PAONIA CARE AND REHABILITATION CENTER

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix tag K-000) are informational only and are a representation of the facility's general characteristics. The facility is a one-story Type V (111) structure and is licensed for 60 beds. The facility is equipped with an automatic fire suppression system installed in accordance with NFPA 13. Census the day of survey was 42. The survey conducted on March 20, 2024 included an inspection for compliance with the fire safety requirements of Chapter 19 of NFPA 101, Life Safety Code, 2012 edition; NFPA 99, 2012 edition; and referenced standards. The facility will meet these requirements when the following deficiencies are corrected. The survey concluded with a discussion of the deficiencies with the Facility Administrator, Facility Maintenance Director and the Facility Maintenance person.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 72. This was evidenced by: 1. Fire Alarm Semi-Annual: Not Provided 2. Smoke Detector Sensitivity Report: Not ProvidedBased on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarmand Signaling Code. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer's calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby thedetector causes a signal at the fire alarm control unit where itssensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by theauthority having jurisdictionThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:1. Dry Barrel Sprinkler Pendant installed in the sidewall postion at Main entry 2. Dry Barrel Sprinkler Pendant installed in the sidewall postion at MCU wing exit discharge 3. Dry Barrel Sprinkler Pendant installed in the sidewall postion at 200 wing exit dischargeNFPA 25 5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the facility maintenance director during the exit conference.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/04/2024 and 03/10/2024, 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 licensure survey was completed on 2/26/24 to 3/1/24. Two deficiencies were cited.

Based on observation, record review and interviews, the facility failed to ensure one (#29) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 35 sample residents. Resident #29 was at nutritional risk with a diagnosis of dementia. Interventions were implemented by the registered dietitian due to the resident's nutritional risk and history of weight loss, however, these interventions were not consistently evaluated for effectiveness. Observations during the survey revealed the resident's intake of nutritional supplements were not accurately documented. When the resident sustained a significant weight loss from 1/2/24 to 2/2/24, the intervention of offering fortified foods was not added until 20 days later. Due to the facility's failure to implement timely nutritional interventions and evaluate the effectiveness of nutritional interventions in place, the resident sustained a 16.3 pound (lbs) weight loss from 1/2/24 to 2/2/24, 10.7% which was considered significant. Findings include: I. Resident statusResident #29, over the age of 65, was admitted on 12/30/22. According to the February 2024 computerized physician order (CPO), diagnoses included dementia, abdominal aortic aneurysm (an enlarged area in the lower portion of the aorta, the body's main artery) and high blood pressure (hypertension). According to the 12/6/23 facility assessment, Resident #29 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS). The assessment documented Resident #29 required set-up or cleaning assistance with meals and maximal assistance with bathing, toileting and dressing. The resident was able to eat independently after set-up assistance was completed. The assessment did not identify weight loss. II. ObservationOn 2/28/24 at 9:46 a.m., Resident #29 was administered 237 milliliters (ml) of a nutritional supplement. Licensed practical nurse (LPN) #1 documented 237 ml of nutritional supplement consumed while the resident was actively drinking the supplement at 9:46 a.m. When the resident stopped drinking the nutritional supplement at 9:54 a.m., the facility coordinator cleared Resident #29's tray, including the nutritional supplement. -The facility coordinator failed to observe or measure for any remaining nutritional supplement and did not communicate the amount of nutritional supplement consumed by Resident #29 to LPN #1. It was unknown how much nutritional supplement was consumed by Resident #29. At 4:16 p.m., LPN #1 discarded a nutritional supplement bottle in which medications were added for medication administration. Some remaining nutritional supplement and pill fragments were in the bottle. LPN #1 documented Resident #29 consumed 237 milliliters of nutritional supplement. III. Record review Review of Resident #29's electronic medical record (EMR) revealed the following documented weights: -On 8/16/23, the resident weighed 157.6 lbs;-On 9/8/23, the resident weighed 154.4 lbs;-On 10/25/23, the resident weighed 147.8 lbs;-On 12/2/23, the resident weighed 150.0 lbs;-On 1/2/24, the resident weighed 152.3 lbs;-On 2/2/24, the resident weighed 136.0 lbs;-On 2/15/24, the resident weighed 137.1 lbs; and, -On 2/23/24, the resident weighed 137.0 lbs. Resident #29's weight record showed the resident lost 16.3 pounds between 1/2/24 and 2/2/24. This was considered significant weight loss of 10.7% of the resident's body weight in one month. The care plan, dated 12/14/23, identified that Resident #29 was at risk for nutritional concerns and he required set-up assistance and a high back chair for all meals. Pertinent interventions included monitoring for decreased oral intake with meals and snacks, set up and supervision while eating, additional time to complete the meal, cueing to remain focused on eating and snacks throughout the day. The dietary quarterly assessment dated 2/19/24 documented a significant weight loss of 10.7%. -The dietary quarterly assessment failed to identify or implement additional nutritional interventions. The Dietary Nutritional assessment, dated 2/22/24, documented Resident #29 had a height of 73 inches and a weight of 137.1 pounds. It documented a significant weight loss of 10.7% in a month and 13.7% weight loss since 8/16/23. The nutritional assessment documented interventions including nutritional supplements three times a day, fortified food and allowing him extra time to finish meals. The nutritional assessment documented the resident did not refuse the nutritional supplements and consumed 100% of nutritional supplements three times a day. -The intervention to offer finger foods to the resident was added 2/22/24, however, this was 20 days after the significant weight loss was identified. The January 2024 and February 2024 medication administration record (MAR) documented nutritional supplements ordered 6/8/23 to be administered three times per day. There were 174 nutritional supplement administration opportunities between 1/1/24 and 2/27/24, of which 30 administrations were not given because the resident was sleeping. There was no documentation to indicate the nutritional supplement was re-offered to the resident when he was awake. The remaining 144 nutritional supplement administrations documented Resident #29 consumed 237 milliliters (ml) or 100% of the nutritional supplement.-However, observations revealed the resident did not consistently consume 100% of the supplement (see observations above). IV. Staff interviewsLPN #1 was interviewed on 2/28/24 at 4:19 p.m. LPN #1 said nutritional supplements should be observed, measured and then appropriately charted. LPN #1 said the resident's MAR should accurately document how many milliliters of nutritional supplements were consumed. LPN #1 said the nutritional supplements were ordered to prevent weight loss for Resident #29. The corporate registered dietitian (CRD) was interviewed on 2/29/24 at 10:30 a.m. The CRD said she had not witnessed Resident #29 consume a nutritional supplement. The CRD said she relied on the milliliters documented to know how much of the nutritional supplement residents' consumed. The CRD said staff should roughly estimate how much of the nutritional supplement had been consumed by a resident. The CRD said she was not aware of Resident #29 not receiving nutritional supplements because he was asleep. The CRD said she was not aware of nursing staff charting nutritional supplement totals before the resident finished consuming them. The director of nursing (DON) was interviewed on 3/1/24 at 12:55 p.m. The DON said if a resident was sleeping staff should re-offer nutritional supplements later in the day and document this. The DON said nutritional supplements should be measured after residents finished consuming them to accurately document the volume consumed. The DON said nursing staff, the CRD and the DON were all responsible for identifying if residents needed additional interventions for weight loss.

