LA VILLA GRANDE CARE CENTER

A survey prompted by #CO37480 and #CO37481 was conducted on 10/8/24. Two deficiencies were cited.

Based on observation, interviews, and record review, the facility failed to ensure services provided met professional standards of practice for two (#3 and #9) of seven residents out of 5 sample residents. Specifically, the facility failed to:-Ensure Resident #9's fluid intake was monitored and managed effectively, which resulted in the resident being sent to the hospital for fluid overload;-Provide Resident #3, who chose not to consistently follow her recommended diabetic diet, with education related to the specific risks associated with not following her dietary recommendations; and,-Ensure Resident #3's diabetic care plan was updated to include documentation of the resident's refusals to comply with her recommended diabetic diet. Findings include:I. Professional standardsAccording to the National Institutes of Health Library of Medicine: Interventions For Improving Adherence To Dietary Salt and Fluid Restrictions In People With Chronic Kidney Disease Stage 4 and 5, retrieved on 10/9/24 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9620929,"When prescribed, fluid restrictions are typically 1000 to 1500 milliliters (ml) per day."According to the National Institutes of Health Library of Medicine: Cardiology Explained chapter 4, retrieved on 10/9/24 from https://www.ncbi.nlm.nih.gov/books/NBK2215,"LV (left ventricular) systolic dysfunction (heart failure on the left side of the heart) is assessed using the ejection fraction (the percentage of the end diastolic volume ejected during systole). In most cases, this is estimated by eye from all the available echocardiogram views. A normal ejection fraction is 50%-80%, but values as low as 5% are compatible with life (end-stage heart failure)."II. Facility policyThe Resident Hydration and Prevention of Dehydration policy, revised October 2017, was received from the director of nursing (DON) on 10/8/24 at 3:44 p.m. It documented in pertinent part,"Physician orders to limit fluids will take priority over calculated fluid needs."The dietitian and nursing staff will educate the resident and family regarding hydration and preventing dehydration."Nursing will monitor and document fluid intake and the dietitian will be kept informed of status, the interdisciplinary team (IDT) will update the care plan and document resident responses to interventions until the team agrees that fluid intake and relating factors are resolved."The Hydration-Clinical Protocol policy, revised September 2017, was received from the DON on 10/8/24 at 3:44 p.m. It documented in pertinent part, "Staff, with physician's input, will identify and report to the physician individuals with signs and symptoms or lab (laboratory) test results that might reflect existing fluid and electrolyte imbalance."The Comprehensive Person-Centered Care Plan policy, revised March 2022, was received from the DON on 10/8/24 at 3:44 p.m. It documented in pertinent part,"If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process."The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided for the above but are not provided due to the resident exercising his of her rights, including the right to refuse treatment."Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making."Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change."The resident has the rightto refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies."III. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on 5/15/24 and discharged to the hospital on 8/14/24. According to the August 2024 computerized physician order (CPO), diagnoses included stage 4 chronic kidney disease, chronic respiratory failure and epileptic seizures. The 8/14/24 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The assessment documented the resident was a poor decision-maker and required cueing and supervision. The resident required moderate assistance with toileting and bathing and was independent with eating. The assessment documented the resident did not have a swallowing disorder and was receiving a therapeutic diet. The assessment documented the resident had no rejections of care. B. Resident representative interviewResident #9's legal representative was interviewed on 10/8/24 at 11:13 a.m. The representative said Resident #9 could not make decisions for herself and she had been her legally-appointed guardian for several years. The representative said she usually visited Resident #9 weekly. The representative said she became sick in late July 2024 to early August 2024 and did not visit Resident #9 for about two weeks. The representative said when she returned to visit after recovering from her illness, Resident #9's feet and legs had become so swollen with fluid that the skin was red and taut on both legs, up to the level of the hip. The resident's representative said she had asked Resident #9's physician for a 2,000 ml fluid restriction per day in April 2024 or May 2024 because it was recommended by Resident #9's kidney doctor. She said she was surprised when the physician ordered a 3,000 ml fluid restriction because that did not seem like a fluid restriction to her. The representative said the fluid restriction was later reduced to 2,500 ml. The representative said she felt the facility gave Resident #9 too much water when the resident requested it. The resident's representative said she was not aware of any interventions the facility had in place to help Resident #9 adhere to her fluid restrictions. The representative said she could not recall if she or Resident #9 were given education regarding techniques to help Resident #9 adhere to her fluid restrictions. The resident's representative said when Resident #9 was hospitalized on 8/14/24, she was told by the emergency room physicians that Resident #9 was given too much water at the facility which caused fluid to build up in Resident #9's lungs and required significant medication and oxygen, for more than two weeks in the hospital, to improve. C. Record reviewResident #9's kidney disease plan of care was initiated on 7/2/24 and revised on 8/22/24. The plan of care documented a goal for Resident #9 to have no signs or symptoms of complications related to fluid overload. Interventions included elevating the resident's feet when she was sitting in a chair, monitoring vital signs as ordered, monitoring changes in the resident's mental status and obtaining weights as ordered. Review of Resident #9's weights documented in the electronic medical record (EMR) revealed the following:-On 5/15/24, the resident weighed 241.4 pounds (lbs);-On 5/17/24, the resident weighed 240.8 lbs;-On 5/18/24, the resident weighed 240.4 lbs;-On 5/29/24, the resident weighed 243 lbs;-On 6/7/24, the resident weighed 257.8 lbs; -On 7/3/24, the resident weighed 261.8 lbs; and,-On 8/6/24, the resident weighed 275.4 lbs. The resident gained 35 lbs from 5/18/24 to 8/6/24, a period of three months.-Despite Resident #9's continued weight gain, there was no documentation to indicate the resident's physician was notified or that the facility put interventions in place to more closely monitor the resident and identify the cause of the resident's significant weight gain after 6/7/24. Review of Resident #9's August 2024 CPO revealed the following physician orders:Consistent Carbohydrate (CCHO) diet with regular texture and thin liquids. No soda or dark colored colas. 2500 ml fluid restriction, ordered on 5/28/24.3,000 ml fluid restriction every shift for nutrition, ordered on 5/16/24 and discontinued on 6/6/24.-The physician's order indicated the resident's fluid restrictions were per shift instead of per day. 2,500 ml fluid restriction every shift for nutrition, ordered on 6/6/24.-The physician's order indicated the resident's fluid restrictions were per shift instead of per day. Resident #9's medication administration record (MAR) fluid intakes were reviewed from 6/6/24 to 8/14/24. The 69 days of 2,500 ml fluid intake/restriction documentation revealed the following:-The resident received more than 2,500 ml of fluid in a 24-hour period of time on nine of those days; -The resident received more than 3,000 ml of fluid in a 24-hour period on seven of those days; and, -The resident received more than 4,000 ml of fluid in a 24-hour period on two of those days. A skilled evaluation nursing note dated 6/25/24 documented Resident #9 was compliant with her fluid restrictions. A skilled evaluation nursing note dated 8/6/24 documented Resident #9 was compliant with her fluid restrictions.-However, according to review of Resident #9's fluid intake documentation on the MARs, the resident had more fluids than was physician ordered on several days (see above). Hospital documentation for Resident #9's hospital stay indicated Resident #9 was admitted for shortness of breath on 8/14/24 and was discharged from the hospital on 9/3/24. An emergency department physician note dated 8/14/24 documented Resident #9's fluid retention was caused by poor fluid intake management of the facility. A hospital physician note dated 8/15/24 documented Resident #9 required 5 liters per minute (LPM) of oxygen to maintain oxygen saturations, which was an increase from her baseline oxygen setting of 1.5 LPM. The note documented Resident #9 was placed on a fluid restriction of 2,000 ml per day in the hospital. The note documented Resident #9 was being admitted to the hospital for heart failure caused by increased fluid intake. The note documented Resident #9 had an ejection fraction of 55% on her echocardiogram performed on 2/18/2020, but it had now worsened to a 40% ejection fraction on the echocardiogram performed 8/15/24. The note documented Resident #9's left ventricle systolic performance was less vigorous and the posterior wall of the heart appeared hypokinetic (less activity). IV. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 8/3/23. According to the October 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes with long term use of insulin, gastroesophageal reflux disease (GERD) and diabetic retinopathy of the eye (damage to the eye from high blood sugar levels). The 8/16/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required setup or clean-up assistance with eating. The assessment documented the resident did not have a swallowing disorder and was receiving a therapeutic diet. The assessment documented the resident had no rejections of care. B. Resident observation and interviewResident #3 was observed in her room on 10/8/24 at 10:22 a.m. On the resident's nightstand was a full size box of cinnamon toast crunch, two boxes of chocolate teddy grahams, two apples and a banana. The resident was eating a separate individual container of cinnamon toast crunch with whole milk and drinking a 7-up soda. Resident #3 said she had been diabetic since 1996. Resident #3 said she did not plan to adhere to her diabetic diet because she never had. She said she knew she was on a consistent carbohydrate (CCHO) diet, but she did not agree with many parts of that diet. Resident #3 said she would not allow anyone to take away her favorite foods or soda for any reason. She said she had four full size candy bars inside her nightstand as well so she could snack whenever she wanted to. Resident #3 said the facility provided her with the individually wrapped cinnamon toast crunch and whole milk for breakfast, but not the 7-up soda she consumed or the other food items on her nightstand. Resident #3 said she had not received education from a dietician or a nurse regarding adherence to her CCHO diet. She said she was not aware she was always supposed to adhere to her CCHO diet. C. Record reviewReview of Resident #3's medical diagnoses plan of care, initiated 6/19/24, documented the resident was on a regular CCHO diet. Interventions included providing and serving Resident #3's CCHO diet as ordered. The type 2 diabetes plan of care was initiated on 9/26/24. Interventions included a dietary consult for nutritional regimen and ongoing monitoring, providing the resident with diabetes education, encouraging the resident to comply with dietary restrictions, monitor compliance with diet and documenting any problems and monitoring and documenting the resident's current level of understanding of the disease process and treatment regimen.-The care plan did not document Resident #3 frequently refused to comply with her recommended diabetic diet.-Despite the care plan documenting the resident was to be provided with education related to her diabetic diet and compliance with the diet, there was no documentation in the resident's EMR to indicate education had been provided to the resident. The GERD plan of care was initiated on 9/26/24. Interventions included avoiding overeating, encouraging a bland diet and avoiding foods and beverages that irritated the esophageal lining, such as alcohol, chocolate, caffeine, acidic or spicy foods and fried or fatty foods. Review of Resident #3's October 2024 CPO revealed a physician's order for a consistent carbohydrate diet, ordered on 8/3/23. An IDT note dated 5/8/24 documented Resident #3 was on a CCHO diet and had variable intakes and refusals.-However, there was no documentation in the resident's EMR regarding the resident's refusals of her recommended diet. A care conference note dated 8/20/24 documented the resident was an insulin dependent diabetic. The care conference documented nursing was managing Resident #3's diabetes and blood sugars. -The care conference note did not indicate the resident's CCHO dietary recommendations were discussed. A performance improvement plan (PIP), dated 8/15/24, was received from the DON on 10/8/24 at 3:19 p.m. The PIP documented the facility's IDT committee would complete an audit of current residents in the facility who may have fluid restrictions and/or dietary recommendations in order to identify those residents who choose not to follow dietary recommendations. It documented the IDT team would complete education with identified residents to inform them of specific risks associated with not following recommendations and update resident care plans if needed. -However, Resident #3's care plan had not been updated to include her refusals to follow her recommended diet and there was no documentation in the resident's EMR to indicate she had been educated about the specific risks associated with not following her dietary recommendations (see above). V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 10/8/24 at 1:28 p.m. CNA #1 said if something had been ordered per shift, it meant it was done twice per day. CNA #1 said Resident #3 only occasionally adhered to her diet order. CNA #1 said Resident #3's family had brought her food items that were typically not given to residents on a CCHO diet. CNA #1 said she did not know if diet education had been provided to Resident #3 or her family. Licensed practical nurse (LPN) # 2 was interviewed on 10/8/24 at 1:32 p.m. LPN #2 said if a resident was non-adherent to their diet order, it would be communicated to the physician and the dietitian and documented in progress notes. LPN #2 said refusals of dietary recommendations would normally be documented in progress notes and discussed with the dietitian. LPN #2 said if something was ordered each shift it could mean either two or three times per day, depending on how many staff shifts the facility had. Registered nurse (RN) #2 was interviewed on 10/8/24 at 1:37 p.m. RN #2 said if a resident did not want to adhere to their diet, the nursing staff would try and educate the resident of the importance of diet adherence. RN #2 said nursing staff would try to involve the dietitian in this process. RN #2 said she was unfamiliar with the process of changing a resident's diet order and would need to ask her peers for assistance in that process. LPN #1 was interviewed on 10/8/24 at 1:44 p.m. LPN #1 said when a resident refused to follow the physician-prescribed diet order, the physician would be notified. LPN #1 said the physician notification should be documented in the progress notes. LPN #1 said nursing staff provided residents with education about the importance of adhering to the physician-prescribed diet and that education should be documented in the progress notes section of the resident's EMR.The registered dietitian (RD) was interviewed on 10/8/24 at 2:28 p.m. The RD said she was present in the facility one day per week on Wednesdays. The RD said it was important that residents with diabetes on a CCHO diet received appropriate servings with meals to ensure resident blood sugars were not erratic. The RD said the facility did not count carbohydrates for diabetic residents on a CCHO diet, but rather, the facility would simply halve the portion of the dessert option. The RD said if the dessert option was cake, the diabetic resident on a CCHO diet would receive a half of a piece of that cake instead of a whole piece. The RD said anyone present in the resident's vicinity while eating was responsible for ensuring the resident was adherent to the physician-prescribed diet order. The RD said nurses could provide education to residents on the importance of diet adherence. The RD said if she were notified, she could provide education to the residents on the importance of diet adherence for diabetes management as well. The RD said if a resident was not interested in diet adherence, she would communicate the resident's preference to the nursing management team. The RD said she would discuss the resident's preference with the physician and the resident's family to identify additional interventions to assist with diet adherence. The RD said the care plan should be updated to reflect the current plan of care. The RD said she had not been informed of any concerns with diet adherence for Resident #3. The RD said she was not aware the resident was eating food items in her room that were not on her recommended diet. The RD said if Resident #3 was consistently making the choice to eat cereal and soda for breakfast then she would need to provide education to the resident and her family regarding the importance of diet adherence. The RD said physician's orders should always be followed. The RD said if something were to be ordered per shift, it could mean very different things, depending on the facility. The RD said it could mean every six hours, every eight hours, or every 12 hours. The RD said she was typically more familiar with seeing a fluid restriction ordered per day rather than per shift. The RD said that the 2,500 ml fluid restriction ordered per shift for Resident #9 did not seem to be an appropriate order and should have been clarified. The RD said a 2,500 ml fluid restriction per shift, even for two shifts a day, would equal 5,000 ml of fluid intake per day, which she did not consider to be a fluid restriction. The RD said she was not aware of how Resident #9's fluid restriction order had been written. The DON was interviewed on 10/8/24 at 2:59 p.m. The DON said if a resident did not want to follow a physician-ordered diet, he would expect nursing staff to educate the resident on the importance of adhering to the diet. The DON said if the education was not effective, he would expect nursing staff to inform the IDT team or the registered dietitian. The DON said nursing administration would then discuss the situation on the next day, identify root causes and perform a dietary assessment of risks and benefits to diet adherence. The DON said he was not aware Resident #3 was non-adherent to her diet. The DON said there were two shifts at the facility. The DON said fluid restrictions varied based on the physician's order. The DON reviewed Resident #9's physician orders. The DON said a 2,500 ml fluid restriction per shift did not seem correct. The DON said his staff should know that a 2,500 ml fluid restriction order always means per day and not per shift. -An attempt to interview Resident #9's physician on 10/8/24, during the survey, was unsuccessful.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to:-Ensure safe and appropriate storage of food items in the refrigerators and pantry; and,-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination. Findings include:I. Failure to store food items appropriately in the refrigerators and the dry storage area A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/16/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices and sugar shall be identified with the common name of the food."In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit."Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (f)) or less for a maximum of seven days. The day of preparation shall be counted as day one."According to the United States Department of Agriculture (USDA) Is Food In Dented Cans Dangerous? (9/18/24) retrieved on 10/16/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous, food from cans that were leaking, bulging, or badly dented should never be eaten. The damaged cans could contain clostridium botulinum (a toxic bacteria). According to the USDA How You Should Handle Food With Mold On It (9/18/24) retrieved on 10/16/24 from https://ask.usda.gov/s/article/How-should-you-handle-food-with-mold-on-it, It documented in pertinent part, "Buying small amounts and using food quickly can help prevent mold growth. But when you see moldy food: Don't sniff the moldy item. This can cause respiratory trouble. If food is covered with mold, discard it. Put it into a small paper bag or wrap it in plastic and dispose of it in a covered trash can that children and animals can't get into. Clean the refrigerator or pantry at the spot where the food was stored. Check nearby items the moldy food might have touched. Mold spreads quickly in fruits and vegetables."B. Facility policy and procedureThe Food Receiving and Storage policy, revised November 2022, was provided by the dietary manager (DM) on 10/8/24 at 1:58 p.m. The policy read in pertinent part, "Foods shall be received and stored in a manner that complies with food handling practices. "When food is delivered to the facility it is inspected for safe transport and quality before being accepted."Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready for use. "Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen or discarded."The hand hygiene policy, revised November 2022, was provided by the dietary manager (DM) on 10/8/24 at 1:59 p.m. The policy read in pertinent part, "This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. C. ObservationsOn 10/8/24 at 9:35 a.m. a can of corn was stocked on the first row of the can goods rack in the dry storage room of the kitchen. The can of corn had a large and deep dent on the side of the can. At 9:40 a.m. the following items were observed in the kitchen's walk-in refrigerator:-Multiple containers of undated strawberries were sitting on a shelf. Four of the containers had moldy strawberries in them; -There were pre-bowled berries in a pan covered with parchment paper. The bowls of berries contained strawberries, blueberries and blackberries. The bowls were not labeled or dated; -A plastic lidded tub of lettuce that was not labeled or dated; and,-A plastic tub of white cheese covered in aluminum foil was not labeled or dated. At 11:52 a.m. the moldy containers of strawberries remained on the shelf in the walk-in refrigerator. The cheese and lettuce tubs remained undated. -During the lunch meal service, beginning at 11:50 a.m. and ending at 1:10 p.m., seven bowls of the undated pre-bowled berries were served. At 12:45 p.m. The DM entered the walk-in refrigerator and removed the moldy strawberry containers. II. Failure to ensure ready-to-eat foods were handled in a sanitary mannerA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/16/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment."If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation."The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings (2/27/24), retrieved on 10/16/24 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, read in pertinent part, "Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients." According to the CDC, hand washing should occur before preparing or eating food, before touching the eyes, nose or mouth, and after touching potential contaminated surfaces. B. ObservationsDuring a continuous observation of the lunch meal service in the kitchen on 10/8/24, beginning at 11:50 a.m and ending at 1:10 p.m., the following was observed: Cook (CK) #1 was observed plating ready-to-eat food for the lunch meal service. At 12:02 p.m. CK #1 touched the side of her head with her left hand and then continued to plate resident meals. -CK #1 did not not perform hand hygiene after touching her head. At 12:35 p.m. CK #2 placed a glove on one hand. -CK #2 did not perform hand hygiene before donning the glove. CK #2 picked up a stack of meal tickets, flipped through the tickets with the gloved hand and separated the tickets in two piles.-CK #2 did not remove the glove or perform hand hygiene after handling the meal tickets. CK #2 placed four premade hamburger patties on to a skillet with the same gloved hand he had used to handle the meal tickets. III. Staff interviewsThe DM was interviewed on 10/8/24 at 12:12 p.m. The DM said all cans of food should be checked for any dents and/or missing labels. She said all the cans should be checked for dents when delivered and stocked. She said damaged cans should be removed from the supply for use and set aside to return to the delivery driver on the next shipment. The DM said a can with a dent could have a small hole in it. She said a hole could allow air to get into the can and cause contamination. She said dents in canned food posed a risk of foodborne illnesses, such as botulism. The DM said all dented cans should be removed because staff would not know if there were small puncture holes that they could not see in the can or if the food inside had gone bad. The DM observed the dented can of corn on the can supply rack. She said the can should not have been placed on the rack with other cans ready for use. She said she would remove the can from the supply and set it in the delivery pick up pile from return. CK #1 was interviewed on 10/8/24 at 12:20 p.m. CK #1 said she prepped the strawberries, blueberries and blackberries for the lunch meal after the new shipment of strawberries arrived. She said she only used the new stock of strawberries that were delivered on the morning of 10/8/24.-However, the parchment paper covering the prepared bowls of berries was not dated to indicate when the berries should be discarded and mold was observed on the strawberries in the remaining containers in the refrigerator (see observation above). CK #2 was interviewed on 10/8/24 at 12:20 p.m. CK #2 said most of the produce that arrived at the facility arrived fresh. He said if he saw mold on any of the produce, he would throw it away. CK #2 said the kitchen staff did not have a routine schedule to check the produce in the refrigerator. He said the kitchen went through so much produce and the ongoing use created a quick turnover which decreased the need for scheduled checks. He said the produce supply was used faster than it went bad. CK #2 said dented cans could be used if they had a dent on them. He said he would not use the cans of food if the seal of the can was broken, if it was visibly open to air, and/or if there was liquid running out of it. The DM was interviewed a second time on 10/8/24 at 12:45 p.m. as she removed the moldy strawberries from the shelf in the walk-in refrigerator (see observation above). The DM said she found four and a half containers of moldy strawberries in the refrigerator. She said one of the strawberry containers had been opened and used. The DM could not identify when the opened pack of strawberries was last used. She said she needed to remove the moldy strawberries because of the risk of mold spreading to the rest of the produce. She said mold grew quickly on strawberries and if one strawberry had mold on it, the mold would quickly spread onto the other strawberries. The DM said all produce in the refrigerator should be labeled and dated. The DM was informed of the undated and labeled tub of cheese covered with an aluminum foil and a covered tub of lettuce. The DM said the cheese and the lettuce should have been dated and labeled. She said the cheese should have been covered with a fitted lid so there was no risk for air entering the cheese. She said a fitted lid for the tub should have been used instead of the aluminum foil. The DM said staff should have been checking the produce daily to make sure there was no mold on the produce and everything was labeled and dated. She said checking the produce daily was an expectation but she did not have it as a set task or a log to sign off that the task had been completed. The DM said she would re-educate staff and create a log to sign off on to ensure the kitchen staff checked all produce in the refrigerator for freshness and made sure all refrigerated items were labeled and dated. Registered nurse (RN) #1 was interviewed on 10/8/24 at 2:26 p.m. RN #1 said she was the facility's infection preventionist. She said all staff received hand hygiene training during the new hire orientation and during the July 2024 skills fair. RN #1 said she did hand hygiene audits throughout the facility to include the kitchen staff. She said she conducted the audit monthly to ensure staff was following safe infection control practices and provide additional training as needed. RN #1 said she reminded the kitchen staff to perform hand hygiene before food preparation and every time they touched a potentially contaminated surface. The registered dietitian (RD) was interviewed on 10/8/24 at 2:31 p.m. The RD said she conducted routine oversight of the kitchen. The RD said, during kitchen walk-throughs, she would make sure the kitchen was clean and in good repair, staff was practicing good hand hygiene and using gloves appropriately. She said she would also make sure food items were labeled and dated. The RD said dented cans should be removed and set aside and not used because of the risk of botulism. She said had not been involved in educating the dietary staff on food borne illnesses. The RD said all produce with mold on it should be removed from the supply stock because of the risk of the mold spreading. The DM was interviewed a third time on 10/8/24 at 2:58 p.m. The DM said she reviewed and re-educated the dietary staff on hand washing, appropriate glove use and making sure the stored food for resident use was routinely inspected for safe consumption and removed from the stock when problems were identified.

