EAGLE RIDGE POST ACUTE

A revisit survey was completed on 9/25/24 for all previous deficiencies cited on 8/20/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO37114 was conducted on 8/19/24 to 8/20/24. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#1) of five residents reviewed for respect and dignity out of 11 sample residents. Specifically, the facility failed to assist Resident #1, who was dependent on staff for all care, to turn in bed when he requested assistance. Findings include:I. Facility policy and procedureThe Resident Rights policy, revised December 2016, was provided by the director of nursing (DON) on 8/22/24 at 11:26 a.m. It read in pertinent part,"Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination, and to be informed of, and participate in, his or her care planning and treatment."II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 12/27/17. According to the August 2024 computerized physician orders (CPO), diagnoses included complete paraplegia (paralysis below the waist) and incomplete quadriplegia (weakness or paralysis in all four limbs), bipolar disorder, and anxiety disorder. The 7/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15 . The MDS assessment indicated Resident #1 had no rejections of care. Resident #1 was dependent upon staff for all activities of daily living (ADL). B. Record reviewThe skin management plan of care, initiated on 2/9/24 and revised on 7/22/24, included interventions to encourage turning and repositioning frequently and as needed and to re-approach the resident at a later time if he refused treatments. Resident #1's behavioral management plan of care, initiated on 11/17/2020 and revised on 7/22/24, included an intervention to give Resident #1 as many choices as possible about his care and activities. A progress note, dated 6/11/24 at 9:18 p.m., documented Resident #1 requested to be turned in bed and the nursing care staff told the resident his next turn was at 10:30 p.m. The progress note documented the nursing care staff told Resident #1 they could not turn the resident every hour as he had requested that evening. The progress note documented that Resident #1 was angry and cursed at the nursing staff when he was told this. A progress note, dated 7/18/24 at 9:42 a.m., documented Resident #1 requested to be left alone when staff attempted to wake the resident. The progress note documented the staff returned with medications to administer to the resident. The progress note documented Resident #1 requested the staff to leave his room again. A progress note, dated 7/18/24 at 9:59 a.m., documented the resident did not respond to the nursing staff when they asked him about his shower preferences. The progress note documented when Resident #1 woke up and was not aggressive with staff he would be informed that the next available shower time to accommodate his preferences would be at 1:00 p.m. A progress note, dated 8/4/24, documented Resident #1 was offered to be turned in bed in the morning and then the resident requested to be turned again at 12:00 p.m. The progress note documented the staff told Resident #1 that it would not be possible to turn him at 12:00 p.m. The progress note documented Resident #1 requested a plan for him to get turned. A progress note, dated 8/13/24, documented Resident #1 was aggravated when the certified nurse aides (CNA) told Resident #1 that there was a time constraint of 25 to 30 minutes on assisting him with repositioning. C. Staff interviewsCNA #1 was interviewed on 8/19/24 at 10:07 a.m. CNA #1 said Resident #1 was known to refuse care but the staff needed to work with his preferences to ensure his care was being done. CNA #1 said some of the nursing staff members worked better with Resident #1 than others. CNA #1 said there had beenseveral agency staff members working in the facility and the turnover rate of staff that Resident #1 knew and trusted had affected how often he refused care. CNA #1 said if Resident #1 requested to be turned in bed after refusing other cares, the care requested should be accommodated. CNA #2 was interviewed on 8/19/24 at 10:13 a.m. CNA #2 said Resident #1 was known to be a difficult resident to work with because he occasionally refused care. CNA #2 said the staff were not always able to accommodate Resident #1's requests to be turned in bed because he required maximum assistance of two staff members and often a hoyer lift as well. Licensed practical purse (LPN) #1 was interviewed on 8/20/24 at 1:34 p.m. LPN #1 said he had spoken to Resident #1 about his skin prevention plan of care previously. LPN #1 said Resident #1 felt frustrated when he could not be repositioned when he requested to do so. LPN #1 said Resident #1 had refused cares from him many times in the past and the staff knew to reoffer or reschedule cares for Resident #1 when he refused care. The DON was interviewed on 8/20/24 at 3:14 p.m. The DON said Resident #1 had the right to request to be turned in bed when he wanted to be and this was important to heal his current pressure ulcers as well as prevent future pressure ulcers from occurring. The DON said Resident #1 was known to refuse care for several years. The DON said staff should honor Resident #1's requests for care according to his daily preferences. The DON said it was unacceptable for nursing staff members to tell residents they could not be turned, even if they refused repositioning earlier in the day. The DON said when the residents refused care it should be reoffered often and usually on the same day. The DON said she did not know why the MDS assessment did not accurately record Resident #1's rejection of care.

Based on record review and interviews, the facility failed to ensure one (#8) of one resident out of 11 sample residents was free of significant medication errors. Specifically, the facility failed to ensure Resident #8 received her full three-week course of antibiotics as recommended by the hospital. Findings include:I. Professional referenceCombating Antibiotic Resistance, reviewed 10/29/19, was retrieved on 8/23/24 from https://www.fda.gov/consumers/consumer-updates/combating-antibiotic-resistance. It read in pertinent part,"Antibiotic resistance is a growing public health concern worldwide."In cooperation with other government agencies, the Food and Drug Administration (FDA) has launched several initiatives to address antibiotic resistance. The agency has issued drug labeling regulations, emphasizing the prudent use of antibiotics. The regulations encourage health care professionals to prescribe antibiotics only when clinically necessary, and to counsel patients about the proper use of such drugs and the importance of taking them as directed."It is important to take the medication as prescribed by your doctor, even if you are feeling better. If treatment stops too soon, and you become sick again, the remaining bacteria may become resistant to the antibiotic that you have taken."II. Resident #8A. Resident statusResident #8, age 77, was admitted on 7/1/24, discharged on 7/27/24 and readmitted on 7/29/24. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes with other diabetic kidney complications, acute osteomyelitis (infection in the bone) of the left ankle and the left foot, encounter for orthopedic aftercare following surgical amputation, sepsis (infection of the blood) and acquired absence of the left great toe. The 8/7/24 minimum data set (MDS) assessment revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment indicated Resident #8 was receiving antibiotics. B. Record reviewThe 7/1/24 admission note documented Resident #8 was admitted to the facility with a wound on her left big toe. The wound bed was pink, slough (dead tissue and pus on the surface on the wound) was present and scant (small amount) drainage was noted. The 7/27/24 progress note documented the staff received verbal orders from the physician to send Resident #8 to the emergency room to be evaluated. The 7/28/24 progress note documented the staff called the emergency room and requested an update on the resident's condition. The hospital staff informed the nurse that Resident #8 had been admitted to the hospital. The 7/29/24 hospital operation summary was uploaded to Resident #8's electronic medical record (EMR). It documented the resident had her left great toe amputated due to osteomyelitis. The surgeon documented Resident #8's postoperative plan included three weeks of antibiotics. Resident #8 received intravenous (IV) antibiotics at the hospital and needed to complete oral antibiotics when she discharged from the hospital. The 7/29/24 progress note documented Resident #8 readmitted to the facility. The 8/2/24 nursing progress note documented the nurse received a clarification regarding Resident #8's order for Vancomycin (antibiotic). The facility reached out to the hospital and the dialysis center and determined the dialysis center was going to administer the resident's IV Vancomycin during the resident's dialysis sessions while the facility planned to administer Resident #8's oral Augmentin (antibiotic). The 8/2/24 nursing progress note documented the facility staff spoke with the pharmacist for a STAT (immediate) order of Augmentin. The note documented the pharmacy informed the facility staff that the Augmentin was set to be delivered that same day, on 8/2/24. The 8/2/24 admission note documented the resident had her great toe amputated on 7/29/24. The August 2024 CPO revealed the resident had a physician's order for five milliliters (ml) of Augmentin oral suspension two times a day for 17 days, ordered 8/2/24. The August 2024 medication administration record (MAR) (from 8/1/24 to 8/31/24) documented the resident had an order for five ml of Augmentin twice a day with a start date of 8/2/24 at 7:00 p.m. and an end date of 8/19/24 at 7:00 p.m. -Resident #8 received 26 doses of Augmentin out of the 32 total doses prescribed. On 8/15/24 at 9:17 p.m., a medication administration note documented the facility ran out of the resident's Augmentin.-Review of the resident's EMR did not indicate the physician was notified that the resident missed the dose of Augmentin or that the pharmacy was notified for a refill of the medication. On 8/16/24 at 8:51 a.m., a medication administration note documented the facility ran out of the resident's Augmentin.-Review of the resident's EMR did not indicate the physician was notified that the resident missed the dose of Augmentin or that the pharmacy was notified for a refill of the medication. On 8/16/24 at 9:15 p.m., a medication administration note documented the facility ran out of the resident's Augmentin.-Review of the resident's EMR did not indicate the physician was notified that the resident missed the dose of Augmentin or that the pharmacy was notified for a refill of the medication. On 8/17/24 at 8:26 a.m., a medication administration note documented the facility ran out of the resident's Augmentin.-Review of the resident's EMR did not indicate the physician was notified that the resident missed the dose of Augmentin or that the pharmacy was notified for a refill of the medication. On 8/17/24 at 7:22 p.m., a medication administration note documented the facility ran out of the resident's Augmentin.-Review of the resident's EMR did not indicate the physician was notified that the resident missed the dose of Augmentin or that the pharmacy was notified for a refill of the medication. The 8/17/24 nursing progress note, documented at 7:59 p.m., revealed the staff called the on-call physician and received an order to hold the resident's Augmentin until Monday 8/19/24. The on-call physician said the staff needed to inform the medical director (MD) on 8/19/24 regarding the discontinuation date for the Augmentin. On 8/18/24 at 9:10 a.m., a medication administration note documented the facility ran out of the resident's Augmentin.-Review of the resident's EMR did not indicate the physician was notified that the resident missed the dose of Augmentin or that the pharmacy was notified for a refill of the medication. III. Staff interviewsThe medical director (MD) was interviewed on 8/20/24 at 11:29 a.m. The MD said she was unable to recall if Resident #8 received a full course of antibiotics for three weeks as prescribed in her postoperative care. The MD said, after reviewing the resident's EMR, the resident did not receive all of the required doses of the Augmentin. The MD said the facility had a lot of agency staff members who did not understand the process to refill medications. The MD said the antibiotic needed to be administered according to the physician's order. She said she was not informed that the resident was out of the Augmentin. Licensed practical nurse (LPN) #1 was interviewed on 8/20/24 at 1:34 p.m. LPN #1 said the night shift nurses ordered medications that were due to be refilled every Monday, Wednesday and Friday. He said the pharmacy took anywhere from one to three days to deliver the medications, depending on what the medications were. LPN #1 said the facility had a backup medication system in the facility which stocked Augmentin. He said it was concerning that Resident #8 did not receive the antibiotics for seven doses and the director of nursing (DON) should have been informed. LPN #1 said he was unaware the medication was not filled by the pharmacy or that the resident missed doses. The pharmacist (PH) was interviewed on 8/20/24 at 1:41 p.m. The PH said the Augmentin was originally ordered on 8/2/24. She said the pharmacy received a refill request from the facility on 8/14/24 at 9:22 p.m. She said the Augmentin was not filled by the pharmacy and she was unable to explain why because there were no notes documented in the system. LPN #2 was interviewed on 8/20/24 at 2:01 p.m. LPN #2 said the night shift nurses refilled the medications every Monday, Wednesday and Friday. LPN #2 said she knew the facility had a backup medication system which stocked antibiotics. She said if the facility's backup system was out of a medication, the staff filled the medication at a community pharmacy and picked up the medications. She said, although she worked on the hall Resident #8 resided, she said she was unaware the resident was out of her Augmentin or that she missed doses of the antibiotic. The DON was interviewed on 8/20/24 at 3:15 p.m. The DON said the staff needed to call the pharmacy as soon as the first missed dose occurred. She said the facility had stocked medications, including antibiotics, that the staff were able to pull the medication from if the pharmacy was unable to deliver it that day. The DON said the nurse was supposed to contact the pharmacy, call the DON and call or send a fax to the on-call physician if a medication had not been refilled. She said the Augmentin ran out on a Friday during the day shift and the pharmacy would have been able to fill the medication. The DON said she was not informed the medication was out and she was not sure why the pharmacy did not fill the medication when the request was received. The DON said all antibiotic courses needed to be completed to prevent antibiotic resistance and Methicillin-resistant Staphylococcus aureus (MRSA- a staph infection that is resistant to antibiotics). IV. Facility follow-upThe DON provided follow-up on 8/22/24 at 11:26 a.m. regarding the missed antibiotics. The follow-up documented the missed doses of the Augmentin was a significant medication error. The DON provided education to all of the nurses and corrective actions to the nurses involved in the seven missed doses. The DON completed an audit to identify if other residents missed doses of medications due to the pharmacy not refilling the medicine or the facility not following up with the pharmacy when medications were not received. The DON said she planned on completing the nurse education by 8/30/24. She said beginning 8/30/24, the DON or designee was going to conduct medication administration audits each week for four weeks then monthly for two months and the audit would be re-evaluated at that point in time. The audits were scheduled to be reviewed monthly in each quality assurance and performance improvement (QAPI) meeting until the committee determined the facility sustained compliance.

A revisit survey was completed on 8/5/24 to 8/7/24 for all previous deficiencies cited on 6/12/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 8/5/24 to 8/7/24 for all previous deficiencies cited on 6/12/24. The facility is in compliance with all regulations surveyed.

The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility's general characteristics. The facility consists of an original single-story Type II (111) structure with a single-story Type V (000) addition. The Type II (111) structure includes a partial basement inaccessible to the residents and houses support services and a boiler room. The Type II (111) and Type V (000) structures are not separated by a distinct, two-hour fire-rated wall. The facility is licensed for 70 beds and operates as a non-secured facility during this survey. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, which includes the interstitial space above the ceiling. The survey was conducted on June 26, 2024, to comply with the fire safety requirements of NFPA 101, Life Safety Code (LSC), 2012 edition, Chapter 19 for Existing Health Care Occupancies. At the time of the survey, the census was reported to be 63 residents. The facility will meet these requirements when the following deficiencies are corrected. Each of the following deficiency items was discussed with the maintenance director and the facility's administration during the survey and then again during the exit conference, which included the facility administrator.

Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1) Roof drainage pipe must be maintained at proper height for an egress pathway of 6 ft 8 in. NFPA 101 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101 7.1.5.1 Means of egress shall be designed and maintained to provide headroom in accordance with other sections of this Code, and such headroom shall be not less than 7 ft 6 in. (2285 mm), with projections from the ceiling not less than 6 ft 8 in. (2030 mm) with a tolerance of -3/4 in. (-19 mm), above the finished floor, unless otherwise specified by any of the following:This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Courtyard egress to the public way is not in accordance with NFPA 101 7.2.1.5.6 Electrically Controlled Egress Door Assemblies. NFPA 101 7.2.1.5.6 Electrically Controlled Egress Door Assemblies. Door assemblies in the means of egress shall be permitted to be electrically locked if equipped with approved, listed hardware, provided that all of the following conditions are met:(1)The hardware for occupant release of the lock is affixed to the door leaf.(2)The hardware has an obvious method of operation that is readily operated in the direction of egress.(3)The hardware is capable of being operated with one hand in the direction of egress.(4)Operation of the hardware interrupts the power supply directly to the electric lock and unlocks the door assembly in the direction of egress.(5)*Loss of power to the listed releasing hardware automatically unlocks the door assembly in the direction of egress.(6)Hardware for new installations is listed in accordance with ANSI/UL 294, Standard for Access Control System Units. This deficiency could affect occupants, including residents, staff, and visitors throughout the facility. Deficient item(s) were discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1) remove all door-holding devices on all fire and smoke doorsNFPA 101 19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. NFPA 101 7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) Need exit signage to public way from kitchen and center south wing. 2) West courtyard egress to the public way needs to be markedNFPA 101 39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10. NFPA 1017.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) Kitchen gas appliance(s) missing cablingNFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 549.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer ' s installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connection installation shall be configured in accordance with the manufacturer ' s installation instructions. 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer ' s installation instructions. This deficiency could affect occupants, including residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Fire alarm Semi-Annual: Not ProvidedBased 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. 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 Alarmand Signaling Code. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 Table14.4.5 Testing FrequenciesThis deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Fire Sprinkler Semi-Annual: Not Provided2) Fire sprinkler 5 Year: Not provided3) Fire sprinkler dry barrel sidewalls dated 2008 due for replacement 4) Fire sprinkler system is missing hydraulic and general information signage5) Fire sprinkler head in the walk-in freezer obstructed 6) Fire sprinkler next to the copy room rated quick response; the entire hallway is standard response need to replace; mixed heat sensitivity not allowed 7) Activity storage in the basement sprinkler pipe not hung properly Based on a record review, it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. NFPA 101, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Chapter 5 Sprinkler SystemsTable 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. NFPA 25, Chapter 13 Common Components and ValvesTable 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. NFPA 25 4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. 4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25 5.3.1.1.1.6*Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. NFPA 25, 5.2 Inspection. 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. 5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible. NFPA 25 5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors. NFPA 25 5.4.1.1* Replacement sprinklers shall have the proper characteristics for the application intended, which include the following:NFPA 25 5.5.1 Whenever a component in a sprinkler system is adjusted, repaired, reconditioned, or replaced, the actions required in Table 5.5.1 shall be performed. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) multiple penetrations through the East firewall in the corridor2) multiple ceiling tiles damaged in corridors3) The center firewall needs one hole patched with fire caulking4) RR304 needs drywall patched in the bathroomNFPA 10119.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.19.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating. 19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke. NFPA 1014.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance. This deficiency could affect occupants, including residents, staff, and visitors within the entire building. Deficient items were discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80. This was evidenced by:1) Fire Dampers (4-6 years)(101 8.5.5.4.1 & 80 19.4): 1.2.24, has 2 deficient dampers that need repaired2) The laundry chute damper failedNFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 80 19.5.3 If the damper is not operable, repairs shall begin without delay. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:1) Fire Doors (annually)(80 5.2): Not provided2) Kitchen egress left door not working3) West fire doors not closing properly 4) East phone data room door is not closing NFPA 101, 8.3.3.1Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80, 5.2 Inspections. 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.5.2.15.3 Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door ' s proper emergency function, the following actions shall be performed:(1)The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.(2)The door shall be tested to ensure emergency operation and closing upon completion of the repairs. These deficiencies can potentially affect occupants, including residents, staff, and visitors throughout the facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 996.3.4.1.1Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3Receptacles not listed as hospital-grade at patient bed locations and in locations where deep sedation or general anesthesia is administered shall be tested at intervals not exceeding 12 months. NFPA 996.3.4.2 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 modifications. 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. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Sealed, Not providedNFPA 110 8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specificationsThis deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) The Oxygen Trans-filling room needs mechanical ventilation within 12" of the floor that terminates outside of the building and is connected to essential electrical systems. NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. NFPA 99 11.5.2.3.1Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility where in patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures. NFPA 99 9.3.7.5.3.4Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system. This deficiency could affect occupants, including residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

A recertification survey with complaint #CO35952, #CO36201, #CO36208 and #CO36210 was completed on 6/5/24 to 6/12/24. Twenty-five deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/5/24 to 6/12/24. Two deficiencies were cited.