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

A recertification survey with complaint #CO32243 was completed on 2/26/24 to 3/1/24. Twenty-three deficiencies were cited.

An Emergency Preparedness survey was conducted on 1/26/24 to 3/1/24. One deficiency was cited.

Based on record review and interviews, the facility failed to have a complete emergency preparedness communication plan. Specifically, the facility failed to have a complete communication plan included an updated emergency use contact list to include all staff who worked in for the facility. Findings include: I. Record review The emergency preparedness plan (EPP) was provided by the maintenance director (MTD) on 2/29/24 at 4:30 p.m. Review of the EPP revealed the facility did not have a contact list which included all staff included in the EPP. II. Staff interview The EPP was reviewed with the MTD on 2/29/24 at 4:30 p.m. The MTD said the facility did not have all contact information for staff. He said he was responsible to ensure the EPP was kept up to date. He said he was currently updating the information in the binder. The MTD said it was important to have all the contact information in case the facility needed to contact staff. He said he would get the list into the binder as soon as possible.

Based on record review and interviews, the facility failed to ensure residents can communicate in their native language for one (#10) resident reviewed for language services out of 35 sample residents. Specifically, the facility failed to provide a system for Resident #10 to receive medical information in his native language. Findings include: I. Facility policyThe Resident Rights policy, not dated, was obtained from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. failed to document the resident's right to receive information in their primary language. II. Resident statusResident #10, over the age of 65, was admitted on 7/7/16. According to the February 2024 computerized physician order (CPO), diagnoses included Alzheimer's dementia, anxiety, diabetes and high blood pressure (hypertension). According to the 1/23/24 minimum data set (MDS) assessment Resident #10 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) score. The assessment documented the resident's preferred language was Spanish. III. Record reviewThe comprehensive care plan dated 4/25/23 documented Resident #10 spoke Spanish as a first language. IV. Staff interviewsThe laundry aide (LA) was interviewed on 2/28/24 at approximately 11:30 a.m. The LA said she spoke Spanish as her native language. She said she was not used as an interpreter. She said she was willing but had not been asked for quite some time. Certified nurse aide (CNA) #4 was interviewed on 2/29/24 at 3:42 p.m. CNA #4 said one other CNA on staff and a housekeeper spoke Spanish, and staff utilized them to communicate with Resident #10. CNA #4 said she only asked Resident #10 simple questions about what he needed because Resident #10 had limited English understanding. RN #1 was interviewed on 2/29/24 at 3:42 p.m. RN #1 said nursing staff used a housekeeper as a primary translator. RN #1 did not know how nursing staff would communicate with Resident #10 should housekeeping staff be unavailable to translate. RN #1 did not know how the nursing staff would provide medical information to Resident #10 in his primary language. The activities director (AD) was interviewed on 2/29/24 at 6:21 p.m. The AD said she communicated with Resident #10 by looking up words on her phone or using simple phrases. The AD said that Resident #10 should be able to regularly talk in his native language. The director of nursing (DON) was interviewed on 3/1/24 at 12:55 p.m. The DON said residents should be able to receive information in their primary language.

Based on record review and interviews the facility failed to ensure that personal funds accounts were managed adequately for six (#19, #20, #1, #4, #10 and #138) of six residents out of 35 sample residents. Specifically, the facility failed to -Have signed written authorizations to manage the personal funds accounts for Residents #1, #4, #20, #138 and #19; and,-Have personal funds withdrawal sheets signed to ensure the residents' permission was obtained to withdraw funds from their personal needs accounts for Residents #1, #10, #4 and #138. Findings include: I. Lack of written authorizations-The facility was unable to provide written authorizations to manage the personal funds account for Residents #1, #4, #20, #138 and #19. The current balance in the personal needs account for Resident #1 was $105.56 as of 3/1/24. The current balance in the personal needs account for Resident #4 was $2,253.24 as of 3/1/24. The current balance in the personal needs account for Resident #20 was $7,180.40 as of 3/1/24. The current balance in the personal needs account for Resident #138 was $3,971.40 as of 3/1/24. The current balance in the personal needs account for Resident #19 was $409.77 as of 3/1/24. II. Personal Funds WithdrawalA. The Personal Funds Withdrawal sheet was reviewed for Resident #1. The resident was found to have two withdrawals from her account with no signed authorization. The withdrawals were as follows:On 8/18/23 a withdrawal for $376.65. On 4/6/23 a withdrawal for $95.70.-The facility provided receipts, however, the facility failed to have the resident or two staff members sign the resident funds request forms. B. The Personal Funds Withdrawal sheet was reviewed for Resident #10. The resident was found to have one withdrawal from his account with no signed authorization. The withdrawal was as follows:On 4/28/23 a withdrawal for $92.37.-The facility provided a receipt and a resident funds request, however, the facility failed to have the resident or a second staff member sign the resident funds request form. C. The Personal Funds Withdrawal sheet was reviewed for Resident #4. The resident was found to have two withdrawals from his account with no signed authorization. The withdrawals were as follows:On 5/10/23 a withdrawal for $6.88. On 7/21/23 a withdrawal for $4.00.-The facility provided receipts and a resident funds request, however, the facility failed to have the resident or a second staff member sign the resident funds request form. D. The Personal Funds Withdrawal sheet was reviewed for Resident #138. The resident was found to have one withdrawal from his account with no signed authorization. The withdrawal was as follows:On 4/3/23 a withdrawal for $235.40.-The facility provided receipts, however, the facility failed to have a resident funds request signed by the resident or by two staff members. III. Staff interviewsThe business office manager (BOM) and nursing home administrator (NHA) were interviewed on 3/1/24 at 4:20 p.m. The BOM said all residents with trust fund accounts in the facility needed to have a signed written authorization for the facility to manage the residents' funds. The BOM said Resident #19 no longer had a financial power of attorney (POA) and when the BOM realized the resident did not have a signed authorization form she had him sign one on 2/29/24 (during the survey). The BOM said the former BOMs did not handle the residents' funds accounts accurately and she planned on fixing the problems. The BOM said all resident funds requests needed to be signed by the resident. She said if the resident was unable to sign the request two staff members were required to sign the form. She said she was unsure why some purchases had receipts and signed resident fund requests and some purchases did not, however, she said now that she was aware of the issue she would fix it. The NHA said the BOM identified a handful of problems when she looked into the residents' accounts. She said the resident trust fund accounts would be included in the facility's quality assurance and performance improvement (QAPI) program.