A complaint survey, prompted by #CO36058, Incident #36196 and Incident #35644 was conducted on 6/24/24 and 6/25/24. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/05/2024 and 02/11/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/29/2024 and 02/04/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 1/17/24 and 1/19/24 for all previous deficiencies cited on 11/16/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/17/24 and 1/19/24 for all previous deficiencies cited on 11/16/23. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/25/2023 and 12/31/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/18/2023 and 12/24/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/11/2023 and 12/17/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). Initial comments, (ID Prefix Tag # K 000), are informational only, representing the facility's general characteristics. This facility is a one-story Type V (111) structure, without a basement. The facility is fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The facility's fire sprinkler system is a wet system with three anti-freeze loops, each containing a propylene glycol solution. The Maintenance Director was previously provided a copy of the August 2010 National Fire Protection Association (NFPA) Safety Alert regarding anti-freeze in residential fire sprinkler systems. At the time of the survey, this facility was licensed for 96 beds and operates a 17-bed wing as a secured unit. The resident census on the day of the survey was 88. The survey, conducted December 13, 2023, inspected for compliance to fire safety requirements of NFPA 101, Life Safety Code (LSC), 2012 edition, Chapter 19 for Existing Health Care Occupancies; NFPA 99, Health Care Facilities Code, 2012 edition; and all referenced standards. The facility will meet these requirements upon completion of a Plan of Correction.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain the egress exit pathway lighting in accordance with NFPA 101, 19.2.8 including 7.8. The following evidenced this:1) Two light bulbs were missing from egress path lighting fixture exiting Blue Spruce. Life Safety Code Section 19.2.8 and 7.8.1.1; 19.2.8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7.8.7.8.1.1 Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within 1 of the smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain the requirements in accordance with NFPA 101, NFPA 72 and NFPA 70. This was evidenced by: 1) Fire alarm FACP had the viewing glass panel cover removed and the entire panel was covered by a facility map. 2) Abandon alarm components were not removed from Transportation/Fax room. NFPA 101 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. NFPA 72 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code. NFPA 70 760.25 Abandoned Cables-The accessible portion of abandoned fire alarm cables shall be removed. Where cables are identified for future use with a tag, the tag shall be of sufficient durability to withstand the environment involved. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one of the smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain and meet the protection requirements in accordance with NFPA 101 and NFPA 10. This was evidenced by: 1) K-class fire extinguisher in kitchen has the top of the extinguisher exceeding 5 ft from the floor. NFPA 101 Life Safety Code 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors in all of the smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain and meet the protection requirements in accordance with NFPA 101 Life Safety Code Section 19.3.6.2.4. This deficient practice could affect all residents in the smoke compartment should smoke spread between use areas and the egress corridor due to the absence of ceiling tiles to limit the transfer of smoke. This was evidenced by the following:1) Ceiling tile missing in the corridor outside Soiled Oxygen. 2) Ceiling tile missing in the business office. Life Safety Code Section 19.3.6.2.4: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors in two of the smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain doors that protect corridor openings in accordance with NFPA 101, section 19.3.6.3. The following evidenced this: 1) Resident room corridor door #223 does not positively latch into the frame. Life Safety Code Section 19.3.6.3.1, in part, requires doors protecting openings in a corridor to be constructed to resist the passage of smoke. Section 19.3.6.3.5, in part, doors shall be provided with means for keeping the doors closed, the device shall be capable of keeping the door closed when 5 lb is applied to the latch side of the door. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors in one smoke compartment. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain doors that protect corridor openings in accordance with NFPA 101. This was evidenced by: 1) Columbine storage room has unprotected wall penetrations. 2) Attic access panel open in riser room off of kitchen. (CDS) (CDS) = CORRECTED DURING SURVEYLife Safety Code Section 19.3.7.3 to comply with section 8.5. Section 8.5.6.2, in part, penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors in two smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain the building services for gas equipment in accordance with NFPA 101, 19.5, 19.5.1.1, 9.1.1, including NFPA 54, National Fuel Gas Code. The following evidenced this:1) Main laundry room has two (2) Type 2 dryers rated at an elevation between 0-2000 ft., verified by reviewing manufactures rating label on the back of each unit. NFPA 54, section 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft. (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft. (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction(3) In accordance with the manufacturer's installation instructions2) Gas fired appliances in kitchen with casters had no restraints9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions. 3) One of two dryers had excessive lint build-up on the back and top of unit. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors in one of the smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on observation during the course of the survey conducted on December 13, 2023, it was determined the facility failed to maintain proper electrical practices in accordance with Life Safety Code Section 19.5.1.1 and NFPA 70. This was evidenced by the following:1) Clearance around outlet had a gap greater than 1/8"NFPA 70 2011 section 314.21 Repairing Noncombustible Surfaces. Noncombustible surfaces that are broken or incomplete around boxes employing a flush-type cover or faceplate shall be repaired so there will be no gaps or open spaces greater than 3 mm (1/8 in.) at the edge of the box. 2) The facility is utilizing multiple power-strips as a substitute for fixed wiring to supply power to a refrigerators and appliances with heating elements that should plug directly to the wall outlet. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors in all of the smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on December 13, 2023.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/04/2023 and 12/10/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/13/2023 and 11/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A licensure survey was completed on 11/13/23 to 11/16/23. One deficiency was cited.

Based on observations, record review, and interviews the facility failed to ensure one resident (#83) of five sample residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable, and to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the facility failed to ensure timely interventions were put in place to prevent the development of pressure injuries to Resident #83's heels which resulted in two unstageable pressure injuries. Resident #83 was admitted to the facility after a fall resulting in her impaired mobility. The resident was at risk for pressure injuries and had a current pressure injury to her sacrum on admission. The resident developed a stage II pressure injury to her right heel and a deep tissue pressure injury to her left heel in less than a week after her admission. The pressure injuries were not identified as unavoidable. Both pressure injuries were identified as healable. The stage II pressure injury to the right heel and the deep tissue pressure injury to the resident's left heel worsened to unstageable pressure injuries a month later. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 11/29/23, "Pressure ulcer classification is as follows: "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate ' at risk ' individuals (a heralding sign of risk). "Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. "Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable "Unstageable: Depth UnknownFull thickness tissue loss inwhich the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and proceduresThe Prevention of Pressure Injuries policy, revised April 2020, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. The policy read in part: "The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the residents care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. "Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes of condition. Use a standardized pressure injury screening tool to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors. "Conduct a comprehensive assessment upon or soon after admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. "During a skin assessment, inspect the presence of erythema, temperature of the skin and soft tissue and edema. "Inspect the skin on a daily basis when performing or assisting with personal care ADLs (activities of daily living). Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, and ischium, trochanter)."Use facility-approved protective dressings for at risk individuals."III. Resident #83 status Resident #83, age greater than 90, was admitted on 9/18/23 and readmitted on 10/26/23. According to the November 2023 computerized physician orders (CPO), diagnoses included multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified abnormalities of gait and mobility, weakness, other reduced mobility, muscle weakness, other lack of coordination, osteoarthritis, chronic kidney disease and need for assistance with personal care. A comprehensive assessment completed on 10/23/23 revealed the resident had moderate cognitive impairment. The resident had one or more unhealed pressure ulcers, including two stage II pressure ulcers, one of which was facility acquired and an unstageable pressure injury. A comprehensive assessment completed on 9/25/23 revealed the resident required substantial to maximal assistance for bed mobility and transfers. IV. Record reviewThe 9/18/23 admission data collection with care plan assessment identified Resident #83 had a stage II pressure ulcer to her sacrum on admission. The admission assessment indicated the resident did not have pressure ulcers/deep tissue injuries or any skin issues to the heels of her feet on admission to the facility. The 9/25/23 Braden scale for predicting pressure sore risk identified Resident #83 was at risk for developing pressure sores. According to the Braden scale, the resident sensory perception was slightly limited. She responded to verbal commands but could not always communicate discomfort or the need to be turned or had some sensory impairment which limits ability to feel pain or discomfort in one or two extremities. Her skin was occasionally moist requiring extra linen changes. Her ability to change and control body position was very limited. The resident was able to make occasional slight changes in her body or extremity position but unable to make frequent or significant changes independently. Resident #83 had a friction and sheer potential problem. The resident had the probability that during a move the resident's skin slid down to some extent against sheets, chairs or other devices. The pressure skin care plan, initiated on 9/19/23, read Resident #83 had an actual impairment to her skin integrity. The care plan goal was for the resident to be free from skin breakdown. Interventions included staff to identify and document potential causative factors and eliminate/resolve where possible. The pressure injury care plan, initiated on 9/29/23, read Resident #83 had a stage II pressure ulcer to her sacrum and right heel and a deep tissue injury to her left heel related to a history of ulcers and impaired mobility due to pelvic fractures. The stage II pressure ulcer to the sacrum resolved on 10/5/23. Interventions initiated on 9/29/23 included to avoid positioning the resident's heels flat on the bed and laying flat on her heels for an extended period of time. A letter from the registered nurse (RN) #2 was provided by the nursing home administrator (NHA) via email on 11/20/23. According to the letter, RN #2 covered the wound rounds the week of 9/17/23 to 9/23/23. The letter read the resident had interventions put in place on the day of her admission (9/18/23) related to stage II pressure injury (sacrum), comorbidities and pressure injury risk. The interventions were identified as turning and repositioning every two hours, air mattress, the registered dietitian to evaluate nutritional needs, protect bony prominences, elevate legs to minimize swelling, pressure relieving cushion to her wheelchair and physical and occupational therapy to increase functional mobility. -The letter did not identify specific interventions to prevent the development of pressure injuries to her heels. A. Right heel unstageable pressure injuryThe pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a stage II pressure injury to her right heel. A foam heel protector and heel protective boots were put in place. The 9/25/23 CPO directed staff to float heels at all times while the resident was in bed using a wedge or boots as tolerated. The 9/25/23 CPO directed staff to provide daily wound review to her right heel. The 9/27/23 wound care physician assistant (PA) progress note read Resident #84 developed two new pressure wounds on her heels on 9/27/23 (9/24/23). According to the progress note, the initial wound encounter measurement of the resident's right heel stage II pressure injury was 5 centimeters (cm) in length by 5 cm in width with a serum filled blister. The PA recommended the staff to implement pressure relieving measures and offloading as tolerated to include a speciality device of a heel protector. The 9/27/23 skin and wound assessment read Resident #83 had a new stage II pressure injury/ulcer to her right heel. The pressure injury was facility acquired on 9/24/23. The stage II pressure injury to her right heel measured 3.9 cm in length by 2 cm in width. According to the assessment, the stage II pressure injury was healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program. The assessment read Resident #83 was admitted to the facility due to a fall with left pubic fracture with a history of pressure ulcers. Her mobility was impaired and the resident required assistance with repositioning/loading heels. The resident was noted to have a stage II pressure injury presenting as a serum filled blister. Staff continue to offload heels. No dressing would be applied until the blister ruptured. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/11/23 skin and wound assessment identified Resident #83's stage II pressure injury/ulcer to her right heel measured 2.4 cm in length by 2 cm in width. The assessment read Resident #83's blister to the right heel ruptured and there was 60% eschar (necrotic) tissue present. The wound physician assistant (PA) assessed and diagnosed the wound as an unstageable pressure ulcer. New orders were placed for Santyl ointment applied daily to break down eschar tissue. The 10/18/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had improved as evidenced by most of the eschar had broken down to slough (thick, yellow nonviable tissue). The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the right heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the wound to the right heel was a stage II pressure injury with slough on the wound bed, thin, watery, pale, red/pink drainage with moderate dressing saturation of 26-75%. There was partial thickness skin loss with exposed dermis. The skin tissue was boggy (mushy to the touch) and the resident had episodic pain. -However, the stage II pressure injury was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's right heel was not reviewed daily as ordered (refer to the 9/25/23 CPO above). The 11/1/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had 40% of wound filled eschar. The resident returned from the hospital with new orders for Triad cream and a foam dressing applied three times a week and as needed. The 11/7/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury was showing improvement. According to the assessment, the resident continued with heel protective boots to float heels while in bed. Her legs were elevated when the resident was in her chair to aid with pressure reduction and fluid. B. Left heel unstageable pressure injuryThe pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a deep tissue injury to her left heel. The resident was treated with betadine qd (daily) and heel protective boots were put in place. The 9/27/23 wound care physician assistant (PA) progress note described the left heel deep tissue pressure injury as a persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer measuring 2 cm by 1.7 cm. The PA recommended applying betadine and floating heels. The 9/27/23 skin and wound assessment read Resident #83 had a new dark purple discoloration to the left heel consistent with a deep tissue injury (DTI) from pressure which was facility acquired on 9/24/23. The left heel DTI measured 2.1 cm in length by 1.5 cm in width. The DTI was identified as healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program and a daily treatment of betadine. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/5/23 skin and wound assessment identified Resident #83's DTI had a slight increase in size. The DTI measured 2.5 cm in length by 2.1 cm in width. The pressurewound log for the week of 10/8/23 and 10/14/23 for Resident #83's left heel DTI identified the resident was COVID-19 positive and required more frequent repositioning. The 10/11/23 skin and wound assessment identified the resident's left heel DTI had an intact blister. The 10/11/23 CPO directed staff to provide daily wound review to her left heel. The 10/18/23 skin and wound assessment identified Resident #83's DTI measured 2.7 cm in length by 1.8 cm in width. The 10/23/23 health status note read Resident #83 was sent to the hospital. The 10/26/23 evaluation summary note read the resident had pressure ulcers to her bilateral heels. The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the left heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the left heel was a DTI with episodic pain and minimal saturation. According to the skilled evaluations a pressure ulcer staging was not applicable.-However, the DTI was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's left heel was not reviewed daily as ordered (refer to the 10/11/23 CPO above). The 10/27/23 CPO directed staff to apply a thick layer of Triad Hydrophilic barrier cream to the resident's bilateral heels and cover with foam dressing three times a week and as needed. The 11/1/23 skin and wound assessment identified Resident #83's the facility acquired DTI was now an unstageable pressure injury/ulcer to her left heel. She had 60% wound filled eschar. The 11/7/23 skin and wound assessment read the wound was improving with no eschar present. V. Staff interviewThe assistant director of nursing (ADON) was interviewed on 11/15/23 at 1:21 p.m. The ADON identified she was the facility wound nurse. The ADON said Resident #83 was admitted on 9/19/23. The resident was admitted with stage II pressure ulcer to her sacrum. The ADON said she was on leave at the time of the resident's admission. She said staff initiated interventions related to the sacrum pressure ulcer but preventive measures directly to prevent pressure ulcers to the resident's heels were not in place. The ADON said the resident was at risk for pressure injuries to her heels because of her history of pressure ulcers, her impaired mobility after a recent fall prior to her admission and her need for more assistance. She said she would have added heel protective boots to protect the heels on admission and a wedge to lift the heels off of the surface of the bed. She said proper interventions were not put in place to prevent the development of pressure injuries to the resident's heels. The ADON said the weekend nurse identified the right heel stage II pressure injury and the left heel DTI on 9/24/23. The ADON said the resident's heels were off loaded starting on 9/25/23. The ADON said both wounds had decreased in size but currently both of the heels had unstageable pressure injuries.

A recertification survey was conducted from 11/13/23 to 11/16/23. Sixteen deficiencies were cited.

An Emergency Preparedness survey was conducted from 11/13/23 to 11/16/23. No deficiencies were cited.

