MANTEY HEIGHTS REHABILITATION & CARE CENTER

A recertification survey with complaint #CO38018 and #CO38090 was completed on 12/16/24 to 12/19/24. Nine deficiencies were cited.

An Emergency Preparedness survey was conducted from 12/16/24 to 12/19/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#63) of two residents out of 46 sample residents. Specifically, the facility failed to ensure Resident #63's proxy selected or refused life-saving treatments within the power of a proxy. Findings include:I. Medical Orders for Scope of Treatment (MOST) formThe MOST form documented that a Proxy-by-Statute (decision maker selected through a proxy process) may not decline artificial nutrition or hydration for an incapacitated resident without an attending physician and a second physician trained in neurology who certified that artificial nutrition or hydration would merely prolong the act of dying and was unlikely to result in the restoration of the resident to independent neurological functioning. II. Resident statusResident #63, age greater than 65, was admitted on 6/25/24. According to the December 2024 computerized physician orders (CPO), diagnoses included vascular dementia, atrial fibrillation (irregular heart rhythm), stroke and anxiety. The 10/1/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. III. Record reviewA proxy selection document, completed on 4/12/24, revealed that Resident #63 lacked decision-making capacity after experiencing multiple strokes and had a proxy appointed. Resident #63's MOST form, completed on 4/14/24, documented the resident was a do-not-resuscitate (DNR), indicating the resident did not want cardiopulmonary resuscitation (CPR). Resident #63's MOST form was completed by his proxy and the proxy declined artificial nutrition on 4/14/24.-However, the facility failed to have a physician's note signed by the resident's physician and a neurologist declaring the artificial nutrition was only prolonging death, as was required and instructed on the MOST form (see above). IV. Staff interviewsThe social services director (SSD) was interviewed on 12/18/24 at 3:41 p.m. The SSD said he was not sure what the legal difference between a proxy and a power of attorney for healthcare was. The SSD reviewed the instructions printed on the back of Resident #63's MOST form. The SSD said he was not aware a proxy could not choose to decline artificial nutrition by tube without supporting documentation by a physician. The director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 12/19/24 at 4:51 p.m. The DON said a proxy was similar to a power of attorney with less legal power. The DON said she did not know if there was any part of the MOST form a proxy could not complete. The DON reviewed Resident #63's MOST form. The DON said she was not aware a proxy could not decline artificial nutrition by tube without supporting documentation by a physician. The NHA said a proxy could not complete the section outlining artificial nutrition on a MOST form. The NHA said Resident #63's MOST form would be updated today (12/19/24) to reflect only the decisions the resident's proxy could legally make.

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Based on observation, record review and interviews, the facility failed to ensure two (#9 and #65) of four residents reviewed for nutrition out of 46 sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being. Resident #9 was admitted to the facility for long-term care on 11/6/15 with diagnoses of unspecified disorder of psychological development, cerebral palsy, and cerebellar ataxia (difficulty with balance). On 8/20/24, Resident #9 weighed 167.2 pounds (lbs). On 9/24/24, Resident #9 weighed 160 lbs., a weight loss of 7.2 lbs (4.3%) in one month, which was not significant. However, the facility failed to implement nutritional interventions or closer monitoring of the resident's weight to prevent further weight loss for the resident. The resident's care plan documented that the facility implemented a nutritional intervention on 11/5/24 which included providing the resident with nutritional supplements two times per day, however, the intervention did not assist the resident to gain weight and the resident's weight continued to decline. On 12/11/24, Resident #9 weighed 144.8 pounds. Resident #9 lost 15.2 lbs (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe weight loss. The resident lost 22.4 lbs (13.4%) from 8/20/24 to 12/11/24, in less than six months, which was considered severe weight loss.-Despite the resident's severe weight loss, the facility failed to implement additional nutritional interventions. Due to the facility's failure to effectively implement nutrition interventions to prevent weight loss timely, Resident #9's weight sustained a severe weight loss of 9.5% in less than three months and 13.4% in less than six months. Additionally, Resident #65 was admitted to the facility on 8/23/24 with diagnoses of chronic kidney disease, asthma and adult failure to thrive. Upon admission, the resident weighed 268.4 pounds (lbs). On 12/3/24, Resident #65 weighed 248.8 lbs. Resident #65 sustained a 19.6 lbs (7.3%) weight change from 8/23/24 to 12/3/24, in less than six months, which was not considered significant weight loss. However, an interview with the registered dietician (RD) revealed that she was unaware Resident #65 was experiencing weight loss because the nursing staff cleaned the trigger alerting that the resident was losing weight. A nutritional assessment performed by the RD on 12/2/24 documented Resident #65 was malnourished, however, the facility failed to implement nutritional interventions to address the resident's malnourishment. Findings include: I. Facility policy and procedureThe Food and Nutrition policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It documented in pertinent part,"The multidisciplinary staff, including nursing staff, the attending physician and the dietician will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutritional plan will be based on this assessment."Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident's medication requirements."Reasonable efforts will be made to accommodate resident choices and preferences."The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed."If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new tray can be issued."Nourishing snacks are available to the residents 24 hours a day. The resident may request a snack as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. The Nutritional Assessment policy, revised October 2017, was provided by the NHA on 12/19/24 at 5:38 p.m. It documented in pertinent part,"As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with 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 preference. II. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 11/6/15. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified disorder of psychological development, cerebral palsy and cerebellar ataxia (difficulty with balance). The 11/4/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required set-up or clean-up assistance while eating and was dependent on staff for assistance with all other activities of daily living (ADL). The assessment documented the resident was 66 inches (5 foot, 6 inches) tall. The assessment documented the resident weighed 161 lbs. The assessment documented the resident had not experienced any weight loss or weight gain. The assessment documented the resident did not require a specialty or therapeutic diet. B. Observations and resident interviewsDuring a continuous observation in the main dining hall on 12/16/24, beginning at 11:18 a.m. and ending at 12:40 p.m., the following was observed:At 11:18 a.m. 13 residents were in the dining room. Resident #9 was sitting at a table by himself. At 12:14 p.m. Resident #9 was served his lunch tray. Resident #9 was provided with thick-handled silverware and a tall divided plate. At 12:26 p.m. Resident #9 finished eating his meal and self-propelled himself in his wheelchair out of the dining room.-Resident #9 was not offered additional food after consuming 100% of his lunch meal. Resident #9 was interviewed on 12/17/24 at 10:21 a.m. Resident #9 said he knew he had lost weight but did not know how much. Resident #9 said he felt weaker now than he did before. Resident #9 said the food in the dining hall did not taste good, but he would eat it anyway. Resident #9 said he sometimes felt hungry after eating a meal. Resident #9 said facility staff did not offer him extra food when he finished eating all of his food. During a continuous observation on 12/18/24, beginning at 4:26 p.m. and ending at 6:02 p.m. the following was observed:At 4:44 p.m. Resident #9 self-propelled himself into the dining room in his wheelchair. Resident #9 sat at a table by himself. At 5:35 p.m. Resident #9 received his dinner tray which included one scoop of plain mashed potatoes, a small plastic cup half full of ice cream and one small glass of chocolate milk. At 5:36 p.m. Resident #9 slammed his cup down on the table and said "This meal is stupid!"At 5:48 p.m. Resident #9 received an additional plate containing two sunny-side up eggs. At 5:56 p.m. Resident #9 finished eating 100% of his meal and drank all of his chocolate milk. Resident #9 then self-propelled himself in his wheelchair out of the dining hall. Resident #9 was interviewed again on 12/18/24 at 6:01 p.m. Resident #9 said he ate all of his dinner and still felt hungry. Resident #9 said he would eat more food if they had something he liked to eat in the kitchen. Resident #9 said he was not offered additional food after eating his entire dinner meal today.-Resident #9 was not offered additional food after consuming 100% of his dinner meal. C. Record reviewThe nutrition care plan, initiated 5/30/17 and revised 11/5/24, revealed a goal of maintaining Resident #9's weight through the review period and ensuring Resident #9 did not have signs or symptoms of malnutrition. Interventions included that the resident often skipped lunch, the resident was not allowed to drink coffee, obtaining and recording weights per the facility protocol, the RD to evaluate and make diet change recommendations as needed, occupational therapy to screen and provide adaptive equipment as needed, providing and serving diet as ordered, providing oral nutritional supplements and recording intakes every meal.-A review of the comprehensive care plan revealed there were no new or revised interventions implemented after the resident sustained severe weight loss on 12/11/24. Resident #9's weights were documented in the EMR as follows:-On 8/20/24, the resident weighed 167.2 lbs;-On 9/3/24, the resident weighed 162.2 lbs;-On 9/17/24, the resident weighed 160.8 lbs;-On 9/24/24, the resident weighed 160 lbs; -On 10/1/24, the resident weighed 160.8 lbs;-On 11/1/24, the resident weighed 161 lbs;-On 12/4/24, the resident weighed 142.2 lbs;-On 12/5/24, the resident weighed 145.6 lbs; and,-On 12/11/24, the resident weighed 144.8 lbs.-The resident lost 15.2 lbs (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe weight loss.-The resident lost 22.4 lbs (13.4%), from 8/20/24 to 12/11/24, in less than six months, which was considered severe weight loss. A review of Resident #9's December 2024 CPO revealed the following physician's orders related to nutrition:Regular diet, regular texture, thin liquid consistency, ordered 8/1/23. Offer snacks three times a day, ordered 4/26/24. Nutritional supplement, two times per day, ordered 11/5/24. Mini-nutritional assessment documentation, dated 8/6/24, documented that Resident #9 was at risk of malnutrition because he had lost between 2.2 and 6.6 lbs in the last three months and had a moderate decrease in food intake.-Despite the resident's documented risk for malnutrition, the facility failed to implement additional nutritional supplements. Dietary profile documentation, dated 11/4/24, documented that Resident #9 required partial assistance with eating. The assessment documented that Resident #9 required special utensils and/or assistive devices to eat. The profile documented that Resident #9 received regular-sized portions, had a good appetite and his favorite meal was dinner. The profile documented Resident #9 enjoyed eating grains and fruits. The profile documented Resident #9 did not like vegetables. The profile documented Resident #9 enjoyed chocolate, peanut butter and bananas. The profile documented that Resident #9 was eating snacks in between meals. Mini-nutritional assessment documentation, dated 11/5/24, documented that Resident #9 had not lost any weight, and had no decrease in food intake. The assessment documented that Resident #9 had a normal nutritional status and was not at risk of malnutrition. -However, the resident had lost 6.2 lbs between 8/20/24 and 11/1/24. The interdisciplinary team (IDT) weight variance note, dated 12/6/24, documented that Resident #9's most recent weight was 145.6 lbs and the resident had experienced a weight loss of 9.3% since he weighed 161 lbs on 11/1/24. The note documented that Resident #9's average intake was 25% to 75% of his meals. The note documented the resident had recently tested positive for COVID-19, but his intakes were improving.-However, despite the identified severe weight loss, the facility failed to implement additional nutritional interventions. Resident #9's meal intake documentation was reviewed between 11/19/24 and 12/18/24. Out of 83 meal opportunities, Resident #9 ate more than 75% of 32 meals, 51% to 75% of five meal opportunities, 26% to 50% of 13 meal opportunities and less than 25% of three meal opportunities. The facility documented Resident #9 refused his meal on 22 occasions. -However, there was no documentation in the resident's EMR of the facility re-offering meals or other meal alternatives to the resident after he refused the offered meals.-Additionally, the resident's nutritional plan of care did not include interventions to address Resident #9's meal refusals (see plan of care above). Resident #9's snack intake documentation was reviewed between 11/19/24 and 12/18/24. In the 30-day review period, snacks were offered three times per day on five days. The facility documented snacks were offered to Resident #9 one time per day on 21 of those days. The facility documented no snacks were offered to Resident #9 on two of those days.-The facility failed to offer snacks three times per day as ordered by the physician (see physician's orders above). III. Resident #65A. Resident statusResident #65, age greater than 65, was admitted on 8/23/24. According to the December 2024 CPO, diagnoses included chronic kidney disease, asthma and adult failure to thrive. The 11/30/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required moderate assistance with bathing and was independent of all other ADLs. The assessment documented the resident was 64 inches (5 foot, 4 inches) tall. The assessment documented the resident weighed 267 lbs. The assessment documented the resident had not experienced any weight loss or weight gain. The assessment documented the resident did not require a specialty or therapeutic diet. The assessment documented the resident did not have any rejections of care. B. Observations and resident interviewResident #65 was interviewed on 12/17/24 at 10:32 a.m. Resident #65 said she was new to the facility and did not like the food that was served. Resident #65 said when she was first admitted to the facility she would often eat breakfast in her room, however, she said the food that was delivered to her room was always cold. Resident #65 said she began going to the dining room in the last few weeks so she could eat her food when it was still warm. Resident #65 said sometimes she could not eat the food because it was room temperature. Resident #65 said she had lost weight because of the food at the facility. Cross-reference F804 for food palatability. During a continuous observation on 12/18/24, beginning at 4:26 p.m. and ending at 6:02 p.m., the following was observed:At 4:56 p.m. Resident #65 entered the dining room and sat at a table with Resident #9. At 5:36 p.m. Resident #65 received her meal tray. She received mashed potatoes with gravy, carrots, a small cup half full of ice cream and a breaded chicken breast. At 5:37 p.m. Resident #65 requested her meal be reheated because it was served cold. An unidentified staff member took Resident #65's tray to the kitchen to reheat it. At 5:39 p.m. an unidentified staff member brought Resident #65's plate of food back to her. Resident #65 began to eat her meal. At 5:59 p.m. Resident #65 left the dining room. Resident #65 had eaten only the gravy off the top of the mashed potatoes and a few carrots, but ate all of her breaded chicken and ice cream. Resident #65 was interviewed again on 12/18/24 at 6:02 p.m. Resident #65 said her food was delivered to her cold at dinner. Resident #65 said the dining staff reheated her food in the kitchen but the food was still cold. Resident #65 said she could not eat the mashed potatoes because they were cold but the gravy on top was warm enough to eat. Resident #65 said she felt very frustrated that the kitchen struggled to bring her food that was warm enough to eat. Resident #65 said she felt it was not important to the facility to serve decent food to residents. C. Record reviewThe nutrition care plan, initiated 9/12/24 and revised 12/2/24, revealed a goal of maintaining Resident #65's weight through the review period, ensuring Resident #65 consumed more than 50% of two meals per day and ensuring Resident #65 did not have signs or symptoms of malnutrition. Interventions included providing and serving supplements as ordered, providing and serving diet as ordered andfor the RD to evaluate and make change recommendations as needed.-However, the resident did not have a physician's order for nutritional supplements and there was no documentation in the resident's EMR to indicate she was receiving a nutritional supplement (see physician's orders below). Resident #65's weights were documented in the electronic medical record (EMR) as follows:-On 8/23/24, the resident weighed 268.4 lbs;-On 8/25/24, the resident weighed 266.8 lbs;-On 8/26/24, the resident weighed 267 lbs;-On 9/2/24, the resident weighed 258 lbs; -On 10/1/24, the resident weighed 254 lbs;-On 11/1/24, the resident weighed 251 lbs; and-On 12/3/24, the resident weighed 248.8 lbs.-The resident lost 19.6 lbs (7.3%), from 8/26/24 to 12/3/24, in less than six months, which was not considered significant weight loss.-A review of Resident #65's December 2024 CPO failed to reveal any physician's orders for nutritional supplements. The Mini-nutritional assessment, dated 9/1/24, documented that Resident #65 was of normal nutritional status and was not at risk for malnutrition. The assessment documented Resident #65 had experienced no weight loss and had no decrease in her food intake. The Mini-nutritional assessment, dated 12/2/24, documented that Resident #65 was malnourished. The assessment documented the resident had experienced a weight loss greater than 6.6 lbs and had a moderate decrease in food intake. The assessment documented that nutritional supplements would be provided and served as ordered.-However, a review of Resident #65's December 2024 CPO revealed there were no physician's orders for nutritional supplements (see physician's orders above). Resident #65's meal intake documentation was reviewed between 11/20/24 and 12/19/24. Out of 86 meal opportunities, Resident #65 ate more than 75% on 50 meal opportunities, 51% to -75% on 16 meal opportunities, 26% to -50% on 13 opportunities and less than 25% of her meal on five opportunities. Resident #65's snack intake documentation was reviewed between 11/20/24 and 12/19/24. In 30 days of opportunities, snacks were offered to Resident #65 on nine of those days. The documentation included 11 days that Resident #65 refused snacks. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 12/18/24 at 8:57 a.m. LPN #2 said she did not know if Resident #9 or Resident #65 were losing weight. LPN #2 reviewed the EMRs for Resident #9 and Resident #65. LPN #2 said Resident #9 was losing weight according to what was documented in the EMR, but she said she did not know why the resident was losing weight. LPN #2 said that offering snacks, supplements and extra food at meal times could all help Resident #9 gain weight. LPN #2 said Resident #65 had lost weight as well but she did not know why. Certified nurse aide (CNA) #7 was interviewed on 12/18/24 at 6:04 p.m. CNA #7 said Resident #9 and Resident #65 were both good at eating at dinner and sometimes enjoyed sitting together. CNA #7 said she did not know if Resident #9 or Resident #65 were experiencing weight loss. CNA #7 said she thought Resident #65 did not enjoy her meal this evening (12/18/24) because she asked it to be heated up but then did not eat it all. CNA #7 said she did not offer Resident #65 additional food because she did not seem to like what she was given the first time. LPN #3 was interviewed on 12/19/24 at 8:49 a.m. LPN #3 said when a resident experienced weight loss, the care plan would be updated and nursing staff and the RD worked together to find a way to stop the weight loss. LPN #3 said what was offered to decrease weight loss was different for every resident. LPN #3 said she did not know if Resident #9 or Resident #65 had experienced weight loss. The RD was interviewed on 12/19/24 at 11:17 a.m. The RD said she had worked at the facility for two years. The RD said she came to the building once a week in the middle of the week. The RD said her nutritional assessment process included reviewing information documented in the EMR, speaking to the residents about their preferences and observing the residents in the dining room, if possible. The RD said when a resident experienced weight loss, she would perform an assessment of the resident, place a progress note in the EMR, discuss the situation weekly in the risk meeting and the resident's care plan was updated with new interventions. The RD said she input the interventions into care plans at the facility. The RD said if a resident continued to lose weight despite new interventions, the resident's care plan should be reviewed and nutritional interventions should be changed or modified. The RD said residents who experienced weight loss should have additional or alternative food offered if they ate their entire plate of food during a meal. The RD said if a resident enjoyed a dessert for example, she would see if the facility could provide a double dessert or a second serving of a food item the resident liked. The RD said it was always better for residents to get their nutrition from food rather than supplements, if possible. The RD said if a resident received a cold meal or a meal that was not palatable to them, she would want the resident to let staff know so they could fix the meal to be more palatable for the resident. The RD said she would discuss food preferences with the resident and update that information in the resident's EMR.The RD reviewed Resident #9's EMR. The RD said Resident #9 was on her radar for weight loss before she took a medical leave in September 2024, but she did not know exactly how much weight he had lost. The RD said a weight loss trigger was inaccurately cleared on 9/3/24 by registered nurse (RN) #3, during the time of her medical leave before she returned to work on 9/12/24. The RD said the clearing of the weight loss trigger caused a delay for the facility to implement interventions for Resident #9.-However, Resident #9's documented weights identified the resident sustained a 15.2 lb (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe, and the facility failed to implement additional nutritional interventions for the resident (see record review above). The RD said she was not aware that Resident #65 was losing weight. The RD said that RN #3 had also cleared the weight loss trigger notification warning in the resident's EMR. The RD said without that notification, she would have to manually calculate weight loss in all residents which was not feasible. The RD said Resident #65's weight loss caught her by surprise. The RD said she had not performed further evaluation or assessment of Resident #65's weight loss. The RD said Resident #65 did not have physician's orders to obtain weights weekly and the facility should begin watching her weight more closely. The director of nursing (DON) was interviewed on 12/19/24 at 4:51 p.m. The DON said she expected the RD to identify residents who experienced weight loss. The DON said she discussed residents who experienced weight loss on a weekly basis and the IDT then determined if there were additional contributing factors to the weight loss. The DON said the IDT would find the cause for the weight loss and could recommend interventions, such as double portions or food alternatives. The DON reviewed Resident #9's EMR. The DON said Resident #9 was not offered enough snacks. The DON said residents who experienced weight loss and consistently ate their entire meal should have additional food offered to them. The DON said Resident #65 should have palatable food offered to her. The DON said Resident #65 was not being monitored for weight loss but would be monitored more closely going forward.

Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care consistent with professional standards of practice, the resident's care plan, goals and preferences for two (#32 and #70) of two residents reviewed for respiratory care out of 46 sample residents. Specifically, the facility failed to: -Implement a care plan focus with purpose, goals and interventions to document Resident #32 and Resident #70's goals for using a Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure (CPAP/BiPAP) machine; -Develop and implement effective interventions to maintain and clean Resident #32 and Resident #70's CPAP/BiPAP machines to ensure the non-invasive mechanical ventilators were maintained in a hygienic manner; and,-Develop and implement effective interventions for oxygen therapy for Resident #32 and Resident #70. Findings include:I. Manufacturer's recommendations The ResMed AirSense10 manufactures User Guide, dated 2021, was provided by the nursing home administrator (NHA) on 12/18/24 at 1:30 p.m. It read in pertinent part, "It is important that you regularly clean your AirSense 10 device to make sure you receive optimal therapy. "Regular cleaning of the tubing assembly, water tub, and mask prevents the growth of germs that can adversely affect health."Wash the water tube and air tube with warm water and mild detergent, rinse thoroughly and allow to dry thoroughly. Wipe the outer machine with a dry clean cloth."Clean the water tub and remove any white powder using a solution of one part household vinegar to 10 parts water. Replace any damaged parts. Check the air filter and replace it every six months or earlier if heavily soiled with dirt or dust. The filters are not washable or reusable."The device records your therapy data, so your care provider can view the data and make changes to your therapy if required."The VOCSN (ventilator, oxygen concentrator, cough assist, suction, and nebulizer) Clinical and Technical Manual, dated 2024, was provided by the NHA on 12/18/24 at 1:30 p.m. It read in pertinent part, "Clean the outside of the machine between each use with a CaviWipe, Super Sani Cloth, Oxivir or Safetec SaniZide Plus cloth. "Inspect the machine: Clean the air filters and fan filters every two weeks with warm water and mild detergent; rinse and allow to air dry. Do this to ensure the internal components are protected from dirt and dust. Replace the filters every six months. "Replace the external bacterial and nebulizer filters every 30 days or when compromised, and the internal bacterial filter when it becomes contaminated."II. Facility policy and procedureThe CPAP/BiPAP Support policy, revised March 2015, was provided by the NHA on 12/19/24 at 3:43 p.m. It read in pertinent part, "Specific cleaning instructions are obtained from the manufacturers/suppliers of the PAP device. Machine cleaning: Wipe the machine with warm soapy water and rinse at least once a week and as needed. "Humidifier is used: Fill with distilled water only in the humidifier chamber. Clean the humidifier weekly and air dry. To disinfect, place the vinegar water solution in the cleaned humidifier, soak for 30 minutes and rinse thoroughly. "Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. Replace disposable filters once a month. "Mask, nasal pillows and tubing: Clean daily by placing in warm soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. "Headgear/strap: Wash with warm water and mild detergent as needed and allow to air dry."III. Resident #32A. Resident status Resident #32, age 74, was admitted on 8/27/24. According to the December 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and respiratory failure with hypoxia (low levels of oxygen in the body's tissues). The 12/6/24 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated the resident used a non-invasive mechanical ventilator. B. Resident interview and observation Resident #32 was interviewed on 12/16/24 at 3:30 p.m. Resident #32 said her CPAP machine was very important to her health and she needed to use the machine to get a good night's sleep. Resident #32 said the nursing staff did not take measures to clean her CPAP machine, so she did it herself. She said it was too hard to clean her CPAP equipment in the sink in her room and there was no good place to dry the tubing. She said when she was home, her husband cleaned her machine for her. Observation of Resident #32's CPAP machine, a ResMed AirSensor 10 model, and room revealed the resident had no vinegar or detergent to be able to effectively clean her CPAP per the manufacturer's recommendations (see above). The larger hose looked dusty and had some whitish sediment inside. The CPAP nasal mask foam and straps were soiled with black marks and a pinkish-orange stain. The mask was stained with a whitish cloudy substance and was hooked to the nightstand, exposed to air and was not protected from airborne debris and bacteria. Resident #32 said she was not sure when the CPAP mask had last been replaced, but she said it had been a while. She said she had used the CPAP machine for 20 years. C. Record reviewReview of Resident #32's December 2024 CPO revealed the following physician's order: Resident to use CPAP when napping/sleeping at the setting of 15, every shift, ordered 10/23/24.-A review of Resident #32's comprehensive care plan revealed the care plan failed to document the resident's use of a CPAP machine and oxygen therapy. IV. Resident #70A. Resident status Resident #70, age less than 65, was admitted on 8/27/24. According to the December 2024 CPO, diagnoses included COPD, respiratory failure with hypoxia and heart failure. The 12/8/24 MDS assessment revealed the resident had intact cognition, however, the BIMS assessment was not completed. The assessment indicated the resident was receiving oxygen therapy and was using a non-invasive mechanical ventilator. B. Resident interview and observation Resident #70 was interviewed on 12/16/24 at 3:30 p.m. Resident #70 said he rented his BiPAP machine from a respiratory provider and the provider checked on the machine once in a while. Resident #70 said he was responsible for cleaning the machine, but he said he was unable to take the tubing and water reservoir apart to clean it due to his limited finger dexterity. Observation of the resident's BiPAP machine, a VOCSN model, revealed the resident had no supplies to clean the machine. The BiPAP mask was placed in the machine stand basket with miscellaneous items exposed to air and was not protected from airborne debris and bacteria. C. Record reviewReview of Resident #70's December 2024 CPO revealed the following physician's orders: Respiratory Orders: BIPAP with 6 LPM (liters per minute) of oxygen bled in at night to maintain O2 (oxygen) saturation between 87 to 94 percent (%) one time a day for COPD, ordered 8/27/24. Continuous oxygen at 6 LPM by nasal cannula. Titrate O2 to keep O2 saturation between 87% to 94%, every shift for COPD, ordered 8/27/24.-A review of Resident #70's comprehensive care plan revealed the care plan failed to document the resident's use of a BiPAP machine and oxygen therapy. V. Staff interviews Registered nurse (RN) #4 was interviewed on 12/18/24 at 11:25 a.m. RN #4 said the daytime nurses were not responsible for maintaining the residents' CPCP/BiPAP machines. She said the night shift nurses changed the oxygen in each of the residents' oxygen devices once a week. RN #4 said she thought the night nurses also cleaned the residents' oxygen machines at night but was not sure what they did to clean the machines. Licensed practical nurse (LPN) #3 was interviewed on 12/19/24 at 1:30 p.m. LPN #3 said the night nurses were responsible for maintaining and cleaning Resident #32 and #70's CPAP/BiPAP machines. The director of nursing (DON) and the NHA were interviewed on 12/19/24 at 4:00 p.m. The DON said the residents' CPAP and BiPAP machines were managed by the respiratory provider who supplied them to the resident. The DON said the company would come to the facility weekly to change tubing and maintain the equipment. The DON said the CPAP/BiPAP mask and tubing should be washed daily and believed the resident or their family were performing those tasks.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature. Findings include:I. Facility policy and procedureThe Food and Nutrition Services policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It read in pertinent part,"Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. "Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident, or a meal does not appear palatable, the nursing staff will report it to the food service manager so that a new food tray can be issued."II. Resident interviewsResident #11 was interviewed on 12/15/24 at 1:59 p.m. Resident #11 said the food was always served cold. Resident #11 said the food was bland and did not taste good. Resident #51 was interviewed on 12/16/24 at 9:02 a.m. Resident #51 said the food was served cold. Resident #10 was interviewed on 12/19/24 at 8:51 a.m. Resident #10 said the food was served cold. Resident #65 was interviewed on 12/18/24 at 6:02 p.m. Resident #65 said she received a chicken cordon bleu with hollandaise sauce, carrots, mashed potatoes with gravy and a dinner roll. Resident #65 said her meal was not good and the food was served cold. She said the staff offered to reheat the plate for the resident. She said after her plate was reheated her food was still cold. Resident #65 said her mashed potatoes were extremely cold. Resident #65 said each time she received cold food she did not want to eat it and felt it was not important to the facility to serve decent food to the residents. III. Resident group interviewA group interview consisting of five residents (#229, #35, #8, #36 and #20) who were assessed by the facility to be interviewable was conducted on 12/19/24 at 5:58 p.m. The residents said meals were served cold and it did not matter if the residents ate in their rooms or the dining room. Resident #20 said the food was bland and most of the time cheese was not served melted. IV. ObservationsDinner observations were completed on 12/18/24 and revealed the following:The cook (CK) prepared chicken cordon bleu with a hollandaise sauce, mashed potatoes with gravy, cooked carrots, dinner roll and ice cream. The alternative meal was served as Italian wedding soup with the residents choice of sides. A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for dinner on 12/18/24 at 6:16 p.m. The test tray consisted of chicken cordon bleu without the hollandaise sauce, mashed potatoes with gravy, a dinner roll and Italian wedding soup. The Italian wedding soup was 115.5 degrees Fahrenheit (F). The soup was salty and the vegetables were undercooked. The mashed potatoes were gummy and gritty. The chicken cordon bleu felt lukewarm and had a temperature of 121 degrees F..V. Resident council notesResident council notes from 12/6/24 revealed the residents were concerned they were still not receiving food that was hot, especially in the dining room. The residents said when they requested their food to be warmed up it was still served cold. VI. Staff interviewsThe dietary manager (DM), the NHA and the director of nursing (DON) were interviewed together on 12/19/24 at 6:11 p.m. The DM said he had to leave during the meal service and was confident in his team's ability to serve dinner. The DM said he failed to try the CK's food before he had to leave. The DM said the soup had been cooking for hours and the vegetables should have been softened by the time it was served. He said he did not know the soup was salty. The DM said when the kitchen ran low on a meal item the CK should start preparing more or delegate it to another staff member to get more food so the residents would not go without food items. The NHA said the facility was aware of the complaints of the food's palatability and that was the reason the facility experienced a lot of turnover in the kitchen. The NHA said with the current DM there have been improvements but the DM had only been in the facility for about a month. The NHA said the food was getting better and was going to continue to improve.