Based on record review and interviews, the facility failed to review and update the emergency plan and its policies at least annually. Specifically, the facility failed to document the emergency plan was reviewed in its entirety annually. Findings include:I. Facility standardsThe Emergency Preparedness Education, undated, was provided by the nursing home administrator (NHA) on 6/5/24 at approximately 10:00 a.m. as part of the facility's admission packet. The education read in pertinent part, "The facility has a comprehensive emergency operation plan in place, so that people can be protected and supported in times of crisis. As a long-term care facility, by federal law, it is required to have emergency operation plans in the event of a natural or man-made disaster. The facility is required to tailor its operation plan to its geographic location and the types of residents it serves. The community must also review the evacuation plan, train new employees in emergency procedures and hold drills and periodic reviews with staff." II. Facility plan The emergency preparedness management plan (EPMP) was provided by the regional operations manager (ROM) and the director of maintenance (DM) on 6/10/24 at 3:04 p.m. -Review of the EPMP revealed the plan was not reviewed annually as required. -The facility plan did not include when the EPMP was last reviewed in its entirety, some of the policies and procedures were not based on current practices and the record of distribution was left blank. III. Staff interview The EPMP was reviewed with the ROM and the DM on 6/10/24 at 3:04 p.m. The DM said he was unable to locate documentation of an annual review. The DM said he was in the course of reviewing specific sections of the plan but did not have an established process to ensure the plan and its policies were reviewed at least annually. The DM said he started reviewing the EPMP the week of the survey (6/5/24 to 6/12/24) after he was told by the NHA he was responsible for the EPMP. He said there was no review date to identify the EPMP was reviewed annually. The DM said on 6/7/24 he reviewed the EPMP to make sure it was updated. The DM said the facility name was added to the EPMP documents and the facility profile was updated to include the facility's current administrator's name and contact number. He said the facility's transfer agreements were reviewed and updated within the last year, on 11/21/23. The ROM said the facility could have done a better job at reviewing the EPMP. He said the facility was in the process of learning the needed components of the EPMP. The DM was interviewed again on 6/12/24 at 8:55 a.m. The DM said he was frustrated that he was not made aware of the EPMP requirements prior to the survey. He said the NHA's were usually responsible for it in the past and he was just told last week he was. The DM said he would learn and review the components of the EPMP to meet the requirements moving forward. The NHA and the corporate clinical manager (CCM) were interviewed together on 6/12/24 at 10:07 a.m. The NHA said the facility knew the EPMP needed to be updated. She said it had been discussed to review in the Quality Assurance and Performance Improvement (QAPI) meeting for several months. The NHA said the facility updated the transfer agreements, the facility assessment, the phone contacts and key contact information. The NHA said in the event of an emergency she was the first point of contact but was not sure what her exact role was regarding emergency preparedness. The CCM said the EPMP would be updated in its entirety the week of 6/18/24, following the survey.

Based on record review and interviews, the facility failed to follow established requirements for testing the emergency preparedness plan. Specifically, the facility failed to:-Participate in a community-based or facility based-full scale exercise or actual emergency; -Complete a second community-based, facility-based full scale or facilitated table top exercise; and,-Analyze the facility's response to and maintain documentation of all drills, tabletop exercises and emergency events and revise the emergency plan as needed. Findings include:I. Facility policy The Disaster Training policy, revised April 2019, was provided by the nursing home administrator (NHA) on 6/17/24 at 4:03 p.m. The policy read in pertinent part, "This facility has established training and education programs that provide specific guidance and instruction on the proper handling of a crisis or disaster situation. Staff members, contract employees, and volunteers are trained upon hire and at least annually on the community's emergency preparedness and response plan and procedures. Exercises, drills, and simulations are conducted on all levels of management within the organization and not just confined to routine fire or evacuation drills."The main objectives for the training are:-To provide staff with relevant information on emergency procedures and emergency management in compliance with local, state, and federal guidelines, as well as nationally recognized standards and best practices;-To foster a culture of emergency preparedness within the facility to help ensure the safety of the residents, families, visitors, and team members; and,-To help ensure that proper planning, response, and recovery programs are in place and are appropriate for the facility."Training exercises are conducted annually to test the emergency plan. Training exercises include all of the following:-Unannounced drills using the emergency procedures;-Community-based, or facility based full scale; and,-Community-based or facility based tabletop exercises that include a group discussion led by a facilitator using a narrative scenario with problems and questions designed to challenge an emergency plan."Emergency training exercises, drills, and simulations are conducted in accordance with all local, state, and federal guidelines."All exercises, drills, and simulations are documented and include the individuals who participated, issues identified, and analysis of the response and any revisions made to the plan."II. Facility plan The emergency preparedness management plan (EPMP) was provided by the regional operations manager (ROM) and the director of maintenance (DM) on 6/10/24 at 3:04 p.m. -Review of the EPMP revealed the plan did not include evidence of the facility's annual participation in a community-based or facility-based-full scale exercise or actual emergency or participation in a second community-based, facility-based full scale or facilitated table top exercise in the last 12 months. Review of the EPMP identified an actual emergency event occurred on 1/17/23 (over one year prior to the survey).-The EPMP did not identify that the facility documented and analyzed annual emergency preparedness or response exercises and made revisions as needed to the EPMP based on the analysis. III. Staff interview The EPMP was reviewed with the ROM and the DM on 6/10/24 at 3:04 p.m. The DM said the last emergency preparedness drill was in January 2023. He said on 1/17/23 the facility initiated a shelter in place in response to an active shooter in the area. He said the facility did not participate in additional drills other than fire drills in the last year. The DM said he recently was informed he was responsible for the EPMP and he did not know how often the facility needed to participate in emergency preparation drills. He said over the last year the facility had not had mock disaster drills or tabletop discussions of potential disasters. He said he last informed the staff the swamp coolers would be turned on related to the upcoming seasonal heat but that was the only recent discussion conducted in the facility. The DM was interviewed again on 6/12/24 at 12:44 p.m. The DM said the facility went into lock down in April 2024 when there was another active shooter in the area. He said after the lock down/shelter in place event, the staff talked about a few things related to what happened but the discussion was not a review or analysis of what the facility did right or needed to improve on in response to the event. The DM said there was no documentation of the April 2024 lock down.

Based on record review and interviews, the facility failed to act promptly upon the grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to timely create effective interventions and maintain a systematic approach to ongoing resident grievances of call light response times addressed in resident council. Findings include:I. Facility policy and procedureThe Resident Council policy, revised April 2017, was provided by the nursing home administrator (NHA) on 6/12/24 at 11:23 a.m. The policy read in pertinent part, "The purpose of the resident council is to provide a forum for:-Residents, families and resident representatives to have input in the operation of the facility;-Discussion of concerns and suggestions for improvement;-Consensus building and communication between residents and facility staff; and, disseminating information and gathering feedback from interested residents."A resident council response form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the items of concern."The quality assurance and performance improvement (QAPI) committee will review information and feedback from the resident council as part of their quality review. Issues documenting on the resident council response forms may be referred to the copy committee if applicable."The Grievance/Complaints, recording and investigating policy, revised April 2017 was provided by the NHA on 6/12/24 at 11:23 a.m. The policy read in pertinent part, "All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances."II. Resident group interviewSix residents (#5, #7, #20, #24, 26 and #34), who were identified as interviewable by the facility and assessment, were interviewed on 6/6/24 at 10:00 a.m. During the group interview the following comments were made regarding call light response time:-"Had to wait a long time for staff to respond to a call light to have assistance off the toilet." -"When staff respond to the call light they turn it off and come back later or do not come back."-"The nurses would turn off the call light and say they would tell someone else but no one returns."-"Feel angry when the staff does not come back to help." -"Staff said they have to find a partner to help with the two person transfer. The CNA could not always able to find a partner so they do a two person transfer by themselves."-"Had to wait anywhere between five minutes and two hours for call lights."-"There was too much staff turnover which contributed to the long call lights.""The slow call lights were sometimes because staff were talking to each other and not responding to the residents."The residents said they had told the staff their call light concerns. The following comments were made: -"When a call concern was brought up, staff said they would look into it or take care of it." -"Grievances were filed but nothing was done about the call lights." -"It does not do any good to file a grievance."-"When trying to talk to the administration they say they have the amount of staff they need or are not able to get all the staff they need."III. Additional resident interviewsResident #7 was interviewed on 6/05/24 10:11 a.m. Resident #7 said she has had to wait over an hour for her call lights to be answered after she initiated it. She said she and her roomate sometimes had to work together to push both call lights to get response from staff. Resident #54 was interviewed on 6/05/24 10:11 a.m. Resident #54 said she had waited over an hour for call light to be answered. Resident #16 was interviewed on 6/5/24 at 2:19 p.m. Resident #16 said nursing staff needed help. He was a two person assistance for turns in bed or transfers with the hoyer lift. He said sometimes he had to wait a really long time for help. Resident #28 was interviewed on 6/5/24 at 3:11 p.m. Resident #28 said when the certified nurse aides (CNA) answered her call light, they would turn it off and say they would come back later. Resident #27 was interviewed on 6/5/24 at 11:21 a.m. Resident #27 said she has had to wait over an hour for staff to respond to her call light. Resident #25 was interviewed on 6/5/24 at 10:38 a.m. Resident #25 said he has had to wait more than an hour for his call light to be answered. Resident #47 was interviewed on 6/5/24 at 12:48 p.m. Resident #47 said lately he had waited 30 minutes for a call light response. Resident #40 was interviewed on 6/5/24 at 5:26 p.m. Resident #40 said the facility was short staffed at night. She said the facility had one CNA in her hall and there were residents who needed multiple staff to transfer them while other residents had to wait. She said the longest wait she has had was 45 minutes. She said she had spoken to the director of nursing (DON) and the night nurses about the concern but nothing had been done about it. IV. Resident council minutes The December 2023, January 2024, February 2024 and June 2024 resident council minutes were provided by the facility on 6/12/24. The March 2024, April 2024 and May 2024 resident council minutes were provided by the director of nursing (DON) on 6/5/24 at 10:48 a.m. via email. The review of the above resident council minutes identified residents indicated concerns with call light response. The concerns were not resolved according to the council minutes, resident interviews (see above interviews) or resident call light response time logs. The December 2023 resident council minutes read call light times were still an issue. According to the minutes the residents said the facility needed more CNAs for day and night shifts. The January 2024 resident council minutes documented under the old business section that the call lights were not answered in a timely manner. The action to address the concern was to follow-up on call light audits and cameras. The status for the concern was unresolved. According to the January 2024 minutes the residents still felt call light timeliness was still a concern. The minutes read a new call light system was in process to be installed. The system would record how long it took to answer a call light. Meanwhile, the facility could look back at cameras to calculate timing of call lights. The February 2024 resident council minutes identified the residents said the call lights were still taking too long to be answered. The ongoing call light concern remained unresolved and noted on the minutes and staff was still working on the concern. There were no new actions identified in the February 2024 resident council minutes to resolve the concern. The March 2024 resident council minutes read the call light concern was unresolved and the residents felt call light response times were still too long per residents. According to the minutes, the facility was still working on the issue but saw an improvement. According to the minutes, the DON educated nursing and touched on the topic in staff meetings. The April 2024 resident council minutes read the call light concern remained unresolved and the NHA was to follow-up with the concern. The minutes read the residents were still upset and wanted results. The residents were waiting too long to be assisted to the restroom and not getting dressed until the afternoon. The call light times were worse in the evenings and on the East hall. The NHA said she would have a staff meeting and bring up the concerns. The NHA would also check with individual resident concerns and address those concerns. The May 2024 resident council minutes read the call light concern was unresolved. According to the minutes, administration asked the residents for specific times and days of the long call lights. The minutes read the NHA said staff were receiving education on the concern and was in the process of hiring more staff. The residents were told to report the date and time of the occurrence so staff could follow up with each individual resident. The June 2024 resident council minutes identified the residents felt the call lights still took too long to answer and remained unresolved but satisfied with some results. V. Grievance formsThe resident grievance forms regarding concerns addressed in resident council and individual call light concerns between January 2024 and June 2024 were provided by the NHA on 6/12/24 at 10:42 a.m. The grievance forms included the nature of the grievance, a findings section, the resolution section to respond to the resident or designee within seven working days of the concern with a resolution, and a date to mark the grievance resolved 10 working days after resolution/action plan was implemented. A 1/8/24 grievance form from a former resident who attended the 1/8/24 resident council, documented the resident felt when she turned the call light on it took 45 minutes for staff to come. Sometimes when staff answered her call light, they would tell her they would be back and then they did not come back. Sometimes staff told her they had to get someone to help them and turn the light off, but nobody returned to provide assistance. The findings on the grievance form read the resident stated when she called for assistance in the morning to get up she had to wait a long time and the resident stated she knew they were busy. The response to the resident within seven working days read staff were spoken to in the west hall about concerns of call lights and time taking to answer them. The staff would be more aware of timing when possible. The grievance form read the grievance was resolved on 1/10/24 and read the resident verbally acknowledged. The grievance form did not identify a follow-up with a resident was conducted to ensure action taken resolved the call light concern 10 days after the action plan was implemented. A 1/8/24 grievance form from a former resident who attended the 1/8/24 resident council, documented the resident felt her call light in the evenings sometimes took 40 minutes for someone to come in. The resident said at night time the call lights took longer than 40 minutes. The findings read it happened once or twice when she needed assistance to go to bed. According to the grievance form, the resolution was to educate the night staff to help assist residents to go to bed early in the center hall. The two hoyer lift residents preferred to go to bed early. The grievance form read the grievance was resolved on 1/10/24 and read the resident verbally acknowledged. -The grievance form did not identify when the education with the night staff was completed or if it was completed. The grievance form did not identify a follow up with a resident was conducted to ensure action taken resolved the call light concern 10 days after the action plan was implemented. A 1/8/24 grievance form from Resident #7 who attended the 1/8/24 resident council, documented she felt her call light took 15 to 20 minutes to answer and then the staff assisted her roommate but not checked on her needs. The resident said she had to push the call light a second time and wait again. According to the grievance, the resident said one day it took four hours to answer her call light and she missed two smoke breaks. The findings read the residents' usual wake time had changed from 10:00 a.m. to 7:00 a.m. The resident wanted to get up at 7:00 a.m. The resolution read staff were educated to ask both residents in the room if they needed assistance. Resident #7 agreed to speak up when the CNAs were in her room to let them know she needed assistance. The grievance form read the grievance was resolved on 1/10/24 and the resident refused to sign. -The grievance form did not identify when the staff were educated. The grievance form did not identify a follow up with a resident was conducted to ensure action taken resolved the call light concern 10 days after the action plan was implemented.-No grievance forms were generated after the February 2024 resident council meeting. A 3/11/24 grievance form from Resident #44 who attended the 3/11/24 resident council, documented the resident felt she waited a considerable amount of time for her call light to be answered. According to the findings a call light audit on the resident's call light time was conducted on 3/11/24 and 3/12/24 with four call light observations. The response time ranged between less than one minute and under six minutes. The resolution read education was provided to the floor staff on answering call lights in a timely manner. The resolution was signed by the DON and the residents on 3/18/24. The date resolved was not marked. Attached to the 3/11/24 grievance form was an education with six staff. The education read call light should not be longer than 10 minutes. It was the responsibility of the employee to answer the call lights promptly and failure to do so would result in disciplinary action. The education read call lights were to be answered as soon as possible for the safety and well being of the residents.-The review of the grievance forms did not identify new grievance forms were generated for call lights after the resident council continued to address concerns with call lights in April 2024, May 2024 and June 2024. VI. Call light auditsThe call light audits were provided by the NHA on 6/12/24 at 11:23 p.m. The call lights audits were conducted in June 2023, September 2023, and November 2023. -The review of call light audits did not identify call light audits were conducted in January 2024 or the following month as indicated in the January 2024 resident council minutes. VII. Staff educationThe all staff education agendas were provided by the NHA on 6/12/24 at 10:47 a.m. The January 2024 staff education read in pertinent part, "Residents continue to stay there light is on for extended periods of time. all staff may answer a call light. It is not just the floor CNAs and nurses responsible for answering call lights. Our new call system is currently being installed. This will allow us to know how long a call light has been on. If you answer the call light and need to find a second person to assist you, please leave the call light on while you are looking for hebe pulled in many directions."-The February 2024 all staff meeting agenda did not identify call light response times were addressed in the meeting.-The March 2024 all staff meeting agenda did not identify call light response times were addressed in the meeting.-The April 2024 all staff meeting did not identify call light response times were addressed in the meeting.-The review of the provided staff education identified the resident council call light response concern was only addressed during the January 2024 all staff meeting. VIII. Call light logsThe call light logs between 3/1/24 and 6/1/24 were reviewed. The call light log identified numerous call lights with high call wait times throughout the facility and throughout the day and night. The following sample call light times were reviewed for 3/1/24, 4/1/24, 5/1/24, and 6/1/24. The following call light response times were logged on 3/1/24 at: -3:38 a.m. for 16 minutes; -4:55 a.m. for 22 minutes;-6:35 a.m. for 35 minutes;-6:58 a.m. for 27 minutes;-7:31 a.m. for 22 minutes;-8:22 a.m. for 21 minutes;-8:42 a.m. for 23 minutes;-10:56 a.m. for 53 minutes;-11:45 a.m. for 29 minutes;-12:44 p.m. for 29 minutes;-1:22 p.m for 23 minutes;-5:19 p.m. for 51 minutes;-5:36 p.m. for 37 minutes;-6:07 p.m. for 38 minutes;-6:31 p.m. for 26 minutes;-6:50 p.m. for 43 minutes;-7:09 p.m. for 20 minutes;-7:28 p.m. for 22 minutes;-7:57 p.m. for 23 minutes; and,-8:33 p.m. for 46 minutes. The following call light response times were logged on 4/1/24 at:-1:00 a.m. for 23 minutes;-5:45 a.m. for 45 minutes;-6:25 a.m. for 20 minutes;-8:41 a.m. for 28 minutes;-9:06 a.m. for 20 minutes;-9:18 a.m. for 43 minutes;-9:52 a.m. for 37 minutes;-10:41 a.m. for 28 minutes;-12:51 p.m. for 22 minutes;-1:17 p.m. for 25minutes;-2:46 p.m. for 28 minutes;-3:19 p.m. for 47 minutes;-3:57 p.m. for 32 minutes;-7:30 p.m. for 46 minutes; and,-11:01 p.m. for 26 minutes. The following call light response times were logged on 5/1/24 at:-12:07 a.m. for 21 minutes;-7:04 a.m. for 24 minutes;-7:20 a.m. for 20 minutes;-7:29 a.m. for 27 minutes;-9:24 a.m. for 31 minutes;-9:44 a.m. for 42 minutes;-10:00 a.m. for 24 minutes;-12:35 p.m. for 3 hours and 58 minutes;-12:40 p.m. for 21 minutes;-12:53 p.m. for 33 minutes;-1:05 p.m. for 44 minutes;-2:05 p.m. for 25 minutes;-2:30 p.m. for 23 minutes;-2:59 p.m. for 21 minutes;-6:00 p.m. for 44 minutes;-6:17 p.m. for 24 minutes;-6:18 p.m. for 34 minutes;-6:21 p.m. for 49 minutes;-6:57 p.m. for 26 minutes;-9:14 p.m. for 36 minutes;-9:17 p.m. for 21 minutes; and,-11:24 p.m. for 21 minutes. The following call light response times were logged on 6/1/24 at:-12:08 a.m. for 24 minutes;-12:24 a.m. for 22 minutes;-12:34 a.m. for 24 minutes;-1:20 a.m. for 47 minutes;-3:01 a.m. for 33 minutes;-6:08 a.m. for 22 minutes;-9:26 a.m. for 23 minutes;-11:48 a.m. for 27 minutes;-1:59 p.m. for 29 minutes;-3:07 p.m. for 21 minutes;-3:27 p.m. for 40 minutes;-6:59 p.m. for 21 minutes;-7:48 p.m. for 25 minutes; and,-8:42 p.m. for 28 minutes. IX. Staff interviewsThe social service director (SSD) was interviewed on 6/11/24 at 1:17 p.m. The SSD said when a concern was brought up in the resident council meeting, she would start a grievance form and delegate the concerns to the appropriate department. She said a response needed to be completed within seven days of the concern. She said the identified concern would be discussed during the following resident council meeting. She said if the residents did not feel the concern was resolved, the concern was considered ongoing until it was resolved. The SSD said the action plan to improve call lights was call light audits and the call light system was upgraded. The activity director (AD) was interviewed on 6/12/24 at 9:39 a.m. The AD said after the resident council meeting, she and the SSD wrote up the grievances together. She said the SSD delegated the grievances. She said the concerns/grievances were reviewed in the next resident council meeting and the residents were asked if they felt the concern was resolved and the concern closed. The AD said the call light wait times had been an ongoing issue for the residents since December 2023. The AD said the NHA told the residents she was trying to figure out how to improve call light times. The AD said there had been some staff education but the residents still felt they had long call light waits. She said the residents said there was some improvement but call light concern had been an important issue for the residents and the residents felt it still was not resolved. The AD said the residents should be able to voice their opinions and feel they were heard and their concerns were followed up on. The NHA was interviewed on 6/12/24 at 9:56 a.m. The NHA said the former assistant director of nursing was responsible for documenting staff education but she was just having staff sign off an education without specifying what education was provided. She said the new call light system and reminding staff to answer call lights was reviewed in the all staff meeting in January 2024. The NHA said she did not have additional records to show additional education with call light response times were completed. The NHA said she was aware of one grievance filed by a resident regarding call lights when the resident was left on the toilet. The NHA said the facility also completed call light audits. The NHA said when a resident filed a grievance, they signed the grievance form and staff talked to them about the concern. The NHA said all grievances should be addressed on a grievance form. The regional operations manager (ROM) was interviewed on 6/12/24 at 11:05 a.m. The ROM said the call light times were reviewed daily in the morning meeting. He said the average wait time was around eight minutes with some occasional outliers. She said there had not been too many concerns other than one resident expressed a concern in March 2024 about staff turning off call lights. The DON was interviewed on 6/12/24 at 12:13 p.m. The DON said she educated some of the staff a couple of months ago that call lights should be answered in 10 minutes or less after a resident complained about long call lights (refer to March 2024 grievance above). She said in January 2024, at the all staff meeting, the staff were reminded it was everyone's responsibility to answer the call lights. The DON said a lot of the call lights could be addressed by non-clinical staff. The DON said prompt response to call lights could reduce falls to prevent the residents from attempting to do things by themself. She said in the monthly resident council meeting usually one resident brought up the call light concern and then the other residents would agree. The DON said she reviewed the call light log and confirmed times of 45 minutes occurred most frequently between 7:00 p.m. and 9:00 p.m. The DON said call lights were not a concern until December 2023. She said there had been a resident census increase but it fluctuated. She said she was trying to get more staff to work the evening hours. She said at night there were three CNAs but she wanted to try to have four CNAs. She said there had been staff turn over recently. She said two CNAs were hired but then quit. She said one of the CNAs might return. She said the facility recently started advertising the positions and agency staff would help provide coverage starting on 6/17/24 to help during the night peak times. The DON said the root cause of the call light concerns was there were three CNAs scheduled at night and the facility needed four CNA's. The DON said she started scheduling four CNAs as of 6/1/24 to provide additional help with night time activities of daily living (ADL) care. The regional operations manager (ROM) was interviewed again on 6/12/24 at 4:32 p.m. The ROM said in every quality assurance and performance improvement (QAPI) meeting, the committee reviewed all the grievances brought up in resident council meetings. He said all grievances from the resident council meetings should receive follow-up within seven days of the identification of the concern. He said if the grievance was not resolved, a new action plan should be created and the interventions should be adjusted.