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#138 and #4) out of seven residents reviewed for personal funds accounts out of 35 sample residents. Specifically, the facility failed to:-Were dispersed within 30 days after discharge for Resident #138; and,-Notify Resident #4, who was Medicaid funded, or his legal representative when the resident's personal funds account reached $200.00 less than the eligibility resource limit. Findings include:I. Record reviewA. Resident #138A review of the current trust account balance provided by the facility revealed Resident #138, who had been discharged over 30 days before, had a remaining balance of $3,971.40 in his personal funds accounts. -There was no documentation the facility had attempted to disperse the funds to the resident. B. Resident #4A review of the current trust account balance revealed Resident #4 had $2,253.24 in his account which was $253.24 over the allotted limit for Medicaid funded residents.-There was no documentation the facility had notified Resident #4 or his legal representative when his personal funds account reached $200 less than the eligibility resource limit. II. Staff interviewsThe business office manager (BOM) and nursing home administrator (NHA) were interviewed together on 3/1/24 at 4:20 p.m. The BOM said if the resident passed away the remainder of their funds would go to the family or towards burial costs. She said their funds would be returned to the state if the resident received Medicaid. She said all funds should be dispersed within 30 days. The BOM said previous BOMs did not close out Resident #138's account and disperse the funds timely. The BOM said she was not aware Resident #4 was over the allotted limit for Medicaid eligibility. She said she would work with the resident's family to complete a spend down of the excess funds so he would not lose his benefits. The NHA said the facility was unable to locate the resident's family and they were not sure what to do with the funds or how long the facility needed to attempt to locate the resident's family. She said the resident trust fund accounts were being included in the facility's quality assurance and performance improvement (QAPI) program. The BOM said she would reach out to a state agency for guidance on Resident #138's account and find out where she needed to send the $3,971.40. She said she was completing a full audit of all resident trust fund accounts to see if there were concerns for other resident accounts as well.

Based on observation, interview and record review, the facility failed to ensure information was discussed and posted on how to file a complaint with the State Agency with six residents who regularly attend monthly resident council meetings (#19, #32, #22, #21, #24 and #9). Failure to post the information had the potential to affect all residents who were not able to find this resource. Specifically, the facility failed to have the required posted information written in a readable font size and placed in an area that had ease of access for the residents. Findings include:I. Resident council interviewResidents who frequently attend monthly resident council meetings and the resident council president (#19, #32, #22, #21, #24 and #9) were interviewed on 2/28/24 at 10:38 a.m. When asked if they knew how to file a complaint with the State Agency, they all answered no. II. ObservationObservations from 8:30 a.m. on 2/26/24 to 2:44 p.m. on 2/29/24 did not reveal the required postings throughout the facility. III. Staff interviewThe social services director (SSD) was interviewed on 2/29/24 at 2:44 p.m. The SSD was unable to locate the resident rights poster anywhere in the facility. The SSD said she was not sure where to find the posted information on how to file a complaint with the State Agency. The SSD said she was not aware the facility needed to have these postings available to the residents and did not know it was required.

Based on observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on two of two units. Specifically, the facility failed to:-Provide linens to residents; and,-Mitigate unpleasant odors throughout the facility; and, -Ensure ceiling fans in resident areas were working. Findings include:I. ObservationsOn 2/26/24 at 9:15 a.m. there was a urine smell on the 200 wing of the building. At 9:20 a.m. in room #209 there were no hand towels or washcloths. At 11:39 a.m. there was a strong body odor near the exit door of the 200 wing of the building, specifically coming from room 215. At 2:24 p.m. in room #213 there were no hand towels or washcloths and the paper towel dispenser did not function when tested. On 2/27/24 at 8:41 a.m. there was a strong odor of urine throughout the 200 wing of the building. At 9:47 a.m. room #215 smelled strongly of urine. There were no hand towels or washcloths in the room and no soap in the soap dispenser. At 9:51 a.m. in room 212 there were no hand towels or washcloths. At 9:55 a.m. in room 201 there were no hand towels or washcloths. Beginning at approximately 11:00 a.m., the following observations were made:-Room #101 had no hand towels or washcloths;-Room #104 had no hand towels or washcloths;-Room #201 had no hand towels or washcloths;-Room #203 had no hand towels or washcloths;-Room #206 had no hand towels or washcloths;-Room #209 had no hand towels or washcloths;-Room #212 had no hand towels or washcloths; and,-Room #214 had no hand towels or washcloths. On 2/28/24 at approximately 9:30 a.m., the following observations were made:-Room #101 had no hand towels or washcloths;-Room #104 had no hand towels or washcloths;-Room #106 had no hand towels or washcloths;-Room #107 had no hand towels or washcloths;-Room #110 had no hand towels or washcloths;-Room #201 had no hand towels or washcloths;-Room #203 had no hand towels or washcloths;-Room #206 had no hand towels or washcloths;-Room #209 had no hand towels or washcloths;-Room #212 had no hand towels or washcloths;-Room #214 had no hand towels or washcloths; and,-Room #216 had no hand towels or washcloths. The towel rack in this room was observed to be broken. At 9:41 a.m. there was a strong urine odor in the hallway of the secured unit. On 2/29/24 at 9:05 a.m. there was a strong odor of urine in the 200 wing of the building. At 11:55 a.m., the shower room on 200 wing had an odor. The maintenance director (MTD) said the fan was on, however, when he put a toilet paper square to the fan, it did not suck the paper up which indicated it was not pulling air. The MTD observed room #110, #104 and #212 and found that the fans were not working in the rooms. The MTD said that the fans not working could contribute to the odors in the building. II. Resident council interviewResidents who frequently attend monthly resident council meetings and the resident council president were interviewed on 2/28/24 at 10:38 a.m. The six residents (#9, #19, #21, #22, #24 and #32) attending the meeting said they did not receive cloth towels and had to use paper towels instead. Two residents said they wanted to use cloth towels. The resident council president said she usually had to get her own towels. During this meeting, the residents said there were unpleasant odors in the building and it was terrible sometimes. The residents said when they have previously tried to complain, the facility staff just told them they were trying but there have not been any improvements. The resident council president, whose room was down the hallway from the smoking area, said she could smell the smoke in the hallway during smoking times. She said she could not handle the smell of smoke. III. Staff InterviewsThe director of nursing was interviewed on 2/28/24 at 5:21 p.m. The DON said the towels were to be supplied by the certified nurse aides. She said that the residents could request also. The housekeeper (HSK) #1 was interviewed on 2/29/24at 12:00 p.m. HSK #1 was observed earlier to spray the hallways with air freshener. HSK #1 said she sprayed the air freshener to make the building smell better. She said there was an odor in the hallways. However, she said she did not know why it was persistent. HSK #1 said she did not have any direct involvement with providing towels. The MTD was interviewed on 2/29/24 at 12:30 p.m. The MTD said the building had an odor. He said he tested the air vents quarterly. He said that individual air vents were on one duct with one exit. He said the system was old and it was not doing the job properly.

