation and it was reviewed annually during their in-service training. She said, "The staff know better."

Based on observations, record review and interviews, the facility failed to ensure that self-administration of medications was clinically appropriate for one (#13) resident out of 23 sample residents. Specifically, the facility failed to ensure Resident #13 had a physician order an assessment and interdisciplinary team documentation stating it was appropriate for Resident #13 to self-administer medication. Findings include: I. Resident status Resident #13, age 85, was admitted on 4/13/23. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary (COPD), anxiety, dependence on supplemental oxygen, congestive heart failure. According to the 7/28/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. II. Observations/interview On 7/24/23 at 10:45 a.m., the resident was sitting in her bed at an angle. She had three small pill containers filled with medication. She was observed opening a Tylenol packet and pouring it into her ice cream and mixing it with a spoon. Resident #13 said she has been taking her medication for some time. No nursing staff were observed to be in the area to ensure Resident #13 took her pills. On 7/25/23 at 10:48 a.m., the resident was again observed to have three small pill containers on her bedside table. The resident was mixing her Tylenol in a yogurt cup. No nursing staff were observed in the area while Resident #13 was taking her pills. III. Record review The resident's medical record did not have a physician's order for self-administering medication, care plan, medication self-administration assessment, swallowing assessment and the interdisciplinary team (IDT) has determined this practice was clinically appropriate. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/25/23 at 2:30 p.m. LPN #1 said Resident #13 was able to self-administer her medication and had been doing it for a while. LPN #1 was reviewing resident's medical chart to find the physician order and assessment which approved Resident #13 to self-administer medication. A request was made for the physician order, medication self-administration assessment and IDT notes for Resident #13. The director of nursing (DON) was interviewed on 7/27/23 at 1:41 p.m. The DON said Resident #13 should have had a physician order for the self-administering of medication prior to taking her medication. The DON said the facility had an old assessment as the resident had been discharged and returned to the facility several times. The DON said the nurse giving the medication should stay and watch Resident #13 take the pills.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 15 of 30 resident rooms in three hallways. Specifically, the facility failed to ensure walls, ceilings and doors were properly maintained. Findings include:I. Initial observationsObservations of the resident living environment was conducted on 7/26/23 at 9:11 a.m. revealed:Room #7: The restroom wall had deep scratches and gouges approximately seven inches long by one inch wide. The baseboard cove underneath the sink had an area approximately 12 inches long which was peeling away from the wall. The shower across from room #7 had six pea sized holes on the wall next to the shower. Room #8: The wall next to the door in the restroom had an area approximately six feet high by half inch wide of cracked plaster. There were three nickel sized holes next to the door frame. Room #10: The entrance door had chipped and splintering wood on the bottom approximately seven inches long by four inches wide. The bathroom wall had deep gouges from the wheelchair hitting the wall approximately five feet long. Room #11: The entrance door had chipped and splintering wood on the bottom approximately six inches long by four inches wide. The vinyl flooring was missing a section approximately 12 inches long by three inches wide next to the restroom door. Room #5: The wall behind the recliner had two damaged areas from the recliner hitting the wall. The damage was approximately six inches long by three inches wide and seven long by two inches wide. Room #21: The transition strip leading into the resident's room had a missing transition strip approximately 36 inches long by three inches wide. The wall above the toilet had a hole approximately two inches in diameter. The wall in front of the toilet had an area approximately five feet long two inches wide which was damaged from the wheelchair hitting the wall. The entrance door had chipped and splintering wood on the bottom approximately five inches long by four inches wide. Room #12: The baseboard cove was missing a section approximately five inches long by four inches wide. The telephone junction box next to the resident's bed was missing a cover. The privacy curtain rail had been removed with the outline still visible on the ceiling. Room #13: The door frame had deep chipped and splintering wood approximately four inches wide by 14 inches high from the wheel chair hitting the door frame. The wall paper outside of room #19 had a section approximately 10 inches long by two inches wide which was cut. The shower room on the north hall had sheetrock damage approximately four feet wide by three feet high. Room #15: The corner section next to the restroom had an area approximately four feet high by one inch wide of chipped and peeling sheetrock. Room #17: The wall above the resident's bed had chipped and peeling sheet rock approximately 16 inches long by six inches wide. The corner piece next to the restroom had chipped and cracking sheetrock approximately four feet long by inches wideRoom # 26: The wall next to the restroom had a section approximately four feet high by three inches wide from the wheelchair hitting the corner. The metal corner piece was visible. The wall paper next to the resident's window was damaged from the chair hitting the wall. Room #27: The wall paper behind the resident's recliner had an area approximately eight inches long by three inches wide which was damaged from the recliner hitting the wall. Room #29: The wall paper was peeling next to the resident's shelf and the shelf was falling off the wall. The corner piece next to the resident restroom had chipped and peeling sheetrock approximately 18 inch high by three inches wide. The metal corner piece was exposed. Room #30: Had a missing piece of baseboard cove approximately six inches long by four inches wide. II. Environmental tour and staff interviewThe environmental tour was conducted with the maintenance director (MTCE) and the nursing home administrator (NHA) on 7/27/23 at 10:05 a.m. The above detailed observations were reviewed. The MTCE documented the environmental concerns. The MTCE said the facility utilized a computer system to identify environmental issues. The MTCE said he did have work orders for the damage identified during the environmental tour. The MTCE said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for one (#14) of five residents reviewed for comprehensive care plans out of 23 sample residents. Specifically, the facility failed to timely develop a care plan for the use of oxygen, timely develop a care plan for visual impairment, develop a care plan for hospice and develop a care plan for activity services for Resident #14. Findings include: I. Facility policyThe Care Plan policy, revised November 2009, provided by the nursing home administrator (NHA) at 1:27 p.m. on 7/27/23, included:"The facility provides care that respects resident choices, supports their participation in the care provided, and recognizes their right to experience achievement of their personal health goals. The goal of the care and treatment of residents' function is to provide individualized care in settings responsive to specific resident needs."A care plan is formulated based on resident assessment. Actions or interventions are planned to meet defined care goals. Residents agree to the planned course of treatment outlined in the plan. Resident involvement is integral to developing the care plan."II. Resident #14A. Resident statusResident #14, age 80, was admitted on 6/23/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure, dependence on supplemental oxygen and type II diabetes mellitus with diabetic retinopathy (damage to the eyes) with macular edema (eye swelling). The 6/29/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She was identified having severely impaired vision, without use of corrective lenses. B. Record reviewThe care plan, reviewed 7/24/23 at 11:12 a.m. did not have a care plan that identified:-The use of supplemental oxygen.