Based on record review and interviews, the facility failed to ensure that personal funds accounts were managed adequately for one (#19) of five residents out of 45 sample residents. Specifically, the facility failed to have personal funds withdrawal sheets signed to ensure the Resident #19' s permission was obtained to withdraw funds from his personal needs account. Findings include: I. Personal funds withdrawalThe Personal Funds Withdrawal sheet was reviewed for Resident #19 on 6/10/24. The resident was found to have three withdrawals from his account with no signed authorization. The withdrawals were as follows:-On 5/7/24 a withdrawal was made for $94.00;-On 4/11/24 a withdrawal was made for $105.00; and,-On 3/4/24 a withdrawal was made for $110.00.-The facility failed to provide receipts or signed authorization from the resident for the withdrawals. II. Staff interviewsThe business office manager (BOM) was interviewed on 6/11/24 at 11:45 a.m. The BOM said Resident #19' s legal representative requested the resident' s funds from the resident' s personal needs account each month to pay for Resident #19' s bills. She said she had another representative who did the same thing but provided a copy of the receipts for the bill. She said she never thought of asking Resident #19' s legal representative to provide receipts. The BOM said she had no way to prove the money was used for the resident' s bills or not. The BOM said she was unaware the resident was supposed to sign a personal funds withdrawal for his legal representative to spend his personal funds. The BOM said she was auditing all of the resident' s accounts to update the consent forms and ensure the residents signed for the use of personal funds.

Based on record review and interviews, the facility failed to inform the resident's representative of a change of condition for one (#173) of four residents reviewed for notification of change out of 45 sample residents. Specifically, the facility failed to ensure Resident #173' s responsible party was notified after an unwitnessed fall. Findings include:I. Facility policy The Fall and Fall Risk, Managing policy, revised March 2018, was provided by the facility on 6/12/24. According to the policy, a fall was: "Unintentionally coming to rest on the ground, floor or lower level, but not as a result of an overwhelming external force. An episode where a resident lost his or her balance and would have fallen, if not for another person or if he or she had not caught himself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred." II. Resident #173 A. Resident status Resident #173, age 68, admitted on 2/5/24 and discharged on 2/14/24. According to the February 2024 computerized physician's orders (CPO), diagnoses included fusion of the spine, cervical region, encounter for surgical aftercare following surgery of the nervous system, acquired absence of left leg below knee, difficulty in walking, lack of coordination, dependence on a wheelchair, muscle weakness and adjustment disorder with mixed anxiety and depressed mood. The 2/14/24 minimum data set (MDS) assessment identified the resident was cognitively intact with a brief interview for mental status with a score of 15 out 15. She required set-up assistance and supervision or touch assistance for transferring. B. Record review The contact information for Resident #173 documented two resident representatives were listed as emergency contacts #1 and #2. III. Failure to notify the designated resident representative after a fallA. Resident representative interviewResident representative #1 was interviewed on 6/11/24 at 5:19 p.m. Resident representative #1 said she was not notified when Resident #173 fell while a resident at the facility, which was concerning her because the resident was there for post surgery care after she broke her neck. She said she received a photograph on 2/14/24 from the resident's care giver after the resident was discharged from the facility. The representative said Resident #173 had a bruise and swelling under her eye and cheekbone. She said Resident #173 told her she had fallen at the facility (cross-reference F689 accident hazards). The resident representative said she was the resident's power of attorney (POA) and emergency contact and should have been made aware of and notified when the resident fell. B. Unwitnessed fall documentation The 2/10/24 nurses note read Resident #173 had an unwitnessed fall on 2/10/24. The resident fell when she was transferring herself from her bed to her scooter and lost her balance then lowered herself to the floor. The resident was found sitting on the floor between the bed and her scooter. According to the note, there were no injuries and the resident did not hit her head. The 2/10/24 change of condition evaluation documented in part that a change of condition had been noted. The symptoms included a fall on 2/10/24. Under the resident representative notification section, the evaluation listed Resident #173 as the family/resident representative notified on 2/10/24 at 6:10 a.m. -The evaluation did not identify the resident's family/representative was notified after the fall. The 2/10/24 unwitnessed incident report identified Resident #173 was notified of her fall on 2/10/24 at 6:47 a.m. -The incident report did not identify the resident's representative was notified after the fall. IV. Staff interviews The director of nursing (DON) was interviewed on 6/12/24 at 11:58 a.m. The DON said staff needed to notify the physician, the DON and the power of attorney (POA) after a resident fell. The DON said the family of the resident should always be contacted when listed as the emergency contact. The DON was interviewed again on 6/12/24 at 4:11 p.m. The DON reviewed the documented notifications after Resident #173's fall on 2/10/24. The DON said the notification of the fall should not have been the resident but the resident's family. She said the resident's emergency contact should have been notified after the fall.

Based on record review and interviews, the facility failed to inform one (#216) of three residents reviewed for beneficiary notices out of 45 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to provide a Notice of Medicare Provider Non-Coverage (NOMNC) to Resident #216 two days prior to discharge of Medicare Part A funded services. Findings include:I. Facility policy and procedureThe NOMNC procedure was provided by the nursing home administrator (NHA) on 6/10/24 at 10:15 a.m. It read in pertinent part,"A Medicare provider must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries or enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility and hospice services. The NOMNC must be delivered at least two calendar days before Medicare-covered services end." II. Record reviewA. Resident #216The electronic medical record (EMR) revealed Resident #216 was discharged from Medicare Part A funded therapy services on 4/16/24. The resident was discharged to her home. The NOMNC was provided by the regional operations manager (ROM) on 6/10/24 at 10:15 a.m. The notice read the resident's last covered day of Medicare Part A services would be 4/15/24. The NOMNC notice was signed by Resident #216 on 4/15/24, the same day her Medicare Part A benefits ended.-Resident #216 was not given timely information about the termination of Medicare Part A services (within the required two calendar days notification timeframe), in order to give the resident the opportunity to appeal the decision if desired. III. Staff interviewsThe admission/discharge coordinator (ADC) was interviewed on 6/11/24 at 11:39 a.m. The ADC said the NOMNC was a notification of the discontinuation of Medicare part A l services. She said she provided NOMNCs to the residents 72 hours before residents'benefits ended. The ADC said there was not a set timeframe when she had to provide the NOMNC. The ADC said she sent the NOMNC to Resident #216's medical durable power of attorney (MDPOA) 72 hours before the resident's benefits were going to expire. The ADC said she sent the NOMNC through the facility's electronic system and the system was unable to provide a confirmation. She said Resident #216's MDPOA lived out of the state and was unable to open the NOMNC to sign it. The ADC said Resident #216's MDPOA called and asked the ADC to have the resident sign the NOMNC and the resident signed it on 4/15/24. The ADC said she signed verbal consents on the NOMNC if the MDPOA did not ask for the resident to sign it. The ADC was interviewed again on 6/12/24 at 8:57 a.m. The ADC said she was unaware there was a requirement for the NOMNC to be provided at least two calendar days before benefits expired. The ADC said she was able to send NOMNCs through the facility's electronic system and she never received a confirmation that it was sent. She said she completed a lot of NOMNCs and there was no way for her to track the forms being sent before the benefits expired.

Based on record review and interviews, the facility failed to investigate an allegation of abuse for one (#17) of three residents reviewed for abuse out of 45 sample residents. Specifically, the facility failed to investigate an incident where Resident #17 reported a staff member threatened him. Findings include:I. Facility policyThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 6/6/24 at 2:40 p.m. It read in pertinent part,"Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. "The program consists of a facility-wide commitment and resource allocation to support the following objectives:-Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone;-Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents;-Establish and maintain a culture of compassion and caring for all residents;-Provide staff orientation and training or orientation programs that include such as abuse prevention and identification and reporting of abuse;-Implement measures to address factors that may lead to abusive situations;-Identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident property;-Investigate and report any allegations within timeframes required by federal requirements; and,-Protect residents from any further harm during investigations."The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, revised September 2022, was provided by the NHA on 6/6/24 at 2:40 p.m. It read in pertinent part,"All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, theft or misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Upon receiving any allegations, the administrator is responsible for determining what actions (if any) are needed for the protection of residents."All allegations are thoroughly investigated. The administrator initiates investigations. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. "All relevant professional and licensing boards are notified when an employee is found to have committed abuse;If the investigation reveals that the allegation(s) of abuse are founded, the employee is terminated;Any allegations of abuse are filed in the accused employee's personnel record;If the investigation reveals that the allegation(s) of abuse are unfounded, the employee may be reinstated to their former position with back pay;Records concerning allegations that are determined to be unfounded are destroyed or archived per human resources policy; and,Corrective actions may include a full review of the incident by the quality assurance performance improvement (QAPI) committee."II. Resident statusResident #17, age greater than 65, was admitted on 5/25/2011. According to the June 2024 computerized physician orders (CPO), diagnoses included paraplegia (paralysis of the lower body), depressive episodes, muscle weakness and the need for assistance with personal care. The 4/16/24 minimum data set (MDS) assessment documented Resident #17 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. III. Resident interviewResident #17 was interviewed on 6/6/24 at 9:14 a.m. Resident #17 said he had an incident with a staff member and she raised her voice and yelled at him over a disagreement. Resident #17 said he did not want the situation to escalate because he was afraid of retaliation. He said he filed a grievance about the staff member being disrespectful. Resident #17 said the NHA told him the staff member was no longer assigned to his care. Resident #17 said he asked not to get in trouble repeatedly and said he was afraid of retaliation. IV. Record reviewA copy of Resident #17's grievance form regarding the staff member was provided by the social services director (SSD) on 6/11/24 at 10:20 a.m. The grievance form documented the following:On 5/1/24 Resident #17 filed a grievance with the NHA. Resident #17 said that on 4/24/24 the admission and discharge coordinator (ADC) entered the resident's room to discuss a billing issue. Resident #17 said he felt threatened by the conversation. He said the ADC pointed outside and told him he would be on the street if the billing matter was not taken care of. The investigation findings documented the NHA had spoken to the ADC to let her know that Resident #17 no longer wanted to discuss personal matters with her. The intervention was documented as Resident #17 no longer wanted the ADC to handle his personal matters and he was fine with the rest of the administrative staff. V. Staff interviewsThe NHA was interviewed on 6/12/24 at 9:01 a.m. The NHA said she did not investigate the incident as abuse because she felt it was not an abuse situation. She said Resident #17 changed his story multiple times and then asked for it to be dropped because he did not want to cause any problems. The NHA said threats were considered abuse and she should have investigated it. She said the ADC was suspended on 6/12/24 (during the survey) and an investigation was started.