Based on resident and staff interviews and record review the facility failed to address and/or act promptly upon the grievances and recommendations of resident council and individual resident concerns on issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to:-Ensure timely interventions were implemented and sustained in response to resident grievances related to consistent palatable temperatures when food was delivered to the residents; and,-Ensure a grievance for Resident #56 was followed up on and resolved in a timely manner. Findings include:I. Facility policy and proceduresThe Grievances/Complaint Filing policy, revised April 2017, was provided by the regional operational manager (ROM) on 11/16/23 at 9:30 a.m. The policy read in part:"Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. "The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. "Any resident, family member, or appointed resident representative may file grievances or complaints concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances may also be voiced or filed regarding care that has not been furnished."All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including a rationale for the response."Upon the receipt of a grievance and or a complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and or complaint. "The resident, or person filing the grievance and or complaint on the behalf of the resident, will be informed verbally and in writing of the findings of the investigation and the actions will be taken to correct any identified problems."II. Resident council minutesThe October 2023 resident council minutes after the 10/10/23 resident council meeting were provided by the facility on 11/13/23. The residents identified food temperatures for meals were cold, specifically room trays. The October 2023 resident council grievance/concern form for the cold food concern was provided by the activity director (AD) on 11/16/23. The grievance form identified the concern with meal temperature and provided the grievance to the nursing home administrator (NHA) on 10/12/23. The NHA responded to the grievance on 11/6/23. According to the grievance form, a corrective action was identified and changes were made to the dietary manager position. The new dietary manager was to start on 11/15/23. The NHA and the dietary manager would educate dietary staff on the use of the hot plates. The November 2023 resident council minutes were reviewed for concern follow up. -The November 2023 resident council minutes did not identify the October 2023 resident council food temperatures concerns were reviewed in the November 2023 resident council meeting for resident resolution to determine if residents felt there were still concerns pertaining to cold food. -The November 2023 resident council minutes did not identify if the October 2023 resident council action plan to educate the staff on the use of hot plates occurred and was effective. -The November 2023 resident council minutes did not identify if the residents felt the concern was resolved or if it was still a concern to be readdressed. -Interviews with residents both in group and individually identified residents still had concerns regarding the temperatures of the food. III. Resident interviews and observationsOn 11/13/23 at 12:20 p.m. the director of nursing (DON) handed out resident meal trays and asked CNA #3 to warm up Resident #18's soup because it was cold. The DON asked CNA #3 how long she warmed up the soup for and the CNA said until it bubbled. Resident #18 was interviewed on 11/13/23 at 2:46 p.m. She said the food was served late, cold, and it was ridiculous. Resident #71 was interviewed on 11/13/23 at 10:45 a.m. Resident #71 said he mainly ate in the dining room. He said lately his meals had been cold. The resident said the meatloaf served on 11/12/23 was cold. Resident #56 was interviewed on 11/14/23 at 8:53 p.m. Resident #56 said she ate in the dining room mainly, however, her meals were sometimes served cold. Resident #189 was interviewed on 11/14/23 at 9:28 a.m. He said he ate in his room and the food was always cold. During the interview the resident was served his breakfast on a room tray. He tasted his breakfast and said the eggs were warm but the bagel was cold. Resident #189 was observed eating breakfast in his room on 11/15/23 at 8:55 a.m. He said the eggs were warm enough but the toast was cold. The resident attempted to butter the toast but the butter did not spread and dug deep into the bread. The resident said he could ask for staff to warm the toast but the other food would be cold as it could take a while for the staff to answer the call light. On 11/15/23 at 1:09 p.m., the tray line was observed. The room trays were served on warm ceramic glazed plates then put onto a hot metal pallet. Cook #1, who was serving the tray line, was observed to take a stack of white plastic dinner plates off the shelf and begin to serve the meal on the plastic plates. -The plastic plates were not warmed prior to placing the resident meals on the plates. The family member of Resident #42 was interviewed on 11/16/23 at 9:33 a.m. She said Resident #42 ate her meals in her room and the food was horrible. She said the food was never warmer than room temperature which affected the taste. IV. Resident group interviewThe resident group interview was conducted on 11/14/23 at 1:40 p.m. with seven residents (#16, #17 #18, #61, #76, #78 and #80). The residents were identified by the facility as interviewable. According to the residents, meal temperatures were still a concern. The residents said the temperature of the food was inconsistent. Some of the food served on the plate was cold when it should have been warm. The residents said the inconsistent temperatures of the food occurred almost daily. The residents said for lunch today (11/14/23) the grilled cheese sandwich was warm but the sweet potatoes were served cold. The residents said they had complained about the food temperatures but had been told by staff there would be a new dietary manager and to "bear with us." The residents said the staff would rewarm the food when asked. V. Staff interviewsThe AD was interviewed on 11/16/23 at 12:04 p.m. The AD said all resident grievances should be followed up on. The AD said concerns from the month prior resident council meeting were reviewed at each resident council for resolution. The AD said if residents brought up new concerns during the monthly meeting she would write up the concern/grievance on a form and submit the concerns to management. The AD said she would make sure to follow up with the appropriate department heads and retrieve the grievance forms with the planned action plan. The AD said during this morning's November 2023 resident council meeting (11/14/23) the resident council did not express a concern with food temperatures. The AD said the NHA spoke to the residents regarding the kitchen and the residents did not have new food complaints related to the temperature. The dietary manager (DM) was interviewed on 11/16/23 at 6:00 p.m. The DM said she had ordered more of the colored ceramic glazed plates. She said the plastic plates were used because the facility did not have enough of the colored ceramic glazed plates. The NHA was interviewed on 11/16/23 at 9:07 p.m. He said the interdisciplinaryteam (IDT) reviewed the kitchen process regarding food concerns. The IDT looked at how the food delivery training and how the service line was working. He said he was trying to get the right people in the right positions. The NHA identified the dietary staff was not trained properly. There was a lack of direction and leadership and meals needed to get the residents quicker. He said the whole dietary system needed to be worked on. The NHA said he knew there were problems in the kitchen and he needed to make a change in kitchen management. He said he hired a new dietary manager this week to help address the needed changes. II. Failure to follow up on grievanceA. Resident statusResident #56, age 83, was admitted on 5/26/23. According to the November 2023 computerized physician orders, diagnoses included dementia without behavioral disturbance, anxiety and abnormalities of gait and mobility. The 6/30/23 minimum data set (MDS) assessment showed the resident had minimal cognitive deficits with a score of 13 out of 15. The resident required limited assistance with activities of daily living. B. Resident interviewResident #56 was interviewed on 11/14/23 at 8:43 a.m. Resident #56 said certified nurse aide (CNA) #6 worked the night shift. She said that she used her call light quite a bit and CNA #6 did not like this. She said the CNA called her a name. She said she asked the CNA #6 to repeat what name she was called, as she had not heard it before but she knew it was derogatory. The CNA responded in a not nice manner that she should know what it meant. The resident said it did not make her feel good that she was called a derogatory name and that she was afraid of CNA #6. She said this occurred three days ago and she had reported it to the assistant director of nurses (ADON). C. Record reviewA complaint grievance form dated 10/17/23 documented, "(name of CNA #6) called me a name I asked her to repeat it. She did but I did not know what it was then she said you don' t know what that means. I know I call a lot for help but I shouldn't be treated like." that. The grievance form dated 10/17/23 failed to show evidence there was a resolution to the grievance and no action plan. The form was not signed by the nursing home administrator. The written notes were as follows:The ADON spoke with the resident and asked her three questions. What word did you hear the CNA #6 say? Resident #56 said no. Was the word in English or Spanish? The resident said English but she did not know what it was. Have you had issues with this CNA before? The resident said, never had a good experience, but never had a negative experience. The director of nurses interviewed the charge nurse, no date on when the interview occurred. Registered nurse (RN) #2 said to her knowledge there were no negative interactions. However, Resident #56 had told RN #2 in the past that she "does not prefer" CNA #6 as her CNA. The DON interviewed CNA #6 in regards to the grievance on 10/17/23. The DON asked CNA #6 if she called Resident #56 any negative or derogatory names "even in jest (joking manner)." CNA #6 denied and said that Resident #56 was a two person transfer. -The progress notes failed to show any evidence that the resident was provided any follow up to the incident or provided support. D. InterviewsThe ADON was interviewed on 11/14/23 at 1:35 p.m. The ADON said she did receive the grievance/complaint from the resident. She said a grievance form was filled out. She said a "little" investigation was completed. She said it was not three days ago, but about a month ago. She said had not heard the resident was afraid of CNA #6. She said that the director of nurses (DON) spoke with CNA #6 and she denied the allegation. The ADON said other residents were not interviewed and not all staff working the shift were interviewed. The social service director (SSD) was interviewed on 11/15/23 at 11:00 a.m. The SSD said that she had been made aware of the grievance form, however, she had not followedup with the resident to report an outcome or to ensure a resolution had occurred and no further issues.

Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#11) of four residents reviewed out of 48 sample residents. Specifically, the facility failed to ensure Resident #11 ' s proxy selected or refused life-saving treatments within the power of a proxy. Findings included:I. Colorado 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 #11, age under 100, was admitted on 6/8/2020. According to the November 2023 computerized physician orders (CPO) diagnoses included dementia, postpolio syndrome (deterioration of nerve cells caused by poliovirus), hearing loss, glaucoma (eye disease), and dysphagia (difficulty swallowing). The 8/23/23 minimum data set (MDS) assessment documented a severe cognitive impairment with a brief interview of mental status (BIMS) score of three out of 15. III. Record reviewResident #11 ' s care plan documented he had a power of attorney (POA) and that the resident was a do-not-resuscitate (DNR).-However, a POA was not documented in Resident #11 ' s chart only a proxy decision maker. Resident #11 ' s proxy was signed on 6/2/2020 by his physician and family member. Resident #11 ' s MOST form was completed and signed on 6/8/2020 by the resident ' s appointed proxy. The MOST form was signed and documented no cardiopulmonary resuscitation (CPR), comfort-focus treatment only, and no artificial nutrition by tube.-However, the back of the MOST form documented that a Proxy decision maker could not refuse artificial nutrition or hydration by tube 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. Record review showed there was no second physician trained in neurology. IV. Staff interviewsThe social services director (SSD) was interviewed on 11/15/23 at 10:30 a.m. The SSD said a proxy was a person who made decisions for residents who did not have a medical durable power of attorney (MDPOA). The SSD said the facility adopted using the MOST form to determine if a resident received CPR or was a DNR. She said the MOST forms were completed by the admitting nurse with the resident and their proxy or MDPOA. Once the MOST form was signed, it was uploaded to the resident ' s electronic medical record. The SSD said the social services department reviewed the MOST forms quarterly and as needed if changes were requested. The SSD said a proxy made decisions for the resident if the resident could not sign or make decisions. She said the social services department asked the resident what their wishes were, even if they were not deemed able to make decisions. She said when the physician determined the resident could not make decisions the doctor entered an order in the resident ' s medical record and tried to inform the resident who their proxy was. The SSD said the nurses should be aware that a proxy could not refuse any nutrition or hydration by tube and that the facility needed to do some training or education with the nurses. She confirmed Resident #11 had a proxy decision maker. She said she believed she knew a proxy could not refuse those treatments at one point but she never noticed Resident #11 ' s MOST form was signed to withhold artificial nutrition and or hydration.

Based on record review and staff interviews, the facility failed to inform resident of the facility's bed hold policy for one (#56) of three residents reviewed for discharge/transfer out of 48 sample residents. Specifically, the facility failed to ensure Resident #56 or the responsible party were informed in writing of the facility's bed hold policy prior to being discharged or transferred from the facility. Findings include:I. Facility policy and procedure The Admission Agreement, dated August 2020, was received on 11/13/23 from the nursing home administrator (NHA). It read in pertinent part, "If a resident will be temporarily absent from the community for hospitalization or therapeutic leave for at least overnight period, an arrangement may be made that the community hold the resident's bed during this time. The applicable state Medicaid program may cover costs related to a bed hold for a certain time period." II. Resident #56A. Resident statusResident #56, age 83, was admitted on 5/26/23. According to the November 2023 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, anxiety and abnormalities of gait and mobility. The 6/30/23 minimum data set (MDS) assessment showed the resident had minimal cognitive deficits with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required limited assistance with activities of daily living. B. Resident interviewResident #56 was interviewed on 11/14/23 at 8:58 a.m. The resident said she was sent to the hospital within the past several months. She said when she did go to the hospital she did not recall receiving a written notice about a bed hold upon transfer, which was described in the admission agreement. B. Record reviewThe 5/23/23 progress note documented the resident was discharged to the hospital. The paramedics transported the resident to the hospital. -The medical record failed to show a written bed hold policy was provided for the discharge to the hospital on 5/23/23. C. InterviewThe director of nurses (DON) and the regional operations manager (ROM) were interviewed on 11/16/23 at 5:41 p.m. The DON said he was unaware of where the bed hold policy was located. The ROM said the residents were to be given a written bed hold policy when they were being discharged. She said the form would be in the electronic medical record. The ROM said she would provide education to the licensed nurses in regards to the bed hold policy.

Based on record review and interviews the facility failed to permit a resident to return to the facility after a leave of absence for one (#86) of three residents reviewed for discharge during hospitalization out of 48 sample residents. Specifically, the facility failed to assess Resident #86's status at the time the resident sought to return to the facility and denied him to return based on his status which led to him going to the hospital. Findings include:I. Facility policyThe Transfer or Discharge Emergency policy, which was undated, was provided by the director of nursing (DON) on 11/16/23 at 6:11 p.m. The policy read in pertinent part,"Resident will not be transferred unless:-The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;-The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;-The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;-The health of individuals in the facility would otherwise be endangered."II. Resident statusResident #86, age 89, was admitted on 9/12/23 and discharged to the hospital on 9/12/23. According to the September 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus without complications, hypertension (high blood pressure), dementia with agitation and depression. The 9/14/23 minimum data set (MDS) assessment did not have a brief interview for mental status (BIMS) completed with the resident. The staff assessment for mental status was completed and documented that Resident #86 had memory problems and was moderately cognitively impaired. The resident had inattention and disorganized thinking that fluctuated (came and went and changed in severity). No behaviors were documented for an altered level of consciousness. III. Medical durable power of attorney (MDPOA) interviewResident #86's MDPOA was interviewed on 11/16/23 at 3:04 p.m. She said the whole situation of the resident's discharge was upsetting. The MDPOA confirmed the resident was not allowed to readmit to the facility. She said she received a call on 9/12/23 at approximately 9:00 p.m. She was told the resident fell and was being sent to the hospital. The MDPOA said she was informed Resident #86 refused his medications before going to the hospital. The MDPOA said she did not get any paperwork from the facility when he was discharged. She said when Resident #86 was stabilized at the hospital, the hospital, hospice provider, and the facility spoke back and forth on the phone. The hospital informed the MDPOA that the facility would not allow the resident to be readmitted to the facility. The MDPOA said there was not a discharge meeting or any communication with the facility after he was discharged on 9/12/23. IV. Record reviewThe progress note dated 9/12/23 at 3:37 p.m. documented the resident had been in his bedroom for two hours and his spouse left approximately one hour before the note was written. A certified nurse aide (CNA) entered the resident's room and checked on him. Resident #86 was attempting to stand unassisted. The CNA approached the resident. The resident became combative, attempted to hit the CNA and did not allow assistance. The resident attempted to grab the female staff member and tried to kiss her. He refused assistance from male staff. The nurse administered Resident #86's scheduled medication successfully and the resident was documented to be self-propelling in his wheelchair to the dining room. A progress note was entered into the resident's chart on 9/12/23 at 5:55 p.m. which documented Resident #86 had an unwitnessed fall in his bedroom. No injuries were noted at the time of the fall. The resident was unable to answer how he fell. The appropriate footwear was in place at the time of the fall and the floor was free of clutter. The resident did not request assistance and the staff placed his call light within reach and gave verbal instructions to use the call light for assistance. Resident #86's MDPOA and the physician were notified of the fall. An interdisciplinary team (IDT) note was entered into the resident's chart on 9/13/23 at 10:26 a.m. It documented the resident was admitted to the facility on 9/12/23. Shortly after admitting the resident became agitated and combative with staff. As needed (PRN) medications for agitation were utilized. The resident did experience a fall while attempting to self-transfer out of bed. He was very confused as he had just been admitted to a new environment and had dementia. During the evening staff attempted to administer medications to the resident which he spit out at the nurse twice. He became verbally and physically aggressive. His MDPOA requested the resident be sent to the emergency room. From the emergency room, the resident was transferred to a hospice care center to receive end-of-life care. A hospice progress note was documented in the resident's chart on 9/12/23 at 11:27 p.m. The emergency room physician called the hospice nurse and stated the resident was sent to the emergency room because he refused his medications and the staff could not keep him safe. The resident received 0.5 milligrams of Ativan (an antianxiety medication) and he rested. He was cooperative with the emergency room staff. Resident #86 had some nausea and vomiting and imaging was ordered. The hospital did not have a medical reason to keep the resident and the doctor requested help from the hospice nurse to make a plan. The hospice note further documented the hospice nurse called the facility to discuss a plan to move forward. The nurse from the facility said she would call the director of nurses (DON.) A different facility nurse called the hospice nurse back and said the facility DON would not be accepting the resident back because the resident tried to push a nurse with a broken foot off her knee scooter and he refused his medications. The facility's staff did not feel they could keep Resident #86 safe.-The electronic medical record failed to show any documentation of the specific resident needs that the facility could not meet, the facility's attempts to meet those needs or the services available at the receiving facility to meet the resident's needs. V. Staff interviewsThe DON was interviewed on 11/14/23 at 4:54 p.m. He said Resident #86 had a lot of behavioral concerns with physical and verbal aggression. He said on 9/12/23, when the resident was aggressive, the staff attempted to administer his PRN medications and the resident spit them out at the nurse twice. The DON said the resident was discharged to the hospital per the physician. He said he did not speak to the hospice nurse and only spoke to the nurse on duty about the resident's behaviors. The DON said he spoke to the nursing home administrator (NHA) and they decided they could not provide the care Resident #86 needed as he needed more acute support. The DON said the nurses were not allowed to administer intravenous (IV) or intramuscular (IM) medications when the resident refused his medications. He said the resident was not safe at the facility or toward the facility's staff therefore they would not have taken him back at all. The night shift nurse supervisor was going to be the resident's one-to-one that night however she had a broken foot and Resident #86 tried to push her off her knee scooter. The DON said the resident walked with the assistance of staff and he did fall the night of his admission. When residents were admitted to the facility with behavioral issues the assistant director of nursing (ADON) reviewed the referrals and obtained more details. The ADON then completed an onsite visit with the resident and their family at their current residence, however, an onsite visit was not completed for Resident #86 before admission. The DON was interviewed again, along with the regional operationsmanager (ROM), on 11/16/23 at 5:15 p.m. The DON said Resident #86 was admitted prior to 9/12/23 for a short-term stay. The DON said the facility was unable to meet the resident's safety needs. Resident #86 was aggressive and belligerent towards the male staff and sexually inappropriate towards the female staff. Resident #86 took his medications crushed and he spit them in the nurse's face twice on 9/12/23. The DON said he had the on-call phone that night and received the information from the staff and consulted with the NHA. The NHA told the DON not to accept Resident #86 back because the facility could not provide for the resident's needs or his safety. The DON confirmed that an evaluation of the resident was not completed after the hospital had informed the facility that he was stable. The ROM said the facility typically accepted residents back but the hospital did not put new interventions in place so the facility could not provide for the resident.

Based on observations, record review, and interviews the facility failed to accurately reflect the resident's status on the minimum data set (MDS) assessments accurately for four (#62, #3, #56, and #51) of 18 residents reviewed out of 48 sample residents. Specifically, the facility failed to:-Ensure Resident #62 was accurately documented as a one-person transfer;-Resident #3 and Resident #51 had pneumococcal vaccination status was accurate; and -The use of antidepressants was coded accurately for Resident #56 Findings include:I. Resident #62A. Resident statusResident #62, age under 95, was admitted on 8/19/22. According to the November 2023 computerized physician orders (CPO) diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke), muscle weakness, difficulty in walking, lack of coordination, need for assistance with personal care, and cognitive communication deficit. The 8/23/23 minimum data set (MDS) assessment documented no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented the resident required a two-person physical assistance for bed mobility and transferring between surfaces. B. ObservationsOn 11/13/23 at 2:10 p.m. Resident #62 was observed in his wheelchair and requested to go to bed. Certified nurse aide (CNA) #7 went into the resident's room at 2:17 p.m. and assisted the resident to bed. CNA #5 entered the room but only provided a shift report and went home. CNA #7 finished getting Resident #62 into bed at 2:25 p.m. On 11/14/23 at 2:37 p.m. Resident #62 was sleeping in bed. Above his bed, he had a picture of a sailboat with one sail. C. Record reviewThe 8/29/23 MDS failed to show the resident's transfer status was accurately documented. The MDS was inaccurate under section G ( functional abilities) as it documented the resident was a two-person transfer. Whereas through observations and interviews, the resident required a one-person assist with transfers. The 6/25/23 and 3/6/23 MDS assessments were also inaccurate. C. Staff interviewsCNA #3 was interviewed on 11/14/23 at 1:42 p.m. CNA #3 said each resident had a sailboat picture in the room which explained what type of transfer they were. One sail meant the resident was a one-person transfer. If the sailboat had two sails the resident was a two-person transfer. Licensed Practical Nurse (LPN) #2 and LPN #3 were interviewed on 11/15/23 at 3:26 p.m. LPN #3 said Resident #62 was a one-person transfer and had never been a two-person transfer. The assistant director of nursing (ADON) was interviewed on 11/15/23 at 3:45 p.m. She said Resident #62 was not a two-person assist for transfer and had never been. She said she did not know why the MDS assessment documented the resident as a two-person transfer. The restorative assistant (RA) was interviewed on 11/15/23 at 3:51 p.m. She said Resident #62 was on her caseload and he was a contact guard and a one-person transfer. The RA said once he was dressed and his bed was raised he stood up with his walker. She said if he was a two-person transfer it had to have been a long time ago. The minimum data set coordinator (MDSC) was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she pulled data from a seven-day look back period when she completed the assessment for transfers. She said she used the highest level of care charted by the staff for the assessment. During Resident #62's assessment he had one entry which was a two-person transfer. The MDSC said after the seven-day look back period she completed a bedside assessment of the resident. She said charting was very important for the MDS assessment. She said the new changes were implemented after Resident #62's MDS assessment was completed in August 2023. II. Resident #3A. Resident statusResident #3, age 85, was admitted on 5/25/22. According to the November 2023 CPO, diagnoses included atrial fibrillation (an irregular and very rapid heart beat), heart failure and hypertension. The 8/17/23 MDS assessment documented Resident #3 had severe cognitive impairment with a BIMS score of three out of 15. -Section O (special treatments, procedures and programs) of the MDS assessment revealed the resident was up to date on her pneumococcal vaccination. -However, this was inaccurate as the resident was not up to date on her pneumococcal vaccination.. -The MDS did not answer the question if the resident was offered the vaccination. B. Record reviewA review of Resident #3's electronic medical record (EMR) revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination on 10/1/16. However, the resident had signed a consent form on 5/25/22 giving permission to receive the updated pneumococcal vaccination and the flu vaccination yearly. C. InterviewThe MDSC was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she reviewed the record and confirmed the resident's pneumococcal vaccination was not up to date, and the MDS should have reflected that it was not up to date. III. Resident #56 A. Resident statusResident #56, age 83, was admitted on 5/26/23. According to the November 2023 CPO, diagnoses included dementia without behavioral disturbance, anxiety and abnormalities of gait and mobility. The 9/30/23 MDS assessment showed the resident had minimal cognitive deficits with a BIMS score of 13 out of 15. The resident required limited assistance with activities of daily living. B. Record reviewThe November 2023 CPO showed an order for Sertraline HCI (an antidepressant medication) tablet 100 mg. Give one tablet one time a day for depression. The start date was 8/4/23. -The MDS assessment inaccurately documented that the resident did not receive an antidepressant. C. InterviewThe MDSC was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she reviewed the record and confirmed the latest MDS assessment dated 9/30/23 was inaccurate. She said she was going to complete a correction MDS assessment. IV. Resident #51A. Resident statusResident #51, age 83, was admitted on 11/10/21. According to the November 2023 CPO, diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke) and muscle weakness. The 10/6/23 MDS assessment documented Resident #51 had moderate cognitive impairment with a BIMS score of eight out of 15. -The MDS assessment inaccurately documented that the resident was up to date on her pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record reviewA review of Resident #51's EMR revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination on 7/1/16. However, the resident had signed a consent form on 11/1/21 giving permission to receive the updated pneumococcal vaccination. C. InterviewThe MDSC was interviewed on 11/16/23 at 3:18 p.m. The MDSC said she reviewed the record and confirmed the resident's pneumococcal vaccination was not up to date and the MDS should have reflected that it was not up to date.