-Visual impairment.-Activity preferences.-The hospice care to be provided by the hospice provider and the care to be provided by the facility. The care plan, reviewed on 7/27/23 at 10:00 a.m. identified impaired vision developed on 7/24/23 (after being identified on survey). Interventions included:-Explain cares and services before providing.-Place items within easy reach and orient to placement.-Use resident's name at all times when communicating with her directly. The July 2023 CPO included:-Oxygen by nasal cannula continuous at 2 liters (L) per minute. Notify the nurse practitioner (NP)/medical doctor (MD) if oxygen saturation is less than 89%. Dated 7/25/23.-Admit to facility with Hospice. Dated 6/27/23. C. InterviewsCertified nurse aide (CNA) #1 was interviewed on 7/26/23 at 11:51 a.m. She said the resident was blind, on hospice and utilized oxygen. She said the nurses told her of the resident's needs. She said the resident did not usually attend activities. She said she had not read the care plan. She said she did not develop the care plans. The activity director (AD) was interviewed on 7/27/23 at 11:40 a.m. She said after the assessment (the MDS assessment), she would develop the activity care plan. She said the care plan included information from the MDS assessment and the interview with the resident to find out their personal preferences. At 2:00 p.m. the AD stated she could not locate an activity care plan for Resident #14. The social services director (SSD) was interviewed on 7/27/23 at 11:58 a.m. She said a care plan for vision, oxygen and hospice care should have been developed when Resident #14 was admitted. She said the vision care plan should have been in place sooner. She said she was new to the position and was looking forward to working with the residents. At 12:55 p.m. the SSD said she was not sure why there was not a hospice care plan. She said going forward she would develop a coordinated effort to the care planning process to identify hospice cares provided by hospice staff. She said going forward the care plans need to be in the electronic record. The MDS coordinator was interviewed on 7/27/23 at 12:30 p.m. She said there should have been an oxygen and hospice care plan in place. She said the vision care plan should have been done earlier by the social services department and the activity care plan should have been completed by the activities director. She said she was not sure why the oxygen and hospice care plans were not in place. She said the care plan directed cares provided to the resident and identified person centered goals and individualized cares. The director of nursing (DON) was interviewed on 7/27/23 at 1:41 p.m. She said care plans for vision, oxygen, activities and hospice should have been in place. She said care plans were individualized and person centered for every resident that identified interventions for each area for staff to know Resident #14 preferences.

Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#23 and #38) of five residents reviewed for activities out of 23 sample residents. Specifically, the facility failed to ensure Resident #23 and Resident #38 were invited and encouraged to attend activities of her preference. Findings include:I. Facility policy and proceduresThe Activities Program policy, undated, was provided on 7/26/23 at 5:53 p.m. by the nursing home administrator (NHA). It read in pertinent part:"An activity program should provide a meaningful balance of physical, intellectual, social and spiritual activities for the resident, to enhance each resident's quality of life. Activity programs shall provide the security of the familiar with the challenge of the new. Each resident shall be encouraged to fulfill these needs within his/her abilities and limitations. The freedom of choice or participation in any group or individual activity will be respected by the staff of the facility. The facility has an obligation to strive to meet these needs by providing qualified personnel and supporting the activity program."II. Activity calendar The activity calendar for 7/24/23 listed the following:-9:30 a.m. chair exercise-10:00 a.m. coffee and news-11:15 a.m. daily chronicles delivery-2:00 p.m. van ride-4:15 p.m. courtesy cartThe activity calendar for 7/25/23 listed the following:10:00 music11:30 trivia with lunch2:00 p.m. Bingo5:00 p.m. hand massage The activity calendar for 7/26/23 listed the following:9:30 noodle ball10:30 coffee and news2:00 p.m. craft time4:00 p.m. trivia5:00 p.m. BingoIII. Resident #23A. Resident statusResident #23, age 96, was admitted on 5/6/19. According to the July 2023 computerized physician orders (CPO), diagnoses included Alzheimer's, dementia and anxiety. According to the 5/27/23 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident had difficulty focusing attention and had disorganized thinking. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The preference for customary routine and activities revealed the resident felt it was very important to listen to music, participate in her favorite activities and go outside when weather was nice. B. ObservationsObservations on 7/24/23 revealed the resident did not have any meaningful activity. -From 8:30 a.m. to 10:54 a.m., Resident #23 was sitting in her wheelchair reclined back in her room sleeping. No television (TV) or music was on while Resident #23 was in her room.-At 10:55 a.m. certified nurse aide (CNA) #3 provided care for Resident #23.-At 11:12 a.m. CNA #3 assisted Resident #23 out of her room and took her to the dining room.-From 1:40 p.m. to 2:45 p.m. Resident #23 was lying in bed from 1:40 p.m. to 2:45 p.m. sleeping. No television (TV) or music was on while Resident #23 was in her room. Observations on 7/25/23 revealed the resident did not have any meaningful activity. -At 9:25 a.m., Resident #23 was sitting reclined in her wheelchair in the common area.-At 9:38 a.m., CNA #3 provided care for Resident #23 and laid Resident #23 down in bed.-From 9:50 a.m. to 10:54 a.m., Resident #23 was lying in bed sleeping from 9:50 a.m. to 10:54 a.m. -At 10:55 a.m., an unknown CNA provided care to Resident #23.-At 11:09 a.m., an unknown CNA assisted Resident #23 out of her room and took her to the dining room.-At 11:12 a.m., Resident #23 was sitting in the dining room from 11:12 a.m. to 12:50 p.m.-At 11:29 a.m. the activity director (AD) walked through assisted dining to the independent dining room and did not invite residents to the trivia activity. -At 12:55 p.m. Resident #23 was assisted out of the dining room and wheeled into the common area next to a table. -At 1:35 p.m., CNA # 4 provided care to Resident #23 and placed Resident #23 in bed.