Based on record review and interviews, the facility failed to coordinate assessment with the preadmission screening resident review (PASRR) program for five (#26, #36, #4, #18 and #22) of eight residents reviewed for PASRR out of 45 sample residents. Specifically, the facility failed to coordinate a PASRR Level II evaluation for Resident #26, #36, #4, #18 and #22. Findings include:I. Resident #26A. Resident statusResident #26, age 71, was admitted on 6/7/23. According to the June 2024 computerized physician orders (CPO), diagnoses included generalized anxiety disorder and bipolar disorder (mental illness that causes shifts in a person's behaviors). The 2/26/24 minimum data set (MDS) assessment documented Resident #26 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #26 experienced feeling down, depressed or hopeless for several days during the review period. B. Record reviewResident #26 had a PASRR Level I identification screen approved on 5/31/23 that documented a PASRR Level II was needed.-A review of Resident #26's electronic medical record (EMR) did not reveal documentation that a Level II PASRR had been completed. II. Resident #36A. Resident statusResident #36, age 84, was admitted on 4/21/23. According to the June 2024 CPO, diagnoses included anxiety disorder and recurrent major depressive disorder. The 5/21/24 MDS assessment documented Resident #36 had a severe cognitive impairment with a BIMS score of four out of 15. Resident #36 had difficulty concentrating on things nearly every day. Resident #36 experienced feeling down, depressed or hopeless for more than half of the days during the review period. B. Record reviewResident #36 had a PASRR Level I identification screen approved on 5/9/23 that documented a PASRR Level II was needed.-A review of Resident #36's EMR did not reveal documentation that a Level II PASRR had been completed. III. Resident #4A. Resident statusResident #4, age 86, was admitted on 8/18/23. According to the June 2024 CPO, diagnoses included major depressive disorder, unspecified intellectual disabilities and adult failure to thrive. The 4/30/24 MDS assessment documented Resident #4 had moderate cognitive impairments with a BIMS score of 12 out of 15. Resident #4 experienced trouble falling asleep or sleeping too much nearly every day. Resident #4 experienced feeling down, depressed or hopeless and felt tired or had little energy for more than half the days during the review period. B. Record reviewResident #4 had a provisional PASRR completed on 8/18/23. He had a PASRR Level I identification screen approved on 4/18/24 that documented a PASRR Level II was needed.-A review of Resident #4's EMR did not reveal documentation that a Level II PASRR had been completed. IV. Resident #18A. Resident statusResident #18, age greater than 65, was admitted on 7/26/23. According to the June 2024 CPO, diagnosis included recurrent major depressive disorder. The 5/21/24 MDS assessment documented Resident #18 was cognitively intact with a BIMS score of 14 out of 15. Resident #18 experienced feeling down, depressed or hopeless and felt tired or had little energy for more than half the days during the review period. B. Record reviewResident #18 had a PASRR Level I identification screen approved on 8/11/23 that documented a PASRR Level II was needed.-A review of Resident #18's EMR did not reveal documentation that a Level II PASRR had been completed. V. Resident #22A. Resident statusResident #22, age, 84, was admitted on 3/11/24 and passed away at the facility on 6/9/24. According to the June 2024 CPO, diagnoses included major depressive disorder. The 3/15/24 MDS assessment documented Resident #22 was cognitively intact with a BIMS score of 15 out of 15. Resident #22 experienced feeling down, depressed or hopeless, felt tired or had little energy, had a poor appetite or overate, felt bad about himself and had trouble concentrating nearly every day. B. Record reviewResident #22had a PASRR Level I identification screen approved on 3/14/24 that documented a PASRR Level II was needed.-A review of Resident #22's EMR did not reveal documentation that a Level II PASRR had been completed prior to Resident #22 passing away on 6/9/24. VI. Staff interviewsThe social services director (SSD) was interviewed on 6/11/24 at 9:53 a.m. The SSD said if a resident was admitted with a provisional PASRR she had 30 days to submit the PASRR Level I. The SSD said if a PASRR Level II was needed, she scheduled the assessment with the evaluator and the resident. The SSD said she identified a problem with the PASRRs that were not followed up on accurately when she completed her quarterly report. She said she was learning the PASRR system because she was from another state and needed more education for the process. The SSD said it was important to complete the PASRRs and the evaluations to ensure the residents received the care and special treatment they needed for their mental health. VII. Facility follow-upThe NHA provided follow-up on 6/17/24 at 4:27 p.m. The follow-up information included the following information:Resident #26 had a new PASRR submitted on 6/17/24 (after the survey exit) and was waiting for an assessor to schedule the PASRR Level II evaluation. Resident #36 had a new PASRR submitted on 6/14/24 (after the survey exit) and had an evaluation scheduled for 6/18/24 at 10:00 a.m. Resident #4 had a new PASRR submitted on 6/14/24 (after the survey exit) and had an evaluation scheduled for 6/17/24 at 2:00 p.m. Resident #18 had a new PASRR submitted on 6/13/24 (after the survey exit) and had an evaluation scheduled for 6/17/24 at 2:00 p.m. Resident #22 passed away on 6/9/24 and a new PASRR was not able to be submitted.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for one (#65) of three residents reviewed for discharge out of 45 sample residents. Specifically, the facility failed to ensure Resident #65's discharge summary included a recapitulation of the resident's stay and a complete final summary of the resident's status. Findings include:A. Resident statusResident #65, age 83, was admitted on 1/30/24 and discharged to another long-term care facility on 4/5/24. According to the April 2024 computerized physician orders (CPO), diagnoses included hyperkalemia (higher than normal potassium in the blood), benign prostatic hyperplasia (enlargement of the prostate) and major depressive disorder. The 2/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision with activities of daily living (ADL). B. Record reviewThe discharge summary dated 4/5/24 documented the resident was discharged to another long-term care facility. -The discharge summary was not completed in its entirety. The following information was missing from the discharge summary:-Physical and mental functional status including activities of daily living (ADLs);-Continence status;-Vision status;-Behavior;-Cognitive status; and,-Pertinent lab results. C. Staff interviewsThe social service director (SSD) was interviewed on 6/11/24 at 11:00 a.m. The SSD said Resident #65 was discharged to another long-term care facility per the family's request. She said when a resident was discharged from the facility, a discharge summary was completed by the interdisciplinary team (IDT). She said each member of the IDT was responsible for completing their section of the discharge summary. The corporate clinical manager (CCM) was interviewed on 6/11/24 at 5:28 p.m. The CCM said, for a discharge summary, each member of the IDT was responsible for completing their section for the recapitulation of the resident's stay. The CCM reviewed Resident #65's discharge summary and said several areas on the discharge summary had not been completed. She said she would provide education to the IDT.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#19) of one resident reviewed for vision problems out of 45 sample residents. Specifically, the facility failed to ensure Resident #19 was assisted to receive his new glasses. Findings include:I. Resident #19A. Resident statusResident #19, age greater than 65, was admitted on 10/11/22. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease with exacerbation and malignant neoplasm of the prostate. The 4/30/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required substantial assistance with activities of daily living (ADL). The MDS assessment documented the resident had adequate vision with eye glasses. B. Resident interviewResident #19 was interviewed on 6/6/24 at 9:52 a.m. Resident #19 said he needed to get new glasses as his current glasses were "out of date." He said his vision was blurry. He said he had seen an eye doctor but the facility had not assisted him with getting new eyeglasses. C. Record reviewThe 2/8/23 eye consult office visit revealed Resident #19 had an eye exam. The note documented the resident needed to have his glasses upgraded with a new prescription. The note had a new prescription for eyeglasses with it. The prescription was signed by the physician on 2/8/23. -Review of Resident #19's electronic medical record (EMR) did not reveal documentation to indicate the resident had his eye glasses replaced.. D. InterviewsThe social service director (SSD) was interviewed on 6/10/24 at 12:15 p.m. The SSD said she would review the record to check to see if the resident received his new glasses. The regional operations manager (ROM) was interviewed on 6/10/24 at 12:45 p.m. The ROM said after reviewing the medical record, it was determined the resident was seen by the eye doctor on 2/8/23, however, the facility missed obtaining the new eyeglasses for Resident #19. He said the SSD made an appointment (during the survey) for the resident to get his new glasses as the prescription was still in good standing. The appointment was scheduled within the next week.

Based on record review and interviews, the facility failed to ensure one (#54) of three residents with limited range of motion received appropriate treatment and services out of 45 sample residents. Specifically, the facility failed to provide restorative therapy services to Resident #54. Findings include:I. Professional ReferenceAccording to the American Association of Post-Acute Nursing (AAPACN) Guidelines for Restorative Nursing Programs, retrieved on 6/17/24 from aapacn.org/restorative-programs-guide/, "The risk for functional decline in long term care residents is a serious issue that often leads to falls, pressure ulcers/injuries, weight loss, depression, and other negative outcomes. To ensure quality outcomes and to comply with federal regulation, nursing facilities must have a comprehensive and effective restorative therapy program that encourages each resident's highest level of function."II. Resident #54A. Resident statusResident #54, age greater than 65, was admitted to the facility on 11/10/23 and readmitted on 1/8/23. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), diabetes and generalized muscle weakness. The 4/9/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required set-up or clean-up assistance with eating. The resident required substantial or maximum assistance with transfers, showers, toileting and personal hygiene. B. Resident interviewResident #54 was interviewed on 6/5/24 at 10:14 a.m. Resident #54 said she was not receiving restorative therapy services to prevent physical decline. Resident #54 said she felt like she had become weaker since her readmission to the facility on 1/10/24. Resident #54 said she wanted to work towards walking more so she could be more independent in her room. Resident #54 said she felt both worried and sad that she was becoming more dependent on staff for assistance when she would rather work with the therapy department to keep as much of her independence as possible. C. Record reviewAn interdisciplinary team (IDT) conference review summary was documented on 1/19/24 at 1:24 p.m by the social services director (SSD). The assessment documented the resident was not receiving restorative therapy services. A physical therapy discharge summary dated, 1/26/24, documented that physical therapy services ended because of a lack of payment source for the resident's physical rehabilitation services. The discharge summary recommended a home exercise program and a restorative therapy program for the resident. The discharge summary documented Resident #54 and facility staff were educated on positioning maneuvers, pressure relieving techniques, safe transfer techniques, assistive device use and compensatory strategies in order to facilitate functional independence for Resident #54.-A review of the June 2024 CPO revealed the resident did not have an order for restorative nursing services. III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 6/10/24 at 10:38 a.m. CNA #2 said she did not know what restorative therapy services were. CNA #2 said she knew physical therapy was provided in the building, but was unsure who provided restorative therapy services to residents. Licensed practical nurse (LPN) #6 was interviewed on 6/12/24 at 10:29 a.m. LPN #6 said she knew what restorative therapy services were, but she was not aware of any restorative therapy services being provided in the building. LPN #6 said Resident #54 was not receiving restorative therapy services. LPN #6 said Resident #54 did not have a physician's order for restorative therapy services. The physical therapist (PT) was interviewed on 6/11/24 at 1:19 p.m. The PT said restorative therapy services were recommended for residents whenever physical therapy ended for a resident without any expectation of improvement. The PT said she had started working at the facility in March 2024 and did not know anything about residents in the facility before that time. The PT said no one in the physical therapy department had worked with Resident #54 in the last several months. The PT said she did not know the resident wished to continue working with restorative therapy services to maintain her current level of function. The director of rehabilitation (DOR) was interviewed on 6/12/24 at 12:24 p.m. The DOR said restorative therapy services were an important maintenance program to maintain a resident's current level of function and to prevent further physical decline. The DOR said the therapy department at the facility did not complete restorative therapy services, but the therapy department would provide recommendations to the nursing staff for residents to receive restorative therapy services, which was documented in the residents' medical record. The DOR said restorative therapy services would have helped prevent physical decline for Resident #54. The director of nursing (DON) was interviewed on 6/12/24 at 1:05 p.m. The DON said restorative therapy services were important to maintain a resident's baseline physical function. The DON said Resident #54 did not receive restorative therapy services. The DON said there was no documentation in Resident #54's medical record to indicate she received restorative therapy services. The DON said the facility had experienced significant turnover in the physical therapy department and recommendations for restorative therapy services were not communicated effectively due to the turnover.-However, PT discharge summary documentation revealed the PT department had communicated and educated nursing staff on the restorative therapy services Resident #54 required on 1/26/24. The nursing home administrator (NHA), the regional operations manager (ROM), and the DON were interviewed together on 06/12/24 at 4:32 p.m. The NHA said the facility had identified restorative therapy services as an area of needed improvement within the facility quality assurance and performance improvement (QAPI) committee. The DON said the facility had been talking about the need to properly offer and complete restorative therapy services for residents in the facility. The DON said she had been working to provide restorative therapy services education to nursing staff. The ROM said the DOR identified a need to hire a restorative therapy services aide to ensure restorative therapy services were appropriately completed. The DON said a restorative therapy services aide would be starting in the facility in July 2024 to provide restorative services to residents.

Based on record review and interviews, the facility failed to provide adequate supervision and assistance to prevent falls, and failed to assess, implement and monitor interventions consistent with resident needs for one (#173) of four residents reviewed for falls out of 45 sample residents. Specifically, the facility failed to:-Assess Resident #173 after a potential fall and after injuries were identified and report the potential fall; -Monitor Resident #173 after facial injuries were identified;-Ensure safe smoking practices were conducted for Resident #173 and care planned; and, -Ensure interventions were care planned for Resident #173 who was identified at moderate risk for falls. Findings include:I. Facility policy The Fall and Fall Risk Managing policy, revised March 2018, was provided by the facility on 6/12/24. The policy documented in pertinent part, "Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risk and cost to prevent the resident from falling and try to minimize complications from falling. "The staff, with input from the attending physician, will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions."If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of the category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and Implement relevant interventions to try to minimize serious consequences of falling." The Smoking Residents policy, revised October 2023, was provided by the nursing home administrator (NHA) on 6/12/24 at 4:26 p.m. According to the policy, the facility established and maintained safe resident smoking practices. The policy read in pertinent part, "Any resident with smoking privileges requiring monitoring shall have direct supervision of a staff member, family member, visitor or volunteer at all times while smoking." II. Resident #173 A. Resident status Resident #173, age 68, was admitted on 2/5/24 and discharged on 2/14/24. According to the February 2024 computerized physicians orders (CPO), diagnoses included fusion of the spine in the cervical region, encounter for surgical aftercare following surgery of the nervous system, acquired absence of left leg below knee, difficulty walking, lack of coordination, dependence on a wheelchair, muscle weakness and adjustment disorder with mixed anxiety and depressed mood. The 2/14/24 minimum data set (MDS) assessment identified the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. She required set-up and supervision or touch assistance for transferring. The MDS assessment documented the resident did not have any falls or injuries since her admission to the facility. III. Resident representative interviewResident #173's representative #1 was interviewed on 6/11/24 at 5:19 p.m. The representative said Resident #173 had a fall at the facility which resulted in a bruise and swelling under her eye and cheekbone. The resident'srepresentative said she was not notified of the fall but believed the fall occurred on 2/12/24 (cross-reference F580 notification of a change in condition). She said Resident #173 told her she fell when she was outside at night smoking. She said the resident told her she slipped off her scooter and hit her face on the concrete. IV. Resident interviewResident #173 was interviewed on 6/11/24 at 6:51 p.m. Resident #173 said she had two falls during her stay at the facility. She said the first fall happened in the morning when she slid offher bed trying to reach for her scooter. Resident #173 said she fell a second time when she went outside alone at night to smoke. She said a cigarette fell on the ground. She said she went to reach for it and her scooter cushion slipped off and she hit the ground hard. She said a CNA came outside to smoke and found her on the ground after 10 to 15 minutes. She said the CNA notified the nurse. The resident said she asked the nurse not to make a report because she was going to be able to be discharged home soon and did not want any setbacks or concerns of her returning home. She said the nurse agreed not to report the incident and told her she hated doing accident reports. Resident #173 said she had a bruise under her eye and her face was swollen the next day. She said another CNA asked her what happened after seeing the facial injuries. The resident said she told the CNA she hit her face on her scooter's handlebars when her cushion slid from her. She said she lied because she wanted to go home and did not want to get anyone in trouble. V. Record reviewResident #173'ssmoking care plan, initiated on 2/5/24, read Resident #173 had potential forinjury related to smoking. The resident'ssafety and hygiene was to be maintained every shift. The care plan did not identify interventions to direct staff of the safe smoking safety needs of Resident #173. -The review of Resident #173'scomprehensive care plan, initiated on 2/5/24, 2/6/24 and 2/9/24 and revised on 2/26/24, did not identify the resident was at risk for falls or fell at the facility. -The care plan did not identify interventions to decrease the risk of her falls. The 2/10/24 fall risk observation/assessment read the resident was at a moderate risk for falls and ambulated with problems and devices. The 2/10/24 nurses note read Resident #173 had an unwitnessed fall on 2/10/24. The resident fell when she was transferring herself from her bed to her scooter and lost her balance then lowered herself to the floor. The resident was found sitting on the floor between the bed and her scooter. According to the note, there were no injuries or bruising and the resident did not hit her head.-The review of the progress notes did not identify there was a second fall between 2/10/24 and the resident's discharge on 2/14/24. -The review of the progress notes did not identify the resident had bruising and swelling to her face or other related injuries. The 2/10/24 change of condition evaluation documented in part, that a change of condition had been noted. The symptoms included a fall on 2/10/24. -The resident was not identified to have injuries to her face. -The review of the resident'sassessments did not identify the resident had a second fall or injuries to her face from a fall or hitting her scooter. The 2/10/24 post fall review documented the resident had not had any falls at the facility prior to the 2/10/24 fall. The 2/10/24 fall risk observation/assessment read the resident was at a moderate risk for falls and ambulated with problems and devices. The 2/10/24 unwitnessed incident report read Resident #173 was transfering from her bed to the scooter, lost her balance and lowered herself to the floor so she would not fall. According to the incident report, the resident was assessed after the fall and there were no injuries observed at the time of the fall. The interdisciplinary team (IDT) fall note read Resident #173 had an unwitnessed fall on 2/10/24 at 6:32 a.m. The note did not identify the details of the fall or if the resident had injuries. According to the note, the intervention after the 2/10/24 fall was to ensure non-slip footwear or non-skid socks were on during resident transfers. The 2/12/24 daily skilled charting form for the night shift, completed on 2/13/24 at 5:15 a.m. read the resident needed extensive assistance with transfers with two staff but was able to reposition herself in bed. According to the skilled charting, the resident had bilateral leg edema and a healing post surgical incision. No other concerns were identified for the resident's skin.-The skilled charting did not identify the resident had a fall or injuries that were being monitored. The 2/13/24 daily skilled charting form for the day shift, completed on 2/13/24 at 2:22 p.m. read the resident was a current smoker and there were no signs or symptoms of distress observed and she used a motorized wheelchair. The form did not identify concerns with the resident'sskin. -The skilled charting form did not identify the resident had a fall or injuries that were being monitoredThe 2/13/24 daily skilled charting form for the night shift, completed on 2/13/24 at 5:46 a.m. did not identify the resident had a fall or injuries that were being monitored. According to the skilled charting, the resident had a healing post surgical incision. No other concerns were identified for the resident'sskin. The 2/13/24 nurse'snote at 9:56 a.m. read day three of three post fall neurological checks. According to the note, there were no delayed injuries voiced or observed. The review of Resident #173's neurological checks with the director of nursing (DON) identified the checks ended the morning of 2/13/24. The checks did not continue until the resident was discharged on 2/14/24. The 2/14/24 at 11:55 a.m. nurse note read discharge instructions were discussed with Resident #173. The resident'scaregiver gathered all the belongings of the resident. The note at discharge did not document the resident'sbruise on her face. VI. Staff interviews The DON was interviewed on 6/12/24 at 11:58 a.m. The DON said all residents should be assessed after a fall. She said the nurses should complete a risk management assessment and check the resident for injuries. She said if the resident hit their head, staff would complete neurological checks for three days. The DON said Resident #173 was at the facility for a short rehabilitation stay. She said the resident was discharged from the facility on 2/14/24. She said the resident fell on 2/10/24 and was seen by the physician on 2/12/24 and there was no bruising noted to the resident'sface. She said the resident did not have injuries from her fall on 2/10/24 and there were no other falls documented or injuries to the resident'sface identified. Certified nurse aide (CNA) #2 was interviewed on 6/12/24 at 1:07 p.m. CNA #2 said she noticed the resident had a bruise under her eye under her eye glasses. She said the bruise was blue in color when she first noticed it. She said the resident told her that she hit her face when she was attempting to transfer from her bed to her scooter and did not want anyone to know she had a bruise. She said the resident did not tell anyone she hit her face. CNA #2 said she reported the bruise to the nurse. The CNA said the bruise started under her eye but then moved down one side of her face by her cheekbone. She said the bruised area was not protruding and then started to fade yellow. The DON was interviewed again on 6/12/24 at 4:11 p.m. The DON said she interviewed all the nurses and CNAs who worked the night of 2/12/24 and those who called her back did not recall Resident #173 falling outside or any other location. The DON said she contacted Resident #173 on 6/12/24 and the resident told her she had a second fall. She said the resident said she fell when she was outside smoking. The DON said the resident said she yelled out and a CNA came outside to find her on the ground. She said the resident said she begged the nurse not to report the fall. The DON said the bruise on her face was from the fall outside. The DON said she interviewed CNA #2 who confirmed the bruise was found under the resident's eye prior to discharge. She said CNA #2 reported the injury to the nurse but the nurse did not notify the DON of the reported bruise. The DON said there was no documentation to show the resident was assessed after the resident fell outside or after a bruise on the resident'sface was identified. The DON said the nurse should have reported the incident and injury to the DON, assessed the resident and documented the fall and injury. The DON said she needed staff to report any incident so the facility could determine the next follow-up action and interventions and notify the physician and family. She said she would follow-up and complete an education with the nurses and the CNAs to report all incidents to the DON and would educate them on the importance of reporting incidents. The DON said she would inform her staff that it was important to timely assess residents after an incident to ensure resident safety and ensure there was no head trauma and the completion of neurological checks. She said staff needed to completely assess the resident to know all the circumstances associated with the fall/and or injuries, monitor for injuries and create interventions to help prevent future falls. The DON said if she had been made aware the resident'scushion slipped/moved from her scooter seat, a non-slip material could have been placed under the seat. The DON said all of the residents were supervised smokers. She said there was a breakdown in the smoking policy. She said the resident should not have been smoking outside alone. She said all of the residents should have their cigarettes in a locked box with the nurse. She said she was not sure if the resident had cigarettes in her room not locked up or if she got the cigarettes from the nurse who knew she went outside to smoke. The DON said the resident told her she did not know if staff knew she went outside to smoke when she fell. The DON said, starting 6/13/24, all staff and resident smokers would be re-educated on the smoking policy and the risk of not following the smoking policy. She said the risk of staff and residents not following the smoking policy could result in burns, falling if the resident attempted to pick up a fallen cigarette and the risk of a fire. The DON said the education would also include agency staff and would be continued with all new hire staff during orientation. VII. Facility follow-upThe facility initiated fall investigation was provided by the DON on 6/12/24 at approximately 4:30 p.m. The investigation included a 6/12/24 interview with CNA #2, an interview with Resident #173 and a list of staff she contacted or attempted to contact who worked the night shift around the approximate time the resident had a second fall or report of injury. The DON's interview with Resident #173 read the resident fell four days or so prior to her discharge. The resident said she went out to the courtyard at 1:00 a.m. or 2:00 a.m. Her cushion on her scooter slipped. According to the documented interview, the resident started to yell and a CNA came outside and found her. The CNA then got a nurse. The resident did not know the name of the nurse but was able to describe her. A 6/12/24 witness statement from CNA #2 read CNA #2 entered Resident #173's room. The resident had glasses on and when she turned her head CNA #2 noticed a bruise on the side of her face. According to the statement, CNA #2 asked the resident what happened and the resident told her she hit her head while transferring. CNA #2 asked the resident if the nurse was aware and the resident said no. CNA #2 left the room and reported the incident to the nurse on duty. CNA #2 did not recall who she reported the incident to. The list of staff the DON contacted documented the staff who returned the DON's call did not recall the incident, injury or CNA #2 reporting a bruise. The staff education on safe resident smoking and smoking policy, conducted on 6/14/24 and 6/17/24, was provided by the NHA on 6/17/24 at 2:36 p.m. via email. According to the provided education, 36 staff members received education on the smoking policy, resident smoking times, and safe smoking standards at the facility to include:-Residents must be supervised by a staff member;-Residents were not allowed to smoke outside of smoking times unlessaccompanied by family or a friend; and,-The cigarettes and lighters were to remain in a locked box at the nurses station and a staff member would light the cigarette for the residents.