Based on record review and interviews the facility failed to permit a resident to return to the facility after going to the hospital for one (#137) of two residents reviewed for discharge out of 35 sample residents. Specifically, the facility failed to allow Resident #137 to return to the facility once he was medically cleared by the hospital to return. Findings include:I. Facility policyThe Discharge Summary and Plan policy, revised October 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 2:39 p.m. It read in pertinent part: "The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing the release of the resident information and as permitted by the resident."A member of the (interdisciplinary team) reviews the final post-discharge plan with the resident and family at least twenty-four hours before the discharge is to take place."II. Admission packetThe termination, transfer or discharge agreement was in the admission packet Resident #137 signed on 10/23/23 and read in pertinent:"The facility may terminate this agreement and the resident's stay and transfer or discharge the resident if:-The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;-The resident's health improved sufficiently so the resident no longer needs the services provided by the facility;-The resident has failed, after reasonable and appropriate notice to pay for (or have paid or treated as paid under the Medical or Medicaid Programs) charges for the resident's care and stay at the facility; or-The facility ceases to operate."III. Resident statusResident #137, age over 65, was admitted on 10/25/23 and discharged to the hospital on 11/8/23. According to the November 2023 computerized physician orders (CPO), diagnoses included unspecified bipolar disorder and unspecified anxiety disorder. The 11/13/23 minimum data set (MDS) agreement revealed the resident was unable to complete a brief interview for mental status (BIMS). A staff assessment for mental status revealed the resident had a memory problem, severe cognitive impairment, delirium, fluctuating inattention and fluctuating disorganized thinking. The assessment revealed the resident had delusions, physical behaviors directed toward others, verbal behaviors directed toward others, behaviors not directed toward others (pacing, rummaging) and rejection of care. IV. Record reviewA progress note, written on 10/26/23 at 2:13 a.m., documented Resident #137 arrived at the facility on 10/25/23 at 7:00 p.m. Resident #137 ambulated independently. Resident #137 was offered dinner and ate approximately 50 percent (%) without any difficulties. The resident was in and out of his room for most of the night and asked questions about how the facility worked. The resident settled down to sleep at approximately 1:00 a.m. and told the nurse he was more of a night person. A progress note, written on 10/26/23 at 5:29 p.m., documented Resident #137 was adjusting moderately to his new surroundings. The resident asked about getting out of the facility. The resident was polite and followed directions and redirection. A progress note, written on 10/27/23 at 4:59 p.m., documented Resident #137 adjusted well to his room and roommate. The resident was independent with ambulation and participated in activities. He had increased confusion in the evening. An order administration note, written on 10/29/23 at 11:53 p.m., documented Resident #137 received a dose of Quetiapine (an antipsychotic medication) because the resident sat on the floor in the hallway and laid down outside the doorway of another resident's room while the other resident slept. All attempts for redirection failed. An order administration note, written on 10/30/23 at 5:50 p.m., documented Resident #137 received a dose of Quetiapine because the resident was very confused about his role at the facility and he did not know if he was being admitted or discharged. Resident #137 was restless and paced up and down the hallways. A behavioral note, written on 11/3/23 at 2:13 a.m., documented Resident #137 was restless during the shift and was crawling around on the floor on his hands and knees in his room and in the activity room. Resident #137 kept his roommate awake and his roommate was very frustrated with the resident. An order administration note, written on 11/3/23 at 12:35 p.m., documented Resident #137 received a dose of Quetiapine because he wandered around the unit most of the morning as he looked for his wallet. He was frustrated and agitated but easily redirected by staff. A behavioral note, written on 11/6/23 at 9:29 a.m., documented that at 8:50 p.m. (on 11/5/23) Resident #137 grabbed another resident from behind and attempted to drag the resident down the hallway which caused both residents to fall on the ground. No injuries were noted on either resident. Resident #137 ran around the facility with no shoes and resisted assistance from the nursing staff. The resident accused staff of stealing his things, hit staff multiple times and yelled at another resident while he was three feet away from the resident. Resident #137 was placed on one-to-one supervision but the resident kept running away from the nursing staff. The resident accused the staff of working with Satan. The resident requested to speak to the police and the nurse called for the police to come to the facility. When the police arrived, Resident #137 had slurred speech and raised both his arms when he swung his fists at staff. An ambulance was called and he was verbally aggressive toward the paramedics and the police officer. The nurse and paramedics decided to send the resident to the emergency room for further evaluation. Resident #137 was sedated by the paramedics and transported to the emergency room. A progress note, written on 11/6/23 at 6:36 p.m., documented Resident #137 returned from the emergency room mid-morning and appeared calm and cooperative. In the afternoon the resident exhibited strange behavior and tried to lay on the floor in an empty room. The resident grabbed the food delivery cart and would not let go of it as he used the cart like a walker. The staff asked Resident #137 to let go of the meal cart and he was aggressive and swung at staff. He had a strong desire to go outside. After he spent a considerable amount of time outside he said he was tired and returned inside to go to bed. A discharge planning summary was completed on 11/6/23. The social services director documented Resident #137 was at the facility for long-term care and there was no plan for the resident to be discharged. A progress note, written on 11/8/23 at 11:11 p.m., documented Resident #137 was aggressive and agitated. The resident