ATLAS POST ACUTE

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 dry-pipe, automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1963 and is license for 146 beds. This re-certification survey conducted on November 19, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Director of Maintenance during the exit conference conducted at the end on-site survey.

Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:Emergency and Exit Lighting Reports Missing June - July 2024 7.9.3 Periodic Testing of Emergency Lighting Equipment. 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1)Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 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 during the survey and the Maintenance Director and Administrator at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Sprinkler yellow tagged | Both dry system and nitrogen system will need to be repaired NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire Drills Missing | Missing May to August 2024 NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: K918 - Generator Reports Missing No reports for May - July 2024 Conductance testing, Transfer time for the generator 8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Maintenance director at the exit conference.

During the survey, it was determined that the facility trans-fill room did not meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). This was evidenced by:1. Ventilation in Oxygen transfer room | Not NFPA 99 compliant | Need a redesign of ventilation to capture gases from within 12inches from the floor and at ceiling level (D)2012 NFPA 999.3.7.4 The transfilling area shall be ventilated in accordance with NFPA 55, the Compressed Gases and Cryogenic Fluids Code. 9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously unless the authority having jurisdiction approves an alternative design. 9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) off the floor and adjacent to the cylinder or containers. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A recertification survey with complaints #CO36850, #CO37720, #CO37759 and Incident #37981 was completed from 10/16/24 to 10/22/24. One deficiency was cited.

An Emergency Preparedness survey was conducted from 10/16/24 to 10/22/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for three (#38, #18, #23) of three residents out of 32 sample residents. Specifically, the facility failed to provide food choices according to resident preferences for Resident #38, Resident #18 and Resident #23. I. Facility policy and procedureThe Resident Food Preferences policy, revised 2015, was provided by the nursing home administrator (NHA) on 10/22/24 at 4:30 p.m. It read in pertinent part, "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent."Nursing staff will document the resident's food and eating preferences in the care plan."II. Resident #38A. Resident statusResident #38, age greater than 65, was admitted on 5/10/21. According to the October 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with peripheral angiopathy (blood vessel disease). According to the 9/12/24 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set-up assistance with eating. The MDS assessment indicated the resident was on a therapeutic diet. B. Resident interviewResident #38 was interviewed on 10/17/24 at 9:42 a.m. The resident said he received two omelets and two sausage patties for breakfast on 10/17/24. He said he did not receive hard boiled eggs per his preference. He said there were many times he did not get hard boiled eggs with his meals and he felt like he only got them when the staff remembered. Resident #38 was interviewed on 10/21/24 at 12:30 p.m. The resident said he had two omelets and two sausage patties for breakfast on 10/21/24. He said he did not receive any hard boiled eggs. Resident #38 was interviewed on 10/22/24 at 3:56 p.m. Resident #38 said a while back when there was a different DM, he had been asked about his meal preferences and if there was anything he wanted on a regular basis. He said he told the DM he liked cottage cheese and that he wanted two hard boiled eggs with every meal. The resident said the staff did not always come the night before and ask him what he wanted to eat the next day. He said if he got something he did not like, or that was cooked poorly, he would not necessarily ask for anything else. C. Record review and observationsThe resident's care plan, revised 8/21/23, revealed the resident was on a therapeutic diet related to his diagnosis of diabetes. He had the potential for nutrition risk, weight fluctuations, and the potential for inconsistent meal intakes related to personal food preferences. Interventions included providing the therapeutic diet as ordered, honoring food preferences as indicated in the meal tracker application, and offering alternate choices as needed. On 8/13/24, a nutritional risk assessment revealed the goals for Resident #38 included consuming over 75% of meals, maintaining or gradually losing weight until goal weight was reached, continuing with the current diet order, monitor meal intakes, weights, and labs, and honor food preferences as able. The October 2024 CPO revealed the resident was on a consistent carbohydrate (diabetic) diet, with regular textured foods, thin liquid consistency, and double protein/entree portions with all meals related to weight loss, ordered on 3/24/24. Resident #38's meal tickets from 10/17/24 and 10/21/24 revealed the following:Double protein/entree portions with all meals. Per resident's request, no dessert on tray for lunch/dinner; he will season his own food. He does not like oregano or cilantro. He wanted two boiled eggs with each meal. On 10/17/24 at 12:40 p.m. Resident #38 was served his lunch in his room. He received two hamburger patties, onions and two cups of coffee. -The resident did not receive hard boiled eggs with his meal. On 10/21/24 at 12:30 p.m., Resident #38 was served his lunch in his room. He received two cups of coffee, a cup of milk, a side of cottage cheese and two hamburger patties. -The resident did not receive hard boiled eggs with his meal. D. Staff interviewsThe dietary manager (DM) was interviewed on 10/21/24 at 3:14 p.m. The DM said the resident's food preferences were obtained within 48 hours of their admission to the facility and yearly after that unless something changed. The DM said she used a dietary interview sheet to obtain the residents'likes, dislikes and preferences. The DM said if the resident's preference or situation changed, she filled out a communication sheet for staff and entered it into the computer system so it printed out on the resident's meal ticket. The registered dietitian (RD) and speech therapist (ST) were interviewed together on 10/22/24 at 2:18 p.m. The RD said Resident #38's original preference sheet, dated 3/7/24, did not indicate a preference for hard boiled eggs with meals. She said the resident likely requested the two hard boiled eggs from the DM by going directly to the kitchen. The ST said the certified nurse aides (CNA) that worked on night shift verified preferences with residents. She said unless a resident said otherwise, they would get those preferences the next day with their meals. She said if a resident did not want their usual preference, the CNAs crossed the preference off their ticket. The ST and the RD said if hard boiled eggs were on Resident #38's meal ticket as his preference, he should have gotten them. The ST said if Resident #38 did not get his eggs, then staff probably did not read the meal ticket. The ST said it was possible that they did not give him the eggs because of what else he had for his meal, like an omelet, but that should have been clarified with the resident first. She said Resident #38 was vocal about making his needs known and he knew he could request eggs if he did not get them. The RD and the ST said the diet orders and preferences on meal tickets should be followed, otherwise residents could choke on a texture they could not handle and the RD could not obtain accurate calorie counts. The ST and the RD said they had educated the kitchen staff on preparing meal trays, verifying orders and preferences with residents and double-checking that resident meals were correct. The ST and the RD said they also audited resident diet orders and preferences every two weeks. CNA #1 was interviewed on 10/22/24 at 3:23 p.m. CNA #1 said menus came out overnight and CNAs asked residents what meals they wanted for the next day. She said the CNAs also double checked to make sure the resident's preferences were up-to-date. She said if the resident did not want what was on the regular menu they could choose from the bistro menu, and the CNAs wrote that on the resident's meal ticket. CNA #1 said when she passed trays at mealtime, she checked the ticket and tray for accuracy, and if something was missing she went to the kitchen to get the missing item. She said the residents knew they could ask for specific items, especially if they were missing from their order. She said the CNAs offered to get requested items for residents. CNA #1 said if food or drink preferences were listed on the ticket, then the resident should be getting those items. She said if a resident specified they wanted hard boiled eggs at every meal and that was written on the ticket, she said she assumed the resident should get them at every meal even at breakfast, unless when asked, the resident said they did not want them at breakfast. CNA #2 was interviewed on 10/22/24 3:42 p.m. CNA #2 said she thought food preferences were obtained upon admission and then added to the meal tickets. She said when trays were passed in the morning, CNAs could ask preferences then and go get different items if the resident requested. She said Resident #38 liked two cups of cottage cheese with his meals, hard boiled eggs and no dessert. She said with breakfast, he still wanted the hard boiled eggs even if he had omelets for his main meal. She said the CNAs noticed if the resident was missing something and they would go get the missing item for him. III. Resident #18 A. Resident status Resident #31, age 72 , was admitted on 5/31/22 and readmitted on 3/1/24. According to the October 2024 CPO, diagnoses included peripheral vascular disease (blood vessels narrow and reduce blood flow), bipolar disorder (a mental illness that causes extreme mood swings) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). The 8/21/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment revealed the resident was on a mechanically altered diet and a therapeutic diet. B. Resident interview Resident #18 was interviewed on 10/16/24 at 11:17 a.m. She said she liked small meals and her meat chopped up because she did not have all her teeth. She said she was not always served small meals. C. Observations On 10/21/24 at 11:30 a.m., cook (CK) #1 prepared Resident #18's lunch meal. CK #1 served Resident #31 a regular portion of ground chicken with sauce, a regular portion of chopped buttered egg noodles with gravy and a regular portion of chopped squash medley. Resident #18's meal ticket indicated she preferred a small portion for lunch. D. Record review The nutrition care plan, revised 8/13/24, revealed the resident received small portion lunches per preference. Interventions included honoring the resident;s food preferences as noted on the tray card system. The 8/20/24 nutritional assessment revealed the resident's likes and dislikes section documented to refer to the resident's meal ticket. IV. Resident #23A. Resident status Resident #23, age 73, was admitted on 5/23/23 and readmitted on 9/6/24. According to the October 2024 CPO, diagnoses included peripheral vascular disease, cerebral infarction (disrupted blood flow to the brain), malignant neoplasm of the colon (colon cancer), anoxic brain injury (brain deprived of oxygen), psychotic disturbance, mood disturbance, anxiety and severe protein-calorie malnutrition (the body does not get enough foot, protein, and calories). The 9/26/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15The MDS assessment revealed the resident was on a mechanically altered diet and a therapeutic diet. B. Resident representative interview Resident #23's representative was interviewed on 10/17/24 at 8:51 a.m. She said the facility called her to see if the resident could take an antidepressant medication because the medication helped increase appetite. She said she asked the facility to offer food he liked to eat to help with his food intake. The representative said Resident #23 liked pancakes, biscuits and gravy and apples. The representative said the resident had an apple fritter recently and an unknown staff member said they would see if he could have more apples in his diet. C. Record review The nutrition care plan, revised 9/10/24, revealed the resident received double portions for all meals. The 9/9/24 nutritional interview revealed the resident liked applesauce as a snack. -The nutritional interview did not document the resident's likes and did not indicate the resident was to receive double portions for all meals. The 10/1/24 interdisciplinary team progress note revealed the resident enjoyed biscuits and gravy and would provide double portions when available. The 10/22/24 interdisciplinary team weight progress note revealed the resident received white gravy at breakfast per his request. The facility provided a grievance form and investigation document for Resident #23. The 9/20/24 grievance form revealed the resident asked for more pureed eggs. The kitchen staff said there were no pureed eggs available. The investigation revealed dietary staff were educated on 9/20/24. The investigation revealed if the dietary staff ran out of a serving, they should prepare more on the spot to meet the resident's request. V. Staff interviewsThe DM was interviewed on 10/21/24 at 3:13 p.m. The DM said she was responsible for obtaining the resident's food preferences. She said she reviewed the food preferences at admission, annually and as needed. She said she documented the preferences on the dietary interview form. She said dietary staff knew a resident's food likes and dislikes based on the resident's meal ticket. The DM said Resident #18 preferred small portions at lunch. She said she did not know Resident #18 received a regular portion of the lunch meal on 10/21/24. She said she would work with the staff to ensure resident's received their food preferences. The DM said Resident #23 liked white gravy, hamburgers and biscuits with gravy. The DM said the meal ticket should indicate to serve double portions of biscuits of gravy. The RD and the ST were interviewed on 10/22/24 at 2:17 p.m. The RD said the DM was responsible for obtaining the resident's food preferences. The RD said the food preferences interview was completed at admission, annually and as needed. The ST said the resident's food preferences were also changed if the resident had weight changes or if their diet order changed based on their therapy sessions. The RD said a resident's routine likes were placed on the meal ticket. The ST said the DM, the RD and the ST had access to the resident's meal tickets. The RD and the ST said Resident #18 preferred small portions at lunch. The RD and the ST did not know Resident #18 received a regular portion of the lunch meal on 10/21/24. The NHA was interviewed on 10/22/24 at 11:11 a.m. The NHA said a dining committee meeting was started about four to five months ago because there was a high number of food grievances. The NHA said the residents who filed a grievance about food were invited to the dining committee. The NHA said another intervention included the manager on duty did a test tray once a day for quality assurance. The NHA said she was not aware Resident #18 was not served a small portion on 10/21/24 and Resident #23 was not served a double portion on 10/21/24 per their preferences. VI. Facility follow up The NHA provided an inservice agenda and sign in sheet on 10/22/24 (during the survey). The nursing and dietary staff were trained on 10/22/24. The training included for the staff to read the resident's meal ticket before giving the meal to the resident. The training said the staff should ensure the resident received the correct diet order, fluids, portion sizes, quantity and supplement. The NHA provided a meal ticket for Resident #23. It revealed the double portion preference was removed. -However, the resident's preference for double portions when biscuits and gravy was on the menu was missing from the meal ticket.

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

A revisit survey was completed on 6/20/24 for all previous deficiencies cited on 4/30/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO36341 and #CO36402 was conducted on 6/11/24. No deficiencies were cited.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 dry-pipe, automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1963 and is license for 146 beds. This re-certification survey conducted on May 28, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Director of Maintenance during the exit conference conducted at the end on-site survey.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency. 1. Kitchen egress door for kitchen no egress sign | Once sign-age is added egress gate will need to be made on motion also NFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. NFPA 101 7.9.2.5 Unit equipment and battery systems for emergency luminaires shall be listed to ANSI/UL 924, Standard for Emergency Lighting and Power Equipment. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. No inspection report available for the kitchen hood system for November NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.4 Table Systems serving moderate-volume cooking operations SemiannuallyThis 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 a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Fire Alarm Panel | Trouble on fire alarm in need of repair NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Biohazard room not sprinklered | Facility Required to sprinkled throughout | Sprinkler head appeared to be removedNFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design or as directed by the authority having jurisdiction. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 1051. Dampers failed on inspection report | facility currently getting damper repaired | item is deficient until repair completed NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. LSC 19.5.2.1 requires air conditioning, heating, ventilating ductwork and related equipment to be installed in accordance with NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 4.3.12.1.1 states egress corridors shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.3.1 through 4.3.12.1.3.4This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A recertification survey with Incident #35155 was completed on 4/24/24 to 4/30/24. Four deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/24/24 to 4/30/24. One deficiency was cited.

Based on record review and interviews, the facility failed to have a complete emergency preparedness communication plan. Specifically, the facility failed to include all contact information for entities providing services under arrangement, which included hospice providers. Findings include: I. Record reviewThe emergency preparedness plan (EPP) was provided by the maintenance director (MTD) on 4/30/24 at 9:20 a.m. -Review of the EPP revealed the facility did not have all contact information for hospice providers included in the EPP. II. Staff interview The EPP was reviewed with the MTD on 4/30/24 at 9:20 a.m. The MTD said the facility did not have all contact information for the hospice providers in the EPP.The MTD said it was important to have all the contact information in case the facility needed to contact the hospice providers for residents who were receiving hospice services. The MTD said it was important to update the EPP annually and as needed to keep up with the requirements.

Based upon observations, interviews and record review, the facility failed to ensure one (#32) of three residents reviewed for assistance with activities of daily living (ADL) received fingernail care out of the 31 sample residents. Specifically, the facility failed to ensure Resident #32's fingernails were trimmed and clean. Findings include: I. Facility policy and procedure The Fingernails/Toenail policy, revised February 2018, was provided by the nursing home administrator (NHA) on 4/30/24 at 1:56 p.m. It revealed in pertinent part, "The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. "Nail care includes daily cleaning and regular trimming. "Proper nail care can aid in the prevention of skin problems around the nail bed. "Trimmed and smooth nails prevent residents from accidentally scratching and injuring their skin."II. Resident #32 A. Resident status Resident #32, age greater than 65, was admitted on 5/25/23. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, muscle weakness, and anoxic brain damage (brain injury related to lack of oxygen). The 2/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He required one person physical assistance with transfers. He required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene. B. ObservationsOn 4/24/24 at 10:21 a.m., Resident #32 was lying in bed. Resident #32's fingernails were visibly soiled. The resident's fingernails were dirty with a dark substance underneath several nails. The resident's fingernails were untrimmed and approximately one inch long. On 4/25/24 at 1:50 p.m. the resident was sitting in his wheelchair in the 600 hall dining room watching television. The resident's fingernails were untrimmed, visibly soiled and had a dark substance under several nails. On 4/29/24 at 3:15 p.m. Resident #32 was observed in his bed in his room. His fingernails were untrimmed and were one inch long. There continued to be dark debris underneath his fingernails. On 4/30/24 at 11:14 a.m. the resident was observed with trimmed but dirty fingernails (dark debris) underneath several nails.-CNA #1 trimmed Resident #32's fingernails on 4/29/24 but did not clean the dark debris from underneath the nails. C. Record review The comprehensive care plan, revised 1/30/24, revealed the resident was at risk for skin breakdown related to anoxic brain damage, generalized weakness, decreased mobility and self inflicted scratches to arms. The interventions included encouraging the resident to allow his fingernails to be trimmed and cleaned. The 2/4/24 progress note documented the resident received fingernail care because his fingernails were long and dirty with dark debris underneath his nails. The resident tolerated it with no behaviors.-However, a review of the resident's electronic medical record (EMR) on 4/30/24, did not reveal documentation to indicate the resident had received further nail care since 2/4/24. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/29/24 at 1:25 p.m. CNA #1 said Resident #32 required assistance with his activities of daily living (ADL), including trimming his fingernails. She said the resident's fingernails were long and had a dark substance underneath them. CNA #1 said dirty and long fingernails could cause injuries such as skin tears.. CNA #1 said she would assist the resident with fingernail care. Licensed practical nurse (LPN) #2 was interviewed on 4/29/24 at 1:40 p.m. LPN #2 said Resident #32 was dependent on staff and required total assistance with his ADLs. LPN #2 said the CNAs were res

Based on observations, record review and interviews, the facility failed to ensure one (#27) of five residents reviewed for unnecessary medications out of 31 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure a resident with a continuous glucose monitor was monitored effectively to include frequency of the glucose monitor changes, training staff on the continuous glucose monitor, and care planning the use of a continuous glucose monitor. Findings include:I. Professional referenceAccording to the Freestyle Libre 2 continuous glucose monitor manufacturer's guidelines, retrieved on 5/1/24 from https://www.freestyle.abbott/us-en/safety-information.html, "What should you know about wearing a Sensor:"-The Sensor can be worn for up to 14 days."-Some individuals may be sensitive to the adhesive that keeps the Sensor attached to the skin. If you notice significant skin irritation around or under your Sensor, remove the Sensor and stop using the System. Contact your healthcare professional before continuing to use the System."-Intense exercise may cause your Sensor to loosen due to sweat or movement of the Sensor. Remove and replace your Sensor if it starts to loosen and follow the instructions to select an appropriate application site."-The System uses all available glucose data to give you readings so you should scan your Sensor at least once every 8 hours for the most accurate performance. Scanning less frequently may result in decreased performance."-Do not reuse Sensors. The Sensor and Sensor Applicator are designed for single use. Reuse may result in no glucose readings and infection. Not suitable for re-sterilization. Further exposure to irradiation may cause inaccurate results."-If a Sensor breaks inside your body, call your healthcare professional."According to the Freestyle Libre 2 continuous glucose monitor manufacturer's guidelines, retrieved on 5/1/24 from https://www.freestyleprovider.abbott/us-en/monitoring-freestyle-libre.html. "Easy to monitor: FreeStyle Libre 2: Minute-to-minute glucose readings stream directly to your patients' smartphones."II. Resident #27A. Resident statusResident #27, age 68, was admitted on 12/1/23. According to the April 2024 computerized physician's order (CPO), diagnoses included Type I diabetes mellitus, muscle weakness and chronic pain. The 3/1/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interviewResident #27 was interviewed on 4/24/24 at 9:50 a.m. Resident #27 said he had a continuous glucose monitor. He said he would report his blood glucose levels to the nurse three times a day when he received the blood glucose levels on his smartphone. C. Record reviewThe care plan, initiated 12/7/23 and revised 4/26/24, identified Resident #27 had a diagnosis of diabetes. Interventions included obtaining blood glucose checks as ordered and reporting to the physician if the blood glucose was outside of set parameters.-The diabetic care plan did not address the use of a continuous glucose monitor. The April 2024 CPO documented the following physician's orders: Monitor the blood sugar via cgm (continuous glucose monitor) to the upper arm before meals every day (QD). Ordered 3/20/24. Okay to use Freestyle Libre 2 cgm (continuous glucose monitor). Ordered 3/7/24.-The April 2024 CPO did not identify the frequency of cgm (continuous glucose monitor) changes or identify that the resident was to report blood glucose levels to the nurse that he received on his smartphone.-The facility was unable to provide documentation to indicate the staff had been trained on how to use Resident #27's Freestyle Libre 2 cgm (continuous glucose monitor). II. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 4/29/24 at 10:40 a.m. LPN #2 said she had not received any training on the continuous glucose monitor. She said she thought the continuous glucose monitor would be changed every eight days. She said there was not an order that identified the day the continuous glucose monitor needed to be changed. She said Resident #27 reported his blood sugars to the nurse on duty. The director of nursing (DON) was interviewed on 4/29/24 at 4:10 p.m. The DON said Resident #27 reported his blood sugars to the nurse. She said he would get the readings on his phone. She said he changed his monitor by himself and kept his own supplies. She said the facility should have kept track of the frequency for when the continuous glucose monitor needed to be changed. She said the continuous glucose monitor was good for 14 days and she would provide education to the staff. She said the facility had just completed an assessment that identified he was able to change his monitor on his own. She said the assessment should have been done sooner. She said there should have been a care plan to identify the use of a continuous glucose monitor. She said the facility would revise the care plan and train the staff on the Freestyle Libre 2 continuous glucose monitor.

Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for one (#20) of three residents reviewed for respiratory care out of 31 sample residents. Specifically, the facility failed to ensure Resident #20 received oxygen therapy in accordance with the physician's order. Findings include:I. Facility policy and procedureThe Oxygen Administration policy, revised October 2010, was provided by the nursing home administrator (NHA) on 4/29/24 at 1:59 p.m. It revealed in pertinent part, "The purpose of this procedure is to provide guidelines for safe oxygen administration."Verify that there is a physician' s order for this procedure. Review the physician' s orders or facility protocol for oxygen administration."Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered". II. Resident #20 A. Resident statusResident #20, age greater than 65, was admitted on 6/6/23. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, anxiety disorder, malignant neoplasm of an unspecified part of the left lung (lung cancer), chronic obstructive pulmonary disease (airflow blockage) and type two diabetes (abnormal glucose levels). The 2/13/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required two person physical assistance for transfers and one person physical assistance with bed mobility, dressing, eating, toileting and personal hygiene. The MDS assessment indicated the resident used oxygen therapy. B. ObservationsOn 4/24/24 at 9:20 a.m., Resident #20 was lying in bed with oxygen in place via nasal cannula. The oxygen concentrator was set at 4 liters per minute (LPM) via nasal cannula. On 4/25/24 at 10:50 a.m. the resident was lying in bed. There were two unidentified staff members in her room assisting her to reposition in bed. The oxygen concentrator was set at 4 LPM of oxygen via nasal cannula. On 4/29/24 at 2:15 p.m. the resident was receiving oxygen at 4 LPM via nasal cannula. On 4/30/24 at 9:14 a.m. the resident was receiving oxygen at 4 LPM via nasal cannula. C. Record reviewThe respiratory care plan, revised 10/10/24, documented the resident required oxygen therapy related to ineffective gas exchange. The interventions included applying oxygen via nasal cannula at 3 LPM continuously and administering medications as ordered by the physician. The April 2024 CPO documented a physician's order for oxygen to be set 3 LPM via nasal cannula continuously to keep the resident's oxygen saturation at or above 90%, ordered on 12/28/24. A review of the April 2024 medication administration record (MAR) from 4/1/24 to 4/30/24 documented the licensed nursing staff documented the resident received 3 LPM of oxygen via nasal cannula.-However, observations on 4/24/24, 4/25/24, 4/29/24 and 4/30/24 revealed the resident was receiving 4 LPM. III. Interviews Certified nurse aide (CNA) #1 was interviewed on 4/29/24 at 1:20 p.m. CNA #1 said the nurses communicated the oxygen rates for each resident to the CNAs. She said the CNAs did not adjust the oxygen settings. She said the licensed nurses set the liter flow on the resident' s oxygen concentrator. CNA #1 said Resident #20's concentrator was set at 4 LPM of oxygen per nasal cannula. Licensed practical nurse (LPN) #2 was interviewed on 4/29/24 at 1:35 p.m. LPN #2 said Resident #20 was receiving 4 LPM of supplemental oxygen. LPN #2 said Resident #20 should have been receiving 3 LPM of oxygen according to the physician' s order. LPN #2 said the physician orders needed to be followed as written to ensure residents received the correct treatments and medications. LPN #2 said the physician should have been contacted to obtain a new order if there was a need to increase the resident's oxygen from 3 LPM to 4 LPM. The director of nursing (DON) was interviewed on 4/30/24 at 2:00 p.m. The DON said a physician's order was required for any medication and treatments. She said in an emergent situation, oxygen could be administered or increased, but a physician's order should be obtained within 24 hours of the change. The DON said it was the responsibility of the licensed nurses to ensure residents were on the correct liter flow of oxygen at the beginning of their shift. The DON said not following the physician' s order could result in medical complications such as shortness of breath, cell damage to the brain. She said she would provide education to the floor nurses to prevent future errors.

Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on two of two medication carts. Specifically, the facility failed to:-Ensure insulin (medication for diabetes) pen injection devices were labeled appropriately with open dates; and,-Ensure inhaler medications were labeled appropriately with open dates. Findings include: I. Professional references According to the Lantus glargine insulin package insert, retrieved 5/6/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, "When in use can be kept at room temperature for up to 28 days." According to the Humalog package insert, retrieved on 5/6/24 from https://uspl.lilly.com/humalog/humalog.html#ug, "Do not use Humalog past the expiration date printed on the label or 28 days after the first usage." According to the Fluticasone inhaler manufacturer's guidelines, retrieved on 5/6/24 from https://www.advair.com/, "Store Fluticasone inhaler in the unopened foil pouch and only open when ready for use. Safely throw away Fluticasone in the trash one month after it is opened or when the counter reads zero, whichever comes first."II. Facility policy and procedures The Storage of Medication policy, revised November 2020, was provided by the nursing home administrator (NHA) on 4/29/24 at 4:50 p.m. It revealed in pertinent part, "The facility stores all drugs and biologics in a safe, secure and orderly manner. "The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. "Medications are stored separately from food and are labeled accordingly." III. Observations and staff interviews On 4/29/24 at 9:55 a.m., the 400 hall medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:-One Fluticasone inhaler that did not have an open date. The medication's box indicated the medication needed to be disposed of one month after opening; and, -One Humalog insulin pen with no open date. LPN #1 was interviewed on 4/29/24 at 10:00 a.m. LPN #1 said insulin medications should be dated when opened to determine when it needed to be discarded..LPN #1 said the medication's box indicated to discard the Fluticasone inhaler one month after opening. LPN #1 said the inhaler was not dated and unsure when it was opened. The 500 hall medication cart was reviewed on 4/29/24 at 10:05 a.m. with LPN #2. The following items were found:-One Humalog insulin pen that was dated with a date of opened 2/22/24; and, -One Lantus insulin pen with a date of opened 3/19/24.-The Humalog insulin pen should have been disposed of on 3/21/24 and the Lantus insulin pen should have been disposed of on 4/16/24. LPN #2 was interviewed on 4/29/24 at 10:10 a.m. LPN #2 said Humalog and Lantus insulin pens were good for 28 days after they were opened. LPN #2 said after 28 days, it was possible the medication would be dangerous to administer to a resident. He said open dates were important to know, as some medications were only good for a specific number of days. The director of nursing (DON) was interviewed on 4/30/24 at 2:10 p.m. The DON said medications such as insulin and inhalers should be labeled with the resident's name and the date it was opened. The DON said some medications were only good for a certain number of days after they were opened. She said the effects of the medication could decrease if it was administered after the date it should have been disposed of. The DON said she would provide education for the nursing staff right away.

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 1/31/24 for all previous deficiencies cited on 12/26/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 12/26/23 for all previous deficiencies cited on 11/2/23. Two deficiencies were cited.

A revisit to the 11/2/2023 survey was completed on 12/26/2023. The facility was in compliance with the regulation surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 dry-pipe, automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1963 and is license for 146 beds. This re-certification survey conducted on November 27, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Director of Maintenance during the exit conference conducted at the end on-site survey.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 1011. Emergency and Exit light annual 90 minute report not available for surveyor 2. Exit sign near room 207 backup battery not working 3. Exit in laundry room does not have a UL Listed Exit signNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 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, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency. Exit sign needed at the end of hallway, near room 314 and opposite hallwayNFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. NFPA 101 7.9.2.5 Unit equipment and battery systems for emergency luminaires shall be listed to ANSI/UL 924, Standard for Emergency Lighting and Power Equipment. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. Hood Suppression | 11/16/23 Report provided | previous inspection report not available for surveyor review 2. Hood Cleaning | 01/13/23 Report provided | latest inspection report not available for review NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.4 Table Systems serving moderate-volume cooking operations SemiannuallyThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. 1. Room 106 - hole in ceiling inside closet 2. Holes in ceiling and around sprinkler pipe in Fire sprinkler Control Room 3. Medical Room behind front desk - hole in ceiling 4. Assistant Director of Nursing office - hole in ceilingNFPA 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 withinthe entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire Drills missing drills for February and March 2023 for second and third shift. Drills being performed within one hour of each otherNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. 1. Oxygen Room - Helium cylinder needs to be removed from room 2. Area needs labeling and proper storage for full and empty tanks. 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. 11.5.2.2 Transfilling Cylinders. 11.5.2.2.1 Mixing of compressed gases cylinders shall be prohibited. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on 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:Polarity and retention | rooms 301,303,304,309,311,403,414,512 failed | no repair report availableNFPA 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 and maintenance director at the exit conference.