Based on observations, record review and interviews the facility failed to ensure 10 (#12, #64, #4, #15, #41, #55, #7, #44, #18 and #129) of 17 residents with an order for a mechanically altered diet texture out of 46 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 #12, #64, #4, #15, #41, #55, #7, #44 and #18 with the correct altered mechanical soft diet texture: and,-Provide Resident #129 with the correct altered pureed diet texture. Findings include:I. Professional referenceThe comparison of National Dysphagia Diet (NDD) and International Dysphagia Diet Standardization Initiative (IDDSI), reviewed July 2021, was retrieved on 12/29/24 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 air way. 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, finalized January 2019, was retrieved on 12/29/24: 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:-Meat is cooked tender and chopped so pieces are no bigger than half an inch by half an inch lump size. If the meat cannot be served soft and tender, the meat needs to be served as minced and moist (chopped with a sauce);-Fish is cooked soft enough to break and serve pieces are no bigger than half an inch by half an inch;-Fruit is soft and chopped into pieces no bigger than half an inch by half an inch with any excess liquid drained. Do not use fibrous parts of the fruit;-Vegetables are steamed or boiled with the final cooked size no bigger than half an inch by half an inch. Stir-fried vegetables are too firm and are not suitable;-Cereal is served with pieces no bigger than half an inch by half an inch with their texture fully softened. Drain excess liquid before serving;-No regular bread due to a high choking risk; and,-Rice requires a sauce to moisten it and hold it together. Rice should not be sticky or gluey and should not separate into individual grains when cooked and served."Food 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."The Pureed Framework, finalized January 2019, was retrieved on 1/2/5 from https://www.iddsi.org/images/Publications-Resources/PatientHandouts/English/Adults/4_pureed_adults_consumer_handout_30jan2019.pdf. It read in pertinent part, "Level 4, pureed foods:-Are usually eaten with a spoon;-Do not require chewing; -Have a smooth texture with no lumps;-Hold shape on a spoon;-Fall off a spoon in a single spoonful when tilted;-Are not sticky; and,-Liquid (like sauces) must not separate from solids."Level 4 - Pureed Food may be used if you are not able to bite or chew food or if your tongue control is reduced. Pureed foods only need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing. It's important that puree foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. Pureed foods are best eaten using a spoon."Examples of foods to avoid:-Mixed thin and thick textures: Soup with pieces of food, cereal with milk;-Hard or dry food: nuts, raw vegetables (carrots, cauliflower, broccoli), dry cakes, bread, dry cereal;-Tough or fibrous foods: steak, pineapple;-Chewy: lollipops/candies/sweets, cheese chunks, marshmallows, chewing gum, sticky mashed potato, dried fruits, sticky foods:-Crispy; crackling, crisp bacon, cornflakes;-Crunchy food: Raw carrot, raw apple, popcorn:-Sharp or spiky: corn chips and crisps;-Crumbly bits: dry cake crumble, dry biscuits;-Pips, seeds: Apple seeds, pumpkin seeds, white of an orange;-Food with skins or outer shell: peas, grapes, chicken skin, salmon skin, sausage skin;-Foods with husks: corn, shredded wheat, bran; -Bone or gristle: chicken bones, fish bones, other bones, meat with gristle;-Round, long shaped food: sausage, grapes;-Sticky or gummy food: nut butter, overcooked oatmeal/porridge, edible gelatin, konjac containing jelly, sticky rice cakes;-Stringy food: beans, rhubarb;-Floppy foods: lettuce, cucumbers, uncooked baby spinach leaves;-Crust formed during cooking or heating: crust or skin that forms on food during cooking or after heating, for example, cheese topping, mashed potato;-Juicy food: where juice separates from the food piece in the mouth, for example watermelon; and,-Visible lumps: Lumps in pureed food or yogurt."II. Facility policyThe Therapeutic Diets policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It read in pertinent part, "Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. A therapeutic diet must be prescribed by the resident's attending physician. A diet order should match the terminology used by the food and nutrition services department. "A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or alter the texture of a diet. If a mechanically altered diet is ordered the provider will specify the texture modification. Snacks will be compatible with the therapeutic diet."III. Facility diet manual for mechanical softThe Diet Manual, revised 2022, was provided by the NHA on 12/19/24 at 10:00 a.m. It read in pertinent part,"Mechanical soft diet (dysphagia advanced level three, similar to IDDSI soft and bite-sized level six): this diet provides a texture modification of the regular diet for residents with mild oral and/or pharyngeal phase dysphagia. Foods must be soft, tender and moist with no thin liquid leaking or dripping from food. The ability to bite off a piece of food is not required. The ability to chew bite-sized pieces is required. Foods that are difficult to chew are chopped, ground, shredded or cooked to make them easier to chew and swallow. "General guidelines:Ease of chewing may be increased by mashing, chopping or slenderizing; pour syrups, honey or juices over bread products such as pancakes, french toast, waffles and muffins; serve soft crackers and other breads in soup; use gravies, broths and sauces on ground meats, poultry and other dishes; well-cooked, soft (or mashed) vegetables without skin, mashed potatoes and vegetable juices are well-tolerated; there are two divisions of mechanical soft chopped half-inch pieces and ground eight-inch pieces. Pay attention to specific differentiations in how to prepare food for both."Avoid vegetables that are raw or crunchy, vegetables with skin or husks like peas and corn, no stringy or floppy vegetables like string beans, celery, lettuce, cucumber and baby spinach leaves; and potatoes with skins or crispy fried potatoes."Protein must be very tender, small pieces and chopped to half-inch pieces moistened with gravy or sauce. Avoid tough or dry meats, poultry or fish."IV. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on 11/24/14. According to the December 2024 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (neurological disorder), malignant neoplasm of floor of mouth (oral cancer), dysphagia (difficulty swallowing) oral and oropharyngeal phase and alcohol dependence with alcohol-induced persisting dementia. The 10/7/24 minimum data set (MDS) assessment revealed Resident #12 was not assessed for a brief interview for mental status (BIMS). The assessment indicated Resident #12 was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 5:30 p.m., the cook (CK) served Resident #12 regular unthickened Italian Wedding soup with chopped vegetables in the soup and a regular dinner roll. Resident #12's meal ticket revealed the resident needed thickened Italian wedding soup and a soaked dinner roll.-The facility failed to serve the resident thickened soup with carrots no bigger than half-inch by half-inch in the soup.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #12's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 11/1/24. Resident #12's dental care plan, initiated 3/19/24, revealed the resident was at risk for alteration of oral hygiene, mouth and or teeth due to a history of oral cancer. Interventions included assisting the resident with coordinating dental care, providing the resident with his diet as ordered and providing oversight management to the resident's care. V. Resident #64A. Resident statusResident #64, age greater than 65, was admitted 8/19/24. According to the December 2024 CPO, diagnoses included Alzheimer's disease with late onset, dysphagia oral and oropharyngeal phase, cognitive communication deficit and dementia. The 12/6/24 MDS assessment revealed Resident #64 had a severe cognitive impairment with a BIMS score of zero out of 15. The assessment indicated Resident #64 required substantial or maximal assistance with eating and was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 5:59 p.m., Resident #64 ordered the main entree, which was chicken cordon bleu. The cook (CK) served the resident a chicken cordon bleu that was cut into one-inch pieces and a whole regular roll.-The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #64's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 10/17/24. Resident #64's nutrition care plan, initiated 9/19/24, revealed the resident was on a regular diet. Interventions included occupational therapy screens and adaptive equipment as needed, providing and serving his diet as ordered, the registered dietitian (RD) to evaluate and make diet change recommendations and referring to the resident's likes and dislikes.-However, the facility failed to update Resident #64's care plan when he was ordered a mechanical soft texture change on 10/17/24. VI. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on 7/5/22. According to the December 2024 CPO, diagnoses included dementia, dysphagia oropharyngeal phase and Alzheimer's disease with late onset. The 10/30/24 MDS assessment revealed Resident #4 was unable to participate in the BIMS assessment due to rarely being understood. The staff assessment revealed Resident #4 had short and long-term memory problems. The resident's daily decision-making skills were severely impaired. The assessment indicated Resident #4 was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 6:04 p.m., the CK served Resident #4 chicken cordon bleu cut into one-inch pieces, and a regular roll cut into bite-sized pieces.-The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch size pieces.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #4's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 12/13/23. Resident #4's nutrition care plan, revised on 4/30/24, revealed the resident was easily distracted during meals. Interventions included providing and serving diet as ordered and referring to the resident's likes and dislikes. VII. Resident #15A. Resident statusResident #15, age greater than 65, was admitted on 10/25/22. According to the December 2024 CPO, diagnoses included dementia and dysphagia oropharyngeal phase. The 10/8/24 MDS assessment revealed Resident #15 was unable to participate in the BIMS assessment due to rarely being understood. The staff assessment revealed Resident #15 had short and long-term memory problems. The resident's daily decision-making skills were severely impaired. The assessment indicated Resident #15 was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 5:09 p.m. the CK served Resident #15 chicken cordon bleu cut into one-inch pieces, a regular dinner roll was cut into bite-sized pieces and a bowl of regular Italian wedding soup.-The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll.-The facility failed to serve the resident soup with carrots no bigger than half-inch by half-inch in the soup. C. Record reviewReview of Resident #15's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 8/2/23. Resident #15's nutrition care plan, revised 11/13/23, revealed the resident was on a mechanical soft diet. Pertinent interventions included having the resident eat at the assist table in the dining room, offering the resident brunch when she slept through breakfast, providing and serving her diet as ordered and referring to her likes and dislikes. VIII. Resident #41A. Resident statusResident #41, age greater than 65, was admitted on 5/5/23. According to the December 2024 CPO, diagnoses included dementia, dysphagia oropharyngeal phase and senile degeneration of the brain. The 12/5/24 MDS assessment revealed Resident #41 had severe cognitive impairment with a BIMS score of one out of 15. The assessment indicated Resident #41 was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 5:14 p.m. the CK served Resident #41 regular Italian Wedding soup with a regular roll cut into bite-sized pieces. Resident #41's meal ticket revealed the soup needed to be thickened and the roll needed to be soaked.-The facility failed to serve the resident thickened soup with carrots no bigger than half-inch by half-inch in the soup.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #41's December 2024 CPO revealed a physician's order for a mechanical soft textured diet with extra gravy or sauce at each meal, ordered 5/6/23. Resident #41's nutrition care plan, revised 11/22/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving her diet as ordered and referring to her likes and dislikes. IX. Resident #55A. Resident statusResident #55, age greater than 65, was admitted on 12/1/23. According to the December 2024 CPO, diagnoses included seizures, cognitive communication deficit and dysphagia oropharyngeal phase. The 9/17/24 MDS assessment revealed Resident #55 had severe cognitive impairment with a BIMS score of three out of 15. The assessment indicated Resident #55 was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 6:05 p.m. the CK served Resident #55 chicken cordon bleu cut into one-inch pieces with no sauce and a regular roll cut into bite-sized pieces.-The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces and serve it with extra gravy or sauce.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #55's December 2024 CPO revealed a physician's order for a mechanical soft textured diet with extra gravy or sauce at each meal and nectar thick liquids, ordered 12/13/24. Resident #55's nutrition care plan, revised 12/18/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving his diet as ordered and referring to his likes and dislikes. X. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on 5/24/23. According to the December 2024 CPO, diagnoses included epilepsy, dementia and dysphagia oropharyngeal phase. The 10/16/24 MDS assessment revealed Resident #7 had a mild cognitive impairment with a BIMS score of 12 out of 15. B. ObservationsOn 12/18/24 at 5:25 p.m. the CK served Resident #7 chicken cordon bleu cut into one-inch pieces and a roll cut into bite-sized pieces.-The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #7's December 2024 CPO revealed a physician's order for a mechanical soft textured diet, ordered 10/24/24. Resident #7's nutrition care plan, revised 7/15/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving her diet as ordered and referring to her likes and dislikes. XI. Resident #44A. Resident statusResident #44, age greater than 65, was admitted on 7/20/22. According to the December 2024 CPO, diagnoses included a mild cognitive impairment and dysphagia oropharyngeal phase. The 10/25/24 MDS assessment revealed Resident #44 was cognitively intact with a BIMS score of 15 out of 15. The assessment indicated Resident #44 was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 5:28 p.m. the CK served Resident #44 two portions of chicken cordon bleu cut into one-inch pieces and two regular rolls cut into bite-sized pieces.-The facility failed to cut the resident's chicken into no bigger than half-inch by half-inch sized pieces.-The facility failed to serve the resident soaked dinner rolls that were very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #44's December 2024 CPO revealed a physician's order for a mechanical soft textured diet and double portions, ordered 7/20/22. Resident #44's nutrition care plan, revised 4/22/24, revealed the resident was on a mechanical soft diet. Interventions included providing double portions with each meal, providing and serving his diet as ordered and referring to his likes and dislikes. XII. Resident #18A. Resident statusResident #18, age greater than 65, was admitted on 3/2/23. According to the December 2024 CPO, diagnoses included heart failure and dysphagia oropharyngeal phase. The 12/10/24 MDS assessment revealed Resident #18 was unable to participate in the BIMS assessment due to rarely being understood. The staff assessment revealed Resident #18 had short and long-term memory problems. The resident's daily decision-making skills were severely impaired. The assessment indicated Resident #18 was on a mechanically altered diet requiring a change in the texture of foods. B. ObservationsOn 12/18/24 at 5:54 p.m. the CK served Resident #18 a bowl of regular Italian wedding soup and a whole regular roll.-The facility failed to serve the resident thickened soup with carrots no bigger than half-inch by half-inch in the soup.-The facility failed to serve the resident a soaked dinner roll that was very moist and soaked through the entire thickness of the roll. C. Record reviewReview of Resident #18's December 2024 CPO revealed a physician's order for a mechanical soft textured diet and nectar thick liquids, ordered 7/12/24. Resident #18's nutrition care plan, revised 3/7/24, revealed the resident was on a mechanical soft diet. Interventions included providing and serving her diet as ordered and referring to her likes and dislikes. XIII. Resident #129A. Resident statusResident #129, age greater than 65, was admitted on 12/12/24. According to the December 2024 CPO, diagnoses included Alzheimer's disease with late onset and dementia. The 12/18/24 MDS assessment revealed Resident #129 had a severe cognitive impairment with a BIMS score of zero out of 15. B. ObservationOn 12/18/24 at 6:12 p.m., the CK served Resident #129 a bowl of watery pureed Italian wedding soup.-The facility failed to serve the resident pureed soup in a thick, mashed potato-like consistency. C. Record reviewReview of Resident #129's December 2024 CPO revealed a physician's order for a pureed textured diet, ordered 12/14/24. Resident #129's nutrition care plan, initiated 12/16/24, revealed the resident was on a pureed diet. Interventions included providing and serving the resident her diet as ordered and referring to her likes and dislikes. XIV. Staff interviewsThe dietary manager (DM) was interviewed on 12/18/24 at 4:45 p.m. The DM said residents who were on a mechanical soft textured diet were able to eat bread that was wet and cut into bite-sized pieces. The CK was interviewed on 12/18/24 at 5:13 p.m. The CK said the residents were able to eat bread if the bread was soft and cut into bite-sized pieces. He was unaware how big or small the pieces needed to be. Dietary aide (DA) #1 was interviewed on 12/18/24 at 5:59 p.m. DA #1 said the residents who received whole rolls did not like having their rolls cut up and that was how he always served the residents no matter what their diet textures were. The DM and the NHA were interviewed together on 12/19/24 at 6:11 p.m. The DM said he was unaware the facility had a diet manual that explained the difference in textures for mechanically altered diets. The NHA said she provided the DM with the diet manual. The DM said he was going to ensure he trained his staff on diet textures. He said if a resident was served the wrong diet texture, the resident could choke and the facility wanted to prevent that. The DM said the chicken needed to be cut in half-inch by half-inch pieces The DM said the CK should have soaked the dinner rolls

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.conditions in the kitchen. Specifically, the facility failed to:-Ensure the staff medications were not stored in the walk-in refrigerator with resident food;-Ensure the staff wore a beard net while preparing and serving meals; and,-Ensure the air vent above the food service line was free of dust and dirt. Findings include:I. Failure to ensure staff medications were not stored in the walk-in refrigeratorA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, Chapter 7-5, effective 3/16/24, was retrieved on 12/29/24, revealed in pertinent part, "Medicines belonging to employees that require refrigeration and are stored in a food refrigerator shall be stored in a package or container and kept inside a covered, leakproof container that is identified as a container for the storage of medicines."B. Observations During the initial tour of the main kitchen on 12/16/24 at 9:57 a.m. the walk-in refrigerator had a plastic bag on the top shelf next to the resident's food. Inside the plastic bag was an insulin pen and glucose test strips. The medication and bag were not labeled. C. Staff interviewsThe dietary manager (DM) was interviewed on 12/16/24 at 1:00 p.m. The DM said the insulin pen belonged to a dining staff member. The DM said he put the insulin pen in the walk-in refrigerator because he had nowhere else to store it. The DM said he was not aware medications could not be stored in the refrigerator with food. II. Ensure kitchen staff wore appropriate hair restraints while preparing and serving foodA. Professional referenceThe Colorado Retail Food Establishment Regulations, Chapter 2-21, effective 3/16/24, were retrieved on 12/29/24, revealed in pertinent part, "Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens."B. ObservationsDuring a continuous observation on 12/16/24, from 11:37 a.m. to 12:33 p.m., the following was observed:At 11:37 a.m., dietary aide (DA) #1 was at the kitchen serving window without a beard net or hair net on. His facial hair was approximately half an inch long. At 11:59 a.m., two unidentified male staff were in the kitchen without beard nets on. The cook (CK) had a beard that was roughly two inches long. At 12:00 p.m., an unidentified maintenance worker was in the kitchen walking around the food preperation area while food was being served without a beard net on. His beard was down to his chest, approximately six to seven inches long. During a continuous observation on 12/18/24, from 4:30 p.m. to 6:15 p.m., the following was observed:From 4:30 p.m. to 6:15 p.m. DA #1 was not wearing a beard net and his facial hair was longer approximately half an inch long. At 5:59 p.m. the CK returned to the kitchen and did not have his beard net on. His beard was approximately two inches long. C. Staff interviewsThe DM was interviewed on 12/16/24 at 1:00 p.m. The DM said he was informed beard nets were only required if the facial hair was longer than one-quarter of an inch. He said he never thought about having the kitchen staff wear beard nets. The DM was interviewed again on 12/19/24 at 6:11 p.m. The DM said he told the staff they needed to wear beard nets in the kitchen and was not sure why some of the staff continued to not wear anything. He said the staff member that had a long beard was a staff member from the maintenance department. The DM said he was not aware that the maintenance staff needed to wear a beard net in the kitchen too. III. Ensure the kitchen vents were free of dust and dirtA. Professional referenceThe Colorado Retail Food Establishment Regulations, Chapter 6-3, effective 3/16/24, were retrieved on 12/29/24, revealed in pertinent part: "Attachments to walls and ceilings such as light fixtures, mechanical room ventilation system components, vent covers, wall mounted fans, decorative items and other attachments shall be easily cleanable."Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt and other materials."B. Facility policy and procedure The Sanitation policy, revised November 2022, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. and read in pertinent part,"All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions."C. ObservationsDuring the initial tour of the kitchen on 12/16/24 at 9:57 a.m. the air vent above the stove and food service line was covered in black dust. Some areas were thick and built up more than other areas. During the meal observation on 12/18/24 at 4:30 p.m. the air vent above the stove and food service line remained covered in black dust. Some of the areas were thick and built up more than other areas. The air conditioning system was on and was blowing the black dust around. D. Staff interviewsThe DM was interviewed on 12/19/24 at 6:11 p.m. The DM said the air conditioning was not supposed to be on during meal service. He said he had not realized the vent was covered in thick, black dust. The DM said he was going to get the air vent cleaned.

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 implement an effective water management plan. Findings include:I. Professional referenceAccording to Center for Disease Control (CDC), "Controlling Legionella in Potable Water Systems", last reviewed 3/15/24, was retrieved on 12/31/24 from https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.htmlIt read in pertinent part, "Operation, maintenance, and control limits guidance:"Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability."Hot water: Store hot water at temperatures above 140°F (degrees Fahrenheit) or 60°C (degrees Celsius). Ensure hot water in circulation does not fall below 120°F (49°C). Recirculate hot water continuously, if possible."Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113°F, 25-45°C). Legionella may grow at temperatures as low as 68°F (20°C)."Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits."Ensure disinfectant residual is detectable throughout the potable water system."Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly."Consider testing for Legionella in accordance with the routine testing module of this toolkit."B. Facility policy and procedureThe Legionella Water Management Program policy and procedure, dated 6/26/23, was provided by the maintenance director (MTD) on 12/17/24 at 2:03 p.m. It documented in pertinent part,"Dead run: flush and drain, if possible. Ideally, remove dead legs or redesign to allow for water recirculation, along with unused equipment and water lines from the system. Eliminate or minimize the use of rubber, plastic and silicone gaskets in the plumbing system. These materials may serve as growth substrates for bacteria, including legionella and other pathogenic microbes. Location: Various locations throughout the building. Frequency: Biannual and ongoing projects ..."-However, the CDC recommended that all dead legs and low flow piping runs should be flushed at least weekly to prevent the growth and spread of legionella (see professional reference above)."Risk factor: Electronic and manual faucets: visually inspect for biofilm, scale, dirt, and debris buildup and clean with mild biocide such as vinegar, acidic cleaner or other cleaner.. Location: All units. Frequency: weekly, 25% of fixtures on a rotational basis ..."-However, the CDC recommended that all dead legs and low flow piping runs should be flushed at least weekly to prevent the growth and spread of legionella (see professional reference above)."Water systems: little-used outlets. Flush for several minutes and until temperature stabilizes and is comparable to supply water. Have a flush program defined in the water management plan by the team."The Housekeeping Cleaning procedure, not dated, was provided by the MTD on 12/17/24 at 4:24 p.m. It documented that housekeeping staff flushed toilets daily. C. Record reviewThe water management maintenance logs were provided by the MTD on 12/17/24 at 3:14 p.m. The maintenance logs documented the facility tested for legionella on 11/6/24 which was negative. The maintenance logs documented the maintenance department was conducting weekly flushing for five minutes and checking water temperatures for many locations throughout the building which included the laundry room sink, boiler room mixing valve, kitchen sinks, therapy room sink, two staff bathrooms, both bathing room tubs and sinks, the salon sink, the basement bathroom, and the basement hot water mixing valve. -The facility failed to document when empty resident rooms had been appropriately flushed to prevent the growth of legionella. On 12/17/24 at 5:12 p.m., the nursing home administrator (NHA) documented that two resident rooms had been unoccupied for seven contiguous days or more in the last 60 days. The NHA documented one of those unoccupied rooms had been vacant for seven contiguous days on two separate occasions.-The water management plan failed to document when empty resident rooms had low flow piping runs and lead legs flushed. D. ObservationsHousekeeper (HK) #1 was observed cleaning room #8 on 12/19/24 at 12:24 p.m. During the room cleaning, the sink faucet was not turned on or flushed. D. Staff interviewsThe MTD was interviewed on 12/17/24 at 4:07 p.m. The MTD said she had taken a legionella water management class previously and understood how to prevent the growth of legionella. The MTD said she started in this role in October 2024. The MTD said the water management plan was not hers and she did not contribute to forming the water management plan. The MTD said a few resident rooms were chosen each month to be flushed. She said not all resident rooms were flushed every month because rooms were chosen on a rotational basis. The MTD said all of the toilets were flushed daily as part of resident use and daily cleaning by housekeeping. The MTD said dead legs and low flow piping runs were flushed biannually. The MTD was interviewed again on 12/17/24 at 4:27 p.m. The MTD said she was told to flush the resident's rooms monthly. The MTD said that housekeepers flush sinks daily as part of their cleaning, but there was no specific documentation that the sinks had been flushed to prevent the growth of legionella. The MTD said the housekeepers documented the type of cleaning that was performed and this was sufficient to prove that sinks had been flushed. The MTD and the regional maintenance director (RMD) were interviewed together on 12/17/24 at 5:06 p.m. The MTD and the RMD said that flushing dead legs and low flow piping runs biannually was sufficient to prevent the growth and spread of legionella. The RMD said if the facility were to create a new dead leg it would be managed in accordance with the written water management plan. HK #1 was interviewed on 12/19/24 at 12:31 p.m. HK #1 said she had worked at the facility for several years. HK #1 said she did not turn on the sink when she cleaned room #8 today (12/19/24). HK #1 said she received training on how to clean resident rooms, but she did not receive education or instruction to flush sinks while she cleaned rooms. HK #1 said she normally flushed the toilets during every room clean.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for two (#28 and #43) of five residents out of 46 sample residents. Specifically, the facility failed to offer pneumococcal vaccinations to Resident #28 or Resident #43. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 1/2/25, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part, "Routine vaccination-pneumococcal: For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20).""For those over the age of 65 who meet age requirements and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20."Special situations: Age 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups."Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies."Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies."II. Resident #28A. Resident statusResident #28, over the age of 65, was admitted on 7/29/24. According to the December 2024 computerized physician orders (CPO), diagnoses included bipolar disorder, gastroesophageal reflux disease (GERD) and benign prostatic hyperplasia (BPH). The 10/29/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident had not received the pneumonia vaccine. The assessment documented the facility did not offer the pneumonia vaccine to the resident. B. Record review-Review of the resident's electronic medical record (EMR) did not reveal documentation of the most recent pneumonia vaccine offered or received by the resident. Documentation provided by the nursing home administrator (NHA) on 12/18/24 at 10:22 a.m. documented that Resident #28 had been offered the pneumonia vaccine on 12/18/24 (during the survey).-The facility failed to offer Resident #28 a pneumococcal vaccination prior to 12/18/24. III. Resident #43A. Resident statusResident #43, over the age of 65, was admitted on 7/5/22. According to the December 2024 CPO, diagnoses included dementia, hypertension (high blood pressure) and depression. The 10/26/24 MDS assessment revealed the resident had severe cognitive impairment and was unable to complete a BIMS assessment because she was rarely understood. The assessment documented the resident received a pneumococcal vaccination on 10/13/24.-However, there was no documentation in the resident's EMR to indicate the resident received a pneumococcal vaccination on 10/13/24 or that a vaccination consent had been obtained prior to 12/18/24 (see record review below). B. Record reviewReview of Resident #43's EMR revealed the resident received a Prevnar 13 pneumococcal vaccination on 8/22/18.-There was no documentation to indicate the resident had received an updated pneumococcal vaccination prior to 12/18/24 (see below). Documentation provided by the NHA on 12/18/24 at 10:22 a.m. documented that Resident #43 had been offered the pneumonia vaccine on 12/18/24 (during the survey).-The facility failed to offer Resident #43 a pneumococcal vaccination prior to 12/18/24. IV. Staff interviewsThe infection preventionist (IP) was interviewed on 12/19/24 at 12:59 p.m. The IP said she had been in her role for a few months and only gained access to the state immunization system in November 2024. The IP said the normal process for the facility was to go through all residents' vaccination consents and declinations at the same time as influenza and COVID-19 immunizations in October of each year. The IP said Resident #28 and Resident #43 were not offered a pneumococcal immunization before 12/18/24. The IP said Resident #28 and Resident #43 should have had a pneumococcal immunization offered to them prior to 12/18/24The director of nursing (DON) was interviewed on 12/19/24 at 4:51 p.m. The DON said vaccinations should be offered to residents according to the recommendations of the CDC. The DON said Resident #28 and Resident #43 should have been offered a pneumococcal vaccination prior to 12/18/24.

A survey prompted by complaint #CO38848 was completed on 12/16/24 to 12/19/24. One deficiency was cited.