Based on observations, record review and interviews, the facility failed to ensure one (#54) of five residents out of 45 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #54 was admitted to the facility for long term care on 11/10/23 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes and generalized muscle weakness. The resident was initially weighed on 11/19/23 and weighed 149 pounds (lbs). The resident was admitted to the hospital from 1/2/24 to 1/8/24 for electrolyte imbalances. Upon readmission to the facility the resident weighed 135.2 lbs. On 1/22/24 and 1/29/24 the resident weighed 123.6 lbs. On 2/5/24 the resident weighed 123 lbs. The resident sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss. The facility failed to assess the resident and implement nutrition interventions after the resident sustained severe weight loss on 2/5/24. The facility did not weigh the resident after she sustained severe weight loss, despite the registered dietitian (RD) requesting the resident to be weighed. Findings include:I. Facility policy and procedureThe nutritional assessment policy, revised October 2017, was provided by the nursing home administrator (NHA) on 6/11/24 at 3:14 p.m. It documented in pertinent part:"The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition."Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident' s risks for nutritional complications. Such interventions will be developed within the context of the resident' s prognosis and personal preferences"II. Resident #54A. Resident statusResident #54, over the age of 65, was admitted to the facility on 11/10/23 and readmitted on 1/8/23. According to the June 2024 computerized physician orders (CPO), diagnoses included COPD, diabetes type II and generalized muscle weakness. The 4/9/24 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. The resident required set-up or clean-up assistance with eating. The resident required substantial or maximum assistance with transfers, showers, toileting and personal hygiene. The assessment documented the resident was 64 inches (5 foot, 4 inches) tall. The assessment did not indicate the residents weight. It documented the resident had not had any significant weight loss or weight gain.-However, the resident had sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss. B. Resident interviewResident #54 was interviewed on 6/6/24 at 9:41 a.m. Resident #54 said she preferred to eat in her room with her roommate. Resident #54 said she was served scrambled eggs for breakfast several times per week and she did not like them because of how bland they were. Resident #54 said she sent her breakfast back several times each week because of how bland the scrambled eggs were. Resident #54 said she had lost weight because of this. Resident #54 said she skipped several meals throughout the week because she did not like to eat the bland eggs. Resident #54 said she often felt very hungry by lunch time. C. ObservationsOn 6/10/24 at 8:12 a.m., Resident #54 was observed to have a breakfast tray on her bedside table. The breakfast had been consumed except for scrambled eggs that were untouched on the breakfast tray. D. Record reviewThe nutrition care plan, initiated on 11/21/23 and revised on 11/28/23, documented the resident was at a minimal nutritional risk with consistent food intake greater than 50%. The care plan documented the resident would be offered nutrition for comfort and pleasure while the resident was receiving hospice services. The interventions included monitoring the resident' s intake, obtaining weights as ordered, completing an assessment by the RD and monitoring the resident' s skin for signs of breakdown. -However, a review of the resident' s electronic medical record (EMR) did not reveal the resident was receiving hospice services. -A review of the comprehensive care plan did not reveal documentation indicating new interventions were implemented after the resident sustained severed weight loss on 2/5/24. The 11/14/23 dietary pre-screen assessment documented the resident liked fried and poached eggs and spicy foods. The resident was hospitalized on 1/2/24, and readmitted to the facility on 1/8/24 for electrolyte imbalances. The December 2023 CPO revealed Resident #54 was to be weighed weekly for four weeks on Friday mornings, initiated on 11/17/23 and discontinued on 12/8/23. The June 2024 CPO revealed the resident had a physician' s order to be weighed weekly for four weeks, every Monday, ordered 1/15/24 and discontinued on 2/6/24. Resident #54' s weights were documented in the EMR as follows:-On 11/19/23, the resident weighed 149 lbs;-On 1/8/24, the resident weighed 135.2 lbs;-On 1/22/24, the resident weighed 123.6 lbs;-On 1/29/24, the resident weighed 123.6 lbs; and,-On 2/5/24, the resident weighed 123 lbs.-The resident lost 12.2 lbs (9%) from 1/8/24 to 2/5/24, in one month, which was considered severe.-The resident lost 26 lbs (17.4%) from 11/19/23 to 2/5/24, in three months, which was considered severe.-No additional physician orders to obtain weight were documented in the resident' s EMR. The facility had not obtained the resident' s weight in more than four months between 2/6/24 and 6/11/24 after this significant weight loss was documented. A review of the certified nurse aide (CNA) task response history (from 5/15/24 to 6/11/24) revealed staff had documented the amount the resident had eaten for 51 out of 81 meal opportunities during the review period. -There were no documented resident refusals for meals. It was documented the resident ate less than 50% of her meals for two of 51 documented meals. The 6/11/24 nutrition progress note documented the resident was last weighed on 2/5/24 when the resident weighed 123 pounds. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/10/24 at 8:42 a.m. LPN #1 said he had seen the kitchen serve Resident #54' s scrambled eggs. He said when this occurred he would ask the kitchen for different eggs. LPN #6 was interviewed on 6/12/24 at 10:29 a.m. LPN #6 said there was not a current physician' s order to weigh Resident #54 weekly or monthly. LPN #6 said nursing staff followed the physician' s order for obtaining the resident's weights. She said a nurse could request to weigh a resident if there was a weight concern identified by nursing staff. The RD was interviewed on 6/12/24 at 11:47 a.m. The RD said the facility did not have a current weight for Resident #54. The RD said she was concerned about the facility using different scales from January 2024 to February 2024 to weigh the resident. The RD said she had verbally requested the nursing staff to obtain additional weights. The RD said she did not document when she requested to have the resident reweighed after 2/5/24. The RD said she did not know why the significant weight loss was not identified or followed up on. The RD said new interventions should have been identified when Resident #54 sustained significant weight loss to prevent further weight loss. The director of nursing (DON) was interviewed on 6/12/24 at 1:05 p.m. The DON said Resident #54 experienced significant weight loss and the facility did not identify it. The DON said no new nutrition interventions were implemented to prevent further weight loss after 2/5/24. The DON said no new weights were obtained for Resident #54 after she sustained severe weight loss on 2/5/24. The DON said Resident #54 should have had her significant weight loss identified in her plan of care and more weights should have been obtained after 2/5/24 to monitor the resident' s status. The DON said the facility could have offered a nutritional supplement, such as a Mighty shake (frozen nutritional supplement), to help maintain Resident #54' s weight. The DON said she was not aware of any inaccurate scales in the facility. The DON was interviewed again on 6/12/24 at 4:32 p.m. The DON said the quality assurance and performance improvement (QAPI) committee had identified that the facility had an issue obtaining and documenting weights in the facility within the last few months, but had not implemented a correction plan. The DON said she needed to work with the RD to ensure residents were getting weighed on a regular basis. The DON said she needed to review weight loss interventions in the facility to ensure they were being updated and documented.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four out of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #5, CNA #4 and CNA #3. Findings include:I. Record reviewCNA #2 (hired on 5/16/23), CNA #5 (hired on 8/18/21), CNA #4 (hired on 4/6/17), and CNA #3 (hired on 2/1/23) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Staff interviewsThe director of nursing (DON) was interviewed on 6/6/24 at 4:25 p.m. The DON said she was the staff development coordinator because the facility just hired someone who was still in training. The NHA and the DON were interviewed together on 6/11/24 at 4:10 p.m. The DON said she was unaware when she provided CNAs with in-service training she needed to base the in-service training on the CNAs performance reviews. The NHA said staff training was an area the facility needed to improve on and it was a work in progress. The NHA said the facility provided each staff member with a performance evaluation and the staff member completed the self-evaluation before they met with the DON. The NHA said she was unsure when these were completed. The NHA said the facility wanted to hold the staff accountable for the evaluations but needed a better tracking system. CNA #5 was interviewed on 6/12/24 at 10:36 a.m. CNA #5 said she had never completed a performance evaluation at the facility.

Based on observations, interviews and record review, the facility failed to post nurse staffing information daily. Specifically, the facility failed to:-Post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift; and,-Maintain staffing data for 18 months as required. Findings include:I. ObservationsObservations in the facility on 6/5/24 at 10:00 a.m. revealed no nurse staffing posting. Observations in the facility on 6/6/24 at 12:00 p.m. revealed no nurse staffing posting. II. Record reviewA request for the required May 2023 to May 2024 staff posting was requested on 6/6/24 at 4:25 p.m. The DON said the facility had not utilized staff posting in over four years (see interview below). III. Staff interviewsThe director of nursing (DON) was interviewed on 6/6/24 at 4:25 p.m. The DON said she was covering as the staff development coordinator until the new staff development coordinator, who was hired, was fully trained. She said she used a sheet similar to the daily working schedule and had them posted at each nurses' station. The DON said she was unaware that the staffing data needed to be posted in a visible area for residents and families. She said when she was a floor nurse the night shift nurse filled out the staffing data posting. She said that form had not been used in over four years.

Based on interviews and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for one (#22) of five residents reviewed for medications out of 45 sample residents. Specifically, the facility failed to ensure as needed (PRN) psychotropic medications were discontinued after 14 days for Resident #22. Findings include:I. Resident statusResident #22, age over 65, was admitted on 3/11/24. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder and chronic systolic (congestive) heart failure. The 3/15/24 minimum data set (MDS) assessment documented Resident #22 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented Resident #22 had felt down, depressed or hopeless, felt tired or had little energy, had a poor appetite, felt bad about himself and had trouble concentrating nearly every day during the assessment look back period. II. Record reviewReview of Resident #22's June 2024 CPO revealed the following physician's order: Lorazepam (an anti-anxiety medication) 2 milligrams (mg)/milliliters (ml), give 0.5 ml every hour as needed for shortness of breath for 90 days, ordered on 6/8/24 with an end date of 9/6/24. III. Staff interviewsThe director of nursing (DON), the nursing home administrator (NHA) and the corporate consultant (CC) were interviewed on 6/11/24 at 4:42 p.m. The DON said she was not sure how long PRN psychotropic medications were ordered for but thought it was for 90 days or six months. The DON asked the CC how long PRN psychotropic medications were ordered for. The CC said psychotropic medications should only be ordered for 14 days at a time unless the resident's physician specified a reason why the medication was ordered for more than 14 days. The CC said she there should have been a rationale documented for Resident #22's order if the physician wanted it to be ordered for 90 days and she did not know why there was not one documented. The NHA said the facility recently switched pharmacies and she was unaware if the pharmacist reviewed PRN psychotropic medications to see if they were ordered for the appropriate length of time. The DON said she entered all of the medication orders for the residents at the facility. The DON said she was going to reach out to the medical director (MD) and get the orders for PRN psychotropic medications corrected to the appropriate length of 14 days. The pharmacist (PH) was interviewed on 6/12/24 at 10:39 a.m. The PH said PRN psychotropic medications should be ordered for 14 days at a time and required the physician to see the resident in order to prescribe the medication again. He said, when he reviewed residents' medications, if he saw a medication ordered for 90 days he requested the physician to change the order to 14 days or document a clinical reason for the 90 days order. The PH said he was behind schedule on his resident medication reviews and therefore he had not yet seen the 90-day PRN order for Resident #22's lorazepam.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards in one of two medication storage rooms and one of two medication storage carts. Specifically, the facility failed to:-Ensure all medications and biologicals were stored appropriately in a secure location; and,-Maintain a medication refrigerator temperature log for one of three medication refrigerators. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pp. 1976, retrieved on 6/19/24, "All drugs are secured in designated areas only accessible to nurses."II. ObservationsOn 6/10/24 at 8:59 p.m., the central hall medication cart was observed in the unlocked position. At 9:02 p.m., registered nurse (RN) #1 approached the medication cart and locked it. III. Record ReviewThe East nursing station refrigerator medication log records from 3/1/24 to 6/10/24 were obtained from the nursing home administrator (NHA) on 6/11/24 at 1:51 p.m. Out of 102 days of documentation opportunities, refrigerator temperatures were documented on 88 of those days. The East medication refrigerator temperatures were documented on only one day (5/31/24) between 5/28/24 and 6/5/24, a nine day period of time. IV. Staff InterviewsRN #1 was interviewed on 6/10/24 at 9:24 p.m. RN #1 said medication carts should always be locked when not in use. Licensed practical nurse (LPN) # 9 was interviewed on 6/11/24 at 10:18 a.m. LPN #9 said medication carts should always be locked when not in use. LPN #9 said night shift nurses were responsible for observing and documenting medication refrigerator temperatures. LPN #9 said it was important for medication refrigerator temperatures to be checked to ensure medications stored within the refrigerators remained safe and effective for resident use. The director of nursing (DON) was interviewed on 6/12/24 at 3:18 p.m. The DON said the night shift nurses were responsible for recording medication refrigerator temperatures. The DON said medication carts should always be locked when not in use. The DON said more education was needed for bedside nursing staff regarding locking medication carts appropriately. The nursing home administrator (NHA) was interviewed on 6/12/24 at 3:40 p.m. The NHA said the refrigerator temperature logging concern was originally identified as a problem in the facility on 5/8/24, and the facility put a performance improvement plan in place at that time. The NHA said the plan included new colorful signage for temperature logging and identifying night shift nurses as responsible for logging temperatures for medication refrigerators. The NHA said the medication refrigerator temperatures should be logged every day.-However, the facility failed to document medication refrigerator temperatures for eight of the 28 days after the performance improvement plan was initiated on 5/8/24.

Based on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserve nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure food was served palatable, attractive and served at the appropriate temperature. Findings include:I. Resident interviewsResident #4 was interviewed on 6/5/24 at 10:25 a.m. Resident #4 said the food was not always good. Resident #4 said the food was under seasoned at times and sometimes he received his meal cold. Resident #22 was interviewed on 6/5/24 at 11:00 a.m. Resident #22 said the food was awful and tasted bad. He said he ate his meals in his room and the food was delivered to him cold. Resident #22 said the food looked how it tasted. He said the food was undercooked and over-seasoned. Resident #57 was interviewed on 6/5/24 at 3:35 p.m. Resident #57 said the food was awful and his lunch on 6/5/24 had no seasoning to it. The resident said his food was normally bland and he did not like to eat it. Resident #17 was interviewed on 6/6/24 at 9:20 a.m. Resident #17 said the quality of the food was not good. He said the food was processed and bland. Resident #54 was interviewed on 6/6/24 at 11:36 a.m. Resident #54 said she skipped several meals a week because the food did not taste good. II. ObservationsA test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for lunch on 6/10/24 at 12:51 p.m. The test tray consisted of spaghetti and meatballs, lima beans, garlic toast and chocolate pudding. -The spaghetti and meatballs were 130 degrees Fahrenheit (F);-The lima beans were 103 degrees F and mushy and bland. The lima beans appeared gray and were not a vibrant green;-The garlic toast was overcooked and hard, chewy and salty. The garlic toast appeared partially burnt; and,-The chocolate pudding was 54.5 degrees F and did not feel cold. III. Staff interviewsThe dietary director (DD) and the nursing home administrator (NHA) were interviewed together on 6/12/24 at 1:17 p.m. The DD said the pudding cups were prepared, portioned out and placed in the walk-in refrigerator until it was time to serve. The DD said the pudding should have been stored on ice during the meal service to help maintain the correct temperature since the pudding was made with dairy products. The DD said cold foods needed to be served below 41 degrees F. The DD said the containers of pudding on the counter were going to be thrown away at the end of the meal service, since they had not been held at the correct temperature. The DD said he wanted the residents to receive the hot foods at 135 degrees F and the hot boxes were set to 135 degrees F. The NHA said more education would be provided and the facility had started a food committee for the residents on 6/12/24 (during the survey). The NHA said the residents' feedback from the food committee was going to help improve the food.