A recertification survey with complaint #CO33986 was completed on 10/30/23 to 11/2/23. Seventeen deficiencies were cited.

An Emergency Preparedness survey was conducted from 10/30/23 to 11/2/23. No deficiencies were cited.

Based on observations, record review and staff interviews the facility failed to ensure the right to self administer medications appropriately in one (#34) out of 39 sample residents. Specifically, the facility failed to-Ensure Resident #34 had an evaluation and a physician's order for Resident #34 to self administer eye drops and nasal spray at the bedside; and,-Ensure Resident #34 had a physician's order to self administer inhalers at the bedsideFindings include:I. Facility policy and procedureThe Self Administration of Medications policy and procedure, reviewed February 2021, was provided by the NHA on 11/2/23 at 1:00 p.m. It read in pertinent part,"As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT ) assesses each resident's cognitive and physical abilities to determine whether self administering medication is safe and clinically appropriate for the resident.""Self administered medications are stored in a safe and secure place, which is not accessible by other residents.""Any medications found at the bedside that are not authorized for self administration are turned over to the nurse in charge for return to the family or responsible party."II. Resident #34A. Resident statusResident #34, age 87, was admitted on 10/2/15. According to the November 2023 computerized physician orders (CPO) the diagnoses included COPD.The 8/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She was independent with eating, toileting, transfers and required set up only for personal hygiene. B. ObservationsOn 10/30/23 at 2:45 p.m. Resident #34 had combivent inhaler, advair inhalers, fluticasone nasal spray and eye drops on her bedside table. C. Record reviewThe medication self administration care plan, initiated 5/3/18, revealed the resident chooses to self administer medications and keep Aspercreme with lidocaine at bedside in a locked drawer. Interventions included obtaining a physician's order to store the medication at the bedside and obtaining a complete physician's order for the resident to self administer the specific medication.-A comprehensive review of the care plan failed to reveal care planned interventions for the self administration of Combivent and Advair inhalers, fluticasone nasal spray or eye drops. The November 2023 CPO did not reveal documentation of a physician's order for self administration of Combivent inhaler, Advair inhaler, fluticasone nasal spray or eye drops. The Self Administration of Medications evaluation, dated 6/22/23, revealed Resident #34 could self administer inhaled and nebulized medications and keep by the bedside.-The self administration of medication evaluation indicated that nasal or eye medications could not be self administered. A physician order was obtained on 11/1/23, during survey, that Resident #34 could self administer inhalers and keep them at the bedside. III. Staff interviewsLPN #3 was interviewed on 11/1/23 at 10:00 a.m. She said residents who self administer medications need a physician order and should be documented on the medical administration record (MAR) . She was not aware that a self evaluation needed to be done prior to allowing a resident to self administer or keep medications at the bedside. The DON was interviewed on 11/1/23 at 10:25 a.m. She said a self administration evaluation was completed and medications that could be self administered identified. She said there needs to be a physician order for which medications could be self administered. She said these medications needed to be locked up at the resident's bedside to keep medications from getting in the hands of other residents. She said that Resident #34 had been self administering her inhaler medications but was not allowed to self administer the nasal spray or eye drops. She said the nasal spray and eye drops should be administered by a nurse and locked back into the medication administration cart.

Based on record review and staff interviews, the facility failed to inform residents of the facility's bed hold policy for one (#85) of three residents reviewed for discharge/transfer out of 39 sample residents. Specifically, the facility failed to ensure Resident #85 or their responsible party were informed in writing of the facility's bed hold policy prior to being discharged or transferred from the facility. Findings include:I. Facility policy and procedure The Bed Holds and Returns policy, dated October 2022, was provided by the director of nurses (DON) on 11/2/23. The policy read in pertinent part, "All residents/representatives are provided written information regarding the facility and state bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalizations). Residents, regardless of payer source, are provided written notice at least twice:a. Notice 1: well in advance or any transfer (admission packet); andb. Notice 2: at the time of transfer (or if the transfer was an emergency, within 24 hours)."II. Resident #85A. Resident statusResident #85, under age 65, was admitted on 12/1/22 and readmitted on 9/30/23. According to the October 2023 computerized physician orders (CPO) diagnoses included cerebral palsy, legal blindness, reduced mobility, major depressive disorder, personality disorder, complete paraplegia and history of diseases of the musculoskeletal system and connective tissue. The 10/4/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, toileting, extensive one person assistance with personal hygiene and set up assistance for eating. B. Resident representative interviewThe resident's responsible party was interviewed on 11/2/23 at 1:00 p.m. The resident's responsible party said the resident was discharged to the hospital for pain. She said she nor her daughter received written notice about a bed hold notice upon transfer, which was described the bed hold policy. B. Record reviewThe 10/13/23 progress note documented the resident was discharged to the hospital. The paramedics transported the resident to the hospital. -The medical record failed to show a written bed hold policy was provided for the discharge to the hospital on 10/13/23. C. InterviewThe director of nurses (DON) was interviewed on 11/3/23 at 11:00 a.m. The DON said the bed hold policy was to be provided in writing to the resident/responsible party upon discharge. The DON reviewed the medical record and was unable to locate any documentation that the bed hold policy was provided in writing to the resident/responsible party.

Based on record review and interviews the facility failed to coordinate assessments with the preadmission screening and resident review (PASRR) program for two (#16 and #32) of nine residents reviewed for PASRR out of 39 sample residents. Specifically, the facility failed to:-Ensure a PASRR level II evaluation was available in the medical record of Resident #16 with a known major mental illness; and,-Ensure a PASRR level II evaluation was completed for Resident #32 after the resident was identified as having a known major mental illness. Findings include:I. Facility policy and procedureThe PASRR policy and procedure, with no review date, was received by the nursing home administration (NHA) on 11/1/23 at 1:50 p.m. It read in pertinent part: "This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. A record of the pre-screening shall be maintained in the resident's medical record. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care."II. Resident #16A. Resident statusResident #16, age 83, was admitted on 9/30/15. According to the October 2023 computerized physician orders (CPO), the diagnoses included depression and bipolar disorder. The 8/11/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervised assistance with transferring, dressing, toilet use and personal hygiene. The PASRR was not coded on the assessment. The 2/26/23 MDS assessment coded the resident had not been evaluated by a level II PASRR. B. Record reviewThe 3/9/2020 post admission PASRR/status change revealed Resident #16 was being reviewed for a change in a psychiatric medication, no serious symptoms were reported by facility and a level II PASRR was already in place at the facility. The mood and symptoms care plan, with a review date of 9/21/23, revealed Resident #16 was at risk for distressing and fluctuating mood symptoms related to depression and bipolar disorder, symptoms included angry outbursts. It indicated the resident would verbalize thoughts and feelings that contribute to depression and the resident would engage in counseling or supportive relationships. Interventions included attempting non pharmacological interventions such as music, art, pet visits, empowering activities such as a volunteer job or engaging in resident council and encouraging the resident to participate in weekly counseling sessions.-The facility failed to produce a PASRR level II evaluation for Resident #16, nor was there a care plan pertaining to any evaluation recommending interventions from an evaluation. -The facility failed to produce any documentation of counseling sessions for Resident #16. III. Resident #32A. Resident statusResident #32, age 69, was admitted on 3/1/23. According to the October 2023 CPO, the diagnoses included anxiety and schizophrenia. The 9/11/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He was independent with transferring, toilet use and personal hygiene. The PASRR was not coded on the assessment. The 3/8/23 MDS coded the resident had been evaluated by a level II PASRR and determined to have a serious mental illness. B. Record review The 7/6/23 PASRR level I revealed Resident #32 would require a level II evaluation regarding known or suspected major mental illness and the facility would be contacted by a PASRR employee regarding scheduling the level II evaluation. The mood and behavior care plan, with a review date of 9/21/23, revealed Resident #32 was at risk of presenting with distressing or fluctuating mood and behaviors related to a diagnosis of schizophrenia, he would become hyper-fixated for short periods of time and facility was monitoring episodes and behaviors of increased rapid pacing and rapid speech. It indicated the resident would demonstrate an improved mood state as evidence by displaying a happier demeanor. Interventions indicated Resident #32 enjoyed listening to music, walking around, socializing with various staff members, being provided supportive visits by social services as needed and watching television in his room. IV. Staff interviewThe social services director (SSD) was interviewed on 11/1/23 at 10:30 a.m. She said every resident admitting to a long term care facility must have a PASRR completed. She said a PASRR was required by a facility to ensure care needs could be met for any resident identified as having a major mental illness. She said it was the responsibility of the hospital or referring facility to make the PASRR referral or the responsibility of the facility to make the PASRR referral if a resident admitted from their home in the community. She said she had only been working in the building since August 2023 and would attempt to locate PASRR level II evaluations for Resident #16 and #32. The nursing home administrator (NHA) was interviewed on 11/1/23 at 1:20 p.m. She said the facility had recognized a lack of follow through with PASRR not being submitted timely and were in the process of conducting a facility audit. She said the goal of the audit was to ensure resident needs were being identified timely. The SSD provided PASRR update on 11/1/23 at 2:38 p.m. regarding Resident's #16 and #32. She was unable to receive the PASRR level II evaluation for Resident #16 as the national provider identifier (NPI- numerical identifier that identifies an individual provider or a healthcare entity) had changed. She said a PASRR level II evaluation was never completed for Resident #32 because the previous social worker had not followed through on scheduling.

Based on record review and interviews, the facility failed to submit a preadmission screening and resident review (PASRR) level I for one (#23) of four residents reviewed for PASRR out of 39 sample residents. Specifically, the facility failed to submit a PASRR level I for Resident #23 who was admitted with a known major mental illness. Findings include:I. Facility policy and procedureThe PASRR policy and procedure, with no review date, was received by the nursing home administration (NHA) on 11/1/23 at 1:50 p.m. It read in pertinent part: "This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions."II. Resident statusResident #23, age 75, was admitted on 6/6/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included major depressive disorder and anxiety. The 9/11/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She required supervision of one staff member with transferring, dressing, toilet use and personal hygiene. The PASSRR was not coded on the assessment. The 6/13/23 MDS assessment coded the resident had not been evaluated by level II PASRR. III. Record reviewThe October 2023 medication administration record (MAR) revealed Resident #23 had orders for Trazadone (antidepressant) for a diagnosis of insomnia, venlafaxine (antidepressant) for diagnosis of depression, seroquel (antipsychotic) for behavior management and ativan (antianxiety) for diagnosis of terminal agitation. The psychotropic medication use care plan, with a last review date of 9/21/23, revealed Resident #23 was at risk for complications related to the use of seroquel, trazodone, ativan and venlafaxine. It indicated she would use the smallest, most effective dose, without side effects for 90 days. Interventions included completing behavior monitoring, monitoring for changes in mental status and functional levels, monitoring for continued need of medication as related to mood and behaviors and monitoring for side effects and consulting physician or pharmacist as needed. -The facility failed to have a PASRR on file for Resident #23IV. Staff interviewsThe nursing home administrator (NHA) was interviewed on 11/1/23 at 1:20 p.m. She said the facility had recognized a lack of follow through with PASRR not being submitted timely and were in the process of conducting a facility audit. She said the goal of the audit was to ensure resident needs were being identified timely. The social services director (SSD) was interviewed on 11/1/23 at 3:00 p.m. She said every resident admitting to a long term care facility must have a PASRR level I completed. She said a PASRR was required by the facility to ensure care needs could be met for any resident identified as having a major mental illness. She said she could not find documentation or any record of a PASRR level I being completed for Resident #23. She said a PASRR level I would be completed and submitted to the overseeing State Agency for Resident #23.

Based on observations, record review and staff interviews the facility failed to provide services for three (#4, #12 and #36) of four reviewed out of 39 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #4, Resident #12 and Resident #36's vital signs were monitored prior to the administration of a blood pressure medication. Findings include:I. Professional referenceKhashayar. F., Arif, J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine.https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 11/8/23. "Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur."The patient's heart rate and blood pressure require monitoring while using beta-blockers."Kizior, R. J, Hodgson, K. J. (2023). Losarten. Saunders Nursing Drug Handbook. Elsevier, p. 720."Obtain blood pressure, heart rate immediately before each dose, in addition to regular monitoring."II. Observations and record reviewOn 11/1/23 at 7:15 a.m. licensed practical nurse (LPN) #1 was observed dispensing and administering Coreg (a beta blocker blood pressure medication) 6.25 mg to Resident #12. At 7:11 a.m. LPN #1 did not check for resident vital signs on the medical record, including the resident's blood pressure and pulse, prior to administration. The November 2023 computerized physician order (CPO) documented a physician order of Carvedilol (Coreg) 6.25 milligrams (mg) twice a day for hypertension.-The CPO did not document any vital sign parameters for when to hold the medication or to notify the physician of irregular vital sign results. At 7:30 a.m. LPN #1 was observed and dispensing Losartan 25 mg 0.5 tablet and Metoprolol 25 mg to Resident #36. LPN #1 did not check the medical record for the resident's vital signs including blood pressure and pulse prior to the administration. The November 2023 CPO documented a physician order of Metoprolol extended release (ER)25 mg by mouth twice a day for chronic heart failure and Losartan 25 mg 0.5 tablet once a day for chronic heart failure.-The CPO documented to monitor blood pressure every shift and call the physician if the systolic blood pressure was greater than 150. At 8:05 a.m. LPN #3 was observed dispensing and administering Metoprolol 75 mg (gave three 25 mg tablets). LPN #3 did not check the medical record for the resident's vital signs including blood pressure and pulse prior to the administration. The November 2023 CPO documented a physician order of Metoprolol ER 25 mg tablets give 75 mg once a day for hypertension.-The CPO did not document any vital sign parameters for when to hold the medication or tonotify the physician of irregular vital sign results. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 11/2/23 at 8:45 a.m. She said that prior to the administration of any blood pressure medication, blood pressure and pulse should be assessed. She said this was done to keep from dropping the blood pressure and pulse too low after administering the medication. The director of nursing (DON) was interviewed on 11/2/23 at 9:17 a.m. She said that any resident on a blood pressure medication should have a blood pressure assessed prior to the administration of any blood pressure medication. She said this was done to ensure the blood pressure and pulse were not too low prior to the administration of the medication. She said the vital signs should be documented on the resident's medical record and attached to the blood pressure order.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for one (#86) resident out of three sample residents reviewed for discharge out of 39 sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay, a final summary of the resident's status and recapitulation of the resident's stay at the facility for Resident #86. Findings include:I. Facility policy and procedureThe Discharge Summary and Plan policy, revised October 2022. It read in pertinent part, "The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with the established regulations governing release of resident information and as permitted by the resident."II. Failure to complete a complete and thorough discharge summary 1. Resident #86A. Resident statusResident #86, age 75, was admitted on 2/8/23 and discharged 8/4/23. According to the August 2023 computerized physician orders (CPO) diagnosis included hemiplegia affecting the right side, vascular dementia, and type II diabetes. The 6/12/23 minimum data set (MDS) assessment showed the resident had moderate cognitive deficits with a score of nine out of 15. The resident needed partial assistance with activities of daily living. The resident was coded as having a discharge plan to return to the community. B. Record reviewThe progress note dated 8/4/23 documented the resident was picked up by his friend. The resident said he had signed himself out and he was not returning to the facility. The resident returned to his house in the community. -The electronic medical record failed to show a discharge summary which included a recapitulation of his stay was completed. C. InterviewThe director of nurses (DON) was interviewed on 11/2/23 at 11:00 a.m. The DON said when a resident discharged a discharge summary was to be completed. The discharge summary was to include a recapitulation of the resident's stay and was to be completed by the interdisciplinary team. She reviewed the record and said there was no discharge summary.

III. Resident #53A. Resident statusResident #53, age 84, was admitted on 9/23/22. According to the November 2023 CPO diagnoses included bilateral venous stasis ulcers in lower extremities. The 9/21/23 MDS assessment documented the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident required supervision or touching assistance with bathing. She had no behaviors or refusal of care. B. Resident interviewResident #53 was interviewed on 10/31/23 at 9:45 a.m. The resident said she had not been receiving her showers. She said often times it was her shower day and she was expecting it, but then no staff would inform her that she was not getting it. She said then she waited. Resident #53 was interviewed on 11/2/23 at 10:20 a.m. The resident said she had not received a shower last week or this week. C. Record reviewReview of bathing records 10/6/23-10/24/23 showed documentation of showers given on 10/6/23 10/12/23 and a refusal on 10/24/23. The resident should have received two showers a week, according to the bathing schedule. The care plan last updated on 8/21/23 identified the resident required assistance with activities of daily living in bathing. Pertinent interventions were to have two staff members to assist with care. D. Staff interviewCNA #5 was interviewed on 11/2/23 at 9:29 a.m. The CNA said he was familiar with Resident #53. He said that she required assistance with her bathing and she did not refuse her showers. He said that the evening shift at times did not get the showers completed since they run out of washcloths and towels. The CNA said the showers were documented in the electronic medical record. The DON was interviewed on 11/2/23 at approximately 11:00 a.m. The DON said she was not aware showers had been missed. She said the residents were scheduled showers and were to receive the showers as scheduled. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (#14 and #53) of three residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure Residents #14 and #53 received assistance with showers as scheduled. Findings include:I. Facility policy and proceduresThe Activities of Daily Living (ADL), Supporting policy, revised in March 2018, was provided by the nursing home administrator (NHA) #1 on 10/30/23 at 8:29 p.m. The policy revealed, residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out activities of daily living independently, would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. With the consent of the resident and in accordance with their plan of care, this included appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). II. Resident #14A. Resident statusResident #14, age under 65, was admitted on 2/23/16 and readmitted on 11/18/22. According to the November 2023 computerized physician orders (CPO), the diagnoses included quadriplegia, spinal stenosis in the cervical region, anxiety, schizoaffective disorder, chronic obstructive pulmonary disease, history of transient ischemic attack, muscle weakness, abnormal posture, reduced mobility, history of musculoskeletal system and connective tissue disorders. The 7/25/23 minimum data set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 with no behaviors. The resident required extensive staff assistance with two plus persons, to physically assist the resident with bed mobility, dressing toileting and personal hygiene. The resident was totally dependent on staff with two plus persons, to physically assist the resident with transfers. During the seven-day review period, the bathing activity did not occur (family and/or non-family staff provided care 100% of the time for this activity). B. Resident interviewThe resident said on 10/30/23 at 10:41 a.m, that he only received a shower (bath) once a week and he wanted two. He said the facility staff did not offer him two showers each week. He said he felt dirty by not receiving at least two showers each week. C. Record reviewCare plan for dependence for ADL care related to quadriplegia, chronic pain, and cognitive loss was initiated on 3/16/21 and revised on 10/27/23. The plan also revealed the resident exhibited or was at risk for alterations in functional mobility related to quadriplegia, osteoarthritis, degenerative disc disease, history of a fall with spinal cord injury at the cervical levels of 4-7, cervical stenosis of the spine, history of lumbar surgery, history of an open reduction and internal fixation right hip. The resident had a history of refusing care/showers/ restorative and would state he was not provided these cares. The relevant interventions were the resident required one to two staff persons for assistance with ADL. Staff were to monitor the resident for shortness of breath, fatigue and/or a change of condition and adjust the ADL task accordingly. Staff were to also encourage the resident to pace himself during an ADL task. Staff were to provide cueing for safety and sequencing to maximize the resident's current level of function. Care plan for a history of being resistant to care as evidenced by not showering, resulting in severe body odor, poor hygiene, and requiring staff to remind the resident to change his clothing was initiated on 5/11/21 and revised on 11/7/21. The plan also detailed the resident preferred showers on Monday, Wednesday, and Friday. The interventions revealed the resident was open to bedside baths, was willing to attempt utilization of a basin, back scrubber and towels/wash cloths with assistance. The resident was very afraid of falling but willing to start with this and work his way up to more confidence in showering was initiated on 9/16/22 and revised on 8/21/23. The resident's Kardex (computerized file system that provided a brief overview and updates of the resident) dated 11/2/23, did not reveal any guidance to nursing staff, related to bathing the resident. The bath schedule sheet revealed Resident #14 received a shower on Tuesday and Thursday, during the morning shift. -This was not congruent with the above care plan that revealed the resident preferred showers on Monday, Wednesday, and Friday. The Weekly Bath and Skin Report revealed the resident received showers on 8/8/23, 8/12/23, 8/31/23, 9/7/23, 10/5/23, 10/12/23/ 10/17/23, 10/19/23 and 10/31/23. The hospice visit documents revealed the resident received showers on 9/14/23, 9/21/23, 9/28/23, 10/26/23. -This is a total of 13 baths in 92 days. The resident should have received a minimum of 26 baths. The facility was unable to provide evidence regarding the resident's refusal of showers, during this 92 day period. D. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 11/1/23 at 1:45 p.m. She said she did provide baths to the resident. She said the resident required two staff assistance with bathing. She said the resident received showers on Tuesdays and Thursdays. She said hospice staff also provided the resident with a shower on Friday. She said she documented the resident received a shower on the resident bathing form and also in the resident's electronic clinical record.. She said she documented it in both places, within an hour after the shower or at least by the end of her shift. She said the resident at times did refuse a shower and wanted to wait until Friday for the hospice staff. She said if a resident refused a shower, she would ask the resident a total of three times and then she would go tell the nurse. She said the nurse would go and ask the resident the reason they did not want the shower and offer toaccommodate another time for a shower. She said the nurse would have to document on the resident bathing form the reason for the refusal. CNA #2 was interviewed on 11/1/23 at 2:05 p.m. She said she did provide showers to the resident. She said the resident received his showers on Tuesdays and Thursdays. She said hospice staff also provided the resident with a shower on Thursdays. She said occasionally, he did refuse a shower. She said she documented the shower in the resident's record and on the bathing form right after the shower had been provided or at least by the end of her shift. She said if a resident refused a shower, she asked them a total of three times and then she would tell a nurse of the refusal. She said the nurse would then talk with the resident and ask the reason for the refusal. She said the nurse would document the reason and sign the resident bathing form. CNA #3 was interviewed on 11/1/23 at 2:12 p.m. She said she did not provide showers for this resident however, she did provide showers for other residents. She said she documented the resident who had received a shower in the resident's record and on the bathing form, either as soon as the shower was concluded or by the end of her shift. She said if a resident refused a shower, she asked the resident three times if they wanted a shower and then she would tell the nurse of the refusal. She said she would document the resident's refusal and the reason for the refusal on the bathing form. She said a nurse would then initial the form beside the resident's reason for refusal. The registered nurse consultant (RNC) was interviewed on 11/1/23 at 4:35 p.m. She said the resident received showers on Tuesday and Thursday. She said the resident required two staff to assist with his showers, and either of the staff could document the shower was provided or refused. She acknowledged the provided documentation revealed, the resident had received a total of 13 showers in 92 days. She said showers were documented both in the resident's record and on the bathing form. She said if a resident refused a shower, the refusal should be documented in the resident's record and on the bathing form. She said if a resident refused a shower, the CNA should ask the resident three times if they wanted to take a shower and then tell the nurse of the refusal. She said the nurse should then go and talk with the resident and obtain the reason for the refusal and try to accommodate a different bathing time for the resident. If the resident continued to refuse a shower, the refusal would be documented on the bathing form and the nurse would initial the refusal. She said if a resident wanted two showers a week, the resident should receive two showers each week. She said, at this time, the facility was unable to find sufficient documentation to demonstrate the resident received two showers per week for the last three months (92 days).

Based on observations, record review and interviews the facility failed to ensure one (#14) of one residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 39 sample residents. Specifically, the facility failed to ensure Resident #14 was provided with preventative measures to help minimize the development of and the worsening of contractures. Resident #14 had a contracture to his left hand and no preventative measures were implemented. When Resident #14 was assessed during the survey on 10/31/23, his left hand finger contractures worsened and he developed a contracture to his right hand. Findings include:I. Facility policy and proceduresThe Activities of Daily Living (ADL) Supporting policy, revised in March 2018, was provided by the nursing home administrator (NHA) on 10/30/23 at 8:29 p.m. The policy revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently. The Resident Mobility and Range of Motion policy, revised July 2017, was provided by the regional director of clinical services (RDCS) on 11/7/23 at 12: 17 p.m. The policy revealed that residents would not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion would receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility would receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility was unavoidable.-As part of the resident's comprehensive assessment, the nurse would identify the resident's current range of motion of his or her joints, limitations in movement or mobility, opportunities for improvement, and previous treatment or services for mobility.-As part of the comprehensive assessment, the nurse would also identify conditions that placed the resident at risk for complications related to ROM and mobility. This included muscle wasting/atrophy, contractures and/or other complications that could cause or contribute to immobility, impaired ROM or injury from falls (postural hypotension, urinary incontinence).-During the resident's assessment, the nurse would identify the underlying factors that might have contributed to a range of motion or mobility problems. These include immobilization (bedfast, chair or wheelchair usage), neurological conditions (cerebral palsy, cerebral-vascular accident), conditions in which movement might lead to pain and/or conditions that limit or immobilize movement of limbs or digits (splints).-The resident's care plan would be developed by the interdisciplinary team based on the comprehensive assessment, and would be revised as needed. The care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in and/or improve mobility/range of motion. Interventions might include therapies, the provision of necessary equipment/exercises, based on professional standards of practice that were consistent with state laws and practice acts.-The care plan would include the type, frequency, duration of interventions, as well as measurable goals and objectives. The resident and representative would be included in determining these goals and objectives. Documentation of the resident's progress toward the goals and objectives would include attempts to address any changes or decline in the resident's condition or needs. The Functional Impairment - Clinical Protocol, revised in March 2018, was provided by the RDCS on 11/6/23 at 12:17 p.m. The policy revealed, upon admission to the facility, whenever a significant change of condition occurred, and periodically during a resident's stay, the physician and staff would assess the resident's function along with their physical condition. As part of the physical examination, the physician would include items that related to function as well as the potential to benefit from rehabilitative services; for example, proprioception, sensation, muscle tone, range of motion, gait, balance, joint swelling/abnormalities, strength, edema, and cognition. The staff and physician would identify individuals with the potential for significant improvement in function or significant decline in function, including the ability to perform ADLs. -As appropriate, the physician would identify and evaluate medical conditions and medications that impacted a resident's function (for example, muscle weakness or pain due to adverse medication effects, persistence of complications from recent hospitalization, and sedation or confusion due to fluid/electrolyte imbalance). The physician and staff would review and analyze the preceding information to evaluate the influence of medical factors on function and vice-versa, to help guide subsequent treatment and care planning. The physician would identify and document the impact of medical conditions on function and identify a resident's potential to benefit from rehabilitative services, such as physical and occupational therapy. The staff and physician would collaborate to identify a rehabilitative or restorative care plan to help improve function, quality of life, meet a resident's goals/needs and attain other desired outcomes such as discharge to the community. Based on a review of available information (including results of the evaluation), the physician would determine if a resident met the criteria for skilled therapy services. The physician and staff would address risk factors related to exercise or activity, and consider any relevant precautions. The physician would order any therapy services based on the above considerations. The physician would pay attention to the relevance and effectiveness of such interventions. The physician would not just sign off therapy orders perfunctorily. -The staff would monitor and document the resident's function (for example, evidence of reduced ADL dependency, improved ambulation, improved balance and gait) and would discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care. The physician would identify the subsequent relevance of therapy services, based on reviewing the resident's progress relative to his/her care goals (functional stabilization or improvement), the status of conditions and the current treatment regimen that have been identified as affecting his/her function. II. Resident interview and observationsThe resident was observed on 10/30/23 at 10:54 a.m., seated in a motorized wheelchair in his room. He had bilateral wrist/hand/finger contractures. He did not have any bilateral splints in place. He said he wanted splints for both of his wrists/hands/fingers. He said he had been asking staff for bilateral splints for over a year and they told him that they would see about getting him some. The resident was observed on 10/30/23 at 12:12 p.m. seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. A staff member was assisting the resident with his meal. The resident was observed on 10/31/23 at 8:45 a.m. seated in a motorized wheelchair by a nurse medication cart. The resident was being administered medication by the nurse. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/1/23 at 7:31 a.m., seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint inplace for either wrist/hand/fingers. The resident was observed on 11/1/23 at 1:43 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/2/23 at 12:49 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident demonstrated he was unable to open his fingers on either hand. III. Resident #14A. Resident statusResident #14, age under 65, was admitted on 2/23/16 and readmitted on 11/18/22. According to the November 2023 computerized physician orders (CPO), diagnoses included quadriplegia, spinal stenosis in the cervical region, anxiety, schizoaffective disorder, chronic obstructive pulmonary disease, history of transient ischemic attack, muscle weakness, abnormal posture, reduced mobility, history of musculoskeletal system and connective tissue disorders. The 7/25/23 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. According to the assessment, the resident did not exhibit behaviors or refuse care. The resident required extensive staff assistance with two plus persons to physical assist for bed mobility, dressing toileting and personal hygiene. The resident was totally dependent on staff and required physical assistance from two or more persons for transfers. The resident had functional limitations in ranges of motion with impairment on both sides that included his upper extremity (shoulder, elbow, wrist, hand). The resident did not receive any therapy services during the seven-day review period. B. Record reviewA care plan for dependence with ADL care related to quadriplegia, and chronic pain, cognitive loss was initiated on 3/16/21 and revised on 10/27/23. The plan also revealed the resident exhibited or was at risk for alterations in functional mobility related to quadriplegia, osteoarthritis, degenerative disc disease, history of a fall with spinal cord injury at the cervical levels of 4-7, cervical stenosis of the spine, history of lumbar surgery, history of an open reduction and internal fixation right hip. The relevant interventions were the resident required one to two staff persons for assistance with ADL. Staff were to monitor the resident for shortness of breath, fatigue and/or a change of condition and adjust the ADL task accordingly. Staff were to also encourage the resident to pace himself during an ADL task. Staff were to provide cueing for safety and sequencing to maximize the resident's current level of function. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for restorative nursing program related to bed mobility/transfers was initiated on 9/14/22 and revised on 8/21/23. The relative interventions were to encourage the resident to utilize the bed bar for repositioning on his wide bariatric bed. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for being at risk for decreased ability to perform ADLs related to recent hospitalization, weakness, decreased mobility, diabetes mellitus, and dizziness was initiated on 5/12/21 and revised on 6/6/23. Relevant interventions were for staff to monitor for decline in ADL function. Staff were to refer to rehabilitation therapy if a decline in ADL was noted. Staff were to monitor for complications of immobility (pressure ulcers, muscular atrophy, contractures, incontinence, urinary/respiratory infections). The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. The occupational therapy (OT) initial evaluation dated 10/27/2020 noted range of motion for the musculoskeletal right upper extremity(elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired.-The passive range of motion for the left index finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees.-The passive range of motion for the left middle finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees.-The active range of motion for the left ring finger metacarpophalangeal joint flexion was 0 (zero) degrees and for the proximal interphalangeal joint flexion was 0 (zero) degrees.-The passive range of motion for the left right finger metacarpophalangeal joint was 75 degrees and for the proximal interphalangeal joint flexion was 75 degrees.-The passive range of motion for the left little finger metacarpophalangeal joint flexion was 70 degrees and for the proximal interphalangeal joint flexion was 75 degrees.-The short term goals were for the resident to tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were for the resident to wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. -There were no short or long term goals for the resident's right wrist/hand/fingers. The occupational therapy (OT) evaluation dated 12/17/22 revealed the right upper extremity was not tested due to mixed tone; non-functional upper extremity loss of motor control that was chronic in nature. The range of motion of the upper extremity was not tested due to clinical reasons of other tone; non-functional upper extremity that was chronic in nature. The left upper extremity range of motion was not tested related to clinical reasons of mixed tone; non-functional upper extremity. The tone was abnormal; upper extremity muscle tone was spastic, hypertonic, and/or hypertonic flaccid. -There was no recommendation for the use of splints. The occupational therapy (OT) evaluation on 1/26/23 revealed the right upper extremity wrist strength was impaired (no measurements were taken). The left upper extremity was impaired (no measurements were taken). The range of motion of the right upper extremity revealed wrist and hand impairment. -There was no recommendation for the use of splints. The Rehabilitation Screening form dated 10/27/23 (completed during the survey) revealed contractures present and a need for splints. The left wrist and right wrist demonstrated moderately and reflected approximately 50% of full ROM. The left and right fingers were severe and reflected 25% or less of full ROM.Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 (completed during the survey) revealed the left wrist had no displays of contractions during active or passive range of motion. The left proximal interphalangeal joints had resting contractures at 90 degrees and passive range of motion to 145 degrees. The right wrist had no displays on contractures. The right wrist active range of motion was limited and would benefit from a resting hand splint. The right interphalangeal joints had resting contractures at 145 degrees, passive range of motion at 170 degrees and would benefit from a resting hand splint. One new goal revealed that the resident would present with a functional wear schedule wearing bilateral hand splints with no redness, or areas of concerns for 15 minutes to preserve joint mobility (target 11/13/23). -The OT assessment dated 10/31/23 (approximately three years later from 10/27/2020) revealed the resident had contractures of both the left and right interphalangeal joints. This assessment's new goal was for bilateral splints for these areas. This assessment revealed the resident now needed a splint for both hands. -The resident's left hand finger contractures worsened at the hand/knuckle joint based on the decline over three years. -The resident did not have any known contractures to his right hand at baseline and based on the current measurement developed a decline in range of motion. IV. Staff interviewsThe director of rehabilitation (DOR), registered nurse consultant (RNC) and the quality improvement specialist consultant (QISC) were interviewed on 11/2/23 at 12:02 p.m. They said the resident only had contracture measurements on 10/27/2020 and during the survey on 10/31/23. They said the OT initial evaluation on 10/27/2020 revealed the resident's range of motion for the musculoskeletal right upper extremity (elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired. The evaluation revealed left hand passive/active range of motion measurements of the resident's fingers and there were no measurements for the resident's right hand. The evaluation had short term goals, that the resident would tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were the resident would wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. There were no short or long term goals for the resident's right wrist/hand/fingers. They said the evaluation only mentioned the resident's left hand, with a recommendation for the use of a splint for the left hand and did not mention the right hand. They said the documentation on the Rehabilitation Screening form dated 10/27/23 revealed the resident had contractures and there was a need for splints. This screening occurred during the survey process. They said the documentation on the Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 revealed a new goal for the resident was to provide bilateral hand splints with no redness or areas of concern for 15 minutes to preserve joint mobility (target 11/13/23). This screening occurred during the survey process. They said the resident did not have any current services for his bilateral hand contractures nor was he on a restorative program for his hand contractures. They acknowledged there was no specific care plan for the resident's bilateral hand contractures.