Based on observation, record review and interviews, the facility failed to ensure two (#9 and #65) of four residents reviewed for nutrition out of 46 sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being. Resident #9 was admitted to the facility for long-term care on 11/6/15 with diagnoses of unspecified disorder of psychological development, cerebral palsy, and cerebellar ataxia (difficulty with balance). On 8/20/24, Resident #9 weighed 167.2 pounds (lbs). On 9/24/24, Resident #9 weighed 160 lbs., a weight loss of 7.2 lbs (4.3%) in one month, which was not significant. However, the facility failed to implement nutritional interventions or closer monitoring of the resident's weight to prevent further weight loss for the resident. The resident's care plan documented that the facility implemented a nutritional intervention on 11/5/24 which included providing the resident with nutritional supplements two times per day, however, the intervention did not assist the resident to gain weight and the resident's weight continued to decline. On 12/11/24, Resident #9 weighed 144.8 pounds. Resident #9 lost 15.2 lbs (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe weight loss. The resident lost 22.4 lbs (13.4%) from 8/20/24 to 12/11/24, in less than six months, which was considered severe weight loss.-Despite the resident's severe weight loss, the facility failed to implement additional nutritional interventions. Due to the facility's failure to effectively implement nutrition interventions to prevent weight loss timely, Resident #9's weight sustained a severe weight loss of 9.5% in less than three months and 13.4% in less than six months. Additionally, Resident #65 was admitted to the facility on 8/23/24 with diagnoses of chronic kidney disease, asthma and adult failure to thrive. Upon admission, the resident weighed 268.4 pounds (lbs). On 12/3/24, Resident #65 weighed 248.8 lbs. Resident #65 sustained a 19.6 lbs (7.3%) weight change from 8/23/24 to 12/3/24, in less than six months, which was not considered significant weight loss. However, an interview with the registered dietician (RD) revealed that she was unaware Resident #65 was experiencing weight loss because the nursing staff cleaned the trigger alerting that the resident was losing weight. A nutritional assessment performed by the RD on 12/2/24 documented Resident #65 was malnourished, however, the facility failed to implement nutritional interventions to address the resident's malnourishment. Findings include: I. Facility policy and procedureThe Food and Nutrition policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/19/24 at 5:38 p.m. It documented in pertinent part,"The multidisciplinary staff, including nursing staff, the attending physician and the dietician will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutritional plan will be based on this assessment."Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident's medication requirements."Reasonable efforts will be made to accommodate resident choices and preferences."The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed."If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new tray can be issued."Nourishing snacks are available to the residents 24 hours a day. The resident may request a snack as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. The Nutritional Assessment policy, revised October 2017, was provided by the NHA on 12/19/24 at 5:38 p.m. It documented in pertinent part,"As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with 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 preference. II. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 11/6/15. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified disorder of psychological development, cerebral palsy and cerebellar ataxia (difficulty with balance). The 11/4/24 facility assessment revealed the resident was moderately cognitively impaired. He required set-up or clean-up assistance while eating and was dependent on staff for assistance with all other activities of daily living (ADL). The assessment documented the resident was 66 inches (5 foot, 6 inches) tall. The assessment documented the resident weighed 161 lbs. The assessment documented the resident had not experienced any weight loss or weight gain. The assessment documented the resident did not require a specialty or therapeutic diet. B. Observations and resident interviewsDuring a continuous observation in the main dining hall on 12/16/24, beginning at 11:18 a.m. and ending at 12:40 p.m., the following was observed:At 11:18 a.m. 13 residents were in the dining room. Resident #9 was sitting at a table by himself. At 12:14 p.m. Resident #9 was served his lunch tray. Resident #9 was provided with thick-handled silverware and a tall divided plate. At 12:26 p.m. Resident #9 finished eating his meal and self-propelled himself in his wheelchair out of the dining room.-Resident #9 was not offered additional food after consuming 100% of his lunch meal. Resident #9 was interviewed on 12/17/24 at 10:21 a.m. Resident #9 said he knew he had lost weight but did not know how much. Resident #9 said he felt weaker now than he did before. Resident #9 said the food in the dining hall did not taste good, but he would eat it anyway. Resident #9 said he sometimes felt hungry after eating a meal. Resident #9 said facility staff did not offer him extra food when he finished eating all of his food. During a continuous observation on 12/18/24, beginning at 4:26 p.m. and ending at 6:02 p.m. the following was observed:At 4:44 p.m. Resident #9 self-propelled himself into the dining room in his wheelchair. Resident #9 sat at a table by himself. At 5:35 p.m. Resident #9 received his dinner tray which included one scoop of plain mashed potatoes, a small plastic cup half full of ice cream and one small glass of chocolate milk. At 5:36 p.m. Resident #9 slammed his cup down on the table and said "This meal is stupid!"At 5:48 p.m. Resident #9 received an additional plate containing two sunny-side up eggs. At 5:56 p.m. Resident #9 finished eating 100% of his meal and drank all of his chocolate milk. Resident #9 then self-propelled himself in his wheelchair out of the dining hall. Resident #9 was interviewed again on 12/18/24 at 6:01 p.m. Resident #9 said he ate all of his dinner and still felt hungry. Resident #9 said he would eat more food if they had something he liked to eat in the kitchen. Resident #9 said he was not offered additional food after eating his entire dinner meal today.-Resident #9 was not offered additional food after consuming 100% of his dinner meal. C. Record reviewThe nutrition care plan, initiated 5/30/17 and revised 11/5/24, revealed a goal of maintaining Resident #9's weight through the review period and ensuring Resident #9 did not have signs or symptoms of malnutrition. Interventions included that the resident often skipped lunch, the resident was not allowed to drink coffee, obtaining and recording weights per the facility protocol, the RD to evaluate and make diet change recommendations as needed, occupational therapy to screen and provide adaptive equipment as needed, providing and serving diet as ordered, providing oral nutritional supplements and recording intakes every meal.-A review of the comprehensive care plan revealed there were no new or revised interventions implemented after the resident sustained severe weight loss on 12/11/24. Resident #9's weights were documented in the EMR as follows:-On 8/20/24, the resident weighed 167.2 lbs;-On 9/3/24, the resident weighed 162.2 lbs;-On 9/17/24, the resident weighed 160.8 lbs;-On 9/24/24, the resident weighed 160 lbs; -On 10/1/24, the resident weighed 160.8 lbs;-On 11/1/24, the resident weighed 161 lbs;-On 12/4/24, the resident weighed 142.2 lbs;-On 12/5/24, the resident weighed 145.6 lbs; and,-On 12/11/24, the resident weighed 144.8 lbs.-The resident lost 15.2 lbs (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe weight loss.-The resident lost 22.4 lbs (13.4%), from 8/20/24 to 12/11/24, in less than six months, which was considered severe weight loss. A review of Resident #9's December 2024 CPO revealed the following physician's orders related to nutrition:Regular diet, regular texture, thin liquid consistency, ordered 8/1/23. Offer snacks three times a day, ordered 4/26/24. Nutritional supplement, two times per day, ordered 11/5/24. Mini-nutritional assessment documentation, dated 8/6/24, documented that Resident #9 was at risk of malnutrition because he had lost between 2.2 and 6.6 lbs in the last three months and had a moderate decrease in food intake.-Despite the resident's documented risk for malnutrition, the facility failed to implement additional nutritional supplements. Dietary profile documentation, dated 11/4/24, documented that Resident #9 required partial assistance with eating. The assessment documented that Resident #9 required special utensils and/or assistive devices to eat. The profile documented that Resident #9 received regular-sized portions, had a good appetite and his favorite meal was dinner. The profile documented Resident #9 enjoyed eating grains and fruits. The profile documented Resident #9 did not like vegetables. The profile documented Resident #9 enjoyed chocolate, peanut butter and bananas. The profile documented that Resident #9 was eating snacks in between meals. Mini-nutritional assessment documentation, dated 11/5/24, documented that Resident #9 had not lost any weight, and had no decrease in food intake. The assessment documented that Resident #9 had a normal nutritional status and was not at risk of malnutrition. -However, the resident had lost 6.2 lbs between 8/20/24 and 11/1/24. The interdisciplinary team (IDT) weight variance note, dated 12/6/24, documented that Resident #9's most recent weight was 145.6 lbs and the resident had experienced a weight loss of 9.3% since he weighed 161 lbs on 11/1/24. The note documented that Resident #9's average intake was 25% to 75% of his meals. The note documented the resident had recently tested positive for COVID-19, but his intakes were improving.-However, despite the identified severe weight loss, the facility failed to implement additional nutritional interventions. Resident #9's meal intake documentation was reviewed between 11/19/24 and 12/18/24. Out of 83 meal opportunities, Resident #9 ate more than 75% of 32 meals, 51% to 75% of five meal opportunities, 26% to 50% of 13 meal opportunities and less than 25% of three meal opportunities. The facility documented Resident #9 refused his meal on 22 occasions. -However, there was no documentation in the resident's EMR of the facility re-offering meals or other meal alternatives to the resident after he refused the offered meals.-Additionally, the resident's nutritional plan of care did not include interventions to address Resident #9's meal refusals (see plan of care above). Resident #9's snack intake documentation was reviewed between 11/19/24 and 12/18/24. In the 30-day review period, snacks were offered three times per day on five days. The facility documented snacks were offered to Resident #9 one time per day on 21 of those days. The facility documented no snacks were offered to Resident #9 on two of those days.-The facility failed to offer snacks three times per day as ordered by the physician (see physician's orders above). III. Resident #65A. Resident statusResident #65, age greater than 65, was admitted on 8/23/24. According to the December 2024 CPO, diagnoses included chronic kidney disease, asthma and adult failure to thrive. The 11/30/24 facility assessment revealed the resident was cognitively intact. She required moderate assistance with bathing and was independent of all other ADLs. The assessment documented the resident was 64 inches (5 foot, 4 inches) tall. The assessment documented the resident weighed 267 lbs. The assessment documented the resident had not experienced any weight loss or weight gain. The assessment documented the resident did not require a specialty or therapeutic diet. The assessment documented the resident did not have any rejections of care. B. Observations and resident interviewResident #65 was interviewed on 12/17/24 at 10:32 a.m. Resident #65 said she was new to the facility and did not like the food that was served. Resident #65 said when she was first admitted to the facility she would often eat breakfast in her room, however, she said the food that was delivered to her room was always cold. Resident #65 said she began going to the dining room in the last few weeks so she could eat her food when it was still warm. Resident #65 said sometimes she could not eat the food because it was room temperature. Resident #65 said she had lost weight because of the food at the facility. During a continuous observation on 12/18/24, beginning at 4:26 p.m. and ending at 6:02 p.m., the following was observed:At 4:56 p.m. Resident #65 entered the dining room and sat at a table with Resident #9. At 5:36 p.m. Resident #65 received her meal tray. She received mashed potatoes with gravy, carrots, a small cup half full of ice cream and a breaded chicken breast. At 5:37 p.m. Resident #65 requested her meal be reheated because it was served cold. An unidentified staff member took Resident #65's tray to the kitchen to reheat it. At 5:39 p.m. an unidentified staff member brought Resident #65's plate of food back to her. Resident #65 began to eat her meal. At 5:59 p.m. Resident #65 left the dining room. Resident #65 had eaten only the gravy off the top of the mashed potatoes and a few carrots, but ate all of her breaded chicken and ice cream. Resident #65 was interviewed again on 12/18/24 at 6:02 p.m. Resident #65 said her food was delivered to her cold at dinner. Resident #65 said the dining staff reheated her food in the kitchen but the food was still cold. Resident #65 said she could not eat the mashed potatoes because they were cold but the gravy on top was warm enough to eat. Resident #65 said she felt very frustrated that the kitchen struggled to bring her food that was warm enough to eat. Resident #65 said she felt it was not important to the facility to serve decent food to residents. C. Record reviewThe nutrition care plan, initiated 9/12/24 and revised 12/2/24, revealed a goal of maintaining Resident #65's weight through the review period, ensuring Resident #65 consumed more than 50% of two meals per day and ensuring Resident #65 did not have signs or symptoms of malnutrition. Interventions included providing and serving supplements as ordered, providing and serving diet as ordered and for the RD to evaluate and make change recommendations as needed.-However, the resident did not have a physician's order for nutritional supplements and therewas no documentation in the resident's EMR to indicate she was receiving a nutritional supplement (see physician's orders below). Resident #65's weights were documented in the electronic medical record (EMR) as follows:-On 8/23/24, the resident weighed 268.4 lbs;-On 8/25/24, the resident weighed 266.8 lbs;-On 8/26/24, the resident weighed 267 lbs;-On 9/2/24, the resident weighed 258 lbs; -On 10/1/24, the resident weighed 254 lbs;-On 11/1/24, the resident weighed 251 lbs; and-On 12/3/24, the resident weighed 248.8 lbs.-The resident lost 19.6 lbs (7.3%), from 8/26/24 to 12/3/24, in less than six months, which was not considered significant weight loss.-A review of Resident #65's December 2024 CPO failed to reveal any physician's orders for nutritional supplements. The Mini-nutritional assessment, dated 9/1/24, documented that Resident #65 was of normal nutritional status and was not at risk for malnutrition. The assessment documented Resident #65 had experienced no weight loss and had no decrease in her food intake. The Mini-nutritional assessment, dated 12/2/24, documented that Resident #65 was malnourished. The assessment documented the resident had experienced a weight loss greater than 6.6 lbs and had a moderate decrease in food intake. The assessment documented that nutritional supplements would be provided and served as ordered.-However, a review of Resident #65's December 2024 CPO revealed there were no physician's orders for nutritional supplements (see physician's orders above). Resident #65's meal intake documentation was reviewed between 11/20/24 and 12/19/24. Out of 86 meal opportunities, Resident #65 ate more than 75% on 50 meal opportunities, 51% to -75% on 16 meal opportunities, 26% to -50% on 13 opportunities and less than 25% of her meal on five opportunities. Resident #65's snack intake documentation was reviewed between 11/20/24 and 12/19/24. In 30 days of opportunities, snacks were offered to Resident #65 on nine of those days. The documentation included 11 days that Resident #65 refused snacks. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 12/18/24 at 8:57 a.m. LPN #2 said she did not know if Resident #9 or Resident #65 were losing weight. LPN #2 reviewed the EMRs for Resident #9 and Resident #65. LPN #2 said Resident #9 was losing weight according to what was documented in the EMR, but she said she did not know why the resident was losing weight. LPN #2 said that offering snacks, supplements and extra food at meal times could all help Resident #9 gain weight. LPN #2 said Resident #65 had lost weight as well but she did not know why. Certified nurse aide (CNA) #7 was interviewed on 12/18/24 at 6:04 p.m. CNA #7 said Resident #9 and Resident #65 were both good at eating at dinner and sometimes enjoyed sitting together. CNA #7 said she did not know if Resident #9 or Resident #65 were experiencing weight loss. CNA #7 said she thought Resident #65 did not enjoy her meal this evening (12/18/24) because she asked it to be heated up but then did not eat it all. CNA #7 said she did not offer Resident #65 additional food because she did not seem to like what she was given the first time. LPN #3 was interviewed on 12/19/24 at 8:49 a.m. LPN #3 said when a resident experienced weight loss, the care plan would be updated and nursing staff and the RD worked together to find a way to stop the weight loss. LPN #3 said what was offered to decrease weight loss was different for every resident. LPN #3 said she did not know if Resident #9 or Resident #65 had experienced weight loss. The RD was interviewed on 12/19/24 at 11:17 a.m. The RD said she had worked at the facility for two years. The RD said she came to the building once a week in the middle of the week. The RD said her nutritional assessment process included reviewing information documented in the EMR, speaking to the residents about their preferences and observing the residents in the dining room, if possible. The RD said when a resident experienced weight loss, she would perform an assessment of the resident, place a progress note in the EMR, discuss the situation weekly in the risk meeting and the resident's care plan was updated with new interventions. The RD said she input the interventions into care plans at the facility. The RD said if a resident continued to lose weight despite new interventions, the resident's care plan should be reviewed and nutritional interventions should be changed or modified. The RD said residents who experienced weight loss should have additional or alternative food offered if they ate their entire plate of food during a meal. The RD said if a resident enjoyed a dessert for example, she would see if the facility could provide a double dessert or a second serving of a food item the resident liked. The RD said it was always better for residents to get their nutrition from food rather than supplements, if possible. The RD said if a resident received a cold meal or a meal that was not palatable to them, she would want the resident to let staff know so they could fix the meal to be more palatable for the resident. The RD said she would discuss food preferences with the resident and update that information in the resident's EMR.The RD reviewed Resident #9's EMR. The RD said Resident #9 was on her radar for weight loss before she took a medical leave in September 2024, but she did not know exactly how much weight he had lost. The RD said a weight loss trigger was inaccurately cleared on 9/3/24 by registered nurse (RN) #3, during the time of her medical leave before she returned to work on 9/12/24. The RD said the clearing of the weight loss trigger caused a delay for the facility to implement interventions for Resident #9.-However, Resident #9's documented weights identified the resident sustained a 15.2 lb (9.5%) from 9/24/24 to 12/11/24, in less than three months, which was considered severe, and the facility failed to implement additional nutritional interventions for the resident (see record review above). The RD said she was not aware that Resident #65 was losing weight. The RD said that RN #3 had also cleared the weight loss trigger notification warning in the resident's EMR. The RD said without that notification, she would have to manually calculate weight loss in all residents which was not feasible. The RD said Resident #65's weight loss caught her by surprise. The RD said she had not performed further evaluation or assessment of Resident #65's weight loss. The RD said Resident #65 did not have physician's orders to obtain weights weekly and the facility should begin watching her weight more closely. The director of nursing (DON) was interviewed on 12/19/24 at 4:51 p.m. The DON said she expected the RD to identify residents who experienced weight loss. The DON said she discussed residents who experienced weight loss on a weekly basis and the IDT then determined if there were additional contributing factors to the weight loss. The DON said the IDT would find the cause for the weight loss and could recommend interventions, such as double portions or food alternatives. The DON reviewed Resident #9's EMR. The DON said Resident #9 was not offered enough snacks. The DON said residents who experienced weight loss and consistently ate their entire meal should have additional food offered to them. The DON said Resident #65 should have palatable food offered to her. The DON said Resident #65 was not being monitored for weight loss but would be monitored more closely going forward.

A complaint survey, prompted by #CO36581 and #CO36933 was conducted on 7/29/24 to 7/30/24. No deficiencies were cited.

A revisit survey was completed on 7/2/24 for all previous deficiencies cited on 5/10/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 7/2/24 for all previous deficiencies cited on 5/10/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 5/7/24, 5/8/24 & 5/10/24 for prtheevious deficiency cited on 3/18/24. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO35745, #CO35964, #CO35974 and #CO35976 was conducted on 5/7/24 to 5/10/24. One deficiency was cited.

Based on interviews and record review, the facility failed to take steps to protect one (#10) of six residents reviewed for abuse out of 24 sample residents. Resident #10, who had a diagnosis of anxiety disorder and was always incontinent of urine and occasionally incontinent of bowel, was dependent on staff assistance for all activities of daily living (ADL), including toileting hygiene, showering, upper and lower body dressing, personal hygiene and transfers. She required maximal assistance from staff to propel her wheelchair. She was able to use her call light to call staff when she needed assistance. On 5/3/24, certified nurse aide (CNA) #2 provided a shower to Resident #10. After the resident's shower, CNA #2 placed Resident #10 in her wheelchair near the bathroom in her room. CNA #2 left Resident #10's room, without making the resident's bed and without telling the resident she would be back or why she was leaving the room and closed the door of the room. Resident #10 was unable to maneuver her wheelchair independently in order to reach her call light, which was left approximately eight feet away from her, to call for assistance. Resident #10 began to feel afraid and began yelling out for help because she could not reach her call light. After 20 minutes, the resident's family member arrived for a visit. The family member heard Resident #10 yelling from the hallway, opened Resident #10's door, found the resident crying and upset and went to find a staff member (CNA #1) who could provide assistance to the resident. Additionally, on several occasions between 3/1/24 and 5/5/24, Resident #10's call light was on for 15 minutes or more before staff provided assistance to the resident. Due to the facility's failure, Resident #10 was afraid when she was left unattended and without access to the call light for 20 minutes. She felt abandoned, like she did not matter and that staff would forget her. Findings include:I. Facility policy and proceduresThe Resident Abuse Prevention policy and procedure, dated August 2017, was provided by the executive director (ED) on 5/10/24 at 5:25 p.m. The policy documented each resident had the right to be free from physical, mental or sexual abuse, neglect, corporal punishment, involuntary seclusion, and physical or chemical restraints. Neglect was defined as a failure to provide agreed upon care or services to a resident, failure to make a reasonable effort to assess what care was necessary for the well-being of the resident, or failure to provide a safe and sanitary environment. The Resident Call System policy and procedure, dated August 2017, was provided by the ED on 5/10/24 at 5:25 p.m. The policy documented each resident was provided with a means to call staff directly for assistance, and calls for assistance were answered as soon as possible, but no later than five minutes. Urgent requests for assistance were addressed immediately. II. Resident #10A. Resident statusResident #10, age 86, was admitted on 11/28/22. According to the May 2024 computerized physician orders (CPO), diagnoses included rheumatoid arthritis, anxiety disorder, Parkinsonism (term for a group of brain conditions that cause movement symptoms, such as slow movements, stiffness, walking and balance problems and tremors) and weakness. The 3/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on staff for toileting hygiene, showering, upper and lower body dressing, personal hygiene and transfers. She had no hallucinations, delusions or refusals of care. She was always incontinent of urine and occasionally incontinent of bowel. She required substantial/maximal assistance with the use of her wheelchair. B. Resident interview and observationsResident #10 was interviewed on 5/7/24 at 11:08 a.m. Resident #10 said there were times when she had to wait for 30 minutes or more for assistance from staff whenshe needed help. She said there was an incident the previous Friday (5/3/24) when she was left in her wheelchair in her room by a staff member who had just helped her bathe but did not finish and she did not have access to her call light. Resident #10 said CNA #2 placed her wheelchair near the bathroom, which was approximately eight feet away from where her call light was. She said CNA #2 left the room, closed the door without telling her she would be back or why she needed to leave and left the resident alone for 20 minutes without ensuring the call light was within reach. Resident #10 said she began to feel afraid and started yelling out for help to get her back into bed. She said her bed did not have any linens on it and had not been made. She said she felt abandoned and as if she did not matter. Resident #10 began to cry during the interview and said she had so many fears about that, and did not like the door to her room closed because she felt like the staff was going to forget her. Resident #10 said after approximately 20 minutes, her family member arrived for a visit, heard her yelling out for help from the hallway and opened the door and found her crying and upset. She said her family member told her she would make her bed and went to find a staff member (CNA #1) who could provide them with linens and assistance. Resident #10 was interviewed again on 5/10/24 at 10:23 a.m. Resident #10 said if staff took too long to answer her call light, she was incontinent of urine which made her bottom sore. She said she wore an incontinence brief and needed to be changed routinely, which was usually why she pushed the call light for help. Resident #10 became tearful and said sometimes it took half an hour to answer her call light, which was too long, and she said it made her feel like she didn't matter and she didn't count. C. Record reviewThe care plan, initiated 6/5/23 and revised 5/10/24, identified Resident #10 had limitations in her ability to perform activities of daily living. Interventions included she required extensive assistance of two staff with bed mobility, position changes, dressing, personal hygiene and bathing. The resident experienced incontinence and required extensive assistance of two staff with toileting and was encouraged to use a call bell to call for assistance. The Past Calls log for Resident #10's use of the call light was reviewed from 3/1/24 through 5/5/24 and revealed the following response times:-The call light elapsed response time was greater than 15 minutes 54 times. -Of those 54 occasions, the response time was greater than 20 minutes 16 times. -Further, on 4/13/24, there was a response time of 30 minutes and on 4/30/24, there was a response time of 56 minutes. III. Incident of neglect of Resident #10 by CNA #2The investigation was reviewed for the incident that occurred on 5/3/24 when Resident #10 was left without access to her call light. In summary, CNA #2 left the resident's room when they returned from the bathing room to obtain sheets to make the bed. CNA #2 went to the laundry room to wait for the dryer to finish drying the linens and when she returned to the resident's room, the bed had already been made. CNA #2 left the room to request staff assistance to place the resident back in bed. CNA #2 was unfamiliar with Resident #10 and did not know her routine. The Investigatory Interview Form for the incident on 5/3/24, completed by the social services director (SSD), was reviewed and documented Resident #10 said she was left in her room without her sheets being changed, assisted back to bed and no call light was provided. The documentation revealed CNA #2 apologized to the resident when she returned to the room, and Resident #10 said she did not like that she was left. The incident was reported and submitted to the State agency. IV. Staff interviewsThe SSD was interviewed on 5/10/24 at 12:27 p.m. The SSD said she was asked to follow up with Resident #10 about the incident that occurred on 5/3/24. The SSD said Resident #10 told her she could not reach her call light for 20 minutes after her shower and said, "It is not fair because I could not do anything" when she was unable to get help. The SSD said it was important for residents to have access to their call lights because it was the only way they could get their needs met, especially if they were not mobile. She said having the call light within reach could prevent possible falls, in case of emergencies, if they needed medicines or had pain or if someone was in their room who should not be. CNA #1 was interviewed on 5/10/24 at 2:47 p.m. CNA #1 said she routinely worked with Resident #10. She said the resident required assistance with dressing, personal hygiene, transfers and toileting and the amount of care she could provide for herself changed over time. She said she thought the resident might be getting weaker. CNA #1 said the resident was incontinent of urine most of the time and was usually wet when she would use her call light to request personal hygiene assistance. CNA #1 said the resident used her call light purposefully and there had always been a reason she needed help when she pushed it. CNA #1 said, on 5/3/24, she was working on a different hall than Resident #10 was on. She said the resident's family member came and got her to request assistance for Resident #10. She said when she entered the resident's room, the resident was crying, frustrated and really upset. She said the call light was not on and was across the room and not within the resident's reach. CNA #1 said CNA #2 was new to the facility and not very familiar with the resident. She said CNA #2 had left Resident #10 in her wheelchair after her shower which the staff usually did not do. CNA #1 assisted the resident to finish putting lotion on her face, changed the bed linens and got her back into bed. CNA #1 said the resident was very particular, and the staff did get busy at times, but she said if it had been her in that position, she probably would have felt abandoned, been crying and upset as Resident #10 had been. CNA #1 said she dropped everything she was doing to take care of the resident as if it had been her in that position. CNA #1 said residents' call lights should be left right next to them, within reach, even for the independent residents, in case they needed assistance. The ED was interviewed on 5/10/24 at 6:22 p.m. The ED said residents should have their call lights within reach at all times. She said, in the past, if she had identified a resident who did not have their call light within reach, she would give it to them, then go to the nurses' station and tell the staff to go make a sweep of all of the residents on the floor to make sure everyone had their call light within reach. She said "Star" rounds were rounds conducted three times each week by a dedicated management staff and that was one of the things they checked on for each resident during those rounds.-During the survey, CNA #2 had been suspended pending the abuse investigation and was unavailable for an interview. V. Facility follow-upThe facility provided additional documentation on 5/13/24, after the survey exit. The documentation included an investigation that was conducted into the call light wait time of 56 minutes on 4/30/24 at 8:39 p.m. The investigation documented Resident #10 became upset when an agency CNA entered her room to provide hour of sleep care and she preferred to not have someone new providing her care. She became visibly agitated and asked the agency CNA to leave the room. The registered nurse (RN) caring for Resident #10 that evening was then approached by another CNA with an urgent concern from another resident that needed to be addressed. The facility alleged that the call light in Resident #10's room was not turned off after care was provided to her by the RN and a different CNA because they forgot to turn it off. -However, there was no additional documentation provided to explain the 4/13/24 call light response time of 30 minutes or the other extended response times of greater than 15 or 20 minutes for Resident #10.

A survey prompted by complaint #CO36141 was completed on 5/7/24 to 5/10/24. One deficiency was cited.

Based on interviews and record review, the facility failed to take steps to protect one (#10) of six residents reviewed for abuse out of 24 sample residents. Resident #10, who had a diagnosis of anxiety disorder and was always incontinent of urine and occasionally incontinent of bowel, was dependent on staff assistance for all activities of daily living (ADL), including toileting hygiene, showering, upper and lower body dressing, personal hygiene and transfers. She required maximal assistance from staff to propel her wheelchair. She was able to use her call light to call staff when she needed assistance. On 5/3/24, certified nurse aide (CNA) #2 provided a shower to Resident #10. After the resident's shower, CNA #2 placed Resident #10 in her wheelchair near the bathroom in her room. CNA #2 left Resident #10's room, without making the resident's bed and without telling the resident she would be back or why she was leaving the room and closed the door of the room. Resident #10 was unable to maneuver her wheelchair independently in order to reach her call light, which was left approximately eight feet away from her, to call for assistance. Resident #10 began to feel afraid and began yelling out for help because she could not reach her call light. After 20 minutes, the resident's family member arrived for a visit. The family member heard Resident #10 yelling from the hallway, opened Resident #10's door, found the resident crying and upset and went to find a staff member (CNA #1) who could provide assistance to the resident. Additionally, on several occasions between 3/1/24 and 5/5/24, Resident #10's call light was on for 15 minutes or more before staff provided assistance to the resident. Due to the facility's failure, Resident #10 was afraid when she was left unattended and without access to the call light for 20 minutes. She felt abandoned, like she did not matter and that staff would forget her. Findings include:I. Facility policy and proceduresThe Resident Abuse Prevention policy and procedure, dated August 2017, was provided by the executive director (ED) on 5/10/24 at 5:25 p.m. The policy documented each resident had the right to be free from physical, mental or sexual abuse, neglect, corporal punishment, involuntary seclusion, and physical or chemical restraints. Neglect was defined as a failure to provide agreed upon care or services to a resident, failure to make a reasonable effort to assess what care was necessary for the well-being of the resident, or failure to provide a safe and sanitary environment. The Resident Call System policy and procedure, dated August 2017, was provided by the ED on 5/10/24 at 5:25 p.m. The policy documented each resident was provided with a means to call staff directly for assistance, and calls for assistance were answered as soon as possible, but no later than five minutes. Urgent requests for assistance were addressed immediately. II. Resident #10A. Resident statusResident #10, age 86, was admitted on 11/28/22. According to the May 2024 computerized physician orders (CPO), diagnoses included rheumatoid arthritis, anxiety disorder, Parkinsonism (term for a group of brain conditions that cause movement symptoms, such as slow movements, stiffness, walking and balance problems and tremors) and weakness. The 3/6/24 facility assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on staff for toileting hygiene, showering, upper and lower body dressing, personal hygiene and transfers. She had no hallucinations, delusions or refusals of care. She was always incontinent of urine and occasionally incontinent of bowel. She required substantial/maximal assistance with the use of her wheelchair. B. Resident interview and observationsResident #10 was interviewed on 5/7/24 at 11:08 a.m. Resident #10 said there were times when she had to wait for 30 minutes or more for assistance from staff when she needed help. She said there was an incident the previous Friday (5/3/24) when she was left in her wheelchair in her room by a staff member who had just helped her bathe but did not finish and she did not have access to her call light. Resident #10 said CNA #2 placed her wheelchair near the bathroom, which was approximately eight feet away from where her call light was. She said CNA #2 left the room, closed the door without telling her she would be back or why she needed to leave and left the resident alone for 20 minutes without ensuring the call light was within reach. Resident #10 said she began to feel afraid and started yelling out for help to get her back into bed. She said her bed did not have any linens on it and had not been made. She said she felt abandoned and as if she did not matter. Resident #10 began to cry during the interview and said she had so many fears about that, and did not like the door to her room closed because she felt like the staff was going to forget her. Resident #10 said after approximately 20 minutes, her family member arrived for a visit, heard her yelling out for help from the hallway and opened the door and found her crying and upset. She said her family member told her she would make her bed and went to find a staff member (CNA #1) who could provide them with linens and assistance. Resident #10 was interviewed again on 5/10/24 at 10:23 a.m. Resident #10 said if staff took too long to answer her call light, she was incontinent of urine which made her bottom sore. She said she wore an incontinence brief and needed to be changed routinely, which was usually why she pushed the call light for help. Resident #10 became tearful and said sometimes it took half an hour to answer her call light, which was too long, and she said it made her feel like she didn't matter and she didn't count. C. Record reviewThe care plan, initiated 6/5/23 and revised 5/10/24, identified Resident #10 had limitations in her ability to perform activities of daily living. Interventions included she required extensive assistance of two staff with bed mobility, position changes, dressing, personal hygiene and bathing. The resident experienced incontinence and required extensive assistance of two staff with toileting and was encouraged to use a call bell to call for assistance. The Past Calls log for Resident #10's use of the call light was reviewed from 3/1/24 through 5/5/24 and revealed the following response times:-The call light elapsed response time was greater than 15 minutes 54 times. -Of those 54 occasions, the response time was greater than 20 minutes 16 times. -Further, on 4/13/24, there was a response time of 30 minutes and on 4/30/24, there was a response time of 56 minutes. III. Incident of neglect of Resident #10 by CNA #2The investigation was reviewed for the incident that occurred on 5/3/24 when Resident #10 was left without access to her call light. In summary, CNA #2 left the resident's room when they returned from the bathing room to obtain sheets to make the bed. CNA #2 went to the laundry room to wait for the dryer to finish drying the linens and when she returned to the resident's room, the bed had already been made. CNA #2 left the room to request staff assistance to place the resident back in bed. CNA #2 was unfamiliar with Resident #10 and did not know her routine. The Investigatory Interview Form for the incident on 5/3/24, completed by the social services director (SSD), was reviewed and documented Resident #10 said she was left in her room without her sheets being changed, assisted back to bed and no call light was provided. The documentation revealed CNA #2 apologized to the resident when she returned to the room, and Resident #10 said she did not like that she was left. The incident was reported and submitted to the State agency. IV. Staff interviewsThe SSD was interviewed on 5/10/24 at 12:27 p.m. The SSD said she was asked to follow up with Resident #10 about the incident that occurred on 5/3/24. The SSD saidResident #10 told her she could not reach her call light for 20 minutes after her shower and said, "It is not fair because I could not do anything" when she was unable to get help. The SSD said it was important for residents to have access to their call lights because it was the only way they could get their needs met, especially if they were not mobile. She said having the call light within reach could prevent possible falls, in case of emergencies, if they needed medicines or had pain or if someone was in their room who should not be. CNA #1 was interviewed on 5/10/24 at 2:47 p.m. CNA #1 said she routinely worked with Resident #10. She said the resident required assistance with dressing, personal hygiene, transfers and toileting and the amount of care she could provide for herself changed over time. She said she thought the resident might be getting weaker. CNA #1 said the resident was incontinent of urine most of the time and was usually wet when she would use her call light to request personal hygiene assistance. CNA #1 said the resident used her call light purposefully and there had always been a reason she needed help when she pushed it. CNA #1 said, on 5/3/24, she was working on a different hall than Resident #10 was on. She said the resident's family member came and got her to request assistance for Resident #10. She said when she entered the resident's room, the resident was crying, frustrated and really upset. She said the call light was not on and was across the room and not within the resident's reach. CNA #1 said CNA #2 was new to the facility and not very familiar with the resident. She said CNA #2 had left Resident #10 in her wheelchair after her shower which the staff usually did not do. CNA #1 assisted the resident to finish putting lotion on her face, changed the bed linens and got her back into bed. CNA #1 said the resident was very particular, and the staff did get busy at times, but she said if it had been her in that position, she probably would have felt abandoned, been crying and upset as Resident #10 had been. CNA #1 said she dropped everything she was doing to take care of the resident as if it had been her in that position. CNA #1 said residents' call lights should be left right next to them, within reach, even for the independent residents, in case they needed assistance. The ED was interviewed on 5/10/24 at 6:22 p.m. The ED said residents should have their call lights within reach at all times. She said, in the past, if she had identified a resident who did not have their call light within reach, she would give it to them, then go to the nurses' station and tell the staff to go make a sweep of all of the residents on the floor to make sure everyone had their call light within reach. She said "Star" rounds were rounds conducted three times each week by a dedicated management staff and that was one of the things they checked on for each resident during those rounds.-During the survey, CNA #2 had been suspended pending the abuse investigation and was unavailable for an interview. V. Facility follow-upThe facility provided additional documentation on 5/13/24, after the survey exit. The documentation included an investigation that was conducted into the call light wait time of 56 minutes on 4/30/24 at 8:39 p.m. The investigation documented Resident #10 became upset when an agency CNA entered her room to provide hour of sleep care and she preferred to not have someone new providing her care. She became visibly agitated and asked the agency CNA to leave the room. The registered nurse (RN) caring for Resident #10 that evening was then approached by another CNA with an urgent concern from another resident that needed to be addressed. The facility alleged that the call light in Resident #10's room was not turned off after care was provided to her by the RN and a different CNA because they forgot to turn it off. -However, there was no additional documentation provided to explain the 4/13/24 call light response time of 30 minutes or the other extended response times of greater than 15 or 20 minutes for Resident #10.

A revisit survey was completed on 5/10/24 for all previous deficiencies cited on 3/18/24. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO35407 was completed 3/12/24 to 3/18/24. One deficiency was cited.

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

A complaint survey, prompted by #CO35242 was conducted on 3/12/24 to 3/18/24. One deficiency was cited.

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

A complaint survey, prompted by #CO34425 was conducted on 1/10/24. No deficiencies were cited.

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

A survey for Incident #33833 was conducted 10/31/23. No deficiencies were cited.

A revisit survey was completed on 10/26/23 for all previous deficiencies cited on 9/12/23. The facility is in compliance with all regulations surveyed.

An desk revisit was conducted and deficiency K-351 was not corrected. A response is required.

A revisit survey was completed on 9/12/23 for all previous deficiencies cited on 7/13/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 9/12/23 for all previous deficiencies cited on 7/13/23. The facility is in compliance with all regulations surveyed.

A complaint survey prompted by #CO33557 was conducted on 9/7/23 to 9/12/23. One deficiency was cited.