Based on observations, record review and interviews the facility failed to ensure two (#62 and #4) of six residents with an order for an altered mechanical soft texture, out of 45 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders. Specifically, the facility failed to provide Resident #62 and Resident #4 the correct mechanically altered diet texture. Findings include:I. Professional referenceThe Common Ground Between National Dysphagia Diet (NDD) and International Dysphagia Diet Standardisation Initiative (IDDSI), reviewed July 2021, retrieved on 6/17/24 from https://iddsi.org/IDDSI/media/images/CountrySpecific/UnitedStates/NDD-to-IDDSI-Implementation.pdf . It read in pertinent part "NDD of 2002 is being replaced by the IDDSI Framework, founded in 2013. This is the only professionally recognized and supported diet framework as of October 2021. NDD level three dysphagia advanced is now IDDSI soft and bite-sized level six. The NDD description stated bite-sized, soft, moist and not sticky. However, bite-sized guidelines were larger than the typical diameter of an airway. The IDDSI name of soft and bite-sized is more descriptive of what food consistency the kitchens should produce."The Soft and Bite-sized Framework, revised January 2019, retrieved on 6/14/24 from, https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/6_Soft_Bite_Sized_Adult_consumer_handout_30Jan2019.pdf. It read in pertinent part, "Level six, soft and bite-sized foods:-Soft, tender and moist, but with no thin liquid leaking or dripping;-Ability to bite off a piece of food is not required;-Ability to chew bite-sized pieces so that they are safe to swallow is required;-Bite-sized piece no bigger than one and a half centimeters by one and a half centimeters (half an inch by half an inch) in size;-Food can be mashed or broken down with pressure from a fork; and-A knife is not required to cut this food. Examples of soft and bite-sized food for adults:-No regular bread due to a high choking risk; andFood characteristics to avoid are soup with pieces of food, cereal with milk, nuts, raw vegetables, dry cakes, bread, dry cereal, steak, pineapple, candies, marshmallows, raw carrot, raw apple, popcorn, peas, grapes, chicken or salmon skin, meat with gristle, overcooked oatmeal, lettuce, cucumber, uncooked baby spinach, crisp bacon, etc."II. Resident #62A. Resident statusResident #62, age greater than 65, was admitted on 5/2/24. According to the June 2024 computerized physician order (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (not enough oxygen going through the body), dysphagia (difficulty swallowing) and dysphagia oropharyngeal phase (difficulty swallowing in the throat and mouth). The 5/13/24 minimum data set (MDS) assessment documented Resident #62 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #62 experienced coughing or choking episodes during meals or when she swallowed her medications. The resident was prescribed a mechanically altered diet. B. Observations and interviewsDuring a continuous observation during the lunch meal on 6/10/24, beginning at 11:18 a.m. and ending at 12:49 p.m., the following was observed:At 11:48 a.m. the dietary director (DD) told the cook (CK) Resident #62' s meal tray was ready to be served. The plate consisted of a sandwich cut in half and soup. The resident' s meal ticket documented she was on a mechanical soft diet. The DD said Resident #62 refused to eat the mechanically altered food so he served her regular food. The DD said he used to offer Resident #62 the mechanical soft food first then would make her a new plate but he wanted to cut back on food waste. The DD said he knew the resident would refuse the mechanically altered diet, so he did not offer it to the resident. C. Record reviewThe June 2024 CPO revealed Resident #62 had a physician' s order for a mechanical soft diet with thin liquids, ordered on 5/27/24. Resident #62' s care plan, revised 5/7/24, documented she was at risk for aspiration, choking or difficulty swallowing related to a diagnosis of dysphagia. An intervention was documented as serving her diet as ordered. III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on 8/18/23. According to the June 2024 CPO, diagnoses included sequelae (residual effects) of cerebral infarction (stroke), dysarthria (difficulty speaking) following cerebral infarction, acute respiratory failure with hypoxia (not enough oxygen throughout the body), dysphagia oropharyngeal phase and dysphagia following cerebral infarction. The 4/30/24 MDS assessment documented Resident #4 had moderate cognitive impairments with a BIMS score of 12 out of 15. Resident #4 had no swallowing problems. Resident #4 was prescribed a mechanically altered diet. B. Observations and interviews During a continuous observation during the lunch meal on 6/10/24, beginning at 11:18 a.m. and ending at 12:49 p.m., the following was observed:At 12:18 p.m. the CK began plating Resident #4' s meal. The meal included regular texture spaghetti with two whole meatballs and half of a slice of garlic toast. Resident #4' s meal ticket documented the resident was prescribed a mechanical soft diet. The CK put Resident #4' s tray in the hot box to be served to the resident in his room. At 12:20 p.m. upon prompting, the CK removed Resident #4' s plate from the hot holding box and the DD made Resident #4 a new plate. The CK put the new tray back into the hot holding box. The DD said he did not realize he was serving an incorrect texture for Resident #4. C. Record reviewThe June 2024 CPO revealed Resident #4 had a physician' s order for a mechanical soft diet with thin liquids, ordered on 8/21/23. Resident #4' s care plan, revised 8/30/23, documented Resident #4 was at minimal nutritional risk, was independent with eating and made his needs known. Interventions included observing for signs or symptoms of dysphagia which included pocketing food, coughing, choking, drooling or holding food in his mouth. IV. Staff interviewsThe nursing home administrator (NHA), the director of nursing (DON) and the corporate consultant (CC) were interviewed together on 6/11/24 at 4:42 p.m. The DON said all physician' s orders entered into the resident' s electronic medical record (EMR) needed to be followed. The DON said a mechanically altered diet was ordered to assist residents with difficulty swallowing. The NHA said mechanical soft diets needed to be followed for the safety of the residents. The NHA said she was unaware of any residents who refused their textures and said she was going to look into it. The registered dietitian (RD) was interviewed on 6/12/24 at 11:47 a.m. The RD said all diet orders needed to be followed by the staff. She said mechanically altered diets were followed because of swallowing concerns and to prevent aspiration or choking. The RD said if a resident refused their prescribed diet texture there needed to be an interdisciplinary team (IDT) meeting to discuss other approaches. The RD said she was unaware of any residents currently at the facility who consistently refused their diets. The DD and the NHA were interviewed together on 6/12/24 at 1:17 p.m. The DD said he needed to provide more training to the dietary department regarding mechanically altered diets. He said he was going to ensure all diet orders were followed by the dietary staff and if the resident refused their mechanically altered diet he was going to make sure it was being tracked in the resident' s EMR.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and three of three unit refrigerators. Specifically, the facility failed to:-Ensure staff followed appropriate hand washing and glove usage in the main kitchen; and,-Ensure food was labeled and stored appropriately in the main kitchen refrigerator and freezer and in three unit refrigerators. Findings include:I. Staff hand hygieneA. Professional referenceAccording to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved on 6/24/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; after handling soiled equipment or utensils; before donning gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands."If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation."B. Facility policy and procedureThe Sanitization policy, revised November 2022, was provided by the nursing home administrator (NHA) on 6/12/24 at 1:30 p.m. It read in pertinent part,"All kitchens, kitchen areas and dining areas are kept clean and free from garbage and debris."C. ObservationsDuring a continuous observation on 6/10/24, beginning at 11:18 a.m. and ending at 12:45 p.m., the following was observed:At 11:45 a.m. the dietary director (DD) put on a pair of gloves and began plating lunch. -The DD did not wash his hands prior to putting on a pair of gloves. At 12:01 p.m. the DD plated a resident's cheeseburger using gloved hands. -The DD removed the pair of gloves and put a new pair on without performing hand hygiene. The DD proceeded to prepare 10 residents' food plates with the same gloves. -The DD used his gloved hands to pick up a slice of garlic toast for each resident's plate after touching multiple meal tickets. At 12:12 p.m. the DD placed two pieces of cheese on a hamburger patty on the flat top and used his gloved hand to push the burger down. -The DD did not change his gloves or wash his hands after touching the cheeseburger. At 12:23 p.m. the DD washed his hands for the first time and put on another pair of gloves. D. Staff interviewsThe DD was interviewed on 6/12/24 at 1:17 p.m. The DD said hand hygiene needed to be completed when gloves were changed, products were switched and upon entering or leaving the kitchen. The DD said he did not realize he was wearing the same pair of gloves and was touching multiple things, including clean and dirty items. II. Food storage and date marking systemA. Professional referenceAccording to the 2022 Food Code U.S. Food and Drug Administration, (1/18/23), retrieved on 6/24/24 from Chapter 3, Page 11 3-301.12, "Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices and sugar shall be identified with the common name of the food."The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 6/24/24 from https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, read in pertinent part, "Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request." The Hormel Health Labs Code Date and Handling Information, revised 2024, was retrieved on 6/24/24 fromhttps://www.hormelhealthlabs.com/wp-content/uploads/HHL-Code-Date_Handling-Sheet-04_2024.pdf, page 12. It revealed in pertinent part, "Mighty nutritional shakes have a shelf life of 14 days in the refrigerator once thawed."B. ObservationsOn 6/5/24 at 8:55 a.m., an initial tour of the kitchen was conducted and the following was observed in the walk-in refrigerator:-A large bowl of meat and sauce did not have a label indicating what the food was and had a date of 5/28/24;-23 single-serving condiment containers with a white condiment that was unlabeled and undated;-A container of chopped lettuce that was open and undated;-A chocolate pie that was unlabeled and undated; and,-Three cartons of egg whites that were opened but were not dated. At 9:10 a.m. the following was observed in the walk-in freezer:-A puff pastry that was uncovered and undated;-A box of raw beef hamburger patties that was uncovered and undated;-A bag of frozen potatoes that were unlabeled and undated; and,-A bag of frozen egg rolls that were undated.-On 6/10/24 at 9:27 p.m. the Center hall refrigerator had seven thawed Mighty Shakes (nutritional health shakes) that were not dated.-At 9:30 p.m. the East hall refrigerator had 14 thawed Mighty Shakes that were not dated.-At 9:35 p.m. the West hall refrigerator had eight thawed Mighty Shakes that were not dated. C. Staff interviewsThe DD was interviewed on 6/12/24 at 1:17 p.m. The DD said the dietary staff were required to label all food stored in the kitchen that was not in the original packaging. The DD said the morning dietary shift stocked the refrigerator and rotated out the health shakes in the unit refrigerators. The DD said the dietary staff needed to date the health shakes when they were thawed and he was unsure how long the health shakes were good for once they were thawed. The DD said the staff followed the manufacturer's use by date that was on the health shakes. The DD said he was going to move the food delivery orders into the refrigerator and freezer himself to ensure things were labeled and dated correctly.

Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#19) of four residents out of 45 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #19's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency. Findings include:I. Resident #19A. Resident statusResident #19, age greater than 65, was admitted on 10/11/22. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) with exacerbation and malignant neoplasm of the prostate. The 4/30/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required substantial assistance with activities of daily living (ADL). The assessment documented the resident was receiving hospice services. B. Resident interviewResident #19 was interviewed on 6/6/24 at 9:58 a.m. Resident #19 said he was not aware he was receiving hospice services. C. Record reviewThe June 2024 CPO revealed a physician's order for Resident #19 to receive a hospice consultation on 1/24/24. -However, there was not a physician's order for hospice care services documented in the June 2024 CPO. The 2/11/24 care plan identified Resident #19 had an end of life care plan and received hospice services for weight loss, worsening skin integrity and abnormal breathing. Pertinent interventions included, to coordinate resident's needs with hospice staff. The care plan did not include hospice on any other part of the care plan to indicate what the hospice care team would be involved with. -The electronic medical record (EMR) failed to reveal any progress notes from the hospice services provider or a hospice care plan. D. Staff interviewThe licensed practical nurse (LPN) #9 was interviewed on 6/10/24 at 3:40 p.m. LPN #9 reviewed Resident #19's EMR and confirmed there was not a physician's order for hospice services. LPN #9 said she was not aware if the resident was receiving hospice services because she could not locate any nurses notes. LPN #9 said the director of nursing (DON) would know if the resident was receiving hospice services.. The DON was interviewed on 6/10/24 at approximately 4:30 p.m. The DON said Resident #19 was receiving hospice services. She said there should be a physician's order for hospice services in the resident's EMR because she was the person who entered physician's orders for hospice services.-However, Resident #19's EMR did not include a physician's order for hospice services (see record review above). The social service director (SSD) was interviewed on 6/10/24 at 4:30 p.m. The SSD said Resident #19 was on hospice services and she was responsible for putting an end of life care plan in the comprehensive care plan. The corporate consultant (CC) was interviewed on 6/11/24 at approximately 4:00 p.m. The CC said, after talking with Resident #19's hospice services provider, she found that the hospice services agency was sending all their progress notes for Resident #19 to the facility's previous medical records director (MRD). She said the hospice services provider said they did not know there was a new MRD at the facility and they did not have the email address for the new MRD in order to know where to send Resident #19's information. The hospice certified nurse aide (HCNA) was interviewed on 6/11/24 at 12:00 p.m. The HCNA said she documented her notes in her phone and then the notes were sent over the hospice services provider. She said the hospice services provider would send the notes to the facility when they received her notes via phone. The new MRD was interviewed on 6/11/24 at 5:00 p.m. The MRD said she now had the hospice services provider's email address and the provider now had her correct email address so they could send the hospice notes for Resident #19 to her. She said she had now received all of the hospice notes for Resident #19.