-From 1:40 p.m. to 2:46 p.m., Resident #23 was lying in bed and fell asleep. There was TV or music was playing in Resident #23's room. Observations on 7/26/23 revealed the resident did not have any meaningful activity. -From 8:45 a.m. to 10:56 a.m. Resident #23 was lying in bed sleeping. There was no TV or music playing. -From 11:12 a.m. to 12:51 p.m. Resident #23 was in the dining room.-At 1:23 p.m., CNA # 6 provided care to Resident #23 and placed Resident #23 in bed. There was no TV or music playing. -From 1:32 p.m. to 3:26 p.m., Resident #23 was lying in bed sleeping. C. Record reviewThe care plan, initiated 5/7/19 and revised 6/3/23, identified the resident's main leisure interest was sleeping throughout the day in her room in her bed. The resident had a lifelong history of enjoying her alone time. Prior to COVID the resident had a personal caregiver who would visit with her throughout the day. At times the resident enjoys listening to country music, she also enjoys listening to game shows on television (TV) and movies. Interventions include activities staff will ensure the residents TV was in working order. Staff to ensure TV was on station the resident enjoyed listening too. Activities staff will invite the resident to attend calendar events. Activities staff will honor resident's right to refuse. The resident became anxious when she was unable to see the activity around her. Staff will provide adaptations and guide the residents hand to items. Staff would provide one-to-one programming visits for at least 15-20 minutes each week. Staff will provide sensory stimulation in the one-to-one programming. One-to-one log note dated 7/25/23 no time given, it read in part: took resident outside 10 minutes before lunch and sat on the porch. Resident nodded yes, when she was asked if she was having a good day.-However, the resident was assisted to the dining room and not taken outside prior to lunch (see observations above). One-to-one log note dated 7/27/23 not time given, it read in part: took resident outside for 15 minutes. The resident nodded yes, when she was asked if she was having a good day and nodded yes when she was asked if she wanted some lunch. D. Staff interviewsCNA #6 was interviewed on 7/26/23 at 1:58 p.m. She said activities were limited for the Resident #23 as she did sleep a lot. IV. Resident #38A. Resident statusResident #38, age 64, was admitted on 7/1/22. According to the July 2023 CPO, diagnoses included vascular dementia, cerebrovascular disease (stroke), anxiety, history of falling and obsessive compulsive disorder. According to the 6/17/23 MDS assessment, the resident was unable to complete the BIMS. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had two falls since admission. The preference for customary routine and activities revealed the resident felt it was very important to listen to music, participate in group activities, be around pets and go outside when weather was nice. B. ObservationsObservations on 7/24/23 revealed the resident did not have any meaningful activity. -From 8:30 a.m. to 10:30 a.m., Resident #38 was lying in bed in her room sleeping from 8:30 a.m. to 10:30 a.m. The resident room was dark with no TV or music playing. -At 10:24 a.m., CNA #6 provided Resident #38 with care and was Resident #38 was in her wheelchair in her room. The resident sat in her room with the curtains still closed. -At 11:00 a.m., CNA #6 assisted Resident #38 to the common area.-At 11:12 a.m., CNA #6 assisted Resident #38 out of the common area and took her to the dining.-At 1:45 p.m., licensed practical nurse (LPN) #1 assisted Resident #38 into her room.-At 1:48 p.m., two unknown CNAs entered Residents #38 room with and transferred Resident #38 into bed. There was no TV or music playing. -From 1:50 p.m. to 2:40 p.m. Resident #38 was lying in bed sleeping. Observations on 7/25/23 revealed the resident did not have any meaningful activity. -From 9:20 a.m. to 10:43 a.m. Resident # 38 was sleeping in her wheel chair in the common area. -At 9:38 a.m., Resident #38 was put to bed. There was no TV or music playing. -From 9:39 a.m. to 10:44 a.m., Resident #38 was sleeping. -At 10:45 a.m., CNA #3 provided care to Resident #38.-At 11:09 a.m., CNA #3 wheeled Resident #38 left her room and took her to the dining room.-From 11:12 a.m. to 12:50 a.m. Resident #38 was sitting in the dining room. -At 11:29 a.m., the AD walked through assisted dining to the independent dining room and did not invite residents to the trivia activity.-At 12:55 p.m., Resident #38 was assisted out of the dining room next to the nursing station. -At 1:45 p.m., LPN #1 assisted Resident #38 into her room. -At 1:50 p.m., CNA #3 and another unknown CNA transferred Resident #38 into bed. There was no TV or music playing. -From 1:55 p.m. to 3:12 p.m., Resident #38 was lying in bed sleeping. Observations on 7/26/23 revealed the resident did not have any meaningful activity. -From 8:45 a.m. to 10:48 a.m., Resident #38 was lying in bed sleeping. -At 10:49 a.m., CNA #8 provided care to Resident #38.-At 11:09 a.m., CNA #4 assisted Resident #38 to the dining room.-From 11:12 a.m. to 12:51 p.m., Resident #38 was in the dining room.-At 1:45 p.m., Resident #38 was seated in her wheelchair in the common area. -At 1:50 p.m., CNA #8 and a male CNA provided care to Resident #38 and placed Resident #38 in bed. There was no TV or music playing. -From 1:51 p.m. to 2:26 p.m. Resident #38 was lying in bed sleeping. B. Record reviewThe care plan, initiated 7/1/22 and revised 6/24/23, identified the resident prefers to be involved in individual/solitary, one to one program visits and group activities on occasion. Interests are being in social areas, going outside (when weather permits, current events, Music, listening to someone read, physical activity, visiting with family, and watching TV. Resident had an activity box in her room with an array of items to choose from. Interventions include activity staff would provide leisure supplies for the resident in her room. These are located in a tub that all staff would have access to. Introduce different activities to the resident as she desires. Ensure the resident curtains are open during the day so she can see outside. She also seems to enjoy having a music TV station on throughout the day as evidence by appearing more relaxed and not yelling out. The resident, at times, seems to enjoy group activities. At times the resident would yell out "Help me!" or talk nonsensical to staff. Staff need to ensure the resident was safe. Staff would try to calm her and if that doesn't work would take her out of the area that was causing her anxiety. Remind/encourage/assist and/or transport to activities as needed. One-to-one log note dated 7/25/23 no time given, it read in part: took resident outside before lunch. The resident fell asleep and started snoring.-However, the resident was assisted to the dining room and not taken outside prior to lunch (see observations above). One-to- one log note dated 7/27/23 not time given, it read in part: took resident outside to look at the flowers. We walked around the front and back patio. The resident said she was having a good day. C. Staff interviewCNA #8 was interviewed on 7/26/23 at 4:26 p.m. She said Resident #38 pretty much slept throughout the day. She said Resident #38 was not very vocal but she did like to be around other residents. V. Administrative interviewThe activity director (AD) was interviewed on 7/26/23 at 11:40 a.m. The AD was informed of the observations above. She said all residents' should be encouraged and invited to all activities. She said both residents were on a one-to-one program, which was supposed to be two to three times a week and should last 20-25 minutes. She said a negative outcome for residents not participating in activities could be boredom, isolation, depression and negative behaviors and wandering.