Based on resident and staff interviews and record review, the facility failed to promote resident dignity and respect for two (#1 and #2) of four residents reviewed for dignity out of 11 sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2 were treated and spoken to in a dignified manner. Findings include:I. Facility policyThe Dignity policy, revised February 2021, was provided by the corporate clinical consultant (CCC) on 9/12/23. The policy read in part: "Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents may exercise their right without interference, corrosion, discrimination or reprisal from any person or entity associated with this facility."The Resident Rights policy, revised February 2021, was provided by the CCC on 9/12/23. The policy read in part: "Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to a dignified existence; be treated with respect, kindness, and dignity; be notified of his or her medical conditions and any changes in her his or her condition; be informed of, and participate in, his or her care planning and treatment; voice grievances to the facility, or other agency that hears grievances, without discrimination or appraisal and without fear or discrimination or reprisal."II. Resident #1A. Resident statusResident #1, age 76, was admitted on 12/30/21. According to the September 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, major depressive disorder (recurrent and moderate), anxiety disorder, and chronic post-traumatic stress (C-PTSD) disorder. The 7/5/23 minimum data set (MDS) assessment showed the resident had mild cognitive impairment, with a brief interview for mental status (BIMS) score of 10 out of 15B. Resident interview Resident #1 was interviewed on 9/7/23 at 2:50 p.m. He said he and the night nurse "locked horns" a couple of weeks ago because he questioned the timeliness of his anti-anxiety medication. Resident #1 said the nurse became upset with him and started to "yell and holler" at him. He said she became so upset that she started to cry and tell him "you think you have PTSD but it was nothing compared to hers." He said she approached him a couple days after the incident and she tried to be nice to him but he just ignored her. He said he had not worked with her since and if it was up to him he would not work with her again. The resident said the night staff saw the interaction. Resident #1 said today (9/7/23), the director of nurses (DON) asked him about the incident with the night nurse. The resident expressed that he did not feel the interaction was abusive but it was not called for. He said he had not had concerns since and felt it was being taken care of. C. Record review Resident #1's witness statement, dated 8/30/23, was provided by the social service director (SSD) on 9/12/23 at 12:42 p.m. According to the resident's statement, referring to events on 8/26/23, RN #1 entered his room "all wound up." He asked for his medication and the nurse said "hang on, I will get them as soon as I can." When she brought the medications, she set them down on his table and left. Resident #1 checked the medication and felt he was missing some. The resident then approached RN #1. The statement read the resident felt the RN was "short" with him and accused him of yelling at her. The RN "snatched the (medication) cup from me." She then came back to his room, returning the medication, and said the medication was all there and she was not coming back. According the the resident statement, RN #1 was tearful and continued to say "you think you have PTSD, well Iam worse." RN #1 approached him the following day and tried to be "chummy" with him, but "he was not having it." The statement read the RN was not like that before and he did not know what her problem was but he would not allow it to happen again. The statement read the resident felt "minimized."Resident #3's witness statement, dated 8/30/23, was provided by the SSD on 9/12/23 at 12:42 p.m. Resident #3 was identified as Resident #1's roommate. According to the statement, Resident #3 told the SSD, RN #1 "blew up on him (Resident #1)" when referring to an interaction between Resident #1 and RN #1 on 8/26/23. The SSD said she clarified what "blew up on him" meant and Resident #3 said RN #1 was "all worked up."A staff witness statement from CNA #1 was provided by the interim nursing home administrator (INHA) on 9/11/23. The statement read the evening of 8/26/23 was very chaotic and frustrating. According to the witness's statement, RN #1 was observed to be very passive aggressive between 9:30 p.m. and 10:00 p.m. RN #1 was talking loud in the hallway saying Resident #1 was being "super needy" and made uncalled for comments. Resident #1 had asked for orange sherbet and RN #1 said "yeah, that will help your heartburn." The statement read the CNA felt RN #1 was being a bully towards Resident #1 out of frustration. III. Resident #2A. Resident statusResident #2, under the age of 65, was admitted on 6/16/14. The 7/19/23 minimum data set (MDS) assessment identified Resident #2's diagnoses included multiple sclerosis (a chronic disease of the central nervous system), depression and neurogenic bladder. The 7/19/23 MDS assessment indicated the resident was cognitively intact, with a BIMS score of 15 out of 15. B. Resident interview Resident #2 was interviewed on 9/11/23 at 10:06 p.m. The resident said RN #1 was working nights on the weekend of 8/26/23. She said her medications did not seem right. Resident #2 said she felt the medication dosage was not correct and asked RN #1 about it. She said she took gabapentin 4 mg tablets at night but was given four 1 mg tablets. The dose was identified to be correct but according to the resident, her multiple sclerosis made it difficult to swallow multiple pills at one time. The resident said the RN #1 was very rude and disrespectful to her in both tone and in the manner in which she spoke to her. Resident #2 said RN #1 continued interrupting her when she was talking and would not let her explain the concern. Resident #2 said her daughter contacted the SSD and requested RN #1 not be allowed to administer medications to her or be allowed in her room. The resident said she had not seen RN #1 since. Resident #2 said she was fearful at first of being "kicked out" after reporting the incident but the SSD assured her that would not happen. She said she no longer felt that she was going to be told to leave. C. Record reviewResident #2's witness statement, dated 8/31/23, identified Resident #2 said RN #1 was very rude to her related to a medication concern. The statement read RN #1 was offensive, did not allow the resident to explain herself, talked over the resident and continued to be rude in the interaction. According to Resident #3's statement, the RN was unwilling to listen or respect her intelligence. The resident told the SSD the interaction was unsettling. The RN was disrespectful and made her feel less intelligent because she was "just a resident." IV. Staff interviewsThe DON was interviewed on 9/7/23 at 5:03 p.m. The DON said was recently out of town and she was told earlier today (9/7/23) by a staff member that Resident #2 was upset. The DON said she interviewed the resident and he told her a nurse had raised his voice to him. The DON said Resident #1 said the nurse told him that his PTSD was nothing compared to hers and was not going to come back to his room that night. The DON said based on the timing and schedule, she determined the nurse was registered nurse (RN) #1. She said the facility was currently investigating the incident. RN #2 was interviewed on 9/7/23 at 5:20 p.m. The RN said Resident #1 told him he did not like when RN #1 did not listen to him when he spoke to her. The INHA was interviewed on 9/7/23 at 5:52 p.m. The INHA said on 8/30/23, there were reports of a "bad customer service moment" with the RN #1. He said the SSD opened an investigation on 8/30/23. He said he was informed the concern was related to the way RN #1 explained PTSD to Resident #1 which upset the resident. The INHA said based on the statements Resident #1 made today (9/7/23) RN #1 would be suspended pending the results of the investigation. LPN #1 was interviewed on 9/11/23 at 1:30 p.m. She said on 8/28/23, it was reported to her by CNA #2 that Resident #1 was upset after interactions with RN #1 on the weekend of 8/26/23. Resident #1 was visibly upset and said RN #1 made fun of his PTSD and that he was giving PTSD to her. Resident #1 said the RN told him and that if he or his roommate, Resident #3, wanting anything else, then they needed to tell her now because she was not going to come back. The LPN said she reported the concern to the SSD on 8/29/23. CNA #2 was interviewed on 9/11/23 at 4:26 p.m. She said Resident #1 said he wanted to pack up up his bags and leave because RN #1 made fun of his PTSD on 8/26/23. The INHA was interviewed with the SSD on 9/12/23 at 12:42 p.m He said after reviewing the resident statements, it was concerning how staff were presenting themselves to the residents. The SSD said part of her role as the SSD was to be an advocate for resident rights. She said the concerned residents felt RN #1 could have been nicer to them. The SSD said a resident stating she was disrespected by a staff member, was not a resident feeling that they were treated with respect and dignity. The INHA said he took respect and dignity concerns just as seriously as abuse. The INHA was interviewed again on 9/12/23 at 3:11 p.m. He said the facility would undergo a "very real" education of respect and dignity with a more structured approach to respect and dignity concerns. V. Facility follow upA written statement was provided by the CCC on 9/12/23 at 3:01 p.m. The statement identified the facility would created and implement a performance improvement/action plan for RN #1 with immediate and sustained expectations regarding respect and dignity for all those who she encounters. The action would include ongoing training, performance, behavior monitoring and supervision with residents and/or staff. In addition, the facility would conduct all staff training regarding dignity and respect expectations and the avenues to report concerns. The facility would also continue their customer service resident rounds to ensure compliance of the facility's policy and procedures of resident rights.

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility's general characteristics. This facility, licensed for eighty eight (88) beds and having 43 resident rooms, is a single story, 27,083 sq ft type V(000) structure with a partial basement and partial crawl space. The basement contains storage, staff multi-use rooms, and mechanical equipment. The structure is protected throughout by a complete NFPA Type 13 automatic fire suppression system. Census on the day of survey was 51. This survey, conducted July, 25 2023 included an inspection for compliance with the fire safety requirements of Chapter 19 (existing healthcare) of NFPA-101, Life Safety Code (2012 edition); NFPA-99, Health Care Facilities Code (2012 edition), and all referenced standards. This facility will meet these requirements upon completion of a Plan of Correction. The survey concluded with a discussion of the deficiencies with the Maintenance Director and Facility Administrator.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartmentincluding the beauty shop should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidence by the following.-The beauty shop 50 square feet and contains storage of flammable and combustibles beauty supplies and is considered as a hazardous area, the door was not equipped with a self-closing device, as required.-Bio Hazard room contains storage of combustibles is considered as a hazardous area, the door was not equipped with a self-closing devise, as required. - Housekeeping room contains storage of combustibles is considered as a hazardous area, the door was not equipped with a self-closing devise, as required. The Director of Maintenance acknowledged the hazardous area enclosures and door condition during a tour of the facility. Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spacesby smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing.

STANDARD is not met as evidenced by: Based observation and discussion during the tour of the facility, it was determined the facility failed to install and maintain fire rated doors per NFPA 101 2012 Edition Chapter 8 Section 8.3.3 paragraph 8.3.4.4. Failure to maintain fire rated door and assemblies in hazardous areas has the potential to harm all occupants, staff and visitor in the building if the fire rated doors failed to operate if a fire was to occur. This was evidence by the following.- No documentation of the kitchens fire roll down door been inspected annually. The Director of Maintenance acknowledged the condition of doors and assemblies during the tour of the facility. 8.3.3 Fire Doors and Windows. 8.3.3.1 Openings 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.

STANDARD is not met as evidenced by: During the walk through of the facility, with the Maintenance Director the facility failed to maintain the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alarm system failed to operate if a fire was to occur. This was evidenced by the following:- Smoke detector is missing in the housekeeping office where the Fire alarm control panel is located. The fire alarm deficiency was discussed with the Director of Maintenance during the survey and again during the exit conference with the Administrator. 9.6.4.2 Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:(1) Auxiliary fire alarm system(2) Central station fire alarm system(3) Proprietary supervising station fire alarm system(4) Remote supervising station fire alarm system

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to install sprinkler protection coverage to all areas in accordance per NFPA 101 Section 19.3.5.1, 9.7.1.1; NFPA 13 Section 8.17.4.2. Failure to protect the facility with an automatic sprinkler system as required increases the risk of death or injury due to fire of all occupants in the facility. This was evidenced by the following:-Basement storage is missing sprinkler head from original layout making the coverage not efficient.-Cabinets blocking sidewall sprinklers at the Monument nurses station The Director of Maintenance acknowledge the lack of sprinkler coverage under the canopy during the tour of the facility. NFPA 101 2012 Edition, Section 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide an adequate source of outside combustion/makeup air for natural gas fueled equipment in accordance with National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Fuel Gas Code. This deficient practice could affect all residents and staff in the core smoke compartment should the natural gas fueled heating equipment malfunction due to improper maintenance. This was evidenced by the following: Combustion/make up air supply sources were not maintained free of obstructions to air intake, as required. The laundry (clothes dryer room) was observed to have outside combustion air intakes that were obstructed by lent, dirt and debris. The Director of Maintenance acknowledged the obstructed air supply intakes during a tour of the facility. Life Safety Code Section 19.5.1 requires that heating, ventilating, and air conditioning comply with the provisions of Section 9.2 and shall be installed in accordance with manufacturer's specifications. Section 9.2.2 requires that heat producing equipment be installed in accordance with NFPA 54, National Fuel Gas Code. Gas fueled equipment must have a continuous source of outside combustion/make-up air in accordance with NFPA 54 Section 5.3 and Section 6.4.

This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide an adequate source of outside combustion/makeup air for natural gas fueled equipment in accordance with National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Fuel Gas Code. This deficient practice could affect all residents and staff in the core smoke compartment should the natural gas fueled heating equipment malfunction due to improper maintenance. This was evidenced by the following: Combustion/make up air supply sources were not maintained free of obstructions to air intake, as required. The laundry (clothes dryer room) was observed to have outside combustion air intakes that were obstructed by lent, dirt and debris. The Director of Maintenance acknowledged the obstructed air supply intakes during a tour of the facility. Life Safety Code Section 19.5.1 requires that heating, ventilating, and air conditioning comply with the provisions of Section 9.2 and shall be installed in accordance with manufacturer's specifications. Section 9.2.2 requires that heat producing equipment be installed in accordance with NFPA 54, National Fuel Gas Code. Gas fueled equipment must have a continuous source of outside combustion/make-up air in accordance with NFPA 54 Section 5.3 and Section 6.4.

A recertification survey was conducted from 7/11/23 to 7/13/23. Twenty-one deficiencies were cited.

An Emergency Preparedness survey was conducted from 7/11/23 to 7/13/23. No deficiencies were cited.

Based on observations, interviews and record review, the facility failed to accommodate the needs of two (#63 and #16) of seven residents reviewed for environmental concerns out of 37 sample residents. Specifically, Residents #63 and #16, who used wheelchairs for ambulation, were unable to access their bathrooms, have privacy while in their bathrooms and/or fully utilize their toiletry items at the sink in shared rooms. Findings include: I. Resident #63 A. Resident status Resident #63, under age 70, was admitted on 1/25/23 and readmitted on 3/6/23. According to the July 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disorder (COPD), pulmonary hypertension, hypoxic respiratory failure and stage 4 kidney disease. According to the 5/3/23 minimum data set (MDS) assessment, he was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He had verbal behaviors directed toward others but no rejection of care. He required extensive assistance with transfers, toilet use and personal hygiene. He was continent of bladder and frequently incontinent of bowel. B. Resident interview and observations Resident #63 was interviewed on 7/11/23 at 9:26 a.m. His room smelled of body odor and urine. Two urinals, one full and the other one-third full of urine, were hanging over the edge of the wastebasket at his bedside near his over-bed table. Resident #63 said he was using a urinal because he could not access his bathroom in his wheelchair. He said he needed a different, more streamlined chair and he had to "raise hell" to get assistance to the bathroom to have a bowel movement because staff were slow to respond to his call light (cross-reference F677 ADLs and F725 sufficient nursing staffing). Resident #63 said even if he was able to access his bathroom in his wheelchair, he was unable to close the bathroom door for privacy. His roommate spent most of his time sitting in a recliner next to the bathroom door. Both residents used wheelchairs, the curtain was drawn between their bedroom areas and the small room was crowded and difficult to maneuver through with the residents' furniture and wheelchairs. Resident #63 and his roommate both said, "These rooms weren't designed for two people in wheelchairs and the bathrooms weren't designed for a person living in a wheelchair." C. Record review The activities of daily living (ADL) care plan, initiated 1/26/23 and revised 3/7/23, identified limitations related to weakness, respiratory status and impaired mobility. The goal was for staff to assist Resident #63 to maintain his functional status and decrease his risks for ADL decline. Interventions included: "I require extensive assistance of 1 with toileting upon arising, before and after meals, at bedtime and as needed" and "Discuss with resident/family/representative any concerns related to loss of independence, decline in function." The 2/15/23 care plan regarding transfer assistance identified, "I have limitations in my ability to transfer and my locomotion related to impaired mobility and weakness." The interventions were: "I require supervision to limited assistance of 1 with my wheelchair mobility" and "I require extensive assistance of 1 to 2 with my transfers." D. Staff interviews Certified nurse aide (CNA) #17 was interviewed on 7/11/23 at 10:00 a.m. He said Resident #63's room was very small, crowded and access to the bathroom was difficult for Resident #63 whose bed was by the door. He said the bathroom was situated so Resident #63 had to make a tight turn to access the bathroom with his wheelchair even with staff assistance. CNA #17 said he assisted residents into the bathroom if they were unable to access their bathroom independently. He said there had been times when he had to assist residents to the bathroom in the shower room because it was more accessible or if the bathroom in the room was occupied by the resident's roommate. The director of rehabilitation (DR) was interviewed on 7/12/23 at 12:32 p.m. She said she would follow up with Resident #63. During a follow-up interview on 7/12/23 at 2:37 p.m., the DR said, "He now has a new wheelchair and he loves it." He was in a 20-inch wide chair and his new chair was 18 inches wide, lighter weight and easier to maneuver and had a new pressure-relieving cushion. She said she offered him a different room where he would have a straight shot into the bathroom and a roommate who did not get out of bed to use the bathroom. "He wants to think about it." II. Resident #16 A. Resident status Resident #16, age 73, was admitted on 4/18/23 and readmitted on 5/18/23. According to the July 2023 CPO, diagnoses included atrial fibrillation, congestive heart failure, hypertension, chronic obstructive pulmonary disease and respiratory failure. According to the 5/24/23 MDS assessment, he was cognitively intact with a BIMS score of 14 out of 15. No behavioral symptoms were documented. His mood symptoms were feeling down, depressed and hopeless; trouble sleeping, feeling tired with little energy; feeling bad about himself and trouble concentrating. He needed limited one-person assistance with transfers and toilet use. He used a wheelchair for ambulation. He was occasionally incontinent of bladder and always continent of bowel. B. Resident interview and observations Resident #16 was interviewed on 7/10/23 at 11:08 a.m. He said he was very short of breath and needed to wear supplemental oxygen all the time. He said the bathroom in his room was "not wheelchair friendly; I have to use my walker." He said it was hard to access his sink because he had to pull his oxygen tubing along, so it was better to have sanitary wipes at his bedside. He said there was not enough shelf space for personal hygiene items at the bathroom sink. Per observation there were two small, narrow wall shelves on either side of the sink, one for each resident. "It's hard to get around in this small space with a wheelchair. I have a lot of problems getting in and out" of the bathroom, sink area and his side of the bedroom. Resident #16 said when he got into the bathroom using the wheelchair or walker, he was unable to close the door for privacy. Resident #16 was observed to share a room with a roommate, who per observation spent most of his time lying in bed facing the bathroom. The curtain was always drawn closed between their bedroom areas. Resident #16 had a walker, a small dresser and a bedside table next to his bed. His television was mounted high on the wall. He spent most of his time in his room watching television using headphones with the curtains drawn closed around him. He said he could not go to activities because he was on oxygen and diuretics. "The bathrooms at the front are for staff and guests only. I can't make it all the way back to my room" if he needed a bathroom because of his bladder urgency and shortness of breath. C. Staff interviews The DR was interviewed on 7/12/23 at 12:32 p.m. She said she would follow up with Resident #16 regarding his room accommodations. During a follow-up interview on 7/12/23 at 2:37 p.m., the DR said she had visited Resident #16 and offered him a room with a layout where he had easier access to the bathroom and he declined. She said he wanted to stay in his current room and did not want a string to close the bathroom door behind him. She said he was unable to close the bathroom door, the privacy curtain at the foot of his roommate's bed did close. She said she did not talk to him about that but she would. The activity director was interviewed on 7/13/23 at 9:00 a.m. She said Resident #16 wanted to move to an assisted living facility and discharge was his current focus. She said Resident #16 did attend activities in the dining room at times and she had seen him access the adjacent restrooms across the hall from the dining room, which residents could also use if they had the keypad code. -However, review of Resident #16's activity participation records revealed he had not attended a group activity since 6/28/23. The environmental tour was conducted on 7/13/23 at 5:54 p.m. with the maintenance director (MTD) and nursing home administrator (NHA). Residents #63's and #16's rooms were observed and Resident #16 was interviewed. Resident #16 said he was okay with the bathroom which he could access with his walker. He reiterated he and his roommate needed more storage space next to the sink for their toiletry items. His roommate said he did not care or notice what Resident #16 did when he went into the bathroom. Resident #63 was observed going into his bathroom in his new wheelchair but the door remained open and his roommate sat in his recliner next to the bathroom door, indicating privacy was still an issue for Residents #16 and #63 and their roommates. The NHA and MTD said they would discuss possible accommodations for Residents #16 and #63.

Based on observations and interviews, the facility failed to ensure resident room temperatures were comfortable and safe for residents in one of three neighborhoods. Specifically, the residents who lived in two of eight resident rooms on the west side of Grand Mesa Hall experienced uncomfortably hot room temperatures when outdoor temperatures were high. Residents said all the rooms in that area of the building were uncomfortably hot and the facility's evaporative cooling system was ineffective. Findings include: I. Observations and resident interviews On 7/10/23 at 8:00 a.m. the facility hallways were observed with signs posted explaining why nursing facilities needed to have the room temperatures kept between 71 and 81 degrees Fahrenheit. High outdoor temperatures during the survey, conducted 7/10 through 7/13/23, ranged from 98 to 101 degrees Fahrenheit, according to the National Weather Service website. Room 31 was observed on 7/10/23 at 9:32 a.m. Her bedroom was uncomfortably hot and she said it was always warm in the bedrooms on that hallway of the facility. Room 28 was observed on 7/10/23 at 3:23 p.m. His bedroom was uncomfortably hot, even though he had two fans turned on and his door was open. Room 31 was observed on 7/11/23 at 2:10 p.m. and was uncomfortably warm. Room 28 was observed on 7/11/23 at 2:14 p.m. His bedroom was still hot, his door was opened and his two fans were turned on. The resident said the bedrooms in that hallway were always hot. He said he spoke to the maintenance staff and other staff about window tinting being installed on the windows of the affected rooms but was told it was too expensive. He said he had two fans running all the time and the door was always open, even though he and his roommate would like it closed sometimes for privacy. Room 28 was observed on 7/12/23 at 6:30 a.m. asleep in his bed. His bedroom felt uncomfortably warm for that time of day. In room 28, both residents were observed on 7/13/23 at 5:01 p.m. sitting near the opened bedroom door with their fans on. They both said it was hot and the only way for them to be cooled was to sit in the doorway. Room 28 was observed on 7/13/23 at 5:48 p.m. with one resident sitting by his opened door because he said his room was "really hot." His roommate sat with him to "cool off." II. Staff interviews Registered nurse (RN) #1 was interviewed on 7/12/23 at 3:40 p.m. He walked into room 28 and said the bedrooms in that hallway were always hot, especially in the afternoon and evening. The staff development coordinator (SDC) was interviewed on 7/13/23 at 5:08 p.m. She said the bedrooms on that hallway were always hot. She said it seemed to be worse in the afternoon and evening because the sun set on that side of the facility. The environmental tour was conducted on 7/13/23 at 5:48 p.m. with the maintenance director (MTD) and nursing home administrator (NHA). The MTD used a laser thermometer to take the temperature in room 28. The area at the window had a temperature of 89 degrees Fahrenheit and the area of the bedroom away from the window had a temperature at 82.9 degrees Fahrenheit. The MTD said if the resident turned off the fans the cool air in the hallway would be able to enter the room via the facility's evaporative cooling system. The resident in room 28 said he had tried that and it did not help. The MTD and the NHA said they would do something to get it taken care of. They did not indicate that room temperatures were regularly monitored or their specific plan for improvement.

Based on observation, interviews and record review, the facility failed to ensure four (#4, #50, #125 and #36) of 11 residents reviewed out of 37 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #4 did not suffer from verbal abuse by Resident #66. The facility failed to ensure effective personalized care planned interventions were in place for Resident #4 to prevent verbal abuse, who had a history of dementia and was exhibiting constant loud vocalizations. On 7/10/23 Resident #66 shouted at Resident #4, while in Resident #4's room, to shut up and stop yelling as she was disturbing him and the entire hallway. Resident #4 was observed hunched over in a wheelchair with hands covering her face. The facility further failed to ensure:-Resident #50 did not suffer from verbal/mental abuse by registered nurse (RN) #1;-Resident #125 did not suffer mistreatment/physical abuse by certified nurse aides (CNAs) #14 and #15; and, -Resident #36 did not suffer from verbal abuse by CNA #1. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention policy and procedure, reviewed April 2021, was provided by the NHA (nursing home administrator) on 7/13/23 at 4:06 p.m. It revealed 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."Protect residents from abuse, neglect, exploitation or misappropriation of property by but not necessarily limited to: a. Facility staff; b. Other residents; c. Consultants; d. Volunteers; e. Staff from other agencies; f. Family members; g. Legal representatives; h. Friends; i. Visitors; j. Any other individual."II. Incident of abuse between Resident #4 and Resident #66A. Resident #661. Resident statusResident #66, age 87, was admitted on 5/2/23. According to the July 2023 computerized physician orders the diagnoses included dementia and major depressive disorder. The 5/8/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of and required 12 out of 15. He required setup assistance with one person assistance for dressing, set up assistance with supervision for bed mobility, eating and was independent with transfers, toileting and personal hygiene. It indicated he was not exhibiting any verbal or physical behaviors towards others. 2. ObservationOn 7/10/23 at 10:35 a.m. Resident #66 was observed standing inside the entryway to Resident #4's room. Resident #66 was observed shouting at Resident #4 to "stop yelling" and "shut up" and she was disturbing him and the whole hallway. He was observed leaving the room and saying that she "yells all the time." He was observed returning to his room. An unidentified nurse was observed standing in the hallway at the medication cart and did not leave the medication cart to investigate the shouting by Resident #66. Resident #4 was observed sitting hunched over in a wheelchair in her room with her hands covering her face. On 7/10/23 at 10:45 the director of nursing (DON) was observed entering Resident #66's room and discussing with him his frustration regarding the constant yelling by Resident #4. On 7/10/23 at 12:00 p.m. the incident of alleged verbal abuse was reported to the nursing home administrator (NHA). 3. Record reviewThe psychosocial well being care plan, initiated on 5/5/23, indicated the resident had alterations in his psychosocial status related to anxiety due to inability to meet current role expectations and acceptance of current health conditions. Interventions included assistance, supervision and support to identify precipitating factors and stressors, support identifying problems that cannot be controlled, support with identification of potential solutions to present problems and when conflict arises, remove resident to a calm safe environment.-A comprehensive review of the care plan failed to reveal person centered identification of precipitating factors for stress and interventions. The care plan was not updated after the verbal altercation on 7/10/23.-A comprehensive review of the progress notes failed to reveal documentation of the 7/10/23 incident or prior incidents of verbal aggression. 4. Resident interviewResident #66 was interviewed on 7/10/23 at 10:45 a.m. He said that Resident #4 yells all the time and sometimes all night long. He said he was unable to concentrate when she was yelling and that it disturbed him. Resident #66 was interviewed on 7/13/23 at 10:00 a.m. He said staff had approached him since the incident on 7/10/23 and had offered him earphones and a change of room. B. Resident #41. Resident statusResident #4, age 92, was admitted on 11/3/22. According to the July 2023 CPO the diagnoses included dementia, cognitive communication deficit and depression. The 4/5/23 MDS assessment revealed the resident had severe cognitive impairment with severe impairment in short and long term memory and severe impairment for cognitive skills in daily decision making. She required the extensive assistance of two people for transfers, the extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene and supervision for eating. It indicated she exhibited verbal behaviors towards others. 2. Record reviewThe abuse care plan, initiated 12/11/22, indicated she had been a victim of abuse. Interventions included observing interactions with others to observe for safety and provide emotional support and opportunity to express herself. The at risk adult care plan, initiated 12/11/22 revised 3/1/23, indicated that she was at risk for abuse, neglect and exploitation due to dementia. Interventions included monitoring interactions with others and observing for safety, providing emotional support and the opportunity to express herself and investigating all allegations of abuse. The mood and behavior care plan, initiated on 12/14/22 revised on 5/8/23, indicated she yells out and becomes disruptive to others around her. Interventions included administration of medications as ordered, anticipate resident's needs, caregivers to provide for positive interaction, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, redirect and remove from the situation.-A comprehensive review of the care plan failed to reveal types of abuse the resident had experienced or personalized interventions to address prevention of the type of abuse. The care plan was not updated after the verbal altercation on 7/10/23.-A comprehensive review of the progress notes failed to reveal any documentation of the incident. On 12/19/22 at 3:13 a.m. the nursing progress notes revealed the resident was in her room with her spouse and the one-to-one care provider. The resident began yelling and calling out asking for staff to help her and her husband. The resident became angry with staff and could not be redirected. She yelled for staff to get him out of the room. Staff moved the husband and the resident stated to staff that she was afraid someone would come in and hurt her. On 12/19/23 at 9:53 p.m. the nursing progress notes revealed the resident became upset with her spouse and told staff to get him out of the room. She became more agitated the longer the husband was in the room. She held onto the certified nursing assistant's (CNA) arm and asked to please not leave her because she was scared. 3. Resident interviewResident #4 was interviewed on 7/13/23 at 10:00 a.m. She was unable to recall the incident on 7/10/23 or express any emotional distress due to the incident. C. Resident #66 to Resident #4 verbal abuse investigationThe 7/10/23 abuse investigation documented a witnessed resident to resident verbal altercation between Resident #66 and Resident #48. It indicated the alleged assailant (Resident #66) entered the victim's (Resident #4) room across the hall and shouted at Resident #4 to shut up and stop yelling. A comprehensive review of Resident #66's and Resident #4's nursing progress notes provided no documentation of the alleged incident or any prior history of verbal aggression by Resident #66. The 7/10/23 abuse investigation conclusion documented on 7/13/23 the verbal abuse was substantiated. It indicated that Resident #4 did not recall the incident and did not verbalize any fear. III. Staff interviewsCertified nurse assistant (CNA) #10 was interviewed on 7/13/23 at 8:45 a.m. She said Resident #4 has some days that were worse than others for yelling and calling out. She said they would intervene by redirecting her, taking her to the dining room to give hot chocolate, sit and talk and check to see if she needed to be changed. She said she was not aware of any other residents expressing being disturbed by Resident #4 yelling out. Registered nurse (RN) #3 was interviewed on 7/13/23 at 2:30 p.m. She said she had observed another resident that had shouted at Resident #4 to "shut up" when she was calling out. She said that male resident had been moved to another hallway. She said, on previous occasions, she had observed Resident #66 shouting out of his door when Resident #4 yelled out to "shut up" and had called staff into his room to see if they could quiet her down. She said staff has tried diversion by taking her to an activities but that Resident #4 was very difficult to redirect. She was not aware of any other interventions tried for Resident #4. She said she was not aware if any staff had spoken to Resident #66 on prior occasions to address interventions for Resident #66's disturbance when Resident #4 was shouting. The nursing home administrator (NHA) was interviewed on 7/13/23 at 6:50 p.m. He said when Resident #4 yelled out that staff would give her alternative activities to distract. He said he was aware of another resident that had told Resident #4 to "shut up" and the resident had been relocated to another room in another hallway. He said he was not aware of Resident #66 expressing that Resident #4 yelling out was disturbing to him. IV. Verbal/mental abuse from registered nurse (RN) #1 toward Resident #50A. Resident statusResident #50, age 76, was admitted on 12/30/21. According to the July 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, major depressive disorder (recurrent and moderate), anxiety disorder, and chronic post-traumatic stress (C-PTSD) disorder. The 7/5/23 minimum data set (MDS) assessment showed the resident had mild cognitive impairment, with a brief interview for mental status (BIMS) score of 10 out of 15. B. Resident interviewResident #50 was interviewed on 7/10/23 at 5:05 p.m. He said registered nurse (RN) #1 gave him a hard time when he requested help. He said on numerous occasions RN #1 told Resident #50 he was "making up issues for attention." He said, "(RN) #1 told me my trauma and PTSD was all in my head. He said I did not need my medications for anxiety or PTSD. Why would I not need the medications my doctor prescribed?"Resident #50 was interviewed again on 7/12/23 at 3:34 p.m. His left eye was red and bloodied. He triggered his call light. RN #1 assessed his eye. While RN #1 retrieved the machine to obtain his vital signs, Resident #50 said, "I am so glad you are in here because (RN #1) would have said it was all in my head or I made things up again. Thank you for being in here. It made it easier to ask for help from (RN #1)."C. Record reviewResident #50's care plan, initiated on 11/1/22 and not revised, identified his diagnosis of PTSD and trauma as a focused area. Interventions were documented as follows:Provide Resident #50 with the opportunity to express his fears and concerns when he felt anxiousResident #50 had the opportunity to speak witha therapist at his discretion. Resident #50 would be empowered to share his experiences and not to be made to feel burdensome when he struggled with his trauma.-The care plan also showed the resident utilized antidepressant medication for his depression and anxiety. A progress note was entered by Resident #50's therapist in the facility's charting system on 1/6/23 at 5:13 p.m. The note read in pertinent part:"(Resident #50) reported his nurse today keeps telling him 'it is all in my head.' Ensuring education of trauma-informed care, will assist (Resident #50) in having his PTSD diagnosis cared for."Another progress note was entered by Resident #50's therapist on 5/19/23 at 3:24 p.m., which read in pertinent part:"He also said there are staff that come up behind him to scare him and he talked about his PTSD and how he worries he may react to that and accidentally hurt someone. Writer will notify the social services director (SSD)."The nursing home administrator (NHA) provided copies of staff members' schedules on 7/11/23 at 9:35 a.m. The schedules confirmed RN #1 was assigned to the hall Resident #50 lived on for 1/6/23 and 5/19/23. D. Staff interviewsThe SSD was interviewed on 7/12/23 at 11:57 a.m. She said Resident #50's care plan documented to allow him to express how he felt or what he feared, therapy was scheduled as needed, and his experiences to be shared without staff making Resident #50 feel like a burden. She said staff needed to avoid preventing the resident from going outside because when the resident was triggered he needed to get out of his room. She said if he was anxious or triggered at night he wheeled himself through the facility to "burn off energy." The SSD said she was informed by the resident's therapist about the allegation against RN #1 on 1/6/23. She said she had spoken to the nurse and he said he attempted to explain something to the resident and it came out wrong. The SSD reminded RN #1 of the trauma informed care trainings and that Resident #50 needed to express how he felt. The SSD said she was not informed of the allegation with RN #1 on 5/19/23. She said since Resident #50 was easily startled staff should approach him in a certain way. She said she would look for the most appropriate place for the information to be entered into and put something in place since it was not care planned already.-The facility failed to report the abuse allegation they were notified about on 1/6/23 and did not ensure the resident was free from further abuse from the staff member (Cross-reference F609 failure to report abuse allegations). Certified nurse aide (CNA) #4 was interviewed on 7/12/23 at 1:50 p.m. CNA #4 said the CNAs were not educated enough on trauma-informed care, triggers for trauma or PTSD and how staff needed to handle the residents' triggers. She said CNAs found this information in the residents' care plans, although triggers and care needed were not always documented in the care plans. The NHA was informed of the allegations on 7/13/23 at 11:08 a.m. He indicated he was unaware despite the two entries in Resident #50's medical record and the interview with the SSD the previous day (above). The NHA said RN #1 would be suspended pending a facility investigation. RN #1 was suspended and replaced by another nurse on 7/13/23 at approximately 5:00 p.m. He said he would provide documentation of the facility's findings and action taken.-However, the NHA provided no further information and there was no evidence the incident was reported to the State Agency (cross-reference F609 failure to report). V. Mistreatment/abuse incident by CNAs #14 and #15 toward Resident #125 A. Resident statusResident #125, age 78, was admitted on 7/6/23. Due to being newly admitted the MDS assessments were not completed but staff reported Resident #125 had a diagnosis of dementia. B. ObservationsOn 7/11/23 at 2:09 p.m. Resident #125 walked near the nurses' station with her one-to-one staff. Certified nurse aide (CNA) #14 walked with Resident #125 while she kept the wheelchair behind the resident as she was unsteady on her feet. CNA #15 approached to switch with the resident's one-to-one staff. CNA #14 explained to CNA #15, Resident #125 was "very confused today, refused to be toileted and refused to sit in her wheelchair or use her walker." The resident placed both hands on the half door to the nurses' station while she looked up at the clock. CNA #14 said, "It is 2:30 p.m. (Resident #125), it is time to get toileted." CNA #15 walked up to the left of the resident (blocked the witness's view) and moved her hands toward the resident's hands. CNA #14 grabbed the resident's gait belt with her fingers pointed down toward the wheelchair. When CNA #15 moved her hands the resident's hands moved with her and CNA #14 pushed down on the gait belt and forcefully pushed Resident #125 into her wheelchair. CNA #15 turned the wheelchair around and Resident #125 immediately stood up and walked away while she utilized the grab bars in the hallway. -The observation was reported to the nursing home administrator (NHA) on 7/11/23 at 4:10 p.m. He said the CNAs would be suspended pending investigation of the incident. B. Staff interviewsThe NHA was interviewed on 7/13/23 at 11:08 a.m. The NHA requested more information on the abuse witnessed. He said CNA #15 said she lightly placed her fingers under Resident #125's fingers and "lightly" lifted her hands while CNA #14 used the gait belt to put the resident in her wheelchair. CNA #14 told the NHA she did not pull the gait belt down but Resident #125's knees buckled and she helped her sit in her wheelchair. Both CNAs were suspended during the investigation. The NHA said Resident #125 was difficult to redirect and was very busy but not safe to herself, other residents or staff. He said the facility did not have specific one-to-one training. There was dementia training on the computer and open office (training provided for staff when the staff had time to stop by) hour training provided on 7/13/23. The NHA said if the one-to-one staff was relieved by an agency staff (staff from an outside agency) they received a report from the current one-to-one staff and the NHA believed there was more information provided to the agency staff but he was unsure and needed to check. He did not provide further information. C. Facility follow-upAn investigative report was completed on 7/16/23 for the incident with Resident #125. The report documented the facility was unable to substantiate the abuse allegation for CNA #15 but substantiated the abuse for CNA #14. The resident's care plan was updated and neither CNA worked at the facility following the investigation. VI. Verbal abuse incident by CNA #1 toward Resident #36A. Resident statusResident #36, age 88, was admitted on 1/25/23. According to the 5/3/23 MDS diagnoses included Alzheimer's disease, dementia and heart failure. The 5/3/23 MDS showed the resident had a severe cognitive impairment with a BIMS score of five out of 15. B. ObservationOn 7/13/23 at 1:50 p.m. Resident #36 was in his wheelchair by the nurses' station. He yelled out repeatedly and incoherently. CNA #1 looked frustrated and approached Resident #36. CNA #1 said "shut up" in a firm voice to Resident #36. CNA #1 stepped closer to Resident #36 and repeated "shut up" louder in a harsh tone. CNA #1 then firmly asked Resident #36, "Why are you yelling?" CNA #1's body looked tense and he walked away and still appeared frustrated. Resident #36 wheeled himself toward the dining room and continued to yell. An unidentified female CNA approached Resident #36 and calmly asked him, "Why are we yelling?" Resident #36 yelled, "because I am a yeller." C. InterviewThe NHA was informed of the observation on 7/13/23 at 3:05 p.m. He said he did not like the phrase "shut up" and would investigate the incident. He said CNA #1 would be suspended immediately pending the investigation. D. Facility follow-upAn investigative report was completed on 7/18/23 for the incident with Resident #36. The report said the facility interviewed staff members and no one witnessed CNA #1 yell at Resident #36 however another resident did. The resident's care plan was updated and CNA #1 no longer worked at the facility following the investigation.