was on the floor in the hallway. Staff removed other residents from the area for safety reasons. The nurse noticed Resident #137 had blood on his hands but he refused first aid from staff. The resident was experiencing delusions and screamed at staff and residents as he tried going into other residents' rooms. He was throwing items, banged his fists on surfaces and attempted to leave the facility through locked doors. The resident refused all attempts of redirection from staff. The resident lunged at the nurse and missed. He ran through the hallways of the facility. He attempted to jump over the half door into the memory care unit office. The nurse called non-emergency dispatch and requested assistance with a resident who was a danger to himself and others. Resident #137 attempted to punch another resident and no contact was made. The police attempted to de-escalate the resident and failed. Paramedics arrived and sedated the resident as two officers restrained him for safety. The resident was transported to the emergency room. A discharge summary, completed on 11/8/23, documented Resident #137 was at the facility for long-term services. The resident became very agitated and was a harm to himself and potentially other residents. He was transferred to the hospital after being sedated for his safety and others. The resident had a previous transfer for a similar situation on 11/5/23 and returned within 24 hours. The resident was awaiting placement from the emergency room with a geriatric psychiatric unit. The discharge summary documented the resident was discharged to the hospital and referrals were not needed for new placement.-There was no documentation to indicate the facility had reassessed Resident #137 when the hospital notified them the resident was medically cleared to return.-There was no documentation from the resident's physician to indicate the specific needs of the resident which could not be met by the facility, what efforts the facility took to attempt to meet the resident's specific needs or the specific services provided by the accepting facility which could not be provided by the current facility. V. Staff interviewsThe director of nursing (DON) was interviewed on 3/1/24 at 1:05 p.m. The DON said Resident #137 handled his admission well at first, however, she said he experienced delusions and had a lot of physical aggression and the police and paramedics were called for assistance on 11/5/23. She said the paramedics sedated Resident #137 and took him to the emergency room. The DON said Resident #137 was returned to the facility on 11/6/23. She said there were no changes made to any of his medications by the hospital. She said the facility worked with the resident's physician to adjust his medications. The DON said Resident #137's second incident on 11/8/23 was similar to the first incident but with increased delusions and physical aggression. She said the police and paramedics responded again and transported the resident to the emergency room. She said she spoke with the staff at the emergency room and requested they hold the resident until the emergency room adjusted his medications so he would be safe to return. She said the hospital refused to keep Resident #137. The DON said while the resident was at the hospital the second time, he was diagnosed with dementia which made it harder to get him admitted to a geriatric psychiatric facility because those types of facilities usually refused residents with a diagnosis of dementia. The DON said she worked with a sister facility who had more experience with behaviors. The DON said she did not reassess Resident #137 immediately on 11/8/23 when the hospital said he was ready for discharge because she wanted him to be kept longer than 24 hours. She said he stayed at the hospital for about a week and was transferred to the sister facility. The DON said she was unaware she needed a physician's order to document the specific needs the facility could not meet, the facility's effort to meet those needs and the specific services the receiving facility was providing to meet the needs of the resident which could not be met at the current facility. The DON said she felt like the facility did everything right for Resident #137 except having the physician's documentation for the facility-initiated discharge.-Despite the DON saying she spoke with the hospital and worked with a sister facility to have the resident transferred there, there was no documentation found in Resident #137's electronic medical record to indicate her attempts (see record review above).

IV. Resident #6A. Resident statusResident #6, over the age of 65, was admitted on 6/19/23. According to the February 2024 CPO, diagnoses included vascular dementia, obsessive-compulsive disorder and depression. According to the 1/30/24 MDS assessment Resident #6 had significant cognitive impairment and was unable to complete the BIMS assessment. B. Record review The speech therapy evaluation dated 7/22/23 documented the need for Resident #6 to sit up at 90 degrees for all meals. Cross-reference F689 for accident hazards. According to the care plan dated 2/23/24, Resident #6 required assistance with transferring, toileting, walking and incontinence care.-The care plan did not include the speech therapy evaluation intervention which documented the need for Resident #6 to sit up at 90 degrees for all meals. D. Staff interviewsCNA #1 was interviewed on 2/29/24 at 5:46 p.m. CNA #1 said Resident #6 needed to be at 75-90 degrees to eatThe speech and language pathologist (SLP) was interviewed on 3/1/24 at 11:48 a.m. The SLP said Resident #6 needed to sit up at 90 degrees for all meals. The SLP said the swallow study evaluation recommendations to be followed by the facility and it should be reflected in the plan of care. V. Resident #5A. Resident statusResident #5, over the age of 65, was admitted on 12/30/23. According to the February 2024 CPO, diagnoses included acute respiratory failure, pneumonia, fibromyalgia and generalized muscle weakness. According to the 1/5/24 MDS assessment Resident #5 had no significant cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #5 required set up or cleaning up assistance with oral hygiene. B. Record review-The comprehensive care plan dated 1/3/24 failed to document Resident #5's oral care assistance needs. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 2/29/24 at 8:19 a.m. LPN #2 said that Resident #5 required set up and take down assistance for oral care. The director of nursing (DON) was interviewed on 2/29/24 at 1:38 p.m. The DON said that oral care should be performed twice a day for residents. The DON said oral care should be documented in the electronic health record. The DON said oral care should have been provided to Resident #5 twice a day every single day. Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for four (#3, #4, #5 and #6) residents of four residents reviewed for care planning out of 35 sample residents. Specifically, the facility failed to:-Develop a bathing care plan focus for Resident #4;-Develop a nutrition care plan focus for Resident #3; -Develop a care plan to include speech therapy interventions at meals for Resident #6; and, -Develop an oral hygiene assistance care plan focus for Resident #5. Findings include:I. Facility policyThe Care Planning policy, not dated, was received from the nursing home administrator on 3/6/24 at 12:34 p.m. It read in pertinent part: "Comprehensive, person-centered care plans are based on resident assessments anddeveloped by an interdisciplinary team (IDT)."-The policy did not include any guidelines or timeframes for creating person-based care plans for residents. II. Resident #4A. Resident statusResident #4, age younger than 65, was admitted to the facility on 7/26/16. According to the February 2024 computerized physician orders (CPO), diagnoses included schizophrenia, anxiety and blindness. The 11/28/23 minimum data assessment (MDS) assessment revealed the resident was moderately cognitively impaired. The resident was mostly independent and needed partial or moderate assistance with bathing. B. Record reviewThe 7/30/17 care plan for activities of daily living, revised 2/25/24, revealed Resident #4 had a performance deficit with bathing and personal hygiene due to decreased vision and mood/behavior concerns. Pertinent interventions and information included the resident needed assistance with bathing and preferred to have a shower in the mornings. The 3/19/17 care plan for activities of daily living, revised 12/7/23, listed Resident #4's personal preferences with care. Pertinent information included that the resident preferred to shower once per week in the afternoon or evening. Pertinent interventions included having staff only ask Resident #4 if he wanted a shower once per week, as asking multiple times created agitation. The Bath Logs from 1/1/24 to 2/29/24 revealed the resident had been offered a shower on four days during this time period and refused each time. C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/28/24 at 3:59 p.m. RN #1 said some residents preferred alternative techniques of bathing, such as sink baths or bed baths and these preferences were noted in the facility's bath sheets. RN #1 said if a resident was offered a bath three times and refused each time they should find another staff member to ask. The social services director (SSD) was interviewed on 2/29/24 at 2:44 p.m. The SSD said that if a resident was repeatedly refusing care, the SSD would educate facility staff on how to use different approaches for the resident and would try to find different ways to navigate the care area. The SSD said that Resident #4 preferred to take a shower every three months,and one of the staff members had some success with getting the resident to agree to bathing. The SSD said the facility staff had tried a variety of bathing methods to see if they would make Resident #4 more comfortable with bathing but could not find any record of these attempts. The director of nursing (DON) was interviewed on 2/29/24 at 4:40 p.m. The DON said Resident #4's bathing preferences should have been documented in the care plan, bathing task and the facility staff's Kardex, an abbreviated care plan for care.. The DON said Resident #4's bathing task was not popping up on their software to alert the nursing staff, which was something they had recently discovered. The DON said Resident #4 did not like water and she thought this was due to some trauma from his past. The DON said the SSD used a trauma screening for residents in her evaluations so that they could create a care plan appropriately. The DON said Resident #4 tried to clean himself up in the sink. III. Resident #3A. Resident statusResident #3, age 75, was admitted to the facility on 12/15/22. According to the February 2024 CPO, diagnoses included atherosclerotic heart disease, diverticulosis and gastro-esophageal reflux. The 11/14/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was mostly dependant and required moderate to substantial assistance to perform most activities of daily living. B. ObservationsOn 2/28/24 at 4:35 p.m. the resident was eating cottage cheese and fruit that appeared to be peaches. On 2/29/24 at 4:40 p.m. the resident was eating cottage cheese and fruit that appeared to be peaches. On 3/1/24 at 11:45 a.m. the resident was eating cottage cheese and fruit that appeared to be peaches. C. Resident interviewResident #3 was interviewed on 2/26/24 at 11:43 a.m. Resident #3 stated the food she received from the facility was very fattening and she chose to eat cottage cheese and fruit for each meal to prevent weight gain. Resident #3 was interviewed again on 2/27/24 at 12:54 p.m. Resident #3 said she worked with the kitchen staff members on her meals and they switched the fruits she received each meal if she ever got tired of them. Resident #3 said the dietary staff did not try to give her other options with meals and she had to lead this change herself. D. Record reviewThe 12/15/22 care plan, revised 1/3/23, revealed Resident #3 had a potential for weight loss due to her disease processes. Pertinent interventions for this included asking Resident #3 and her family for past food preferences, offering alternate meals as needed if the resident ate less than 50% of her meals and providing and serving her diet as ordered. The 12/15/22 care plan, revised 1/3/23, revealed Resident #3 had gastroesophageal reflux disease. Pertinent interventions for this included encouraging the resident to consume a bland diet and providing the resident with small frequent meals. A medical progress note from 2/8/24 from an interdisciplinary team (IDT) meeting revealed Resident #3 was trying to eat healthy and was eating cottage cheese and fruit for most meals. The dietary quarterly assessment for Resident #3 was completed on 2/12/24. The assessment revealed that Resident #3 was tolerating her diet, was on a regular diet and the resident preferred to eat in her room.-There was no mention of Resident #3's dietary preferences. E. Staff interviewCook (CK) #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said Resident #3 ordered cottage cheese and fruit for lunch and dinner every day. CK #1 said Resident #3 would not eat anything else from the menu.