Based on observations, record review and interviews, the facility failed to ensure that the resident ' s environment was free from accident hazards for one (#4) of three resident reviewed for falls out of 39 sample residents. Specifically, the facility failed to: -Ensure that fall risk assessments were in place, before and after a fall, for Resident #4 with a history of falls;-Document neurological assessments after Resident #4 fell; and, -Document an interdisciplinary team (IDT) review to establish causative factors of the fall and failed to implement and care plan new interventions. Findings include:I. Facility policy and procedureThe Fall Risk Assessment policy and procedure, reviewed March 2018, was provided by the nursing home administration (NHA) on 10/30/23 at 8:29 p.m. read, in pertinent part:"The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. "The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation mobility, gait balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence and cognition."The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable."The Assessing Falls and Their Causes policy and procedure, reviewed March 2018, was provided by the NHA on 10/30/23 at 8:29 p.m. read, in pertinent part: "When a resident falls, the following information should be recorded in the resident ' s medical record: the condition in which the resident was found, assessment data (including vital signs and any obvious injuries), interventions, notification of the physician and family, completion of a falls risk assessment, appropriate interventions taken to prevent future falls, the signature and title of the person recording the data."The Neurological Assessment policy and procedure, reviewed October 2010, was provided by the NHA on 11/2/23 at 1:00 p.m. read, in pertinent part:"Neurological assessments are indicated: upon physician order, following an unwitnessed fall, following a fall or other accident/injury involving head trauma, or when indicated by resident ' s condition."II. Resident #4A. Resident statusResident #4, age 94, was admitted on 9/16/2020. According to the November 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), right femoral fracture, history of repeated falls and syncope. The 8/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was dependent with toileting, transfers, personal hygiene and required set up assistance only with eating. It documented that the resident had a fall with a major injury since the prior assessment. B. ObservationsOn 10/30/23 at 1:57 p.m. Resident #4 was observed lying on an air mattress that was not lipped. Resident #4 ' s bed was not in a low position. C. Record reviewThe fall risk care plan, initiated on 9/12/19 revised on 6/15/21, indicated that Resident #4 was at risk for fall due to impaired mobility, medication side effects, cognitive loss, syncope, history of falls and poor safety awareness. Interventions included non-skid footwear, place glasses within reach, requested a scoop air mattress from the hospice provider and utilize a low bed. -A comprehensive review of the care plan failed to indicate that a lipped mattress was put in place after requesting one from hospice on 3/26/23.-A comprehensive review of the care plan failed to care plan additional interventions post fall 5/23/23. The 3/26/23 nursing progress notes revealed Resident #4 had an unwitnessed fall. The resident was found lying on her back on the floor next to her bed with her feet straight. It indicated that no injuries were observed post incident. The resident was assisted by a mechanical lift back into bed. The 5/23/23 nursing progress notes revealed Resident #4 had an unwitnessed fall and was assisted off the floor and into her wheelchair. She then was assisted from her wheelchair back into her bed. It indicated that no injuries were observed post incident. It indicated that a neurological check flow sheet was initiated. It indicated that the registered nurse, the hospice provider and family were notified.-A comprehensive review of Resident #4 ' s medical record failed to reveal documentation of a neurological flow sheet. The 5/23/23 hospice nursing progress notes revealed Resident #4 had a fall while attempting to get out of bed to the bathroom. It documented that there was significant swelling to the right knee and thigh and had limited movement to the right leg and knee that was worse since the fall and could not bed her knee without pain. It indicated notification of the physician, supervisor and family. It indicated an order for a portable x-ray. The 5/23/23 portable right knee x-ray indicated a fracture of the distal femoral medial condyle (the bone on the inside of the knee) with malalignment. The 10/26/23 fall risk assessment indicated Resident #4 was high risk for falls.-A comprehensive review of Resident #4 ' s medical record failed to reveal prior fall risk assessments before or after the 3/26/23 fall, a fall risk assessment conducted after the fall or an interdisciplinary team (IDT) note post fall on 5//23/23. The 6/15/23 occupational therapy evaluation notes revealed Resident #4 ' s goal was to be able to get up in a wheelchair for at least two hours and self propel her room to the dining room to participate in meals and social activities. It documented she was not able to tolerate use of a sling for transfer from bed to wheelchair and was experiencing pain in her right knee of 8 out of 10 pain scale. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 11/2/23 at 8:45 a.m. She said that after a fall a RN assessment should be done prior to the resident being removed from the floor to assess for fractures or other injuries. She said neurological checks should be initiated and completed. She said the facility administrator, the physician, family and hospice should be notified after a fall. She said after a fall happened an investigation should be done to identify contributing factors and then should be care planned. The director of nursing (DON) was interviewed on 11/2/23 at 9:19 a.m. She said after a resident falls, an RN assessment, skin assessment and a post fall risk assessment should be completed. She said the DON, NHA, physician, family and hospice should be notified. She said residents with a history of falling should have risk assessments done. She said risk assessment should be done on admission, quarterly and after a fall. She said after a fall an IDT review should be done to determine a root cause and documented in the resident ' s medical record, interventions initiated and care planned. She said Resident #4 was currently not ambulatory and primarily bedbound. She said she was not aware of what was in place for Resident #4 to prevent falls.

Based on observations, record review and interviews, the facility failed to provide effective pain management program for two (#53 and #4) of three residents reviewed for pain management out of 39 sample residents. Resident #53 had pain control during a wound dressing change on 10/31/23 at 4:15 p.m. The resident experienced severe pain during the dressing change. The resident was administered a pain medication at 3:40 p.m., although the resident told the nurse that she was in pain, the dressing change continued. The resident was not offered any other type of pain intervention. In addition, the facility failed to for Resident #4: -Have a pain parameters for as needed (PRN) pain medications; and, -Thoroughly assess the resident's pain. Findings include:I. Facility policyThe Pain -Clinical Protocol policy, updated October 2022, was received on 11/2/23 at 1:00 p.m. from the nursing home administrator. The policy read in pertinent part, "The staff and physician will identify the characteristics of pain such as location, intensity, frequency pattern and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example wound care."II. Resident #53A. Resident statusResident #53, age 84, was admitted on 9/23/22. According to the November 2023 computerized physician orders (CPO)diagnosis included bilateral venous stasis ulcers in lower extremities. The 9/21/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The he resident as having two venous and arterial ulcers. The resident had an open lesion and received non sterile dressings. The pain section documented that the resident received PRN (as needed) pain medication. Resident #53 did not receive non-medication interventions for pain. B. Resident interview and observationResident #53 was interviewed on 10/31/23 at 9:45 a.m. The resident said she had two wounds on both of her lower legs. She said the dressings were changed daily. The resident was observed to have both of her legs wrapped in Curlex wrap with the date of 10/30/23 written on the dressing. C. Wound care observations and resident interviewWound care treatment was observed for Resident #53 on 11/1/23 at 4:15 p.m. The wound care was completed by registered nurse (RN) #1, registered nurse (RN) #3. The quality improvement specialist consultant (QISC) was in the room for a short while. RN #3 was the wound nurse. Certified nurse aide (CNA) #5 was in the room to assist with resident care. The overbed table was used to hold the wound care supplies. RN #1 began to remove the old dressing, spraying the area where the dressing was being pulled away to expose the skin. The dressing was not pre soaked or saturated. As a result when RN #1 pulled off the dressing, Resident #53 verbalized her pain as RN #1 was pulling off the dressing. The resident said, "you are debriding the wound. It hurts. Stop!" RN #1 did not stop and continued, she responded by saying this was how it was performed and she had performed rounds with the wound physician. She said this as she sprayed the bandage. The resident continued to state the pain she felt as RN #1 continued with the above actions. The QISC intervened and asked if the resident had been given any pain medications before the procedure began. The resident stated that she had not received any pain medications. The QISC asked for a check of the medication administration record (MAR) to see if the resident had received any pain medications prior to the procedure. The QISC returned to the room and said the MAR showed the resident had received Oxycodone 5mg by mouth at 3:40 p.m. The resident was notified and no further medications were administered. The QISC left the resident's room. The resident continued to complain of the pain as RN #1 removed the bandage. RN #1 responded by saying; "I know. I know." The resident responded by saying, "you have no idea what another person's pain is!"After the dressing was removed from each lower extremity, the outer layer of the resident's skin (epidermis) was absent and exposed the second layer of skin (dermis) on the back of the resident's lower leg. The dressing was removed and as the wound cleaner was sprayed on the open wounds, she would say each time it was sprayed that her skin stung, as it was sprayed on the open wounds. Resident #53 was interviewed on 11/2/23 at 8:20 a.m. The resident expressed that during the dressing change on 11/1/23 she sustained "a lot of pain" and she felt her stated feelings were disregarded, as she expressed the amount of pain she was in, although RN #1 continued with the dressing change. D. Record reviewThe care plan last updated on 9/27/23 identified the resident was at risk for skin breakdown related to decreased activity, diabetes, peripheral vascular disease. The care plan showed the resident had actual wounds to her bilateral lower extremities. Pertinent approaches were to observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. Complete a weekly skin check by licensed nurse weekly. According to the medication administration orders (MAR) for November 2023 the resident was receiving following medications for pain:Acetaminophen 325 milligram (mg), two tablets every eight hours as needed for mild pain. The order was started on 9/23/22. The order directed to notify the physician if more than three doses in 48 hours. Do not exceed 3 grams a day. Oxycodone HCI oral tablet 5 mg, give one tablet by mouth every six hours as needed for pain 6-10 (with 10 being the worst on the scale). The most recent wound assessment completed on 10/27/23 by the wound care physician (WCP) revealed the resident had two wounds on her bilateral lower extremities. The November 2023 treatment administration record (TAR) showed the physician order was as follows:Left lower leg wash with wound cleaner and pat dry with a 4 X 4 gauze. Apply xeroform to open areas. Cover with ABD (absorbent dressing) and kerlix (to cover wounds) every day and as needed every day shift for wound care. The order was started on 10/21/23E. InterviewThe director of nurses (DON) and the QISC were interviewed on 11/2/23 at 1:40 p.m. The QISC said the resident had bilateral venous stasis wounds on her lower extremities. She said the wound physician was involved and saw her weekly. The DON said the dressing changes were to be completed one time a day and as needed. The DON said the resident's legs were to be washed with wound cleanser and the order was to pat it dry with gauze. The DON said after hearing how the dressing was removed (see above) she said the orders would have to be clarified with the physician, as it did not direct how to remove the dressing. The QISC said she had left the room to verify the medication which was administered. She said once they saw the resident had received pain medication and it was not effective for the dressing change, then they should have stopped the dressing changes until the physician could have been called for additional pain medications. The QISC was interviewed a second time on 11/2/23 at approximately 5:30 p.m. The QISC said they spoke with the resident and she verified that the resident had excessive pain with the dressing change on 11/2/23. III. Resident #4A. Resident statusResident #4, age 94, was admitted on 9/16/2020. According to the November 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), right femoral fracture and opioid dependence. The 8/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was dependent with toileting, transfers, personal hygiene and required set up assistance only with eating. It indicated the resident was on a scheduled pain medication program, received PRN medications and did received pharmacological interventions for pain management. B. Record reviewThe pain management care plan, initiated on 9/12/19 revised on 4/16/21, indicated the resident had pain related to chronic pain with narcotic dependence history. Interventions included pain medications per physician order, assist with repositioning for comfort, document complaints and non verbal signs of pain, encourage resident to communicate pain, implement relaxation and distraction techniques, observe for potential side effects of medication, therapy to screen as necessary, utilize pain scale as indicated.-A review of Resident #4's comprehensive care plan did not reveal a person centered approach with identification of location, type or intensity of pain the resident experienced. It did not include personalized non-pharmacological interventions to address the resident's pain. It did not identify a baseline assessment of pain or person centered pain management goals. The October 2023 medication administration record (MAR) documented the resident was prescribed the following medications:-Acetaminophen 650 milligrams (mg) at bedtime for pain, ordered 6/9/21.-Methadone 5 mg at bedtime for pain, ordered 6/12/22.-Methadone 2.5 mg once a day for pain, ordered 7/1/22.-Acetaminophen 650 mg every 6 hours as needed for mild pain, ordered 3/31/23.-Hydromorphone 2 mg every two hours as needed for pain, ordered 9/18/23.-A comprehensive review of the October 2023 MAR failed to document location, intensity and type of resident's pain being treated for Acetaminophen, Methadone and Hydromorphone. -The physician orders did not include specific pain scale parameters for the PRN Acetaminophen and Hydromorphone. -The documentation did not include a pain assessment prior to or after the administration of pain medications. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 11/2/23 at 11:40 a.m. She said pain assessment should be done prior and after any administration of a pain medication. She said residents that were on multiple pain medications, had been determining which pain medications they wanted to take and parameters were not always ordered for pain medications. The DON was interviewed on 11/2/23 at 1:23 p.m. She said pain medication assessment evaluations should be done on admission and quarterly and when there was a change in the resident's condition. She said there should be physician ordered parameters for all pain medications. She said that pain assessments should be done before and after pain medications administration and documented on the MAR. She said that it had been identified that pain assessment evaluations and pain assessment documentation on the MAR were not being done and were an issue.

Based on observations, record review, and interviews, the facility failed to ensure that a consent and a safety bed rail evaluation was in place for one (#12) of one resident with bed rails out of 39 sample residents. Specifically, the facility failed to:-Failed to obtain a consent for Resident #12 with safety risks versus benefit and alternatives prior to the use of half bed rails; and,-Failed to obtain a safety evaluation for Resident #12 prior to the use of half bed rails. Findings include:I. Professional referenceThe U.S. Food and Drug Administration (FDA). (2023). Recommendations for Health Care Providers Using Adult Portable Bed Rails.https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails, retrieved on 11/8/23 included the following recommendations,"Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment."Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient."II. Facility policy and procedureThe Bed Safety and Bed Rails policy and procedure, revised August 2022, was provided by the nursing home administration (NHA) on 11/2/23 at 1:00 p.m. It read in pertinent part,"The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent."If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs: the resident's risk associated with the use of bed rails; input from the resident and/or representative; and consultation with the attending physician."III. Resident #12A. Resident statusResident #12, age 71. was admitted on 9/19/22. According to the November 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus and morbid obesity. The 10/4/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status of nine out of 15. She was dependent with transfers, toileting and personal hygiene, substantial/maximal assistance of two people with bed mobility and set up assistance for eating. B. ObservationsOn 11/1/23 at 8:40 a.m. Resident #12 was observed lying in bed with two metal half rails up on bed. Two staff members were observed assisting the resident by boosting the resident up in bed. The resident was not observed attempting to use rails to help boost herself up in bed. On 11/1/23 at 10:35 a.m. Resident #12 was observed to be lying in bed with the two metal half rails up on the bed. C. Record reviewThe November CPO revealed an order for half bed rails to be used as a positioning enabler for turning and repositioning in bed, ordered on 9/26/22. The 12/19/22 bed rail evaluation recommendations included no bed rails to be used. The 11/1/23 bed rail observation assessment, conducted and provided during survey, indicated the half bed rails were being used as positioning enabler due to Resident #12's immobility and difficulty positioning in bed. The activities of daily living (ADL) care plan, initiated on 12/23/19 revised on 10/31/23, indicated Resident #12 was at risk for decreased ability to perform ADLs. Interventions included using bed rails as a positioning enabler.-A comprehensive review of the medical record failed to reveal a bed rail evaluation or consent done prior to the initiation of bed rails as a positioning enabler. The medical record revealed a bed rail evaluation after the bed rails were initiated that indicated to not usebed rails. The medical record failed to reveal quarterly reassessments for the use of the half bed rails. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 11/2/23 at 8:45 a.m. She said Resident #12 used the side rails as a positioning enabler because of her bed mobility issues. She said before side rails could be used a consent needed to be done with a side rail assessment and evaluation completed. The director of nursing (DON) was interviewed on 11/2/23 at 9:15 a.m. She said before side rails could be used a bed rail evaluation and consent needed to be completed. She said evaluation could be completed by herself, an RN or the maintenance staff and the evaluation included checking for gaps between the rails and the bed. She said there needed to be an order for bed rails before they could be used. She said side rail assessment should be done quarterly and put in the care plan. She said that Resident #12 used the half side rails to help position herself in bed.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for three licensed practical nurses (LPNs) and and one registered nurses (RNs). Specifically, the facility failed to:-Complete competencies for LPN #1, #3 and #2; and,-Complete competencies for RN #5Cross-reference F760 failure to identify skill training and competencies for staff education in mathematics calculations for liquid medications. I. ObservationOn 11/1/23 at 7:35 a.m. licensed practical nurse (LPN) #1 checked Resident #36 ' s oral morphine order on the medication administration record which read Morphine 20 milligrams (mg)/5 milliliters (ml) give 0.25 ml. LPN #1 obtained the oral morphine from the medication administration cart which read 100 mg/5 ml. He then pulled up 0.25 ml of the 100mg/5ml concentration and administered it to Resident #36. II. CompetenciesThe competency files for LPN #1, LPN #2, LPN #3 and RN #5 were reviewed. Competencies for mathematical calculations for liquid medications was not provided. III. InterviewThe quality improvement specialist consultant (QISC) was interviewed on 11/1/23 at approximately 3:00 p.m. The QISC said they did not have competencies on mathematical calculations for liquid medications. She said they were providing training. IV. Facility follow-upThe facility provided documentation on 11/1/23 that the nurses were provided on the spot medication administration for liquid narcotics and ensuring math was correct.

Based on observations, record review and staff interviews, the facility failed to ensure the mediation error rate was not greater than five percent. Specifically the facility's medication error rate was 7.14% with two errors out of 28 opportunities. Findings include:I. Professional referenceHanson, A., Haddad, L. M. (9/5/22). Nursing Right of Medication Administration. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK560654/ retrieved on 11/9/23."Right dose-incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct medication and the patient's identity is verified, with first checking to ensure it is the correct strength for the patient."Right time-administering medication at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another should be given to maintain a therapeutic effect or level. A guiding principle of this right is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms."Kizior, R. J., Hodgson, K. J. (2023). Apixaban. Saunders Nursing Drug Handbook. Elsevier, p. 74."Black Box Alert: Discontinuation in absence of alternative anticoagulation increases risk of thrombotic (blood clot) events."II. Medication administration to Resident #36On 11/1/23 at 7:30 a.m. licensed practical nurse (LPN) #1 checked Resident #36's order on the medication administration record (MAR) for Apixaban 5 milligrams (mg). LPN #1 was unable to administer medication due to her inability to locate the medication in the medication cart and documented the medication as held.-LPN #1 failed to administer Apixaban in a timely manner or follow up on the unavailability of the medication. The November 2023 computerized physician order (CPO) revealed Apixaban 5 mg twice a day to prevent thromboembolism (blood clot) due to chronic atrial fibrillation (irregular heartbeat). At 7:35 a.m. LPN #1 checked Resident #36's oral morphine order on the medication administration record which read Morphine 20 milligrams (mg)/5 milliliters (ml) give 0.25 ml. LPN #1 obtained the oral morphine from the medication administration cart which read 100 mg/5 ml. He then pulled up 0.25 ml of the 100mg/5ml concentration and administered it to Resident #36.-LPN #1 failed to verify the concentration of Morphine Sulfate oral solution against the order on the MAR. He failed to notify and clarify the order with the physician and pharmacy. The November 2023 CPO revealed Morphine Sulfate oral solution 20 mg/5ml. Give 0.25 ml by mouth every one hour as needed for pain and shortness of breath. III. Staff interviewLPN #1 was interviewed on 11/1/23 at 7:59 a.m. He said the Morphine 100 mg/5ml should be the correct concentration and the 20 mg/5 ml on the MAR was an error. He said when there was a discrepancy between the medication order and the medication provided should be clarified prior to the administration of any medication to prevent an error. He said the Apixaban had been reordered on Monday but did not know if the medication had come in. Nursing home administrator (NHA) #1 was interviewed on 11/1/23 at 8:20 a.m. She said that medication concentrations dispensed and administered should be verified with the order on the MAR. She said if there was a discrepancy, the medication and the order needed to be clarified with the physician prior to the administration to prevent an error. The regional director of clinical services (RDCS) was interviewed on 11/1/23 at 8:23 a.m. She said that Apixaban doses should be administered as ordered to prevent blood clots.

Based on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#36) of four residents reviewed for medication errors of 39 sample residents. Specifically, the facility failed to ensure that Resident #36 was administered the correct dose of oral morphine by verifying the correct concentration of oral morphine on the medication administration record (MAR) with the correct concentration of the oral morphine provided. Findings include:I. Professional referenceHanson, A., Haddad, L. M. (September 5, 2022). Nursing Right of Medication Administration. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK560654/ retrieved on 11/9/23."Right dose-Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct medication and the patient's identity is verified, with first checking to ensure it is the correct strength for the patient."II. ObservationsOn 11/1/23 at 7:35 a.m. licensed practical nurse (LPN) #1 checked Resident #36's oral morphine order on the medication administration record which read Morphine 20 milligrams (mg)/5 milliliters (ml) give 0.25 ml. LPN #1 obtained the oral morphine from the medication administration cart which read 100 mg/5 ml. He then pulled up 0.25 ml of the 100mg/5ml concentration and administered it to Resident #36.-LPN #1 failed to verify the concentration of the medication provided against the order on the MAR. He failed to notify and clarify the order with the physician and pharmacy. The November 2023 computerized physician order (CPO) revealed Morphine Sulfate oral solution 20 mg/5ml. Give 0.25 ml by mouth every one hour as needed for pain and shortness of breath. III. Staff interviewsLPN #1 was interviewed on 11/1/23 at 7:59 a.m. He said the Morphine 100 mg/5ml should be the correct concentration and the 20 mg/5 ml on the MAR was an error. He said when there was a discrepancy between the medication order and the medication provided should be clarified prior to the administration of any medication to prevent an error. Nursing home administration (NHA) #1 was interviewed on 11/1/23 at 8:20 a.m. She said that medication concentrations dispensed and administered should be verified with the order on the MAR. She said if there was a discrepancy between the medication and the order needed to be clarified with the physician prior to the administration to prevent an error.