Based on record review, observations, and interviews, the facility failed to ensure two (#1 and #7) of five residents received services and assistance to prevent a reduction in range of motion out of 23 sample residents. According to diagnoses on admission, Resident #1 did not admit to the facility with a contracture to her left hand but based on observations and interviews on 7/24-7/26/23, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her left hand. Further, the facility failed to provide the resident occupational therapy (OT) as ordered after the identification of a possible ligament injury to the left wrist on 1/16/23. The facility's failure to provide services to maintain the resident's mobility contributed to a decline in the mobility of the resident's left wrist and hand. Resident #7 was ordered assistance with hand splinting from the facility staff post surgical revision of her left hand. Interview and record review revealed the facility failed to ensure the resident was receiving assistance as ordered 3/14/23, 3/16/23, 3/25/23, 4/4/23, and 5/4/23, to maintain mobility or decrease further loss of range of motion of the resident's left hand. Findings include:I. Resident #1A. Resident status Resident #1, age 88, was admitted to the facility on 7/16/21. According to the July 2023 computerized physician's orders (CPO), diagnoses included diabetes type II, dementia with agitation and disorders of bone density and bone structure. The 6/23/23 minimum data set (MDS) assessment showed the resident had significant cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive one-two person physical assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. The resident had no functional limitations in range of motion of her upper or lower extremities. She was enrolled in hospice and had not received any therapy or restorative services during the MDS look back period. -No diagnosis of arthritis or cellulitis (bacterial infection to the skin) was indicated. B. Resident observationsThe resident was observed on 7/24/23 at 10:48 a.m. inside the activity room. The fingers on resident's left hand were curled and while participating in a balloon catch activity, the resident was unable to open her left hand at all. Resident #1 was observed on 7/25/23 at 12:15 p.m. in the lunchroom. The resident was attempting to adjust the front of her shirt with her left hand but she was only able to pinch the material with her thumb. Her left hand remained curled into a fist. Resident #1 was observed on 7/26/23 at 12:16 p.m. in the lunchroom. She was able to feed herself using her right hand but was not able to use her left hand. Her left hand rested on her lap, fingers curled in a fist position. C. Record reviewThe comprehensive care plan initiated on 7/21/21 revealed the resident had a history of cellulitis in her left hand. Interventions were to assist the resident to the bathroom as needed, offer non medicinal means of pain relief, encourage the resident to comply with recommended interventions to help prevent skin breakdown, and notify the medical director or hospice of any skin breakdown. The resident had decreased range of motion with interventions to keep the call light within reach and keep frequently used items in reach. -The care plan did not indicate the reason, the location of, or the extent of the resident's decreased range of motion. The CPO reviewed from 7/17/22-7/26/23 revealed:-X-ray of left wrist due to red, swollen and warm-ordered on 7/17/22.-Keflex 500 milligram (MG])- give one tablet by mouth four times a day for cellulitis for five days-ordered on 7/18/22.-Voltaren gel 1%- apply to left wrist topically two times a day for joint pain and swelling for two weeks-ordered on 9/6/22.-Keflex 500 MG- give one tablet by mouth four times a day for cellulitis in the left hand for five days-ordered on 9/3/22.-Voltaren gel 1%- apply to left wrist topically two times a day for arthritic pain for two months-ordered on 9/27/22.-Aspercreme lotion 10%- apply to left wrist topically every eight hours as needed for pain- ordered on 10/28/22.-Occupational therapy (OT) to evaluate and treat for decreased range of motion and use of left upper extremities-ordered on 10/24/22 and discontinued 12/5/22.-OT to continue with therapy three times a week for thirty days related to wheelchair management, self-care training, therapeutic activities, therapeutic exercises and manual techniques due to lack of coordination and muscle weakness dated 10/26/22 and discontinued 2/6/23.-Restorative therapy for active assistive range of motion with rod; shoulder and elbow flex extension three times weekly or as tolerated- ordered 1/4/23 and discontinued 3/15/23.-X-ray of left hand and fingers for swelling and pain-ordered on 1/11/23.-Voltaren gel 1%- apply to left hand and knuckles topically two times a day for pain- ordered on 1/11/23.-OT to evaluate and treat diagnosis of left wrist scapholunate (small bones in the wrist) ligament injury- ordered on 1/16/23.-Voltaren gel 1%- apply to left hand and knuckles topically every six hours as needed for pain- ordered on 1/20/23.-No further orders were located pertaining to the resident's left wrist or hand. Physician visit notes dated from 9/27/22 to 1/17/23 revealed: -Physician visit note dated 9/27/22 revealed the reason for the appointment was for a swollen left wrist and left hand. The resident was able to hold objects in her left hand and still maintained range of motion. Voltaren gel was continued daily for joint arthropathy (disease of the joint). -Physician visit note dated 10/21/22 revealed the reason for the appointment was due to an abnormal reduction of circulating white blood cells. During the visit, the physician noted the nurses reported the resident was displaying signs of pain and discomfort with no recent falls or specific areas of concern identified. The resident was unable to describe the pain. The resident was still able to move all four extremities however, chronic arthritic changes were noted by the physician.-Physician visit note dated 1/11/23 revealed the reason for the appointment was left hand pain and swelling. The resident presented with acute pain, redness and swelling to her left hand and knuckles. She had a history of arthritis in her left wrist. An x-ray of the left hand was ordered to rule out any possible injuries and a topical gel was provided for relief of pain and swelling.-Physician visit note dated 1/12/23 revealed the reason for the appointment was left hand pain and swelling. The swelling had improved but the joints remained tender to the touch. At this time, the note documented the resident was l able to open her left hand and perform a range of motion activities but with discomfort.