Based on observations, 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 qualify of care, quality of life, and resident safety. Specifically, the facility's quality assurance and performance improvement (QAPI) program committee failed to effectively identify and address concerns related to residents' quality of care, quality of life, staff training and infection prevention and control. Findings include:I. Facility policy and procedureThe Quality Assurance and Performance Improvement Program (QAPI) Analysis and Action policy, dated March 2020, was provided by the nursing home administrator (NHA) on 6/17/24 at 2:36 p.m. via email. The policy read in pertinent part, "The QAPI program, overseen by the QAPI committee, is designed to identify and address quality deficiencies through the analysis of the underlying causes and actions targeted at correcting systems at a comprehensive level. The methodology for analysis and action is guided by a written QAPI plan that includes:-Definition of the problem, based on information obtained through data, self-assessment and feedback systems;-Analysis of root cause of the problem from a system's perspective;-Measurable goals or benchmarks for improvement;-To take interventions aimed at correcting the problem and achieving the state of goals or benchmarks; and,-Methods and frequency of monitoring performance improvement objectives."II. Cross-referenced citationsCross-reference F565: The facility failed to ensure effective interventions to resident council grievances of call light response time. Cross-reference F567: The facility failed to ensure proper consent and notification of spending of personal funds. Cross-reference F580: The facility failed to ensure a resident's representative was notified after a change in condition. Cross-reference F582: The facility failed to give the proper two day notification before Medicare A benefits expired. Cross-reference F610: The facility failed to investigate a potential allegation of abuse. Cross-reference F644: The facility failed to submit a PASRR Level I based on diagnosis. Cross-reference F645: The facility failed to complete a PASRR Level II after a PASRR Level I determination. Cross-reference F661: The facility failed to ensure a discharge summary was completed after a resident was discharged. Cross-reference F685: The facility failed to ensure a resident received eye glasses after an eye exam. Cross-reference F688: The facility failed to provide restorative nursing services. Cross-reference F689: The facility failed to assess a resident after injuries were identified after a potential fall. Cross-reference F692:The facility failed to implement interventions to prevent further weight loss after a resident had significant weight loss. Cross-reference F730: The facility failed to complete annual evaluations for certified nurse aides (CNA). Cross-reference F732: The facility failed to have an accurate nursing staff posting. Cross-reference F744: The facility failed to provide adequate dementia care training for the secure unit; failed to implement a dementia care plan for refusals of food, medications, fluids and vital signs. Cross-reference F758: The facility failed to limit PRN (as needed) psychotropic medications to 14 days or have physician documentation of the rationale. Cross-reference F761: The facility failed to ensure all medications were stored appropriately and maintain medication refrigerator temperature logs. Cross-reference F804: The facility failed to serve palatable food in taste and temperature. Cross-reference F805: The facility failed to serve food according to a physician's order. Cross-reference F812: The facility failed to prepare, store and serve food in a sanitary manner. Cross-reference F842: The facility failed to accurately document fluid intake. Cross-reference F849: The facility failed to ensure the facility received hospice notes and physician orders. Cross-reference F880: The facility failed to implement an effective infection prevention and control program, to include identifying residents who required enhanced barrier precautions, ensure personal protective equipment was available, ensure the facility had an effective water management plan, ensure resident rooms were properly sanitized, ensure residents had clean bed linens after wound dressing changes and ensure residents were offered hand hygiene before meals. Cross-reference F882: The facility failed to have an infection preventionist at least part time to run an effective infection control program. Cross-reference F908: The facility failed to ensure the use of appropriate medical grade blood pressure cuffs. Cross-reference F943: The facility failed to ensure all staff completed abuse training annually. Cross-reference F947: The facility failed to ensure CNAs received 12 hours of required training annually. Cross-reference EP004: The facility failed to ensure the emergency preparedness plan was reviewed annually. Cross-reference EP039: The facility failed to conduct emergency exercises annually. II. InterviewsThe NHA, the regional operations manager (ROM) and the director of nursing (DON) were interviewed together on 6/12/24 at 4:32 p.m. The NHA said the QAPI committee meeting was held monthly. The NHA said the meeting included the interdisciplinary (IDT) team as well as the medical director and pharmacist. The NHA said the QAPI committee identified areas of concerns, created performance improvement plans, set goals and reviewed the progress of the plans and determined if additional meetings and education were needed on the concerns and/or one-on-on interventions. The NHA said to ensure systematic change, the facility continued the conversations of the identified concern and determined if revisions to the plan were necessary. The NHA said several of the identified concerns were reviewed in the QAPI meetings but the facility had had changes to personnel and the support provided was not enough. The NHA said the facility had to make significant changes over the last few months. The NHA said the changes were underway but not as quickly as the facility would want. The ROM said the QAPI committee was not really conducting a full quality assurance review with the ongoing concerns. He said the IDT discussed several of the identified concerns in the morning stand up meetings, but not all the discussed concerns were brought to QAPI, so the breakdown of the problems did not fully occur. The ROM said the facility's QAPI plan failed. The DON said some areas of concern had been overlooked. The DON said the QAPI committee needed to look at all concerns and potential concerns with fresh eyes. The DON said the committee needed to hold each other accountable and determine what the facility could do to help each other with the identification and correction of the concerns.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate during resident room cleaning;-Ensure housekeeping staff properly used a disinfectant chemical per manufacturer's instructions when cleaning resident rooms; -Ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions (EBP);-Ensure a process was in place to ensure staff were aware of which residents required EBP;-Provide clean linens after performing wound care and a wound dressing change;-Offer hand hygiene to residents before meals; and,-Implement an effective water management plan. Findings include:I. Housekeeping failuresA. Facility policy and procedureThe Infection Prevention and Control Program policy, revised October 2018, was received from the nursing home administrator (NHA) on 6/10/24 at 10:24 a.m. It documented in pertinent part,"Policies and procedures reflect the current infection prevention and control standards of practice."Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures, implementing appropriate isolation precautions when necessary, and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC)."The Hand Hygiene policy, revised October 2023, was provided by the nursing home administrator (NHA) on 4/12/24 at 2:59 p.m. It read in pertinent part: "All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections."All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors."Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, bodily fluids, or contaminated surfaces, after touching a resident, after touching a resident's environment, before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal."The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/20/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It 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: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. "Proceed from cleaner to 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 and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."B. Manufacturer's guidelines for Diffense disinfecting cleanerThe Diffense disinfecting cleaner instructions were retrieved from https://www.spartanchemical.com/products/product/102403#top on 6/18/24. It read in pertinent part: "Diffense offers 60-second disinfection for most common bacteria and viruses."Diffense kills clostridium difficile (C-diff) in 8 (eight) minutes."C. ObservationsOn 6/10/24 at 10:18 a.m. housekeeper (HSKP) #2 was observed cleaning room #204. HSKP #2 sprayed high-touch surfaces with Diffense disinfecting cleaner. While spraying high-touch surfaces, HSKP #2 touched the toilet seat with gloved hands. HSKP #2 then cleaned the sink and mirror. After cleaning the sink and mirror, HSKP #2 changed her gloves and performed hand hygiene. HSKP #2 then donned new gloves and began cleaning the door and cabinet handles. HSKP #2 sprayed the door and cabinet handles with Diffense disinfecting spray, then immediately wiped the wet spray off with a dry cloth. -The call light cord in the bathroom was not touched or cleaned by HSKP #2 during the room cleaning process.-HSKP #2 failed to change gloves and perform hand hygiene after touching the toilet seat before cleaning the sink and mirror.-HSKP #2 failed to allow the disinfectant to remain on surfaces for the manufacturer's recommended dwell time to ensure effective disinfection. -HSKP #2 failed to clean the room call light cord. On 6/11/24 at 10:12 a.m. HSKP #3 was observed cleaning room #312. HSKP #3 was observed to spray Diffense disinfecting cleaner on the room's door handles before immediately wiping off the wet spray with a dry cloth. -The call light cord in the bathroom was not touched or cleaned by HSKP #3 during the room cleaning process.-HSKP #3 failed to allow the disinfectant to remain on surfaces for the manufacturer's recommended dwell time to ensure effective disinfection. D. Staff interviewsHSKP #2 was interviewed on 6/10/24 at 10:38 a.m. HSKP #2 said she was not fluent in the English language, and this created a communication barrier between both spanish-speaking housekeepers and administrative staff. HSKP #2 said Diffense disinfecting cleaner required one minute to kill most bacteria and viruses, and required three minutes to kill clostridium difficile.-However, according to the manufacturer's guideline, the disinfectant required eight minutes to kill clostridium difficile (see manufacturer's guidelines above). HSKP #2 said she had not left the Diffense disinfecting spray on the door and cabinet handles for long enough before wiping it off with a dry cloth. HSKP #2 said gloves must be changed in between contaminated surfaces. HSKP #2 said she had not received training in the facility for how to clean rooms in her preferred language because her supervisors did not speak Spanish. HSKP #3 was interviewed on 6/11/24 at 10:11 a.m. HSKP #3 said she was not fluent in the English language, and this created a communication barrier between the housekeeping staff and all other staff who only spoke English. HSKP #3 said the Diffense disinfecting cleaner had a 60-second dwell time to kill bacteria. HSKP #3 said she did not allow the disinfectant to dwell for 60 seconds before wiping it off with a cloth. HSKP #3 said she had not received training on how to clean a room from her supervisor in her preferred language. The NHA was interviewed on 6/11/24 at 2:04 p.m. The NHA said she was currently acting in the role of the housekeeping supervisor. The NHA said housekeepers should change their gloves and perform hand hygiene after touching a resident's toilet. The NHA said housekeepers should allow enough time for the Diffense disinfectant solution to properly disinfect the high touch surface areas before wiping off the disinfectant. The NHA said door handles, call lights, and cabinet handles were considered high-touch areas that should be disinfected every day to prevent the spread of infection. II. Enhanced barrier precautions (EBP)A. Facility policy and procedureThe Enhanced Barrier Precautions policy, undated, was received from the NHA on 6/10/24 at 10:24 a.m. It documented in pertinent part,"All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.""Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves."Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders."Make gowns and gloves available immediately outside of the resident's room."The infection preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education."The Personal Protective Equipment policy, dated October 2018, was received from the NHA on 6/10/24 at 10:24 a.m. It documented in pertinent part, "PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed."B. Record reviewAccording to the EMR of Resident #19 (admitted 10/11/22), the resident had an ostomy, which necessitated EBP to be identified and PPE to be worn during direct care of the resident. According to the EMR of Resident #16 (admitted 12/27/17), the resident had a wound and a catheter, which necessitated EBP to be identified and PPE to be worn during direct care of the resident. According to the EMR of Resident #34 (admitted 3/8/24), the resident had a catheter, which necessitated EBP to be identified and PPE to be worn during direct care of the resident. C. ObservationsOn 6/10/24 at 10:31 a.m. licensed practical nurse (LPN) #1 was observed assisting Resident #19 to the bathroom without wearing PPE.On 6/10/24 at 4:19 p.m., an unidentified staff member was observed assisting Resident #16 without wearing PPE. The director of nursing observed this with the survey team. (see interview below)On 6/10/24 at 9:27 p.m. LPN #8 was observed assisting Resident #16 with eating and drinking without wearing PPE.On 6/10/24 at 9:39 p.m. LPN #8 was observed assisting Resident #34 to the bathroom in his room without wearing PPE.D. Staff interviewsCNA # 2 was interviewed on 6/10/24 at 10:38 a.m. CNA #2 said that she did not know what enhanced barrier precautions were or which residents required PPE for EBP. CNA #2 said if she was unsure if a resident required PPE during care, she would ask a nurse what to do. Licensed practical nurse (LPN) #1 was interviewed on 6/10/24 at 11:29 a.m. LPN #1 said that he was unsure if one of the residents identified as needing EBP required contact isolation precautions instead. LPN #1 said that he followed the directions of what was on the isolation door sign when he did wound care. LPN #1 said if a room did not have an isolation type sign on the door, there was no requirement to wear PPE during resident care.-However, Resident #19 required PPE for EBP when staff provided direct care for the resident (see observations above). The DON was interviewed on 6/10/24 at 4:23 p.m. The DON said the staff member assisting Resident #16 should have been wearing PPE while assisting the resident. She said staff should wear PPE with residents who were on EBP when providing direct care to residents.-However, staff members continued to assist residents on EBP without wearing PPE after the DON's interview. (see observations above)III. Failure to offer hand hygiene to residents before mealsA. ObservationsOn 6/5/24 at 11:53 a.m. an unidentified resident in a plaid shirt was observed using his hands to wheel himself in his wheelchair to a table in the main dining hall. -The resident was not offered hand hygiene before his meal was served. On 6/5/24 at 11:55 a.m., Resident #2 was observed using his hand to wheel himself in his wheelchair to the main dining hall. -The resident was not offered hand hygiene before his meal was served. The resident ate a hamburger which required the use of his hands. On 6/5/24 at 12:03 p.m. Resident #19 was observed using his hands to wheel himself in his wheelchair to the main dining hall. -The resident was not offered hand hygiene before his meal was served.-On 6/10/24 at 11:58 a.m. residents eating at the table in the common area of the rehabilitation unit were not offered hand hygiene prior to receiving their meal. B. Resident InterviewResident #5 was interviewed on 6/5/24 at 11:47 a.m. Resident #5 said nursing staff did not normally offer hand hygiene to all residents before meals. Resident #5 said she tried to assist nursing care staff with remembering to offer hand hygiene to residents, but she was unable to watch everyone because she also needs to eat a meal during meal times. C. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 6/6/24 at 3:14 p.m. CNA #7 said residents should be offered hand hygiene before meals. The NHA and the regional operations manager (ROM) were interviewed on 6/12/24 at 4:32 p.m. The NHA said that the facility had not identified hand hygiene as a concern in the facility. The NHA said all staff assisted during meal times with resident trays. The NHA said the facility needed to do more to ensure residents received hand hygiene before meals. The ROM said hand hygiene concerns had been discussed among administration several times in the recent past. IV. Failure to change soiled bedding after wound dressing changeA. ObservationsOn 6/10/24 at 11:29 a.m. Resident #166's wound dressing change was observed with LPN #1. A draw sheet containing a mixture of blood and yellow drainage was observed under the resident's legs during the wound dressing change. After the leg wound dressing changes had been completed by LPN #1, the resident's leg, with the new dressing on it, was placed on top of the old draw sheet containing the old wound drainage. LPN #1 proceeded to doff (remove) his PPE, performed hand hygiene and left the room.-Resident #166's bed linens were not appropriately changed after his wound dressing change. (see Resident #166 interview below)B. Resident InterviewResident #166 was interviewed on 6/11/24 at 1:05 p.m. Resident #166 said no one had changed his soiled draw sheet from 6/10/24 dressing change. Resident #166 volunteered to lift his top bed sheet which exposed a blood and yellow fluid-soaked bed sheet under the resident's legs.-The facility failed to change soiled linens for more than 24 hours following a wound dressing change. C. Staff interviewThe DON was interviewed on 6/11/24 at 1:14 p.m. The DON said a newly-changed wound dressing should not be placed on dirty linens. The DON said placing a new wound dressing on soiled linens could invite contamination of the wound. The DON said more education was needed in the facility to ensure cleaned wounds were not placed on soiled bed linens. V. Failure to have an effective water planA. Facility policyThe Legionella Water Management Program policy was obtained from the director of maintenance (DM) on 6/11/24 at 2:51 p.m. It documented in pertinent part,"As part of the infection control program, our facility has a water management program, which is overseen by the water management team.""The purpose of the water management program is to identify areas in the water system where legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease.""The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a legionella water management program."B. Record reviewThe facility's water management plan was requested from the DM. On 6/11/24 at 2:51 p.m. the DM provided the following information:A facility water map which contained hand-drawn lines in pen indicating where water pipes were in the building.-The facility failed to assess all locations where legionella and other waterborne pathogens could spread in the facility (see interview below). A document which identified the facility had tested for Legionella on 8/23/23 and the test was negative.-However, the test was completed as an independent action of the facility and was not a part of a documented full water management plan (see interview below).-The documentation provided by the DM failed to include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. and-Additionally, the documentation failed to identify measures implemented by the facility, such as visible inspections, disinfectant use and water temperature monitoring, to prevent the growth of opportunistic waterborne pathogens and how to monitor the measures. C. Staff interviewsThe DM and the ROM were interviewed together on 6/11/24 at 3:01 p.m. The DM said he did not know what a water management program was or what elements were required to be in compliance with federal regulations. The DM said the water management program responsibility was given to him a week prior to the survey and he was not given any guidance or training regarding water management programs. The DM said the facility's water systems had been upgraded many times over the years and he did not know where all the water pipes in the facility were. The DM said there could be old pipes with stagnant water in the facility that he did not know about. The DM said he knew empty rooms needed to have the water run weekly, but that had not been a problem in the facility as there has not been a vacant room in the facility for seven continuous days. The DM said the facility map with hand-drawn lines was provided to demonstrate that he knew where all water pipe access points were in the facility. The ROM said the facility did not have a water management program in place currently. The ROM said he understood the facility was not in compliance with water management program requirements. The ROM said that he did not know how to develop a federally-compliant management plan and would research it. The ROM was interviewed again on 6/12/24 at 4:32 p.m. The ROM said the Quality Assurance and Performance Improvement (QAPI) committee had not previously identified concerns with the water management program in the facility.

Based on observations and interviews, the facility failed to ensure a qualified infection preventionist (IP) was in place for providing guidance to the facility on the infection control policy and programs which had the potential to affect all 74 residents residing in the facility at the time of the survey. Specifically, the facility failed to have a designated IP who had the time necessary to properly assess, develop, implement, monitor, and manage the infection prevention and control program (IPCP) for the facility. Findings include: I. Facility policy and procedureThe Infection Prevention and Control Program policy, revised October 2018, was received from the nursing home administrator (NHA) on 6/10/24 at 10:24 a.m. It documented in pertinent part,"Policies and procedures reflect the current infection prevention and control standards of practice."II. ObservationsObservations throughout the survey (from 6/5/24 to 6/12/24) revealed multiple infection control failures within the facility. Cross-reference F880 for failure to implement an effective infection prevention and control program. III. InterviewsThe director of nursing (DON) was interviewed on 6/10/24 at 3:51 p.m. The DON said she was also the infection preventionist and was operating in both roles at the facility. The DON said she did not have enough time to effectively conduct the infection preventionist's responsibilities. The regional operations manager (ROM) was interviewed on 6/12/24 at 4:35 p.m. The ROM said he recognized the DON could not complete all of the infection preventionist assignments she was currently responsible for. The ROM said the facility had been working to hire another staff member to take over the role of the infection preventionist for the DON.

Based on observations, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, the facility failed to ensure facility staff used a blood pressure cuffs which were rated for medical use. Findings include:I. Professional referenceAccording to the Davis Advantage for Basic Nursing handbook, third edition, retrieved on 6/17/24 from Treas, Leslie S., et al. Davis Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. Davis Company, 2022., Blood Pressure - Practical Knowledge,"Electronic blood pressure monitors may be less accurate than those with an aneroid monitor (a manual blood pressure measuring device). To ensure accuracy, you should auscultate (listen to) a baseline blood pressure before initiating automatic monitoring."Ensure devices are rated for medical use."The width of the blood pressure cuff bladder of a properly fitting cuff will cover approximately two-thirds of the length of the upper arm for an adult, and the entire upper arm for a child."Alternative sites you can use are the forearm, thigh, or calf. However, systolic pressure may be 20 to 30 mmHg (millimeters of mercury) higher in the lower extremities than in the arms, but diastolic pressures are similar."Abnormally high or low blood pressure readings should be rechecked by the provider."According to Medaval Certified Accuracy (a company that provides accreditation, validation and equivalence services for medical devices) Equate 4000 series (UA-4000WM, retrieved on 6/20/24 from https://www.medaval.ie/resources/EN/devices/Equate-4000-Series-UA-4000WM.html, "The Equate 4000 Series (UA-4000WM) is an automatic blood pressure monitor. Medaval has not found evidence proving the accuracy of its blood pressure measurement technology. Blood pressure measurements are taken from the upper arm. It is intended for self-measurement and home use."II. ObservationsOn 6/6/24 at 9:48 a.m., licensed practical nurse (LPN) #5 was observed using an Equate model VA-4000WM blood pressure cuff to take Resident #166's blood pressure. -LPN #5 did not use a blood pressure cuff rated for medical use to obtain Resident #166's blood pressure (see professional references above and interview below). On 6/10/24 at 9:08 p.m., registered nurse (RN) #1 was observed taking Resident #51's blood pressure using an Ever Ready First Aid wrist blood pressure cuff. -RN #1 did not use a blood pressure cuff rated for medical use to obtain Resident #51's blood pressure (see professional references above and interview below). III. Staff interviewsLPN #5 was interviewed on 6/6/24 at 9:49 a.m. LPN #5 said she used the Equate model VA-4000WM blood pressure cuff to obtain blood pressures on residents. RN #1 was interviewed on 6/10/24 at 9:19 p.m. RN #1 said that she used the Ever Ready First Aid blood pressure cuff to take blood pressures on residents. RN #1 said if the reading was inaccurate she would use the Equate model VA-4000WM blood pressure cuff to obtain physician-ordered blood pressures on residents. LPN #6 was interviewed on 6/11/24 at 10:18 a.m. LPN #6 said she used the Equate model VA-4000WM blood pressure cuff to obtain physician-ordered blood pressures on residents. The nursing home administrator (NHA) was interviewed on 6/11/24 at 3:41 p.m. The NHA said the Equate model VA-4000WM blood pressure cuff and the Ever Ready First Aid blood pressure cuff were not rated for medical use. The NHA said there was no documentation to indicate that the Equate model VA-4000WM blood pressure cuff and the Ever Ready First Aid blood pressure cuff were safe or accurate to use at the facility to obtain accurate resident blood pressures. The NHA said the facility was ordering new blood pressure cuffs on 6/11/24 that were rated for medical use. The NHA said new blood pressures would be obtained on all residents in the facility using blood pressure equipment rated for medical use by the end of the day on 6/11/24. The NHA said it was important to use blood pressure cuffs rated for medical use to ensure blood pressure readings could be accurately obtained.

Based on record review and interview, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically, the facility failed to: -Ensure the activities assistant (AA), the cook (CK) and housekeeper (HSKP) #1 received annual training that covered abuse, reporting incidents of abuse and resident abuse prevention over the last 12 months; and,-Ensure the CK, dietary aide (DA) #2 and the maintenance assistant (MA) received annual training that covered dementia management. Findings include:I. Facility policiesThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, was provided by the nursing home administrator (NHA) on 6/6/24 at 2:40 p.m. It read in pertinent part, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect, exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives provide staff orientation and training or orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior."The Dementia Clinical Protocol policy, revised 2001, was provided by the NHA on 6/10/24 at 1:00 p.m. It read in pertinent part, "Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the review."II. Training recordsA request was made for training records for the past 12 months (June 2023 to June 2024) for documentation to indicate the AA, the CK, HSKP #1 and the MA had participated in annual abuse and dementia training. The NHA provided the training records on 6/10/24 at approximately 1:00 p.m. -The training records indicated the CK, the AA and HSKP #1 had not received training that covered abuse, reporting incidents of abuse and resident abuse prevention over the past 12 months. -The training records further indicated DA #2, the CK and the MA had not received training that covered dementia management over the past 12 months. III. Staff interviewsThe director of nursing (DON) was interviewed on 6/6/24 at 4:25 p.m. The DON said she was the staff development coordinator because the facility hired someone who was still in training. The NHA and the DON were interviewed together on 6/11/24 at 4:10 p.m. The DON said the facility offered a four-hour dementia class to the staff and abuse training was provided through the facility' s electronic training system. The NHA said she was unaware that non-clinical staff needed abuse and dementia training. The NHA said she was unable to find the completed abuse training for the CK, the AA and HSKP #1. The NHA said she was unable to find the completed dementia training for DA #2, the CK and the MA. The NHA said she was working on a new process to track the trainings.

Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for four out of five staff reviewed. Specifically, the facility failed to ensure CNA #2, #5, #4 and #1 received 12 hours of continuing education annually in all required training topic areas, including dementia management training and resident abuse prevention training. Findings includeI. Training record reviewFive randomly selected CNA training records were reviewed on 6/10/24. Of the five employees reviewed, four of the CNAs (#2, #5 #4 and #1) did not receive a full 12 hours of annual training. A. CNA #2-CNA #2, hired on 5/16/23, had participated in six hours and 45 minutes of training during the annual training year. B. CNA #5-CNA #5, hired on 8/18/21, had participated in a four-hour dementia class. The nursing home administrator (NHA) was unable to provide her complete training record, including completed training for abuse, neglect or exploitation. C. CNA #4-CNA #4, hired on 4/6/17, had participated in four hours and 30 minutes of training during the annual training year and had no record of completing abuse, neglect or exploitation training. D. CNA #1-CNA #1, hired on 4/6/23, had participated in six hours and 30 mins of training during the annual training year. II. Staff interviewsThe director of nursing (DON) was interviewed on 6/6/24 at 4:25 p.m. The DON said she was the staff development coordinator because the facility just hired someone who was still in training. The NHA and the DON were interviewed together on 6/11/24 at 4:10 p.m. The DON said she was unaware when she provided CNAs with in-service training she needed to document the length of the training. The NHA said staff training was an area the facility needed to improve and it was a work in progress. CNA #5 was interviewed on 6/12/24 at 10:36 a.m. CNA #5 said the staff were assigned training on the computer and she tried to complete it when she was able to. She said she completed a four-hour dementia training that she signed up for to attend.

A survey prompted by complaint #CO36484 was completed on 6/5/24 to 6/12/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#54) of five residents out of 45 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #54 was admitted to the facility for long term care on 11/10/23 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes and generalized muscle weakness. The resident was initially weighed on 11/19/23 and weighed 149 pounds (lbs). The resident was admitted to the hospital from 1/2/24 to 1/8/24 for electrolyte imbalances. Upon readmission to the facility the resident weighed 135.2 lbs. On 1/22/24 and 1/29/24 the resident weighed 123.6 lbs. On 2/5/24 the resident weighed 123 lbs. The resident sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss. The facility failed to assess the resident and implement nutrition interventions after the resident sustained severe weight loss on 2/5/24. The facility did not weigh the resident after she sustained severe weight loss, despite the registered dietitian (RD) requesting the resident to be weighed. Findings include:I. Facility policy and procedureThe nutritional assessment policy, revised October 2017, was provided by the nursing home administrator (NHA) on 6/11/24 at 3:14 p.m. It documented in pertinent part:"The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition."Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident' s risks for nutritional complications. Such interventions will be developed within the context of the resident' s prognosis and personal preferences"II. Resident #54A. Resident statusResident #54, over the age of 65, was admitted to the facility on 11/10/23 and readmitted on 1/8/23. According to the June 2024 computerized physician orders (CPO), diagnoses included COPD, diabetes type II and generalized muscle weakness. The 4/9/24 facility assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required set-up or clean-up assistance with eating. The resident required substantial or maximum assistance with transfers, showers, toileting and personal hygiene. The assessment documented the resident was 64 inches (5 foot, 4 inches) tall. The assessment did not indicate the residents weight. It documented the resident had not had any significant weight loss or weight gain.-However, the resident had sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss. B. Resident interviewResident #54 was interviewed on 6/6/24 at 9:41 a.m. Resident #54 said she preferred to eat in her room with her roommate. Resident #54 said she was served scrambled eggs for breakfast several times per week and she did not like them because of how bland they were. Resident #54 said she sent her breakfast back several times each week because of how bland the scrambled eggs were. Resident #54 said she had lost weight because of this. Resident #54 said she skipped several meals throughout the week because she did not like to eat the bland eggs. Resident #54 said she often felt very hungry by lunch time. C. ObservationsOn 6/10/24 at 8:12 a.m., Resident #54 was observed to have a breakfast tray on her bedside table. The breakfast had been consumed except for scrambled eggs that were untouched on the breakfast tray. D. Record reviewThe nutrition care plan, initiated on 11/21/23 and revised on 11/28/23, documented the resident was at a minimal nutritional risk with consistent food intake greater than 50%. The care plan documented the resident would be offered nutrition for comfort and pleasure while the resident was receiving hospice services. The interventions included monitoring the resident' s intake, obtaining weights as ordered, completing an assessment by the RD and monitoring the resident' s skin for signs of breakdown. -However, a review of the resident' s electronic medical record (EMR) did not reveal the resident was receiving hospice services. -A review of the comprehensive care plan did not reveal documentation indicating new interventions were implemented after the resident sustained severed weight loss on 2/5/24. The 11/14/23 dietary pre-screen assessment documented the resident liked fried and poached eggs and spicy foods. The resident was hospitalized on 1/2/24, and readmitted to the facility on 1/8/24 for electrolyte imbalances. The December 2023 CPO revealed Resident #54 was to be weighed weekly for four weeks on Friday mornings, initiated on 11/17/23 and discontinued on 12/8/23. The June 2024 CPO revealed the resident had a physician' s order to be weighed weekly for four weeks, every Monday, ordered 1/15/24 and discontinued on 2/6/24. Resident #54' s weights were documented in the EMR as follows:-On 11/19/23, the resident weighed 149 lbs;-On 1/8/24, the resident weighed 135.2 lbs;-On 1/22/24, the resident weighed 123.6 lbs;-On 1/29/24, the resident weighed 123.6 lbs; and,-On 2/5/24, the resident weighed 123 lbs.-The resident lost 12.2 lbs (9%) from 1/8/24 to 2/5/24, in one month, which was considered severe.-The resident lost 26 lbs (17.4%) from 11/19/23 to 2/5/24, in three months, which was considered severe.-No additional physician orders to obtain weight were documented in the resident' s EMR. The facility had not obtained the resident' s weight in more than four months between 2/6/24 and 6/11/24 after this significant weight loss was documented. A review of the certified nurse aide (CNA) task response history (from 5/15/24 to 6/11/24) revealed staff had documented the amount the resident had eaten for 51 out of 81 meal opportunities during the review period. -There were no documented resident refusals for meals. It was documented the resident ate less than 50% of her meals for two of 51 documented meals. The 6/11/24 nutrition progress note documented the resident was last weighed on 2/5/24 when the resident weighed 123 pounds. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/10/24 at 8:42 a.m. LPN #1 said he had seen the kitchen serve Resident #54' s scrambled eggs. He said when this occurred he would ask the kitchen for different eggs. LPN #6 was interviewed on 6/12/24 at 10:29 a.m. LPN #6 said there was not a current physician' s order to weigh Resident #54 weekly or monthly. LPN #6 said nursing staff followed the physician' s order for obtaining the resident's weights. She said a nurse could request to weigh a resident if there was a weight concern identified by nursing staff. The RD was interviewed on 6/12/24 at 11:47 a.m. The RD said the facility did not have a current weight for Resident #54. The RD said she was concerned about the facility using different scales from January 2024 to February 2024 to weigh the resident. The RD said she had verbally requested the nursing staff to obtain additional weights. The RD said she did not document when she requested to have the resident reweighed after 2/5/24. The RD said she did not know why the significant weight loss was not identified or followed up on. The RD said new interventions should have been identified when Resident #54 sustained significant weight loss to prevent further weight loss. The director of nursing (DON) was interviewed on 6/12/24 at 1:05 p.m. The DON said Resident #54 experienced significant weight loss and the facility did not identify it. The DON said no new nutrition interventions were implemented to prevent further weight loss after 2/5/24. The DON said no new weights were obtained for Resident #54 after she sustained severe weight loss on 2/5/24. The DON said Resident #54 should have had her significant weight loss identified in her plan of care and more weights should have been obtained after 2/5/24 to monitor the resident' s status. The DON said the facility could have offered a nutritional supplement, such as a Mighty shake (frozen nutritional supplement), to help maintain Resident #54' s weight. The DON said she was not aware of any inaccurate scales in the facility. The DON was interviewed again on 6/12/24 at 4:32 p.m. The DON said the Quality Assurance and Performance Improvement (QAPI) committee had identified that the facility had an issue obtaining and documenting weights in the facility within the last few months, but had not implemented a correction plan. The DON said she needed to work with the RD to ensure residents were getting weighed on a regular basis. The DON said she needed to review weight loss interventions in the facility to ensure they were being updated and documented.

A revisit survey was completed on 1/22/24 for all previous deficiencies cited on 11/17/23. The facility is in compliance with all regulations surveyed.

A survey prompted by #CO32855, #CO34030, #CO34182 and #CO34071 was conducted on 11/4/23 through 11/17/23. One deficiency was cited.

Based on record review and interviews, the facility failed to take steps to prevent one (#2) of three residents reviewed for wandering of 12 sample residents safe from eloping from the facility. Specifically, the facility:-Failed to identify goals and interventions on the baseline care plan to ensure Resident #2 ' s health and safety related to elopement;-Failed to ensure a thorough shift report was provided to the oncoming nurse during change of shift to inform of Resident #2 ' s wandering activities, and-Failed to ensure Resident #2 did not elope from the facility. Findings include:I. Facility policy and procedureThe Elopement, Risk Reduction Strategies, and Management of Missing Residents policy, dated 7/17/23, was provided by the director of nursing (DON) on November 22, 2023 at 6:57 a.m. It included the following:An elopement risk assessment is completed by the nursing staff on all residents at admission, readmission, quarterly, upon change of condition, and after an elopement event. The initial resident assessment is conducted at admission if possible, otherwise no later than eight hours from admission. A facility-approved risk assessment tool (or scoring system is utilized. The assessment is based on various risk factors that may precipitate an elopement event. The risk score includes a defined parameter which, when reached, indicates an increased risk and prompts risk reduction strategies, as described below. The risk assessment and new resident observation addresses the resident ' s mobility and psychological, behavioral, physical, and cognitive functions. Specific risk factors include: An involuntary admission, a history of wandering prior to admission or finding the resident "lost" in the facility after admission. Any cognitive impairment which results in an inability of the resident to appreciate safety risks and an inability to protect themselves. Actual wandering behaviors (wandering due to boredom or lack of activity, pacing, exit-seeking or hovering at exits. The policy included the following risk reduction measures for residents identified as high risk for elopement: Frequent monitoring of the resident ' s whereabouts, room placement close to communal areas, promoting activities that are in full view of staff members, alternate activities to maintain the interest level of the wanderer, and implementation of wander bracelet or other electronic alert system. The policy did not include risk reduction measures for residents identified to be "at risk to wander."II. Resident #2 A. Resident #2 statusResident #2, age 82, was admitted on 7/14/23 for a five-day respite stay. According to the July 2023 computerized physician orders, diagnoses included Alzheimer ' s disease and recurrent major depressive disorder. The 7/14/23 minimum data set (MDS) entry assessment documented the resident was admitted to the facility from the community, and a comprehensive MDS assessment was not due. The 7/16/23 MDS discharge assessment documented the resident had an unplanned discharge from the facility to an acute hospital, with no return anticipated. B. Record reviewThe baseline care plan, initiated 7/14/23, identified health and safety concerns related to the resident ' s cognition. He was admitted to the facility for a five-day respite stay and was confused as to place and dates. He was independent with bed mobility, transfers, and walking, and required set up help with dressing, toileting and grooming/hygiene. The care plan documented the resident was "ambulating throughout the building at this time, gait steady." He was identified to be at risk for falls as evidenced by impaired cognition, Alzheimer ' s disease, and "poor safety awareness yet is independent with mobility ..." The section for Elopement Risk was void of documentation. There were no interventions or goals identified to ensure his health and safety. The activities section of the baseline care plan identified Resident #2 ' s activities and hobbies documented that he liked movies, but was unable to answer which kinds of movies when given a list to choose from. He said he did not really like TV or music. There were no interventions or goals identified related to his activity preferences. The Admission Evaluation Assessment, dated 7/14/23 at 7:05 p.m., documented the resident had a walker at home but did not use it, ambulation was unsteady at times, was oriented to the call light but was forgetful, and "will continue to monitor."The Wandering Risk Observation/Assessment, dated 7/14/23, documented a score of nine out of 23, which indicated he was at risk to wander. (Low risk score was zero to eight, at risk to wander was nine to 10, and high risk to wander was 11 to 23). The assessment included Resident #2 had a history of wandering (past hospitalization or history from resident/family). The Nursing—Daily Skilled Charting, dated 7/14/23 at 10:31 p.m., documented Resident #2 was confused most of the time, wandering looking for downstairs. A call was placed to the resident ' s family member who confirmed the resident had confusion. "One on one monitoring" was documented, but no additional details or documentation was completed regarding this. The teaching/training notes included call light was in reach but not used as instructed, and staff to anticipate needs, and "every two hour checks." There was no documentation to indicate every two hour checks were completed. The Nursing—Daily Skilled Charting, dated 7/15/23 at 10:47 a.m., documented Resident #2 was confused and unable to make his needs known due to confusion, and did not understand how to use the call light, but it was kept in reach. "Staff anticipate his needs and provide cares ...Monitor stand by assist ambulating in halls, wonders [sic] into other residents ' rooms."There were no additional interventions implemented to address Resident #24 ' s wandering. The Incident Report for Resident #2 ' s elopement documented the event occurred on 7/15/23 and the facility became aware that he was missing at 6:15 p.m. He was last seen at 5:45 p.m. walking near the main entrance of the facility. The facility notified the resident ' s son, who was out of town, and the local police department who also began to search for him as well. Another resident informed facility staff that she had seen Resident #2 sitting on a bench outside the main entrance at 5:45 p.m., and when she reentered the facility at 6:15 p.m., he was no longer sitting there. A full search of the facility rooms were completed three times, and multiple staff members were walking the streets in search of the resident. The incident report documented the resident was "not known to be an exit seeker or elopement risk," which was not consistent with the above Wandering Risk Observation/Assessment or the Nursing Daily Skilled Charting documentation. There was no additional documentation or discharge summary related to Resident #2 ' s current disposition or discharge from the facility. C. Family interviewsResident #2 ' s family member was interviewed on 11/9/23 at 2:42 p.m. She said after the facility notified her that the resident was missing, she immediately got on the phone and called her children to go out and start looking for him as well. She said a local hospital notified them that Resident #2 was found at approximately 2:40 a.m. on the railroad tracks by a railroad worker. The location was approximately four blocks from the facility and missing for over seven hours. He had cuts on his arms, elbows, knees and had a bruise on the side of his face. He was taken to a local emergency department by ambulance and they were told he had no significant injuries. She said they did not want the resident to return to the facility when he was discharged and they took him home. III. Staff interviewsRegistered nurse (RN) #1 was Resident #2 ' s nurse on the day of his elopement, and she was interviewed on 11/14/23 at 3:10 p.m. She said she was not informed that Resident #2 was at risk for elopement or that he had tried to elope previously. She said during the afternoon of that shift, she had been informed that someone had seen the resident outside, in an alcove on a bench in front of the facility. She explained that if she would have known he was at risk for elopement, she would not have allowed him to be outside alone. She said he was not wearing a wander guard and the facility staff initiated a search for him immediately when they realized he was missing. She said the facility did not have a photo to give the police, so a family member was asked to provide that to aid in their search. She said she was very upset that he was missing and was determined to stay at the facility until he was found, but it was getting late and she was forced to go home. She said she did not take the time to read the previous nursing documentation that stated he was wandering at times in the facility. The activities director (AD) was interviewed on the afternoon of 11/17/23 and she said had been in that position for a few months. She remembered Resident #2 and said he was admitted late in the afternoon on a Friday, and he was not evaluated by the activities staff before the weekend. She said there were no therapeutic interventions implemented for him related to person centered activities. The DON was interviewed on 11/17/23 at 3:30 p.m. She said she had been the facility ' s DON since September 2023, and was in that position at the time of Resident #2 ' s elopement. She said the nursing change of shift report usually included general aspects about the residents ' day, any changes that were noticed that day or from previous shifts, any behaviors, new orders, and vital signs changes. She said residents were allowed to go outside and out the front doors without supervision, if they did not have a wander guard on. The DON said the facility ' s process for first assessing residents for their risk of wandering or elopement was completed during their initial assessment to the facility upon admission. She said their electronic medical record included a pop up screen that prompted the nurse to complete upon admission. She said prior to Resident #2 ' s elopement, the initial elopement assessment was required to be completed within eight hours, but that had been shortened to four hours for all newly admitted residents. The DON said it could be difficult to determine a resident ' s risk for wandering when they were new to the facility, and would hope the family could provide a wandering history. She said nursing staff might place a wander guard on someone if there was a concern, and see if it was appropriate. She said placing a wander guard long term required getting permission from the family and receiving an order for it from the physician. Moving forward, she said they would be watching residents who were confused more closely, because they do not want someone to get out and become missing. The DON said she was not aware that the family of Resident #2 said he had a history of wandering, or that he was identified by the facility staff as "at risk to wander." She said Resident #2 was admitted on a weekend evening (Friday), and she would have expected the nursing staff to place a wander guard on him until the department heads were in the facility to help make that final decision and stated, "because we can always take someone outside if they want to go out with a wander guard."The DON said the one to one monitoring meant that one staff member would sit with that resident for 24 hours per day, which she did not feel was possible due to their current level of staffing. Rather, she said frequent monitoring would be something they could implement, which would be every 15 or 30 minute checks. She said a floor nurse could initiate having the certified nurse aides (CNA) complete frequent checks and document them, and to keep doing them until the resident settled down or they could figure out a better way to care for them. The DON said another intervention that could have been implemented for Resident #2 when he was wandering into other residents ' rooms was redirection or distraction with an activity. She said even though Resident #2 was admitted for a five day respite stay, he should have had his interests and activities explored because they did not want a person sitting in their room for five days without anything to do, unless it was their preference to do so. The DON said knowing what was charted in Resident #2 ' s clinical record, and he was wandering and actively exit seeking, he should have had a wander guard placed. She said, "That is the safest way."

A COVID-19 survey with complaint #CO30805, #CO30910 and #CO30920 was conducted 2/21/23. No deficiencies were cited.

An Emergency Preparedness COVID-19 survey was conducted on 2/21/23. No deficiencies were cited.