Based on record review and interviews the facility failed to report incidents of potential abuse to the State Survey and Certification agency in accordance with State law for three (#4, #66 and #50) of 11 residents reviewed for abuse out of 37 sample residents. Specifically, the facility failed to report:-An incident of verbal abuse involving Resident #4 and Resident #66; and, -Incidents involving verbal/mental abuse by registered nurse (RN) #1 toward Resident #50 to the State Survey and Certification Agency. Cross-reference F600, failure to ensure residents were free from abuse. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention policy and procedure, last reviewed April 2021, was provided by the nursing home administrator (NHA) on 7/18/23 at 4:06 p.m. It read in pertinent part:"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."II. Abuse incident involving Residents #66 and #4A. Record reviewAn incident of verbal abuse by Resident #66 toward Resident #4 occurred on 7/10/23, that was reported to the nursing home administrator (NHA). (Cross-reference F600 for abuse.)-The facility provided documentation that an investigation was in progress on 7/13/23 but they failed to report the incident to the State Survey Agency until 7/13/23 after interview with the NHA (see below). B. Staff interviewThe NHA was interviewed on 7/13/23 at 1:30 p.m. He reviewed the investigation and said it did not meet criteria for abuse because Resident #4 did not express fear and did not remember the incident, therefore he did not report it to the State Survey Agency.-However, any allegation/incident of abuse must be reported to the State Agency. The facility substantiated verbal abuse occurred (cross-reference F600). III. Verbal/mental abuse from registered nurse (RN) #1 toward Resident #50A. Resident interview Resident #50 reported verbal/mental abuse by RN #1 during interviews on 7/10/23 and 7/12/23 (cross-reference F600 abuse). B. Record reviewMedical record review revealed Resident #50 had reported verbal/mental abuse to his therapist, documented in progress notes on 1/6/23 and 5/19/23.-Although documented in the medical record, there was no evidence of facility follow-up and investigation. Further, there was no evidence the therapist reported Resident #50's concerns to the NHA. C. Staff interviewThe NHA was interviewed on 7/13/23 at 11:08 a.m. He said RN #1 was suspended pending a facility investigation. He said he would provide the facility's investigative findings.-However, as of 7/26/23 no further information was provided and there was no evidence the incident was reported to the State Agency.

Based on record review and interviews, the facility failed to coordinate assessment with the preadmission screening resident review (PASRR) program for one (#50) of two residents reviewed for PASRR out of 37 sample residents. Specifically, the facility failed to submit another PASRR assessment when Resident #50's diagnosis changed in June 2023. Finding include:I. Facility policy The policy regarding PASRR assessments was requested from the nursing home administrator (NHA) on 7/12/23 at 2:40 p.m. The NHA said the facility did not have a policy for PASRRs. II. Resident statusResident #50, age 76, was admitted on 12/30/21. According to the July 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, major depressive disorder (recurrent and moderate), anxiety disorder, and chronic post-traumatic stress disorder (C-PTSD). The 7/5/23 minimum data set (MDS) assessment showed the resident had a mild cognitive impairment, with a brief interview for mental status (BIMS) score of 10 out of 15. A PASRR II was needed but not completed. III. Resident interviewResident #50 was interviewed on 7/10/23 at 5:08 p.m. He said he attended certain appointments at the veterans affairs (VA) hospital. He said he received some therapy sessions but it was not enough therapy services for his trauma and C-PTSD. He had not been seen by his therapist consistently and desired to see her more. "I really need help processing my trauma from a lot of my family members passing away unexpectedly and my PTSD from serving in the war. I do not feel like I am getting enough help from this facility." He said some of the staff listened when he needed to vent, or when he expressed anxiety or fears, but not all of the staff. Resident #50 said some nurses had not understood his diagnosis or how they needed to help him. He was upset a nurse said his C-PTSD and trauma were "all in my head and I did not need to take my medications my doctor ordered for me." (Cross-reference F600 abuse)IV. Record reviewResident #50's care plan, initiated on 11/1/22 and not revised, identified his diagnosis of PTSD and trauma as a focused area. Interventions were documented as follows:Provide Resident #50 with the opportunity to express his fears and concerns when he felt anxious. Resident #50 had the opportunity to speak with a therapist at his discretion. Resident #50 would be empowered to share his experiences and not to be made to feel burdensome when he struggled with his trauma. The care plan also showed the resident utilized antidepressant medication for his depression and anxiety.-However, the care plan failed to show how staff needed to help Resident #50 with his anxiety and depression. A PASRR I was completed on 1/1/22. The documentation showed a PASRR II was not needed due to Resident #50's diagnoses at the time of admission.-The diagnosis of major depressive disorder was changed from a single episode to recurrent and entered in his CPO in June 2023. The facility failed to submit another PASRR assessment to get recommended services for Resident #50. V. Staff interviewsThe social services director (SSD) was interviewed on 7/12/23 at 11:57 a.m. She said a PASRR II was not needed for Resident #50 when he was admitted. She said since his major depressive disorder changed from a single occurrence to recurrent, he needed a PASRR II. The SSD said she was not aware the diagnosis changed in June 2023. She requested a new PASRR assessment during the interview. The SSD said Resident #50 had a trauma-informed care plan (noted above) for staff to allow expression of how he felt and his fears, he attended therapy as needed, and for him to share his experiences without feeling like he was a burden. She said the care plan was created based on Resident #50's wishes. The SSD said she would be notified of residents who received a new mental illness or developmental disability diagnosis and she would submit for a PASRR assessment, however, she was not notified of a diagnosis change for Resident #50. Certified nurse aide (CNA) #4 was interviewed on 7/12/23 at 1:50 p.m. CNA #4 said the CNAs were not educated enough on trauma-informed care, triggers for trauma or PTSD, and how staff needed to handle the residents' triggers. She said CNAs found this information in the residents' care plans, although triggers and care needed were not always documented in the care plans. The activities director (AD) was interviewed on 7/13/23 at 9:04 a.m. She said she and her activity aides (AA) received training for trauma-informed care in new employee orientation. The AD went over triggers for residents with her aides through their files since the aides did not have access to the facility's charting system. She said she ensured she went over each resident's trauma-informed care plans. CNA #2 was interviewed on 7/13/23 at 4:54 p.m. She said trauma-informed care and dementia training was provided by the facility every six months.

Based on observations, interviews and record review, the facility failed to ensure adequate assistance with activities of daily living (ADLs) for four (#8, #63, #50 and #7) of nine residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure:-Resident #8 received adequate assistance with bathing, grooming and toilet use/incontinence;-Resident #63 received adequate assistance with bathing and grooming;-Resident #50 received adequate assistance with showers; and-Resident #7 received adequate assistance with showers. All the above residents needed physical assistance from staff with these ADLs. Residents #50 and #7 said the lack of showers affected their psychosocial well-being. Findings include: I. Facility policy The Activities of Daily Living (ADLs)-Supporting policy, provided by the nursing home administrator (NHA) on 7/13/23 at 6:00 p.m., documented in pertinent part: "Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. "Residents will be provided with care, treatment and services to ensure their ADLs do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing ADLs are unavoidable. "Appropriate care and services will be provided for residents in accordance with the plan of care including support and assistance with:a. hygiene (bathing, dressing, grooming and oral care);b. mobility (transfer and ambulation, including walking);c. elimination (toileting);d. dining (meals and snacks); ande. communication (speech, language and any functional communication system). "If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. "The resident's response to interventions will be monitored, evaluated and revised as appropriate." II. Resident #8 A. Resident status Resident #8, age 76, was admitted on 6/30/22. According to the July 2023 computerized physician orders (CPO), diagnoses included autistic disorder, legal blindness, hearing loss, major depression and history of falling. According to the 4/8/23 minimum data set (MDS) assessment, he had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. No interpreter was needed. He had mood symptoms of feeling down, depressed and hopeless. No behaviors or rejection of care were documented. He required limited assistance with bed mobility, dressing, toilet use and personal hygiene. He needed physical assistance with part of the bathing activity. He was frequently incontinent of bladder. -Since his admission MDS assessment on 7/6/22, Resident #8 had experienced declines in cognitive status from a BIMS score of five down to two out of 15, and a continence status decline from continence to frequent incontinence of bladder. Although he was deaf, legally blind and did not speak, no American sign language (ASL) interpreter was involved in the MDS assessment processes. B. Resident representative interviewResident #8's representative was interviewed by phone on 7/10/23 at 4:30 p.m. The representative said he had "talked to them and talked to them" at the facility about ensuring Resident #8 received showers, assistance to the bathroom, changing his briefs and cutting his hair which he preferred short. "That's why he's there, because he needs assistance." C. Observations Observations of Resident #8 revealed:On 7/10/23 at 9:44 a.m., he was sitting in a wheelchair, head down, sleeping, facing the window with the blinds closed. At 10:07 a.m. he looked up but did not respond to a greeting. He was holding his television remote, unable to get past the home screen on his television (TV). He smelled of urine, feces and body odor. His hair was oily and disheveled, he had quarter-inch-long stubble on his face, his nails were long jagged and had dark matter underneath, his glasses were smudged and needed cleaning, his belly was exposed and his clothing was covered with food debris. Certified nurse aide (CNA) #1 knocked and entered his room, said "Let's get you out of your room, I'll take you to the cafe," and wheeled him out. The CNA did not offer to take him to the bathroom or provide grooming assistance. On 7/11/23 at 4:26 p.m. he was sleeping at a dining room table alone. His hair was oily and disheveled but he had been shaved. On 7/12/23 at 6:59 a.m. he was in bed sleeping, wearing the same plaid shirt from the day before. At 9:26 a.m. he was sitting in his wheelchair in his room waving for assistance. He smelled of urine. A CNA was notified and went in to assist him. On 7/13/23 between 8:00 a.m. and 9:00 a.m., Resident #8 was observed sitting at a dining room table alone and waved for assistance. A CNA was notified and she approached and wrote Resident #8 a note, "What can I do?" He responded by writing "hamburg." She acknowledged they would get him a hamburger for lunch and asked what else she could do. He touched his belly and she asked him if his stomach hurt, then determined he needed the bathroom, asked and he responded yes. She wheeled him out of the dining room and down the hall and left him sitting outside his room which was being cleaned by housekeeping staff. She told him she would check back with him and went back to the dining room.-10 minutes later, Resident #8 was still sitting in the hall in front of his room. The housekeeper had moved on to the next room and no CNAs were observed nearby. The transportation director, who was a CNA, was notified and said she would assist Resident #8. Just then CNA #9 approached Resident #8, said she would help him and took him into the bathroom. -Throughout the survey, conducted on 7/10, 7/11, 7/12 and 7/13/23, Resident #8 was observed needing ADL assistance that was not provided in a timely manner. (Cross-reference F725, sufficient nursing staffing.) D. Record review Resident #8's care plan, initiated 11/1/22 and not revised, identified unique communication needs "which cause me to engage in behavior that others may find offensive and socially unacceptable. Such as disrobing in places others can observe me, smearing feces, and invading upon others' personal space." Interventions were: provide assistance to complete hygiene tasks as needed, ranging from cues to hands-on assistance; provide reminders of others' personal space; and remind to close the curtain and/or door to room when changing or performing hygiene tasks. Resident #8's care plan, initiated 7/8/22 and revised 1/13/23, identified limitations in his ability to perform ADLs. The goal was for staff to help him maintain his functional status and/or assist with completing ADLs. Interventions included:-"Toileting: I am continent of bowel and bladder and may require set-up/supervision with toileting;-Bathing: I require limited assistance from 1 staff with my bathing. I prefer a shower 5 times a week." -The ADL care plan documented Resident #8 was continent, but his MDS assessment documented he was frequently incontinent of bladder (see above). The care plan for meeting emotional, intellectual, physical, spiritual and social needs, initiated on 2/16/23, documented, "I would like to maintain my independence as long as possible. Choosing between a shower (which is okay most of the time) and a bath (which I do enjoy soaking and scrubbing in at least once a month) is important to my autonomy. Please help support me in this goal." -There was no care plan for refusal of care or refusal of showers. Review of Resident #8's Bath Look Back for the past two months revealed he did not receive his care-planned five baths per week. He was documented to receive baths/showers on:5/15/23, 5/19/23, 5/22/23, 5/24/23, 5/31/23 (six days since last shower), 6/3/23, 6/5/23, 6/9/23, 6/12/23, 6/16/23, 6/21/23, 6/26/23, 6/28/23, 7/1/23, 7/5/23 and 7/7/23. -Resident #16 received 16 out of his requested and care planned 40 showers in a two-month period. -No showers were documented after 7/7/23. There were several days between documented showers although the resident preferred showers five times per week. Two refusals were documented (5/19/23 and 7/7/23) but the resident accepted showers later the same day, indicating refusals were not an issue. A progress note documented on 7/12/23 at 12:28 p.m. by the activity director documented in part, "(Resident #8) was at activities, then got a haircut." There was no documentation that he received a shower. E. InterviewsLPN #4 was interviewed on 7/12/23 at 10:27 a.m. She said she had never seen Resident #8 say no to care. "I've actually seen him grab his clothes and go sit by the shower." She said they did have a bath aide for a while who would provide 20 to 30 showers a day and the residents loved her. Without a bath aide, residents were doing without timely bathing assistance. III. Resident #63 A. Resident status Resident #63, under age 70, was admitted on 1/25/23 and readmitted on 3/6/23. According to the July 2023 CPO, diagnoses included chronic obstructive pulmonary disorder (COPD), pulmonary hypertension, hypoxic respiratory failure and stage 4 kidney disease. According to the 5/3/23 MDS assessment, he was cognitively intact with a BIMS score of 14 out of 15. He had verbal behaviors directed toward others but no rejection of care. He required extensive assistance with transfers, toilet use and personal hygiene. He needed physical assistance with part of the bathing activity. He was continent of bladder and frequently incontinent of bowel. B. Resident interview and observations Resident #63 was interviewed on 7/11/23 at 9:28 a.m. He said he had gone three weeks without a bath. He said he preferred baths to showers and would like baths every other day but he was "lucky to get once a week." His room smelled of body odor and urine. Two urinals, one full and the other one-third full of urine, were hanging over the edge of the wastebasket at his bedside near his over-bed table. His fingernails were long and had dark brown matter underneath. He acknowledged he needed nail care, and said he would like to have nail care with his baths every other day. C. Record review Resident #63's care plan, initiated on 3/7/23, identified limitations with his ability to perform ADLs related to weakness, respiratory status and impaired mobility. Interventions included:"Bathing: I require extensive assistance of 1 staff with bathing. I prefer a bath or shower 2x week.-Toileting: I require extensive assistance of 1 with toileting upon arising, before and/or after meals, at bedtime and as needed.-Personal care/oral care: I require extensive assistance of 1 with my hygiene and oral care." -There was no care plan for refusal of care or refusal of baths/showers. Review of Resident #63's Bath Look Back for the past two months revealed he had showers or baths on 5/18/23 (shower), 5/24/23 (tub bath), 5/31/23 (shower), 6/10/23 (shower), and 7/5/23 (tub bath). Resident #63 received five out of his preferred 30 and 16 care planned showers in a two-month period. There were five refusals during the two-month period, two in one day on 7/2/23, but no evidence the underlying cause of the refusal was identified, or that baths were offered again the following day. III. Resident #50A. Resident statusResident #50, age 76, was admitted on 12/30/21. According to the July 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, major depressive disorder (recurrent and moderate), anxiety disorder, and chronic post-traumatic stress (C-PTSD) disorder. The 7/5/23 minimum data set (MDS) assessment showed the resident had a mild cognitive impairment, with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS showed Resident #50 needed one person assistance during a shower with physical support from staff for part of the shower. B. Resident observationsOn 7/10/23 at 5:23 p.m. Resident #50 had greasy hair and looked disheveled. His fingernails were long and dirty. On 7/11/23 at 2:00 p.m. Resident #50's hair was greasy and his fingernails remained long and dirty. On 7/12/23 at 6:30 a.m. Resident #50 was asleep and his hair was still greasy.-At 7:02 a.m. Resident #50 was asleep and his hair was still greasy.-At 3:34 p.m. Resident #50's hair was greasy and his fingernails were long and dirty. His facial skin looked oily and his shirt was dirty. On 7/13/23 at 3:00 p.m. Resident #50 still had greasy hair, his fingernails were long and dirty, his skin was oily, and his shirt was dirty.-At 5:01 p.m. Resident #50 had changed his shirt but his fingernails and hair remained the same. C. Resident interviewsResident #50 was interviewed on 7/10/23 at 4:53 p.m. He said showers were supposed to be once a week but he had not showered since a couple of Saturdays ago (7/1/23). He said he preferred to shower two times a week but the facility did not have enough staff. Resident #50 said not showering affected his mental well-being. Resident #50 was interviewed on 7/13/23 at 5:01 p.m. He said he would be itchy and felt gross when he did not shower at least once a week. D. Record reviewThe resident shower charts from May 2023 to July 2023 were provided by the director of nursing (DON) on 7/13/23 at 5:09 p.m. Shower entries were documented as follows for those months:5/15/23-Showered5/18/23-Showered5/25/23-Showered 6/1/23-NA (non applicable)6/5/23-NA6/8/23-Refusal6/12/23-Showered 6/15/23-NA6/19/23-NA6/22/23-NA6/26/23-NA6/29/23-NA7/3/23-NA7/6/23-Refusal7/10/23-NA-The last documented shower for Resident #50 was 6/12/23, which meant he had not showered in a month. IV. Resident #7A. Resident statusResident #7, age 71, was admitted on 4/14/22. According to the July 2023 computerized physician orders (CPO) diagnoses included major depressive disorder (recurrent and severe), schizoaffective disorder (depressive type), and anxiety disorder. The 4/13/23 minimum data set (MDS) assessment showed Resident #7 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS showed Resident #7 needed one person assistance from staff during a shower with transferring. B. Resident observationsOn 7/10/23 at 9:32 a.m. Resident #7 had greasy hair.-At 1:39 p.m. Resident #7 had greasy hair and part of it was slicked back. On 7/11/23 at 2:10 p.m. Resident #7 was asleep and her hair was still greasy. On 7/12/23 at 9:56 a.m. Resident #7 attended resident council. She looked disheveled, her shirt looked dirty, and she had greasy hair. C. Resident interviewResident #7 was interviewed on 7/10/23 at 9:32 a.m. She said she did not get showered enough. She tracked her showers on her calendar and her last shower documented was on 6/30/23. Resident #7 said not showering increased her anxiety and depression. She said she preferred to shower every day but would "take a shower every other day at this point to shower consistently."D. Record reviewResident #7's shower entries were documented as follows for May to June 2023: 5/15/23-Showered5/17/23-Showered6/1/23-Showered 6/5/23-NA6/8/23-Bathed6/12/23-Refusal6/14/23-NA6/19/23-NA6/21/23-NA6/26/23-NA6/28/23-Showered6/30/23-Showered7/3/23-NA7/5/23-NA7/10/23-NA7/12/23-NA-The last documented shower for Resident #7 was 6/30/23, which meant it had been two weeks since her last shower. V. Resident council interviewThe resident council members were interviewed on 7/12/23 at 9:56 a.m. The residents said it was getting longer in between showers. The residents said they chose if they took a bath or a shower and it was always honored, however, the number of times they preferred to shower each week was not honored. This angered the residents because they said they paid a lot of money to live at the facility and they could not even shower. VI. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 7/11/23 at 2:45 p.m. He said when the facility was short-staffed showers were not consistent. He said the facility used to have two shower aides but if other CNAs called out the shower aides covered the floor and showers would not be completed. He said the facility needed more floor staff, especially CNAs for the residents to get the care they needed. CNA #4 was interviewed on 7/12/23 at 1:50 p.m. She said they facility did not have enough staff to provide the residents with the care they needed. She said, "When we are short-staffed showers, oral hygiene, and repositioning gets skipped. I worked an extra shift every week to provide showers to the residents because on my days off it does not happen." She said CNAs documented showers as refusals when they could not be completed. CNA #4 said usually no one asked the residents if they wanted a shower, they just documented refusals. She said if she saw a documented refusal she went and asked the resident if they wanted a shower, to ensure it was a refusal. If the resident said they wanted a shower she showered them, if she had the time. She said she had spoken to the DON about being short-staffed and she only heard "we are working on it" back. She said she got frustrated because the residents should get the care they wanted and the care they needed. The assistant director of nursing (ADON) was interviewed on 7/12/23 at 2:46 p.m. She said the facility was aware showers were not consistent and she worked on a plan to correct it. She said if the CNAs felt there were not enough CNAs on the floor they resident would not get showered. She said upper management had offered to cover the floor so the resident received a shower. She said, "We want the floor staff to come to us (management) when they need help. It is an all hands on deck situation." She said management frequented the floor to make their presence known. The ADON was redoing the bathing preferences so they matched the residents' orders in their charting system. She said the facility had tried hard to fix the problem. The facility had posted a bathing aide position online but no one applied. She said the managers needed to assign a CNA to showers each day since the bathing aide position could not be filled. The director of nursing (DON) and nursing home administrator (NHA) were interviewed 7/13/23 at 8:00 p.m. regarding quality assurance/process improvement. The NHA said bathing had been a challenge and it was something they were working to address.

Based on observations, record review and interviews, the facility failed to provide an individualized activity program to meet the psychosocial needs of one (#8) of six residents reviewed out of 37 sample residents. Specifically, Resident #8 had specialized activity needs due to diagnoses of autism and major depression. Resident #8 was deaf and did not speak. The facility failed to develop effective methods to communicate with the resident, family and interdisciplinary team to assess, develop and implement activities in keeping with his preferences and communication needs to ensure he reached his highest practicable psychosocial potential and well-being. The facility failed to meet Resident #8's specialized, person-centered activity needs which contributed to his isolation. Findings include: I. Resident status Resident #8, age 76, was admitted on 6/30/22. According to the July 2023 computerized physician orders, diagnoses included autistic disorder, legal blindness, hearing loss and major depression. According to the 4/8/23 minimum data set (MDS) assessment, he had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. No interpreter was needed. He had mood symptoms of feeling down, depressed and hopeless. No behaviors or rejection of care were documented. Since his admission MDS assessment on 7/6/22, Resident #8 had experienced a decline in cognitive status from a BIMS score of five on 7/6/22 down to two out of 15 on 4/8/23. Although he was deaf, legally blind and did not speak, no American sign language (ASL) interpreter was documented as involved in the MDS assessment processes. According to the 7/6/22 admission MDS assessment, Resident #8's activity preferences includedreading books, newspapers and magazines; going outside when the weather was nice; religious services and practices; animals and pets; keeping up with the news and snacks between meals. The resident and representative were not able to participate in the activity assessment. II. Observations Resident #8 was observed throughout the survey, conducted 7/10, 7/11, 7/12 and 7/13/23, spending most of his time in his room, in the dining/activity area sitting alone on the periphery of a group activity, or sitting in the hallway near the nurses' station. He was not observed engaged in activities. When in his room, his television was sometimes on but no actual show or movie or closed captioning was observed on the screen. His television, which was mounted high on the corner of his wall, was sometimes obstructed by the open bathroom door in the room he shared with a roommate. His blinds were usually closed. No books, magazines or newspapers were observed in his room. No music was playing. Resident #8 was observed communicating with staff in writing on paper that staff provided, but no white board was observed in the resident's room for communication. Staff were not observed communicating with him in sign language other than brief interactions involving brief answers to basic questions about care needs. Resident #8 did not appear to make eye contact and/or communicate with people he did not recognize. III. Representative interview Resident #8's representative was interviewed on 7/10/23 at 4:49 p.m. He said Resident #8 did not participate in activities at the facility but he did enjoy bingo. He said the resident spoke a combination of "old and new" ASL and could read lips. IV. Record review Resident #8's care plan, initiated 7/7/22 and not revised, identified he met PASRR II (Preadmission Screening and Resident Review) level of determination. Interventions were: resident to receive appropriate specialized services as indicated on PASRR Level II and resident to receive appropriate specialized services to attain or maintain his highest practicable psychological, physical, functional and psychosocial well-being. The activities care plan, initiated 7/11/22 and not revised, documented Resident #8 had little or no activity programming involvement due to his diagnosis of autism and he did not wish to participate in groups. Interventions were:"I am a night owl. I prefer to stay up late and sleep in. I do not want to be involved in early morning activities. If you are bringing me a Daily Chronicle (the facility newsletter) and I am sleeping in, it is okay to enter my room and place it on my over the bed table so I can read it at my convenience.-I am a quiet person, related to I am mute and deaf. I enjoy books, watching TV and taking the Daily Chronicle. However, I have my own patterns and habits and it is very important I stick with them. Please allow me the privacy to do so comfortably.-I am Catholic and I enjoy personal Bible study but have no interest in attending non-denominational services here in the facility.-I enjoy nice weather. I would like to go outside, but may need assistance/encouragement to go since I currently do not have going outside in my daily routine. My routine is everything to me.-Remind me that I may leave programs at any time, and am not required to stay for the entire program should I choose to attend/participate in an activity." The care plan for communication, initiated 7/11/22 and not revised, documented, "I am autistic, legally blind, deaf and mute and am at risk for miscommunication. I am able to make my needs known." Interventions were:"Although I am legally blind I can read and write. I have notebooks and pens to use for communication.-I am allergic to fish.-I can use sign language to communicate.-I have dry erase white boards to use for my communication as needed.-My autism requires that I am given additional processing time when you make a request of me. Please ensure I have had time to read your request and respond prior to rushing to the next request.-Staff will be patient and pay attention to me and repeat my requests as needed to validate understanding.-Staff will stick to a topic and avoid quick shifts from topic to topic, so I may easily follow.-Use yes/no questions when I am having difficulty or as needed." The resident's 8/11/22 PASRR contingent notification documented a formal developmental disability determination was required. Specialized services recommended were: assistive technology, case management, day habilitation-specialized habilitation, day habilitation-supported community, connections and transportation. Resident #8 also had a PASRR Level II related to major depression but no related specialized services were recommended. -Almost one year later, the facility had failed to develop a care plan to provide the recommended specialized services from the PASRR Level II regarding Resident #8's autism diagnosis. Resident #8's activity participation documentation, provided by the activity director on 7/13/23 in the afternoon, documented he attended an average of 16.6 activities per week for a total of 133 activities. Those included mostly group activities, Daily Chronicle which involved handing him a facility newsletter, and one-on-one visits daily at 8:00 a.m. although he liked to sleep in. -There was no documentation he was taken outside when the weather was nice per his documented preference. Only two activities appeared to involve pet visits per his documented preferences. Eight activities involved music. Four activities involved treats and snacks. Participation in bingo was never documented although his representative (see above) said Resident #8 enjoyed bingo. V. Staff interviews The social services director (SSD) was interviewed on 7/13/23 at 12:27 p.m. She said Resident #8 had never received the specialized services recommended by the PASRR Level II because his representative was not really interested in him going into waiver services or day programming. She said Resident #8 was still being evaluated by the community centered board and she was waiting for their determination of whether he qualified for services. The SSD said she had been in contact with the county developmental services representative and was still awaiting a response. She said she needed to contact them again. "The outside service provider is slow (to respond) here." The SSD said Resident #8 did not participate in activities. He liked to observe from a distance. She said she felt that was part of his autism. "He's more of an observer of people than really getting in there and interacting with people. He tells us 'no' for bingo." She said she just brought him another white board that morning for communication and he told her "no," so she responded she was putting it in his drawer so he could "tell us what you need." She said writing and signing were his ways of communicating and he did like to write on the white board. "I think he will seek out staff he recognizes most and tell other people 'no.'" The activity director (AD) was interviewed on 7/13/23 at 9:00 a.m. She discussed Resident #8's activity preferences and the types of activities the facility provided for him. She said he used to love big bright pictures of fish and farm equipment in an activity book she prepared for him. That had "kind of gone by the wayside recently," but occasionally he would still look at it. She said he received a Daily Chronicle every morning, he kept up with activities and he enjoyed music events. Her goal was to keep him socialized. The AD said Resident #8 participated passively in group activities in the dining room with things he could watch and see. She said he enjoyed trivia. She would read off questions without singling out anyone, make her own guess known, look over at him and see him looking and sometimes he would nod. Sometimes he would just look around. "He's very sensory engaged." She said he had never participated in bingo and did not go to bingo. She thought staff had offered him a bingo card once and he waved the card away but watched the activity from a distance. She said his favorite activities were the music programs but he did not have music in his room. She did not know if his television had closed captioning. When an activity was not fulfilling a need he extracted himself from it. When he disengaged they would involve him in more one-on-one activities. Because of his disabilities he needed "that extra" one-on-one because he had risk factors she could not ignore. She read over the one-on-one activity documentation from her computer and said he was planned for three times one-on-one activities weekly. "We put as much on his plate for options as we can. He's Catholic and he likes religious pictures but he doesn't really want to participate" in Catholic services. She said one-on-one activities usually involved a chat with the activities assistant for at least 15 minutes, sometimes up to 45 minutes. She said she had not reviewed the PASRR Level II, and acknowledged day habilitation services as recommended on the PASRR level II would probably be beneficial to him. She said she would start reviewing PASRR level IIs to determine residents' applicable activities needs. She said she participated in care conferences when she was in the building and she participated in interdisciplinary team meetings.