-Physician visit note dated 1/16/23 revealed the reason for the appointment was left hand pain and x-ray results. The x-rays revealed soft tissue swelling and arthritic changes of the hand with a suspected injury to the ligaments in the small bones of the resident's left wrist. The swelling had resolved but the resident was still displaying discomfort with her range of motion in the left wrist. A referral was recommended for OT to treat and evaluate the ligament injury. Review of therapy notes revealed:An OT therapist plan of care notes dated 11/23/22 revealed the resident was being seen for cellulitis of the left upper limb. The resident's level of functioning was bilateral upper extremity functional activity tolerance with moderate cues for left upper extremity use, no reported pain. The goal was for the resident to be able to feed herself with finger foods and use a cup to drink with stand by assistance from a therapist. The underlying impairments documented were decreased strength and range of motion in the left upper extremity requiring moderate assistance from staff. The OT therapist discharge notes dated 12/22/2 revealed the resident was able to feed herself with finger foods and use a cup to drink with verbal cues provided by staff. The goal of increasing strength and range of motion in the left upper extremity was not met due to resident pain. Record review failed to reveal a comprehensive assessment of the resident's range of motion by physical or occupational therapy since the resident's admission in July 2021, since resolution of her left wrist cellulitis in the fall of 2022, or since x-rays revealed ligament damage in 1/16/23. Further, record review revealed no evaluation or treatment recommendations from OT following the physician order on 1/16/23 for a referral to OT to treat and evaluate the ligament injury. Progress notes dated from 1/17/23 to 7/27/23 revealed the resident received restorative services to maintain mobility; however, there was no documentation regarding exercises for or the resident's mobility of her left wrist and hand. -Restorative therapy note dated 1/19/23 revealed the restorative therapist was working with the resident three times a week on upper body exercises to build up strength.-Restorative therapy note dated 1/26/23 revealed the resident was stable with restorative. She did refuse to participate at times but the restorative therapist would continue to encourage her to participate.-Restorative program note dated 2/2/23 revealed the resident remained stable with the restorative therapist's encouragement.-Restorative therapy note dated 2/10/23 revealed the resident continued with the restorative program and was totally physically dependent on the restorative therapist to perform all exercises.-Restorative therapy note dated 2/14/23 revealed the resident continued with the restorative program to work on upper body range of motion to prevent decline.-Restorative therapy note dated to 2/16/23 revealed the resident continued to refuse to participate at times and required restorative therapist encouragement.-Restorative therapy note dated 2/23/23 revealed the resident continued to work with the restorative therapist three times a week. She continued to receive encouragement to participate.-Restorative therapy note dated 3/2/23 revealed no changes to the resident's exercise program and she required total physical assistance from the restorative therapist to participate.-Nursing note dated 3/30/23 revealed the resident had been newly admitted to hospice services for a diagnosis of Alzheimer's disease.-There were no notes located after 3/22/23 referring to the status or treatment of the resident's left wrist and hand arthritis. D. Interviews and observationCNA #9 was interviewed on 7/26/23 at 9:45 a.m. She stated Resident #1 had a contracture to her left hand and she did not have a brace or hand splint. CNA #9 stated she did not know if occupational therapy or restorative therapy were working with Resident #1. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He said occupational therapy had worked with Resident #1 from 10/25/22 to 12/22/22. One of the goals was to strengthen the left upper extremity. Resident #1 had an incomplete range of motion in the left hand but it was not contractured at that time. He was not aware of the recommended referral from the physician on1/16/23. (See above)The minimum data set coordinator (MDS) was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said she had not worked with Resident #1 since she enrolled in hospice services on 3/30/23. Restorative had worked with her on upper extremity strength and range of motion. She could not recall if Resident #1 had a contracture in her left hand when she was discharged from restorative therapy services in March. The hospice aide (HA) was interviewed on 7/27/23 at 12:30 p.m. She was taking Resident #1 down the hallway and attempted to open the resident's left hand during the interview. The resident was unable to open any of her fingers without the HA's assistance and without grimacing and showing signs of pain. The HA stated it was very painful for the resident to try to open the left hand when she tried to clean the inside of the hand during showers. She said the hand was always closed when she came to see the resident and she had not seen any intervention in place to manage the contracture. The director of nursing (DON) was interviewed on 7/27/23 at 1:40 p.m. The DON was unaware Resident #1 had a contraction to her left hand, did not know what treatment the resident was receiving and did not know the status of her range of motion. The hospice clinical director (HCD) was interviewed via phone on 7/27/23 at 1:21 p.m. She stated she did not see anything in the resident's hospice records regarding her left hand. If there was a decline related condition, like a hand contracture, it would be documented in the hospice records if it occurred while the resident was on hospice services. II. Resident #7A. Resident status Resident #7, age 71,was admitted to the facility on 5/5/21. According to the July 2023 CPO, diagnoses included diabetes type II, contracture of the left hand (dated 4/2/23), fibromyalgia, bipolar disorder, chronic pain syndrome and injury of extensor muscle, fascia and tendon of left ring finger (dated 2/21/23). The 5/10/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive two person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She required total assistance for bathing and locomotion. The resident had not received any orthopedic surgery to repair bones, tendons, or ligaments in hand. The resident had an upper extremity impairment on one side limiting range of motion. The resident received occupational and physical therapy three times in the seven day lookback period. B. Resident observation and interviewResident #7 was interviewed on 7/26/23 at 9:30 a.m. She stated she had surgery on her left hand in January 2023 and was supposed to be doing therapy but therapy did not help her learn how to put a hand splint on and off on her own. She said she needed the staff's help but they did not do it for her except for maybe one time a week. Her splint was observed on her table next