Based on observations, interviews, and record review the facility failed to provide appropriate treatment and services to maintain or improve the resident' s ability to perform activities of daily living (ADLs) for one (#52) of two residents reviewed for eating out of 48 sample residents. Specifically, the facility failed to provide Resident #52 with adaptive equipment to maintain his ability to feed himself. Findings included:I. Resident statusResident #52, age greater than 65, was admitted on 5/28/21. According to the November 2023 computerized physician orders (CPO), diagnoses included heart failure, dysphagia (difficulty swallowing), and dementia. The 9/7/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required two-person physical assistance with bed mobility, toileting, and transferring between surfaces. He required setup or clean-up assistance with eating and drinking. II. Record reviewA review of Resident #52' s activities of daily living (ADL) care plan, revised on 3/10/23, revealed the resident had an alteration in his ability to perform ADLs. Pertinent interventions included:Setting up the resident' s meal tray at all meals so the resident could feed himself, OT (occupational therapy) to screen and provide adaptive equipment for feeding as needed; andProvide regular and mechanical soft diet. Monitor intake and record every meal.-However, documentation did not indicate the OT was informed the resident had a hard time feeding himself or that the OT assessed Resident #52 and provided the resident with adaptive equipment for self-feeding. A review of Resident #52' s hearing care plan, revised on 5/30/21, revealed the resident was hard of hearing. An intervention was documented for staff to observe and report an actual or suspected decline in the resident' s cognitive status, mood, ADLs, oral motor function, or hearing.-However, the staff did not report the resident had a hard time feeding himself. III. ObservationsOn 11/16/23 at 10:00 a.m. Resident #52 was observed eating breakfast in his bedroom. Resident #52 was slumped over to his left side attempting to eat scrambled eggs and breakfast sausage that was ground up with a fork. As Resident #52 put the fork to his mouth the food fell off and landed on his bed near his left hip. Resident #52 asked for assistance with eating because he could not put the food in his mouth. CNA #2 went into the room to assist the resident.-Resident #52 did not have any adaptive silverware so he could feed himself. At 10:26 a.m. Resident #52 was observed sitting in his room. The resident asked for a peanut butter and jelly sandwich because he was still hungry. His meal ticket documented that he ate 50-75% of his breakfast. CNA #2 said he assisted the resident with the rest of his breakfast because the resident was dropping the food on the bed. CNA #2 said he would get him a snack. At 1:31 p.m. Resident #52 requested mashed potatoes and gravy because he was still hungry. His meal ticket documented he ate 100% of his lunch and CNA #8 said she had to feed Resident #52 his lunch.-Resident #52 did not have any adaptive silverware so he could feed himself. IV. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 11/16/23 at 10:26 a.m. He said Resident #52 normally ate hot cereal and mashed potatoes and gravy for breakfast but he wanted to try something different and ordered scrambled eggs and sausage. CNA #2 said the resident had an easier time eating foods that stuck to a spoon, which was why he ate mashed potatoes and gravy all the time. He said Resident #52 had a hard time feeding himself because his hands shook. He said he assisted the resident with the rest of his breakfast since he had a hard time feeding himself with a fork. CNA #2 said Resident #52 told him he had a hard time swallowing so CNA #2 alternated his food with fluids. He said the resident ate 50-75% of his meal and had two cups of apple juice and some water. He said Resident #52 used a normal fork and it was hard for him to eat if he did not have a spoon. CNA #2 was unaware of how to request an occupational therapy (OT) assessment for silverware that worked for the resident to feed himself or how to get staff to assist him at each meal. CNA #8 was interviewed on 11/16/23 at 1:31 p.m. She said she fed Resident #52 100% of his lunch because he had a hard time feeding himself. She said he ate mashed potatoes and gravy, two cups of applesauce, and half of a banana. Resident #52 requested more mashed potatoes and gravy and CNA #8 was going to get him some more.-CNA #8 did not indicate she was aware the OT should be notified to assess the resident for adaptive silverware to enable Resident #52 to feed himself more effectively. The registered dietitian (RD) was interviewed on 11/16/23 at 3:51 p.m. She said Resident #52 was a nutritional risk for weight loss. She said she was unaware Resident #52 struggled to feed himself and therefore was not provided adaptive silverware at meals. She said she would request an assessment from the OT for adaptive silverware.

Based on observations, record review and interviews the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#71) of one resident reviewed for hearing problems out of 48 sample residents. Specifically, the facility failed to ensure Resident #71 was assisted to see an audiologist. Findings include:I. Resident #71A. Resident statusResident #71, age, was admitted on 3/10/23. According to the November 2023 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness, and monoplegia of upper limb. The 9/2/23 minimum data set (MDS) assessment showed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required substantial assistance with activities of daily living. The MDS assessment coded the resident as having minimal difficulty in certain environments such as noisy settings or a person who speaks softly. B. Resident interviewResident #71 was interviewed on 11/13/23 at 10:49 a.m. The resident said he had hearing difficulties as he had a broken ear drum from a fall. He said he needed to see an audiologist, however, he said the facility had not offered him the opportunity to see one. C. Record reviewThe 3/10/23 health status note documented the resident said he had hearing aides, however, they were lost at home. The note documented the resident was very hard of hearing and that he could hardly hear anything out of his right ear after the fall. The hearing in his left ear was better. The note documented the resident said he could hear better if the person was looking at him as he could read lips. The 3/11/23 evaluation summary documented the resident had poor hearing. The 6/2/23 multidisciplinary care conference documented, "Ancillary services offered, but response was only curse words. Will ask again at a later time." The 9/1/23 multidisciplinary care conference documented vision, podiatry and dental services were offered. -There was no evidence that audiology services had been offered to the resident. -The medical record failed to show the resident had been offered audiology services to evaluate his hearing during his time at the facility. D. InterviewsThe social services director (SSD) was interviewed on 11/15/23 at 2:00 p.m. The SSD said she offered ancillary services dependent on the resident. She said if a resident was admitted for short term then she would not offer ancillary services. The SSD said she would offer vision and dental services, but it was up to the resident on audiology services. The SSD said she would review Resident #71's electronic medical record. The resident's power of attorney (POA) was interviewed on 11/15/23 at 5:12 p.m. The POA said the resident was hard of hearing. She said when he fell he had broken his ear drum. She said she had attended the care conferences, but the resident had not been offered any audiology services. The SSD was interviewed a second time on 11/16/23 at 1:00 p.m. The SSD said she reviewed the record and said ancillary services were offered such as vision, dental and podiatry. She was unable to show evidence that audiology services had been offered to the resident.

Based on observations, record review, and interviews the facility failed to ensure one resident (#83) of five sample residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable, and to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the facility failed to ensure timely interventions were put in place to prevent the development of pressure injuries to Resident #83's heels which resulted in two unstageable pressure injuries. Resident #83 was admitted to the facility after a fall resulting in her impaired mobility. The resident was at risk for pressure injuries and had a current pressure injury to her sacrum on admission. The resident developed a stage II pressure injury to her right heel and a deep tissue pressure injury to her left heel in less than a week after her admission. The pressure injuries were not identified as unavoidable. Both pressure injuries were identified as healable. The stage II pressure injury to the right heel and the deep tissue pressure injury to the resident's left heel worsened to unstageable pressure injuries a month later. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 11/29/23, "Pressure ulcer classification is as follows: "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). "Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. "Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable "Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility policy and proceduresThe Prevention of Pressure Injuries policy, revised April 2020, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. The policy read in part: "The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the residents care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. "Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes of condition. Use a standardized pressure injury screening tool to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors. "Conduct a comprehensive assessment upon or soon after admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. "During a skin assessment, inspect the presence of erythema, temperature of the skin and soft tissue and edema. "Inspect the skin on a daily basis when performing or assisting with personal care ADLs (activities of daily living). Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, and ischium, trochanter)."Use facility-approved protective dressings for at risk individuals."III. Resident #83 status Resident #83, age greater than 90, was admitted on 9/18/23 and readmitted on 10/26/23. According to the November 2023 computerized physician orders (CPO), diagnoses included multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified abnormalities of gait and mobility, weakness, other reduced mobility, muscle weakness, other lack of coordination, osteoarthritis, chronic kidney disease and need for assistance with personal care. The 10/23/23 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a staff assessment for mental status. According to the 10/23/23 MDS assessment, the resident had one or more unhealed pressure ulcers. The resident had two stage II pressure ulcers, one of which was facility acquired. It read the resident had an unstageable pressure injury. The 9/25/23 MDS assessment identified the resident required substantial to maximal assistance for bed mobility and transfers. IV. Record reviewThe 9/18/23 admission data collection with care plan assessment identified Resident #83 had a stage II pressure ulcer to her sacrum on admission. The admission assessment indicated the resident did not have pressure ulcers/deep tissue injuries or any skin issues to the heels of her feet on admission to the facility. The 9/25/23 Braden scale for predicting pressure sore risk identified Resident #83 was at risk for developing pressure sores. According to the Braden scale, the resident sensory perception was slightly limited. She responded to verbal commands but could not always communicate discomfort or the need to be turned or had some sensory impairment which limits ability to feel pain or discomfort in one or two extremities. Her skin was occasionally moist requiring extra linen changes. Her ability to change and control body position was very limited. The resident was able to make occasional slight changes in her body or extremity position but unable to make frequent or significant changes independently. Resident #83 had a friction and sheer potential problem. The resident had the probability that during a move the resident's skin slid down to some extent against sheets, chairs or other devices. The pressure skin care plan, initiated on 9/19/23, read Resident #83 had an actual impairment to her skin integrity. The care plan goal was for the resident to be free from skin breakdown. Interventions included staff to identify and document potential causative factors and eliminate/resolve where possible. The pressure injury care plan, initiated on 9/29/23, read Resident #83 had a stage II pressure ulcer to her sacrum and right heel and a deep tissue injury to her left heel related to a history of ulcers and impaired mobility due to pelvic fractures. The stage II pressure ulcer to the sacrum resolved on 10/5/23. Interventions initiated on 9/29/23 included to avoid positioning the resident's heels flat on the bed and laying flat on her heels for an extended period of time. A letter from the registered nurse (RN) #2 was provided by the nursing home administrator (NHA) via email on 11/20/23. According to the letter, RN #2 covered the wound rounds the week of 9/17/23 to 9/23/23. The letter read the resident had interventions put in place on the day of her admission (9/18/23) related to stage II pressure injury (sacrum), comorbidities and pressure injury risk. The interventions were identified as turning and repositioning every two hours, air mattress, the registered dietitian to evaluate nutritional needs, protect bony prominences, elevate legs to minimize swelling, pressure relieving cushion to her wheelchair and physical and occupational therapy to increase functional mobility. -The letter did not identify specific interventions to prevent the development of pressure injuries to her heels. A. Right heel unstageable pressure injuryThe pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a stage II pressure injury to her right heel. A foam heel protector and heel protective boots were put in place. The 9/25/23 CPO directed staff to float heels at all times while the resident was in bed using a wedge or boots as tolerated. The 9/25/23 CPO directed staff to provide daily wound review to her right heel. The 9/27/23 wound care physician assistant (PA) progress note read Resident #84 developed two new pressure wounds on her heels on 9/27/23 (9/24/23). According to the progress note, the initial wound encounter measurement of the resident's right heel stage II pressure injury was 5 centimeters (cm) in length by 5 cm in width with a serum filled blister. The PA recommended the staff to implement pressure relieving measures and offloading as tolerated to include a speciality device of a heel protector. The 9/27/23 skin and wound assessment read Resident #83 had a new stage II pressure injury/ulcer to her right heel. The pressure injury was facility acquired on 9/24/23. The stage II pressure injury to her right heel measured 3.9 cm in length by 2 cm in width. According to the assessment, the stage II pressure injury was healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program. The assessment read Resident #83 was admitted to the facility due to a fall with left pubic fracture with a history of pressure ulcers. Her mobility was impaired and the resident required assistance with repositioning/loading heels. The resident was noted to have a stage II pressure injury presenting as a serum filled blister. Staff continue to offload heels. No dressing would be applied until the blister ruptured. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/11/23 skin and wound assessment identified Resident #83's stage II pressure injury/ulcer to her right heel measured 2.4 cm in length by 2 cm in width. The assessment read Resident #83's blister to the right heel ruptured and there was 60% eschar (necrotic) tissue present. The wound physician assistant (PA) assessed and diagnosed the wound as an unstageable pressure ulcer. New orders were placed for Santyl ointment applied daily to break down eschar tissue. The 10/18/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had improved as evidenced by most of the eschar had broken down to slough (thick, yellow nonviable tissue). The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the right heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the wound to the right heel was a stage II pressure injury with slough on the wound bed, thin, watery, pale, red/pink drainage with moderate dressing saturation of 26-75%. There was partial thickness skin loss with exposed dermis. The skin tissue was boggy (mushy to the touch) and the resident had episodic pain. -However, the stage II pressure injury was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's right heel was not reviewed daily as ordered (refer to the 9/25/23 CPO above). The 11/1/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had 40% of wound filled eschar. The resident returned from the hospital with new orders for Triad cream and a foam dressing applied three times a week and as needed. The 11/7/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury was showing improvement. According to the assessment, the resident continued with heel protective boots to float heels while in bed. Her legs were elevated when the resident was in her chair to aid with pressure reduction and fluid. B. Left heel unstageable pressure injuryThe pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a deep tissue injury to her left heel. The resident was treated with betadine qd (daily) and heel protective boots were put in place. The 9/27/23 wound care physician assistant (PA) progress note described the left heel deep tissue pressure injury as a persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer measuring 2 cm by 1.7 cm. The PA recommended applying betadine and floating heels. The 9/27/23 skin and wound assessment read Resident #83 had a new dark purple discoloration to the left heel consistent with a deep tissue injury (DTI) from pressure which was facility acquired on 9/24/23. The left heel DTI measured 2.1 cm in length by 1.5 cm in width. The DTI was identified as healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program and a daily treatment of betadine. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/5/23 skin and wound assessment identified Resident #83's DTI had a slight increase in size. The DTI measured 2.5 cm in length by 2.1 cm in width. The pressure wound log for the week of 10/8/23 and 10/14/23 for Resident #83's left heel DTI identified the resident was COVID-19 positive and required more frequent repositioning. The 10/11/23 skin and wound assessment identified the resident's left heel DTI had an intact blister. The 10/11/23 CPO directed staff to provide daily wound review to her left heel. The 10/18/23 skin and wound assessment identified Resident #83's DTI measured 2.7 cm in length by 1.8 cm in width. The 10/23/23 health status note read Resident #83 was sent to the hospital. The 10/26/23 evaluation summary note read the resident had pressure ulcers to her bilateral heels. The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the left heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the left heel was a DTI with episodic pain and minimal saturation. According to the skilled evaluations a pressure ulcer staging was not applicable.-However, the DTI was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's left heel was not reviewed daily as ordered (refer to the 10/11/23 CPO above). The 10/27/23 CPO directed staff to apply a thick layer of Triad Hydrophilic barrier cream to the resident's bilateral heels and cover with foam dressing three times a week and as needed. The 11/1/23 skin and wound assessment identified Resident #83's the facility acquired DTI was now an unstageable pressure injury/ulcer to her left heel. She had 60% wound filled eschar. The 11/7/23 skin and wound assessment read the wound was improving with no eschar present. V. Staff interviewThe assistant director of nursing (ADON) was interviewed on 11/15/23 at 1:21 p.m. The ADON identified she was the facility wound nurse. The ADON said Resident #83 was admitted on 9/19/23. The resident was admitted with stage II pressure ulcer to her sacrum. The ADON said she was on leave at the time of the resident's admission. She said staff initiated interventions related to the sacrum pressure ulcer but preventive measures directly to prevent pressure ulcers to the resident's heels were not in place. The ADON said the resident was at risk for pressure injuries to her heels because of her history of pressure ulcers, her impaired mobility after a recent fall prior to her admission and her need for more assistance. She said she would have added heel protective boots to protect the heels on admission and a wedge to lift the heels off of the surface of the bed. She said proper interventions were not put in place to prevent the development of pressure injuries to the resident's heels. The ADON said the weekend nurse identified the right heel stage II pressure injury and the left heel DTI on 9/24/23. The ADON said the resident's heels were off loaded starting on 9/25/23. The ADON said both wounds had decreased in size but currently both of the heels had unstageable pressure injuries.