Based on interviews and record review, the facility failed to develop and implement an effective discharge plan that focused on each resident's goals and involved the resident in the development of the discharge plan for one (#36) of two residents reviewed for discharge planning out of 35 sample residents. Specifically, the facility failed to:-Ensure Resident #6's discharge planning needs were identified and documented in order to develop an appropriate discharge plan; and,-Involve the interdisciplinary team in the ongoing discharge process. Findings include:I. Facility policyThe Discharge Summary and Plan policy, revised October 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 2:39 p.m. It read in pertinent part: "The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing the release of the resident information and as permitted by the resident."A member of the (interdisciplinary team) reviews the final post-discharge plan with the resident and family at least twenty-four hours before the discharge is to take place."II. Resident #36A. Resident statusResident #36, age over 65, was admitted on 7/24/23 and discharged to another facility on 1/5/24. According to the January 2024 computerized physician order (CPO), diagnoses included Alzheimer's disease, dementia with agitation and unspecified diastolic (congestive) heart failure. According to the 1/5/24 minimum data set (MDS) assessment Resident #36 had a severe cognitive impairment. The staff interview documented Resident #36 had a memory problem, moderate cognitive impairment, fluctuating inattention and fluctuating disorganized thinking. The 11/6/23 MDS assessment prior to Resident #36 discharging documented the resident was not actively planning to discharge and the resident's clinical record documented only to ask questions about discharge planning on comprehensive assessments. B. Representative interviewResident #36's representative was interviewed on 2/29/24 at 10:43 a.m. He said he was unaware who initiated the transfer of the resident to another facility but he assumed it was the Veteran's Affairs (VA) hospital. He said Resident #36 had VA benefits and wanted to use them but could not at the facility where he was originally staying. The resident and his family were not involved in the discharge planning. C. Record reviewResident #36's discharge care plan, initiated on 11/7/23, documented the resident planned to remain in a long-term care facility. The intervention documented was for social services will initiate discharge planning and facilitate a return to the community if applicable and desired by the resident. A progress note, written on 7/24/23, which documented Resident #36 was admitted around 8:45 a.m. Resident #36 was transported by his family and was at the facility for a respite stay. An interdisciplinary team (IDT) note was written on 8/10/23 and documented Resident #36's family decided the resident would stay in long-term care instead of their initial plan for a respite stay. A social service note, written on 8/28/23, documented the social service director (SSD) talked to the resident's family about Resident #36's room change to the memory care unit. The family was documented as happy with the new room. A social service note, written on 10/13/23, documented the SSD sent a referral to another long-term care facility as requested by hospice and Resident #36's family.-There was no further follow up documentation regarding the referral or any indication the resident was planning to discharge to another facility. A progress note written on 1/5/24 by the NHA revealed Resident #36 had been discharged to another facility.-No other progress notes were written in Resident #36's chart from 10/13/23 to 1/5/24, when the resident was discharged from the facility. A discharge summary, completed on 1/5/24, revealed Resident #36 was admitted to the facility as respite care and transitioned to long-term care with hospice. The discharge summary included information on Resident #36's activities, mental and physical status and level of assistance needed, among other pertinent information.-The facility failed to document why the transfer was initiated. III. Staff interviewThe director of nursing (DON) was interviewed on 3/1/24 at 1:05 p.m. The DON said Resident #36 was admitted to the facility because the VA hospital was not accepting residents at the time. The DON said Resident #36's representative was hoping to arrange coverage through the VA while keeping the resident at the facility but was unable to. The DON said Resident #36's family spoke with her and the staff at the VA to arrange the resident's discharge and said discharges were usually discussed during the facility's morning meeting with their interdisciplinary team. The DON said discharge summaries should document why a resident was being discharged or transferred. The DON said Resident #36's discharge planning was not documented and the summary did not contain information regarding why he was discharged.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#5 and #10) of two residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to: Provide set-up teeth brushing assistance for Resident #5; and,Provide set-up bathing assistance for Resident #10. Findings include: I. Facility policyThe Activities of Daily Living (ADLs) policy, dated March 2018, was received from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. It documented that residents who are unable to complete activities of daily living will receive appropriate care and services, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). II. Resident #5A. Resident statusResident #5, over the age of 65, was admitted on 12/30/23. According to the February 2024 computerized physician order (CPO), diagnoses included acute respiratory failure, pneumonia, fibromyalgia and generalized muscle weakness. According to the 1/5/24 minimum data set (MDS) assessment Resident #5 had no significant cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented Resident #5 required set up or cleaning up assistance with oral hygiene. B. Resident interviewResident #5 was interviewed on 2/26/24 at 3:37 p.m. Resident #5 said she required assistance with setting up teeth brushing since she had surgery on both arms. Resident #5 said she had not brushed her teeth in six days. Resident #5 said she preferred to brush her teeth twice a day. C. Record review-Review of the comprehensive care plan dated 1/3/24 failed to document Resident #5's oral care assistance needs. Oral hygiene documented in the resident's electronic health record (EHR) documented 24 events out of an estimated 58 events where nursing staff offered set-up assistance with oral care in 29 days between 1/29/24 and 2/27/24. D. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 2/29/24 at 8:19 a.m. LPN #2 said Resident #5 required set up and take down assistance for oral care. The director of nursing (DON) was interviewed on 2/29/24 at 1:38 p.m. The DON said oral care should be performed twice a day for residents. The DON said oral care should be documented in the resident's electronic health record. The DON said oral care should have been provided to Resident #5 twice a day every single day. III. Resident #10A. Resident statusResident #10, over the age of 65, was admitted on 7/7/16. According to the February 2024 CPO, diagnoses included Alzheimer's dementia, anxiety, diabetes and high blood pressure (hypertension). According to the 1/23/24 MDS assessment Resident #10 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) assessment. Resident #10 required set up or touch assistance with tub or shower transfers. B. ObservationsOn 2/28/24 at 10:02 a.m. Resident #10 was sitting in the recliner chair in his room. The resident room smelled strongly of urine. On 2/29/24 at 10:06 a.m. Resident #10's room smelled strongly of urine while Resident #10 was sitting in his recliner chair. B. Record reviewThe care plan dated 1/25/23 documented Resident #10 preferred morning showers twice a week. The care plan documented Resident #10's bathing assistance needs which included set-up assistance, supervision of bathing and occasional one person assistance with bathing. The bathing records documented one event of offering set-up bathing assistance to Resident #10 in the month of January 2024. C. Staff interviewThe director of nursing (DON) was interviewed on 2/29/24 at 1:38 p.m. The DON said all residents should be bathed twice per week while accommodating resident preferences.