III. Resident #53A. Resident statusResident #53, age 84, was admitted on 9/23/22. According to the November 2023 computerized physician orders (CPO) diagnosis included bilateral venous stasis ulcers in lower extremities. The 9/21/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident had two venous and arterial ulcers. The resident had an open lesion and received non sterile dressings. B. Record reviewThe treatment administration record (TAR) dated 11/1/23 showed the dressing change for the resident's bilateral lower extremities were completed by registered nurse (RN) #1. Although, RN #4 (an agency licensed nurse) signed off as completing the dressing change. An observation on 11/1/23 showed the dressing change was completed by RN #1. C. Staff interviewThe DON was interviewed on 11/2/23 at 1:40 p.m. The DON said the licensed nurse who was completing the dressing change needed to sign off on the treatment administration record. She said the medical record needed to be accurate. Based on observations, record review and interviews, the facility failed to ensure medical records were kept in a secure and confidential manner and the medical record was complete and accurate in keeping with accepted standards of practice for three (#85, #23 and #53) out of 39 sample residents reviewed. Specifically, the facility failed to ensure:-Resident #85's discharge to the hospital was accurately documented; -For Resident #23 hours of sleep were not recorded; and, -Resident #53's treatment administration record (TAR) was accurately documented. Findings include:I. Resident #85A. Resident status Resident #85, under age 65, was admitted on 12/1/22 and readmitted on 9/30/23. According to the October 2023 computerized physician orders (CPO), diagnoses included cerebral palsy, legal blindness, reduced mobility, major depressive disorder, personality disorder, complete paraplegia and history of diseases of the musculoskeletal system and connective tissue. The 10/4/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, toileting, extensive one person assistance with personal hygiene and set up assistance for eating. B. Resident representative interviewThe resident's representative was interviewed on 11/2/23 at 1:00 p.m. She said the resident was discharged to the hospital for pain. She said the resident called the paramedics herself, as she was having too much pain in her abdomen. She said the resident had been complaining of pain, however, it was not addressed. C. Record reviewThe 10/13/23 progress note documented the resident called 911 and was discharged to the hospital for pain. The interact change of condition documented she was sent out to the hospital for diarrhea. -The record review had nothing documented in regards to the vomiting and nauseous (see interview below).-The progress note failed to show a physician order was obtained timely to discharge the resident to the hospital. The physician order was documented as received 10/16/23. D. Staff interviewThe director of nurses (DON) was interviewed on 11/2/23 at 11:30 a.m. The DON said the resident was discharged to the hospital. She said the resident called 911. She said that she complained of vomiting and was nauseous. She said the nurses were to document the situation for the discharge in the interact form. She said that she had provided training that the entire situation needed to be documented in the electronic medical record. She said the physician order needed to be obtained at the time. She said it could have been obtained, however, not documented until 10/16/23. II. Resident #23A. Resident statusResident #23, age 75, was admitted on 6/6/23. According to the October 2023 computerized physician orders (CPO), the diagnoses included major depressive disorder, anxiety and insomnia. The 9/11/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She required supervision of one staff member with transferring, dressing, toilet use and personal hygiene. B. Record reviewThe October 2023 medication administration record (MAR) revealed Resident #23's hours of sleep were to be monitored twice a day related to use of melatonin for a diagnosis of insomnia. The MAR failed to reveal a number to indicate the hours of sleep and only displayed a check mark with a staff member's initials. C. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 11/1/23 at 10:00 a.m. She said there was no area to document hours of sleep for the melatonin. She said the order should have a drop down box associated with it to document the hours of sleep. She said she would identify who put the order in the chart and ask for it to be fixed. The assistant director of nursing (ADON) was interviewed on 11/2/23 at 11:00 a.m. She said she had not provided a drop down option on Resident #23's melatonin order for recording of actual hours of sleep. She said LPN #4 had brought this to her attention today and it was corrected.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for three out of three units at the facility. Specifically, the facility failed to:-Ensure residents' personal toiletry items were labeled appropriately; -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure a wound cleanser was placed in an appropriate place; and, -Ensure the staff had knowledge to ensure blood glucose meters were cleaned properly;Findings include: I. Failure to ensure resident toiletry items were marked in shared rooms A. Observations11/1/23 at 1:30 p.m. -Room #404 a shared room, had an unmarked comb at the sink.-Room #411 a shared room, had an unmarked and unbagged urinal in the bathroom.-The 500 hall shower room had a used unmarked deodorant. -Room #514 a shared room, had blue container with no name, which had lipstick and other toiletry items at the sink which was unmarked. Also a bar of soap was sitting directly on the sink. II. Failed to ensure residents were provided with an opportunity to participate in hand hygiene before meals A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 11/10/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html revealed in part, "Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. "The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by the CDC, inactivate SARS-CoV-2. "ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. "The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink."B. Facility policyThe Handwashing/Hand Hygiene policy, dated August 2019, was reviewed by the regional director clinical services (RDCS) on 11/2/23 at 5:53 p.m. The policy read in pertinent part, "This facility considers hand hygiene the primary means to prevent the spread of infections. All personal shall be trained and regularly in services on the importance of hand hygiene in preventing the transmission of health care -associated infections. All personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections together personnel, residents and visitors."C. ObservationsOn 10/31/23 at approximately 12:00 p.m. the residents in the main dining room were not offered hand hygiene prior to their meal being served. On 11/1/23 at 11:42 a.m. certified nurse aide (CNA )#2 was observed to pass hand hygiene towelettes to residents in the dining room. The CNA was observed to help clean residents hands, collecting used towelettes and passing out new towelettes to the residents in the dining room. However, she did not perform hand hygiene for herself between each task. On 11/1/23 at 1:43 p.m., licensed practical nurse (LPN) #2 was observed to take the vital signs of a resident. She wore gloves while she took the vitals. After completing the vitals, she wore the gloves to hallway, and pushed the vital sign machine down the hall. She then picked up the disinfectant wipe container with her gloved hands, and then cleaned the machine. She failed to perform hand hygiene after leaving the resident room. On 11/1/23 at 501 p.m., the room trays arrived on the 300 unit. At 5:08 p.m., an unidentified certified nurse aide (CNA) passed a room tray to room #305. No handwashing was offered to the resident. The staffing coordinator (SC) was observed to pass several trays to residents on the 300 unit. Room #306, #315 and room #304. Residents were not offered hand hygiene. On 11/1/23 at 5:31 p.m., the room trays arrived on the 500 unit. At 5:38 p.m., LPN #4 was observed to pass a room tray to the resident in room 501. However, hand hygiene was not offered. D. Staff interviewThe newly appointed infection preventionist (WN) and the regional nurse consultant (RNC) were interviewed on 11/2/23 at 2:30 p.m. The RNC said the staff were to wash or use hand sanitizer in before and after each task. The RNC said the staff had been trained and educated on hand hygiene. She said the staff were to offer handwashing to residents prior to their meal served. III. Exterior trash dumpsterA. ObservationOn 11/2/23 at 4:30 p.m., with the food service manager present, the dumpster was observed to have approximately 20 dirty used gloves scattered around the ground of the dumpster. Two gloves which were directly in front of the dumpster had light brown substance all over the gloves. B. Staff interviewThe food service manager was interviewed on 11/2/23 at 4:30 p.m. The food service manager said the dumpster was cleaned by himself and the maintenance director. He said every piece of trash including gloves needed to make it into the dumpster. IV. Failure to ensure wound cleanser was placed in an appropriate placeA. ObservationOn 11/1/23 at 4:45 p.m., registered nurse (RN) #1 was observed to complete wound dressing changes on Resident #53. RN #1 used the wound cleanser and then hung the bottle by the sprayer on the lip of the trash can. RN #1 said she had no other place to put the wound cleanser bottle. B. Staff interviewThe director of nurses (DON) and the quality improvement specialist consultant (QISC) were interviewed on 11/2/23 at 1:40 p.m. The QISC said the wound cleanser bottle should not be placed on the trash can, as it was not a clean area. V. Standard precautions for resident glucometersA. Professional referenceInstitute for Safe Medical Practices. (July 2021). Infection transmission risk with shared glucometers, fingerstick devices, and insulin pens. https://www.ismp.org/resources/infection-transmission-risk-shared-glucometers-fingerstick-devices-and-insulin-pens retrieved on 11/7/23."Whenever possible, blood glucometers should not be shared. If they must be shared, each device should be cleaned and disinfected after every use, per the manufacturer's instructions."B. Manufacturer guidelinesEvencare G3 meter manufacturer cleaning and disinfecting procedure guidelines, provided by the nursing home administrator (NHA) on 11/1/23 at 1:50 p.m, included the following guidelines,"The Evencare G3 meter should be cleaned and disinfected between each patient."CaviWipes germicidal wipes manufacturer guidelines (2023), https://www.metrex.com/en-us/caviwipes1v retrieved on 11/7/23, included the following guidelines,"One minute contact time for virucidal, bactericidal (including tuberculosis) activity."Clorox Healthcare Bleach germicidal wipes manufacturer guidelines (2023), https://www.cloroxpro.com/products/clorox-healthcare/bleach-germicidal-disinfectants/?upc=044600303581, retrieved on 11/7/23, included the following guidelines,"Kills human immunodeficiency virus (HIV) in 30 seconds, hepatitis C virus (HCV) in one minute, three minutes for all pathogens listed on label."B. ObservationsOn 11/1/23 at 7:15 a.m. licensed practical nurse (LPN) #1 took out from the medication cart a glucometer not labeled for a resident to check Resident #12's morning glucose. He then returned the glucometer to the medication cart, disposed of Resident #12 test strip from the glucometer that contained blood and wiped down the glucometer with a Cavi wipe with a disinfectant time of one minute. He did not keep the glucometer wet for the designated one minute disinfectant time. C. Staff interviewsLPN #1 was interviewed on 11/1/23 at 7:20 a.m. He said each medication cart had a shared glucometer and residents did not have their own designated glucometers. He said the product they were supposed to use were Cavi wipes and that the glucometers needed to stay wet for three minutes to clean glucometers between each resident. LPN #3 was interviewed on 11/1/23 at 8:05 a.m. She said residents did not have individually designated glucometers. She said there was one glucometer on each medication cart to use between residents. She said they cleaned the glucometers with the Sani Cloth germicidal wipes and the disinfectant time was three to five minutes. She said they also had bleach wipes and there was a three minute disinfectant time. Registered nurse #1 was interviewed on 11/2/23 at 8:45 a.m. She said that Cavi wipes were used for glucometers after each use. They need to be wiped, wrapped and left wet for two minutes. She said they also use bleach wipes and glucometers needed to stay wet for two minutes. The DON was interviewed on 11/2/23 at 9:12 a.m. She said the facility had one glucometer for each medication cart and they were to be cleaned after every use. She said they had different products they were using including the Cavi wipes and the bleach wipes. She said she did not know what the disinfectant time was for each of these products but said that the manufacturer's recommendations for each of these products should be followed when disinfecting the glucometers after every use. She said using multiple products for the use of cleaning glucometers was confusing for staff in ensuring that the proper manufacturer guidelines for disinfection were followed.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#64, #34, #26, #21 and #52) of eight residents reviewed for immunizations out of 39 sample residents. Specifically, the facility failed to:-Offer Resident #64 and #21 the pneumococcal vaccine upon admission; -Offer additional doses of the pneumococcal vaccine to Resident #26 and #34; and,-Offer Resident #52 the pneumococcal vaccine after signing a consent to receive. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 11/5/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: "Routine vaccination - pneumococcal-For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20)." (see notes)-For those "over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20." "Special situations: Age 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups.-Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies.-Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies." II. Facility policy The Pneumococcal Vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 10/30/23. It read in pertinent part, "All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, wil be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination."III. Resident #64A. Resident status Resident #64, age 62, was admitted on 5/11/21. According to the November 2023 computerized physician orders (CPO) diagnoses included, type II diabetes, history of transient ischemia attack and cerebral infarction (stroke) without residual deficits. The 8/22/23 minimum data set assessment (MDS) revealed Resident #64 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. -The MDS documented, that the resident was not up to date on the pneumococcal vaccination, due to not being offered. B. Record reviewA review of Resident #64's electronic medical record (EMR) revealed the immunization tracking sheet showed the resident had not received the pneumococcal vaccination. -The EMR showed a blank consent as it was not signed and did not show any decision. IV. Resident #34A. Resident statusResident #34, age 87, was admitted on 10/2/15. According to the November 2023 CPO the diagnoses included COPD.The 8/3/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15.-The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record reviewA review of Resident #34's EMR revealed the immunization tracking sheet showed the resident received pneumovax dose one on 7/28/14 and the Pneumococcal Polysaccharide vaccination (PPV23) on the same date of 7/28/14. -There was no evidence that the resident had been offered the pneumococcal vaccine any other date. V. Resident #26A. Resident statusResident #26, age 88, was admitted on 9/7/21. According to the November 2023 CPO diagnoses included chronic hypoxic respiratory failure, chronic heart failure (CHF), atrial fibrillation and type II diabetes. The 9/14/23 MDS assessment revealed the resident had minimal cognitively impairment with a brief interview for mental status score of 13 out of 15.-The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination.-The annual 6/22/23 MDS coded the resident as not being up to date on the pneumonia vaccination because it was not offered. B. Record reviewA review of Resident #26's EMR revealed the immunization tracking sheet showed the resident received the Prevnar 13 on 12/23/14. -There was no evidence that the resident had been offered the pneumococcal vaccine any other date. VI. Resident #21A. Resident statusResident #21, age 90, was admitted on 12/26/19. According to the 7/8/23 MDS assessment diagnoses included coronary artery disease and chronic obstructive pulmonary disease. The 7/8/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of seven out of 15.-The MDS documented the resident was not up to date on the pneumococcal vaccination, due to not being offered. B. Record reviewA review of Resident #21's EMR revealed the immunization tracking sheet showed the resident had not received the pneumococcal vaccination. -There was no evidence that the resident had been offered the pneumococcal vaccine any other date. VII. Resident #52A. Resident statusResident #52, age 72, was admitted on 3/20/23. According to the November 2023 CPO diagnoses included hypertension and pulmonary embolism. The 9/24/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15.-The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record reviewA review of Resident #52's EMR revealed the immunization tracking sheet showed the consent required for the Prevnar 13 pneumonia vaccination. A pneumococcal vaccination consent form signed on 3/9/22 (the year was incorrect on the form, as the resident was admitted on 3/20/23) showed the resident gave consent to receive the Prevnar 13 vaccination. However, the resident had not received it. VIII. InterviewThe regional nurse consultant (RNC) and the new infection preventionist (RN #3) were interviewed on 11/2/23 at 2:30 p.m. The RNC said the facility offered residents pneumonia vaccinations. She said at admission the resident's vaccination record was obtained. She said the Colorado Immunization Information System (CIIS) was utilized. She said the admitting nurse would then offer and provide education to the resident on the importance of being vaccinated against pneumonia.

A licensure survey was completed on 10/30/23 to 11/2/23. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide effective pain management program for two (#53 and #4) of three residents reviewed for pain management out of 39 sample residents. Resident #53 had pain control during a wound dressing change on 10/31/23 at 4:15 p.m. The resident experienced severe pain during the dressing change. The resident was administered a pain medication at 3:40 p.m., although the resident told the nurse that she was in pain, the dressing change continued. The resident was not offered any other type of pain intervention. In addition, the facility failed to for Resident #4: -Have a pain parameters for as needed (PRN) pain medications; and, -Thoroughly assess the resident's pain. Findings include:I. Facility policyThe Pain -Clinical Protocol policy, updated October 2022, was received on 11/2/23 at 1:00 p.m. from the nursing home administrator. The policy read in pertinent part, "The staff and physician will identify the characteristics of pain such as location, intensity, frequency pattern and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example wound care."II. Resident #53A. Resident statusResident #53, age 84, was admitted on 9/23/22. According to the November 2023 computerized physician orders (CPO)diagnosis included bilateral venous stasis ulcers in lower extremities. The 9/21/23 facility assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The he resident as having two venous and arterial ulcers. The resident had an open lesion and received non sterile dressings. The pain section documented that the resident received PRN (as needed) pain medication. Resident #53 did not receive non-medication interventions for pain. B. Resident interview and observationResident #53 was interviewed on 10/31/23 at 9:45 a.m. The resident said she had two wounds on both of her lower legs. She said the dressings were changed daily. The resident was observed to have both of her legs wrapped in Curlex wrap with the date of 10/30/23 written on the dressing. C. Wound care observations and resident interviewWound care treatment was observed for Resident #53 on 11/1/23 at 4:15 p.m. The wound care was completed by registered nurse (RN) #1, registered nurse (RN) #3. The quality improvement specialist consultant (QISC) was in the room for a short while. RN #3 was the wound nurse. Certified nurse aide (CNA) #5 was in the room to assist with resident care. The overbed table was used to hold the wound care supplies. RN #1 began to remove the old dressing, spraying the area where the dressing was being pulled away to expose the skin. The dressing was not pre soaked or saturated. As a result when RN #1 pulled off the dressing, Resident #53 verbalized her pain as RN #1 was pulling off the dressing. The resident said, "you are debriding the wound. It hurts. Stop!" RN #1 did not stop and continued, she responded by saying this was how it was performed and she had performed rounds with the wound physician. She said this as she sprayed the bandage. The resident continued to state the pain she felt as RN #1 continued with the above actions. The QISC intervened and asked if the resident had been given any pain medications before the procedure began. The resident stated that she had not received any pain medications. The QISC asked for a check of the medication administration record (MAR) to see if the resident had received any pain medications prior to the procedure. The QISC returned to the room and said the MAR showed the resident had received Oxycodone 5mg by mouth at 3:40 p.m. The resident was notified and no further medications were administered. The QISC left the resident's room. The resident continued to complain of the pain as RN #1 removed the bandage. RN #1 responded by saying; "I know. I know." The resident responded by saying, "you have no idea what another person's pain is!"After the dressing was removed from each lower extremity, the outer layer of the resident's skin (epidermis) was absent and exposed the second layer of skin (dermis) on the back of the resident's lower leg. The dressing was removed and as the wound cleaner was sprayed on the open wounds, she would say each time it was sprayed that her skin stung, as it was sprayed on the open wounds. Resident #53 was interviewed on 11/2/23 at 8:20 a.m. The resident expressed that during the dressing change on 11/1/23 she sustained "a lot of pain" and she felt her stated feelings were disregarded, as she expressed the amount of pain she was in, although RN #1 continued with the dressing change. D. Record reviewThe care plan last updated on 9/27/23 identified the resident was at risk for skin breakdown related to decreased activity, diabetes, peripheral vascular disease. The care plan showed the resident had actual wounds to her bilateral lower extremities. Pertinent approaches were to observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. Complete a weekly skin check by licensed nurse weekly. According to the medication administration orders (MAR) for November 2023 the resident was receiving following medications for pain:Acetaminophen 325 milligram (mg), two tablets every eight hours as needed for mild pain. The order was started on 9/23/22. The order directed to notify the physician if more than three doses in 48 hours. Do not exceed 3 grams a day. Oxycodone HCI oral tablet 5 mg, give one tablet by mouth every six hours as needed for pain 6-10 (with 10 being the worst on the scale). The most recent wound assessment completed on 10/27/23 by the wound care physician (WCP) revealed the resident had two wounds on her bilateral lower extremities. The November 2023 treatment administration record (TAR) showed the physician order was as follows:Left lower leg wash with wound cleaner and pat dry with a 4 X 4 gauze. Apply xeroform to open areas. Cover with ABD (absorbent dressing) and kerlix (to cover wounds) every day and as needed every day shift for wound care. The order was started on 10/21/23E. InterviewThe director of nurses (DON) and the QISC were interviewed on 11/2/23 at 1:40 p.m. The QISC said the resident had bilateral venous stasis wounds on her lower extremities. She said the wound physician was involved and saw her weekly. The DON said the dressing changes were to be completed one time a day and as needed. The DON said the resident's legs were to be washed with wound cleanser and the order was to pat it dry with gauze. The DON said after hearing how the dressing was removed (see above) she said the orders would have to be clarified with the physician, as it did not direct how to remove the dressing. The QISC said she had left the room to verify the medication which was administered. She said once they saw the resident had received pain medication and it was not effective for the dressing change, then they should have stopped the dressing changes until the physician could have been called for additional pain medications. The QISC was interviewed a second time on 11/2/23 at approximately 5:30 p.m. The QISC said they spoke with the resident and she verified that the resident had excessive pain with the dressing change on 11/2/23. III. Resident #4A. Resident statusResident #4, age 94, was admitted on 9/16/2020. According to the November 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), right femoral fracture and opioid dependence. The 8/3/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was dependent with toileting, transfers, personal hygiene and required set up assistanceonly with eating. It indicated the resident was on a scheduled pain medication program, received PRN medications and did received pharmacological interventions for pain management. B. Record reviewThe pain management care plan, initiated on 9/12/19 revised on 4/16/21, indicated the resident had pain related to chronic pain with narcotic dependence history. Interventions included pain medications per physician order, assist with repositioning for comfort, document complaints and non verbal signs of pain, encourage resident to communicate pain, implement relaxation and distraction techniques, observe for potential side effects of medication, therapy to screen as necessary, utilize pain scale as indicated.-A review of Resident #4's comprehensive care plan did not reveal a person centered approach with identification of location, type or intensity of pain the resident experienced. It did not include personalized non-pharmacological interventions to address the resident's pain. It did not identify a baseline assessment of pain or person centered pain management goals. The October 2023 medication administration record (MAR) documented the resident was prescribed the following medications:-Acetaminophen 650 milligrams (mg) at bedtime for pain, ordered 6/9/21.-Methadone 5 mg at bedtime for pain, ordered 6/12/22.-Methadone 2.5 mg once a day for pain, ordered 7/1/22.-Acetaminophen 650 mg every 6 hours as needed for mild pain, ordered 3/31/23.-Hydromorphone 2 mg every two hours as needed for pain, ordered 9/18/23.-A comprehensive review of the October 2023 MAR failed to document location, intensity and type of resident's pain being treated for Acetaminophen, Methadone and Hydromorphone. -The physician orders did not include specific pain scale parameters for the PRN Acetaminophen and Hydromorphone. -The documentation did not include a pain assessment prior to or after the administration of pain medications. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 11/2/23 at 11:40 a.m. She said pain assessment should be done prior and after any administration of a pain medication. She said residents that were on multiple pain medications, had been determining which pain medications they wanted to take and parameters were not always ordered for pain medications. The DON was interviewed on 11/2/23 at 1:23 p.m. She said pain medication assessment evaluations should be done on admission and quarterly and when there was a change in the resident's condition. She said there should be physician ordered parameters for all pain medications. She said that pain assessments should be done before and after pain medications administration and documented on the MAR. She said that it had been identified that pain assessment evaluations and pain assessment documentation on the MAR were not being done and were an issue.

Based on observations, record review and interviews the facility failed to ensure one (#14) of one residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 39 sample residents. Specifically, the facility failed to ensure Resident #14 was provided with preventative measures to help minimize the development of and the worsening of contractures. Resident #14 had a contracture to his left hand and no preventative measures were implemented. When Resident #14 was assessed during the survey on 10/31/23, his left hand finger contractures worsened and he developed a contracture to his right hand. Findings include:I. Facility policy and proceduresThe Activities of Daily Living (ADL) Supporting policy, revised in March 2018, was provided by the nursing home administrator (NHA) on 10/30/23 at 8:29 p.m. The policy revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently. The Resident Mobility and Range of Motion policy, revised July 2017, was provided by the regional director of clinical services (RDCS) on 11/7/23 at 12: 17 p.m. The policy revealed that residents would not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion would receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility would receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility was unavoidable.-As part of the resident's comprehensive assessment, the nurse would identify the resident's current range of motion of his or her joints, limitations in movement or mobility, opportunities for improvement, and previous treatment or services for mobility.-As part of the comprehensive assessment, the nurse would also identify conditions that placed the resident at risk for complications related to ROM and mobility. This included muscle wasting/atrophy, contractures and/or other complications that could cause or contribute to immobility, impaired ROM or injury from falls (postural hypotension, urinary incontinence).-During the resident's assessment, the nurse would identify the underlying factors that might have contributed to a range of motion or mobility problems. These include immobilization (bedfast, chair or wheelchair usage), neurological conditions (cerebral palsy, cerebral-vascular accident), conditions in which movement might lead to pain and/or conditions that limit or immobilize movement of limbs or digits (splints).-The resident's care plan would be developed by the interdisciplinary team based on the comprehensive assessment, and would be revised as needed. The care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in and/or improve mobility/range of motion. Interventions might include therapies, the provision of necessary equipment/exercises, based on professional standards of practice that were consistent with state laws and practice acts.-The care plan would include the type, frequency, duration of interventions, as well as measurable goals and objectives. The resident and representative would be included in determining these goals and objectives. Documentation of the resident's progress toward the goals and objectives would include attempts to address any changes or decline in the resident's condition or needs. The Functional Impairment - Clinical Protocol, revised in March 2018, was provided by the RDCS on 11/6/23 at 12:17 p.m. The policy revealed, upon admission to the facility, whenever a significant change of condition occurred, and periodically during a resident's stay, the physician and staff would assess the resident's function along with their physical condition. As part of the physical examination, the physician would include items that related to function as well as the potential to benefit from rehabilitative services; for example, proprioception, sensation, muscle tone, range of motion, gait, balance, joint swelling/abnormalities, strength, edema, and cognition. The staff and physician would identify individuals with the potential for significant improvement in function or significant decline in function, including the ability to perform ADLs. -As appropriate, the physician would identify and evaluate medical conditions and medications that impacted a resident's function (for example, muscle weakness or pain due to adverse medication effects, persistence of complications from recent hospitalization, and sedation or confusion due to fluid/electrolyte imbalance). The physician and staff would review and analyze the preceding information to evaluate the influence of medical factors on function and vice-versa, to help guide subsequent treatment and care planning. The physician would identify and document the impact of medical conditions on function and identify a resident's potential to benefit from rehabilitative services, such as physical and occupational therapy. The staff and physician would collaborate to identify a rehabilitative or restorative care plan to help improve function, quality of life, meet a resident's goals/needs and attain other desired outcomes such as discharge to the community. Based on a review of available information (including results of the evaluation), the physician would determine if a resident met the criteria for skilled therapy services. The physician and staff would address risk factors related to exercise or activity, and consider any relevant precautions. The physician would order any therapy services based on the above considerations. The physician would pay attention to the relevance and effectiveness of such interventions. The physician would not just sign off therapy orders perfunctorily. -The staff would monitor and document the resident's function (for example, evidence of reduced ADL dependency, improved ambulation, improved balance and gait) and would discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care. The physician would identify the subsequent relevance of therapy services, based on reviewing the resident's progress relative to his/her care goals (functional stabilization or improvement), the status of conditions and the current treatment regimen that have been identified as affecting his/her function. II. Resident interview and observationsThe resident was observed on 10/30/23 at 10:54 a.m., seated in a motorized wheelchair in his room. He had bilateral wrist/hand/finger contractures. He did not have any bilateral splints in place. He said he wanted splints for both of his wrists/hands/fingers. He said he had been asking staff for bilateral splints for over a year and they told him that they would see about getting him some. The resident was observed on 10/30/23 at 12:12 p.m. seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. A staff member was assisting the resident with his meal. The resident was observed on 10/31/23 at 8:45 a.m. seated in a motorized wheelchair by a nurse medication cart. The resident was being administered medication by the nurse. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/1/23 at 7:31 a.m., seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint inplace for either wrist/hand/fingers. The resident was observed on 11/1/23 at 1:43 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/2/23 at 12:49 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident demonstrated he was unable to open his fingers on either hand. III. Resident #14A. Resident statusResident #14, age under 65, was admitted on 2/23/16 and readmitted on 11/18/22. According to the November 2023 computerized physician orders (CPO), diagnoses included quadriplegia, spinal stenosis in the cervical region, anxiety, schizoaffective disorder, chronic obstructive pulmonary disease, history of transient ischemic attack, muscle weakness, abnormal posture, reduced mobility, history of musculoskeletal system and connective tissue disorders. The 7/25/23 facility assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. According to the assessment, the resident did not exhibit behaviors or refuse care. The resident required extensive staff assistance with two plus persons to physical assist for bed mobility, dressing toileting and personal hygiene. The resident was totally dependent on staff and required physical assistance from two or more persons for transfers. The resident had functional limitations in ranges of motion with impairment on both sides that included his upper extremity (shoulder, elbow, wrist, hand). The resident did not receive any therapy services during the seven-day review period. B. Record reviewA care plan for dependence with ADL care related to quadriplegia, and chronic pain, cognitive loss was initiated on 3/16/21 and revised on 10/27/23. The plan also revealed the resident exhibited or was at risk for alterations in functional mobility related to quadriplegia, osteoarthritis, degenerative disc disease, history of a fall with spinal cord injury at the cervical levels of 4-7, cervical stenosis of the spine, history of lumbar surgery, history of an open reduction and internal fixation right hip. The relevant interventions were the resident required one to two staff persons for assistance with ADL. Staff were to monitor the resident for shortness of breath, fatigue and/or a change of condition and adjust the ADL task accordingly. Staff were to also encourage the resident to pace himself during an ADL task. Staff were to provide cueing for safety and sequencing to maximize the resident's current level of function. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for restorative nursing program related to bed mobility/transfers was initiated on 9/14/22 and revised on 8/21/23. The relative interventions were to encourage the resident to utilize the bed bar for repositioning on his wide bariatric bed. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for being at risk for decreased ability to perform ADLs related to recent hospitalization, weakness, decreased mobility, diabetes mellitus, and dizziness was initiated on 5/12/21 and revised on 6/6/23. Relevant interventions were for staff to monitor for decline in ADL function. Staff were to refer to rehabilitation therapy if a decline in ADL was noted. Staff were to monitor for complications of immobility (pressure ulcers, muscular atrophy, contractures, incontinence, urinary/respiratory infections). The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. The occupational therapy (OT) initial evaluation dated 10/27/2020 noted range of motion for the musculoskeletal right upper extremity (elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired.-The passive range of motion for the left index finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees.-The passive range of motion for the left middle finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees.-The active range of motion for the left ring finger metacarpophalangeal joint flexion was 0 (zero) degrees and for the proximal interphalangeal joint flexion was 0 (zero) degrees.-The passive range of motion for the left right finger metacarpophalangeal joint was 75 degrees and for the proximal interphalangeal joint flexion was 75 degrees.-The passive range of motion for the left little finger metacarpophalangeal joint flexion was 70 degrees and for the proximal interphalangeal joint flexion was 75 degrees.-The short term goals were for the resident to tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were for the resident to wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. -There were no short or long term goals for the resident's right wrist/hand/fingers. The occupational therapy (OT) evaluation dated 12/17/22 revealed the right upper extremity was not tested due to mixed tone; non-functional upper extremity loss of motor control that was chronic in nature. The range of motion of the upper extremity was not tested due to clinical reasons of other tone; non-functional upper extremity that was chronic in nature. The left upper extremity range of motion was not tested related to clinical reasons of mixed tone; non-functional upper extremity. The tone was abnormal; upper extremity muscle tone was spastic, hypertonic, and/or hypertonic flaccid. -There was no recommendation for the use of splints. The occupational therapy (OT) evaluation on 1/26/23 revealed the right upper extremity wrist strength was impaired (no measurements were taken). The left upper extremity was impaired (no measurements were taken). The range of motion of the right upper extremity revealed wrist and hand impairment. -There was no recommendation for the use of splints. The Rehabilitation Screening form dated 10/27/23 (completed during the survey) revealed contractures present and a need for splints. The left wrist and right wrist demonstrated moderately and reflected approximately 50% of full ROM. The left and right fingers were severe and reflected 25% or less of full ROM.Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 (completed during the survey) revealed the left wrist had no displays of contractions during active or passive range of motion. The left proximal interphalangeal joints had resting contractures at 90 degrees and passive range of motion to 145 degrees. The right wrist had no displays on contractures. The right wrist active range of motion was limited and would benefit from a resting hand splint. The right interphalangeal joints had resting contractures at 145 degrees, passive range of motion at 170 degrees and would benefit from a resting hand splint. One new goal revealed that the resident would present with a functional wear schedule wearing bilateral hand splints with no redness, or areas of concerns for 15 minutes to preserve joint mobility (target 11/13/23). -The OT assessment dated 10/31/23 (approximately three years later from 10/27/2020) revealed the resident had contractures of both the left and right interphalangeal joints. This assessment's new goal was for bilateral splints for these areas. This assessment revealed the resident now needed a splint for both hands. -The resident's left hand finger contractures worsened at the hand/knuckle joint based on the decline over three years. -The resident did not have any known contractures to his right hand at baseline and based on the current measurement developed a decline in range of motion. IV. Staff interviewsThe director of rehabilitation (DOR), registered nurse consultant (RNC) and the quality improvement specialist consultant (QISC) were interviewed on 11/2/23 at 12:02 p.m. They said the resident only had contracture measurements on 10/27/2020 and during the survey on 10/31/23. They said the OT initial evaluation on 10/27/2020 revealed the resident's range of motion for the musculoskeletal right upper extremity (elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired. The evaluation revealed left hand passive/active range of motion measurements of the resident's fingers and there were no measurements for the resident's right hand. The evaluation had short term goals, that the resident would tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were the resident would wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. There were no short or long term goals for the resident's right wrist/hand/fingers. They said the evaluation only mentioned the resident's left hand, with a recommendation for the use of a splint for the left hand and did not mention the right hand. They said the documentation on the Rehabilitation Screening form dated 10/27/23 revealed the resident had contractures and there was a need for splints. This screening occurred during the survey process. They said the documentation on the Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 revealed a new goal for the resident was to provide bilateral hand splints with no redness or areas of concern for 15 minutes to preserve joint mobility (target 11/13/23). This screening occurred during the survey process. They said the resident did not have any current services for his bilateral hand contractures nor was he on a restorative program for his hand contractures. They acknowledged there was no specific care plan for the resident's bilateral hand contractures.