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Based on observations and interviews the facility failed to employ sufficient dietary and food and nutrition staff to carry out the functions of the food and nutrition services. Specifically, the facility failed to provide sufficient numbers of adequately trained food and nutrition staff which contributed to prolonged wait times for meals and overall decreased the residents ' satisfaction with their dining experience. Findings included:I. Meal timesThe meal service times were posted outside of the facility ' s dining room:A. Breakfast"Hush no rush breakfast:" 6:30 a.m. to 8:45 a.m. Aspen cart: 7:00 a.m. to 7:15 a.m. Columbine cart: 7:15 a.m. to 7:30 a.m. Blue Spruce cart: 7:30 a.m. to 7:45 a.m. B. LunchAspen cart: 11:25 a.m. to 11:35 a.m. Columbine cart: 11:35 a.m. to 11:55 a.m. Blue Spruce cart: 11:45 a.m. to 12:00 p.m. Main dining room: 12:00 p.m. to 1:00 p.m. C. DinnerAspen cart: 4:30 p.m. to 4:45 p.m. Blue Spruce cart: 4:45 p.m. tp 5:00 p.m. Main dining room: 5:00 p.m. to 6:00 p.m. Columbine cart: 5:20 p.m. to 5:35 p.m. II. Resident interviewsResident #71 was interviewed on 11/13/23 at 10:42 a.m. The resident said he was assisted to the dining room prior to 12:00 p.m., but then he sat there for nearly an hour before his meal was served. Resident #16 was interviewed on 11/13/23 at 12:43 p.m. The resident said that the meals were routinely late and served 45 minutes to over an hour late. He said this was a daily occurrence, and that noon meal was the worst. He said it was frustrating. Resident #61 was interviewed on 11/13/23 at 12:46 p.m. Resident #61 said the dining room was always late, and it made her angry that she had to sit and wait for over an hour. She said it was late daily. She said the kitchen did not have enough staff. She said they do not change the service in the dining room, so because she is in the back she always gets her meal about an hour late past the posted meal time. Resident #18 was interviewed on 11/13/23 at 2:46 p.m. She said the meals were served late and it was ridiculous. Resident #65 was interviewed on 11/13/23 at 3:39 p.m. He said meals were served an hour late. Resident #61 was interviewed a second time on 11/13/23 at 6:08 p.m. The resident said she received her dinner meal just about 10 minutes ago. Resident #56 was interviewed on 11/14/23 at 8:53 a.m. Resident #56 said the meals were an hour late. She said it did not make her feel good that she had to sit in the dining room for such a long time waiting for her meal. Resident #27 and Resident #71 were interviewed on 11/15/23 at 1:01 p.m. Resident #27 said he had been in the dining room since 12:00 p.m. He said his patience was wearing thin. He said the facility knew what time they were supposed to be ready with meals each day but continued to be late as the residents just sat there and waited. Resident #71 said the food should be served remotely close to 12:00 p.m. and it frustrated him. Resident #13 and Resident #78 were interviewed on 11/15/23 at 1:01 p.m. They said they had been waiting for over an hour. Resident #13 said the facility had a hard time keeping staff. Resident #54 was interviewed on 11/15/23 at 1:01 p.m. She said she had been in the dining room since 12:00 p.m. She said waiting drove her crazy and the kitchen needed to get it together. Resident #10 was interviewed on 11/15/23 at 1:10 p.m. She said she waited a long time for her meal. She said waiting made her feel unwanted. Resident #10 said she had family coming to visit her and she felt she would not be able to see them because she was still in the dining room waiting for lunch. Resident #15 and her daughter were interviewed on 11/15/23 at 1:11 p.m. Resident #15 said she had been in the dining room since a little before 12:00 p.m. She said the kitchen often did not serve lunch until 1:15 p.m. and sometimes lunch was not served until 2:15 p.m. Resident #15 ' s daughter said her mom got tired of waiting and went back and forth between the dining room and her bedroom. III. ObservationsA. The main dining room was observed on 11/13/23-At 11:50 a.m., there were approximately 20 residents in the dining room awaiting their meal.-At 11:58 a.m., Resident #26 was talking to her tablemate that she was wondering why the service had not started. She asked a staff member, and she was told that it was not time for lunch. -At 12:20 p.m. an unidentified staff member told the residents in the dining room that drinks were coming and thanked the residents for their patience. -At 12:28 p.m., the window from the kitchen to the dining room was open-At 12:38 p.m., an unidentified certified nurse aide began to pass drinks to the residents in the dining room.-At 12:44 p.m., the first tray was served out to the dining room.-At 1:20 p.m., the last tray was served. B. The Columbine hallway meal trays were observed on 11/13/23.-At 12:20 p.m., the meal trays arrived and the registered nurse (RN) started checking the trays.-At 12:22 p.m., the director of nursing (DON) assisted the RN and certified nurse aide (CNA) with delivering the trays. The CNA went to the dining room and retrieved some sodas for a few residents.-At 12:47 p.m., all meal trays were delivered to the residents of Columbine Hall. C. The main dining room was observed on 11/14/23-At 12:08 p.m., the dining room was filled with 29 residents waiting for the noon meal service. -At 12:41 p.m., the first lunch tray was served in the dining room.-At 1:24 p.m., the last tray was served in the dining room. D. The breakfast room trays on the Blue Spruce West were observed on 11/15/23. The posted meal time for the Blue Spruce cart was between 7:30 a.m. and 7:45 a.m. -At 8:53 a.m., the first tray was passed from the meal cart. E. The kitchen tray line service On 11/15/23 at 11:26 a.m. the tray line was observed for the noon meal. The kitchen had a dishwasher, a dietary aide, cook #1 and cook #2. Cook #2 came in earlier than scheduled to help with the noon meal. -At 11:26 a.m., the meal continued to be prepared.-At 11:32 a.m., cook #1 began to take the food temperatures on the tray line. The mashed potatoes and gravy were under temperature and had to be placed in the warmer.-At 11:48 a.m., Cook #1 began to serve the room trays for the Aspen unit. She began plating the first four plates but waited before she made more since the potatoes and gravy were being warmed up. -At 12:20 p.m., the puree salisbury steak needed to be remade as there was a metal shaving in the meat. -At 12:26 p.m. a CNA entered the kitchen and asked for Aspen Hall ' s cart and was told it was not ready yet. Aspen Hall ' s meal cart went out at 12:28 p.m. incomplete because the puree was not ready. -At 1:07 p.m. Columbine hall room trays were sent out. -At 1:07 a.m., the dining room window was opened, however, realized she had forgotten about Blue Spruce Hall ' s meal cart. Cook #2 assisted with Blue Spruce trays while Cook #1 served the dining room. The restorative assistant (RA) took the meal tickets for the dining room so the trays would be served by the table. The RA got frustrated because Cook #1 mixed up the meal tickets and the trays were not being served as a table. Cook #1 left the kitchen and Cook #2 took over and served plates. -At 1:12 p.m., the meal service stopped as the tray line ran out of salisbury steaks. -At 1:38 p.m., the tray line ran out of the mechanical soft salisbury steak, and had to make additional. -At 1:41 p.m., there were not enough pies cut for dessert. The dietary aide had to cut and dish up more pies. -At 1:40 p.m., the Blue Spruce trays were completed and sent to the hall.-At 1:50 p.m., the dining room was completed with service. F. The dinner meal trays were observed on 11/15/23.-At 5:15 p.m. Aspen ' s meal cart was sent out from the kitchen.-At 5:25 p.m. Columbine ' s meal cart was sent out from the kitchen. IV. Staff interviewsCook #1 was interviewed on 11/15/23 at 11:30 a.m. The cook #1 said she was fairly new in the position. She said that she did not have enough time to prepare the meal between breakfast and lunch. She said the kitchen needed additional staff to help with the service. Cook #2 was interviewed on 11/15/23 at 1:30 p.m. The cook #2 said the kitchen lacked experienced staff. He said the tray line needed to learn how to start lunch when still working with the breakfast meal. CNA #3 was interviewed on 11/15/23 at 1:13 p.m. She said lunch was usually served late and was the worst of all the meals. CNA #1 was interviewed on 11/15/23 at 1:17 p.m. She said the CNAs checked the meal tickets and the trays to ensure the orders were correct and if the trays were wrong they were sent back to the table to be fixed. She said the meals were late because the kitchen staff were a new team and were trying to figure things out. The dietary manager (DM) was interviewed on 11/16/23 at 6:08 p.m. She said the residents and staff had complained about the meals being late and she felt it was because of a lack of time management. She said the staff needed to prioritize the meals and what needed to be cooked or prepped. She said the kitchen staff did not understand multitasking and said if pork was on the menu for lunch the staff needed to cook it in the oven while they served breakfast. She said there was usually a dishwasher, cook, dietary aide (DA), and bistro cook in the kitchen, at least four staff worked during the day. She said four staff were enough to run the kitchen and it ran smoothly. The DM said the cook and bistro cook ran into each other sometimes because of the kitchen ' s layout. She said the bistro side should be set up so staff did not run around the kitchen or run out of things during meal service. She said all the kitchen staff needed training and they did not have a dietary manager for a month and a half. She said she was going to provide training to the kitchen staff on the menu extensions, menus, and recipes because they were very confusing to read.

Based on observations, record review, and interviews, the facility failed to provide a therapeutic diet for one (#52) of two out of 48 sample residents. Specifically, the facility failed to adequately thicken Resident #52 ' s liquids per his physician's order. Findings include:I. Facility policyThe Therapeutic Diets policy, revised October 2017, was provided by the regional operations manager on 11/16/23 at 9:30 a.m. and read in pertinent:2. A therapeutic diet must be prescribed by the resident ' s attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. 3. Diet orders should match the terminology used by the food and nutrition services department. 4. 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 to alter the texture of a diet, for example:a. diabetic/caloric controlled diet;b. Low sodium diet;c. cardiac diet; andd. Altered consistency diet. 5. If a "mechanically altered diet" is ordered, the provider will specify the texture modification. 6. The resident has the right not to comply with therapeutic diets. 9. Snacks will be compatible with the therapeutic diet. II. Thickened liquid instructionsAccording to the Thick and Easy Thickener can instructions were:1. Add level-measured thickener into empty, dry glass or container 2. Measure the desired liquid into a separate container 3. Add liquid to thickener quickly while stirring briskly with a whisk or fork until dissolved 4. Allow five to 10 minutes for the product to reach the desired thickness-The amount of thickener powder needed is based on the amount of liquid used. III. Resident #52A. Resident statusResident #52, age 90, was admitted on 5/28/21. According to the November 2023 computerized physician orders (CPO) diagnoses included heart failure, dysphagia (difficulty swallowing), and dementia. The 9/7/23 minimum data set (MDS) assessment documented a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The MDS documented the resident required a two-person physical assistance with bed mobility, toileting, and transferring between surfaces. It documented that Resident #52 required setup or clean-up assistance with eating and drinking. B. Record reviewThe November 2023 CPO showed an order that read a general diet that was mechanically soft in texture and liquids were a nectar-thick consistency. The start date was 7/26/23. Resident #52 ' s care plan, last updated on 3/10/23, failed update to include the nectar thick consistency liquid. The resident's meal ticket documented nectar thick liquids. IV. ObservationsOn 11/13/23 at 1:23 p.m. the director of nursing (DON) was preparing Resident #52 ' s drinks and lunch tray. The DON asked registered nurse (RN) #3 about which milk the resident preferred and if it needed to be thickened. RN #3 said he preferred lactose-free milk and it needed to be nectar thick. The DON grabbed a plastic medication spoon and scooped less than a teaspoon of the thickener then added it to the cup of lactose-free milk. The DON stirred the thickener into the cup for approximately five seconds and served the resident his lunch tray. -However, the DON did not wait until the milk was thickened before serving it. On 11/14/23 at 2:40 p.m., the resident's room failed to have thickened water at his bedside. On 11/14/23 at 2:40 p.m. Resident #52 asked for a snack and water. RN #3 grabbed the resident a snack and room-temperature water which she did not add thickener to. Resident #52 was coughing and RN #3 elevated the head of his bed to 45 degrees to assist with his cough. At 3:42 p.m. Resident #52 was still coughing. RN #3 gave him some applesauce but he continued to cough. V. Staff interviewsRN #3 was interviewed on 11/14/23 at 4:28 p.m. RN #3 said when a resident required thickened liquids then all of their liquids needed to be thickened, which included water. She said the resident had a physician's order for the thickened liquid. She was aware Resident #52 was on nectar thick liquids. She said if she noticed a resident was choking she checked the resident ' s airway and asked for a speech therapy evaluation. Licensed Practical Nurse (LPN) #2 and LPN #3 were interviewed on 11/15/23 at 3:29 p.m. LPN #2 said she preferred if the liquids were already thickened but she thickened them if they were not. LPN #2 said she was sure the facility had trained the staff on thickening liquids but she had been thickening for so long she said she really could not say. LPN #3 said she followed the instructions on the thickening powder ' s can. She said she poured the powder into the drink and stirred it then waited. The can instructions said to wait one to four minutes but LPN #3 said you could tell when it was thickened. She said it was important to let it thicken or the resident could choke. The DON was interviewed on 11/15/23 at 3:32 p.m. He said he waited at least a minute after he added the thickening powder but waited based on the manufacturer's recommendations. He said he would not give the resident their drink after he stirred in the powder because it needed to activate. Certified nurse aide (CNA) #2 was interviewed on 11/16/23 at 10:26 a.m. He said Resident #52 had a hard time swallowing so when CNA #2 assisted Resident #52 with eating he alternated food with a drink. He said the resident had two cups of apple juice and some water with breakfast. CNA #2 said Resident #52 did not need a thickener in his liquids. CNA #2 reviewed the resident ' s meal ticket and he realized Resident #52 was actually on nectar thick liquids. He said the facility must have recently changed his consistency. He said when a resident was on thickened liquids there was a sign posted on their door. A hummingbird indicated the resident was nectar-thick, a honey bee indicated the resident was honey-thick, and a pudding cup indicated the resident was pudding-thick. He said only one resident on the hall had a hummingbird sign on their door and the resident was not Resident #52. CNA #9 was interviewed on 11/16/23 at 12:23 p.m. CNA #3 said she measured the thickening powder based on the amount of fluid ounces for the drink. She said she read the can when she thickened drinks to make sure she used the right amount of powder and waited the correct amount of time before she served the drink to the resident so it was the right consistency. The dietary manager (DM) was interviewed on 11/16/23 at 6:08 p.m. The DM said the kitchen did order nectar thick water, juice, and milk, but also utilized the thickening powder. She said the facility had nectar thick liquids on hand and she ordered more but also ordered honey thick so both liquids would be on hand. The DM said if someone did not know how to thicken liquids they thickened it wrong and would provide training on proper thickened liquids and textured food.

Based on observations, record review, and staff interviews the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to:-Ensure cold food items were held at the proper temperature to reduce the potential risk of foodborne illness;-Ensure the garbage disposal was not held up by cement blocks which were not cleanable;-Ensure the kitchen had a cleaning schedule;-Ensure the nourishment refrigerators were monitored;-Ensure the temperature of the refrigerators were taken; and-Ensure the health shakes were stored properlyFindings included:I. Facility policyThe Food Receiving and Storage policy, revised in November of 2022, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. and read in pertinent:"Policy Interpretation and Implementation:1. Critical control point- means a specific point, procedure, or step in the food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. 2. Danger zone- means temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that all the rapid growth of pathogenic microorganisms that can cause foodborne illness. 4. Food services, or other designated staff, maintain clean and temperature-appropriate or humidity-appropriate food storage areas at all times. Dry food storage:1. Non-refrigerated foods are stored in a designated "dry storage" unit which is temperature and humidity-controlled, free of insects and rodents, and kept clean. 3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry foods that are stored in bins are removed from their original packaging, labeled, and dated ("use by" date). Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage:1. All foods stored in the refrigerator or freezer are covered, labeled, and dated ("use by" date). 5. The functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designees and documented according to state-specific requirements. 7. Refrigerated foods are labeled, dated, and monitored so they are used by their "use by" date, frozen, or discarded. Foods and snacks kept on nursing units:1. All food items to be kept at or below 41 degrees Fahrenheit located at the nurses ' stations and labeled with a "use by" date. 5. Other opened containers are dated and sealed or covered during storage. 6. Partially eaten food is not kept in the refrigerator. 7. Medications, blood, or blood products are not stored in the same refrigerator with food."II. Reach in refrigeratorA refrigerator temperature log was hanging on the outside of the main kitchen ' s prepped food refrigerator. The log documented temperatures for: 11/18/23 at 8:00 a.m. at 37 degrees Fahrenheit,11/18/23 at 4:30 p.m. at 36 degrees Fahrenheit,And 11/19/23 at 5:00 a.m. at 37 degrees Fahrenheit. No other temperatures were documented for 11/1/23 to 11/17/23. The low-temperature machines log only had temperatures documented for 11/14/23, 11/15/23, and 11/16/23. Temperatures were not recorded for 11/1/23 to 11/13/23. III. Failure to ensure the kitchen had cleanable surfaceA. 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. "Wall and ceiling covering materials shall be attached so that they are easily cleanable."B. ObservationsOn 11/13/23 at 8:30 a.m., the initial tour of the kitchen showed the garbage disposal near the dish machine was held up by three cement blocks (4 inches wide X 8 inches height and 16 inches long). The blocks were visibly dirty. The surface was not cleanable. C. InterviewThe maintenance director (MTD) was interviewed on 11/16/23 at 8:11 p.m. The MTD said that the garbage disposal was replaced in August 2023. He said that the new garbage disposal was too heavy as it was a heavier duty disposal and it could not stand alone. He said he had not seen the cement blocks. He said he was unaware all surfaces in the kitchen needed to be cleanable. IV. Health shakesHealth shakes directions on the carton documented to store frozen. Once thawed, it had to be used within 14 days. A. ObservationsAspen nutrition freezer-The freezer had approximately 15 health shakes. The health shakes had stickers with various dates which were older than two weeks. Blue Spruce -The freezer had approximately 15 health shakes. The health shakes had stickers with various dates which were older than two weeks. B. InterviewThe DM was interviewed on 11/16/23 at 6:08 p.m. The DM said the health shakes were sent from the kitchen thawed. She said the date on the health shake were when it was to be used by. She said the shakes should not be thawed and then refrozen. She said if something was dated it should not go back into the freezer, if it was not used completely then it should be discarded. V. Ensure the entire kitchen area was clean and free from dirt, grime and food debris. Initial tour kitchen observations on 11/13/23-The trash can by the hand-washing sink was overflowing. -The floor in the kitchen needed to be scrubbed. The floor had dark substances in the grout of the tile and dried food on the floor.-The walk in refrigerator floor needed to be swept and mopped. -Two large trash cans were covered in grime and old food. 11/15/23-At 11:26 a.m., the two large trash cans were covered in grime and old food.-The floor continued to need cleaning. The floor continued to have the dark substance in the grout of the tile and dried food on the floor. -B. InterviewThe DM was interviewed on 11/16/23 at 6:08 p.m. She said the kitchen floor did look "grubby" but the kitchen staff swept and mopped every night. She said the kitchen did not have a cleaning schedule but she would implement one. She said the trash can needed to be emptied more frequently so it did not over flow. VI. Holding temperatures on the medication cartsA. Professional reference The 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, retrieved on 11/29/23. It read in pertinent part; "The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control."B. Observations on 11/16/23The following temperatures were observed with the dietary manager.-At 6:46 p.m., the Blue spruce East had an open applesauce which was at 52.5 degrees F. The cooler had a melted cold pack.-At 6:49 p.m., the medication cart on Blue Spruce was observed to have a cooler on it. Inside the cooler was an opened Ensure nutritional shake. The temperature was 62.4 degrees F. An open applesauce was on the cart with no mechanism to keep cold the temperature was 74 degrees F. -At 6;56 p.m., the Columbine medication cart had a open yogurt in the cooler. The ice packs were melted and it was 70.5 degrees F. C. InterviewRegistered nurse (RN) #6 was interviewed on 11/16/23 at 12:19 p.m. She said the night shift cleaned the coolers on the medication carts. She said that when she started her shift she would put the ice packs into the cooler. The DM was interviewed on 11/16/23 at 6:08 p.m. The DM said the cold food needed to be at 41 degrees F and below. She said the nurses handled the food on the medication carts. She said she would provide education about the importance of ice packs. VII. Nutrition refrigeratorA. ObservationsColumbine nutrition refrigerator Blue spruce refrigerator-At 12:12 p.m. there was an ice pack which was used for injuries in the freezer.-At 12:19 p.m., there was an ice pack which was used for injuries in the freezer.-A partially drank coffee cup was in the refrigerator with no name and was undated. There was a sandwich labeled in the refrigerator but was dated 10/20/23. Aspen nutrition refrigerator -At 12:23 p.m. there was an ice pack which was used for injuries in the freezer. Blue spruce refrigerator-At 12:12 p.m. there was an ice pack which was used for injuries in the freezer. B. InterviewThe DM was interviewed on 11/16/23 at 6:08 p.m. The DM said the nutrition refrigerators should not have ice packs used for body injuries. She said only food and fluid for residents was to be stored in the refrigerators. She said anything in the refrigerator needed to be labeled and dated.