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Based on observations, record review, and interviews, the facility failed to ensure one (#35) of nine residents reviewed for weight loss out of 37 sample residents maintained adequate nutritional parameters. Specifically, Resident #35 had a condition change when she experienced a fall with a fracture on 4/2/23 (cross-reference F689 falls/accidents). Resident #35's weights, taken on 3/30/23 and 5/11/23, more than one month apart, demonstrated a 10-pound weight loss from 201.6 to 191 pounds, which was not followed up with timely nutritional assessments and interventions. Resident #35 was observed needing extensive to total assistance with dining although her assessments and care plan identified she was independent with setup help only; staff who provided care for Resident #35 said she had needed an extensive level of assistance for about one month. There was no evidence of a thorough assessment of the resident's current dining assistance needs as of 7/13/23. The facility failed to respond in a timely manner to Resident #35's dining assistance needs and failed to assess and implement measures to ensure she received the assistance and nutrition needed to prevent significant weight loss. These failures contributed to Resident #35 experiencing significant, unplanned weight loss of more than 10 percent within six months. Findings include: I. Facility policy and procedures The Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol policy, provided by the director of nursing (DON) on 7/14/23 at 5:01 p.m., included: The nursing staff would monitor and document the weight and dietary intake of residents in a format which permitted comparisons over time. The staff and physician would define the individual's current nutritional status (weight, food/fluid intake and pertinent laboratory values) and identify individuals with weight loss or gain and significant risk for impaired nutrition. The staff would report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. When medical conditions or adverse consequences were causing or contributing to altered nutritional status, the physician and staff would collaborate in adjusting interventions, taking into account the status of those causes and the resident's responses, goals, wishes, prognosis, and complications. II. Resident status Resident #35, age 96, was admitted on 12/14/18. According to the July 2023 computerized physician orders, diagnoses included Alzheimer's disease, vascular dementia, type II diabetes mellitus with hyperglycemia, and need for assist with personal care. According to the 6/22/23 minimum data set (MDS) assessment, Resident #35 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She had a delirium indicator of inattention, being easily distractible, and having difficulty keeping track of what was being said. She needed extensive two-plus person assistance with most activities of daily living (ADLs) and was independent with setup help only for eating. She had no chewing or swallowing difficulties. She weighed 198 pounds (lbs) and weight loss/gain was "no or unknown."-The MDS was inaccurate in that the resident's need for dining assistance and her recent weight loss were not identified (see below). III. Observations and staff interviews According to the meal service schedule, breakfast was served from 7:00 to 8:00 a.m., lunch from 11:30 a.m. to 12:30 p.m., and dinner from 5:00 to 6:00 p.m. Per observations, room trays were served first. On 7/10/23 at 9:45 a.m. Resident #35 was sitting in the hallway by the nurses' station near the main dining room repeatedly saying she wanted to go to bed. After repeating herself several times, staff assisted Resident #35 to her room. (Per meal intake records she ate 76-100% for breakfast.) Observations afterward throughout thesurvey conducted 7/10/23 through 7/13/23, revealed Resident #35 spent her time in bed, sleeping off and on. She also ate her meals in bed. When Resident #35 was approached as she lay in bed, she would sometimes wake up, reach out with her hand and ask if there was anything to eat. Her meals were often left covered and out of her reach on her bedside table for extended time periods after meals were served and frequently no staff were observed nearby to assist her with eating. Specifically: -On 7/12/23 at 7:51 a.m., Resident #35 was lying in bed and her breakfast tray was covered and sitting on her bedside table out of her reach, not set up for her. At 8:10 a.m. it was in the same place. At 8:34 a.m., her breakfast tray was gone. At 8:43 a.m., certified nurse aide (CNA) #1 said he assisted her to eat her breakfast and she enjoyed it. (She ate 76-100% per the meal intake record.) -On 7/13/23 at 8:00 a.m., Resident #35's breakfast was covered on her bedside table and out of her reach. CNAs #1 and #9 were assisting another resident to get out of bed. After assisting the other resident, CNA #1 took Resident #35's plate of pancakes to heat them up in the microwave and assisted her to eat her breakfast, after cutting up her pancakes into bite-sized pieces and adding syrup for her. -At 8:45 a.m., CNA #1 said Resident #35 ate all her bacon and wanted more and he was going to get her more. CNA #1 said her milk was probably not cold anymore. He said she would drink milk but only if assisted. He said if they set up her room tray and left her food within her reach she would pull it onto herself from the bedside table. He said she had been wanting to sleep more and more lately. CNA #1 said Resident #35 needed total assistance with eating and had needed this level of assistance for about the last month. (She ate 76-100% per meal intake records, see below.) CNAs #1 and #9 were interviewed on 7/13/23 at 8:45 a.m. CNAs #1 and #9 said they did not have enough staff to assist residents with dining timely while also providing care for residents on their hall (cross-reference F725, sufficient nursing staffing). IV. Record review Resident #35's weights, reviewed in the weights and vitals section of her medical record for the previous seven months, revealed the following: 7/11/23 - 189.6 Lbs 7/6/23 - 190.4 Lbs 6/7/23 - 198.0 Lbs 5/25/23 - 195.8 Lbs 5/17/23 - 197.0 Lbs 5/16/23 - 196.6 Lbs 5/11/23 - 191.0 Lbs 3/30/23 - 201.6 Lbs 3/22/23 - 190.8 Lbs 3/16/23 - 195.0 Lbs 3/9/23 - 195.6 Lbs 2/23/23 - 207.4 Lbs 2/9/23 - 201.4 Lbs 1/3/23 - 211.8 Lbs -Between 3/30 and 5/11/23, the resident had a fall with fracture (on 4/2/23) and lost 10 pounds. However, contrary to facility policy (see above) there was insufficient evidence her weight and nutritional status were closely monitored after that weight loss. Further, there was no evidence the physician was notified of Resident #35's weight loss and new orders requested until 7/11/23 after the survey began (see below). Physician orders: Resident #35's July 2023 CPO documented the following pertinent orders:-Offer snacks between meals, prefers sandwiches three times daily for nutrition ordered 3/16/23;-Regular texture diet, thin consistency fluids ordered 3/23/23;-Nutritional supplement twice daily for weight loss ordered 7/11/23. However, there was no documentation in the July 2023 medication administration record that the supplement was given on 7/11, 7/12, or 7/13/23. The nutritional care plan, initiated on 12/26/18 and revised on 6/19/23, identified dementia, coronary artery disease, hypertension, and obesity, with a 13 lb weight loss in 180 days, but weight stable for 90 days. The goal was adequate nutritional status and consuming more than 50 percent of at least two meals every day. Interventions were: monitor intake and record every meal, obtain weight and record per facility protocol, offer snacks between meals, provide and serve diet as ordered, RD to make diet change recommendations as needed. Other pertinent care plan entries documented specifically: Resident #35's activity needs care plan identified the following on 10/6/22: "I ask for food often and I believe I am hungry. It may or may not be a real physical hunger, but having food supplicates me when I'm feeling anxious or confused. Any offer to get me something helps ease my mind." The care plan identified ADL limitations, with eating/dining needs documented on 12/20/21 as "prompting and cueing during meals." The care plan further identified on 3/14/19, "I am at potential risk for sustaining injury while consuming foods/fluids due to my functional limitations to balance or grip steadily cups, utensils and/or plates." The goal was no injury and the intervention was "assist me by providing cueing-verbally and visuals as appropriate." Resident #35's most recent nutritional assessment, dated and signed on 6/19/23 by the registered dietitian (RD), documented her most recent weight was 198 pounds on 6/7/23 (12 days before). There was no decrease in food intake and no weight loss. There had been no acute disease or stress recently (although the resident had a fall with a fracture on 4/2/23). Her score was 11, indicating risk of malnutrition. -The nutritional assessment was inaccurate or incomplete in that her weight was not current; her recent meal intakes, nutritional/fluid needs, and recent lab values were not documented; and her dining assistance needs were not assessed. Nutrition at risk (NAR) meeting minutes regarding Resident #35 were requested on the afternoon of 7/13/23 and the following note was the only documentation provided: On 7/11/23 at 1:27 p.m. the registered dietitian (RD) documented, "WEIGHT WARNING: -10.0% change over 180 day(s) [ 10.4% , 22.0 ] Noted wt (weight) stability this week. Will cont (continue) to offer and encourage all meals, supplements, and snacks to promote wt stability. Will cont to follow care plan and monitor with weekly weights." -There was no evidence consistent weekly weights were implemented before 7/11/23 (see weight list above which showed gaps of more than one month at a time).-The care plan was not revised regarding actual weight loss and recommended interventions.-There was no physician order for weekly weights per the RD's recommendation.-Twice-daily supplements were not given on 7/11, 7/12, or 7/13/23 in keeping with the RD recommendation and physician order. Meal and snack intake records, reviewed from 6/29/23 through 7/13/23, revealed Resident #35 consumed:Breakfast - 76-100% 10 times, 51-75% three times, 0% twice (once during survey on 7/11/23)Lunch - 76-100% five times, 51-75% nine times, 25-51% once (during survey on 7/11/23)Dinner - 76-100% four times, 51-75% six times, 25-51% or 0% four timesSnacks were accepted 24 times out of 45 opportunities. V. Interviews Resident #35's daughter was interviewed by phone on 7/12/23 at 3:52 p.m. She saidlast Sunday (7/9/23) when she visited Resident #35, her meal was sitting out, and "she nibbled at it but didn't really eat it. She was dozing on and off too, maybe she was just too tired to eat. I tasted it and the ham was not hot." Resident #35's daughter said the room tray sat there for about an hour after she arrived, and when she saw a staff person she requested that they take it away and bring her mother some ice cream. Resident #35 was unable to use utensils to eat her ice cream, so her daughter assisted her to eat. "Sometimes I wonder if they need more help. There's Mom's lunch and an hour later there's nobody there to assist her" (cross-reference F725, sufficient nursing staff). The RD was interviewed on 7/13/23 at 4:14 p.m. She said she had not ever observed Resident #35 during meals, and this was the first she had heard of the resident needing extensive to total assistance with eating. She said if the resident chose not to go to the dining room she should receive assistance in her room. "In my opinion therapy should have done an assessment. The first thing I would do is notify the therapy department to do an evaluation for self-feeding. That's how I would handle it if somebody had let me know that information." The RD said appetite decreased along with dementia for older adults, and she always used a food-first approach. She said Resident #35 triggered for significant weight loss in July 2023. "She's now on weekly weights and we discuss her weekly. I think I started charting on (Resident #35) in February. We started weighing her weekly to establish the difference between true weight loss and diuretic use and then she sort of stabilized. They started sandwiches and bacon for snacks at the beginning of March. From the beginning of June to now there had been an almost 10-pound weight loss. "Sandwiches are not working any longer. That's when I decided to put the supplements on board. We've been following her for better than four months now." The RD said Resident #35's intakes in May through June 2023 were stable, but in July there was a decrease in her intake: 25-50% for breakfast and lunch and 50-75% for dinner times seven days. The RD said she was not aware the supplements she recommended on 7/11/23 were not yet being given.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference F689 accident hazards and F677 activities of daily living (ADLs). Findings include:I. Facility policyThe Staffing, Sufficient and Competent Nursing policy, revised August 2022, read in pertinent part: "Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care services for all residents in accordance with resident care plans and the facility assessment. "Staffing numbers and the skills required of direct care staff are determined by the needs of the residents based on each residence plan of care, the resident assessment and the facility assessment. Factors considered in the determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity." II. Resident census and conditionsAccording to the 7/10/23 Resident Census and Conditions of Residents report, the resident census was 69 and the following care needs were identified:-37 residents needed assistance from one or two staff with bathing and 15 residents were dependent. Two residents were independent.-49 residents needed assistance from one or two staff members for toilet use and two residents were dependent; 11 residents were independent.-51 residents needed assistance from one or two staff members for dressing and one was dependent; 10 residents were independent.-47 residents needed assistance from one or two staff members and four were dependent for transfers; nine residents were independent.-34 residents needed assistance from one or two staff members with eating and two were dependent; 26 residents were independent. -22 residents required supplemental oxygen and management.-30 residents had a dementia related diagnosis. -Three residents had an intellectual and/or developmental disability. The director of nursing (DON) provided a breakdown of the number of residents with specific and high care needs/supervision and assistance on 7/13/23 at 7:20 p.m. -15 residents required two person transfers.-13 residents were at a high risk for falls. -Seven residents had wandering behaviors. III. ObservationsOn 7/10/23 at 5:19 p.m. Resident #50 triggered his call light. Registered nurse (RN) #4 answered the call light at 5:32 p.m., 13 minutes later.-At 6:13 p.m. room 16's call light was on. No staff were observed in the hallway to answer the call light. -At 6:23 p.m. the nursing home administrator (NHA) answered the call light. The resident said the sun was in her eyes. Her blinds were adjusted. On 7/11/23 at 2:16 p.m. Resident #50 triggered his call light. Housekeeping came into the room and dropped off his roommate's clothing and left. An unidentified CNA informed the residents there was live music in the dining room and left. The activities director (AD) entered the room and informed Resident #50's roommate about a meeting and left the room. At 2:26 p.m. the emergency bathroom call light was triggered, which caused the call light to blink. The call light was confirmed to be working above the door and no staff were seen in the hallway. At 2:31 p.m. CNA #4 responded to the call light. When she walked into the room she talked rudely but changed her tone once she saw someone else in the room. She said, "What do you guys need-oh hello, is everything okay?" The call light went unanswered for 15 minutes.-The DON and ADON said anyone in the facility could answer call lights, however the facility staff failed to check in and see what the residents needed. On 7/13/23 at 5:56 p.m. registered nurse (RN) #3 attempted to calm a confused resident who was yelling at RN #3 as the RN was trying to prepare for her medication pass. Approximately 10 minutes later a certified nurse aide (CNA) attempted to redirect the resident's behaviors, however, the resident continued to yell at the RN. -At 6:17 p.m. Resident #55 was observed in his wheelchair near the nursing desk. The resident had a strong odor of urine. -At 6:20 p.m. Resident #36 was observed in his restroom alone. The door to his room and bathroom was left open. The resident was loudly yelling as he sat on the toilet. Review of the resident's care plan identified Resident #36 required extensive assistance from one person and he had a history of multiple falls, including two falls in the previous month. Three other room call lights were seen down his hallway. -At 6:26 p.m. Resident #36 pulled the call light in the restroom.-At 6:29 p.m. Resident #36 was assisted in the restroom. -At 6:48 p.m. Resident #55 was observed rolling himself down the hallway. The resident continued to have a strong odor of urine. IV. Resident interviews and record reviewResident #22 was interviewed on 7/10/23 at 9:30 a.m. She said call light response was too slow when she needed the bedpan or incontinence care. "I'm two feet away from the bathroom but I can't get there." She said she felt upset and angry when she had to wait so long for call light response. Review of her call light audit/response times, reviewed from 6/29/23 through 7/13/23 at 8:28 a.m., revealed her average call light response time was six minutes but the highest elapsed time was 44 minutes. The following wait times for more than 15 minutes were documented for Resident #22:21 minutes 46 seconds on 6/29/23 at 5:53 p.m., 24 minutes and 16 seconds on 6/30/23 at 2:31 p.m., 22 minutes 43 seconds on 7/1/23 at 11:45 a.m., 23 minutes 52 seconds on 7/1/23 at 8:20 p.m., 34 minutes 59 seconds on 7/2/23 at 7:51 a.m., 18 minutes 43 seconds on 7/3/23 at 3:18 p.m., 26 minutes 35 seconds on 7/3/23 at 4:37 p.m., 23 minutes 16 seconds on 7/3/23 at 5:43 p.m., 21 minutes 56 seconds on 7/4/23 at 6:43 p.m., 25 minutes 50 seconds on 7/4/23 at 8:31 p.m., 42 minutes 54 seconds on 7/4/23 at 9:07 p.m., 24 minutes 31 seconds on 7/5/23 at 11:20 a.m., 44 minutes six seconds on 7/6/23 at 6:29 p.m., 15 minutes 51 seconds on 7/7/23 at 9:29 a.m., 16 minutes 25 seconds on 7/7/23 at 2:11 p.m., 15 minutes 19 seconds on 7/8/23 at 10:07 p.m., 23 minutes 44 seconds on 7/9/23 at 5:51 p.m., 17 minutes 33 seconds on 7/10/23 at 7:27 a.m., 26 minutes 42 seconds on 7/10/23 at 8:44 p.m., 23 minutes 18 seconds on 7/11/23 at 4:19 p.m., 15 minutes 35 seconds on 7/12/23 at 7:59 p.m. Resident #7 was interviewed on 7/10/23 at 9:32 a.m. She said she did not get showered enough. She tracked her showers on her calendar and her last shower documented was on 6/30/23. Resident #7 said not showering increased her anxiety and depression. She said she preferred to shower every day but would "take a shower every other day at this point to shower consistently." She said the facility seemed to be short-staffed or the facility had a high turnover rate. She said call lights took a very long time to be answered, especially in the afternoons and the weekends. Resident #16 was interviewed on 7/10/23 at 11:08 a.m. He said call light response was slow and it depended on how many staff were around to help. He said it typically took 10 to 15 minutes for his call light to be answered. He tried not to use his call light too often because there were other residents who needed more assistance than he did. He said the longest he had to wait was shortly after he was admitted, around lunch time, and he waited so long he fell asleep in the bathroom sitting on the toilet. "That's when they wouldn't let me get up without calling somebody but now I can. I'm not going to sit in the bathroom half the morning. Good grief, you could die in there." Resident #10 was interviewed on 7/10/23 at 2:15 p.m. She said there were not enough staff on Sundays. "They always have call-offs so they're short-handed on Sundays but you just expect it." She said it took a long time to get any response on Sundays. She said she waited too long for assistance to the bathroom and sometimes she ended up wet, all the way through her briefs to her clothes. She said it made her feel angry and it happened about once a week. Resident #50 was interviewed on 7/10/23 at 4:53 p.m. He said showers were supposed to be once a week but he had not showered since a couple of Saturdays ago (7/1/23). He said he preferred to shower two times a week but the facility did not have enough staff. Resident #50 said not showering affected his mental well-being. He said call lights took too long to be answered and the facility always had a lot of new staff because people would quit.-The past six months of call light logs were provided by the nursing home administrator on 7/13/23 at 11:45 a.m. Resident #50 had 26 call lights triggered that went unanswered for over 15 minutes from January 2023-July 2023. Resident #7 had 282 call lights triggered that went unanswered for over 15 minutes from January 2023-July 2023. The resident council members were interviewed on 7/12/23 at 9:56 a.m. The residents said it was getting longer in between showers. The residents chose if they took a bath or a shower and it was always honored, however, the number of times they preferred to shower each week was not honored. This angered the residents because they said they paid a lot of money to live at the facility and they could not even shower. The residents said call lights took a long time to be answered and sometimes it would be 30-45 minutes before someone responded to their call light. V. Resident council minutesThe resident council minutes were reviewed from April 2023 to July 2023. The minutes on 4/7/23 said the residents reported call light times took up to 45 minutes for staff to respond and the longest wait times to have call lights answered were around 2:00 p.m. at shift change. The minutes from 5/5/23 said the residents reported the call light times still needed to improve. A resident said it was getting longer in between when they received a bath or shower. The shower complaint was documented as being addressed with that resident because it was not a complaint from the council members. The residents said they would like the registered nurses (RNs) and certified nurse aides (CNAs) to introduce themselves when they came onto their shift so the resident knew who to ask for help. The minutes from 7/7/23 said the residents requested the floor staff to introduce themselves and communicate what they could do for the residents when they came onto their shift. VI. Staff interviewsCNA #3 was interviewed on 7/11/23 at 2:45 p.m. He said when the facility was short-staffed showers were not consistent. He said the facility used to have two shower aides but if other CNAs called out the shower aides covered the floor and showers would not be completed. He said the facility needed more floor staff, especially CNAs for the residents to get the care they needed. He said he was informed by another CNA that the staffing ratio was one CNA for 60 residents. CNA #3 said call lights were answered as fast as he could get to them but sometimes he could not get to them timely. If he saw a blinking light, which indicated the emergency bathroom light was triggered, he made it a priority to answer the light. When CNA #3 made rounds during his shift he said he would make a list of everything residents wanted or needed and prioritize the list. He said he did the best he could to answer all requests timely. He said when the facility was short-staffed he would take longer to answer call lights and unfortunately it would be over 30 minutes sometimes. He said, "In reality we need more staff to safely run the floor and provide care to the residents." He said sometimes he completed lifts alone, instead of with two staff, because there was "just was not another staff available to help." He said he expressed his concerns to management about being understaffed but never really received a response. A CNA who requested anonymity was interviewed on 7/12/23 at 6:33 a.m. S/he said evening staffing around 6:00 p.m. was a problem, when there was sometimes only one staff person on each hall and they needed more help for transferring residents, serving and assisting residents to eat and drink. Often the CNAs were serving meal trays so one staff was left in the dining room to assist residents. The management staff always left at 5:30 p.m. and when the problem was brought to their attention they would just say they were working on it. "When there's lack of staff we pull staff to the floor. For example, we lost the shower aide and staff don't have time to give showers." Licensed practical nurse (LPN) #4 was interviewed on 7/12/23 at 10:27 a.m. She said she reported to management she was tired of her aides (the CNAs) and peers being burned out and management was not helping carry the load. They admit people left and right and they cannot provide the care residents deserve and are entitled to. Often there was only one person assisting residents in the dining room. LPN #4 said she hoped management staff would stagger their hours for coverage but that had not happened. LPN #4 said there was one CNA on her hall of 24 residents and from 2:00 to 6:00 p.m. "Hearts are breaking because we can't take care of the residents." She said residents were doing without showers and baths, oral care and nail care, and the quiet residents were overlooked. "I know the aides are doing their best and I hate to keep telling them 'do better.'" She said some dependent residents did not receive dining assistance when they did not have enough staff. "None of the residents who need assistance are getting the assist they need at dinner time." She said there were residents who yelled out during care or sitting in the hallway. "I usually try to offer food (to residents who yell) but it's almost like staff get kind of callous to it. She said they did have a bath aide for a while and she would do 20 or 30 baths a day. "The residents loved her." She said the major problem was staffing and she did not understand why the facility continued to "admit and admit" residents they were unable to care for. CNA #12 was interviewed on 7/12/23 at 12:38 p.m. briefly between passing resident room trays. She said, "I'm not supposed to be here today. It's my day off."CNA #4 was interviewed on 7/12/23 at 1:50 p.m. She said the facility did not have enough staff to provide the residents with the care they needed. She said, "When we are short-staffed showers, oral hygiene, and repositioning gets skipped. I worked an extra shift every week to provide showers to the residents because on my days off it does not happen." She said CNAs documented showers as refusals when they could not be completed. CNA #4 said, "Usually no one asked the residents if they wanted a shower, they just documented refusals." She said if she saw a documented refusal she went and asked the resident if they wanted a shower, to ensure it was a refusal. If the resident said they wanted a shower she showered them, if she had the time. She said she had spoken to the DON about being short-staffed and she only heard "we are working on it" back. She said she got frustrated because the residents should get the care they wanted and the care they needed. CNA #4 said call lights were not answered timely, mainly because there would be one CNA working each hallway (roughly 20 residents). She said one CNA to 20-28 residents seemed pretty normal. CNA #4 also said if the facility provided two CNAs per hallway, it would make shifts run smoother and care would be provided the way it was needed. Shesaid sometimes she transferred residents in a sit-to-stand lift, even though two staff were required because no one provided help or they were short-staffed. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 7/12/23 at 2:46 p.m. The DON said it was facility policy for two staff to be used while providing any mechanical lifts and that she spoke to many CNAs because "they choose to do that (use the lifts with one staff). The DON said her door was always open if floor staff needed help or they could ask the nurse assigned on any hallway that was not actively passing medications. She said there were also four clinical staff that were licensed and could assist with lifts. She said she educated staff on that topic because the CNAs did not know they needed two staff for mechanical lifts. The DON said she felt the facility had sufficient staff especially because she told the CNAs they could ask the licensed clinical staff for help on the floor. She said she knew the facility was hiring and posted vacancies online or attended job fairs to fill the vacancies. She said ever since she worked at the facility the CNAs had always complained about not having enough floor staff. The ADON said she worked on fixing the showering problem. She said a central theme is that "you are giving me more work but you are not giving me more people on the floor. It is all hands on deck and we all have to be out on the floor to get care and showers completed." The ADON said the CNAs have the biggest complaint of not having enough floor staff and if they felt they were understaffed they would not bathe anyone. She said upper management covered the floor so showers could be provided and they were frequently on the floor to make their presence known. "We want the floor staff to come to us when they need help." The ADON said any staff member, manager, or facility staff member could answer a call light and they provided care within their scope of practice or grabbed someone who could provide care that was not within their scope of practice. She said the facility listened to their residents and were redoing the bathing preferences list so they matched the residents' charts. She said the facility tried hard to fix the problem. The facility tried hiring bathing aides but decided they would need to assign a CNA each shift for showers. RN #1 was interviewed on 7/12/23 at 2:55 p.m. He said a CNA who was scheduled to work on his hall was injured so currently he had only one CNA working on his hall. The RN said his hall, (the first hall) was the biggest hall (with 29 residents) and had a lot of resident care needs. He said the hall really needed three CNAs or two really good CNAs. He said staff levels came in waves, sometimes there were days they had enough staff and sometimes there was not enough. He said the facility used a temporary agency to help staff the CNAs but the temporary staff did not always show up for their shifts. He said the facility did not have a bath aide. He said there was a high turnover with the bath aide position. CNA #1 interviewed on 7/12/23 at 3:10 p.m. The CNA said he was "running" to get to everyone. The CNA was slightly out of breath. The CNA the told RN #1 there was "just not enough of us" referring to staff. The CNA in the third hall was interviewed on 7/12/23 at 3:22 p.m. She said she was the only CNA in her hall (with 20 residents). The nursing staff scheduler (NSS) was interviewed on 7/12/23 at 3:18 p.m. She said she was trying to get staff to come in to work tonight and was waiting on call backs. CNA #11 was interviewed on 7/12/23 at 3:29 p.m. She said she was a temporary CNA and it was her first day. She said she was working on the second hallway. She said she was not familiar with the residents but would ask CNA #1 if she had questions. CNA #1 was observed in a resident's room on the second hallwayThe driver was interviewed on 7/12/23 at 3:25 p.m. The driver said he was CNA. He said he was CNA and was asked to do a resident's shower this afternoon. He said he did many jobs in the facility, including in the maintenance and dietary department. The NSS was interviewed with the NHA on 7/12/23 at 3:33 p.m. The NHA said the current census was 69 residents. The NSS said to meet resident needs, she tried to schedule a minimum of five CNAs during the day and evenings and three nurses; and, three CNAs and two nurses overnight for the three resident halls daily. She said the facility currently had open nurse and CNA positions and they were using temporary staff and current staff to fill the open positions. The NSS said the facility currently had positions open five day CNAs, four evening CNAs, a night CNA, and a bath aide. She said they needed two day nurse positions filled and one night nurse. The NHA said in addition to the open positions, the facility was trying to hire positions for census growth. The NSS said there were good days and bad days with the daily staffing levels. The NSS said daily staff schedules were impacted by frequent shift call offs and the staff did not want to work on the weekends. She said the weekends seem to "run crazier." The NHA said the facility had a manager on duty who usually worked a few hours on the weekends and there was always a nurse manager on call. The NSS said the facility had some staff on restricted/light duty and were not able to do their regular assignments. The NSS said the facility had the one bath aide position open for a couple of months. The facility had two shower rooms. The facility would hire a second bath aide as the resident census increased. The facility used the current floor staff to try to cover resident bathing. -However, resident showers were not being provided consistently according to resident preference and schedule (cross-reference F677). The NSS said it had been a challenge to get people to work at the facility. The facility offered incentives; working with local CNA classes; online advertising: and, recruiting at job fairs. The NSS said the facility was trying to retain current staff by boosting positivity. The facility offered raffle prizes, special meals and a shaved ice truck was going to come to the facility. The NSS said the facility tried to talk to the staff to get staff's perspective on what the staff needed for staffing levels to accommodate residents timely and safely. CNA #5 was interviewed on 7/12/23 at 6:11 p.m. She said she was the restorative aide for the facility. CNA #5 said she was pulled to cover a hallway from 3:00 p.m. to 6:00 p.m. She said it was hard when she had to work the floor because she had 28 residents on a restorative program which kept her already busy. The staffing development coordinator (SDC) was interviewed on 7/13/23 at 2:34 p.m. The SDC said she was also the infection control nurse. She was often approached to help the CNAs and nursing staff with resident transfers, catheters and blood draws. She said sometimes she worked a cart when needed or helped call in staff to work. The SDC said the summer season tended to have less staff available to work. She said there had been staff turn over. She said between 6:00 and 10:00 p.m. was when residents had a lot of care needs. The SDC said 29 residents reside on the first hallway and the second and third hallway each have 20 residents. The SDC said two nurses usually worked the 6:00 p.m. to 6:00 a.m. shift. She said the facility was looking for a third nurse. She said the nurses at night split the three halls. The SDC said there were usually three to four CNAs at night. She said she thought there was enough staff most of the time. CNA #12 was interviewed on 7/13/23 at 5:43 p.m. She said she worked during the day and never at night. She said she was often the one CNA in her hall. CNA #12 said when she needed help with a resident, she would ask a CNA from another hall or her nurse for assistance. She said sometimes it was hard to be the only CNA on the hall for 20 residents but she tried her best so the residents did not have to wait too long. LPN #1 was interviewed on 7/13/23 at 5:55 p.m. She said when there was only one CNA on a hall, there was no staff to give baths/showers to residents. She said so many CNAs were getting burned out and the facility was losing good CNAs. She said she wished management would stagger their schedule so they could help more after hours (evening/weekends). CNA #13 was interviewed on 7/13/23 at 6:54 p.m. She said when there was not enough staff she could do it herself but it takes time to get to all residents. . She said there were 30 to 45 residents who required to be checked and changed in the evening and night. She said the hall really could use two CNAs on the hall before 10:00 p.m. RN #3 was interviewed on 7/13/23 at 6:17 p.m. She said she primarily worked the day shift but sometimes would help cover a shift till 10:00 p.m. She said during the day there was only one nurse per hallway. She said when she was hired at the facility there were two nurses scheduled on the first hallway. She said each hall had a lot of high care residents and she did not feel the facility had enough staff currently to address all the needs. The director of nursing (DON) was interviewed on 7/13/23 at 7:07 p.m. She said the number of call offs had impacted staffing levels. The DON said the facility tried to offer incentives such as bonuses for picking up as needed shifts but staff would rather have more time at home with their family. The DON said the facility was trying to get three nurses at night when possible and two nurses in the first hall during the day. The DON said after dinner to bedtime was often a high impact time when many residents need a lot of assistance. She said she wanted to work on more staffing at that time. She said she recently spoke with her assistant director of nursing (ADON) to possibly work a Tuesday through Saturday shift or Sunday through Thursday. The DON said maybe the nurse managers could work a staggered day shift, coming in later and working after dinner but then the nurse managers would not be available for the morning meetings. She said the SDC often helped with staffing coverages when needed. She said when they hire more nurse managers, the facility may have more flexibility with staggered schedules. The DON said she was trying to get a call light system in her office so she knew when there were a lot of call lights on at one time, so she would know when staff needed help. She said she had told staff to come and get her if needed more assistance with the residents. The DON said she tried to be on the floor as much as possible for resident care but had to focus on her job too. She said she might be able to use a laptop computer and work outside of her office so she could see when needs arise and help. VII. Staff schedulesThree months of the nurse and CNA working schedule was provided by the facility on 7/10/23. The review of schedules identified multiple staff call offs throughout the weeks. The following schedules did not include staff that were originally scheduled but called off for their shift. The May 2023, June 2023 and July 2023 working schedules, identified shifts that were under the facility's preferred schedule minimum of five CNAs during the day and evenings and three nurses; and, three CNAs and two nurses overnight for the three resident halls daily (see the staff scheduler and the director of nursing interview above). The May 2023 working schedule beginning on 5/10/23, identified the following: -On 5/10/23, four CNAs worked between 2:00 p.m. and 6:30 p.m.; three CNAs worked between 6:30 p.m. and 10:00 p.m. -On 5/12/23, four CNAs worked between 2:00 p.m. and 6:00 p.m. and two CNAs worked between 6:00 p.m. and 10:00 p.m. -On 5/13/23, four CNAs worked between 6:00 a.m. and 2:00 p.m.; two CNAs worked between 10:00 p.m. and 6:00 a.m.; and one nurse worked. -On 5/14/23 four CNAs worked between 6:00 a.m. and 10:00 a.m.; three CNAs worked between 10:00 a.m.and 2:00 p.m.; two CNAs worked between 2:00 p.m. and 6:00 p.m.; and three CNAs worked between 6:00 p.m. and 10:00 p.m. -On 5/19/23 four CNAs worked between 6:00 p.m. and 10:00 p.m. -On 5/21/23, four CNAs worked between 3:00 p.m. and 6:00 p.m. and three CNAs worked between 6:00 p.m. and 10:00 p.m. -On 5/28/23, four CNAs worked between 6:00 a.m. and 2:00 p.m.; four CNAs worked between 2:00 p.m. and 9:00 p.m.; and three CNAs between 9:00 p.m. and 10:00 p.m. The May 2023 working schedule identified three nurses worked from 6:00 a.m. and 6:00 p.m. -On 5/14/23 a fourth nurse was added between 12:00 and 6:00 p.m. Two nurses at night routinely scheduled except on 5/13/23 when there was only one nurse. The June 2023 working schedule identified the following shifts under the facility's preferred schedule minimum. -On 6/11/23, four CNAs worked between 6:00 p.m. and 10:00 p.m. -On 6/14/23, three CNAs worked between 6:30 p.m. and 10:00 p.m. -On 6/15/23, four CNAs worked between 6:30 p.m. and 10:00 p.m.-On 6/18/23, four CNAs worked between 6:00 p.m. and 10:00 p.m. -On 6/24/23, four CNAs worked between 6:00 p.m. and 10:00 p.m.; one CNA worked 10:00 p.m. and 11:00 p.m.; and, two CNAs worked between 11:00 p.m. and 6:00 a.m. -On 6/26/23, three CNAs worked between 10:00 p.m. and 2:00 a.m.; two CNAs worked between 2:00 a.m. and 6:00 a.m.-On 6/27/23, four CNAs worked between 6:30 p.m. and 10:00 p.m.-On 6/28/23, four CNAs worked between 6:30 p.m. and 10:00 p.m.-On 6/29/23, three CNAs worked between 6:00 p.m. and 10:00 p.m. The June 2023 working schedule identified three nurses worked from 6:00 a.m. and 6:00 p.m. -On 6/19/23, 6/20/23, 6/23/23, 6/24/23, 6/24/23, and 6/30/23 a fourth nurse was added, but was in training. Two nurses at night routinely scheduled except on 6/27/23 and 6/28/23 with a third nurse was scheduled or when a nurse was in training on 6/5/23; 6/6/23; 6/7/23; 6/12/23; 6/13/23; 6/15/23; and 6/19/23. The July 2023 working schedule identified the following shifts under the facility's preferred schedule minimum. -On 7/1/23, four CNAs worked between 6:00 p.m. and 10:00 p.m. -On 7/2/23, four CNAs worked between 6:00 p.m. and 10:00 p.m. According to the schedule, one CNA worked a 17 hour shift, between 6:00 a.m. and 11:00 p.m. -On 7/4/23, four CNAs worked between 12:00 p.m. and 2:00 p.m.; and three CNAs worked between 2:00 p.m. and 6:00 p.m.-On 7/6/23, three CNAs worked between 6:00 p.m. and 10:00 p.m. -On 7/9/23, three CNAs worked between 6:00 p.m. and 10:00 p.m.-On 7/12/23, four CNAs worked between 2:00 p.m. and 6:00 p.mThe July 2023 working schedule identified three nurses worked from 6:00 a.m. and 6:00 p.m. -On 7/2/23 the third nurse was identified to be in training. Two nurses at night routinely scheduled except when a third nurse was in training on 7/7/23, 7/8/23 and 7/9/23.