A revisit survey was completed on 10/26/23 for all previous deficiencies cited on 9/6/23. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO33506 and Incident #32113 and #32633 was completed on 9/5/23 and 9/6/23. Two deficiencies were cited.

Based on interviews and record review, the facility failed to prevent resident to resident altercations involving three (#1, #2 and #3) of three residents reviewed out of eight sample residents. Specifically, the facility failed to protect Residents #1 and #3 from physical abuse by Resident #2. Cross-reference F610, failure to investigate abuse incidents. Findings include: I. Facility policy and procedure The Resident to Resident Altercation policy, revised September 2022, was received from the nursing home administrator (NHA) on 9/6/23 10:10 a.m. The policy documented in part, "All altercations, including those that may represent resident-to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator." II. Resident status and record reviewA. Resident #1 (victim)Resident #1, age 72, was admitted on 10/24/22. According to the September 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, history of falls, presence of unspecified artificial shoulder joint and difficulty walking. According to the 8/2/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. Resident #1's care plan, initiated 10/24/22 and revised 7/17/23, identified the resident reported past experiences of undisclosed trauma as evidenced by repeated, disturbing memories, thoughts or images of a stressful experience from the past, and feeling upset when reminded of a stressful experience from the past. Interventions include encouraging the resident to identify personal trauma and triggers and take steps to eliminate/minimize. Be sensitive to privacy and confidentiality. Maintain communication that is consistent, open, respectful and compassionate. The care plan, initiated 10/24/22 and revised 7/17/23, identified the resident exhibited or had the potential to demonstrate verbal behaviors related to history of verbal behaviors and aggressive confrontations with other residents. Interventions included removing the resident from the environment, if needed. Gently guide the resident from the environment while speaking to him calmly and respectfully. Allow the resident time for expression of feelings; provide empathy, encouragement and reassurance. B. Resident #2 (assailant)Resident #2, age 60, was admitted on 2/3/23. According to the September 2023 CPO, diagnoses included acute chronic respiratory failure, schizophrenia, mild neurocognitive disorder and personal history of traumatic brain injury. According to the 8/3/23 MDS assessment, the resident had no cognitive impairment with a BIMS score of 14 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. Resident #2's care plan, initiated 2/3/23 and revised 8/29/23, identified the resident had the potential to exhibit physical behaviors related to cognitive deficits due to traumatic brain injury (TBI), ineffective coping skills, poor anger management, poor impulse control, psychiatric disorder, schizophrenia and other mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Interventions included evaluating the nature and circumstances (triggers) of the physical behavior with the resident. Discuss findings with the resident's caregivers and adjust care delivery appropriately. Social Service visits to provide support, as needed and/or requested by the resident. -The interventions failed to provide direction for staff to redirect the resident when the resident engaged in aggressive behavioral expressions towards other vulnerable residents. C. Resident #3 (victim)Resident #3, age 89, was admitted on 3/12/22. According to the September 2023 CPO, diagnoses included dementia, history of falling and cognitive communication deficit. According to the 5/17/23 MDS assessment, the resident was not administered the BIMS. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. Resident #3's care plan, initiated 3/12/22 and revised 6/8/23, identified the resident had the potential to exhibit physical behaviors related to: cognitive dementia with behaviors, poor impulse control, language barrier, and history of aggressive behaviors. The resident had episodes of striking out at others with his cane. Had a history of wandering in and out of other residents' rooms on all three halls and using others' bathrooms. The resident was not always easily redirected back to his room. The resident would often urinate in the hallways and corners, and urinate and/or have bowel movements in his pants even though he was able to go to the bathroom on his own. The resident had a history of resident to resident altercations. The resident would refuse medications. Interventions include hospice to provide supplement nursing and CNA visits at least two times a week. Attempt non-pharmacological interventions when the resident exhibits verbal/physical or exit seeking behavior, offer one-to-one programming as tolerated, snacks or conversation. Redirect the resident away from areas that may encourage resident to resident altercations. III. Physical altercation between Residents #1 and #2A. Nursing progress notesNursing progress notes in Resident #2's medical record, dated 8/30/23, documented the resident was sitting in a chair in the smoking area when another resident walked by and bumped him with his walker. Resident #2 kicked the other resident. No injury was noted to this resident and no complaint of pain. The residents voiced no fear of anyone. Nursing progress notes in Resident #1's medical record, dated 9/2/23 at 10:24 a.m., documented Resident #1 was kicked by another resident. Seventy-two hour charting was initiated. "No complaints of pain to area, no signs or symptoms of distress. The resident continues to go outside and smoke in designated smoking area. Will continue to monitor."B. Facility investigation A written request was made on 9/6/23 at 8:33 a.m. for the incident/investigation for the resident-to-resident altercation between Resident #1 and Resident #2 on 8/29/23. No investigation was provided. C. Staff interviews The social service director (SSD) and social services assistant (SSA) #1 were interviewed on 9/6/23 at 9:04 a.m. The SSD said she was recently hired on 8/23/23. She said, "I don't really know much about the incidents other than there were three incidents." She said one was on 4/23/23, 6/23/23 and 8/29/23. SSA #1 said she did not participate in any abuse investigations. She said, "The previous social service director would do all of the investigations so I didn't have anything to do with it." The nursing home administrator (NHA) was interviewed on 9/6/23 at 9:16 a.m. regarding Resident #1's abuse investigation. She said the investigation was completed on 8/29/23 by the director of nursing (DON) who was the abuse coordinator as everyone on staff were new employees during the transition. The activity director (AD) was interviewed on 9/6/23 at 9:36 a.m. She said she did not witness the incident but assisted after the fact. She said Resident #1 and Resident #2 were separated and Resident #2 was sent inside the facility. She said the facility was currently keeping both residents separated during smoking breaks. Certified nurse aide (CNA) #6 was interviewed on 9/6/23 at 10:30 a.m. CNA #6 said she and the activities director were assisting the smokers out on the patio. She said Resident #1 walked by Resident #2 with his front wheel walker and apparently hit Resident #2's foot with his front wheel walker. She said Resident #2 leaned back in his chair and started kicking Resident #1 in his legsand, "I had to catch Resident #1 as he almost fell from the altercation." She said, "The activity director (AD) and I separated the residents." She said the activity director sent Resident #2 inside the building and reported the incident to the social service director and director of nursing. The director of nursing (DON) was interviewed on 9/6/23 at 10:54 a.m. The DON said she was recently put into the position and was the investigator of the incident above, which occurred on 8/29/23. She said she was the abuse coordinator and she filed a report with the State Agency. The DON did not acknowledge if the incident on 8/29/23 was substantiated or not. The DON said she and the SSD were currently developing the facility's investigation book to ensure the alleged abuse incident was being investigated correctly. IV. Resident to resident physical altercation between Resident #3 and #2. A. Facility investigation The registered nurse (RN) interview investigation statement dated 6/2/23 at 12:30 p.m. revealed that CNA #5 was helping another resident when she heard an interaction. When she turned around she saw the alleged victim (Resident #3) attempting to stand and Resident #2 kicked another resident (Resident #3). The RN then went to assess the residents. The assessment revealed no injuries were observed at the time of the incident. Resident #2 was interviewed after the altercation and stated it was in self-defense. -The facility investigation did not identify if the incident was unsubstantiated or substantiated. B. Record review A social service note dated 6/1/23 at 2:12 p.m. documented Resident #3 had an altercation with another resident. The local police department had been called. The ombudsman had been contacted as well. Social service notes dated 6/1/23 at 1:13 p.m. documented in part the police department did conduct an interview with the resident about the incident that happened. A translator was used. Social service notes dated 6/1/23 at 1:13 p.m. documented in part the DON had the incident case number and a card with the investigating police officer's name and phone number. C. Staff interviews CNA #5 was interviewed on 9/6/23 at 11:05 a.m. She said she was in the dining room when she heard a commotion with two residents. She turned around to see Resident #3 was trying to stand up when Resident #2 pushed him on the shoulder. She said Resident #2 then kicked Resident #3 in the leg making direct contact, which made Resident #3 sit back down. The DON was interviewed on 9/6/23 at 10:54 a.m. The DON said she was the abuse coordinator. The DON did not acknowledge if the incidents listed above were substantiated or unsubstantiated.

Based on record review, resident and staff interviews, the facility failed to investigate an allegation of abuse for one (#1) of three residents reviewed for abuse out of eight sample residents. Specifically, the facility failed to thoroughly investigate an allegation of resident to resident altercation on 4/21/23 and an altercation on 8/29/23 between Resident #1 and Resident #2 in a timely manner. Cross-reference F600 resident to resident altercation. Findings include: I. Facility policy The Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating, dated 9/22/22, was provided by the nursing home administrator on 9/6/23 at 10:10 a.m. It read in pertinent part: "All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported."II. Allegation 4/21/23A. Resident interviewResident #1 was interviewed on 9/6/23 at 2:26 p.m. Resident #1 said Resident #2 was always being aggressive with him. Resident #1 said on 4/21/23 he was defending a female resident because she was yelling out. Resident #1 said Resident #2 was yelling at the female resident and telling her to shut her mouth and quit yelling. Resident #1 said he told Resident #2 to stop yelling at her "and that was when he came after me." Resident #1 said Resident #2 kicked his walker "and the walker hit my leg and almost made me fall." Resident #1 said he reported it to a nurse and they said they would look into it but he never heard anything else. B. Facility investigationThe 4/21/23 investigation contained Resident #1 and Resident #2's face sheets, care plans and five resident interviews. The facility had documentation of five resident interviews conducted on 4/24/23 asking if they had any issues with Resident #2 two residents had issues with. Interview questions dated 4/24/23 for resident in room #314 documented in part:-Do you have a concern for your safety when you are around other residents? "No."-Do you get along with other residents? Everybody except Resident #2. Interview questions dated 4/24/23 for resident in room #609B documented in part:-Do you have a concern for your safety when you are around other residents? "Yes just Resident #2." -Do you get along with other residents? "Yes"-The facility failed to follow up with the two residents who had issues with Resident #2. The facility failed to follow up with Resident #2. In addition, the facility failed to follow up with Resident #1. -The facility failed to have an investigation into what occurred on 4/21/23. C. Progress noteSocial service assistant (SSA) #2 notes dated 4/26/23 in Resident #2's medical record documented in part, this worker and co-worker SSA #1 interviewed Resident #2 about an incident that happened with another resident around the first of the month. Resident #2 said that the other resident was yelling and harassing him. Resident #2 said that he told me to mind my own business. Resident #2 was asked what happened after that. Resident #2 said, "I told him to shut up and I sat down and kept my mouth shut." Resident #2 was asked if he was concerned for his safety. Resident #2 said "No." Resident #2 said, "I don't have anything against him, I just avoid him." This SSA #2 asked Resident #2 if anything like this happened before with the resident, and Resident #2 said, "No, I just avoid him."D. Staff interview Certified nurse aide (CNA) #3 was interviewed on 9/5/23 at 2:19 p.m. She said she had heard about the altercation Resident #1 was having with Resident #2. She said she had not been involved in the incident on 4/21/23. CNA #3 said, "I have witnessed Resident #2 trying to trip Resident #1 while he was walking down the hall." CNA #3 said the charting system was down and she reported it to nursing. The nursing home administrator (NHA) was interviewed on 9/6/23 at 9:16 a.m. regarding Resident #1's abuse investigation. She said the investigation folder only had Resident #1 and Resident #2's face sheets, care plan and five resident interviews. She said, "It was not a good investigation." The SSA was interviewed on 9/6/23 at 9:34 a.m. She said she did not participate in the investigation on 4/21/23. She said, "The previous social service director would do all of the investigations so I didn't have anything to do with it." The director of nursing (DON) was interviewed on 9/6/23 at 10:54 a.m. The DON said she was recently put into the position and was not in the facility at the time of the 4/21/23 incident. She said she was the abuse coordinator. The DON said she did not find anything in the resident chart which defined the alleged abuse had been investigated. She said, "It looks like to me they reported the incident on 4/21/23 but didn't investigate it." The DON said she was currently developing her own investigation book to ensure the alleged abuse incidents were being investigated correctly. III. Resident to resident physical altercation between Resident #1 and #2A. Nursing progress notesNursing progress notes in Resident #2's medical record, dated 8/30/23, documented the resident was sitting in a chair in the smoking area when another resident walked by and bumped him with his walker. Resident #2 kicked the other resident. No injury was noted to this resident, and no complaint of pain. The residents voiced no fear of anyone. Nursing progress notes in Resident #1's medical record, dated 9/2/23 at 10:24 a.m., documented Resident #1 was kicked by another resident. Seventy-two hour charting was initiated. "No complaints of pain to area, no signs or symptoms of distress. The resident continues to go outside and smoke in designated smoking area. Will continue to monitor."B. Facility investigation A written request was made on 9/6/23 at 8:33 a.m. for the incident/investigation for the resident-to-resident altercation between Resident #1 and Resident #2 on 8/29/23. No investigation was provided. C. Staff interviews The social service director (SSD) and SSA #1 were interviewed on 9/6/23 at 9:04 a.m. The SSD said she was recently hired on 8/23/23. She said, "I don't really know much about the incidents other than there were three incidents." She said one was on 4/23/23, 6/23/23 and 8/29/23. The NHA was interviewed on 9/6/23 at 9:16 a.m. regarding Resident #1's abuse investigation. She said the investigation on 8/29/23 was completed by the director of nursing who was the abuse coordinator as everyone on staff were new employees during the transition. The DON was interviewed on 9/6/23 at 10:54 a.m. The DON said she was recently put into the position and was the investigator of the 8/29/23 incident. She said she was the abuse coordinator and she filed the report with the State Agency. The DON did not acknowledge if the incident on 8/29/23 was substantiated or not. The DON said she and the SSD were currently developing the facility's investigation book to ensure the alleged abuse incident was being investigated correctly.

A complaint survey, prompted by #CO33322 and #CO33433 was conducted on 8/22/23 to 8/23/23. No deficiencies were cited.

A revisit survey was completed on 8/7/23 for all previous deficiencies cited on 6/23/23. The facility is in compliance with all regulations surveyed.

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

A revisit to the 4/24/2023 survey was completed on 6/23/2023. The facility was in compliance with the regulations surveyed.

A revisit survey was completed on 6/23/23 for all previous deficiencies cited on 4/24/23. One deficiency was cited.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 dry-pipe, automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1963 and is license for 146 beds. This re-certification survey conducted on May 04, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Director of Maintenance during the exit conference conducted at the end on-site survey.

STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit leading to an exit discharge is compromised. This was evidenced by the following: Riverwalk Dining Room 2 fire doors are not equipped with approved Panic Hardware and Fire Exit Hardware. NFPA 101-2012, Chapter 7, Panic Hardware and Fire Exit Hardware, Section 7.2.1.7.2. Only approved panic hardware shall be used on door assemblies that are not fire-rated door assemblies. Only approved fire exit hardware shall be used on fire-rated door assemblies. New panic hardware and new fire exit hardware shall comply with ANSI/UL 305, Standard for Safety Panic Hardware and ANSI/BHMAA156.3, Exit Devices. This exit discharge deficiency was discussed during the exit conference with the Administrator.

STANDARD is not met as evidenced by: Based on observation, testing and staff interview of the emergency lighting during the facility tour, it was determined the facility failed to maintain the battery-powered emergency lights in accordance with 7.9.2 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:No documentation was available during record review of the facility required testing of the battery-powered emergency lighting system at 30 day intervals for not less than 30 seconds or annually for not less than 1 ½ hours. 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provided for building egress. This was evidence by the following. Facility failed to provide proper exit signage in the kitchen no directional arrows pointing in the direction of means of egress. Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. The Director of Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

STANDARD is not met as evidenced by: During the tour of the facility with the staff, it was determined that the facility failed to provide proper coverage of the Dry Chemical Extinguishing System as required by NFPA 12, (Chapter 9, and Section 9.3.2). This deficient practice could affect all residents, and staff should a fire occur. This was evidence by the following. The dry chemical discharge nozzle arranged to protect the cooking surface of the gas-fired cooking equipment located under the hood. Standard for Dry Chemical Extinguishing Systems 9.3.1 Dry chemical fire extinguishing systems for commercial kitchen hood, duct, and cooking appliances shall comply with ANSI/UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or equivalent listing standard. The Maintenance Director acknowledge deficiency of the dry chemical system during a tour of the facility.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4. This deficient practice could affect all residents, staff and visitors should the portable fire extinguishers fail to operate effectively due to non-code compliant maintenance. This was evidence by the following. 1. Type K fire extinguisher is not charged in the kitchen. 2. A placard was not conspicuously place near the K Class fire extinguisher in the kitchen that states (The fire protection system shall be actuated prior to using the fire extinguisher). Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers2010 NFPA 10 5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. The Maintenance Director acknowledge the lack of maintenance and inspection requirements of the portable fire extinguishers deficiency during record review of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. This was evidenced by the following: 1. Corridor doors were not maintained to close and positively latch, as required. Door to resident's rooms 306 and 308 and Steel City Dining room would not close and latch into the door frame without excessive force. 2. Riverwalk hall both double fire doors would not close and latch into the door frame. 3. Walkinstick hall both double fire doors would not close and latch into the door frame. The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke. The Director of Maintenance acknowledge the corridor door condition during the facility tour.

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

STANDARD is not met as evidenced by: Based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. This deficient practice could affect all residents, staff and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to lack of testing. This was evidenced by the following:No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patients care areas 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). 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation orgeneral anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. The non-hospital grade electrical outlets testing at patient's care areas deficiency was discussed with the Director of Maintenance during the survey and again during the exit conference with the Administrator.

STANDARD is not met as evidenced by: Based on observation during the course testing the transfer switch on the generator it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 6 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evidenced by the following. 1. At the time of the survey, no records were available to verify testing and recording of the EPSS Loads L1, L2 and L3 after transfer. 2. Generator was not equipped with battery-powered lighting. 5-3.1 The Level I and Level 2 EPS equipment location shall be provided with batty-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. NFPA 110, Section 6-4.1. Level I and Level EPSSs, including all appurtenant components, shall be inspected and shall be exercised under load at least monthly. NFPA 110-2010 section 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. The emergency power supply system deficiency item was discussed with the Director of Maintenance during the survey and again during the exit conference with the Administrator.

A licensure survey was completed on 4/17/23 to 4/24/23. Two deficiencies were cited.

Based on observations, interviews and record review, the facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living (ADLs) for two (#8 and #11) out of three reviewed for ADLs out of 42 sample residents. Resident #8 admitted to the facility for long term care with diagnoses of cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture), legal blindness, paraplegia (paralysis of the lower body), reduced mobility, lack of coordination, major and depressive disorder. The resident required extensive two person assistance with most ADLs. The resident had used an electric wheelchair for independence and mobility since she was four years old. The facility failed to repair the resident's electric wheelchair which prevented her from getting out of bed, attending activities and the ability to socialize with staff and other residents. The resident stated due to not being able to use her electric wheelchair, it "has been death to me" and said "they (the facility) took my legs away. I can't leave my room." She said the facility did not feel like her home anymore. Per staff interviews, the resident was not herself and upset since she was unable to get out of her room due to not having her electric wheelchair. In addition, the facility failed to ensure strategies were in place to effectively communicate with Resident #11, who spoke a language other than English and assess Resident #11's wheelchair and ambulation to maintain his mobility. Findings include:I. Resident #8A. Resident statusResident #8, under age 65, was admitted to the facility on 5/13/13 and readmitted on 12/21/22. According to the April 2023 computerized physician orders (CPO) diagnoses included cerebral palsy, legal blindness, reduced mobility, lack of coordination, major depressive disorder, personality disorder, generalized anxiety disorder, stiffness of joints, muscle weakness, contractures of left elbow, right elbow, left wrist, and right wrist, complete paraplegia and history of diseases of the musculoskeletal system and connective tissue. The 3/29/23 facility assessment documented the resident had a minor cognitive deficit with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, toileting, extensive one person assistance with personal hygiene and set up assistance for eating. The resident used an electric wheelchair. B. Resident interview and observationThe resident was interviewed on 4/17/23 at 4:47 p.m. The resident said her personalized electric wheelchair was broken. The tray that was used for her to do activities was broken. She said a certified nurse aide (CNA) broke the tray by letting it slam to the floor rather than letting it go slowly. She said her electric wheel chair which she used for mobility would not turn on. The resident said the wheelchair had been broken for approximately five weeks. She said she had written a letter to administration to inform them the wheelchair was broken and it still had not been fixed. The resident said she had been using an electric wheelchair since the age of four years old. She said she could not use a manual chair. The resident was interviewed a second time on 4/18/23 at 2:58 p.m. The resident said the electric wheelchair had been working on her birthday and three days later it stopped working. The resident said she had been sitting in the wheelchair in the room and attempted to turn it on to move into position to get into bed and it would not turn on and it had not worked since. She said a few days after it had stopped working she had asked a CNA to check the chair to see if it would work and it would not. She said that neither staff or administration had informed her about either a new chair or fixing the current one. She said she started using an electric wheelchair at age four and that was all she had ever known, she said using a manual wheelchair would be like "death to me." She said she would have to depend on everyone to move her in the chair. She felt the facility had dehumanized her by not fixing the wheelchair, "they took my legs away. I can't leave my room."During the interview at 3:08 p.m. the resident called a family member. The family member said the facility staff have not been nice at all and she felt she had to stay away and could not visit the resident. She said the facility informed her they would have to pay out of pocket to get the wheelchair fixed or a new one and the facility had not offered any assistance, "they are not helping at all." She said the resident had been praying to die and the resident had been suffering mental anguish because the wheelchair was not working. As a result of the wheel chair not working, the resident has had to stay in bed, otherwise, she was always up and about. The resident said she felt the facility was not a home anymore. The resident was interviewed a third time on 4/19/23 at 10:16 a.m. She said that her family member had the wheelchair company and had been informed there had been appointments scheduled to come inspect the wheelchair to see what would be needed to fix it and that the appointments had been canceled by the facility. She had been informed that she was qualified for new parts that would fix the chair. She said this information makes her feel like they kept her in bed on purpose when they did not need to. During the survey from 4/17/23 to 4/24/23 the resident did not leave her bed. C. Record reviewCare planThe care plan for daily routine, revised on 10/24/22, documented the resident indicated it was important that she had the opportunity to engage in daily routines that are meaningful to her. Interventions include it was important for her to be able to choose her bedtime, watching tv (television), and to engage in her favorite activities. The care plan for psychosocial distress, revised on 10/24/23, documented the resident exhibited psychosocial distress with her own well-being. Interventions include: monitor mood state or behavioral symptoms impacting social relationships, encourage resident participation in activity preferences, encourage the resident to notify and seek out staff support as indicated for support and intervention. The care plan for distressed mood, revised on 2/7/22, documented the resident is at risk for distressed/fluctuating mood symptoms related to sadness/depression. The resident may exhibit depressed mood through mood swings, self-isolation, less talkative increased tearfulness, increased sleep, decreased appetite, and repeatedly going over thoughts. Interventions include: monitor for signs/symptoms of worsening sadness/depression, social services to provide support as needed. Progress notesAn encounter with the physician note dated 2/3/23, documented "a persistence of depression and the tray and wheelchair being broken again, stuck in the reclined position, thus being confined to her bed and not happy. She said that her mood sucks, often has low energy and is getting worse. The resident said she has severe anxiety and a main source of was due to isolation. She said she tries to stay busy by hanging out with other residents. She said she was unable to do art because the tray for the wheelchair was broken and would take six months to replace, she had tried to do some art but was unsuccessful."A social services note dated 2/10/23 documented a phone call with a wheelchair company regarding the expense to fix the electric wheelchair. A social services note dated 2/22/23 documented social services communication with the insurance company regarding lack of funds to repair the electric wheelchair. Nursing note dated 3/3/23 documented the resident had been up in her electric wheelchair and participating in activities that day.-The wheelchair was running due to the maintenance director wrapping the joystick (see director of nursing interview), however the wheelchair was still not functioning properly. A social services note dated 3/31/23 documented a phone call with a care coordinator regarding the expense to fix the broken electric wheelchair. Interdisciplinary team (IDT) note dated 4/5/23 documented the resident's electric wheelchair was not working and therapy had been working with the wheelchair company for maintenance and the resident potentially needs a new wheelchair. A nursing note dated 4/10/23 documented the residents refusal to use a manual wheelchair because they were ill fitting, caused pain, and she would be unable to move herself, requiring another person to move her. A general note dated 4/11/23 documented the electric wheelchair was broken and then reported the resident being frustrated with the chair being broken and she was unwilling to use a manual wheelchair due to being uncomfortable and the resident was in bed during the visit. D. Wheelchair company interview and documentationThe director of the wheelchair company was interviewed over the phone on 4/24/23 at 1:14 p.m. He said he was the director for the area. He remembered speaking to the family member. He said once a wheelchair was paid for by Medicaid it stayed covered by them. He said he had informed the family member that appointments had been scheduled visits but did not know why they had been canceled. The director delivered documentation for 10/19/22 that revealed, "an order for repairs was created but canceled later the same day. The facility manager called and wanted to process an order for a new chair, the repair order was canceled and forwarded to another department. On 10/19/22 the rehabilitation department of the wheelchair company received a call from the facility to start an order for a new chair, they were informed that Medicaid did not pay for a new wheelchair in a skilled nursing facility, the order was canceled on 10/31/22. No further contact had been established since 10/31/22." -The facility did not contact the wheelchair company to establish a repair order again. E. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/19/23 at 10:44 a.m. She said the resident would rather have the electric wheelchair than any other one, she would not be able to use a manual wheelchair, someone would have to move her. The RN said the resident would visit a lot and go eat in the dining room, she said now she could not do those things. RN #2 was interviewed on 4/19/23 at 10:44 a.m. The RN said the resident used to be all over the place in the electric wheelchair since she loved to get out. The activities director (AD) was interviewed on 4/19/23 at 12:40 p.m. The AD said the resident liked to get out and do activities. She said the resident and another resident enjoyed having a book club and that she was very social and enjoyed visiting people in the building. The AD said the resident liked being in her room sitting in the chair listening to music, watching tv and playing solitary type games on the tv. The AD said the resident was upset about the wheelchair being broken. The DON was interviewed on 4/19/23 at 2:00 p.m. The DON said the tray and the wheelchair were broken and have been for a few months. The DON said the resident could fill out a grievance form if something was broken. The DON said the previous maintenance director had wrapped the joy stick, the controller of the wheelchair, to keep it working. The DON said the therapy department would be the contact for the wheelchair company not the social services department. She said they have attempted to have it fixed but did not explain how. II. Resident #11A. Resident statusResident #11, age 89, was admitted on 2/13/18. According to the April 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease and other intervertebral disc degeneration, lumbar region. The 2/20/23 facility assessment revealed the resident was cognitively impaired with a brief interview for mental status score of zero out of 15. He required extensive assistance with dressing, toilet use, and personal hygiene. He used a wheelchair and walker for mobility. Hospice care was coded. No therapy or restorative nursing minutes were coded. B. Resident observationsOn 4/17/23 at 12:10 p.m. Resident #11 sitting in an oversized wheelchair in the dining room. C. Resident interview and representative interviewOn 4/19/23 at 1:36 p.m. Resident #11 was interviewed and he shook his head up and down when asked how he was doing. Resident #11 had difficulty understanding what was asked due to a language barrier. Resident #11's daughter was interviewed by phone on 4/20/23 at 5:03 p.m. She said her father spoke little English. She said the facility had a language line for him and staff should be using it to communicate with him. She said that she asked for physical therapy (PT) for her father and the facility told her that when they ask him to participate in PT he always says no. She said she had been told they could not force him to do PT. She said to the facility if they could encourage him to go and they told her no. The daughter said that Resident #11's wheelchair was issued from the facility. She said he had a walker in his room and should be using it. She he had a regular cane and the facility took the cane away from him. She said that her father was prone to falling and needed assistance. D. Record reviewThe care plan, dated 4/17/23, documented that Resident #11 had communication challenges secondary to speaking a foreign language. Interventions documented: to provide Resident #11 with a translator to aid in communications. The care plan, revised on 4/22/21, indicated Resident #11 had impaired communication as evidenced by language barrier. His primary language is Cantonese. Interventions documented: interpreter as needed. Refer to Speech Therapy for screening as appropriate. Encourage the resident/patient to speak slowly. Encourage and validate meaning or nonverbal communication. Break tasks down into smaller steps. Allow sufficient time for the resident/patient to process and respond. Give one direction at a time or ask one question at a time and repeat directions. The care plan, revised on 10/4/22, indicated Resident #11 required assistance for ADL in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility, dementia, frailty. Interventions documented: provide resident supervision set up assistance with ADLs, may need one person assist at times especially with toileting and grooming. He walks with a walker. Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted. Provide cueing for safety and sequencing to maximize current level of function. Arrange resident/patient environment as much as possible to facilitate ADL performance as indicated. Provide resident set-up supervision assist for bed mobility. E. InterviewsCertified nurse aide #2 (CNA) was interviewed on 4/23/23 at 9:30 p.m. CNA #2 said he had never used the language line to communicate with Resident #11. Licensed practical nurse #3 (LPN) was interviewed on 4/23/23 at 9:35 p.m. LPN #3 said that Resident #11 did not understand much and he was not very verbal. LPN #3 said that no staff had used the language line and was not sure if they had a language line. LPN #3 was not able to find where the language line information was kept. The social service director (SSD) was interviewed on 4/24/23 at 11:40 a.m. The SSD said she contacted the family first and asked what the resident was able to understand. She said the language line had been downloaded onto tablets. She said the chaplain was going to get someone to interpret, but had not happened. The SSD said Resident #11 would point at things to get his point across. She said she had a picture book for him and he stated, "I talk" and did not like the pictures. She said he was the first resident the facility have had communication issues with. She said she was not sure how much he understood or what the staff were asking. She said he was more verbal with things he liked. The SSD was unable to pull up the language line on her tablet. The social service assistant (SSA) was interviewed on 4/24/23 at 12:00 p.m. He said the language line software was easy to use and was able to pull up the information. The SSA said all staff had access to either video chat or phone chat in the preferred language needed. He said staff had not been trained on how to use the language line. Licensed practical nurse (LPN) #1 was interviewed on 4/24/23 at 12:09 p.m. LPN #1 said she had never used the tablet to communicate with Resident #11. LPN #1 pulled a tablet out from behind the nurses station and was able to log in. LPN #1 said she would ask yes or no questions with Resident #11. Certified nurse aide (CNA) #4 was interviewed on 4/24/23 at 12:25 p.m. CNA #4 said that she used simple words in order to communicate with Resident #11. CNA #4 said she had never had a full conversation with Resident #11. The director of rehabilitation (DOR) was interviewed on 4/24/23 at 7:00 p.m. She said Resident #11's wheelchair was 20 inches and was too big for him. She said she would send additional information about Resident #11's wheelchair. -However, no documentation was provided before exit on 4/24/23.