Based on record review and interviews the facility failed to ensure the facility ' s binding arbitration agreement was thoroughly and accurately explained to the residents before signing the agreement for two residents (#189 and #190) of five out of 48 sample residents. Specifically, the facility failed to:-Thoroughly explain the arbitration agreement in a form and in a manner to ensure Resident #189 and Resident #190 understood the agreement before signing the agreement;-Accurately inform Resident #189 and Resident #190 when the agreement could be rescinded before the residents signed the agreement; and, -Ensure staff reviewing the agreement with Resident #189 and Resident #190 understood the components of the agreement. Findings include:I. The arbitration agreementThe voluntarily executed mutual arbitration agreement, undated, was provided by the nursing home administrator (NHA) on 11/13/23. The agreement read in part: "This document waves the right to a trial by judge or jury: read carefully. Your decision to enter this agreement is voluntary and not a condition of admission to the community. However, once executed, the agreement requires arbitration of claims as defined and explained below. "Agreement to arbitrate. Arbitration is a cost effective, private and time saving alternative means of resolving disputes outside of the courts. The dispute is heard and decided by a neutral arbitrator selected by the parties, rather than a judge or jury. This agreement does not waive or limit any Party' s right to assert claims against the other party, but rather provides an alternative venue for those claims to be resolved. By executing this agreement, the resident and community agree that any and all actions, claims, controversies, or disputes of any kind whether in contract or tort, statutory or common law personal injury property damage, legal or equitable, or otherwise, either currently existing or arising in the future, arising out of or relating in any way to the to the provision of assisted living, skilled nursing or healthcare services or any other goods or services provided under the terms of any agreement between the parties, including disputes involving the scope of this agreement, or any other dispute involving acts or omissions that cause damage or injury to either party and including wrongful death and survival actions, and where the amount in controversy exceeds $25,000 (collectively, "Claims"), shall be resolved exclusively by binding arbitration and not by lawsuit or the judicial process (except to the extent that applicable law provides for judicial review of arbitration proceedings)."The resident has the right to seek legal counsel concerning this agreement, and has the right to rescind this agreement by written notice to us within 90 days after the agreement has been signed and executed by both parties unless said agreement was signed in contemplation of the resident being hospitalized in which case the agreement may be rescinded by written notice to us within 90 days after release or discharge from the hospital or other health care institution. Both parties to this agreement, by entering it, have agreed the use of binding arbitration in lieu of having any such dispute decided in a court of law before a jury. "The agreement shall continue in full force and effect beyond the residents' stay at the community and shall survive death of the resident and the existence or operation of the community. The agreement shall be binding on this and all subsequent admission/readmissions to, or transfers within, the community."If any provision, sentence, word, phrase, paragraph, or portion of this agreement is declared to be unlawful, invalid or unenforceable for any reason, the remaining terms and provisions of this agreement show remain in full force and effect. "The parties acknowledge agree that: -The community has explained this agreement to the resident and his/her legal representative, if present and provided the resident and his or her legal representative with an opportunity to ask questions;-Each party has executed this agreement on their own free will and without corrosion or distress from the other;-The resident has been informed of the legal right to seek legal counsel concerning this agreement at his or her own cost;-Execution of the agreement is not a precondition of residency or to the receipt of services from the community; and,- The community has provided a copy of the fully executed agreement to the resident and or his legal representative. "This agreement contains a binding arbitration provision which may be enforced by the parties. By signing this agreement, the parties understand and agree that they are relinquishing and waiving their right to have any claim decided in court of law before a judge or a jury. Instead, disputes between the parties shall be resolved by the binding arbitration agreement."By signing this agreement you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than by a jury or a court trial." II. Staff interviewThe central supply clerk (CSC) was interviewed on 11/16/23 at 8:43 a.m. She said she had been reviewing arbitration agreements with the new admission residents and/or their representatives for the past couple of weeks while the admissions coordinator was on leave. She said she explained to the residents, if the residents were able to make their own decisions, the arbitration agreement was the process to use an arbitrator who was a representative from the community/mediator. If the resident wanted to sue the facility, the mediator could help with the process instead of going to court. The CSC said she told the residents that at any point they could opt out of the arbitration agreement. -However, on the contrary, the arbitration agreement (above) revealed that the resident had only 90 days to rescind the agreement. -The agreement did not indicate the resident could opt out/rescind the agreement at any time. The CSC was interviewed a second time on 11/16/23 at 9:25 a.m. She said the residents had 90 days to opt out of the agreement. III. Record reviewThe facility admission packet was provided by the NHA on 11/13/23. The admission packet included the binding arbitration agreement. Three arbitration agreements signed by the CSC for recent new admissions to the facility were provided by the facility on 11/16/23. Two of the three agreements were signed by the resident. The arbitration agreements were reviewed for Resident #189 and Resident #190. Resident #189 was admitted on 11/7/23. The arbitration agreement was signed by the CSC on 11/7/23. The arbitration agreement was signed by the Resident #189 on 11/8/23. Resident #190 was admitted on 11/7/23. The arbitration agreement was signed by the CSC on 11/7/23. The arbitration agreement was signed by the Resident #190 on 11/10/23. IV. Resident interviewsResident #190 was interviewed on 11/16/23 at 4:02 p.m. The resident said she did not know what the arbitration agreement was. She said she did not know what she signed. She said she signed so many things. Resident #189 was interviewed on 11/16/23 at 4:50 p.m. Resident #189 said he was not aware of signing anything about arbitration or being able to opt out of an arbitration agreement. He said when admitted to the facility, he was given a lot of things to sign and he was in a lot of pain at the time because of the injury to his leg. He said if the facility reviewed the arbitration agreement with him and he signed, then the staff just brushed over it. Resident #189 said he knew arbitration was a legal matter but he did not know anything more about it. He said he would have spoken to his sister about it before signing it. The resident contacted his sister on the phone. Resident #189 finished his phone call and said he did not talk to her about signing the arbitration agreement when he was admitted so he did not think he would have signed the agreement. The resident was shown the signed arbitration agreement. He said he did not know the agreement was something he already signed and wanted someone to explain it to him. V. Additional Staff interviewsThe regional operation manager (ROM) was interviewed on 11/16/23 at 9:11 a.m. She said all but two current facility residents had an arbitration agreement in place. The NHA was interviewed on 11/16/23 at 5:36 p.m. The NHA said his understanding of the arbitration agreement was that the residents or their representatives agreed to go to mediation if there was a dispute. The arbitration agreement needed to be thoroughly explained to the signing residents or their representatives. The residents signing the agreement must receive a clear understanding when the resident - could opt out. The NHA said the CSC, family advisors and the business office manager would all have more education on arbitration agreements starting on 11/16/23. He said he would send out a letter thoroughly explaining the arbitration process. The NHA said Resident #189 would have someone explain the arbitration agreement to him.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for three out of three units at the facility. Specifically, the facility failed to:-Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure staff performed hand hygiene in between tasks;-Ensure proper use of a clean field/surface during wound care for Resident #83;-Ensure proper hand hygiene was in place during wound care, specifically when donning and doffing gloves; and,-Ensure appropriate personal protective equipment was used as ordered during wound care, specifically a gown. Findings include:I. Failure to ensure residents were provided with an opportunity to participate in hand hygiene before meals and staff performed hand hygieneA. Professional referenceThe Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 11/10/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html revealed in part, "Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. "The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by the CDC, inactivate SARS-CoV-2. "ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. "The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink."B. Facility policyThe Handwashing/Hand Hygiene policy, dated August 2019, was provided by the infection control preventionist (IP) on 11/16/23 at 4:00 p.m. The policy read in pertinent part, "This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare -associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors."C. ObservationsOn 11/13/23 at 12:19 p.m., the main dining room was observed. Certified nurse aide (CNA) #10 had gloves on and was observed to touch a resident's back to wake a resident up. CNA #10 proceeded to assist another resident with the same gloved hands. She then passed out the wet wipes to the residents to wash their hands prior to the meal, however, did not perform hand hygiene in between each task. With the same gloved hands she then cleaned the hands of Resident #59. On 11/13/23 at 12:20 p.m. the noon meals were served to the residents eating in their rooms on the Columbine unit, however, hand hygiene was not offered or provided to the residents. On 11/15/23 at 8:46 a.m., an unidentified CNA was taking the vitals of a resident. She did not perform hand hygiene prior to taking the vitals of another resident. On 11/15/23 at 12:08 p.m., CNA #11 was assisting a resident to the table and offered the resident hand wipes. She then immediately assisted another resident to the table. She did not performhand hygiene in between tasks. CNA #11 proceeded to physically assist a resident with cleaning her hands with the wipes. She failed to perform hand hygiene prior to touching the glasses to pass out drinks to the residents. On 11/14/23 at 11:50 a.m., the IP was observed to pass wet wipes to the residents. As he passed out the clean wipes other residents would hand him the dirty used wipes. He would then continue to hand out clean wipes using the hand with the dirty wipes. The IP did not perform hand hygiene in between tasks or residents. On 11/15/23 at 8:39 a.m. breakfast was served to the residents eating in their rooms on the Columbine unit, however, hand hygiene was not offered or provided to the residents. On 11/15/23 at 8:53 p.m., the trays on the Blue Spruce West unit were passed to residents in their rooms. However, hand washing did not get offered to the residents in the rooms. On 11/15/23 at 8:39 a.m. breakfast was served to the residents eating in their rooms on the Columbine unit, however, hand hygiene was not offered or provided to the residents. D. InterviewThe infection preventionist (IP) and the regional nurse consultant (RNC) were interviewed on 11/16/23 at 2:02 p.m. The IP said the staff were to wash their hands with soap and water or use hand sanitizer before and after each task. The IP said the staff had been trained and educated on hand hygiene. He said the staff were to offer handwashing to residents prior to their meals being served. II. Failure to ensure appropriate infection control procedures during wound careA. Facility policy The Wound Care policy, dated October 2010, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. The policy read in pertinent part:-"The purpose of this procedure is to provide guidelines for care of wounds to promote healing.-"Verify that there is a physician's order for this procedure. -"The following equipment supplies will be necessary when performing this procedure: dressing material as indicated; disposable cloth, as indicated; antiseptic as ordered; and personal protective equipment. -"Use disposable cloth to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Arrange supplies so they can be easily reached.-Wash and dry hands thoroughly.-Position the resident. Place a disposable cloth next to the resident under the wound to serve as a barrier to protect the bed lining and other body sites.-Put on exam glove. Loosen tape and remove dressing.-Pull glove over dressing and discard onto proper reciprocal. Wash and dry hands thoroughly.-Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces or other body fluids is likely. Mask and eyewear will only be necessary if splashing of blood or other body fluids into eyes or mouth is likely.-Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers.-Pour liquid solutions directly on the gauze sponges on their papers.-Wear exam gloves for holding gauze to catch irrigation solutions that pour directly over the wound.-Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.-Place one gauze to cover all broken skin. Wash tissue around that usually is covered by the dressing tape or gauze with antiseptic or soap and water.-Dress wound. Pick up the sponge with paper and apply directly to the area. Mark tape with initials time and date and apply to dressing. Be certain all clean items are on a clean field.-Remove the Disposable cloth next to the resident and discard into the designated container.-Discard disposable items in the designated container. discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly."B. Resident status Resident #189, age 78, was admitted on 11/7/23. According to the November 2023 computerized physician orders (CPO), diagnoses included unspecified systolic congestive heart failure, contusion of the left lower leg, subsequent encounter, fluid overload, reduced mobility and need for assistance with personal care. Resident #189 was a new admission to the facility and the minimum data set (MDS) assessment was not due for completion. C. Resident interviewResident #189 was interviewed on 11/14/23 at 9:15 a.m. He said he was newly admitted from the hospital after an accident on his scooter. He said his left lower leg was injured in the accident and he had a wound vacuum on his leg over the contusion (bruise). D. Record The 11/7/23 CPO directed staff to provide skin care per facility protocol, including when skin issues were present. The 11/08/23 care plan read Resident #83 had an actual impairment to his skin integrity. According to the care plan, staff should keep the resident' s skin clean and dry. The 11/8/23 CPO directed staff to practice enhanced barrier precautions of gown and gloves with wound care or involved personal care related to the presence of the wound. The 11/10/23 CPO directed staff to change the wound vacuum dressing on Tuesdays and Fridays. The 11/10/23 skin and wound evaluation read Resident #83 had a hematoma (pooling of blood outside the blood vessels contained under the skin) to his front left lateral (outside surface) lower leg from an accident on 10/23/23, prior to the resident' s admission. The hematoma measured 11.8 centimeters (cm) in length by 7.1 cm in width. According to the evaluation, the skin was fragile and at risk for breakdown. His wound was treated with negative pressure wound therapy (a wound vacuum/suction pump, tubing and dressing to promote healing). The evaluation identified the dressing would be changed on 11/15/23 when the wound physician assistant (PA) was in the facility to assess the wound. E. Observation Wound care observations for Resident #189 were conducted between 11/15/23 at 9:07 a.m. and 9:27 a.m. The wound care was completed by the assistant director of nursing (ADON). The wound PA assessed the condition of the wound during the dressing change. The wound was measured at 12.2 cm by 8 cm. The following practices were observed during the wound care by the ADON:-The ADON wore gloves but she did not wear a gown for enhanced barrier precautions as ordered by the physician (see CPO above). -The clean negative pressure wound therapy supplies were placed directly on top of the residents table next to books, papers and other personal items of the resident. -The clean wound supplies were not placed on a disposable cloth. -The table was not disinfected to kill potential viruses and bacteria on the surface of the table. -The supplies were not placed on a clean field/surface. -The resident had his left leg elevated on a pillow with a pillow case he used throughout the day. The wound care was conducted while the leg remained directly on the pillow. A disposable cloth was not placed near the resident and under the wound as a barrier to protect bedding surfaces and other body sites.-A disposable cloth was not placed near the resident during the wound care to establish a clean field/surface for wound care supplies. -Unused alcohol wipe packets and used alcohol wipes used to remove the old wound dressing were placed directly on the resident's leg pillow. -The packaged peel and stick dressing was placed directly on top of the pillow. -The ADON removed the packaged dressing with her gloved hands and placed the scissors directly on top of the pillow next to the resident' s leg. -The ADON then used the scissors to cut the peel and stick dressing. She placed the cut edges of the dressing on half of the wound surface edges. The ADON placed the scissors back on the pillow. -The ADON picked up the scissors and proceeded to cut more of the peel and stick dressing. Her gloves got stuck to the dressing. She removed her gloves and threw the dressing away. She donned new gloves. -The ADON did not perform hand hygiene after doffing her gloves and donning new gloves. She picked up the scissors again from the pillow and completed shaping the dressing. -The ADON dropped the scissors on the floor. She picked up the scissors and left the room to sterilize them. The ADON returned to the room with clean gloves and retrieved the packaged foam and tubing from the resident' s table. The ADON opened the packaging with her gloved hands and proceeded to complete the wound dressing and attach the tubing to the wound vac. F. Staff interviewThe ADON was interviewed on 11/15/23 at 1:35 p.m. The ADON said Resident #189 admitted to the facility with a large hematoma that required drainage through a wound vac. The ADON said she was not wound certified but had had a lot of experience with wound care. The ADON said during wound care, infection control procedures needed to be practiced. She said hand hygiene needed to be completed before and after wound care. The ADON said gloves needed to be changed after touching a wound area. She said she probably should have used hand hygiene everytime she changed her gloves. The ADON said the wound care should have been completed with a clean work surface to prevent potential contamination to the resident' s wound. She said she would not consider his table or his pillow a clean surface to place his wound care supplies on. She said she should not have put the scissors she was using to cut his dressing onto his pillow where he rested his leg. She said she should have wiped off his table before placing the clean wound supplies on the surface of the table.

Based on record review and staff interviews the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#3, #16 #62, #51 and #59) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to:-Offer Resident #62 a pneumococcal vaccination upon admission; -Offer additional doses of the pneumococcal vaccine to Residents #3, #16 and #51; and,-Administer annual flu vaccinations to Residents #51, #3, #59. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 9/28/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: "Routine vaccination - pneumococcal-For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20)." (see notes)-For those "over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20." "Special situations: Age 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups.-Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies.-Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies." II. Facility policyThe Influenza, Prevention and Control of Seasonal Vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 11/13/23. It read in pertinent part, "The infection preventionist organizes and oversees an annual influenza vaccine campaign. All residents and staff are offered the vaccine prior to the onset of the influenza season."The Pneumococcal Vaccine policy, revised March 2022, was provided by the NHA on 11/13/23 at 4:47 p.m. It read in pertinent part, "All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination."III. Resident #62A. Resident #62Resident #62, age greater than 90, was admitted on 8/19/22. According to the November 2023 computerized physician orders (CPO), diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke) and muscle weakness. The 8/23/23 minimum data set (MDS) assessment documented no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. -The MDS inaccurately documented that the resident was not offered the pneumococcal vaccination. B. Record reviewA review of Resident #62's electronic medical record (EMR) revealed the immunization tracking sheet did not show the resident received the pneumococcal vaccination. However, the resident had signed a consent form on 8/19/22 giving permission to receive the pneumococcal vaccination. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The Colorado Immunization Information System (CIIS) showed the pneumococcal vaccination was recommended on 5/31/22. IV. Resident #3A. Resident statusResident #3, age 85, was admitted on 5/25/22. According to the November 2023 CPO, diagnoses included atrial l fibrillation (a quivering or irregular heartbeat), heart failure and hypertension. The 8/17/23 MDS assessment documented Resident #3 had severe cognitive impairment with a BIMS score of three out of 15. -The MDS assessment inaccurately documented the resident was up to date on her pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record reviewA review of Resident #3's EMR revealed the immunization tracking sheet showed the resident received a pneumococcal vaccination on 10/1/16. However, the resident had signed a consent form on 5/25/22 giving permission to receive the updated pneumococcal vaccination and the flu vaccination yearly. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The resident had not yet received the flu vaccination as of 11/16/23 for the 2023-2024 flu season. V. Resident #51A. Resident #51Resident #51, age 83, was admitted on 11/10/21. According to the November 2023 CPO, diagnoses included dementia, unspecified sequelae of cerebral infarction (stroke) and muscle weakness. The 10/6/23 minimum data set (MDS) assessment documented Resident #51 had moderate cognitive impairment with a BIMS score of eight out of 15. -The MDS assessment inaccurately documented the resident was up to date on her pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record reviewA review of Resident #51's EMR revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination on 7/1/16. However, the resident had signed a consent form on 11/1/21 giving permission to receive the updated pneumococcal vaccination and the flu vaccination yearly. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The resident had not yet received the flu vaccination as of 11/16/23 for the 2023-2024 flu season. VI. Resident #16A. Resident statusResident #16, age 85, was admitted on 6/29/23. According to the November 2023 CPO, diagnoses included hypertension and peripheral vascular disease. The 9/23/23 MDS assessment revealed Resident #16 was cognitively intact with a BIMS score of 15 out of 15. -The MDS assessment inaccurately documented the resident was up to date on his pneumococcal vaccination. -The MDS assessment failed to document if the vaccination was offered. B. Record reviewA review of Resident #16's EMR revealed the immunization tracking sheet showed the resident received the pneumococcal vaccination dose two on 10/23/07. However, the EMR failed to show evidence that the resident received the first dose of the pneumococcal vaccination. The EMR failed to show a CIIS wasreviewed to verify the resident's vaccination status. A consent was signed by the resident's power of attorney requesting a pneumococcal vaccination to be administered on 6/8/23. VII. Resident #59A. Resident statusResident #59, age 80, was admitted on 6/27/22. According to the November 2023 CPO, diagnoses included cerebral vascular disease and hypertension. The 9/26/23 MDS assessment revealed Resident #59 was cognitively intact with a BIMS score of 15 out of 15. -The MDS inaccurately documented that the resident had been offered and refused the annual flu vaccination, whereas, he had provided consent to receive the flu vaccination yearly. B. Record reviewA review of Resident #59's EMR revealed the immunization tracking sheet showed the resident had not received the flu vaccination. However, the resident had signed a consent form on 6/27/22 giving permission to receive the flu vaccination yearly. -The EMR failed to show that the resident had been administered the pneumococcal vaccination after the consent was signed. -The resident had not yet received the flu vaccination as of 11/16/23 for the 2023-2024 flu season. VII. InterviewsThe infection preventionist (IP) and the regional nurse consultant was interviewed on 11/16/23 at 2:02 p.m. The IP said the Colorado Immunization Information system (CIIS) database was utilized to ensure the resident's vaccination record was received. He said the admitting nurse would then offer and provide education to the resident in regard to the importance of being vaccinated against pneumonia and influenza. He said if the resident accepted the pneumonia vaccination then the consent was signed and the vaccination was administered after receiving the physician's order. He said if the resident refused then the resident signed the consent form documenting that they refused. He said that the facility followed the CDC pneumococcal vaccination timing for adults. The IP said that he had performed an audit last week during a mock survey, and he realized not all of the residents were up to date on the pneumococcal vaccinations. He said he had no plan developed for getting residents up to date on their pneumococcal vaccinations. The IP said the flu vaccinations had not yet been administered for the 2023-2024 flu season. He said that he had not received the vaccinations. He said the flu vaccination was ordered late. On 10/1/23 he emailed the pharmacy consultant to inquire about ordering the flu vaccine. However, did not receive a timely response, and once he received a response he ordered the flu vaccinations on 11/6/23. The IP said he had attempted to get a mobile flu clinic to come to the facility, however, they were all booked up. He said the medical director was aware the vaccinations had not been provided. He said the vaccinations could take six weeks to arrive at the facility.