to her TV.Resident #7 was observed on 7/26/23 at 9:30 a.m. Two of the fingers on her left hand appeared bent over and the resident, when asked, was not able to open them. C. Record reviewThe comprehensive care plan revised on 6/21/23 revealed the resident had a surgical repair of the left ring finger related to trigger finger type stiffening. Interventions included applying topical treatments as ordered and administering medication as ordered. The resident required assistance with self-care deficits related to a trigger finger surgical procedure due to tendon pain and to help decrease contracture like range of motion. Interventions were for staff to provide a level of assistance as required and to set up items needed within the residence reach. -The care plan did not include the use of a hand splint. The CPO reviewed from 12/1/22 to 7/26/23 revealed:-Surgical revision appointment for left hand on 12/7/22 at joint clinic- ordered on 12/1/22. -Post operative instructions from the surgical center to keep the operative hand elevated and watch for signs of infection- ordered 12/7/22.-X-ray to left wrist for pain- ordered on 1/30/23.-Physical and occupational therapy to evaluate and treat with no directions specified for order- ordered on 2/4/23 and discontinued 3/6/23.-Order from physician requesting occupational therapy (OT) for hand activities of daily living needs-ordered on 3/10/23 and discontinued on 7/3/23.-Physical therapy (PT) to evaluate and treat five times a week for twelve weeks for therapeutic activities, therapeutic exercises, neuromuscular reeducation related to muscle wasting- ordered on 2/8/23 and discontinued 6/15/23.-Order for OT for hand activities of daily living needs- ordered on 3/10/23 and discontinued on 7/3/23.-Order for splint replacement: remove to let resident move finger and retape each shift- ordered on 3/16/23 and discontinued 3/25/23.-Order for splint replacement: remove to let resident move finger and retape tape each shift- ordered on 3/25/23 and discontinued 5/4/23.-Occupational therapy for the resident to continue with occupational therapy services for 12 visits in 30 days for self-care, wheelchair management, and splinting- ordered on 4/4/23 and discontinued 5/4/23. -Physician order to use left hand brace (splint) 2 hours a day- ordered on 5/4/23 with no end date.-Occupational therapy order to evaluate and treat for left hand trigger finger ordered on 7/24/23.-Occupational therapy for the resident to be seen three times a week for four weeks for diagnosis of self-care, wheelchair assessment, and short arm splint- ordered on 7/24/23. Physician records reviewed from 3/14/23 to 7/26/23 revealed:-Physicians order dated 3/14/23 from the bone and joint clinic for physical therapy two to three times per week for four to six weeks. Finger splint to be applied to the left ring finger to aid in extension related to deformity of left ring finger.-Physician follow-up note dated 3/14/23 revealed the resident had seen the hand surgeon that day and was placed on a finger splint with instructions to tighten with tape daily to help with contracture of 4th digit. -The certified nurse aide (CNA) facility tasks for July 2023 did not reveal instructions to assist the resident with putting on or removing a hand splint. Further, review of the resident's treatment records did not document the implementation of current splint orders. Restorative progress notes revealed one note, dated 6/30/23, that read the restorative CNA washed the resident's left hand and was able to put her hand splint on for one to two hours. D. Staff interviews Registered nurse (RN) #1 was interviewed on 7/26/23 at 9:10 a.m. She said Resident #7 had a contracture to her left hand and had a hand splint staff were to assist her with. CNA #9 was interviewed on 7/26/23 at 9:45 a.m. CNA #9 did know if Resident #7 had a hand brace or splint. Certified occupational therapy assistant (COTA) #1 was interviewed on 7/26/23 at 12:00 p.m. He stated the therapy department had just met with Resident #7 to initiate occupational therapy for her left hand at her request. He stated she had a hand brace but she was incapable of using it without staff assistance. The minimum data set coordinator (MDS) was interviewed on 7/27/23 at 12:00 p.m. She stated she was also the restorative therapy nurse. She said Resident #7 was receiving restorative therapy services from 5/25/23 until 7/3/23. Restorative was working with the resident on range of motion to promote extension of fingers on the left hand. She was working with Resident #7 on putting on a hand splint. The DON was interviewed on 7/27/23 at 1:40 p.m. She said was aware Resident #7 had a contracture in her left hand but did not know if there was a splint ordered for the resident to wear.

Based on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure safe water temperatures. Findings include:I. Water temperatures7/24/23-At 1:03 p.m., the temperature of the tap water was obtained in room #7. The water was found to be 129 degrees Fahrenheit (F);-Room #3's water temperature was 129 degrees F;-Room #5's water temperature was 128 degrees F;-Room #10's water temperature was 129 degrees F;The east shower room 129 degrees F;-Room #25's water temperature was 139 degrees F;-Room #27's water temperature was 139 degrees F;-Room #30's water temperature was 139 degrees F; and,-The shower room faucet was 138 degrees F.-At 1:12 p.m., certified occupational therapist assistant (COTA) #2 observed the temperature of the resident's water in room #30. The temperature was 139.9 degrees F. COTA #2 said the thermometer reading was 139.9 degrees F. COTA #2 was unsure what the water temperature was supposed to be kept at.-At 1:23 p.m., the maintenance director (MTCE) observed the water temperature in room #30. The temperature was 139.9 degrees F.The maintenance supervisor MTCE was interviewed on 7/24/23 at 1:23 p.m. He stated the facility immediately purged all the hot water from the lines. The MTD said the boiler had recently been replaced. The MTCE said the water had been holding at 117 degrees F. The MTCE said the water mixing valve may have been the issue and he was currently checking to see if it was functioning correctly. The MTCE said the facility monitored the water temperatures weekly and would provide the temperature logs. The nursing home administrator (NHA) was interviewed on 7/24/23 at 1:30 p.m. The NHA was informed of the observations above. The NHA said there had not been any residents burned by the water. She said she was not familiar with what the water temperature should be but would check. Certified nurse aide (CNA) #3 was interviewed on 7/24/23 at 4:05 p.m. CNA #3 the CNAs provided showers to the residents. She said she checked the water temperature on her wrist to ensure the water temperature was not too hot. She said if the resident was cognitively alert she would allow the resident to tell her as well but would constantly check the water temperature.

Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#13) of four residents reviewed for supplemental oxygen use out of 23 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #13. Findings include: I. Facility policy The Oxygen Administration Policy, no revision date, was provided on 7/26/23 at 5:57 p.m. by the nursing home administrator (NHA). It read in pertinent part, "Oxygen administration may be initiated by a licensed nurse in an emergency to relieve respiratory distress and followed with notification of the physicians for orders to continue the administration." II. Resident statusResident #13, age 85, was admitted on 4/13/23. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary (COPD), anxiety, dependence on supplemental oxygen and congestive heart failure. According to the 7/28/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. III. Observations On 7/24/23 at 11:25 a.m. Resident #13 was lying in her bed. Residents #13 oxygen cannula was wrapped in a ball and was on the side of the resident's bed. On 7/25/23 at 2:30 p.m. Resident #13 was lying in her bed. Residents #13 oxygen cannula was wrapped in a ball and was on the side of the resident's bed. IV. Record review The care plan, initiated 7/19/23, identified the resident had potential for complications and discomfort related to chronic obstructive pulmonary disease (COPD), sleep apnea and shortness of breath while lying flat. Interventions include monitor for signs and symptoms of respiratory distress and report to medical doctor s needed (PRN): respirations, pulse oximetry, increased heart rate (Tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, Cough, Pleuritic pain, accessory muscle usage, skin color. Oxygen while sleeping as ordered and elevate the head of my bed during sleep hours. The July 2023 CPO included an order dated 4/13/23 for oxygen at 2 liters per minute (LPM) continuously. Notify nurse practitioner/medical doctor if oxygen SAT (saturation) was less than 89%. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/25/23 at 2:30 p.m. LPN #1 said oxygen was a medication. She said the Resident #13 only wore her oxygen at night and did not require it during the day. LPN #1 went to the resident's room and stated the resident was not wearing her oxygen cannula and removed it from the wall next to Resident #13's bed. LPN #1 helped Resident #13 put on her cannula and exited the resident's room. She said the resident physicians order was in the evening or as needed. LPN #1 reviewed Resident #13's physician order. She said, "That was interesting because I thought it was only in the evening." LPN #1 said she would get clarification from the physician. The DON was interviewed on 7/27/23 at 1:41 p.m. She said oxygen was a medication. She said Resident #13's oxygen should have been administered as the provider ordered it. The DON said a negative outcome from not being administered oxygen when ordered could alter mental status, dizziness and falls and could have put the residents in respiratory distress.

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

Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure appropriate hand hygiene by food service staff. Findings include: I. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. "Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by;2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device." II. Observations Observation of the meal service was conducted on 7/26/23 at 10:15 a.m. Cook (CK) #1 was preparing pureed and mechanical meals for the lunch meal. The CK was cutting whole pork loin for the lunch meal. The CK cut the whole pork loin into two inch slices. She placed the pan which the pork loin were in and placed it on the stove top. The CK left two end pieces of pork and grabbed them with her gloved hand and placed them on the pan which was on the stove top. She would wipe her gloved hands on the side of her apron. She walked into the dish room and returned with the blender. She proceeded to place six slices of the pork loin into the food processor and poured some broth into the processor to get the right consistency. She again poured the broth into the food processor and placed the plastic container on the counter. She wiped her hand on the side of her apron. She proceeded to stir the pureed pork loin until the right consistency was reached. She then grabbed several more slices of pork loin with her gloved hand and placed them into the food processor. She added more broth until she got the right consistency. She then walked over to the dish rack and grabbed two small metal containers. She poured the pureed pork into both metal containers and then reached into the food processor and scooped the rest of the pureed pork out with her gloved hand, scraping all pureed out of the food processor and placing it into the metal containers. She opened a sanitizing wipe and cleaned the thermometer and took the temperature. She then wrapped the pureed pork with aluminum foil and then placed it into the heating oven. She wiped her hands on the side of her apron and returned to the food processing area and removed the food processor and took it into the dirty dish area and returned to the serving line. The CK completed the same process for mechanically altered pork. The CK did not perform hand hygiene during this process. CK #1 was observed preparing the pureed bread for the lunch meal. The CK walked into the dirty dish room and retrieved the food processor. She placed it in the food preparation area. She was walking to the other side of the kitchen to retrieve rolls when she grabbed her apron and sneezed several times into her apron holding it with her hand. She proceeded to grab bread rolls and returned to the food preparation area. She then walked into the walk-in refrigerator and grabbed a gallon of milk and proceeded to puree the rolls. She walked over to the dish rack and proceeded to grab a metal container and poured the pureed rollinto the container. She wrapped the container with plastic wrap. The CK did not perform hand hygiene during this process. DA #2 was observed preparing the service ware for the meals. DA #2 placed the utensil into a napkin. DA #2 was observed getting up and leaving the kitchen area several times. DA #2 was observed swatting away flies in the area. She would rub her forearm and then continued to wrap the service ware. DA #2 placed the service ware onto a tray. DA #2 did not perform hand hygiene during this process. DA #1 was observed preparing ham sandwiches for the lunch meals. DA #1 put on a pair of gloves. DA #1 was observed touching her nose and adjusting her glasses. She walked over to the bread rack and grabbed a loaf of bread. She walked into the walk-in refrigerator and retrieved a bag of cheese and placed them on the counter. DA #1 opened the bread and proceeded to grab eight slices of bread, placing them on the side of the green cutting board. DA #1 wiped her forehead and touched her nose. DA #1 then went into the walking refrigerator grabbing the door handle with her gloved hand. She retrieved a bag of cooked ham. DA #1 then reached into the bag of ham, grabbing a slice of ham and cutting each slice in half on the green cutting board. DA #1 then placed the bread on the green cutting board and proceeded to reach into the bag of cheese and would place a slice of cheese on the bread. DA #1 then grabbed a slice of ham and placed it on the bread making a total of four sandwiches. DA #1 would wipe her hand on the side of the apron and continue to touch her face. DA #1 would place her hand on the top of the sandwich and proceed to cut it in half. DA #1 reached above the counter and grabbed small sandwich bags. DA #1 grabbed each sandwich into the bag and then reached into her pocket and retrieved a pen writing the date on the bag. DA #1 completed the same process for four more sandwiches. DA #1 did not perform hand hygiene during this process. III. Staff interview The dietary manager (DM) was interviewed on 7/27/23 at 9:30 a.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. She said staff should never touch ready to eat foods with their hands. She said they should use serving tongs even if they have gloves on and they should use a spatula when taking food out of a container. Staff should wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash their hands between tasks to avoid cross contamination.