Based on observations, interviews and record review, the facility failed to ensure residents had the right to a dignified existence out of 42 sample residents. The facility failed to ensure residents experienced a dignified living experience by ensuring residents were treated with respect and dignity. Residents of the facility expressed being yelled and chastised by staff and retaliation by the facility. A resident stated he was tired of "feeling like we are nobody, he served his country for freedom and he can't die with dignity; he wanted to be treated like a human being, not a child."Furthermore, the facility failed to treat Resident #83 with respect and dignity. Findings include:I. Residents being treated with respect and dignity A. Resident group interviewThe resident group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. The resident in the council meeting said the following: The residents said that dignity and respect had always been a thing around here as residents were always being yelled at and chastised by the staff. One resident said "I am tired of the retaliation. When you blow the whistle they retaliate." One of the residents said "I am tired of feeling like we are nobody, we are grown adults." The resident then said "it makes me wonder why I served my country for freedom and we can't die with dignity. I want to be treated like a human being, not like a child." B. Administrative interviewThe director of nursing (DON) was interviewed on 4/20/23 at 5:00 p.m. The DON said the staff treat the residents with respect and dignity. She said when she received a complaint, she would ensure it was investigated to rule out abuse. She said at times the complaint could be customer service oriented, then the staff would be educated on customer service. She said customer service was taught at orientation and it included respect and dignity. Staff were trained to listen to residents and to ensure the resident was cared for in a dignified manner. She said residents had the right to complain and not to be fearful of retaliation. II. Resident #83A. Resident statusResident # 83, age 81, was admitted to the facility on 12/21/22. The April 2023 computerized physicians orders (CPO) indicated that the resident had a diagnosis of chronic obstructive pulmonary disease, insomnia, anxiety disorder, hallucinations, type 2 diabetes and chronic kidney disease. The 3/22/23 facility assessment indicated the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. Resident #83 required supervision with eating, support was provided with showers, however the resident refused each time. The resident required the use of a manual wheelchair. The resident was independent with toilet use, dressing, and bed mobility. B. ObservationsOn 4/19/23 at approximately 1:45 p.m. loud arguing between Resident #83 and the receptionist could be heard. Resident #83 was at the front receptionist desk. The resident was telling the receptionist that she had not done something that he had requested. He was talking loud, using foul language and his tone of voice was argumentative. The receptionist was observed to engage the resident with her tone of voice, was also argumentative and she continued to reply back to the resident in a disrespectful manner. She did not talk to the resident in a manner which provided dignity. C. Resident interviewResident # 83 was interviewed on 4/18/23 at approximately 2:00 p.m. The resident said he did not like how the facility staff spoke to him. He said he had to deal with a lot of issues in his life, but the way he was spoken to by facility staff made him upset. He said the staff would not believe him when he asked for assistance and the request was always matched with an argument from the staff. He said he knew he did not communicate his needs in a pleasant manner. The resident was interviewed a second time on 4/19/23 at approximately 2:45 p.m. The resident said that he felt like his right to be treated with dignity was taken from him. He said that he did not think the receptionist should talk to him the way she did. D. Record reviewThe care plan, revised 1/27/23, included that arguing with Resident # 83 made his situation worse which made him feel like he had been scolded in front of the other residents. The social services (SS) advised the staff for the resident to be spoken to in a calm manner which diffuses a situation. E. Staff interviews The DON was interviewed on 4/19/23 at 2:08 p.m. She said Resident #83 had been asking the staff all day about the refrigerator in his room to be repaired. She said Resident #83 told her he felt like he had been disrespected by the staff. Resident #83 spoke of an incident in which he spoke to the receptionist about his refrigerator. He said she told him that it was not her job to look at his refrigerator and that he should go talk to the maintenance department about his problem. Certified nurse aide (CNA) #9 was interviewed on 4/19/23 at 4:00 p.m. The CNA confirmed she observed the interaction between the receptionist and Resident #83. She said that although Resident #83 could be difficult, the receptionist should have "walked away" when he was using foul language rather than using the disrespectful tone.

A recertification survey with complaints #CO31174, #CO31697, #CO31700, and #CO31724 was completed from 4/17/23 to 4/24/23. Seventeen deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/17/23 to 4/24/23. No deficiencies were cited.

Based on observations, interviews and record review, the facility failed to ensure residents had the right to a dignified existence out of 42 sample residents. The facility failed to ensure residents experienced a dignified living experience by ensuring residents were treated with respect and dignity. Residents of the facility expressed being yelled and chastised by staff and retaliation by the facility. A resident stated he was tired of "feeling like we are nobody, he served his country for freedom and he can't die with dignity; he wanted to be treated like a human being, not a child."Furthermore, the facility failed to treat Resident #83 with respect and dignity. Findings include:I. Residents being treated with respect and dignity (cross-reference F565 resident group response)A. Resident group interviewThe resident group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. The resident in the council meeting said the following: The residents said that dignity and respect had always been a thing around here as residents were always being yelled at and chastised by the staff. One resident said "I am tired of the retaliation. When you blow the whistle they retaliate." One of the residents said "I am tired of feeling like we are nobody, we are grown adults." The resident then said "it makes me wonder why I served my country for freedom and we can't die with dignity. I want to be treated like a human being, not like a child." B. Administrative interviewThe director of nursing (DON) was interviewed on 4/20/23 at 5:00 p.m. The DON said the staff treat the residents with respect and dignity. She said when she received a complaint, she would ensure it was investigated to rule out abuse. She said at times the complaint could be customer service oriented, then the staff would be educated on customer service. She said customer service was taught at orientation and it included respect and dignity. Staff were trained to listen to residents and to ensure the resident was cared for in a dignified manner. She said residents had the right to complain and not to be fearful of retaliation. II. Resident #83A. Resident statusResident # 83, age 81, was admitted to the facility on 12/21/22. The April 2023 computerized physicians orders (CPO) indicated that the resident had a diagnosis of chronic obstructive pulmonary disease, insomnia, anxiety disorder, hallucinations, type 2 diabetes and chronic kidney disease. The 3/22/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. Resident #83 required supervision with eating, support was provided with showers, however the resident refused each time. The resident required the use of a manual wheelchair. The resident was independent with toilet use, dressing, and bed mobility. B. ObservationOn 4/19/23 at approximately 1:45 p.m. loud arguing between Resident #83 and the receptionist could be heard. Resident #83 was at the front receptionist desk. The resident was telling the receptionist that she had not done something that he had requested. He was talking loud, using foul language and his tone of voice was argumentative. The receptionist was observed to engage the resident with her tone of voice, was also argumentative and she continued to reply back to the resident in a disrespectful manner. She did not talk to the resident in a manner which provided dignity. C. Resident interviewResident # 83 was interviewed on 4/18/23 at approximately 2:00 p.m. The resident said he did not like how the facility staff spoke to him. He said he had to deal with a lot of issues in his life, but the way he was spoken to by facility staff made him upset. He said the staff would not believe him when he asked for assistance and the request was always matched with an argument from the staff. He said he knew he did not communicate his needs in a pleasant manner. The resident was interviewed a second time on 4/19/23 at approximately 2:45 p.m. The resident said that he felt like his right to be treated with dignity was taken from him. He said that he did not think the receptionist should talk to him the way she did. D. Record reviewThe care plan, revised 1/27/23, included that arguing with Resident # 83 made his situation worse which made him feel like he had been scolded in front of the other residents. The social services (SS) advised the staff for the resident to be spoken to in a calm manner which diffuses a situation. E. Staff interviews The DON was interviewed on 4/19/23 at 2:08 p.m. She said Resident #83 had been asking the staff all day about the refrigerator in his room to be repaired. She said Resident #83 told her he felt like he had been disrespected by the staff. Resident #83 spoke of an incident in which he spoke to the receptionist about his refrigerator. He said she told him that it was not her job to look at his refrigerator and that he should go talk to the maintenance department about his problem. Certified nurse aide (CNA) #9 was interviewed on 4/19/23 at 4:00 p.m. The CNA confirmed she observed the interaction between the receptionist and Resident #83. She said that although Resident #83 could be difficult, the receptionist should have "walked away" when he was using foul language rather than using the disrespectful tone.

Based on observation, record review and interviews, the facility failed to ensure the residents had a right to to be informed of the results or actions taken regarding resident concerns. Specifically, the facility failed to accurately document, demonstrate their response and rationale for complaints, grievances and concerns that were brought up by residents. Findings include: I. Facility policyThe Grievance/Concern policy, last revised on 6/1/22, was provided by the DON on 4/25/23 at 12:33 p.m. It read in pertinent part, "The patient/resident has the right to voice grievances to the (name) or other agency or entity that hear grievances without discrimination or reprisal and without fear of discrimination or reprisal. Service location leadership will investigate, document, and follow up on all concerns and grievances registered by any patient or patient representative. Social Services personnel will serve as patient advocates in the grievance/concern process. "The Center Executive Director (CED) will service as the Grievance Officer who is responsible for overseeing the grievance process. A description of the procedure for voicing grievances/concerns will be on each unit in prominent location and must include; the right to file grievances orally (meaning spoken) or in writing, the right to file grievances anonymously, the contact information of the grievance official with whom a grievance can be filed, the right to obtain a written decision regarding their grievance; and the contact information of independent entities with whom grievances may be filed. "When the grievance/concern is logged, the CED and appropriate department managers will be notified; immediate action will be taken to prevent further potential violations on any patient right while the alleged violation is being investigated. The department manager will; contact the person filing the grievance to acknowledge receipt, investigate the grievance, take corrective actions, if needed, engage the support of the Ombudsman, if warranted, and notify the person filing the grievance of resolution within 72 hours. If the grievance/concern is unable to be resolved satisfactorily, refer the patient/representative to the Market President and/or Market Lead Clinical Specialist for assistance."II. Resident council not being held consistently and privatelyA. Resident group interviewThe group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. One resident said staff had postponed their resident council meeting because the facility did not have enough staff. He said the residents went three months without a meeting because not all staff were available and staff kept postponing the meeting. One resident said staff did not offer a meeting place, so the meetings took place in the main dining room area. One resident said that resident council meetings have never been offered for residents only and staff have always been present every time. B. Resident council minutesThe 3/3/23 resident council meeting minutes documented the February 2023 meeting was delayed as not all managers were able to attend. -There was no evidence which showed a resident council meeting was held in February 2023. III. Resident voiced grievances and concernsA. Resident group interviewThe group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. The residents said when they wrote a grievance the social workers chose which ones they wanted to address. The residents said staff did not want to be bothered by their complaints/grievances and they tried to shut them up. The residents said the social service director (SSD) favorite line was "shut up and give us a chance." The residents said staff were not responding to their complaints within 72 hours. One resident said the problem was some residents were afraid to file a complaint/grievance because of retaliation. One resident said he wrote a grievance and never heard anything back from it. One resident said the staff say they would check the grievances and get back to them, but they never get back to them. One resident said that staff met with her, there was no resolution to the problem and was told that was how that staff were. She said she told staff she should not have to put up with their behavior. B. ObservationOn 4/20/23 at 3:37 p.m. while walking around to the different units with the SSD to check the bulletin boards, grievance forms were not located on the bulletin boards. The process on how to file a grievance was not located on the bulletin boards. The only grievance forms were located outside of the SSD's office. IV. InterviewsThe social service director (SSD) was interviewed on 4/20/23 at 3:37 p.m. The SSD said she was responsible for making sure that the bulletin boards down each wing were updated with forms and policies. The social service assistant (SSA) was interviewed on 4/24/23 at 2:40 p.m. The SSA said the social workers were in charge of the grievance process. He said their department dealt with non-medical grievances. The SSA said depending on the complaint the department or individual gets the original copy of the grievance. He said that a grievance was addressed within 72 hours.

Based on record review and interviews, the facility failed to provide residents with the opportunity to review their medical records. Specifically, the facility failed to ensure residents were able to access their medical record when requested. Findings include:I. Facility policyThe Authorization for Release of Information policy, revised on 5/1/22, by the director of nursing (DON) on 4/25/23 at 5:59 p.m. It read in pertinent part, "The company will disclose protected health information (PHI) upon receipt of a valid authorization. "Provide access to view all records (including trust fund ledgers, contracts, and other documents between patient and service location) pertaining to a patient to the patient/legal representative as soon as possible and no later than 24 hours of receipt of an oral or written request (excluding weekends and service location holidays)."Provide copies of records to patient/legal representative in the form or format requested, if they are readily producible in such form or format, within two (2) working days of a request. The legal representative must complete a written request that shall include the following, or complete a Request and Authorization for Release of Information; a meaningful description of the information to be disclosed, the name of the individual or the name of the person authorized to make the requested disclosure, the name or other identification of the recipient of the information, a description of each purpose of the disclosure (the statement 'at the request of the individual' is sufficient when the individual initiates the authorization and does not or elects not to, provide a statement of the purpose), an expiration date or an expiration event that relates to the individual, and a signature to make health decisions on behalf of the individual and the date."Charging a fee is done at the discretion of the Privacy Officer Designee/Administrator. A reasonable, cost-based fee may be charged for the provision of copies, provided that the fee includes only the cost of; labor for copying the records requested by the individual, whether in paper or electronic form, supplies for creating the paper copy or electronic media if the individual requests that the electronic copy be provided on portable media, postage, when the individual has requested the copy by mailed. "E-mail the Request and Authorization for Release of Information or other written request the Information Regarding Request for Release of Medical Records form and any backup documentation (POA, guardianship, estate paperwork) to (email) If the documents provided require additional involvement by the Law Department an email response should be expected within 48 hours. Otherwise, the service location should produce the records to the requesting party as per the guidelines within this policy. "An authorization is not valid if the authorization contains any of the following defects; the expiration date has passed or the event has occurred (information already released in accordance with an authorization), the authorization is missing one or more items of content described above, the authorization is known to have been revoked by the patient or patient's legal representative, the authorization violates a privacy rule standard on conditioning or compound authorizations (the patient was required to sign the authorization in order to receive treatment or the authorization was combined with another document), and material information in the authorization is known to be false by the service location or region, market, area, or corporate department." II. Facility welcome packetThe 2023 Welcome Packet read in pertinent part, "You have the following rights regarding your medical care: To access all your records and reports, including clinical records (medical records and reports) promptly (on weekdays)."III. Resident group interviewThe group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. One resident said that staff had given him problems when requesting to get his medical records. He said that no staff was able to get his records so he waited for a long time and finally was able to get some of his records but not all of them. Another resident said that staff were against telling him about his medical records. He said that staff have told them that they will get back to them about their records and they never did. A few of the residents said they did not know the process to access their records. IV. InterviewsThe social service director (SSD) was interviewed on 4/24/23 at 12:16 p.m. The SSD said residents needed to fill out a form in order to request their records. The SSD said the director of nursing (DON) got the records. The SSD said that the minimum data set (MDS) coordinator would help out if needed to get records. She did not know how long the process was to get records out to residents. The SSD said that sometimes the facility had to send for records as all the records were not stored at their facility. She said that records were usually received the next day or two. The health information manager (HCM) was interviewed on 4/25/23 at 2:15 p.m. The HCM said residents were required to fill out a request for release of records form and put down what dates they wanted. When the form was completed, she said she sent the request form to the corporate office and that corporation determined if they released the records or not. She said that she was not sure if any residents have ever been denied their records. The HCM said that it took 24 hours for approval of records from the corporate office.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to have the required posted information written in a readable font size and placed in an area that had ease of access for the residents. Findings include: I. Resident group interviewThe group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. Ten out of the 12 residents did not know how to file a complaint with the State Agency department or where to find the information posted. II. ObservationOn 4/20/23 the legal resident rights were posted in one location at the front of the building on a shelf across from the front desk. The legal rights were put in picture frames printed in small font. There were no postings on each of the units with a list of names, addresses (mailing and email), and telephone numbers of all the pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state laws provide jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. There was nothing posted about how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation. III. Staff interviewThe social service director (SSD) was interviewed on 4/20/23 at 3:37 p.m. The SSD said she was responsible for keeping up on the boards and making sure that they were up to date with the appropriate information. The SSD said she did not know that she needed to post information regarding a list of names, addresses (mailing and email), and telephone numbers of all the pertinent State Agencies and advocacy groups. She acknowledged there was no posting of the pertinent information.

Based on observations, record review and interviews the facility failed to protect the residents rights to provide privacy with mail and packages delivered to the facility. Specifically, the facility failed to ensure residents were provided privacy when receiving and opening personal packages. Findings include:I. Facility PolicyThe Patient/Resident Mail Delivery policy, last revised on 4/1/18, received from the director of nurses on 4/25/23 at 12:33 p.m. read in pertinent part, "patients/residents/guests have the right to privacy in written communications, to send and promptly receive unopened mail and other letters, packages, and other material delivered to the facility for the patient/resident/guest, including those delivered through a means other than a postal service. The recreation director or designee will:-Coordinate patient/resident mail delivery.-Ensure that mail is delivered to the person unopened or postmarked or postmarked (for outing mail) within 24 hours, including Saturday."II. Facility welcome packetThe 2023 Welcome Packet read in pertinent part, "You have the following rights:To have privacy in sending and getting mail and emails. III. Resident group interviewThe resident group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. One resident said that the activity staff made him open his package in front of them. The resident said that he received some generic vitamins and was told from the activity staff that they had to take them from him. The resident said he was pretty upset that they would not allow him to have my vitamins. Two other residents verified that the activity staff member had made the resident open his package in front of them and took his vitamins. Another resident said when he first arrived at the facility his social security mail was open, so he took his mail, went and talked to the administrator and told them that he would not tolerate this. One of the residents said the business office took the mail, held onto the mail, screened the mail, and forced the residents to open our packages in front of them. The residents said they have been told they did not get mail on Saturday. They said sometimes it was delivered and sometimes it was not. IV. Staff InterviewsThe activity director (AD) was interviewed on 4/24/23 at 2:45 p.m. The AD said the business office got the mail, they sorted it out and gave the resident mail to the activities department. She said once the mail had been sorted out that they delivered the mail the same day. She said she had never had any issues with residents having concerns about their mail being opened up. The AD was interviewed again on 4/24/23 at 4:10 p.m. The AD said they were allowed to know what was in the packages the residents receive. The AD said if the resident gets medicine and if it was something they should not be taking then it became a safety issue. She said the activity staff asked the residents to open the package in front of them, but if they say no she said they walk out and advise the nurse that they received a package. The AD said having the residents open their packages in front of them was not a violation of privacy. The AD said if the residents got medications the activity staff would take them and take it to the senior director or social worker. The business office manager (BOM) was interviewed on 4/24/23 at 5:43 p.m. The BOM said she had retrieved the mail from the conference room closet. She said it was Saturdays (4/22/23) mail. She said the mail was placed in the closet and then it was sorted, she said there was no staff available to separate the mail between resident and facility mail on Saturdays, so it was held back and delivered on Monday. The director of nurses (DON) was interviewed on 4/24/23 at 6:30 p.m. The DON acknowledged the previous nursing home administrator had put into effect, when a package was delivered to a resident then the package had to be opened in front of the activity associate. The reason was because she wanted to ensure no medications were being delivered.

Based on observation and interviews, the facility failed to ensure that each resident had the right to examine the results of the most recent Federal survey of the facility conducted by the Federal or State surveyors and any plan of correction in effect with respect to the facility. Specifically, the facility failed to:-Have a posting in a prominent location of where the survey results were kept; and,-Have three years of survey results available to view. Findings include:I. Facility welcome packetThe 2023 Welcome Packet read in pertinent part, "You have the following rights: To review the nursing home's health and fire safety inspection results."II. Resident group interviewThe group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. The residents said they were not aware they could view the Federal/State survey results. The residents said they were not aware of any location and they had not been told of the results of the survey. They said they would be interested in reading the results of the surveys. III. ObservationsOn 4/20/23 at 3:37 p.m., the facility did not have the posting notification of the availability of survey reports in areas of the facility that were prominent and accessible to the public. At 4:05 p.m., the survey binder was located on top of a table behind the front desk. The survey binder was not up to date, as it did not have the past three years of surveys in it and the corrections of the findings. The survey binder had the survey results from 8/31/21, 9/2/21, 6/1/22, 10/20/22, and 12/28/22. -However, the binder was missing11 additional surveys. The following surveys which were completed within the last three years which were not included in the binder were:-4/20/2020;-9/9/2020;-12/15/2020;-1/20/21;-5/17/21;-7/8/21;-7/23/21 life safety;-2/9/22;-8/2/22;-8/23/22; and,-11/8/22 life safety. IV. InterviewsThe social service director (SSD) was interviewed on 4/20/23 at 3:55 p.m. The SSD did not know where the binder of past inspections were kept and had to ask the director of nursing (DON). The director of nursing (DON) was interviewed on 4/20/23 at 4:00 p.m. The DON said the survey binder was kept up front. The DON said the previous nursing home administrator had viewed the binder last. The survey book was not up to date, as it did not have the past three years of complaint investigations. The survey book was missing the plan of corrections for the surveys.

Based on observation and interviews, the facility failed to provide a homelike environment for residents on six of six hallways and common areas. Specifically, the facility failed to inform and encourage residents and their families to decorate resident rooms with personal belongings to make it homelike. Findings include:I. ObservationsResident roomsMultiple resident rooms throughout the facility on 4/17/23 had no homelike or personalized decorations. The walls were bare or had a facility style picture, nothing personalized. -Room 101 had no homelike or personalized decorations.-Room 104 had no homelike or personalized decorations. -Room 201 had no homelike or personalized decorations.-Room 306 had no homelike or personalized decorations.-Room 305B had no homelike or personalized decorations.-Room 312B had no homelike or personalized decorations.-Room 404 B had no decorations or personalized decoration. -Room 411B had no homelike or personalized decorations.-Room 410A had no homelike or personalized decorations.-Room 607 was observed on 4/17/23 at 10:30 a.m. The resident's room was to be plain and bare. There were no pictures on the wall and had no family photos. The resident's room did not look like anyone was living there and was not homelike. -Room 515 a was observed on 4/19/23 at 9:52 a.m. The resident's room had no personal items (no pictures or decor in the room). II. Resident representative interviewResident #11's representative was interviewed on 4/20/23 at 5:03 p.m. She stated that no staff told her her father could have personal belongings in his room. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/24/23 at 11:00 a.m. The nurse said the residents could have decorations in their rooms, that was their choice. She said the social services department should inform residents and family members they could bring personalized belongings in for the residents' rooms. RN #2 was interviewed on 4/24/23 at 11:00 a.m. She said residents could choose to decorate their rooms and that it was their choice if they wanted stuff in their rooms. The social worker (SW) was interviewed on 4/24/23 at 11:40 a.m. The SW stated that residents were allowed to have their own personal items in their rooms. She said she told the families to not bring in valuables. The SW stated the family brought in a television for Resident #11.

Based on record review, observations and interviews the facility failed to develop and implement a comprehensive, resident centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (#16) out of 42 sample residents. Specifically, the facility did not ensure Resident #16's comprehensive care plans were developed and included his discharge planning and goals. Findings include:I. Resident #16A. Resident statusResident #16, age 60, was admitted 2/3/23. According to the April 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, history of traumatic brain injury, mild neurogenic disorder, seizures and schizophrenia. According to the minimum data set (MDS) assessment on 2/10/23, the resident did not participate in assessment and goal setting, and the overall discharge expectation was coded as unknown or uncertain. B. Resident interviewsResident #16 was interviewed on 4/19/23 at 12:00 p.m. The resident stated he would like to get into an assisted living setting. The resident said he had been treated like a teenager and wanted a place that had more privacy. Resident #16 said he had not spoken with the social services department about his desired goal for discharge to an assisted living setting. C. Record reviewThe care plan was initiated on 2/3/23. However, the care plan did not indicate stated goals and objectives of Resident #16. First documented note from social services department was on 2/6/23, which documented that Resident #16 refused a copy of the care plan. -The care plan continued to not include his discharge plans or goals. II. Staff interviewThe social services director (SSD) was interviewed on 4/20/23 at 10:00 a.m. She was not aware Resident #16 was interested in moving to an assisted living setting. The director of nursing (DON) was interviewed on 4/24/23 at 4:45 p.m. The DON said that care plans should be updated in a timely manner. The social worker then reviewed with the resident and family.