Based on resident interview, observations and staff interviews, the facility failed to ensure one resident (#83) of three residents' call light system was functioning in its entirety out of 48 sample residents..Specifically, the facility failed to:-Ensure Resident #83's restroom call light was functioning properly; and, -Ensure a timely response to repair Resident #83's call light after staff became aware the call light was not working. Findings include:I. Facility policy The Call System policy, dated September 2022, was provided by the director of nursing (DON) on 11/15/23 at 4:50 p.m. The policy read in part:"Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation."Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. "Call system communication may be audible or visual. The system may be wired or wireless."The resident call system remains functional at all times. If audible communication is used, the volume is maintained and audible level that can be easily heard. If visual communication is used, the lights remain functional. "The call system is routinely maintained and tested by the maintenance department."Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately."II. Resident status Resident #83, age 92, was admitted on 9/18/23 and readmitted on 10/26/23. According to the November 2023 computerized physician orders (CPO), diagnoses included multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified abnormalities of gait and mobility, weakness, other reduced mobility, muscle weakness, other lack of coordination, osteoarthritis, chronic kidney disease and need for assistance with personal care. The 11/1/23 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The care plan for Resident #83, revised on 11/10/23, identified the resident was at a high risk for falls and had an increased risk for actual/potential limitations in her ability to perform activities of daily living (ADLs). Resident #83 care plan directed staff to encourage the resident to use the call bell/light to call for assistance as needed and ensure the resident's call light was within reach. The care plan revealed Resident #83 required prompt response to all requests for assistance. III. Resident observation and interviewResident #83 was interviewed on 11/13/23 at 2:15 p.m. The resident said when staff came in to answer her call light, the staff often turned off the call light and would tell her they would be back to help but then it took a long time before the staff would come back to assist her. Resident #83 said before breakfast this morning (11/13/23) she was assisted to the restroom by a certified nurse aide (CNA) who left her in the restroom. Resident #83 said when she was done using the restroom she pulled the restroom call light but no staff came to help her. The resident said she had to yell for help until the assistant director of nursing (ADON) heard her and came in. Resident #83 said she felt she was in the restroom for almost two hours waiting for staff. Resident #83 said it was an awful long scary time. She said she was concerned because she recently had a major fall when she was at home. She said staff were usually not available to answer call lights around meal times because they were all in the dining rooms.-At 3:00 p.m. the ADON entered Resident #83's room. The resident said the ADON was the one who found her in the restroom yelling for help. The ADON said she heard the resident yelling and entered the restroom on the morning of 11/13/23 around breakfast time. The resident said she did not understand why a staff member would assist her to the restroom and then not come back to help her when she was done. The ADON said the resident restroom call light was on but it was not signaling above her room door indicating the resident needed assistance. She said the call light was signaling over the hallway shower room door, next door to the resident room. Resident #83 told the ADON that she was afraid when no staff came to assist her and she could not assist herself out of the restroom. On 11/15/23 at 11:15 a.m. the restroom call light was observed with registered nurse (RN) #1, two days after the call light was identified in need of repair. The RN revealed the restroom call light in Resident #83's room was still not working over the resident room door when the restroom call light pad was pushed or when the emergency restroom pull string was pulled. The call light over the shower room door turned on. -At 1:54 p.m. the ADON tested the restroom call light again and identified that the restroom call light still did not signal the light over Resident 83's room. -At 2:35 p.m. the maintenance service director (MSD) observed the restroom call light signaled over the hallway shower room door instead of above Resident 83's room door. IV. Staff interviewThe ADON was interviewed on 11/15/23 at 1:51 p.m. The ADON said she had verbally reported the call light concern to the MSD in the early afternoon of 11/13/23 after she identified Resident #83's restroom call light was not working properly. The ADON said a CNA had also identified Resident #83's restroom call light was signaling over the shower room earlier in the morning of 11/13/23. The ADON said she had not heard additional reports of the call light not working properly. The ADON said she thought the call light was fixed. She said if the call light was still not working it would normally be something she would have heard about. The MSD was interviewed on 11/15/23 at 1:58 p.m. The MSD said he was not sure if Resident 83's call light not working was reported to maintenance. He said he would have to check with his maintenance assistant. -At 2:11 p.m. the MSD said he did not have a work order put in by staff identifying a call light was not working in the room of Resident #83. The MSD said he spoke to the maintenance assistant and neither the maintenance assistant or he had any recollection of anyone verbally telling either of them a call light was not working properly. The MSD was interviewed again on 11/15/23 at 2:35 p.m. He said the call light system was new to the facility and was installed in July 2023. The call light system could be remotely fixed usually by contacting the call light system vendor who had remote access. The MSD said he completed five resident room call light audits a week to ensure the call system was working properly. -At 2:59 p.m. the MSD said he looked at the call light audits and said Resident 83's room call lights (room and restroom) were last checked and in working order on 8/23/23. -At 3:53 p.m. the MSD said the call light was fixed remotely. He said it only took three minutes to repair the problem but he just needed to know it was broken. He said he had multiple tasks he was trying to do in the course of a day. He said if the staff told him in passing something needed to be fixed, the staff still needed to document the request so it could be tracked and he could make sure it was done. The MSD said it was the facility policy for staff to do a work order for a maintenance request and the staff all knew the policy. The staff had been trained in spring 2023 on how to use the work order program and there were directions on how to use the work order program at each nursing station. The MSD said he felt assured that all other resident room call lights were working properly because the staff were usually good about telling him when there was a concern and would put in a work order. He said there had been no other work orders requested to repair other resident call lights. The MSD said he would speak to the interdisciplinary team to discuss what more could be done to help prevent a similar situation from happening again related to timely communication when repairs needed to be completed. The social service director (SSD) was interviewed on 11/16/23 at 11:07 a.m. The SSD said Resident #83 had a fear of falling because of a past fall before she was admitted to the facility. The SSD said it would be important to decrease Resident #83's fall risk to help reduce her fears. The nursing home administrator (NHA) was interviewed on 11/16/23 at 2:48 p.m. He said staff had received prior training to communicate facility repair needs on a work order through the facility work order request system and education would be provided to staff again to remind and ensure knowledge of the work order system. V. Record reviewThe maintenance call light function audit was provided by the MSD on 11/15/23 at 3:53 p.m. The audit identified Resident #83's room and restroom were in good working order on 8/23/23. The audit identified the room of Resident #83 was last audited prior to Resident #83 admission. VI. Facility follow upThe Maintenance Work Order in-service was provided by the MSD on 11/16/23 at 6:31 p.m. The in-service identified facility staff were educated again on 11/16/23. The in-service read: "Work orders are to be submitted in the facility (maintenance work order) system that can be accessed through any computer in the facility or through (the electronic records program) used by clinical staff."Verbal work requests are not valid when given to maintenance and are subject to lack of follow through at the fault of the requester unless a work order has been officially submitted for all types of work in the building done by maintenance."Emergency verbal work will always be responded to; however verbal emergency work still always requires a submission of a work order by the individual who becomes aware of the repair."Work orders are required documentation of work that is being completed by maintenance and supports the individual who first becomes aware of any necessary work that needs to be completed as it is through these work orders that important and critical repairs are being completed in a reasonable time frame (usually 24 hours) unless certain obstacles arise. "All submitted and completed work orders can be pulled at any time to verify repairs needed along with any detailed notes for the repair."All work orders must provide location, room numbers, name a person putting the work order in, name of and reason for the person being affected, and plenty of supporting detail to ensure work can be completed as soon as possible."By signing this you acknowledge you have been trained in how to and know why it is important to put in work orders." The Maintenance Work Order inservice attendance sheet identified 18 staff members received the education including the ADON and RN #1.

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

A revisit survey was completed on 9/21/23 for all previous deficiencies cited on 7/19/23. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/11/2023 and 09/17/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/04/2023 and 09/10/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/14/2023 and 08/20/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A focused infection control survey was conducted on 7/19/23. One deficiency was cited.

An Emergency Preparedness focused infection control survey was conducted 7/19/23. No deficiencies were cited.

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 in one of three units. Specifically, the facility failed to ensure:-High touch surface areas were not potentially cross contaminated;-Consistent hand hygiene was performed between doffing and donning gloves; and,-Shared equipment, specifically transfer devices, was consistently wiped down between resident use. Findings include:I. Facility policy and procedureThe Infection Prevention and Control Program policy, revised October 2018, was provided by the nursing home administrator (NHA) on 7/19/23. The policy read in pertinent part: "An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. "The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance Improvement program."Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment (PPE)." The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the NHA on 7/24/23. According to the policy, staff should perform hand hygiene after removing gloves. II. ObservationsA. Resident room cleaning Housekeeper (HK) #1 was observed cleaning three resident rooms on 7/19/23 between 10:22 a.m. and 11:06 p.m. -At 10:22 a.m. HK #1 donned gloves and entered room 233. She did not perform hand hygiene before she donned her gloves. Between 10:22 a.m. and 10:27 a.m., HK #1 wiped down the window ledge and bedside table, and cleaned the sink. She changed her cleaning cloth and doffed and donned new gloves after each area was cleaned but did not perform hand hygiene after she doffed her gloves and before she donned new gloves. -At 10:27 a.m. HK #1 entered the resident room restroom and proceeded to scrub the inside of the toilet with a scrub brush and wiped down the toilet seat and outer surfaces with a cleaning cloth. The HK then used the same cleaning cloth to wipe down the toilet, the housekeeper wiped grab bars on the wall next to the toilet. -At 10:29 a.m. HK #1 doffed her gloves, unlocked her cleaning cart and placed the toilet cleaner in the cart. HK #1 did not perform hand hygiene after she cleaned the restroom and doffed her gloves. She donned new gloves and proceeded to sweep the room. While sweeping, she touched the restroom door handle and outside resident room door handle with her potentially contaminated gloves. The HK finished sweeping the room and doffed her gloves. She did not perform hand hygiene after she removed the gloves. -At 10:35 a.m. HK #1 donned new gloves, placed a wet mop pad on the floor and proceeded to mop. -At 10:37 a.m. HK #1 removed the used pad from the mop head used on the floor, with her gloved hands, and touched the door handle. The HK used more two mop pads to complete the remainder of the room. She did not change her gloves and perform hand hygiene after removing the mop pad. The HK mopped the bathroom, touching the bathroom door handle. -At 10:40 a.m. HK #1 finished mopping, doffed her gloves and performed hand hygiene by use of alcohol based hand rub (ABHR) located on her cart. She did not wipe off the resident room door handles after touching the handles with the same gloves she used to remove the used mop heads from the mop handle. -Between 10:45 a.m. and 11:07 a.m. HK #1 cleaned room 229. She collected trash, wiped down the window blinds, and wiped down the bedside table, touching the resident mug and water container, and cleaned the sink with gloved hands. The HK changed her cleaning clothes and gloves after completing each area. She did not perform hand hygiene between doffing and donning of the gloves. -At 10:53 a.m. HK #1 entered the restroom and scrubbed the inside of the toilet bowl, flushed the toilet with her gloves hands, wiped down the toilet seat and outside of the toilet bowl with a cleaning cloth. She did not wipe down the flush handle with a clean cloth after she touched the handle with the same gloved hands used to scrub the toilet. HK #1 proceeded to then use the same cloth to wipe down the hand holds of the commode, before wiping the inside of the commode bowl. HK #1 doffed her gloves, unlocked the cart and placed the cleaner back in the cart. She did not perform hand hygiene after she cleaned the restroom and doffed her gloves. -At 11:01 a.m. HK #1 donned new gloves, swept the room and doffed the gloves. She did not perform hand hygiene after removing her gloves.-At 11:03 a.m. HK #1 proceeded to mop the room. -At 11:06 a.m. the HK removed the used mop pad from the floor, placed a new mop pad on the mop handle, removed a piece of debris off the floor with her gloved hands and threw the debris away, touching the door handle with her gloved hand. HK #1 finished mopping the room, doffed gloves and performed hand hygiene. She did not wipe down the door handle after touching it with her contaminated gloves. -At 11:12 a.m. HK #1 entered and proceeded to clean room 225. She changed her cleaning cloth and gloves after each task, including wiping the resident room door handles and frame, but she did perform hand hygiene when she donned and doffed gloves. -At 11:21 a.m. the HK scrubbed the inside of the toilet bowl and wiped it down with a cleaning cloth. HK #1 then used the same cleaning cloth to wipe the grab bar, the flush handle of the toilet and the inside restroom door handle. -At 11:25 a.m. HK #1 doffed her gloves and placed the toilet cleaner in the cleaning cart, and donned new gloves. She did not perform hand hygiene after cleaning the restroom and doffing her gloves. She did not perform hand hygiene before she donned new gloves and proceeded to sweep and mop the room. The HK completed the cleaning of the room, doffed her gloves and performed hand hygiene. B. Shared equipment disinfection CNA #1 and CNA #2 retrieved a sit to stand transfer device and entered room 222 on 7/19/23 at 1:31 p.m. The CNAs assisted the resident into the restroom by use of the transfer device. The CNAs exited room 222, leaving the transfer device in the room with the resident.-At 1:38 p.m. CNA #1 retrieved the transfer device out of room 222 and entered room 209 to assist another resident. Between 1:38 p.m. and 1:50 p.m. The CNAs removed the transfer device from room 209 and re-entered room 222. The CNAs assisted the resident in room 222 in the restroom with the transfer device. The shared transfer device was not cleaned between resident use in rooms 209 and 222. -At 1:50 p.m. CNA #1 exited the room with a bag and entered the soiled utility room as CNA #2 retrieved disinfectant wipes from the utility room and wiped down the transfer device. III. Record review The 9/3/22 and 10/6/22 staff inservice summary was provided by the infection preventionist (IP) on 7/19/23. The inservice summary identified staff were in-serviced on infection control procedures including standard precautions. The inservice summary identified staff reviewed CDC guidance of the "Implementation of personal protective equipment use in nursing homes to prevent the spread of multidrug resistant organisms." The guidance read in part: "Standard precautions are a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Proper selection and use of PPE, such as gowns and gloves, is one component ofstandard precautions, along with hand hygiene, safe injection practices, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable medical equipment. Use of PPE is based on staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens." The inservice attendance sheet identified HK #1 attended the inservice on 9/3/22. The 3/2/23 housekeeping meetings minutes identified the housekeepers were informed there had been several complaints regarding the cleanliness in the facility, including resident rooms. The meeting minutes identified the housekeepers were reminded of areas to clean including the cleaning of resident commodes, risers and the entire surface of the toilets. -The meeting minutes did not identify housekeepers were reminded to use hand hygiene before and after glove use. The minutes did not identify the order of the cleaning of the room surface areas in resident rooms to prevent potential cross-contamination. The unit specific cleaning checklist was provided by the NHA on 7/25/23. The checklist directed housekeeping to clean all touchable surfaces such as door handles, grab bars, resident furniture, and toilets. The checklist did not identify the order of the touchable surface cleaning, to prevent the potential spend of transmission based viruses and infections. IV. Staff interviewsHK #1 was interviewed on 7/19/23 at 11:35 a.m. She said to prevent cross-contamination, she would not use the same cleaning cloth she would clean the toilet with to clean the sink. HK #1 said she was trained to use a different cloth for each side of the room and in every new area, along with a new mop pad for each side and in the bathroom. The HK said hand hygiene should be done after she changed her gloves. Registered nurse (RN) #1 was interviewed on 7/19/23. She said performing hand hygiene was the number one way to stop the spread of infections. CNA #1 was interviewed on 7/19/23 at 2:28 p.m. She said shared equipment such as the mechanical lifts and other transfer devices should be disinfected between each resident. She said even when the staff was busy, they needed to take their time to wipe down the equipment after use. CNA #2 was interviewed on 7/19/23 at 2:34 p.m. She said shared equipment needed to be wiped down after use. She said disinfect wipes were in the cabinet at the nurses station and the utility room. The infection preventionist (IP) was interviewed on 7/19/23 at 3:10 p.m. The IP said lifts and other shared equipment should be cleaned at the end of every shift and after every resident use to stop the spread of pathogens. The IP said he recently conducted hand hygiene audits with the nursing staff with on the spot education/reminders as needed. He said he was in the process of updating the new hire orientation training which included infection control. The IP said on 7/14/23 he started staff competencies for seasoned nursing staff, which included infection control. The IP said departments such as housekeeping, received their job specific infection control training from their supervisor. The IP said the facility had a COVID outbreak between 3/22/23 and 5/1/23. The IP said there were multiple positive staff and 23 positive residents who contracted COVID during the outbreak. The IP said he did not review or identify concerns with shared equipment use or housekeeping cleaning practices during or after the outbreak. The housekeeping director (HKD) was interviewed on 7/19/23 at 6:24 p.m. The HKD said she did random trained and reminded her staff on basics of cleaning and infection control. She said she has told housekeepers to use new cleaning cloths after every new task and perform hand hygiene after every change of gloves. The HKD said the housekeepers should clean the room starting from the top surfaces and working their way down to the bottom surfaces, with floor as the last cleaning step. The HKD said dirty floors would contaminate the gloves. She said the housekeepers should avoid touching any clean surfaces after removing the used mop pads. She said grab bars should be cleaned before wiping down the toilet. The NHA and the DON were interviewed on 7/19/23 at approximately 7:20 p.m. The NHA and the DON said the facility would continue to remind and educate staff on proper infection control procedures.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/12/2023 and 06/18/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/29/2023 and 06/04/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/22/2023 and 05/28/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit to the 3/21/23 survey was completed on 5/2/23 and 5/3/23. The facility was in compliance with the regulations surveyed.

A revisit to the 3/21/23 survey was completed on 5/2/23 and 5/3/23. The facility was in compliance with the regulations surveyed.

A revisit survey was completed on 4/27/23 for all previous deficiencies cited on 2/23/23. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO31553 was completed 3/23/23. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) of three residents reviewed for falls out of eight sample residents. Specifically, the facility:-Failed to ensure certified nurse aide (CNA) #4 followed proper procedure while providing cares to Resident #1 and ensure the resident was safe;-Failed to implement two-person assistance when providing cares to Resident #1, which was identified as a resident need on their facility assessment, and,-Failed to implement a care-planned intervention to provide two-person assistance when providing cares to Resident #1. On the morning of 12/30/22, CNA #4 was preparing to assist Resident #1 with personal cares while she was in bed. The resident required two-person extensive assistance with activities of daily living (ADL). However, the CNA assisted the resident independently, without a second person, and the resident suffered a fall from the bed that resulted in pain, transportation to the emergency department, bilateral femur fractures and a hematoma (solid swelling of clotted blood) on her thigh. Findings include:I. Facility policy and procedureThe Managing Falls and Fall Risk policy and procedure, dated March 2018, was provided by the assistant director of nurses (ADON) on 3/22/23 at 3:22 p.m. It included in pertinent part: "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors included delirium or other cognitive impairment, pain, lower extremity weakness, medication side effects, functional impairments, visual deficits, incontinence, heart failure, neurological disorders and balance and gait disorders. A resident-centered fall prevention plan would be implemented to reduce the specific risk factors for falls for each resident."II. Resident #1 A. Resident statusResident #1, age 71, was admitted on 1/7/17 and readmitted on 1/13/23. According to the March 2023 computerized physician orders, diagnoses included severe morbid obesity, generalized muscle weakness, difficulty in walking, and fractures of right and left femurs. The 10/11/22 facility assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two plus person's physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She had no rejection of care. B. Record reviewThe care plan, initiated 11/27/2020 and revised 3/17/23, identified the resident preferred to have only female caregivers provide personal cares. Interventions included she would let female caregivers provide all personal cares, if possible provide female staff from other units to provide care, and staff would provide cares in teams of two for safety. The care plan, initiated 7/4/17 and revised 3/17/23, identified the resident required assistance with ADLs related to obesity, decreased mobility, and the aging process. Interventions included she was totally dependent on two-plus staff for repositioning and turning in bed, required extensive assistance by two staff to dress her, and was totally dependent on at least two staff to check and change her incontinence brief. The CNA Kardex Report dated 12/30/22, included the following categories and interventions: she was totally dependent on two-plus staff for repositioning and turning in bed, she was totally dependent on at least two staff to check and change her incontinence brief, she required extensive assistance by two staff members to dress herThe Nursing Quarterly Data Collection for Fall Risk, dated 10/10/22, identified the resident's score was "0.0," which indicated she was not at risk to fall. A progress note, dated 12/30/22 at 6:27 a.m., was written by a registered nurse (RN) and documented she was called to assess Resident #1 after a fall out of the bed. The resident was being turned when she rolled out of the left side of the bed onto her anterior surface. The RN assessed all of the resident's joints with pain noted in the anterior right knee. She was turned to her back with the assistance of four staff members with splinting provided to the lower extremities. A mechanical lift was used to transfer the resident into the bed. The resident had a large discoloration to her right knee that extended to the proximal lower leg and discoloration to the anterior right foot with swelling in both areas. There was a discoloration to her left knee and a small area on the mid anterior lower leg with swelling. Any assessment attempted by the RN of the right knee resulted in extreme pain. The resident was being changed by only one CNA at the time, which resulted in her rolling out of the bed. The medical doctor was contacted to obtain an order to transfer the resident to the hospital. The progress note included, "Future intervention would be to always have two staff for all cares."The facility's investigation was reviewed and included the following: A CNA assigned to Resident #1's hall stated that he and CNA #4 began their check and changes and had completed changing all of the residents on the hall, with Resident #1 being their last resident. He stated CNA #4 went in on her own to speak to the resident due to him recently being "kicked out" because he was a male, which was the resident's preference to not have male caregivers. CNA #4 voiced that it was "okay" for her to change Resident #1 alone, due to trust amongst one another. The investigation documented CNA #4 was interviewed and reported during the care the resident rolled out of bed and experienced a witnessed fall. The resident stated, "I rolled out of the bed." The CNA verbalized that Resident #1 fell while she was attempting to adjust/reach for a personal item, causing her momentum to shift without the ability to stop herself, which resulted in the fall. Interviews conducted indicated that the resident had a history of "kicking other staff members out and declining cares." The resident's preference is not to have males change her. CNA #4 stated that the resident verbalized "okay" to being changed alone. The hospital emergency department admission history and physical, dated 12/30/23, was reviewed and documented the x-ray results of her bilateral legs included pain after a fall which resulted in severely comminuted (multiple bone splinters or fragments) impacted distal femur fracture with some posterior displacement. The patella (knee cap) was displaced laterally (to the side). The resident experienced low blood pressure and heart rate after she was given pain medication and required resuscitation with fluids. She was admitted to the hospital and did not return to the facility until 1/13/23 (14 days later). III. Staff interviewsThe director of nurses (DON), ADON and nursing home administrator (NHA) were interviewed on 3/21/23 at approximately 3:30 p.m. and explained the facility did not currently have a facility coordinator (staff that completed resident facility assessments) who could be interviewed. The facility assessment dated 10/11/22 was reviewed and the DON said Resident #1 was assessed to require extensive assistance of two people for bed mobility. The ADON clarified the staff were providing more than 50 percent of the assistance but the resident was able to participate some, less than 50 percent. The ADON said the two people would mean there was one person on each side of the bed so one would help roll and the other would help hold the resident during turning and bed mobility. The NHA was interviewed on 3/21/23 at 4:04 p.m., and he said on the day Resident #1 fell out of bed, two CNAs working on that floor; a male and a female CNA (CNA #4) were conducting rounds. He said CNA #4 made the decision to go in and ask Resident #1 if it was okay to provide cares to her without the assistance of a second staff member, and that CNA #4 admitted to not asking anyone for help. The NHA said staffing was not low and there was an extra staff member working that morning until 10:00 a.m. He said CNA #4 had initiated cares with the resident by herself, when the resident reached for a personal item and then fell out of bed. He said there was a time prior when Resident #1 would accuse the staff of stealing things from her, so they initiated "cares in pairs" for mechanical lift use as well as for behavioral reasons. Restorative certified nurse aide (RCNA) #1 was interviewed on 3/21/23 at 4:20 p.m., and she said she routinely worked with Resident #1. She said the facility had multiple ways to communicate to staff which residents required two-person cares and assistance. A sign was posted on the wall in each resident's room above their bed to indicate whether the person required a mechanical lift for transfers as well as how many staff were required to provide assistance for cares. In addition, she said a "CNA Book" was located at each of the nurses' stations with a list of which residents required a mechanical lift, the sling size, their room number and their name. She said all clinical staff were trained prior to starting work on the floors about this. The RCNA showed the list that was posted in the CNA book in December 2022, and it revealed Resident #1 required transfers with a Hoyer mechanical lift with a green sling. The RCNA said she also checked the residents' care plans to ensure the interventions were care-planned approaches. The RCNA said Resident #1 was supposed to have two-person assistance for personal cares as well, which included bed mobility, which was for both the resident's and the staff's safety. The RCNA said Resident #1 was able to make safe decisions about her care "sometimes," but not always, and at times the resident would "grab the straps" on the mechanical lift during transfers, "and that "was not safe." She said Resident #1 had a history of falsely accusing staff of mistreating her, so the facility began providing care to her in pairs, with two staff members present. The RCNA said the resident was particular about which CNAs provided her with care, and she did not like male caregivers. CNA #3 was interviewed on 3/21/23 at 4:55 p.m., and she said she routinely worked with Resident #1. She said Resident #1 could brush her hair, wash her face, and brush her teeth if she was provided with set up assistance. She said when the resident was turned in bed, they were always supposed to provide assistance with two people because the resident was very large and "could roll off." The CNA said Resident #1 had days where she was alert and could make good safety decisions about her care, and she had days where she was confused, and was not consistently alert and oriented. CNA #3 said the facility had provided clinical staff with additional training on how to safely provide care for Resident #1 after her fall, but said she did not receive the training. Instead, she said she was "told by nurses what they were doing now" to provide care for the resident. RN #3 was interviewed on 3/21/23 at 5:07 p.m., and she said she routinely worked with Resident #1. She said the resident could not provide much care for herself and before the accident, she required two-person assistance for ADL care, transfers, changing her, and rolling her in bed "because she was very large." She said Resident #1 was confused at times and would accuse staff of random things that were not true, and did not like men in her room. She had a cognitive communication deficit with garbled speech and was difficult to understand at times. RN #3 said it was not a normal behavior of Resident #1 that she would accept care assistance from a single staff person because she was always scared she was going to roll off the bed, and knew it was in her best interest for safety to have the assistance of two staff members at a time. RN #3 stated, "She didn't really have good safety awareness and had a fear of falling."RN #3 said one staff member would go in and help her at times because there was not enough staff. She said as recently as last night, she was aware of a single staff member providing care and assistance to a resident who required two-person assistance. RN #3 said after Resident #1 fell on 12/30/22 and returned to the facility from the hospital, a change was made that required her to receive the assistance of four staff members during cares and transfers, and there was never a time after that she did not have four people assist her. The RN stated, "Everyone felt really bad. We did that to her." The medical director (MD) was interviewed on 3/21/23 at 3:08 p.m., and she said since Resident #1 was assessed by the facility to need two-person assistance for bed mobility and cares, then she should have been provided with that assistance. The MD said the resident's history with making her own reasonable, safe decisions was not reliable and she did not make appropriate decisions at times. The DON, ADON and NHA were interviewed on 3/21/23 at 5:29 p.m. The ADON said staff knew which residents required two-person cares because it was listed on the CNA Kardex, which could be accessed by CNAs and nurses. She said each residents' room also had laminated signs above the bed that indicated how much assistance they required. If a resident who required two-person assistance told a staff member it was acceptable to provide one-person assistance to them, they should still provide assistance of two staff members because it was for resident and staff safety. IV. Facility follow-upThe NHA provided the following documentation on 3/22/23 at 4:11 p.m., which included the facility's response to Resident #1's fall on 12/30/22. The NHA said the audits were done recently and not during the time, the performance improvement plan was put in place, and included the following:An Ad Hoc Quality Assurance Performance Improvement/Four Point Plan of Correction Agenda and Summary, which was dated 1/3/23. The meeting was attended by 11 interdisciplinary team (IDT) members and identified an opportunity for improvement that included verifying that residents who required two-person cares was reflected on both the resident care plans and Kardex. Audits were to be completed by 1/6/23. All direct care staff would be educated on residents who required two-person cares and educated to check the Kardex when cares were provided, which was to be completed by 1/20/23. In addition, the DON or designee would complete the audits twice a week for four weeks to ensure that staff were following the plan of care. A Staff In-Service Summary, dated 1/12/23, included a review by the ADON that explained what the Kardex was and where it was located. There was no attendance record included. An undated, untitled Attendance record was provided, which included the signatures of 25 staff members. Four staff (two CNAs, one licensed practical nurse, and one RN) audits were included, which were undated to know when they were completed, and each included the following three questions:1. When you are unsure of how a resident transfers, where can you find this information?2. Do you know how to access the Kardex/Care Plan to find this information?3. Ask for demonstration on where to find how a specific resident transfers. One of the four staff members audited did not know how to access the Kardex/Care Plan, and required a demonstration of the process.