Based on record review and interviews, the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to unavailable and missed medications that rose to the scope and severity of immediate jeopardy during the survey on 7/24/23 to 8/14/23. Due to the missed medications, it caused distress and decline to Resident #7 and Resident #25. Findings include:I. Facility policyThe Quality Assessment Performance Improvement Plan, dated 4/3/23, was provided by the nursing home administrator (NHA) on 7/24/23 at 1:00 p.m. It revealed in pertinent part, "Our facility's QAPI plan serves as guide for our overall quality improvement program and initiatives. The decision making within the facility will be driven by quality assurance performance improvement principles. These decisions will assist in promoting quality of care and quality of life of residents. In addition, these principles will lead to an emphasis on resident choice, person directed care and resident transitions. Any system that affects the satisfaction of residents, families and associates will be considered an area of opportunity. This will include systems affecting the quality of care, quality of life and safety of residents."Our QAPI efforts and activities across departments in order to better work together in assuring that areas of concern are being addressed and services are continually improved."The facility provides care and services to residents across the continuum of care. Because these services have an impact on the clinical care of the resident, all departments will be involved in QAPI efforts to continuously improve the clinical care provided. QAPI efforts will also incorporate healthcare partners in order to provide safe, effective care transitions to the residents we serve. These efforts are established in order to continuously improve our services."The QAPI program at this facility is comprehensive, data-driven and involves the full range of care and services offered, including the full range of departments. QAPI principles are utilized in order to align business and clinical care decisions within the facility in order to provide residents with individualized care to meet their specific goals." II. Cross-reference citation Cross-reference F760: The facility failed to ensure Resident #7 had medication available to include vital medications and Resident #25 received all medications as ordered by the medical provider. The facility failed to ensure medications were available for Resident #7 on several occasions including during the recertification process. The facility failed to administer medications to Resident #25, citing the resident was sleeping but failed to notify the providers of the several missed doses. The facility's failure to ensure Residents #7 and #25 received their medications as ordered contributed to Resident #7 experiencing increasing distress (fear, anxiety, behavioral symptoms) and Resident #25 experiencing signs of distress (agitation, behavioral symptoms). The facility's failure to develop, implement, and monitor medication administration processes to prevent repeated, significant medication errors contributed actual decline in Resident #7 and #25's quality of life and created the potential for serious physical and psychosocial harm if the situation was not immediately corrected. III. InterviewsThe director of nursing (DON) and the NHA were interviewed on 8/14/23 at 11:40 a.m. The DON said the missed medications for Resident #7 due to unavailability was investigated and narrowed down to one nurse. She said education was provided by the facility to include the DON and the facility reaching out to the pharmacy consultant to help with education as well. When the facility discovered the medication was still not being administered due to unavailability for Resident #7, they terminated the nurse on 7/11/23. She said she was aware the issue was still occurring during the recertification survey. The DON said the facility knew of non-compliance with the medication pass and educated the nurses on the importance of the medication and the process of ordering medications to prevent running out of the medication. The DON said she did not consider the medications for Resident #25 missed doses. She said the resident had the right to sleep. She said when the nurse documented sleeping it was considered acceptable documentation. She said the doses not given when the resident was sleeping were not communicated with the provider. The DON said as of 8/14/23, the facility was current on notification to providers of missed medications. The DON said the plan going forward was she would implement ordering medications that qualified for auto-refill and until it happened she or a designee would check the medication carts weekly to ensure a minimum of a seven day supply to help prevent future missed doses due to unavailability. She said there would be a review of residents who sleep during medication administration times and contact providers to discuss the medication orders.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on all hand held showers in four of four showers rooms, increasing the risk of contamination to the facility's main water supply. Findings include: I. Backflow prevention devices A. Professional references According to the Environmental Protection Agency's Cross-Connection Control, 11/2/22 https://www.epa.gov/system/files/documents/2021-12/ds-toolbox-fact-sheets_ccc.pdf, it read in pertinent part, "Cross-connections are actual or potential connections between a potable water supply and non-potable water plumbing. Backflow is the unintended reversal of water flow through a cross-connection, which can result in a potentially serious public health hazard. A cross-connection control and backflow prevention program helps prevent contaminants from entering a drinking water distribution system. This fact sheet is part of EPA's (Environmental Protection Agency) Distribution System Toolbox developed to summarize best management practices that public water systems (PWSs), particularly small systems, can use to maintain distribution system water quality and protect public health." B. Observation Observations of the resident living environment conducted on 7/26/23 at 9:11 a.m. revealed: The east, north and west shower rooms did not have backflow valves installed on the hand held showers in all shower rooms. The hand held shower in the west shower room was positioned on the floor of the shower pan. The hand held shower was long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pan. II. Staff interview The maintenance supervisor (MTCE) was interviewed on 7/27/23 at 10:34 a.m. The MTCE observed the hand held shower in all shower rooms. He said the hand held showers on the west, east and north shower rooms should have had functioning backflow prevention valves on them. He said he would place the backflow valves on all of the shower room immediately.

Based on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen was free from flies. Findings include:I. Professional referencesA. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) page 186, "The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by:-Routinely inspecting incoming shipments of food and supplies-Routinely inspecting the premises for evidence of pests-Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and-Eliminating harborage conditions."B. According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019, pp. 95-96:"-Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects should be kept out of all areas of a health-care facility.-From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on:-Excluding pests from entering the indoor environment and-Applying pesticides as needed."II. Main kitchen observations and interviewsOn 7/24/23 at 8:56 a.m., during the initial tour of the main kitchen, two staff members were observed working in the kitchen preparing food and were observed swatting away flies. Flies were observed in all food preparation areas. Two staff members were observed utilizing their hands to clear flies from the area. Several flies were observed on walls, clean dishes, scoops and tongs and the dishwashing machine. The kitchen had four trash cans with all trash cans uncovered. On 7/25/23 at 8:24 a.m., during the morning kitchen tour three staff members were working in the kitchen preparing food, while swatting flies away from the tables, food and themselves. The kitchen had four trash cans with all trash cans uncovered. Observations during lunch preparation on 7/26/23 at 10:30 a.m., revealed flies were around the food racks, counters, service ware and on food which was being prepared for the lunch menu. The flies were observed in the dishwashing area with flies on clean plates and pans stored on the dish racks. A cook was observed swatting flies away with her hand. She said, "These flies are terrible and they are getting worse."The dietary manager was interviewed on 7/27/23 at 9:30 a.m. She said the flies in the kitchen just seem to be getting worse and "I don ' t really know where they are coming from." She said a negative outcome with the flies was the flies could be carriers of bacteria and just a plain nuisance. The maintenance director (MTCE) and pest control technician (PCT) was interviewed on 7/27/23 at 2:59 p.m. The MTCE said he had not heard of any problems with flies in the kitchen. The MTCE said they have two blue lights in the kitchen and may need to add more blue lights to help get rid of the flies. The PCT was told of the observations above of the trash cans not having trash lids. The PCT said that could be the problem of the increase of flies in the kitchen. The MTCE said he would speak with the DM and get some orders.