Based on observations, interviews and record review, the facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living (ADLs) for two (#8 and #11) out of three reviewed for ADLs out of 42 sample residents. Resident #8 admitted to the facility for long term care with diagnoses of cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture), legal blindness, paraplegia (paralysis of the lower body), reduced mobility, lack of coordination, major and depressive disorder. The resident required extensive two person assistance with most ADLs. The resident had used an electric wheelchair for independence and mobility since she was four years old. The facility failed to repair the resident's electric wheelchair which prevented her from getting out of bed, attending activities and the ability to socialize with staff and other residents (cross-reference F679 for activites). The resident stated due to not being able to use her electric wheelchair, it "has been death to me" and said "they (the facility) took my legs away. I can't leave my room." She said the facility did not feel like her home anymore. Per staff interviews, the resident was not herself and upset since she was unable to get out of her room due to not having her electric wheelchair. In addition, the facility failed to ensure strategies were in place to effectively communicate with Resident #11, who spoke a language other than English and assess Resident #11's wheelchair and ambulation to maintain his mobility. Findings include:I. Resident #8A. Resident statusResident #8, under age 65, was admitted to the facility on 5/13/13 and readmitted on 12/21/22. According to the April 2023 computerized physician orders (CPO) diagnoses included cerebral palsy, legal blindness, reduced mobility, lack of coordination, major depressive disorder, personality disorder, generalized anxiety disorder, stiffness of joints, muscle weakness, contractures of left elbow, right elbow, left wrist, and right wrist, complete paraplegia and history of diseases of the musculoskeletal system and connective tissue. The 3/29/23 minimum data set (MDS) assessment documented the resident had a minor cognitive deficit with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, toileting, extensive one person assistance with personal hygiene and set up assistance for eating. The resident used an electric wheelchair. B. Resident interview and observationThe resident was interviewed on 4/17/23 at 4:47 p.m. The resident said her personalized electric wheelchair was broken. The tray that was used for her to do activities was broken. She said a certified nurse aide (CNA) broke the tray by letting it slam to the floor rather than letting it go slowly. She said her electric wheel chair which she used for mobility would not turn on. The resident said the wheelchair had been broken for approximately five weeks. She said she had written a letter to administration to inform them the wheelchair was broken and it still had not been fixed. The resident said she had been using an electric wheelchair since the age of four years old. She said she could not use a manual chair. The resident was interviewed a second time on 4/18/23 at 2:58 p.m. The resident said the electric wheelchair had been working on her birthday and three days later it stopped working. The resident said she had been sitting in the wheelchair in the room and attempted to turn it on to move into position to get into bed and it would not turn on and it had not worked since. She said a few days after it had stopped working she had asked a CNA to check the chair to see if it would work and it would not. She said that neither staff or administration had informed her about either a new chair or fixing the current one. She said she started using an electric wheelchair at age four and that was all she had ever known, she said using a manual wheelchair would be like "death to me." She said she would have to depend on everyone to move her in the chair. She felt the facility had dehumanized her by not fixing the wheelchair, "they took my legs away. I can't leave my room."During the interview at 3:08 p.m. the resident called a family member. The family member said the facility staff have not been nice at all and she felt she had to stay away and could not visit the resident. She said the facility informed her they would have to pay out of pocket to get the wheelchair fixed or a new one and the facility had not offered any assistance, "they are not helping at all." She said the resident had been praying to die and the resident had been suffering mental anguish because the wheelchair was not working. As a result of the wheel chair not working, the resident has had to stay in bed, otherwise, she was always up and about. The resident said she felt the facility was not a home anymore. The resident was interviewed a third time on 4/19/23 at 10:16 a.m. She said that her family member had the wheelchair company and had been informed there had been appointments scheduled to come inspect the wheelchair to see what would be needed to fix it and that the appointments had been canceled by the facility. She had been informed that she was qualified for new parts that would fix the chair. She said this information makes her feel like they kept her in bed on purpose when they did not need to. During the survey from 4/17/23 to 4/24/23 the resident did not leave her bed. C. Record reviewCare planThe care plan for daily routine, revised on 10/24/22, documented the resident indicated it was important that she had the opportunity to engage in daily routines that are meaningful to her. Interventions include it was important for her to be able to choose her bedtime, watching tv (television), and to engage in her favorite activities. The care plan for psychosocial distress, revised on 10/24/23, documented the resident exhibited psychosocial distress with her own well-being. Interventions include: monitor mood state or behavioral symptoms impacting social relationships, encourage resident participation in activity preferences, encourage the resident to notify and seek out staff support as indicated for support and intervention. The care plan for distressed mood, revised on 2/7/22, documented the resident is at risk for distressed/fluctuating mood symptoms related to sadness/depression. The resident may exhibit depressed mood through mood swings, self-isolation, less talkative increased tearfulness, increased sleep, decreased appetite, and repeatedly going over thoughts. Interventions include: monitor for signs/symptoms of worsening sadness/depression, social services to provide support as needed. Progress notesAn encounter with the physician note dated 2/3/23, documented "a persistence of depression and the tray and wheelchair being broken again, stuck in the reclined position, thus being confined to her bed and not happy. She said that her mood sucks, often has low energy and is getting worse. The resident said she has severe anxiety and a main source of was due to isolation. She said she tries to stay busy by hanging out with other residents. She said she was unable to do art because the tray for the wheelchair was broken and would take six months to replace, she had tried to do some art but was unsuccessful."A social services note dated 2/10/23 documented a phone call with a wheelchair company regarding the expense to fix the electric wheelchair. A social services note dated 2/22/23 documented social services communication with the insurance company regarding lack of funds to repair the electric wheelchair. Nursing note dated 3/3/23 documented the resident had been up in her electric wheelchair and participating in activities that day.-The wheelchair was running due to the maintenance director wrapping the joystick (see director of nursing interview), however the wheelchair was still not functioning properly. A social services note dated 3/31/23 documented a phone call with a care coordinator regarding the expense to fix the broken electric wheelchair. Interdisciplinary team (IDT) note dated 4/5/23 documented the resident's electric wheelchair was not working and therapy had been working with the wheelchair company for maintenance and the resident potentially needs a new wheelchair. A nursing note dated 4/10/23 documented the residents refusal to use a manual wheelchair because they were ill fitting, caused pain, and she would be unable to move herself, requiring another person to move her. A general note dated 4/11/23 documented the electric wheelchair was broken and then reported the resident being frustrated with the chair being broken and she was unwilling to use a manual wheelchair due to being uncomfortable and the resident was in bed during the visit. D. Wheelchair company interview and documentationThe director of the wheelchair company was interviewed over the phone on 4/24/23 at 1:14 p.m. He said he was the director for the area. He remembered speaking to the family member. He said once a wheelchair was paid for by Medicaid it stayed covered by them. He said he had informed the family member that appointments had been scheduled visits but did not know why they had been canceled. The director delivered documentation for 10/19/22 that revealed, "an order for repairs was created but canceled later the same day. The facility manager called and wanted to process an order for a new chair, the repair order was canceled and forwarded to another department. On 10/19/22 the rehabilitation department of the wheelchair company received a call from the facility to start an order for a new chair, they were informed that Medicaid did not pay for a new wheelchair in a skilled nursing facility, the order was canceled on 10/31/22. No further contact had been established since 10/31/22." -The facility did not contact the wheelchair company to establish a repair order again. E. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/19/23 at 10:44 a.m. She said the resident would rather have the electric wheelchair than any other one, she would not be able to use a manual wheelchair, someone would have to move her. The RN said the resident would visit a lot and go eat in the dining room, she said now she could not do those things. RN #2 was interviewed on 4/19/23 at 10:44 a.m. The RN said the resident used to be all over the place in the electric wheelchair since she loved to get out. The activities director (AD) was interviewed on 4/19/23 at 12:40 p.m. The AD said the resident liked to get out and do activities. She said the resident and another resident enjoyed having a book club and that she was very social and enjoyed visiting people in the building. The AD said the resident liked being in her room sitting in the chair listening to music, watching tv and playing solitary type games on the tv. The AD said the resident was upset about the wheelchair being broken. The DON was interviewed on 4/19/23 at 2:00 p.m. The DON said the tray and the wheelchair were broken and have been for a few months. The DON said the resident could fill out a grievance form if something was broken. The DON said the previous maintenance director had wrapped the joy stick, the controller of the wheelchair, to keep it working. The DON said the therapy department would be the contact for the wheelchair company not the social services department. She said they have attempted to have it fixed but did not explain how. II. Resident #11A. Resident statusResident #11, age 89, was admitted on 2/13/18. According to the April 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease and other intervertebral disc degeneration, lumbar region. The 2/20/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of zero out of 15. He required extensive assistance with dressing, toilet use, and personal hygiene. He used a wheelchair and walker for mobility. Hospice care was coded. No therapy or restorative nursing minutes were coded. B. Resident observationsOn 4/17/23 at 12:10 p.m. Resident #11 sitting in an oversized wheelchair in the dining room. C. Resident interview and representative interviewOn 4/19/23 at 1:36 p.m. Resident #11 was interviewed and he shook his head up and down when asked how he was doing. Resident #11 had difficulty understanding what was asked due to a language barrier. Resident #11's daughter was interviewed by phone on 4/20/23 at 5:03 p.m. She said her father spoke little English. She said the facility had a language line for him and staff should be using it to communicate with him. She said that she asked for physical therapy (PT) for her father and the facility told her that when they ask him to participate in PT he always says no. She said she had been told they could not force him to do PT. She said to the facility if they could encourage him to go and they told her no. The daughter said that Resident #11's wheelchair was issued from the facility. She said he had a walker in his room and should be using it. She he had a regular cane and the facility took the cane away from him. She said that her father was prone to falling and needed assistance. D. Record reviewThe care plan, dated 4/17/23, documented that Resident #11 had communication challenges secondary to speaking a foreign language. Interventions documented: to provide Resident #11 with a translator to aid in communications. The care plan, revised on 4/22/21, indicated Resident #11 had impaired communication as evidenced by language barrier. His primary language is Cantonese. Interventions documented: interpreter as needed. Refer to Speech Therapy for screening as appropriate. Encourage the resident/patient to speak slowly. Encourage and validate meaning or nonverbal communication. Break tasks down into smaller steps. Allow sufficient time for the resident/patient to process and respond. Give one direction at a time or ask one question at a time and repeat directions. The care plan, revised on 10/4/22, indicated Resident #11 required assistance for ADL in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility, dementia, frailty. Interventions documented: provide resident supervision set up assistance with ADLs, may need one person assist at times especially with toileting and grooming. He walks with a walker. Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted. Provide cueing for safety and sequencing to maximize current level of function. Arrange resident/patient environment as much as possible to facilitate ADL performance as indicated. Provide resident set-up supervision assist for bed mobility. E. InterviewsCertified nurse aide #2 (CNA) was interviewed on 4/23/23 at 9:30 p.m. CNA #2 said he had never used the language line to communicate with Resident #11. Licensed practical nurse #3 (LPN) was interviewed on 4/23/23 at 9:35 p.m. LPN #3 said that Resident #11 did not understand much and he was not very verbal. LPN #3 said that no staff had used the language line and was not sure if they had a language line. LPN #3 was not able to find where the language line information was kept. The social service director (SSD) was interviewed on 4/24/23 at 11:40 a.m. The SSD said she contacted the family first and asked what the resident was able to understand. She said the language line had been downloaded onto tablets. She said the chaplain was going to get someone to interpret, but had not happened. The SSD said Resident #11 would point at things to get his point across. She said she had a picture book for him and he stated, "I talk" and did not like the pictures. She said he was the first resident the facility have had communication issues with. She said she was not sure how much he understood or what the staff were asking. She said he was more verbal with things he liked. The SSD was unable to pull up the language line on her tablet. The social service assistant (SSA) was interviewed on 4/24/23 at 12:00 p.m. He said the language line software was easy to use and was able to pull up the information. The SSA said all staff had access to either video chat or phone chat in the preferred language needed. He said staff had not been trained on how to use the language line. Licensed practical nurse (LPN) #1 was interviewed on 4/24/23 at 12:09 p.m. LPN #1 said she had never used the tablet to communicate with Resident #11. LPN #1 pulled a tablet out from behind the nurses station and was able to log in. LPN #1 said she would ask yes or no questions with Resident #11. Certified nurse aide (CNA) #4 was interviewed on 4/24/23 at 12:25 p.m. CNA #4 said that she used simple words in order to communicate with Resident #11. CNA #4 said she had never had a full conversation with Resident #11. The director of rehabilitation (DOR) was interviewed on 4/24/23 at 7:00 p.m. She said Resident #11's wheelchair was 20 inches and was too big for him. She said she would send additional information about Resident #11's wheelchair. -However, no documentation was provided before exit on 4/24/23.

Based on observations, record reviews, and interviews, the facility failed to ensure that four (#68, #83, #13 and #42) out of six reviewed for activities of daily living received services to maintain grooming, personal and oral hygiene out of 42 sample residents. Specifically, the facility failed to ensure:-Resident #68 and Resident #83 received showers; and,-Resident #42 and #13 received nail care. Findings include:I. Facility policyThe Activities of Daily Living (ADL) policy, revised 6/1/21, was received from the director of nursing (DON) on 4/24/23. The ADL policy read in part, "a resident who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene."II. Failure to meet receive showersA. Resident #68 1. Resident statusResident #68, age 62, was admitted 11/23/21. According to the April, 2023 computerized physician orders (CPO), medical diagnoses include chronic obstructive pulmonary disease (COPD), paranoid schizophrenia, type 2 diabetes, chronic kidney disease, muscle weakness, and abnormal gait and mobility. The 4/3/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a score of 10 out of 15 for the brief interview for mental status (BIMS). The resident required two plus person physical assistance for transfer and mobility, and one person assistance for bathing. The MDS assessment showed the resident had no behavior problems and did not refuse care. 2. Resident interviewThe resident was interviewed on 4/17/23 at 2:25 p.m. The resident said that he had not had a shower for weeks. He said that he wanted to have his two showers a week. The resident was interviewed a second time on 4/18/23 at approximately 11:15 a.m. The resident said he had not been offered a shower. He said he had not refused any showers. 3. Record reviewThe care plan, revised on 11/14/22, identified the resident was at risk to perform activities of daily living (ADLs). The care plan documented he often would decline showers on his preferred shower days. -Intervention category of the care plan did not indicate any plan for when he refused to shower. Progress notes reviewed from 3/1/23 through 4/24/23 did not include documentation regarding any shower refusals. One nursing note on 3/29/23 noted that Resident #68 refused to shower on that date. The Weekly Bath and Shower Report and Master Bathing list received from DON on 4/20/23 for Resident #68 showed the resident was scheduled for bathing once weekly on Wednesdays. Per weekly bath report, Resident #68 refused bathing every week from 3/8/23 through 4/19/23, for the past seven weeks.-The medical record had only one nursing note on 3/29/23 which documented Resident #68 refused to shower on that date. There were no additional progress notes when the resident refused over seven weeks. 4. InterviewsCertified nurse aide (CNA) #1 was interviewed on 4/20/23 at 2:30 p.m. CNA #1 said Resident #68 required assistance most of the time with activities of daily living, which included showers. CNA #1 said Resident #68 usually refused his showers. CNA #1 said the process when a resident refused to shower, the licensed nurse for the unit needed to be notified. The licensed nurse would then speak to the resident and have another CNA go in the resident's room to offer a shower. She said the resident was asked multiple times (at least three) per day to shower. The DON was interviewed on 4/24/23 at 4:45pm. The DON said when a resident refused a shower, the CNAs approached the resident again. If the resident still refused, the CNA asked the licensed nurse to assist. The nurse verified and then asked the resident again about showering. The DON said that if the resident refused to shower three times in a row, social services was notified by staff. The social services director (SSD) was interviewed on 4/24/23 at 6:00 p.m. The SSD said the social service assistant was responsible for going back to talk with CNAs and the resident for any resident issues. She stated she found out at the beginning of April 2023 that Resident #68 was not receiving his showers. The SSD did not identify any interventions or approaches used by the social work team to achieve showers being completed for this resident. III. Fingernails not maintainedA. Resident #421. Resident statusResident #42, age 72, was admitted on 12/1/22. According to the March 2023 computerized physician orders (CPO), the diagnoses included anoxic brain damage, not elsewhere classified. The 3/10/23 minimum data set (MDS) assessment revealed the resident had a moderate impairment with a brief interview for mental status score of nine out of 15. He required extensive assistance with bed mobility, transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. The resident refused to bathe, get dressed or get out of bed. 2. ObservationOn 4/18/23 at 5:18 p.m., an unidentified CNA served the dinner meal to Resident # 42. The CNA put a sanitizing wipe on his lap. However, the resident did not use it and no staff helped him. He then began to eat his meal. The resident nails were visibly soiled with dark matter under his fingernails. On 4/19/23 at approximately 9:00 a.m., the resident was lying in bed. His breakfast tray was on a bedside table. The resident's nails and nail beds had a dark substance under the nails and around the nail bed of his fingers bilaterally. The resident's nails were approximately half an inch over his nail bed. At 4:30 p.m. Resident #42's fingernails had dark brown matter under his fingernails. At 4:40 p.m., the licensed practical nurse (LPN #2) sat next to Resident #42 and explained to him that she was going to cut his fingernails. Resident #42 was calm and cooperative as the LPN cut and filed down his fingernails. 3. Record reviewThe care plan, revised on 3/24/23, identified the resident required dependent of one (staff) for activities of daily living (ADL). The resident was dependent on staff with bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility, and behavioral symptoms. Pertinent interventions included, "attempt to have male staff provide care when the resident was resistant with other staff. Communicate what you are doing with resident prior to providing care; allow resident time to process to prevent frustration."The care plan, revised on 12/12/22, documented that Resident #42 exhibits, or has the potential to exhibit physical behaviors related to history of harm to others; kicking and punching staff while attempting to perform basic needs for resident. Interventions documented explain all care, including procedures (one-step at a time), and the reason for performing the care before initiating. -Although the resident had a care plan for refusal of care, the resident let the nurse cut his nails (see observation above). 4. InterviewLPN #2 was interviewed on 4/19/23 at 4:36 p.m. LPN #2 said the best time to cut residents ' fingernails was during or after showers. She said resident nails should be cut when needed. She said the resident had refused to have his nails cut in the past, but would then need to be re-approached. LPN #2 said his fingernails were long and dirty and needed to be cut. B. Resident #131. Resident statusResident #13, age less than 65, was admitted on 6/25/21. According to the April 2023 CPO, the diagnoses included epilepsy, unspecified, cognitive communication deficit and muscle weakness and lack of coordination. The 1/27/23 MDS assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status score of 12 out of 15. He required supervision with personal hygiene as he has a history of declining to shower. 2. Resident interview and observationThe resident was interviewed on 4/18/23 at approximately 3:00 p.m. The resident said that he needed help to clip his nails. He said he had requested from the staff, but had not received assistance. The resident's nails on both of his hands were approximately half of an inch over his nail bed. On 4/19/23 at 4:49 p.m., registered nurse (RN) #1 observed the resident's nails and acknowledged they needed to be cut, as they were long. Resident #13 was interviewed again on 4/20/23 at approximately 10:00 a.m. The resident said his nails were clipped and cleaned last night. He said they feel much better. 3. Record reviewThe care plan, revised on 1/3/23, identified Resident #13 was at risk for decreased ability to perform ADL(s) related weakness, and debility. Pertinent interventions included: required one-person assist with ADLs, may need supervision set up. 4. InterviewRN #1 was interviewed on 4/19/23 at 4:49 p.m. RN #1 said the best time to cut a resident's fingernails was during their shower times. She stated fingernails should be looked at once a week. She acknowledged after observing Resident #13 fingernails, they need to be cut and cleaned up.

Based on observations, interview and record review, the facility failed to provide activities that meet the interests and choices of residents for one resident (#8) of three residents reviewed for activites out of 42 sample residents. Specifically, the facility failed to provide activities and interactions for Resident #8. Findings include:I. Resident #8A. Resident statusResident #8, under age 65, was admitted to the facility on 5/13/13 and readmitted on 12/21/22. According to the April 2023 computerized physician orders (CPO) the diagnoses include cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture), legal blindness, reduced mobility, lack of coordination, major depressive disorder, personality disorder, generalized anxiety disorder, stiffness of joints, muscle weakness, contractures of left elbow, right elbow, left wrist, and right wrist, complete paraplegia (paralysis of lower body), and history of diseases of the musculoskeletal system and connective tissue. The 3/29/23 minimum data set (MDS) assessment documented the resident had a minor cognitive deficit with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, toileting, extensive one person assistance with personal hygiene and set up assistance for eating. B. Resident interview and observations (cross-reference F676 for activities of daily living)The resident was interviewed on 4/17/23 at 4:47 p.m. The resident said her electric wheelchair was broken. The tray that she used to do activities was broken. She said a certified nurse assistant (CNA) broke the tray by letting it slam to the floor rather than letting it go slowly. Observation of the resident's room indicated that the resident enjoyed coloring and other activities. The resident was in bed and the wheelchair was not in use and had a large amount of wrapping around the joystick activator. The resident was interviewed on 4/18/23 at 2:58 p.m. The resident said she could not do activities or leave the room because of the wheelchair not working. The resident said she felt the facility was not a home anymore..The resident was interviewed on 4/19/23 at 10:16 a.m. She said since her wheelchair was broken she was unable to go to karaoke, poker, or Uno (card game). She said she used to go on the facility outings including a bowling trip. She said she had all kinds of papers to color in the closet but could not color them because she did not have the tray on her wheelchair. She said she felt the facility kept her in the bed on purpose. She said she did not get to see friends anymore because she did not get out of bed due to not having her wheelchair. The resident said she had depression and she was trying to keep it from getting worse but the longer she laid in bed the worse it got. The resident had one visitor other than providers and the resident was unable to leave the room for activities or dining during the survey 4/17/23 to 4/24/23. C. Record review The care plan for activities, revised on 10/24/22, documented that it was important for the resident that she have the opportunity to engage in activities, she liked to play games, to color, attend resident council, and be aware of facility happenings. Goals included the resident will continue to attend groups or activities of her interest. Interventions include: initiate interactions with the resident and welcome ideas for the activities department including outing choices and provide pictures to color as requested or as needed. The care plan for a lap tray, revised on 10/24/22, documented the resident utilizes a lap tray for safety but also for diversional activities, meals, and sensory integration due to weak core muscle strength related to cerebral palsy diagnosis. Interventions include: the lap tray will be used for recreational activities and meals as resident desires, and the resident is alert and oriented times three and decides when she wants to take the lap tray off. The care plan for patient interaction/engagement, revised on 10/24/22, documented the resident saying it was important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. Interventions include: the importance of engaging in favorite activities. Progress notes A social services note dated 2/10/23 documented a phone call with a wheelchair company regarding the expense to fix the electric wheelchair. A social services note dated 3/31/23 documented a phone call with a care coordinator regarding the expense to fix the broken electric wheelchair. The interdisciplinary team (IDT) note dated 4/5/23 documented the resident's electric wheelchair was not working. An IDT note dated 4/5/23 documented the wheelchair was not working. A nursing note dated 4/10/23 documented the residents refusal to use a manual wheelchair because they were ill fitting, caused pain, and she would be unable to move herself, requiring another person to move her. A general note dated 4/11/23 documented the electric wheelchair was broken and then reported the resident being frustrated with the chair being broken and she is unwilling to use a manual wheelchair due to being uncomfortable. D. Staff interviews Registered nurse (RN) #1 was interviewed on 4/19/23 at 10:44 a.m. The RN said the resident's wheelchair was broken. She was unaware if the facility had done anything to fix it and the resident would not be able to use a manual wheelchair, someone would have to move her. The nurse said the resident used to visit a lot and would go eat in the dining room, but she could not now. RN #2 was interviewed on 4/19/23 at 10:44 a.m The nurse said the resident used to be all over the place in her wheelchair and she loved to get out of her room. The activities director (AD) was interviewed on 4/19/23 at 12:40 p.m. The AD said the resident liked to get out and do activities. She said the resident and another resident enjoyed having a book club and that she was very social and enjoyed visiting people in the building. The AD said the resident liked being in her room sitting in the electric wheelchair listening to music, watching television , and playing solitaire type games on the television. The AD said the resident was upset about the wheelchair being broken. The AD acknowledged they did not consider a one-to-one activities program for the resident since she was not able to attend activities. The activities assistant (AA) #1 was interviewed on 4/19/23 at 12:44 p.m. AA #1 said she had not gone in to see the resident in the last two days. The director of nursing (DON) was interviewed on 4/19/23 at 2:00 p.m. The DON said the tray and the wheelchair were broken and have been for a few months. The DON said the resident could fill out a grievance form if something was broken. The DON said the previous maintenance director had wrapped the joy stick, the controller of the wheelchair, to keep it working.

Based on observations, interviews, and record review, the facility failed to ensure that two (#6 and #19) residents out of 42 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #6 and Resident #19. Findings include:I. Facility policyThe Memory Support Program Policy for Staff Education and Training, revised 5/1/22, was provided by the director of nursing (DON) on 4/26/23 at 9:29 a.m. It read in pertinent part:"-All direct care staff assigned to the Memory Support Program as well as ancillary staff and volunteers, receive orientation to the Memory Support Program.-In-service training programs are conducted monthly for program staff-Dementia education covered modules: Module 1, Understanding the world of dementia, the person and the disease, Module 2, Being with a person with dementia, listening and speaking, and Module 3, Being with a person with dementia, actions and reactions-The purpose of the Hand-in-Hand training is to provide nursing homes with a high quality training that emphasizes person-centered care in the care of persons with dementia."II. Resident #6A. Resident statusResident #6, age 69, was admitted 5/31/17. According to the April 2023 computerized physician orders (CPO), diagnoses included cognitive communication deficit, dementia, legal blindness, diabetes, chronic obstructive pulmonary disease and morbid obesity. The 2/8/23 minimum data set (MDS) assessment documented moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of fifteen. The resident had behavioral symptoms not directed toward others (vocal, screaming) that interfered with the resident participation in activities or social interactions, and intruded on the privacy or activity of others, and disrupted care. The behaviors were unchanged from behavior status from the prior assessments. The resident ' s functional status of two plus person assist for transfer, dependence for eating, hygiene and showering. According to her activity preference assessment she liked listening to music s and participating in religious services or practices were very important to her. B. Resident interviewOn 4/17/23 at approximately 10:00 a.m., the resident was attempted to be interviewed. The resident yelled out help from her room. The resident was unable to answer any questions, as she kept repeating she needed help, although could not describe what type of help was needed. The call light was on the floor out of reach. C Observations and interview4/17/23-At 10:05 a.m., the resident was in her room yelling out help. She was lying in bed. 4/18/23 -At 3:33 p.m, Resident #6 was sitting up in a chair, observed to be yelling help at least five times over one minute. The resident was quiet and calmly conversing immediately after a certified nurse aide (CNA) entered the room. When the CNA left the room, Resident #6 yelled for help again. Resident #16, who was in his room, which was directly across the hallway from Resident #6, yelled shut up, toward the room of Resident #6. -At 3:48 p.m., the resident continued to yell for help. She was lying in bed.-At 4:19 p.m., the resident continued to yell from bed help. 4/19/23 -At 9:06 a.m., the resident was sitting in chair, and continued to yell for help.-At 9:50 a.m., the resident continued to yell for help, staff passed by the room while the resident was yelling.-At 10:06 a.m., the resident continued to yell for help.-At 2:00 p.m., the resident was lying in bed, and continued to yell for help.-At 2:45 p.m., the resident was lying in bed, continued to yell for help, and a staff member passed by the room without stopping.-At 4:56 p.m., door was closed and the resident continued to yell for help.-At 5:19 p.m., door was open, CNA #1 entered the room, and the resident then wastalking calmly with staff about her family. 4/20/23-At 2:24 p.m., the resident was calling out from bed, help me with foul language. No staff were observed to enter her room to check to see what type of help she needed. At 2:40 p.m., licensed nurse (LPN) #5 said the resident had a dry mouth and that she wanted to see if she could get an order for Biotene (dry mouth rinse). She said that could be part of the problem with her hollering out. -At 2:52 p.m., the resident was calling out continuously. 4/24/23-At 10:15 a.m., the door was open, the resident was in bed, yelled for help over a five minute period, and staff did not respond to the room.-At 11:51 a.m., resident yelled for help every one to two minutes over a five minute period, with no staff response to the room.-At 1:30 p.m., resident was lying in bed, continued to yell for help. D. Record review The April 2023 CPO showed the following medications were ordered:-Seroquel 50 mg (milligrams) by mouth three times daily, for visual hallucinations/dementia, with a start date 4/19/23; and, -Trazodone 50 mg by mouth at bedtime for vascular dementia, with a start date of 4/10/23. The care plan, last updated on 2/28/23, identified problems with self- management due to dementia, including restless/agitated behavior, socially inappropriate, disruptive behavior, as evidenced by frequently calling out for help and crying. Care plan interventions included: assessment for pain, developing activity plan centering around interests and history that takes lifetime values, attitudes, leisure patterns and psychosocial well-being into consideration, treating mood distress through medication therapy or individual counseling, inviting to worship services, using reassuring phrases to help minimize the feelings of fear and anxiety, offering non-pharmacologic interventions when calling out, providing consistent, trusted caregiver when possible, removing resident from environment if needed, monitoring for medication side effects, postponing activity if combative or resistive, listening and remaining calm, allowing to express feelings, and providing empathy, encouragement, and reassurance. The 4/1/23 to 4/22/23 activity participation record received from DON on 4/24/23, revealed Resident #6 participated in socializing activity (no documentation indicated whether in or out of room) 63% of days, music 36% and spiritual/religious services 0%. -There were no refusals indicated on the record. The activity focus of the care plan, revised on 2/7/23, indicated that Resident #6 thought it was important to engage in daily routines that she found meaningful. The care plan noted the following preferences: Christian faith was important to her, loved to talk about past baking and cooking experiences, loved music and preferred Tejano and Country Western music, liked keeping up on the news through use of TV (television), getting nails done, socializing with others, attending music performances, and it was important to her to vote. The social services (SS) progress note on 4/20/23 at 3:19 p.m. documented the SS was directed by staff to reach out to the family of Resident #6. The social services director (SSD) reached the grandson of Resident #6. The resident spoke with him, spoke clearly and was understood by grandson, then the resident was calm after the call with no yelling and had a better dinner experience. Nursing progress note reported that the resident screamed out when awake at the following times: 3/15/23 at 12:27 p.m., 3/25/23 at 12:36 p.m., 3/31/23 at 11:12 a.m., 4/9/23 at 11:29 a.m., 4/10/23 at 11:20 a.m., 4/12/23 at 5:48 p.m., and 4/13/23 at 3:13 p.m. Per nursing note, on 4/9/23, when asked what was wrong, the resident stated that she wanted someone to sit with her. E. Change in medication regimenSeroquel dose was increased from 112.5 milligrams per day to 150 milligrams per day on 4/19/23 with the associated diagnosis of visual hallucinations/dementia. Behavioral tracking was noted for Seroquel. There were no target behaviors associated with the Seroquel. F. InterviewsAn unidentified CNA was interviewed on 4/19/23 at approximately 10:00 a.m. The CNA said Resident #6 called out for help frequently during the day. Resident #53 was interviewed on 4/19/23 at 1:00 p.m. Resident #53 ' s room was directly across from Resident #6 room, said that the resident was yelling help all of the time during the day, and sometimes the resident began yelling at 4:30 a.m. Resident #53 said it had been going on for a long time. CNA #2 was interviewed on 4/23/23 at 8:40 p.m. CNA #2 said he cared for Resident #6 for several years and has found low volume Spanish music seemed to help the resident calm down. She did well when the CNA would sit and talk with her for a little while. The CNA said he had not had specific training to manage the behaviors of Resident #6. LPN #3 was interviewed on 4/23/23 at 9:00 p.m. LPN #3 said Resident #6 called out for help sometimes during the night and usually calmed with reassurance. The LPN said that she usually checked with Resident #6 to see if she had pain and there were times that she needed Ibuprofen at night. The activity director (AD) was interviewed on 4/24/23 at 4:00 p.m. The AD said Resident #6 was not on a formal one-to-one program. The AD stated the CNAs got her up into her wheelchair and then assisted her to activities and Resident #6 often thought she was falling out of the chair when she was sitting up. The AD acknowledged Resident #6 did call out from her room for assistance. The AD said someone from activities department tried to see Resident #6 at least once per week, when the resident tolerated. The activities department had not had volunteers to help this resident to keep her company due to COVID, and AD stated she was working on it. The AD acknowledged the resident's socialization needs were not being met. The director of nursing (DON) was interviewed on 4/24/23 at 4:45 p.m. The DON said she was aware that Resident #6 called out for help on a daily basis. She said different things worked in the past for Resident #6 that no longer worked. There were many attempts geared at helping the resident through diversional activities. The DON said they had re-implemented things they had done before to see if they would work. The DON said when the resident was calling out, staff should not walk by her room without going in to ensure resident needs were being met. The DON stated that the social services department offered training early 2022 regarding how to deal with behavioral issues, like those of Resident #6. Dementia training was provided annually. Daily rounds occurred on residents. Resident #6 has not been addressed in the interdisciplinary meeting (IDT) team meeting. The DON was not aware that the recent Seroquel medication was increased. The social services director (SSD) was interviewed on 4/24/23 at 6:00 p.m. The SSD said she was aware that Resident #6 often yelled out for help. The SSD said she had reached out to the family of the resident, the school of blind, psychiatrist and arranged to get the resident on call with her grandson. The SSD indicated that these strategies did not resolve issues and said she did not have staff to be one-to-one with Resident #6. III. Resident #19A. Resident statusResident #19, age 75, was admitted on 11/28/17. According to the April, 2023 CPO, diagnoses included dementia with agitation, type 2 diabetes, dysphagia (swallowing difficulty)and osteoarthritis. The 2/18/23 minimum data set (MDS) assessment indicated that a brief interview for mental status could not be conducted for this resident. The staff assessment of mental status indicated memory problems with severely impaired decision making. No behavioral symptoms directed at others such as verbal/vocal screaming or disruptive sounds. No mood interview was conducted because the resident rarely/never understood. B. ObservationsOn 4/17/23 at 12:30 p.m. Resident #19 was in a wheelchair and was being assisted with her meal by staff in the dining room. The resident yelled out five times during lunch with other residents present. Staff were present, but did not respond. Resident #19 said "I want to die them" once. On 4/18/23 at 2:34 p.m., the resident yelled at the CNAs in the room. On 4/19/23 at 9:52 a.m., the resident was sitting in a wheelchair next to bed. The television was on and there were lack of personal items or décor in the room. On 4/19/23 at 10:05 a.m., the resident yelled out two times in fifteen minutes. On 4/20/23 at 2:24 p.m., the resident was sitting in her room. The television was on, but it was on closed caption and the volume could not be heard. C. Record reviewThe care plan for Resident #19, last revised 4/6/23, identified socially inappropriate/maladaptive behavior related to her dementia. Interventions included assessment for pain on regular basis, developing an activity plan centering around Resident #19 interest and history, that takes lifetime interests, attitudes, leisure patterns, and psychosocial well-being into consideration. Other interventions included using frequent reassuring phrases to help minimize feelings of fear or anxiety, and non-pharmacologic interventions. Care plan identified focus of need for assistance with activities, last revised 3/13/23, which included a one-to-one program as tolerated. Interventions included introducing a calendar of events, highlighting opportunities to participate in activities of interest, participation in Catholic services weekly as tolerated, individual accommodations with decreased stimuli, and invitation to music/entertainment as tolerated. Care plan focus of verbal behaviors with staff, revised 4/6/23, included the following interventions: monitoring medications for side effects, monitor for pain, evaluate circumstances (triggers) of resident behavior, evaluate need for psychological consult, provide consistent, trusted caregivers, remove resident from environment as needed, and divert by giving alternative objects or activities. Review of the 4/1/23 to 4/22/23 activity participation record revealed that Resident #19 participated in social activity (talking on phone, social/talking, not documented whether in or out of room) 63% of the time and relaxing (looking out window, resting) 63% of the time. -No documentation was noted for refusal of any activities. D. InterviewsAn unidentified CNA was interviewed on 4/19/23 at approximately 10:00 a.m. The CNA said Resident #19 and another resident in the hallway yelled out frequently. LPN #3 was interviewed on 4/23/23 at 9:00 p.m. LPN #3 said that she knew he residents well, and Resident #19 was usually calm during the night and did not yell out. LPN #3 said that she only yelled out when moved. LPN #1 was interviewed on 4/24/23 at 2:00pm. LPN #1 said Resident #19 could not coordinate to hold finger foods in her hands to feed herself. Staff needed to assist Resident #19 for all of her meals. The AD was interviewed on 4/24/23 at 4:05 p.m. The AD said Resident #19 had declined a lot over the past year. She used to participate in activities and often sat in the front lobby. The AD stated the resident did not know who she was talking to. The AD said she had tried to arrange activities with Resident #19 and planned to put this resident on a one-to-one schedule, but had not yet done it. The AD said Resident #19 hit and grabbed others, which made it difficult. The AD said Resident #19 had a television and radio in the room. The AD stated, "I don't think that her socialization needs are being met at the moment."The DON was interviewed on 4/24/23 at 4:45 p.m. The DON stated Resident #19 recently moved to a different unit and there has been a change of staff in the unit. The DON said she would like to see what therapy services could be done for Resident #19. The DON said that dementia care had not been a topic of discussion at quality assurance meetings.

Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure:-Resident food was palatable in taste, texture, appearance and temperature; -Meals were served at a palatable temperature; and, -Condiments were provided with meals. Findings include:I. Resident interviewsResident #45 was interviewed on 4/17/23 at 10:06 a.m. The resident said the food was not good. She said she had complained that when the facility did not have french fries or tater tots, they gave the residents a blob of mashed potatoes. She said she had taken pictures of the pizza that was not appetizing and showed the dietary manager (DM) so he could see what it looked like. She said she had asked for salad for lunch and dinner because the vegetables were overcooked. She said the facility did not have any dressing and they informed her that they did not have the ability to make any. She said the facility overcooked the chicken so it was too dry. Resident #67 was interviewed on 4/17/23 at 10:07 a.m. The resident said he was not a picky eater but when he took the lid off the previous day's breakfast, it smelled like burned hair. He said lunch was ham, it was brown/purple and shriveled up. Resident #31 was interviewed on 4/17/23 at 10:10 a.m. The resident said sometimes the meals were not that great. Resident #4 was interviewed on 4/17/23 at 10:18 a.m. The resident said she had soupy oatmeal and she liked it better when it was thick. Resident #20 was interviewed on 4/17/23 at 10:22 a.m. The resident said the eggs were cold and hard. Resident #81 was interviewed on 4/17/23 at 10:26 a.m. The resident said breakfast had been an egg sandwich and it was cold. Resident #29 was interviewed on 4/17/23 at 10:49 a.m. The resident said she did not like breakfast. She only ate the egg and the oatmeal was watery and it did not look like regular oatmeal. She said over the last several days breakfast had been no good, it was an egg between two slices of bread that had not been toasted with cheese. She said she could not believe what they served the residents to eat. Resident #8 was interviewed on 4/17/23 4:58 p.m. The resident said most of the time the food was cold, especially since she could not go to the dining room. Resident #83 was interviewed on 4/18/23 at 12:00 p.m. He said the food at the facility was not edible therefore he purchased his own food to keep in his room. He said the staff tried to convince him to eat the facility food but he would not eat it. He said the food at the facility had no flavor. Resident #53 was interviewed on 4/19/23 at 1:00 p.m. The resident said the meatloaf was terrible. II. Resident council interviewResident council was interviewed on 4/20/23 at 11:00 a.m. 12 residents attended and participated in a resident council meeting. The majority of the residents stated the food was terrible, awful and had no flavor. One resident said sometimes the hamburgers were under cooked. Another resident said the food was not prepared properly and was served cold. One resident said the fish had been served raw a few times. Residents reported the facility had run out of food and this had happened numerous times. One resident said he had voiced his concern about the food and nothing happened to resolve the problem. One resident said she made her own meals at least twice a week. One resident said he had food enhancers such as crackers, beef jerky, peanut butter, cheese wiz, salsa and chips and salami kept in his room. He said he had seasonings to give his food some flavor. III. ObservationThe kitchen was continuously observed on 4/19/23 at 7:30 a.m. until 8:30 a.m. for the breakfast meal. Food temperatures at the serving table were:-Pureed eggs 102.5 degrees F; and,-Pureed cinnamon rolls 95.1 degrees F. Meals were not being served at 7:55 a.m. The first deliverycart went to the floor for delivery of breakfast at 8:16 a.m. and serving ended at 8:30 a.m. Only trays that had requested brown sugar had sugar, none of the trays had salt or pepper or any other kind of condiment. The room trays were served on warmed plates, with an insulated cover. However, the plates did not have a hot pellet to keep the plate warm. A test tray of pureed breakfast items was tested at 8:32 a.m. by four surveyors. There were no condiments, including sugar, salt or pepper, available. The temperatures of the meal were:-The eggs were 91 degrees F and described as bland, gritty and not flavorful;-The cinnamon rolls were 82.9 degrees F and described as gummy, gluey in texture and had small chucks of dough in it;-The oatmeal was 120 degrees F and was described as watery, bland, not sweet and was liquidy; and, -The milk was 42 degrees F.IV. Record reviewDining committee meeting minutes dated 3/28/23 at 2:00 p.m. documented the residents complained about the menu and food being delivered cold. The resident council minutes from 3/28/23 read in pertinent parts "(name of resident) said the kitchen has been running out of foods. Residents are complaining about having fish and chicken all the time and would like different options."V. Staff interviewsThe dietary manager (DM) and area dietary manager (ADM) were interviewed on 4/20/23 at 2:32 p.m. The DM said he was aware there had been food complaints. He said that the complaints that he had heard from residents included the food required more seasoning. He said the residents did receive salt with their meals, but did not want to add more salt to the food, as some residents could not have salt. He said he heard complaints on repetitive food items and requesting different types of deserts. The DM said the plate warmers were going out and needed to be replaced. The ADM said the facility has not had the heating pellets for over a year. She said that the facility was hoping to get some of the heating pellets for the room trays. The DM said he was required to complete one test tray a month. He said due to the resident complaints, he recently started a food committee. He said the menu was about to change.

Based on observations, interviews, and record review the facility failed to provide snacks for residents who want to eat at non-traditional times or outside of scheduled meal times. Specifically, the facility failed to:-Provide enough snacks for residents; -Ensure residents were able to obtain snacks after the kitchen closed; and, -Ensure snacks were held at the appropriate temperatures. Finding include:I. Facility policy and procedureThe Snack policy and procedure, revised September 2019, was provided by the area dietary manager (ADM) on 4/24/23 at 4:36 p.m. It read in pertinent part: "snacks and beverages will be provided as identified in the individual plans of care."Bedtime snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times."The Dining services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime."All snacks will be properly stored for time and temperature control, as appropriate."II. Facility censusAt the time of the survey from 4/17/23 to 4/24/23 the facility had a census of 92 residents. III. ObservationsDuring a kitchen tour on 4/19/23 at 4:00 p.m. snacks were labeled for residents who received them; there were no other snacks available for residents. At 4:15 p.m. the nourishment room refrigerator was observed to have no snacks other than milk to be distributed and had a temperature of 50.3 degrees F. Room 202 was observed on 4/20/23 at approximately 12:00 p.m. The room had a rack with multiple types of snacks the resident purchased including dried soups, crackers, nutbars, candy, and other types of snacks. It was observed 4/17/23 to 4/24/23 there were no bulk snacks available during the day, snacks were only available to residents who had an ordered snack and in the evening when the kitchen closed. IV. Resident interviewsResident #14 was interviewed on 4/18/23 at 10:20 a.m. The resident said in the past no staff member had woken him for dinner, so he was not served his dinner and went to bed hungry. Resident #43 was interviewed on 4/18/23 at 10:47 a.m. The resident said he had to get his own snacks since he was not provided snacks by the facility. On 4/20/23 at 11:00 a.m. 12 residents attended and participated in a resident council meeting. The residents said they rarely received snacks and there were usually not enough snacks for everyone. The residents said if someone was sleeping, they did not get snacks. One resident said he asked for cottage cheese for a snack and he received a little serving. Another resident said she asked for a peanut butter and jelly sandwich and it had barely any peanut butter and jelly on it. One resident stated that he had food enhancers such as crackers, beef jerky, peanut butter, cheese wiz, salsa and chips and salami kept in his room. V. Staff interviewsThe dietary manager (DM) was interviewed on 4/19/23 at 4:15 p.m. The DM said the snacks would be placed in the nourishment refrigerator for overnight use after the dinner meal. He said the kitchen would make sandwiches, applesauce and other items available at that time. The DM and the ADM were interviewed on 4/20/23 at 2:32 p.m. The DM said there was a list of residents who received snacks and they prepared extras for any resident that wanted something. The DM said they had decided how many to prepare and did not send out snacks for everyone to reduce waste. The supplement shakes were only available to those with a physician's order. Certified nurse aide (CNA) #2 and CNA #7 were interviewed on 4/23/23 at 8:40 p.m. The CNAs said they have limited snacks for their unit. They said snacks were not available at least four times a week. CNA #7 showed a metal container with a few yogurts with names on them and health shakes, the CNA said when she went to the kitchen at dinner, she grabbed some graham crackers. CNA #7 said there were not enough snacks for all the residents. CNA#7 said she had bought snacks for the residents. CNA#7 said the administration knew there were not enough snacks for all of the residents. CNA #4 was interviewed on 4/23/23 at 8:45 p.m. She said the staff did not have snacks quite a bit of the time. She said she had to go look at the other units to see if they have any snacks. She said the CNAs and herself had to buy snacks for the residents. She said they did not have access to the kitchen when it closed after dinner. CNA #8 was interviewed on 4/23/23. The CNA said the staff did not always have snacks. He said he looked on other units for any extra snacks. He said a snack list came out with the assigned snacks with resident names but not enough snacks for other residents not on the list. VI. Record reviewA list of residents with orders for snacks, delivered by the ADM on 4/24/23 at 4:36 p.m. It documented 61 residents had orders for snacks. Of the 61 residents who received snacks, 20 received a supplement shake. This list did not indicate how often residents should receive snacks. Snacks included supplements, yogurt, pudding, peanut butter and jelly sandwiches, other types of sandwiches and cookies.

Based on observation and interviews the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation procedures. Specifically, the facility failed to-Ensure meat was thawed appropriately;-Ensure food was kept at the appropriate temperature;-Ensure ready to eat food was handled appropriately; and, -Ensure health shakes were dated when thawed. Findings include:I. Ensure meat was thawed properly appropriate food temperaturesA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf read in pertinent part, "potentially hazardous foods (time/temperature control for safety foods) shall be thawed:A. Under refrigeration that maintain the food temperature at 41°F (5°C) or less; orB. Completely submerged and with packaging removed under running water:1. At a water temperature of 70°F (21°C) or below,2. With sufficient water velocity to agitate and float off loose particles in an overflow."B. ObservationOn 4/17/23 at 8:45 a.m., there was a box of ground beef defrosting on the sink. There was no water running on the ground beef or it was not submerged under running water. -At 9:40 a.m. The hamburger continued to sit on the sink defrosting. II. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food-borne illness. A. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, "The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control." B. Ensuring holding temperatures 1. ObservationThe kitchen tray line was continuously observed on 4/19/23 at 7:30 a.m. until 8:30 a.m. for the breakfast meal. Food temperatures at the tray line were as follows:-Pureed eggs 102.5 degrees F; and, -Pureed cinnamon rolls 95.1 degrees F.The food temperatures on the tray line after the last resident was served on 4/24/23 at 1:09 p.m. were as follows: -Broccoli was 127.1 degrees F;-Chicken dijon was 132.6 degrees F;-Pureed chicken was 121.5 degrees F; and-Ground chicken was 124.3 degrees F.The pudding and supplement shakes were not being stored in a cool container. The temperature of pudding to go with some meals was 49.6 degrees F and supplement shakes were 54.2 degrees F.2. Medication carts 4/19/23-At 2:41 p.m. during a tour with the dietary manager (DM) it was observed there was pudding on the medication carts. The temperature of the pudding on the 300/400 hall medication cart #1 was 80.7 degrees. The pudding on the medication cart #1 on the 500/600 hallway had a temperature of 54.9 degrees, mediation cart #2 pudding had a temperature of 44.3 degrees. The pudding containers had no mechanism to keep them cold. On 4/20/23 at 12:15 p.m., multiple medication carts in the facility had pudding cups in non-cooled containers. C. Staff interviewsThe cook was interviewed on 4/24/23 at 1:15 p.m. The cook said the food on the steam table should be held at 150 degrees and above. Registered nurse (RN) #1 was interviewed on 4/19/23 at 3:55 p.m. The RN #1 was interviewed with the DM present. The RN said she was not sure what the temperature of the pudding should be. She said that the nurse was responsible for preparing the mechanism to keep the pudding cold. But she used a coffee cup. Licenced practical nurse (LPN) #2 was interviewed on 4/19/23 at 4:00 p.m. LPN #2 was interviewed with the DM present. The nurse said she filled the container with ice but it melted quickly. She said there was not a thermometer in the medication cart to check the temperature of the pudding. The DM and the regional area dietary manager (ADM) were interviewed on 4/24/23 at 2:32 p.m. The DM said the food tray items needed to be at 135 degrees F for hot foods and cold foods needed to be at 41 degrees F and below. He said that he was newer in his position, but that he had been providing training to the staff. The ADD said the food should be heated to 165 degrees F prior to service if it was below 135 degrees F before it was served. The DM said the kitchen made the pudding with milk, then portioned it out into individual cups. III. Ensure ready to eat food was handled appropriatelyA. Professional reference The FDA Food Code (2022) ch. 2 pp. 5, 18-19, read in pertinent part: "Employees are preventing cross-contamination of ready to eat foods with bare hand by properly using suitable utensils such as tongs or dispensing equipment;"Food employees shall keep their hands and exposed portions of their arms clean, using the following cleaning procedure: rinse under clean, running water, apply cleaning compound, rub together vigorously for at least 10 to 15 seconds paying particular attention to removing soil, thoroughly rinse under clean running water and immediately drying;"Food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils; after handling soiled equipment or utensils, before donning gloves to initiate a task that involves working with food." B. ObservationsOn 4/18/23 at approximately 5:00 p.m., an unidentified certified nurse aide (CNA) was observed to touch a sandwich with bare hands and hand it to the resident. On 4/19/24 at 7:15 a.m., the cook was observed to pick up the cinnamon roll with her gloved hand. However, she had been touching other items such as the tray line tickets, a cart which was nearby. On 4/24/23 at approximately 11:45 a.m. during observation of lunch service the dietary assistant (DA) #1 picked up a lunch roll with her bare hands and placed it on a resident tray. DA #2 was observed picking up ready to eat hamburger buns with soiled gloves after handling utensils and other non-food items, and failing to wash hands and put on new gloves. The DM told DA #2 to go wash his hands. C. Interviews The DM and ADM were interviewed on 4/20/23 at 2:32 p,m. The DM said when handling ready to eat foods the staff were supposed to take the gloves off each time and wash their hands. He acknowledged that this did not happen with DA #2 until after he asked DA #2 to go wash his hands. He said utensils could be used also. IV. Health shakesA. Facility standardsThe Labeling and Dating inservice, undated, was delivered by the ADM on 4/24/23 at 4:36 p.m., it read in pertinent part "Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a first in first out manner."Guidelines - items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate 'use by' date. "Leftovers must be labeled and dated with the date they were prepared and the 'use by' date."All ready to eat, time/temperature control for safety foods that are to be held for more than 24 hours at a temperature of 40 degrees F or less."B. Observation and record reviewThe health shakes label documented to store frozen and to discard after 14 days when thawed. During the initial walk-through of the kitchen on 4/17/23 at 8:45 a.m., there were two boxes with health shakes which were defrosted. Box #1 had 13 shakes and box #2 had 12 health shakes. There were no dates on the carton to identify when they were thawed. The nourishment refrigerator was observed on 4/23/23 at 8:45 p.m. There were 12 thawed health shakes in the refrigerator, however, none of them had dates on the health shakes. The DM and ADM were interviewed on 4/20/23 at 2:32 p,m. The DM said the health shakes were to have dates on the health shakes as to when they were pulled. He acknowledged the thawed shake needed to be discarded after 14 days.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, quality of life, quality of care and infection control. Findings include:I. Facility policyThe Quality Assurance and Performance Improvement (QAPI) Plan, last revised on 8/5/22, was received from the director of nurses (DON) on 5/18/23. The plan read in pertinent parts, "All staff and stake holders are involved in QAPI to improve the quality of life and quality of care that our patients and residents experience. The Center's approach to QAPI culture and processes is standardized by implementing the following key elements: data driven and comprehensive, addressing all aspects of care, quality of life and resident centered rights and choice. Review, analyze trends and identify potential improvement opportunities for performance data where trends are worsening or levels have exceeded targets are completed prior to the quality assurance performance improvement committee."II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correctF584During the abbreviated survey on 2/9/22 F584 (home like environment) was cited at a "E" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "E" scope and severity. F676During the abbreviated survey on 2/9/22 F676 (activities of daily living) was cited at a "D" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "G" scope and severity. F677During the abbreviated survey on 6/1/22 F677 (activities of daily living for dependent residents) was cited at a "E" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "E" scope and severity. F744 During the recertification survey on 7/8/21 F744 (dementia care) was cited at a "D" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "D" scope and severity. F804During the abbreviated survey on 6/1/22 F804 (nutritive value, palatability) was cited at a "E" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "E" scope and severity. F812During the abbreviated survey on 2/9/22 F812 (kitchen sanitation) was cited at a "F" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "F" scope and severity. F867During the recertification survey on 7/8/21 F867 (quality assurance) was cited at a "F" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "F" scope and severity. F 880During the recertification survey on 7/8/21 F880 (infection control) was cited at a "L" scope and severity. During the abbreviated survey on 2/9/22 F 880 (infection control) was cited at a "E" scope and severity. During the recertification survey on 4/24/23, the facility was cited at a "F" scope and severity. III. Cross-reference citationsF550Cross-reference F550 Dignity: The facility failed to ensure residents were treated with respect and dignity. F565Cross-reference F565 Resident group response: The facility failed to hold resident council meetings consistently in a private area and respond to their grievances and concerns. F574Cross-reference F574 Required notices and contact information: The facility failed to ensure the facility posted notices were readable and in a prominent area. F576Cross-reference F576 Right to forms of communication: The facility failed to ensure residents received privacy with mail. F577Cross-reference F577 Right to survey results: The facility failed to ensure the previous Federal andState survey results were available. F809 Cross-reference F809 Snacks: The facility failed to ensure residents were offered evening snacks. IV. InterviewsThe DON was interviewed on 4/24/23 at 7:32 p.m. The interim nursing home administrator (INHA) was not available to attend the interview. The DON said the INHA had been at the facility for a few months. She said the QAPI committee met monthly with all department heads, the medical director, the pharmacist and when available a floor staff. The DON said the meeting had an agenda. She said the agenda changed monthly. She said areas were identified from grievances, audits and concerns from residents and family. The QAPI committee looked for trends and then root causes and then put a performance improvement plan in place. The DON said snacks were not provided to residents had been brought to the QAPI meeting in January 2023. She said the kitchen was going to order snack carts, so the snacks would be passed out on the cart, however, the carts were too small so they needed to reorder. The DON said infection control was discussed every meeting and they reviewed the antibiotics and tracking and trending. She said the committee had not identified the lack of cleaning high touch areas, offering hand washing to residents or cleaning durable medical equipment. The DON said resident rights issues and dignity had not been identified in the QAPI program. The DON said the privacy of communication (mail) had been discussed a little while back with the previous NHA and activity director. The decision was to have packages opened in front of an activity associate to ensure medications were not in the packages. The DON said overall she believed the facility had a good QAPI program, however, the participants for the QAPI needed to have a better understanding of the process and how to identify items.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to:-Ensure high touch areas were cleaned; -Ensure nursing staff disinfected shared equipment (vitals machines and lifts) between residents;-Ensure residents were provided with an opportunity to participate in hand hygiene prior to meals; and, -Ensure residents' personal property were labeled and stored appropriately. Findings include:I. Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areasA. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 4/26/23 revealed, in pertinent part: "High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment." The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 4/26/23 read in pertinent part, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility."Common high-touch surfaces include:-bedrails-IV (intravenous) poles-sink handles-bedside tables-counters-edges of privacy curtains-patient monitoring equipment (keyboards, control panels)-call bells-door knobs"Proceed From Cleaner To DirtierProceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include:-During terminal cleaning, clean low-touch surfaces before high-touch surfaces.-Clean patient areas ( patient zones) before patient toilets.-Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone.-Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."B. Facility policy and procedureThe Infection Control policy and procedure, dated 10/17/22, was received on 4/19/23 from the director of nurses (DON)read in pertinent part, "Clean and disinfect the environment, especially high touch surfaces, using an EPA (Environmental Protection Agency) approved, hospital grade disinfectant."C. ObservationsThe front entry had a computer which must be signed into by any visitors and all staff. The computer needed to be touched to enter a name and phone number. Throughout the survey from 4/17/23 through 4/24/23, the computer had not been disinfected. On 4/24/23 at 12:02 p.m., housekeeper (HSK) #2 was observed to clean room #x. The HSK cleaned the door handle to the bathroom, however, she did not clean the pull cord, the light switch, the handles of the sink, the door knob to the entry of the room. D. InterviewsHSK #2 was interviewed on 4/24/23 at 12:15 p.m. The HSK said she was newly hired. She said high touch areas got cleaned once a day. She said she did not have any training on how frequently the high touch areas needed to be cleaned. The DON and the infection control preventionist (IP) were interviewed on 4/24/23 at 6:00 p.m. The DON said the resident rooms were cleaned daily. She said the room cleaning should include the light switches, pull cords and door knobs. She said other high touch areas needed to be cleaned frequently. The IP said the entrance computer needed to be cleaned in between each usage. He said the receptionist was responsible to ensure it was cleaned in between uses. The HSK supervisor was interviewed on 4/24/23 at 6:30 p.m. The HSK supervisor said HSK #2 had received training for three days prior to working alone. She said she would provide more education on ensuring the high touch areas were cleaned in the resident rooms. II. Failed to ensure residents were provided with an opportunity to participate in hand hygiene prior to mealsA. Professional referenceThe Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 4/27/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html revealed in part, "Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. "The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2. "ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment."The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink."B. Facility policy and procedureThe Infection Control policy and procedure, dated 10/17/22, was received on 4/19/23 from the DON, read in pertinent part, "HCP (healthcare personal) will assist/remind patients to complete hand hygiene as needed per policy."C. ObservationsOn 4/17/23 at approximately 12:00 p.m., the residents in the assisted dining room were not provided the opportunity to perform hand hygiene. The meal trays were passed out, without staff offering hand hygiene. On 4/18/23 at 5:18 p.m., an unidentified CNA served the dinner meal to Resident #42. The CNA put a sanitizing wipe on his lap. However, the resident did not use it, and no staff helped him. He then began to eat his meal. The resident nails were visibly soiled. At 5:20 p.m. an unidentified CNA asked the other unidentified CNA if hand hand hygiene was offered to residents down the 600 wing before dinner trays were passed out; he said yes they were all provided with hand hygiene care. However, continuous observations between 2:00 p.m. and 5:30 p.m., hand hygiene was not observed to be offered or provided. The CNA did not have the hand wipes on him when trays were passed out. On 4/19/23 at 4:56 p.m., the room tray cart arrived on Rock Canyon station. The trays were passed to rooms by CNAs and the health information manager (HIM). The HIM walked into room #307 and served a room tray to the resident. No offering of hand hygiene was provided. CNA #11 was observed to pass several trays without offering hand hygiene to the residents. D. InterviewThe DON was interviewed on 4/20/23 at approximately 3:00 p.m. The DON was informed that hand hygiene prior to meals being served were not offered. The DON said all staff were aware that residents' hands needed to be washed prior to the meal being served. She said the facility had completed training on the importance of offering hand hygiene. III. Failure to clean medical equipmentA. Facility policy and procedureThe Infection Control policy and procedure, dated 10/17/22, was received on 4/19/23 from the DON, read in pertinent part, "Clean and disinfect patient care items using appropriate EPA approved, hospital grade disinfectant and following manufacturer's instructions."B. ObservationsOn 4/18/23 at approximately 1:00 p.m., an unidentified CNA was observed to take the vitals of a resident. She then wiped the vital sign machine with a sanitation wipe which was designated to be used for hands. On 4/18/23 at 4:24 p.m., CNA #10 was observed to use the hoyer (mechanical) lift on a resident. The CNA then immediately put the hoyer lift at the end of the hall for storage. She failed to clean the lift. C. InterviewThe DON and the IP were interviewed on 4/24/23 at 6:00 p.m. The IP said the wipes which were to be used on the durable medical equipment was the Micro kill, or a bleach wipe. The sanitation wipes which were used for hands were not be used. IV. Resident personal itemsA. ObservationsOn 4/18/23 at 10:45 a.m., room #310 had an unmarked hair brush laying on the sink in a shared room. 4/24/23 -At 10:39 a.m., the shower room on the 600 hall had an unmarked hair brush with hair in it stored on the shelf. -At 10:45 a.m., room #612 a shared room, had no markings on the towel bar to distinguish which towel belonged to which resident. -At 10:46 a.m., room #609 had an unmarked hair brush and unmarked urinal not bagged in the bathroom. The towels had no markings on the towel bar to distinguish which towel belonged to which resident. One of the residents was asked which towel was his, and he said he had no idea, he used either of them. -At 11:00 a.m. room #604 had an unmarked toothbrush on the sink; no towels were marked in a shared room.-At approximately 11:00 a.m., room #514 had two bars of soap at the sink, an unmarked towel bar in a shared room.-At approximately 11:10 a.m., Room #314 had no marking on the towel rack, in a shared room. The resident did not know which towel was hers versus her roommate. B. InterviewThe DON and the IP were interviewed on 4/24/23 at 6:00 p.m. The DON said unmarked items were the responsibility of the CNAs. The urinals needed to have a name or room number. She said the CNAs should mark all personal items, such as toothbrushes, and hair brushes or put it into a basin with a name. She said on the towel bar the towel closest to the door was bed A and the furthest was bed B. She acknowledged the residents did not know the location of their towel in a shared room.

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 03/27/2023 and 04/02/2023, 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.