A survey for Incident #31092 was conducted on 3/21/23. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) of three residents reviewed for falls out of eight sample residents. Specifically, the facility:-Failed to ensure certified nurse aide (CNA) #4 followed proper procedure while providing cares to Resident #1 and ensure the resident was safe;-Failed to implement two-person assistance when providing cares to Resident #1, which was identified as a resident need on their minimum data set (MDS) assessment, and,-Failed to implement a care-planned intervention to provide two-person assistance when providing cares to Resident #1. On the morning of 12/30/22, CNA #4 was preparing to assist Resident #1 with personal cares while she was in bed. The resident required two-person extensive assistance with activities of daily living (ADL). However, the CNA assisted the resident independently, without a second person, and the resident suffered a fall from the bed that resulted in pain, transportation to the emergency department, bilateral femur fractures and a hematoma (solid swelling of clotted blood) on her thigh. Findings include:I. Facility policy and procedureThe Managing Falls and Fall Risk policy and procedure, dated March 2018, was provided by the assistant director of nurses (ADON) on 3/22/23 at 3:22 p.m. It included in pertinent part: "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors included delirium or other cognitive impairment, pain, lower extremity weakness, medication side effects, functional impairments, visual deficits, incontinence, heart failure, neurological disorders and balance and gait disorders. A resident-centered fall prevention plan would be implemented to reduce the specific risk factors for falls for each resident."II. Resident #1 A. Resident statusResident #1, age 71, was admitted on 1/7/17 and readmitted on 1/13/23. According to the March 2023 computerized physician orders, diagnoses included severe morbid obesity, generalized muscle weakness, difficulty in walking, and fractures of right and left femurs. The 10/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two plus person's physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She had no rejection of care. B. Record reviewThe care plan, initiated 11/27/2020 and revised 3/17/23, identified the resident preferred to have only female caregivers provide personal cares. Interventions included she would let female caregivers provide all personal cares, if possible provide female staff from other units to provide care, and staff would provide cares in teams of two for safety. The care plan, initiated 7/4/17 and revised 3/17/23, identified the resident required assistance with ADLs related to obesity, decreased mobility, and the aging process. Interventions included she was totally dependent on two-plus staff for repositioning and turning in bed, required extensive assistance by two staff to dress her, and was totally dependent on at least two staff to check and change her incontinence brief. The CNA Kardex Report dated 12/30/22, included the following categories and interventions: she was totally dependent on two-plus staff for repositioning and turning in bed, she was totally dependent on at least two staff to check and change her incontinence brief, she required extensive assistance by two staff members to dress herThe Nursing Quarterly Data Collection for Fall Risk, dated 10/10/22, identified the resident's score was "0.0," which indicated she was not at risk to fall. A progress note, dated 12/30/22 at 6:27 a.m., was written by a registered nurse (RN) and documented she was called to assess Resident #1 after a fall out of the bed. The resident was being turned when she rolled out of the left side of the bed onto her anterior surface. The RN assessed all of the resident's joints with pain noted in the anterior right knee. She was turned to her back with the assistance of four staff members with splinting provided to the lower extremities. A mechanical lift was used to transfer the resident into the bed. The resident had a large discoloration to her right knee that extended to the proximal lower leg and discoloration to the anterior right foot with swelling in both areas. There was a discoloration to her left knee and a small area on the mid anterior lower leg with swelling. Any assessment attempted by the RN of the right knee resulted in extreme pain. The resident was being changed by only one CNA at the time, which resulted in her rolling out of the bed. The medical doctor was contacted to obtain an order to transfer the resident to the hospital. The progress note included, "Future intervention would be to always have two staff for all cares."The facility's investigation was reviewed and included the following: A CNA assigned to Resident #1's hall stated that he and CNA #4 began their check and changes and had completed changing all of the residents on the hall, with Resident #1 being their last resident. He stated CNA #4 went in on her own to speak to the resident due to him recently being "kicked out" because he was a male, which was the resident's preference to not have male caregivers. CNA #4 voiced that it was "okay" for her to change Resident #1 alone, due to trust amongst one another. The investigation documented CNA #4 was interviewed and reported during the care the resident rolled out of bed and experienced a witnessed fall. The resident stated, "I rolled out of the bed." The CNA verbalized that Resident #1 fell while she was attempting to adjust/reach for a personal item, causing her momentum to shift without the ability to stop herself, which resulted in the fall. Interviews conducted indicated that the resident had a history of "kicking other staff members out and declining cares." The resident's preference is not to have males change her. CNA #4 stated that the resident verbalized "okay" to being changed alone. The hospital emergency department admission history and physical, dated 12/30/23, was reviewed and documented the x-ray results of her bilateral legs included pain after a fall which resulted in severely comminuted (multiple bone splinters or fragments) impacted distal femur fracture with some posterior displacement. The patella (knee cap) was displaced laterally (to the side). The resident experienced low blood pressure and heart rate after she was given pain medication and required resuscitation with fluids. She was admitted to the hospital and did not return to the facility until 1/13/23 (14 days later). III. Staff interviewsThe director of nurses (DON), ADON and nursing home administrator (NHA) were interviewed on 3/21/23 at approximately 3:30 p.m. and explained the facility did not currently have an MDS coordinator who could be interviewed. The MDS assessment dated 10/11/22 was reviewed and the DON said Resident #1 was assessed to require extensive assistance of two people for bed mobility. The ADON clarified the staff were providing more than 50 percent of the assistance but the resident was able to participate some, less than 50 percent. The ADON said the two people would mean there was one person on each side of the bed so one would help roll and the other would help hold the resident during turning and bed mobility. The NHA was interviewed on 3/21/23 at 4:04 p.m., and he said on the day Resident #1 fell out of bed, two CNAs working on that floor; a male and a female CNA (CNA #4) were conducting rounds. He said CNA #4 made the decision to go in and ask Resident #1 if it was okay to provide cares to her without the assistance of a second staff member, and that CNA #4 admitted to not asking anyone for help. The NHA said staffing was not low and there was an extra staff member working that morning until 10:00 a.m. He said CNA #4 had initiated cares with the resident by herself, when the resident reached for a personal item and then fell out of bed. He said there was a time prior when Resident #1 would accuse the staff of stealing things from her, so they initiated "cares in pairs" for mechanical lift use as well as for behavioral reasons. Restorative certified nurse aide (RCNA) #1 was interviewed on 3/21/23 at 4:20 p.m., and she said she routinely worked with Resident #1. She said the facility had multiple ways to communicate to staff which residents required two-person cares and assistance. A sign was posted on the wall in each resident's room above their bed to indicate whether the person required a mechanical lift for transfers as well as how many staff were required to provide assistance for cares. In addition, she said a "CNA Book" was located at each of the nurses' stations with a list of which residents required a mechanical lift, the sling size, their room number and their name. She said all clinical staff were trained prior to starting work on the floors about this. The RCNA showed the list that was posted in the CNA book in December 2022, and it revealed Resident #1 required transfers with a Hoyer mechanical lift with a green sling. The RCNA said she also checked the residents' care plans to ensure the interventions were care-planned approaches. The RCNA said Resident #1 was supposed to have two-person assistance for personal cares as well, which included bed mobility, which was for both the resident's and the staff's safety. The RCNA said Resident #1 was able to make safe decisions about her care "sometimes," but not always, and at times the resident would "grab the straps" on the mechanical lift during transfers, "and that "was not safe." She said Resident #1 had a history of falsely accusing staff of mistreating her, so the facility began providing care to her in pairs, with two staff members present. The RCNA said the resident was particular about which CNAs provided her with care, and she did not like male caregivers. CNA #3 was interviewed on 3/21/23 at 4:55 p.m., and she said she routinely worked with Resident #1. She said Resident #1 could brush her hair, wash her face, and brush her teeth if she was provided with set up assistance. She said when the resident was turned in bed, they were always supposed to provide assistance with two people because the resident was very large and "could roll off." The CNA said Resident #1 had days where she was alert and could make good safety decisions about her care, and she had days where she was confused, and was not consistently alert and oriented. CNA #3 said the facility had provided clinical staff with additional training on how to safely provide care for Resident #1 after her fall, but said she did not receive the training. Instead, she said she was "told by nurses what they were doing now" to provide care for the resident. RN #3 was interviewed on 3/21/23 at 5:07 p.m., and she said she routinely worked with Resident #1. She said the resident could not provide much care for herself and before the accident, she required two-person assistance for ADL care, transfers, changing her, and rolling her in bed "because she was very large." She said Resident #1 was confused at times and would accuse staff of random things that were not true, and did not like men in her room. She had a cognitive communication deficit with garbled speech and was difficult to understand at times. RN #3 said it was not a normal behavior of Resident #1 that she would accept care assistance from a single staff person because she was always scared she was going to roll off the bed, and knew it was in her best interest for safety to have the assistance of two staff members at a time. RN #3 stated, "She didn't really have good safety awareness and had a fear of falling."RN #3 said one staff member would go in and help her at times because there was not enough staff. She said as recently as last night, she was aware of a single staff member providing care and assistance to a resident who required two-person assistance. RN #3 said after Resident #1 fell on 12/30/22 and returned to the facility from the hospital, a change was made that required her to receive the assistance of four staff members during cares and transfers, and there was never a time after that she did not have four people assist her. The RN stated, "Everyone felt really bad. We did that to her." The medical director (MD) was interviewed on 3/21/23 at 3:08 p.m., and she said since Resident #1 was assessed by the facility to need two-person assistance for bed mobility and cares, then she should have been provided with that assistance. The MD said the resident's history with making her own reasonable, safe decisions was not reliable and she did not make appropriate decisions at times. The DON, ADON and NHA were interviewed on 3/21/23 at 5:29 p.m. The ADON said staff knew which residents required two-person cares because it was listed on the CNA Kardex, which could be accessed by CNAs and nurses. She said each residents' room also had laminated signs above the bed that indicated how much assistance they required. If a resident who required two-person assistance told a staff member it was acceptable to provide one-person assistance to them, they should still provide assistance of two staff members because it was for resident and staff safety. IV. Facility follow-upThe NHA provided the following documentation on 3/22/23 at 4:11 p.m., which included the facility's response to Resident #1's fall on 12/30/22. The NHA said the audits were done recently and not during the time, the performance improvement plan was put in place, and included the following:An Ad Hoc Quality Assurance Performance Improvement/Four Point Plan of Correction Agenda and Summary, which was dated 1/3/23. The meeting was attended by 11 interdisciplinary team (IDT) members and identified an opportunity for improvement that included verifying that residents who required two-person cares was reflected on both the resident care plans and Kardex. Audits were to be completed by 1/6/23. All direct care staff would be educated on residents who required two-person cares and educated to check the Kardex when cares were provided, which was to be completed by 1/20/23. In addition, the DON or designee would complete the audits twice a week for four weeks to ensure that staff were following the plan of care. A Staff In-Service Summary, dated 1/12/23, included a review by the ADON that explained what the Kardex was and where it was located. There was no attendance record included. An undated, untitled Attendance record was provided, which included the signatures of 25 staff members. Four staff (two CNAs, one licensed practical nurse, and one RN) audits were included, which were undated to know when they were completed, and each included the following three questions:1. When you are unsure of how a resident transfers, where can you find this information?2. Do you know how to access the Kardex/Care Plan to find this information?3. Ask for demonstration on where to find how a specific resident transfers. One of the four staff members audited did not know how to access the Kardex/Care Plan, and required a demonstration of the process.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/20/2023 and 02/26/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A survey for Incidents #30729 and #30744 was conducted on 2/23/23. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure four (#3, #4, #5 and #6) of six sample residents were free from physical abuse by Resident #2 in six separate incidents over a four-month period. Specifically, Resident #2 physically abused:-Resident #3 on 2/5/23;-Resident #4 on 1/6/23, 2/8/23 and 2/21/23;-Resident #5 on 12/20/22; and-Resident #6 on 2/5/23. The facility failed to protect the residents, all of whom were vulnerable and diagnosed with dementia, from physical abuse. Cross-reference F744, failure to provide adequate dementia care services. Findings include: I. Facility policy The Abuse and Neglect - Clinical Protocol policy, revised March 2018, provided by the nursing home administrator (NHA) on 2/23/23 at 3:00 p.m., included: "The physician will help identify individuals with a history of having been abused or neglected, or those showing evidence of possible abuse or neglect." "The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents with unmanaged problematic behavior." "The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect." II. Resident status A. Resident #2 Resident #2, age 85, was admitted on 1/8/21. According to the February 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia without behavioral disturbance, major depressive disorder, and dementia with agitation. The 12/11/22 minimum data set (MDS) assessment documented severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She had behavioral symptoms of rejection of care and wandering. She needed supervision, oversight, cueing, encouragement and set-up help for ambulation with a walker; and needed extensive assistance for toilet use and personal hygiene. B. Resident #3 Resident #3, age 81, was admitted on 4/30/21 with diagnoses including Alzheimer's disease, dementia without behavioral disturbance, major depressive disorder, and unsteadiness on her feet according to the February 2023 CPO. The 2/11/23 MDS assessment documented severe cognitive impairment with a BIMS score of zero out of 15. She had delirium symptoms of inattention and disorganized thinking, and a behavioral symptom of rejecting care. C. Resident #4 Resident #4, age 86, was admitted on 12/29/21 with diagnoses including dementia according to the February 2023 CPO. The 1/6/23 MDS assessment documented severe cognitive impairment with a BIMS score of four out of 15. She had a delirium symptom of disorganized thinking, and no behavioral symptoms. She needed limited physical assistance with most activities of daily living (ADLs), and used a wheelchair for ambulation. D. Resident #5 Resident #5, age 89, was admitted on 12/30/21 with diagnoses including dementia and arthritis, according to the 1/11/23 MDS assessment. She had severe cognitive impairment with a BIMS score of three out of 15 and delirium symptoms of inattention and disorganized thinking. Behavioral symptoms of physical and verbal aggression and care rejection were documented. She needed extensive ADL assistance and used a wheelchair for ambulation. E. Resident #6 Resident #6, age 85, was admitted on 7/25/2020 with diagnoses including dementia and depression, according to the 1/25/23 MDS assessment. She had severe cognitive impairment with a BIMS score of three out of 15, and a delirium symptom of disorganized thinking. No behavioral symptoms were documented. She needed extensive ADL assistance and used a wheelchair for ambulation. III. Resident-to-resident abuse incidents by Resident #2 towards other residents Review of facility investigative reports and medical record progress notes revealed the following, in chronological order. A. 12/20/22 in

Based on record review and interviews, the facility failed to provide adequate dementia care services to meet residents' needs and ensure they were free from aggressive behavioral symptoms, which affected five (#2, #3, #4, #5 and #6) out of six sample residents. Specifically, the facility failed to assess and implement effective approaches to:-Meet Resident #2's needs and prevent aggression toward other residents; and-Ensure vulnerable Residents #3, #4, #5 and #6 were free from aggression from Resident #2, and received the highest practicable physical, mental and psychosocial quality of care and safety in their home. Cross-reference F600, failure to ensure freedom from resident-to-resident abuse. Findings include: I. Facility policy The Dementia - Clinical Protocol policy, revised November 2018, provided by the nursing home administrator (NHA) on 2/23/23 at 3:00 p.m., included: "For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life." "The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements." "If a psychiatric consultant is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress." "The 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-to-resident abuse incidents Cross-reference F600 for resident status and further details. Review of facility investigations and progress notes in the residents' medical records revealed Resident #2 physically abused Residents #3, #4, #5 and #6, all of whom were diagnosed with dementia, during the following incidents: -On 12/20/22, Resident #2 punched Resident #5 three times in the face with a closed fist before staff could respond to protect Resident #5. -On 1/6/23, Resident #2 struck Resident #4 in the face, leaving a red mark on her cheek. -On 2/5/23, Resident #2 ran over Resident #6's toes with her walker. -On 2/5/23, Resident #2 grabbed Resident #3 by both wrists, squeezing and twisting her wrists and hands, causing bruising to Resident #3's left hand. -On 2/8/23, Resident #2 stomped on Resident #4's foot. -On 2/21/23, Resident #2 punched toward Resident #4 who punched her back, causing her to fall to the floor. Investigation documentation revealed the residents did not remember the incidents when they were interviewed afterward. Documented action taken after each incident was to separate the residents and keep Resident #2 within line of sight for safety. After the incident on 2/21/23, the facility implemented 20- to 30-minute checks with Resident #4, and every-15-minute checks with Resident #2 (see care plan below). -Line of sight supervision was not effectively implemented, as evidenced by Resident #2's continued abuse of other residents. III. Record review Resident #2's care plan, revised on 2/24/23 (during the survey), identified, "I may become physically or verbally aggressive towards staff and others due to poor impulse control, anger, and frustration secondary to dementia." Approaches were:-"Give me as many choices as possible about care and activities.-I do best with 1-2 people for redirection.-When I become upset, engage me in conversation. Talk to me about: my family, basket weaving, music, vacations to the beach, baking, gardening.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/09/2023 and 01/15/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/02/2023 and 01/08/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.