Based on record review and interviews, the facility failed to provide the necessary behavioral healthcare and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (#7) of four residents reviewed for behavioral services out of 37 sample residents. Specifically, the facility failed to document Resident #7's suicidal ideation and self-harm tendencies to ensure staff knew what behaviors or statements to watch for and how to help Resident #7 with her increased anxiety and depression. Findings include:I. Facility policyThe Suicide Threats policy, revised in December 2007, was provided by the nursing home administrator (NHA) on 7/13/23 at 6:00 p.m. The policy included: Resident suicide threats shall be taken seriously and addressed appropriately."1. Staff shall report any resident threats of suicide immediately to the nursing supervisor or the charge registered nurse (RN). 2. The nursing supervisor or charge RN shall immediately assess the situation and shall notify the charge RN or supervisor and/or director of nursing (DON) services of such threats. 3. A staff member shall remain with the resident until the nursing supervisor or charge RN arrives to evaluate the resident. 4. After assessing the resident in more detail, the nursing supervisor or charge RN shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record."II. Resident statusResident #7, age 71, was admitted on 4/14/22. According to the July 2023 computerized physician orders (CPO) diagnoses included major depressive disorder (recurrent and severe), schizoaffective disorder (depressive type), and anxiety disorder. The 4/13/23 minimum data set (MDS) assessment showed Resident #7 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. III. Resident interviewResident #7 was interviewed on 7/10/23 at 1:47 p.m. The resident was lying in bed and stared into space without the television or any music playing. She said she requested a new anxiety medication to help calm her down, especially in the evenings. However, she said "the doctors dropped the ball and the RNs cannot administer anything without an order." She said she felt like her anxiety and depression were worsening. Her anxiety was worse in the evenings which caused her heart to race. Her evening medications were not strong enough to help and made it hard to sleep at night because of the anxiety and increased heart rate. Resident #7 said she was unaware of her care plan and never received a copy. She was unaware of what the facility implemented to help her. She said she made all her choices about her care and did not have a power of attorney (POA). She also said she was not aware of what medications she was prescribed and what exactly the medications were prescribed for. IV. Record reviewAccording to Resident #7's July 2023 CPO the pertinent medications she was prescribed were as follows:Zoloft, an antidepressant medicationAlprazolam, an antianxiety medicationClonazepam, a medication used for seizures and anxietyClozapine, an antipsychotic medicationResident #7's care plan, revised 7/29/22, documented focus areas that she used an antipsychotic medication for schizophrenia, she used an antidepressant medication, and she used a medication often to treat anxiety with her seizure disorder. The goals and interventions were documented to focus on monitoring side effects and symptoms of the medications.-The facility failed to update the care plan with Resident #7's diagnoses in detail, show triggers, how staff handled behavioral changes, or what worked best for Resident #7 when she experienced episodes of anxiety, depression or hallucinations. A PASRR II evaluation was completed for Resident #7 on 5/2/22, effective on 5/6/22. It showed the resident had inpatient psychiatric care multiple times. Two times were for when the voices (hallucinations) "got bad," three times for suicidal ideation, and once followed an overdose attempt. Resident #7 said her voices never fully went away but she learned to ignore them. The specialized services recommended for mental illness was individual therapy. Resident #7 had suicidal ideation on 5/17/23. A progress noted documented the resident approached a staff member and explained that she felt her medications needed to be evaluated because she was anxious and began thinking about suicide again. The resident said she did not feel she would harm herself but started having ideas. Another progress note documented Resident #7 would have attempted to harm herself if she had the right tool since the safety razor (shaver) would not break apart and she was unsuccessful in harming herself. The SSD explained to Resident #7 she would not have harmed herself with the type of razor she used. Documentation from the emergency room showed the resident had an "extremely superficial abrasion (scrap) or laceration (cut) on her wrists." The emergency room medical team tried to determine if the resident was safe to be discharged. Resident #7 was monitored overnight and medically cleared the following day 5/18/23. She was discharged back to the facility and agreed to express changes in moods and suicidal ideation. A psychiatric progress note was documented by the resident's nurse practitioner (NP) in the resident's medical record on 5/19/23 at 1:17 p.m. The NP documented the resident was discharged to the emergency room due to suicidal ideation and attempted self-harm and discharged back to the facility. The NP said she talked with the facility staff and found out Resident #7's Clozapine (antipsychotic medication) was delivered late again and the resident went a couple of days without her medication. A progress note documented by the resident's therapist on 5/19/23 at 3:30 p.m. read:"(Resident #7) had been discharged from care, however, due to recent suicidal ideation, writer made a visit. She was open to meeting with writer. She verbalized that 'her voices' were getting worse and telling her to hurt herself. We discussed this and she believes the Xanax her NP has increased for her is helping. She continues to tell the voices to leave her alone. She would benefit from psychiatric support more consistently as her mental health needs are outside the scope of practice related to her needs and ability to provide care and support. Will update the social services director (SSD) on this. (Resident #7) did say she is currently on 15 minutes checks and is unsure how long this will be. She denied suicidal ideation on this date. She gave writer verbal permission to coordinate with NP as needed."IV. Staff interviewsThe SSD was interviewed on 7/10/23 at 12 p.m. She said Resident #7 threatened suicide on 5/17/23. Resident #7 was observed with a safety razor blade, used for shaving, and tried to break apart the blade to cut her wrist. Resident #7 initially said she wanted to harm herself and the SSD was notified. The SSD visited the resident and asked if she could remove the sharps from her bedroom. Resident #7 agreed and sharps were removed. The facility attempted to notify the resident's psychiatric nurse practitioner (NP) however the NP had walked into the facility for a visit with Resident #7. The NP stayed with the resident while the SSD called the crisis hotline for guidance on the situation. It was recommended to send Resident #7 out to the emergency room for a psychiatric evaluation. The SSD explained suicidal ideation was "pretty routine" for the resident. The facility attempted to complete an intake from a psychiatric hospital however four appointments were missed by the psychiatric hospital staff. Resident #7 expressed fear to the SSD to complete the intake in person and declined that option. The SSD said the resident's anxiety in the evening being increased was an ongoing issue and that was why her NP visited the resident frequently. Resident #7's antidepressant was increased and the NP hoped it would help with the anxiety. Resident #7's team looked for the right medication without success. The facility provided supportive care for Resident #7 and ensured she attended the activities she liked. If the resident refused to participate in bingo (a preferred activity) the SSD ensured she visited the resident and checked that she was doing okay. She said the staff watched her patterns but the resident's care plan was not updated to focus on Resident #7's suicidal ideation or self-harm. The SSD said the care plan was not updated after the incident on 5/17/23 either. The SSD said the resident tried to kill herself because of her hallucinations, however "If she listened to the voices she would try to harm/kill herself in ways that would not actually allow her to kill herself." The SSD was interviewed again on 7/13/23 at 3:57 p.m. She said Resident #7's primary care doctor (PCP) prescribed all her medications until her NP took over the psychiatric medications. Now her PCP handled all of her regular medications and the NP handled all of her psychiatric medications. The SSD said if Resident #7's NP declined a medication change then Resident #7 requested her PCP for the medication change. She said Resident #7 was great about self-reported anxiety to staff members or the SSD. The SSD said she was not aware the resident's Clozapine had not been delivered and could have caused increased mania which led Resident #7 to want to kill herself. The SSD said she would follow up on the psychiatric progress note her NP wrote after the incident occurred.

Based on interviews and record review, the facility failed to ensure four (#4, #36, #50 and #125) of 11 residents reviewed out of 37 sample residents had personalized behavioral interventions in place. Specifically, the failed to ensure:-Resident #4, who had a history of dementia, had effective personalized behavioral interventions care planned and in place who was exhibiting verbally disruptive behaviors and was at risk for abuse; and-Residents #36, #50 and #125 had personalized behavioral interventions care planned for dementia and trauma informed care for these residents that were difficult to redirect and had triggered behaviors. Findings include:I. Facility policy and procedureThe Dementia Clinical Protocol policy and procedure, reviewed November 2018, and was provided by the nursing home administrator (NHA) on 7/13/23 at 6:00 p.m. It revealed in pertinent part,"The staff and physician will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's conditions, related complications, and functional abilities and impairments."The interdisciplinary team (IDT) will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors."II. Resident #4A. Resident statusResident #4, age 92, was admitted on 11/3/22. According to the July 2023 CPOs the diagnoses included dementia, cognitive communication deficit and depression. The 4/5/23 MDS assessment revealed the resident had severe cognitive impairment with severe impairment in short and long term memory and severe impairment for cognitive skills in daily decision making. She required the extensive assistance of two people for transfers, the extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene and supervision for eating. It indicated she exhibited verbal behaviors towards others. B. ObservationOn 7/10/23 at 10:35 a.m. Resident #66 was observed standing inside the entryway to Resident #4's room. Resident #66 was observed shouting at Resident #4 to "stop yelling" and "shut up" and she was disturbing him and the whole hallway. He was observed leaving the room and saying that she "yells all the time." He was observed returning to his room. An unidentified nurse was observed standing in the hallway at the medication cart and did not leave the medication cart to investigate the shouting by Resident #66. Resident #4 was observed sitting hunched over in a wheelchair in her room with her hands covering her face. On 7/11/23 at 2:30 p.m. Resident #4 was observed lying in bed with the bed low to the ground. Resident was yelling out "help." An unidentified certified nursing aide (CNA) was observed entering the room and checkin on the resident.-At 2:50 p.m. Resident #4 was heard calling out "help." Resident #66 was heard calling out from his room across the hall "shut up."-At 3:05 p.m. two unidentified CNAs were observed transferring Resident #4 from the bed to a wheelchair. Staff were observed wheeling resident around the unit in the wheelchair. Resident #4 was wheeled into her room and continued to be hollering "help."C. Record reviewThe abuse care plant, initiated 12/11/22, indicated she had been a victim of abuse. Interventions included observing interactions with others to observe for safety and provide emotional support and opportunity to express herself. The at risk adult care plan, initiated 12/11/22 revised 3/1/23, indicated that she was at risk for abuse, neglect and exploitation due to dementia. Interventions included monitoring interactions with others and observing for safety, providing emotional support and the opportunity to express herself and investigating all allegations of abuse. The mood and behavior care plan, initiated on 12/14/22 revised on 5/8/23, indicated she yells outand becomes disruptive to others around her. Interventions included administration of medications as ordered, anticipate resident's needs, caregivers to provide for positive interaction, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, redirect and remove from the situation. A comprehensive review of the care plan failed to reveal effective personalized behavioral interventions to improve or prevent disruptive verbal behaviors. The July 2023 treatment administration record (TAR) revealed documentation of behavioral monitoring. On 7/1/23 no behaviors were documented being observed. On 7/2/23 no behaviors were documented being observed. On 7/3/23 no behaviors were documented being observed. On 7/4/23 on the 6:00 p.m. to 6:00 a.m. shift refusal of care and insomnia was documented. Interventions included redirection, one to one visit/supportive listening, activity, return to room, hydration/nutrition offered, repositioning and backrub. Outcome was documented as sleeping. On 7/5/23 on the 6:00 a.m. to 6:00 p.m. shift refusal of care and insomnia was documented. Interventions included redirection, one to one visit/supportive listening, activity, return to room, hydration/nutrition offered, repositioning and backrub. Outcome was documented as sleeping. On 7/6/23 no behaviors were documented being observed. On 7/7/23 no behaviors were documented being observed. On 7/8/23 no behaviors were documented being observed. On 7/9/23 on the 6:00 p.m. to 6:00 a.m. shift refusal of care and insomnia was documented. Interventions included redirection, one to one visit/supportive listening, activity, return to room, hydration/nutrition offered, repositioning and backrub. Outcome was documented as sleeping. On 7/10/23 on the 6:00 a.m. to 6:00 p.m. shift, tearfulness/increased sadness, refusal of care and insomnia was documented. Interventions included redirection, one to one visit/supportive listening, activity, return to room, hydration/nutrition offered, repositioning and backrub. Outcome was documented as sleeping. On 7/10/23 on the 6:00 p.m. to 6:00 a.m. shift refusal of care and insomnia was documented. Interventions included redirection, one to one visit/supportive listening, activity, return to room, hydration/nutrition offered, repositioning and backrub. Outcome was documented as sleeping. On 7/11/23 on the 6:00 a.m. to 6:00 p.m. shift, tearful/increased sadness was documented. Interventions included redirection, activity and hydration/nutrition offered. A comprehensive review of behavioral monitoring failed to reveal documentation of verbal behaviors with interventions. D. Staff interviewsCertified nurse assistant (CNA) #10 was interviewed on 7/13/23 at 8:45 a.m. She said Resident #4 has some days that were worse than others for yelling and calling out. She said they would intervene by redirecting her, taking her to the dining room to give hot chocolate, sit and talk and check to see if she needed to be changed. She was not aware of anything specific that made the verbal behaviors better or worse. She said she was not aware of any other residents expressing being disturbed by Resident #4 yelling out. Registered nurse (RN) #3 was interviewed on 7/13/23 at 2:30 p.m. She said when Resident #4 yells out, staff has tried diversion by taking her to an activities but that Resident #4 was very difficult to redirect. She was not aware of any other interventions tried for Resident #4. She said was aware that Resident #4's verbal behaviors have disturbed other residents. She said one resident was moved to another hallway because her verbal behaviors were disturbing him and he had shouted at her. She said she was aware of a recent incident with a resident that lived across the hall and he had shouted at her to shut up. The director of nursing (DON) was interviewed on 7/13/23 at 6:50 p.m. She said that when Resident #4 yelled out that staff would give her alternative activities to distract. She said Resident #4 was difficult to distract and redirect. The nursing home administrator (NHA) was interviewed on 7/13/23 at 6:50 p.m. He said he was aware that Resident #4's verbal behaviors had disturbed a resident in the past where the resident had to be moved to another hallway. III. Resident #50A. Resident statusResident #50, age 76, was admitted on 12/30/21. According to the July 2023 computerized physician orders (CPO) diagnoses included unspecified dementia, major depressive disorder (recurrent and moderate), anxiety disorder, and chronic post-traumatic stress (C-PTSD) disorder. The 7/5/23 minimum data set (MDS) assessment showed the resident had a mild cognitive impairment, with a brief interview for mental status (BIMS) score of 10 out of 15. B. Resident interviewResident #50 was interviewed on 7/10/23 at 5:05 p.m. He said registered nurse (RN) #1 gave him a hard time when he requested help. He said on numerous occasions RN #1 told Resident #50 he was "making up issues for attention." He elaborated with "RN #1 told me my trauma and PTSD was all in my head. He said I did not need my medications for anxiety or PTSD. Why would I not need the medications my doctor prescribed?"Resident #50 was interviewed again on 7/12/23 at 3:34 p.m. His left eye was red and bloodied. He triggered his call light. RN #1 assessed his eye. While RN #1 retrieved the machine to obtain his vital signs, Resident #50 said "I am so glad you are in here because RN #1 would have said it was all in my head or I made things up again. Thank you for being in here. It made it easier to ask for help from RN #1."C. Record reviewResident #50's care plan, initiated on 11/1/22 and not revised, identified his diagnosis of PTSD and trauma as a focused area. Interventions were documented as follows:Provide Resident #50 with the opportunity to express his fears and concerns when he felt anxious. Resident #50 had the opportunity to speak with a therapist at his discretion. Resident #50 would be empowered to share his experiences and not to be made to feel burdensome when he struggled with his trauma. The care plan also showed the resident utilized antidepressant medication for his depression and anxiety. A progress note was entered by Resident #50's therapist in the facility's charting system on 1/6/23 at 5:13 p.m. The note read in pertinent part:"Resident #50 reported his nurse today keeps telling him 'it is all in my head.' Ensuring education of trauma informed care, will assist Resident #50 in having his PTSD diagnosis cared for."Another progress note was entered by Resident #50's therapist on 5/19/23 at 3:24 p.m., which read in pertinent part:"He also said there are staff that come up behind him to scare him and he talked about his PTSD and how he worries he may react to that and accidentally hurt someone. Writer will notify the social services director (SSD)."The nursing home administrator (NHA) provided copies of staff members' schedules on 7/11/23 at 9:35 a.m. The schedules confirmed RN #1 was assigned to the hall Resident #50 lived on for 1/6/23 and 5/19/23. IV. Resident #125A. Resident statusResident #125, age 78, was admitted on 7/6/23. Due to being newly admitted the MDS assessments were not completed but staff reported Resident #125 had a diagnosis of dementia. B. ObservationsOn 7/11/23 at 2:09 p.m. Resident #125 walked near the nurses' station with her one-to-one staff. Certified nurse aide (CNA) #14 walked with Resident #125 while she kept the wheelchair behind the resident as she was unsteady on her feet. CNA #15 approached to switch with the resident's one-to-one staff. CNA #14 explained to CNA #15, Resident #125 was "very confused today, refused to be toileted, and refused to sit in her wheelchair or use her walker." The resident placed both hands on the half door to the nurses' station while she looked up at the clock. CNA #14 said "it is 2:30 p.m. Resident #125, it is time to get toileted." CNA #15 walked up to the left of the resident (blocked the witness's view) and moved her hands toward the resident's hands. CNA #14 grabbed the resident's gait belt with her fingers pointed down toward the wheelchair. When CNA #15 moved her hands the resident's hands moved with her and CNA #14 pushed down on the gait belt and forcefully pushed Resident #125 into her wheelchair. CNA #15 turned the wheelchair around and Resident #125 immediately stood up and walked away while she utilized the grab bars in the hallway. -The observation was reported to the nursing home administrator (NHA) on 7/11/23 at 4:10 p.m. V. Resident #36A. Resident statusResident #36, age 88, was admitted on 1/25/23. According to the 5/3/23 MDS diagnoses included Alzheimer's disease, dementia, and heart failure. The MDS showed the resident had a severe cognitive impairment with a BIMS score of five out of 15. B. ObservationsOn 7/13/23 at 1:50 p.m. Resident #36 was in his wheelchair by the nurses' station. He yelled out repeatedly and incoherently. CNA #1 looked frustrated and approached Resident #36. CNA #1 said "shut up" in a firm voice to Resident #36. CNA #1 stepped closer to Resident #36 and repeated "shut up" louder in a harsh tone. CNA #1 then firmly asked Resident #36 "why are you yelling?" CNA #1's body looked tense and he walked away and still appeared frustrated. Resident #36 wheeled himself toward the dining room and continued to yell. An unidentified female CNA approached Resident #36 and calmly asked him "why are we yelling?" Resident #36 yelled, "because I am a yeller." VI. Staff interviewsThe SSD was interviewed on 7/12/23 at 11:57 a.m. She said Resident #50's care plan documented to allow him to express how he felt or what he feared, therapy was scheduled as needed, and his experiences to be shared without staff making Resident #50 feel like a burden. She said staff needed to avoid preventing the resident from going outside because when the resident was triggered he needed to get out of his room. She said if he was anxious or triggered at night he wheeled himself through the facility to "burn off energy." The SSD said she was informed, by the resident's therapist, about the allegation against RN #1 on 1/6/23. She said she had spoken to the nurse and he attempted to explain something to the resident and it came out wrong. The SSD reminded RN #1 of the trauma informed care trainings and that Resident #50 needed to express how he felt. The SSD said she was not informed of the allegation with RN #1 on 5/19/23. She said since Resident #50 was easily startled staff should approach him in a certain way. She said she would look for the most appropriate place for the information to be entered into and put something in place since it was not care planned for already.-The facility failed to report the abuse allegation they were notified about on 1/6/23 and did not ensure the resident was free from further abuse from the staff member (cross-reference F600 abuse and F609 failure to report). CNA #4 was interviewed on 7/12/23 at 1:50 p.m. CNA #4 said the CNAs were not educated enough on trauma-informed care, triggers for trauma or PTSD, and how staff needed to handle the residents' triggers. She said CNAs found this information in the residents' care plans, although triggers and care needed were not always documented in the care plans. The NHA was interviewed on 7/13/23 at 11:08 a.m. The NHA requested more information on the abuse witnessed. He said CNA #15 said she lightly placed her fingers under Resident #125's fingers and "lightly" lifted her hands while CNA #14 used the gait belt to put the resident in her wheelchair. CNA #14 told the NHA she did not pull the gait belt down but Resident #125's knees buckled and she helped her sit in her wheelchair. Both CNAs were suspended during the investigation. The NHA said Resident #125 was difficult to redirect and was very busy but not safe to herself, other residents, or staff. He said the facility did not have specific one-to-one training. There was dementia training on the computer and open office hour training provided on 7/13/23. The NHA said if the one-to-one staff was relieved by an agency staff (staff from an outside agency) they received report from the current one-to-one staff and the NHA believe there was more information provided to the agency staff but he was unsure and needed to check. The NHA was informed of the observation on 7/13/23 at 3:05 p.m. He said he did not like the phrase "shut up" and would investigate the incident. CNA #1 was suspended pending the investigation.

Based on observations, record review and staff interviews, the facility failed to ensure the medication error rate was not greater than five percent. Specifically the facility's medication error rate was 7.41% with two errors out of 27 opportunities. Findings include:I. Facility policy and procedureThe Administering Medications policy and procedure, reviewed April 2019, provided by the nursing home administrator (NHA) on 7/13/23 at 6:00 p.m. It revealed in pertinent part,"The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication."II. Professional referenceAccording to the Levemir FlexPen manufacturer guidelines, updated December 2022, retrieved from https://www.mynovoinsulin.com/content/dam/diabetes-patient/mynovoinsulin/branded/Levemir/Downloads/US22LV00014_LEV_FlexPen_Quick_Guide.pdf on 7/20/23 included the following recommendations,"Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Press and hold the green push button, Make sure a drop of insulin appears at the needle tip."III. Medication administration to Resident #3On 7/12/23 at 7:30 a.m. registered nurse (RN) #1 checked Resident #3's insulin order of Levemir five units to be administered every morning. He obtained her labeled Levemir insulin pen. He then placed a disposable needle onto the Levemir FlexPen. He then entered Resident #3's room dialed five units into the insulin pen and administered the insulin into the back of Resident #3's arm. He returned to the medication cart and disposed of the used needle into the sharps container. RN #1 was observed not priming the pen prior to dialing in the dose to be administered (cross-reference F760 for significant medication error). IV. Medication administration to Resident #50On 7/12/23 at 7:15 a.m. RN #1 was checked Resident #50's Spiriva inhaler order for two puffs every day and obtained the resident's labeled inhaler. RN #1 entered Resident #50's room and gave Resident #50 the Spiriva inhaler for the resident to self administer. Resident #50 was observed self administering one puff and returned inhaler to RN #1. RN #1 then returned to the medication cart.-RN #1 was not observed to confirm with Resident #50 the correct dosage of two puffs with Resident #50. V. Staff interviewRN #1 was interviewed on 7/12/23 at 7:20 a.m. He confirmed the correct dosage for Spiriva was two puffs. RN #1 was interviewed on 7/12/23 at 7:35 a.m. He said prior to administering insulin from a Levemir FlexPen he said that the pen should be primed with at least one unit of insulin prior to dialing in the dose of insulin to be administered and administering it to the resident. He said an incorrect dose of insulin could be administered if the pen was not primed before administration. He said he had not primed the pen prior to administration. The director of nursing (DON) was interviewed on 7/12/23 at 7:37 a.m. She said insulin pens should be primed by pushing at least one unit through the pen prior to administering the ordered dose of insulin. She said this needed to be done to ensure the proper dose of insulin was administered.-However, according to the manufacturer's instructions the insulin pen should be primed with two units prior to administering the dose of insulin.

Based on observation, record review and interviews, the facility failed to ensure that residents were free from significant mediation errors for one (#3) of four residents reviewed for medication errors out of 37 sample residents. Specifically, the facility failed to ensure that Resident #3 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include:I. Professional referenceAccording to the Levemir FlexPen manufacturer guidelines, last updated, December 2022, retrieved from https://www.mynovoinsulin.com/content/dam/diabetes-patient/mynovoinsulin/branded/Levemir/Downloads/US22LV00014_LEV_FlexPen_Quick_Guide.pdf on 7/20/23 included the following recommendations,"Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Press and hold the green push button, Make sure a drop of insulin appears at the needle tip."II. Resident #3A. Resident statusResident #3, age 73, was admitted on 11/29/11. According to the July 2023 computerized physician order (CPO), diagnoses included type two diabetes mellitus. The 6/2/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required the extensive assistance of one person for toileting, the limited assistance of one person for transfers, dressing, personal hygiene, set up with supervision bed mobility and was independent with eating. B. ObservationOn 7/12/23 at 7:30 a.m. registered nurse (RN) #1 checked Resident #3's insulin order of Levemir five units to be administered every morning. He obtained her labeled Levemir insulin pen. He then placed a disposable needle onto the Levemir FlexPen. He then entered Resident #3's room dialed five units into the insulin pen and administered the insulin into the back of Resident #3's arm. He returned to the medication cart and disposed of the used needle into the sharps container. RN #1 was observed not priming the pen prior to dialing in the dose to be administered. C. Record reviewThe 7/12/23 CPO revealed Levemir FlexPen insulin pen to inject five units subcutaneously every morning for diabetes mellitus. D. Staff interviewsRN #1 was interviewed on 7/12/23 at 7:35 a.m. He said prior to administering insulin from a Levemir FlexPen he said that the pen should be primed with at least one unit of insulin prior to dialing in the dose of insulin to be administered and administering it to the resident. He said an incorrect dose of insulin could be administered if the pen was not primed before administration. He said he had not primed the pen prior to administration. The director of nursing (DON) was interviewed on 7/12/23 at 7:37 a.m. She said insulin pens should be primed by pushing at least one unit through the pen prior to administering the ordered dose of insulin. She said this needed to be done to ensure the proper dose of insulin was administered.-However, according to the manufacturer's instructions the insulin pen should be primed with two units prior to administering the dose of insulin.

Based on observations and staff interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of three medication storage rooms. Specifically, the facility failed to:-Ensure expired medications were timely removed from the medication storage area and refrigerator; and,-Ensure expired tuberculin purified protein derivative (PPD) was removed timely from the medication storage refrigerator. Findings include:I. Professional referenceSanofi Pasteur. (2020). Package insert. Tuberculin Purified Protein Derivative (Mantoux): Tubersol. Food and Drug Administration (FDA). https://www.fda.gov/media/74866/download, retrieved on 7/20/23 at 1:38 p.m."A vial of Tubersol (tuberculin purified protein derivative) which has been entered and in use for 30 days should be discarded. Do not use it after the expiration date."U. S. Food and Drug Administration (FDA). (2/8/21). Don't be tempted to use expired medications. https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines#:~:text=Expired%20medical%20products%20can%20be,serious%20illnesses%20and%20antibiotic%20resistance retrieved on 7/20/23 at 1:50 p.m."Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength."Once the expiration date has passed there is no guarantee that the medicine will be safe and effective."II. ObservationsOn 7/13/23 at 10:00 a.m. the medication storage room was inspected with the director of nursing (DON) and the following was found:-Tuberculin PPD was found in refrigerator opened on 6/8/23 and marked as outdated on 7/8/23.-Lorazepam (antianxiety medication) 1 milliliter (ml) vial found in refrigerator opened and marked as expired on packaging on 6/13/23.-Epinephrine (used to treat severe allergies) 1 milligram (mg) prefilled ampule marked as expired on packaging 6/16/23. III. Staff interviewsRegistered nurse (RN) #3 was interviewed 7/13/23 at 10:30 a.m. She said the medications in the medication storage room refrigerators were supposed to be checked by the RNs. She said she did not know if any staff specifically was responsible to check or if there was a specific shift that was responsible. She said she was unaware of any checklist to verify if the medication storage room and refrigerators had been checked. RN #5 was interviewed on 7/13/23 at 11:00 a.m. She said nurses were responsible for checking medication expiration dates in the medication storage room refrigerator. She said it was not the responsibility of any one shift or any one nurse. She said there was no formal process to ensure that this was done. She said expired medication could become ineffective or unexpected side effects may occur if they were past their expiration dates. The DON was interviewed on 7/13/23 at 11:15 a.m. She said the RNs were responsible for checking the medications in the medication storage room refrigerators. She said usually the night staff were responsible for it but there was no set process and no checklist reminders. She said expired medications could potentially become ineffective and unexpected side effects could occur.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include:I. Resident group interviewA group interview was conducted on 7/12/23 at 9:56 a.m. with four alert and oriented residents (#7, #26, #30 and #40). All the residents in the group interview said that the food was not palatable. Some of the comments were as follows:-The food was salty.-Chicken was dry and fatty.-The food was institutional food (lacked quality, variety and value). -The food came at room temperature. II. Resident interviews Resident #72 was interviewed on 7/10/23 at 9:10 a.m. The resident said he wanted eggs over medium but he was served runny eggs and scrambled eggs. Resident #43 was interviewed on 7/10/23 at 1:56 p.m. The resident said the food was bland and he would love to have a burrito or Thai chili. Resident #47's family representative was interviewed on 7/10/23 at 4:10 p.m. She said the pancakes served in the morning were too hard. She said she was unable to slice the pancakes with a knife. Resident #61 was interviewed on 7/11/23 at 9:24 a.m. The resident said the food was sometimes served cold. He said when he was served over medium eggs and the outside of the egg was crusty. III. ObservationMeal tray pass was observed for lunch and dinner meals in two units. -The meal tray pass for Grand Mesa was observed on 7/10/23 at 11:47 a.m. The roll was served on top of chicken, green beans and rice which made the roll soggy. -The meal tray pass for Monument was observed on 7/10/23 at 12:01 p.m. The roll was served on top of chicken, green beans and rice which made the roll soggy. -The meal tray pass for Grand Mesa was observed on 7/10/23 at 5:35 p.m. The roll was served on top of macaroni and cheese and vegetables which made the roll soggy. IV. Test trayA test tray, regular diet was evaluated on 7/12/23 at 12:39 by three surveyors. The menu was beef patty with gravy, baked potato, mixed vegetables, roll and sour cream. An alternative menu was chicken in gravy, baked potato, mixed vegetables, roll and sour cream. The following was observed: -All hot menu items were served on one plate with a roll on top.-The vegetables were under seasoned.-The beef was a hamburger patty that was not seasoned and bland.-The gravy on top of the beef had too much pepper and tasted processed. -The chicken tasted like canned chicken. -The gravy with the thicken tasted like a gravy packet and was not seasoned. -The sour cream temperature was 64.7 degrees F. V. InterviewThe cook was interviewed on 7/12/23 at 7:02 am. The cook said the pancakes could be hard if they were in the steamer for a long time. The registered dietitian (RD) was interviewed on 7/13/23 at 1:30 p.m. The RD said there should be a cooling mechanism for the sour cream. The RD said cold foods should be held at 41 degrees F or below. The nursing home administrator (NHA) was interviewed on 7/13/23 at 3:30 p.m. He said he was aware that residents had complained about food in resident council meetings back to April 2023 and that those complaints were addressed. He was not aware that additional residents complained about the food. -However, according to the resident group and resident interviews there were still food concerns that may not have been addressed especially for those who did not attend the resident council meetings.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to:-Ensure cold food items were at appropriate temperatures;-Ensure expired food was discarded; and, -Ensure food items removed from its original packaging and opened had a dating system. Findings include:I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food-borne illness. A. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, "The food shall have an initial temperature of 41ºF (Fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control." (Retrieved 7/18/23). B. Ensuring holding temperatures 1. Medication carts On 7/12/23 at 10:23 a.m., there was a cooler on a medication cart for the Grand Mesa unit. There was one yogurt and chocolate pudding in the cooler. The yogurt and chocolate pudding was not cold to touch. The yogurt was 60 degrees F and the chocolate pudding was 62 degrees F. At 10:36 a.m., there was a cooler on a medication cart for the Monument unit. There was one yogurt in the cooler. The yogurt was not cold to touch and the temperature was 61.8 degrees F. 2. Temperature of coldOn 7/12/23 during the lunch, sour cream was served in individual plastic containers, with no mechanism to keep them cold. At 12:39 p.m. after all residents were served lunch the sour cream temperature was 64.7 degrees F. 3. InterviewsCertified nursing assistant (CNA #8) was interviewed on 7/12/23 at 12:50 p.m. She said the sour cream was served with the hot food on a plate for residents who had their meal in their room. Registered nurse (RN) #1 was interviewed on 7/12/23 at 10:28 a.m. The RN said he did not know what the temperature of the yogurt or the pudding located in the cooler that was located on the medication cart was supposed to be. He did not have a thermometer on the cart or with him to check the temperature. The RN removed the pudding and yogurt from the cooler and added more ice to the cooler. Licensed practice nurse (LPN) #3 was interviewed on 7/12/23 at 10:45 a.m. The LPN said she did know what the temperature of the yogurt located on the medication cart was supposed to be. She did not have a thermometer on the cart or with her to check the temperature. The registered dietitian (RD) was interviewed on 7/13/23 at 1:30 p.m. The RD said there should be a cooling mechanism for the yogurt and pudding located on the medication carts. The RD said cold foods should be held at 41 degrees F or below. II. Food labelA. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, "A date marking system may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; 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." (Retrieved 7/18/23). B. Food label 1. Main KitchenOn 7/10/23 at 8:10 a.m. the main kitchen had the following items:-In the prep refrigerator, orange thickened liquid, lemon thickened liquid and cranberry thickened liquid; per the label on the thicken liquids once opened it needs to be used within seven days; -Underneath a prep counter, soft white bread, hot dog buns and hamburger buns in plastic bags with no expiration date or an open date; -In the pantry, English muffins were in a bag with no expiration date or opened date. 2. Monument dining room On 7/10/23 at 11:40 am., the dining room had the following items: -In the refrigerator, apple and lemon thickened liquids with no open dates and sliced watermelon in a ziplock container with no date; and, -In the cabinet between the refrigerator and the microwave, bread in a plastic bag with no expiration date or a date when opened. 3. InterviewsThe dietary manager (DM) was interviewed on 7/10/23 at 3:59 p.m. He said the opened items should have had a date when the food item was opened and when to use the food. The RD was interviewed on 7/13/23 at 1:30 p.m. She said the opened items should have had a date when it was opened and when to use the food. III. Expired FoodA. Professional ReferencesThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf."The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety." (Retrieved 7/18/23)B. Expired foodOn 7/10/23 at 8:10 a.m. the kitchen main refrigerator had bean sprouts in a plastic opened bag inside a box. The box was marked 6/29. The bean sprouts were brown, had liquid and had a foul odor. C. InterviewsThe DM was interviewed on 7/10/23 at 3:59 p.m. He said bean sprouts were expired and should have been discarded. The RD was interviewed on 7/13/23 at 1:30 p.m. She said expired food should be discarded.

Based on observation, record review and interviews the facility failed to maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for one (#47) of four residents reviewed for hospice care services out of 37 sample residents. Specifically, the facility failed to for Resident #47:-Demonstrate documentation of a collaboration of care between the facility and the hospice provider; -Delineate care responsibilities between facility care staff and hospice care staff and the frequency of the hospice staff visits; and,-Documentation of hospice staff visits and the hospice plan of care. Findings include:I. Facility policyThe Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 7/12/23 at 4:51 p.m. The policy read in pertinent part:"In general, it is the responsibility of hospice to manage the resident's care as it relates to the terminal illness and related conditions, including: determining the appropriate plan of care, providing medical direction, nursing and clinical management of the terminal illness."It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative."Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility in order to maintain the resident's highest practicable physical, mental and psychosocial well being." II. Resident statusResident #47, age 97, was admitted on 6/19/23. According to the July 2023 computerized physician orders (CPO), diagnoses included Parkinson's Disease, type two diabetes, cachexia (weakness and wasting of the body), hypotension (low blood pressure), dysphagia (difficulty swallowing) and anorexia (abnormally low body weight). The 6/26/23 minimum data set (MDS) assessment documented the resident had cognitive impairment with a brief interview of mental status (BIMS) was eight out of 15. It revealed the resident had hospice and oxygen therapy treatment. III. Observations and interviews A hospice nurse visited the resident on 7/12/23 at 10:34 a.m. The hospice nurse stated the resident's oxygen saturations were in the 80s (with normal range being 95 or higher). The resident was lying in bed sleeping. The resident did not have oxygen on. At 2:10 p.m. the resident was sleeping with his mouth open and was not provided oxygen. -After the hospice nurse assessed the resident's oxygen saturation in the 80s, he did not communicate that with the care staff at the facility (see staff interviews below). Licensed practical nurse (LPN) #3 was interviewed on 7/12/23 at 2:10 p.m. She said the hospice staff went in the morning to see the resident because the facility asked them to come due his change of condition. She said the hospice staff would give a report if there was a change in condition based on their visit. She said she was not aware of the resident's oxygen saturation being in the 80s and was not given a report from the hospice nurse. She said sometimes they would leave orders or documentation in a tray by the unit fax machine. She went to the tray and was unable to find any documentation. The LPN went to check on the resident who shared his room with his wife. The LPN obtained his oxygen saturation level and said it was 84. The wife stated the hospice nurse visited in the morning and mentioned his oxygen was low. At 2:46 p.m. the LPN spoke with the hospice provider and placed oxygen on the resident and the resident was sitting comfortably. On 7/13/23 at 8:13 a.m. the resident was sitting upright in bed sleeping with oxygen via nasal cannula. IV. Representative interview The resident's representative was interviewed on 7/10/23 at 4:10 p.m. She said since the resident was admitted to the facility she had a hard time ensuring communication among all his providers. She stated she requested a meeting between the facility, the hospice provider and Veterans Affairs which was not held until 7/3/23 (which was two weeks after his admission). V. Record reviewThe July 2023 CPO revealed the resident admitted with an order for hospice services dated 6/19/23 for terminal disease process. The CPO revealed the resident had a respiratory order for oxygen two liters per minute via nasal cannula at bedtime and as needed, ordered 6/19/23. The resident's comprehensive care plan was reviewed and the plan for hospice was initiated on 7/2/23. Pertinent care plan interventions initiated 7/2/23 included:-Work effectively with the hospice team to ensure that my spiritual, emotional, intellectual, physical and social needs are met. -Work with nursing staff to provide maximum comfort for me -The care plan did not delineate the care provided by the hospice provider and did not indicate the frequency of their visits. The hospice plan of care and visits from the hospice staff for Resident #47 were requested on 7/12/23. They were provided by the NHA the following day on 7/13/23. -However, the hospice documentation was not available for the facility staff to review in order to coordinate Resident #47's care. VI. Administrative interview The director of nursing (DON) was interviewed on 7/14/23 at 2:41 p.m. She said she was not aware that the daughter expressed concerns about the facility, hospice and Veterans Affairs not working together. The DON said if the resident's oxygen saturation was 84, she would place oxygen on the resident, call the doctor and remedy the situation.

Based on interviews and record review, the facility failed to ensure its quality assurance and process improvement (QAPI) committee prioritized its improvement activities, developed and implemented action plans, measured the success of those actions, tracked performance, regularly reviewed and analyzed and acted on data collected. Specifically, the facility failed to identify and implement effective action plans to address repeat deficiencies and resident quality of life and quality of care issues related to abuse prevention, activities of daily living, dementia care, quality assurance and infection control. Findings include: I. Repeat deficiencies A. Abuse: cross-reference F600 abuse and F609 failure to report abuse allegations. Failure to investigate abuse allegations was cited at a harm level during the previous recertification survey on 5/19/22, 3/24/22 and was cited again during the current recertification survey on 7/13/23. B. Activities of daily living (ADLs): cross-reference F677. Failure to provide assistance with ADLs in keeping with resident needs and preferences was cited during the previous recertification survey on 5/19/22 and was cited again during the current recertification survey on 7/13/23. C. Dementia care: cross-reference F744. Failure to provide dementia care services was cited during the previous recertification survey on 5/19/22 and was cited again during the current recertification survey on 7/13/23. D. Quality assurance and process improvement. Failure to ensure the QAPI committee prioritized its improvement activities and developed and implemented effective action plans was cited during the previous recertification survey on 5/19/22 and was cited again during the current recertification survey on 7/13/23. E. Infection control: cross-reference F880. Failure to provide an effective infection control program was cited during the previous recertification survey on 5/19/22 and was cited again during the current recertification survey on 7/13/23. II. Staff interview The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 7/13/23 at 8:00 p.m. regarding QAPI with their corporate operations consultant present. The NHA said their QAPI committee were looking at tracking and trending related to abuse. He said bathing and ADL assistance had been a challenge and it was something they were working to address. He said they tracked and trended staffing challenges, did a weekly call with the regional support team related to staff retention and recruiting, and had been doing that for a while. He said they had a recruiter just for the local market to help support the two local facilities. Regarding dementia care they developed education they were actually providing to staff that day, specifically for their residents at risk regarding their needs. Regarding infection control and Legionella mitigation they had chosen a company that developed a water management program that outlined the necessary tasks and kept track of everything through their operations computer system. He did not know why their Legionella mitigation treatment had been delayed. Regarding QAPI, he said he felt they were going to need to look at developing effective action plans and ensure they got their processes tightened.

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure remedial actions were followed and timely implemented after the identification of Legionella was detected in the facility's water. Findings include:I. Professional referenceThe Center for Disease Control and Prevention (CDC) recommendations for Legionella, last reviewed on 3/25/21, was retrieved on 7/17/23 at https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html under Heathcare Water Mangement read in pertinent part: "Healthcare facilities, such as hospitals and nursing homes, usually serve the populations at highest risk for Legionnaires' disease. These include older people and those who have certain risk factors, such as being a current or former smoker, having a chronic disease, or having a weakened immune system. Also, healthcare facilities can have large complex water systems that promote Legionella (the bacterium that causes legionnaires' disease) growth if not properly maintained. For these reasons, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) consider it essential that hospitals and nursing homes have a water management program that is effective in limiting legionella and other opportunistic pathogens of premise plumbing (waterborne pathogens, for short) from growing and spreading in their facility. "Legionella and other waterborne pathogens occur naturally in the environment, in bodies of water like lakes, rivers, and streams. Although municipalities treat their water with disinfectants like chlorine that can kill these pathogens, a number of factors may allow these pathogens to enter a building's water distribution system, such as construction (including renovations and installation of new equipment). Vibrations and changes in water pressure can dislodge biofilm and release legionella or other waterborne pathogens. Biofilm is a slimy layer in pipes in which pathogens can live; it can give pathogens a safe harbor from disinfectants."Water management programs identify hazardous conditions and take steps to minimize the growth and spread of legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. "In general, the principles of effective water management include:-Maintaining water temperatures outside the ideal range for legionella growth (77-113 Fahrenheit).-Preventing water stagnation.-Ensuring adequate disinfection.-Maintaining premise plumbing, equipment, and fixtures to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for legionella."Members of a building water management program team work together to:-Identify ways to minimize growth and spread of legionella and other waterborne pathogens-Conduct routine checks of control measures to monitor areas at risk.-Take corrective action if a problem is found. "Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions. Programs should include predetermined responses to correct hazardous conditions if the team detects them."II. Facility policy and procedureThe Legionella Testing procedure under the Water Management Plan, expiring 6/15/24, was provided by the maintenance director (MTD) of 7/13/23. The MTD identified the provided procedure was the facility's new Legionella policy. The procedure read: "Legionella are commonly found in almost all natural water resources, so sampling of water systems and services will often yield positive results. Failure to detect legionella should not lead to the relaxation of control measures and monitoring. Neither should monitoring for the presence of legionella in a cooling system be used as a substitute in any way for vigilance with control strategies and those measures identified in the risk assessment. If a legionella positive sample is found outside of control limits, more frequent samples may be required as part of the review of the system operation, in order to establish the source of contamination and determine whether the system is back within control limits as specified in the water management plan."According to the procedure, testing for Legionella requires a skilled microbiological laboratory and proper training for assessment and interpretation. Legionella testing was a common undertaking for hot and cold water systems, particularly in healthcare establishments, where there are concentrations of susceptible individuals, and can be valuable in cases of unproven techniques or in all systems in which control is difficult. III. Identification of Legionella in the facilityThe 3/4/22 certificate of analysis Legionella summary sheet was provided by the MTD on 7/13/23 at 3:36 p.m. The summary sheet identified four water samples that were collected from the facility on 2/23/22. The samples were analyzed and reported back to the facility on 3/4/22. According to the analysis, one out of the four samples identified an isolated Legionella species that was not pneumophila. The Legionella summary sheet provided a description of Legionella species that was not pneumophila: "The genus legionella is a pathogenic group of gram-negative bacteria. This organism lives in potable and non-potable water. Legionella is not transmissible from person to person, furthermore, most people exposed to the bacteria do not become ill. Through the use of serokits (a testing method), the lab has determined that this specific organism does not belong to pneumophila species." The analysis Legionella summary sheet read a water sample was taken from a room in a construction location. The summary read a sample, with a volume of 250 milliliters (ML), with a minimal risk level (MRL) of 0.4, within a colony-forming unit (CFU) per ML, detected a legionella species at 15.6 CFU per ML. The three other samples from different locations within the facility identified no Legionella isolated. The 3/4/22 analysis Legionella summary sheet listed remedial actions by level. Level four identified immediate action was needed. The cleaning and or biocide treatment of the equipment was indicated. The level four remedial action read: "This level of legionella represents a moderately high level of concern, since it is approaching levels that may cause outbreaks. It is uncommon for samples to contain (a) number of legionella that fall in this category." IV. InterviewsThe MTD was interviewed on 7/13/23 at 12:53 p.m. The MD said he circulated the water weekly to help prevent the development of Legionella in stagnant water. He said he circulated the water by running it in various parts of the facility every week. The MTD said the facility was due for another Legionella test. He said the last time the facility was tested was in February 2022. He said testing was due annually. The February 2022 Legionella test identified low levels of Legionella was found in one of the rooms under construction. He said the room was not occupied by a resident at the time the Legionella was identified. The faucets in the rooms under construction were not regularly used. The MTD said he felt he corrected the problem by running the water in the area to flush the pipes. The area where the Legionella was found was no longer under construction and the water was routinely used, helping prevent the water from sitting in the pipes. He said the facility has not had more water samples collected and analyzed since February 2022, to ensure the facility did not have Legionella in the water.-The MTD flushed the pipes after Legionella was detected but he did not clean or use biocide treatment (asindicated by the report, see above). The MTD said the facility had a new management plan, created by an outside contractor, as of June 2023. Part of the plan was to sanitize the water system, track temperatures and follow a water management schedule that was tracked on the facility's preventive maintenance log. The MTD said he still needed to add disinfectant to the water according to the water management plan. He said he recently received the kits to collect the samples. He said he was planning on collecting the samples on 7/17/23 and sending the samples to the laboratory for Legionella testing. The staff development coordinator (SDC) was interviewed on 7/13/23 at 2:11 p.m. She identified herself as the facility's infection preventionist (IP). The IP said it was important to have a water management plan in place to identify and prevent the spread of Legionella in the water. She said Legionella could potentially make the staff and residents sick. The IP said Legionella created a lower respiratory infection that could quickly turn into pneumonia and could be debilitating. She said the facility's job was to protect the residents and prevent Legionella from infecting residents. She said the facility had an evaporative/swamp cooler. The cooler puts water in the air causing a potential risk in Legionella, if Legionella was identified in the water. She said she was not aware of reports of Legionella in the water. The IP said the facility had residents with pneumonia but none of the residents with pneumonia were diagnosed with Legionnaires disease. The MTD was interviewed again on 7/13/23 at 3:27 p.m. The MTD said he was not aware the Legionella test was due. He said he found out the test was last done over a year ago when he saw a bill from the laboratory last done in February 2022. He said he notified his corporate maintenance consultant and the nursing home administrator (NHA) to request approval for a new Legionella testing kit because the test should be done annually. The NHA approved the kits and had a water management contractor come into the facility and create a water management plan. The MTD said stagnant water created a potential risk for Legionella. He said additional devices in the facility could contribute to the spread of Legionella if not properly maintained such as the ice machine, the evaporative cooler, sink faucets and shower heads. He said he recently received a verbal education on Legionella risk factors when the contractor created the water management plan in June 2023. The MTD said a better facility record keeping could have helped prevent missing annual Legionella tests. He said the new water management plan now includes a breakdown on when each water management step should be completed. He said the water management plan has now been added to the life safety book. The preventive maintenance log now includes weekly flushes of the faucets and a directive to test annually for Legionella. The MTD said when the facility received the report from the February 2022 testing identifying the Legionella, he started the flushing of the pipes weekly. The MTD said he requested a water management program setup to implement the recommended steps to address the Legionella. The MTD said no other measurements were done besides flushing the pipes because there was a dispute regarding which contractor the facility should use for their water management program and the associated costs; the facility was in between nursing home administrators and then the facility went into a COVID outbreak occupying the facility's focus. The MTD said having the new water management plan with outlined timelines to complete each water management procedure and adding the procedures and testing schedule to the preventive maintenance tracking log, would prevent future occurrences of missed Legionella testing dates and Legionella identification follow through. He said the water management plan had been added to the life safety book. The MTD said he would send off the testing kits after he collects them on 7/17/23 and start flushing the water systems three times a week until the new Legionella testing results come back from the lab. The NHA was interviewed on 7/13/23 at 4:36 p.m. The NHA said the MTD requested a contractor to come into the facility to set up a solid water management plan. The NHA said he approved the contractor to come to the facility and the regional corporate maintenance director set up the contractor to create the water management plan. The NHA said he was not the NHA the last time the facility was tested for Legionella and was not aware of the finding of the test in February 2022. The NHA was informed Legionella was identified with one of the water samples during the February 2022 test. A microbiologist from the laboratory used during the February 2022 legionella testing was interviewed on 7/13/23 at 4:51 p.m. The microbiologist reviewed the results from the February 2022 test. The microbiologist said with samples at 15.6, level four actions needed to be taken (see above for level four remedial action). The microbiologist said older adults' immune system were not as strong as younger persons and were more susceptible to Legionella. V. Record reviewThe water management plan, dated 6/26/23, was provided by the MTD on 7/13/23 at 3:47 p.m. The water management plan identified its purpose was to establish the minimum Legionellosis risk management requirements through procedures that minimize the risk of Legionnaires' disease. According to the water management plan, the prevention of outbreaks caused by hot and cold-water systems depends on a comprehensive application of a water management plan with thorough attention to good design, management and control systems. The water management plan under the hot and cold water systems for little used outlets, identified the facility should flush little used water outlets for several minutes twice a week where uses are at high risk. According to the management plan, faucets should be used daily or handled as little used outlets. The risk assessment under water management plan identified under general risk factors read the facility housed and treated residents who had chronic and acute medical problems or weakened immune systems. Additional risks included:-The facility housed residents over 65 years of age;-The facility contained multiple housing units and a centralized water heating system;-The facility had any centrally installed misters, atomizers, air washers or humidifiers or ice machines or pools;-The facility had kitchen and beauty shop facilities;-The facility had laundry room facilities; and, -The facility had recirculating pumps installed on the water heaters. The risk assessment identified the following devices in the facility that could spread contaminated water droplets:-Aerators;-Backflow preventers and check valves;-Dead runs;-Expansion tanks;-Eye wash stations;-Electronic and manual faucets;-Ice machines;-Medical devices to include continuous positive airway pressure (CPAP) machines and heater-cooler units;-Pipes, valves and fittings that are not in continuous use;-Shower heads and hoses; -Water filters; and,-Water heaters.

Based on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in safe, working condition. Findings include:I. ObservationsOn 7/10/23 at 8:10 a.m. a kitchen inspection revealed the hand washing sink and a food preparation sink had low pressure and was not warm to touch. At 4:21 p.m. the hand washing sink and food preparation sink had low pressure and was not warm to touch. On 7/11/23 at 11:19 a.m., the hand washing sink and food preparation sink had low pressure and was not warm to touch. On 7/12/23 at 7:02 a.m. the hand washing sink and food preparation sink had low pressure and was not warm to touch. II. Staff interviewsCook #3 was interviewed on 7/10/23 at 4:21 p.m. She said the maintenance department was aware that the hand washing sink did not have enough pressure and did not get as hot as she wanted it to be. She said sometimes her hands did not feel as clean as they should be after she washed her hands. Cook #1 was interviewed on 7/11/23 at 11:19 a.m. She said the hand washing sink did not have enough pressure and did not get as hot as she wanted it to be. She showed that the water sink for the food preparation was not warm and did not have enough pressure. She said she used a lot of soap because she did not think her hands were clean enough since the water pressure was low and the water temperature was not warm. The maintenance director (MTD) was interviewed on 7/11/23 at 3:13 p.m. He said he was aware the hand washing sink was not as hot as it was supposed to be and that it did not have enough pressure. He said they were working on it with their new water management plan. He was not aware of the food preparation sink. The nursing home administrator (NHA) was interviewed on 7/12/23 at 9:13 a.m. He was not aware of the water pressure and temperature. He said he would look into it. The MTD was interviewed again on 7/12/23 at 4:05 p.m. He said the water pressure and temperature was fixed. -However, the water pressure and temperature were not fixed until identified during the survey. The NHA was interviewed on 7/12/23 at 4:10 p.m. He said he was not notified by the MTD or other staff about the water pressure and temperature. He said there was not a mechanism in place to ensure the water pressure and temperature was at an appropriate level.

A licensure survey was completed on 7/11/23 to 7/13/23. Two deficiencies were cited.

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

Based on observations, record review, and interviews, the facility failed to ensure one (#35) of nine residents reviewed for weight loss out of 37 sample residents maintained adequate nutritional parameters. Specifically, Resident #35 had a condition change when she experienced a fall with a fracture on 4/2/23 (cross-reference S704 falls/accidents). Resident #35's weights, taken on 3/30/23 and 5/11/23, more than one month apart, demonstrated a 10-pound weight loss from 201.6 to 191 pounds, which was not followed up with timely nutritional assessments and interventions. Resident #35 was observed needing extensive to total assistance with dining although her assessments and care plan identified she was independent with setup help only; staff who provided care for Resident #35 said she had needed an extensive level of assistance for about one month. There was no evidence of a thorough assessment of the resident's current dining assistance needs as of 7/13/23. The facility failed to respond in a timely manner to Resident #35's dining assistance needs and failed to assess and implement measures to ensure she received the assistance and nutrition needed to prevent significant weight loss. These failures contributed to Resident #35 experiencing significant, unplanned weight loss of more than 10 percent within six months. Findings include: I. Facility policy and procedures The Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol policy, provided by the director of nursing (DON) on 7/14/23 at 5:01 p.m., included: The nursing staff would monitor and document the weight and dietary intake of residents in a format which permitted comparisons over time. The staff and physician would define the individual's current nutritional status (weight, food/fluid intake and pertinent laboratory values) and identify individuals with weight loss or gain and significant risk for impaired nutrition. The staff would report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. When medical conditions or adverse consequences were causing or contributing to altered nutritional status, the physician and staff would collaborate in adjusting interventions, taking into account the status of those causes and the resident's responses, goals, wishes, prognosis, and complications. II. Resident status Resident #35, age 96, was admitted on 12/14/18. According to the July 2023 computerized physician orders, diagnoses included Alzheimer's disease, vascular dementia, type II diabetes mellitus with hyperglycemia, and need for assist with personal care. According to the 6/22/23 facility assessment, Resident #35 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She had a delirium indicator of inattention, being easily distractible, and having difficulty keeping track of what was being said. She needed extensive two-plus person assistance with most activities of daily living (ADLs) and was independent with setup help only for eating. She had no chewing or swallowing difficulties. She weighed 198 pounds (lbs) and weight loss/gain was "no or unknown."-The facility assessment was inaccurate in that the resident's need for dining assistance and her recent weight loss were not identified (see below). III. Observations and staff interviews According to the meal service schedule, breakfast was served from 7:00 to 8:00 a.m., lunch from 11:30 a.m. to 12:30 p.m., and dinner from 5:00 to 6:00 p.m. Per observations, room trays were served first. On 7/10/23 at 9:45 a.m. Resident #35 was sitting in the hallway by the nurses' station near the main dining room repeatedly saying she wanted to go to bed. After repeating herself several times, staff assisted Resident #35 to her room. (Per meal intake records she ate 76-100% for breakfast.) Observations afterward throughout the survey conducted 7/10/23 through 7/13/23, revealed Resident #35 spent her time in bed, sleeping off and on. She also ate her meals in bed. When Resident #35 was approached as she lay in bed, she would sometimes wake up, reach out with her hand and ask if there was anything to eat. Her meals were often left covered and out of her reach on her bedside table for extended time periods after meals were served and frequently no staff were observed nearby to assist her with eating. Specifically: -On 7/12/23 at 7:51 a.m., Resident #35 was lying in bed and her breakfast tray was covered and sitting on her bedside table out of her reach, not set up for her. At 8:10 a.m. it was in the same place. At 8:34 a.m., her breakfast tray was gone. At 8:43 a.m., certified nurse aide (CNA) #1 said he assisted her to eat her breakfast and she enjoyed it. (She ate 76-100% per the meal intake record.) -On 7/13/23 at 8:00 a.m., Resident #35's breakfast was covered on her bedside table and out of her reach. CNAs #1 and #9 were assisting another resident to get out of bed. After assisting the other resident, CNA #1 took Resident #35's plate of pancakes to heat them up in the microwave and assisted her to eat her breakfast, after cutting up her pancakes into bite-sized pieces and adding syrup for her. -At 8:45 a.m., CNA #1 said Resident #35 ate all her bacon and wanted more and he was going to get her more. CNA #1 said her milk was probably not cold anymore. He said she would drink milk but only if assisted. He said if they set up her room tray and left her food within her reach she would pull it onto herself from the bedside table. He said she had been wanting to sleep more and more lately. CNA #1 said Resident #35 needed total assistance with eating and had needed this level of assistance for about the last month. (She ate 76-100% per meal intake records, see below.) CNAs #1 and #9 were interviewed on 7/13/23 at 8:45 a.m. CNAs #1 and #9 said they did not have enough staff to assist residents with dining timely while also providing care for residents on their hall. IV. Record review Resident #35's weights, reviewed in the weights and vitals section of her medical record for the previous seven months, revealed the following: 7/11/23 - 189.6 Lbs 7/6/23 - 190.4 Lbs 6/7/23 - 198.0 Lbs 5/25/23 - 195.8 Lbs 5/17/23 - 197.0 Lbs 5/16/23 - 196.6 Lbs 5/11/23 - 191.0 Lbs 3/30/23 - 201.6 Lbs 3/22/23 - 190.8 Lbs 3/16/23 - 195.0 Lbs 3/9/23 - 195.6 Lbs 2/23/23 - 207.4 Lbs 2/9/23 - 201.4 Lbs 1/3/23 - 211.8 Lbs -Between 3/30 and 5/11/23, the resident had a fall with fracture (on 4/2/23) and lost 10 pounds. However, contrary to facility policy (see above) there was insufficient evidence her weight and nutritional status were closely monitored after that weight loss. Further, there was no evidence the physician was notified of Resident #35's weight loss and new orders requested until 7/11/23 after the survey began (see below). Physician orders: Resident #35's July 2023 CPO documented the following pertinent orders:-Offer snacks between meals, prefers sandwiches three times daily for nutrition ordered 3/16/23;-Regular texture diet, thin consistency fluids ordered 3/23/23;-Nutritional supplement twice daily for weight loss ordered 7/11/23. However, there was no documentation in the July 2023 medication administration record that the supplement was given on 7/11, 7/12, or 7/13/23. The nutritional care plan, initiated on 12/26/18 and revised on 6/19/23, identified dementia, coronary artery disease, hypertension, and obesity, with a 13 lb weight loss in 180 days, but weight stable for 90 days. The goal was adequate nutritional status and consuming more than 50 percent of at least two meals every day. Interventions were: monitor intake and record every meal, obtain weight and record per facility protocol, offer snacks between meals, provide and serve diet as ordered, RD to make diet change recommendations as needed. Other pertinent care plan entries documented specifically: Resident #35's activity needs care plan identified the following on 10/6/22: "I ask for food often and I believe I am hungry. It may or may not be a real physical hunger, but having food supplicates me when I'm feeling anxious or confused. Any offer to get me something helps ease my mind." The care plan identified ADL limitations, with eating/dining needs documented on 12/20/21 as "prompting and cueing during meals." The care plan further identified on 3/14/19, "I am at potential risk for sustaining injury while consuming foods/fluids due to my functional limitations to balance or grip steadily cups, utensils and/or plates." The goal was no injury and the intervention was "assist me by providing cueing-verbally and visuals as appropriate." Resident #35's most recent nutritional assessment, dated and signed on 6/19/23 by the registered dietitian (RD), documented her most recent weight was 198 pounds on 6/7/23 (12 days before). There was no decrease in food intake and no weight loss. There had been no acute disease or stress recently (although the resident had a fall with a fracture on 4/2/23). Her score was 11, indicating risk of malnutrition. -The nutritional assessment was inaccurate or incomplete in that her weight was not current; her recent meal intakes, nutritional/fluid needs, and recent lab values were not documented; and her dining assistance needs were not assessed. Nutrition at risk (NAR) meeting minutes regarding Resident #35 were requested on the afternoon of 7/13/23 and the following note was the only documentation provided: On 7/11/23 at 1:27 p.m. the registered dietitian (RD) documented, "WEIGHT WARNING: -10.0% change over 180 day(s) [ 10.4% , 22.0 ] Noted wt (weight) stability this week. Will cont (continue) to offer and encourage all meals, supplements, and snacks to promote wt stability. Will cont to follow care plan and monitor with weekly weights." -There was no evidence consistent weekly weights were implemented before 7/11/23 (see weight list above which showed gaps of more than one month at a time).-The care plan was not revised regarding actual weight loss and recommended interventions.-There was no physician order for weekly weights per the RD's recommendation.-Twice-daily supplements were not given on 7/11, 7/12, or 7/13/23 in keeping with the RD recommendation and physician order. Meal and snack intake records, reviewed from 6/29/23 through 7/13/23, revealed Resident #35 consumed:Breakfast - 76-100% 10 times, 51-75% three times, 0% twice (once during survey on 7/11/23)Lunch - 76-100% five times, 51-75% nine times, 25-51% once (during survey on 7/11/23)Dinner - 76-100% four times, 51-75% six times, 25-51% or 0% four timesSnacks were accepted 24 times out of 45 opportunities. V. Interviews Resident #35's daughter was interviewed by phone on 7/12/23 at 3:52 p.m. She saidlast Sunday (7/9/23) when she visited Resident #35, her meal was sitting out, and "she nibbled at it but didn't really eat it. She was dozing on and off too, maybe she was just too tired to eat. I tasted it and the ham was not hot." Resident #35's daughter said the room tray sat there for aboutan hour after she arrived, and when she saw a staff person she requested that they take it away and bring her mother some ice cream. Resident #35 was unable to use utensils to eat her ice cream, so her daughter assisted her to eat. "Sometimes I wonder if they need more help. There's Mom's lunch and an hour later there's nobody there to assist her." The RD was interviewed on 7/13/23 at 4:14 p.m. She said she had not ever observed Resident #35 during meals, and this was the first she had heard of the resident needing extensive to total assistance with eating. She said if the resident chose not to go to the dining room she should receive assistance in her room. "In my opinion therapy should have done an assessment. The first thing I would do is notify the therapy department to do an evaluation for self-feeding. That's how I would handle it if somebody had let me know that information." The RD said appetite decreased along with dementia for older adults, and she always used a food-first approach. She said Resident #35 triggered for significant weight loss in July 2023. "She's now on weekly weights and we discuss her weekly. I think I started charting on (Resident #35) in February. We started weighing her weekly to establish the difference between true weight loss and diuretic use and then she sort of stabilized. They started sandwiches and bacon for snacks at the beginning of March. From the beginning of June to now there had been an almost 10-pound weight loss. "Sandwiches are not working any longer. That's when I decided to put the supplements on board. We've been following her for better than four months now." The RD said Resident #35's intakes in May through June 2023 were stable, but in July there was a decrease in her intake: 25-50% for breakfast and lunch and 50-75% for dinner times seven days. The RD said she was not aware the supplements she recommended on 7/11/23 were not yet being given.

A complaint survey, prompted by #CO30564 was conducted on 1/17/23. No deficiencies were cited.