Based on observations, record review, and interviews, the facility failed to provide person-centered, individualized activities to meet the psychosocial needs of five (#1, #28, #20, #29 and #10) out of eight residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to:-Create a program of Spanish-language activities for Resident #10 in order to support his physical, cognitive, social and emotional health;-Provide person-centered activities to accommodate Resident #28's preferences; -Create a program of activities that were accessible for Resident #20 with visual impairment; and, -Provide meaningful, engaging activities for Resident #1 and Resident #29. Findings include:I. Facility policyThe Activity Programs policy, no date of creation or revision, was received from the nursing home administrator (NHA) on 3/6/24 at 12:34 p.m. It read in pertinent part: "Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident."Activities offered are based on the comprehensive resident-centered assessment and thepreferences of each resident."Individualized and group activities are provided reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents."II. Resident #1A. Resident statusResident #1, age 93, was admitted to the facility on 4/30/14. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia, osteoarthritis and intervertebral disk disorder. The 1/16/24 minimum data assessment (MDS) assessment revealed the resident was severely cognitively impaired.. The resident was dependent and required supervision and assistance with all activities of daily living (ADL). B. Resident representative interviewThe resident's representative was interviewed on 2/27/24 at 8:57 a.m. The representative said Resident #1 may be able to participate in activities but she was not sure how much she could process due to her dementia. The representative said Resident #1 sat in group activities but tone-on-one interactions with staff were more important to her. C. ObservationsOn 2/26/24 at 8:35 a.m. Resident #1 sat in a recliner in the activities room. Resident #1 was not involved in any meaningful activities. At 11:00 a.m. Resident #1 was transferred from the recliner in the activities room to her wheelchair. Resident #1 had not moved or been engaged in any meaningful activities since 8:35 a.m. At 4:04 p.m. the activities director (AD) was talking to Resident #1 in her room. On 2/27/24 at 8:43 a.m. Resident #1 was in the activity room sitting hunched over in her wheelchair. No meaningful activities were taking place. At 2:55 p.m. Resident #1 was sitting in her wheelchair in the activities room. Resident #1 was holding stuffed animal and was not engaged in any meaningful activities. At 3:35 p.m. Resident #1 was sitting in her wheelchair in a different location of the activities room. Resident #1 had dropped her stuffed animal and was chewing and sucking on her fingers. At 3:45 p.m. Resident #1 was sitting in her wheelchair in the same location and position. Resident #1 was petting the stuffed animal that was on the floor and was not engaged in any meaningful activity. At 3:47 p.m. Resident #1 was assisted to her room by the nursing home administrator (NHA). The NHA then applied lotion to Resident #1's hands. At 3:51 p.m. Resident #1 was assisted to the activities room. At 4:41 p.m. Resident #1 was sitting in her wheelchair in the activities room. Resident #1 was hunched over looking at her hands and her stuffed animal was on the ground next to her wheelchair. Resident #1 was not engaged in any meaningful activities. On 2/28/24 at 9:28 a.m. Resident #1 was sitting in her reclining chair with her legs up. At 9:29 a.m. the AD went around to each room on the hall and offered residents a donut and juice. At 9:47 a.m. the AD finished providing conducting the activity involving donuts. The AD did not engage with Resident #1 during this activity due to her being on a pureed diet (see orders and interview below). At 10:45 a.m. Resident #1 was still in her reclining chair. At 10:50 a.m. an unidentified certified nurse aide (CNA) checked on Resident #1. The CNA helped Resident #1 with her drink before leaving the room. At 11:00 a.m. Resident #1 was still in her reclining chair. At 11:03 a.m. registered nurse (RN) #1 went into Resident #1's room to provide medications and walked out of the room after administering the medications. Resident #1 was still in her reclining chair in the same position. At 11:15 a.m. Resident #1 was still in her reclining chair. At 11:22 a.m. the AD went into Resident #1's room to invite her roommate to join an activity but did not invite Resident #1. At 11:30 a.m. Resident #1 was still in her reclining chair. At 5:42 p.m. Resident #1 was alone in her room. Resident #1 was sitting in her wheelchair and rubbing her hands. On 2/29/24 at 9:14 a.m. Resident #1 was sitting in her wheelchair in the activities room. Resident #1 was holding her stuffed animal and had her eyes closed. Resident #1 was not engaged in any meaningful activities. At 9:32 a.m. Resident #1 was assisted away from activities by an unidentified CNA and left in the hallway outside of her room. Resident #1 remained in the hallway alone until 9:40 a.m., at which time the CNA assisted Resident #1 into her room and provided care. D. Record review Resident #1 had physician orders for a pureed texture diet and significant assistance with each meal. The 9/26/16 care plan, revised on 12/10/22, revealed that Resident #1 was at risk of decreased group interaction without encouragement and assistance due to her cognitive impairment. Pertinent interventions noted that Resident #1 enjoyed having a baby doll or stuffed animal to take care of, that the resident enjoyed music and going outdoors and that the resident needed one-to-one assistance for any activities due to her cognitive impairment. Group activity logs from 1/31/24 to 2/29/24 revealed Resident #1 had joined seven group activities during that time. One-on-one activity logs from 1/31/24 to 2/29/24 revealed Resident #1 had listened to music once and had one-on-one interactions with staff nine times during that time. Resident #1 had connected with family via phone or video communication four times during that period. E. InterviewsThe AD was interviewed on 2/29/24 at 4:48 p.m. The AD said for residents with disabilities, she asked them what they would like to do. When the AD did activities that involved food, she had a printout of the residents' dietary needs on her cart. The AD said when she was doing activities that involved foods like donuts, she offered pudding to residents on pureed diets. CNA #4 was interviewed on 3/1/24 at 3:36 p.m. The CNA said Resident #1 liked to take naps after meals and loved to hold stuffed animals. The CNA said Resident #1 liked to sit in the activities room. Since Resident #1 sat in the activities room for long periods of time, the CNA said it was best for Resident #1 to be assisted into one of the reclining chairs in the room. III. Resident #10A. Resident statusResident #10, over the age of 65, was admitted on 7/7/16. According to the February 2024 CPO, diagnoses included Alzheimer's dementia, anxiety, diabetes and high blood pressure (hypertension). According to the 1/23/24 MDS assessment, Resident #10 had significant cognitive impairment and was unable to complete the BIMS.According to the 4/4/23 MDS assessment, it was very important for Resident #10 to listen to music and be able to do his favorite activities. B. ObservationsOn 2/26/24 at 12:00 p.m., Resident #10, who spoke primarily Spanish, was sitting in the television (TV) lounge. -The TV was on, however, it was in the English language. On 2/27/24 at 2:55 p.m., Resident #10 was sleeping in bed in his room during a scheduled group activity in the main activities room. On 2/28/24 at 10:02 a.m., Resident #10 was watching TV in his room. A donut with chocolate frosting and sprinkles and a Glucerna shake were on his bedside table. Several residents were socializing in the main activities room. On 2/28/24 at 1:51 p.m., Resident #10 was watching TV in his room during a scheduled group activity. C. Record reviewReview of the care plan, revised 1/18/24 documented that Resident #10 was at risk for social isolation and decreased group interaction and spoke Spanish as a primary language. The resident enjoyed activities including television, animals, the outdoors, and visiting with other residents and staff. The resident needed to be invited to activities. D. Staff InterviewsCNA #4 was interviewed on 2/29/24 at 3:42 p.m. CNA #4 said nursing staff used a housekeeper who spoke Spanish if they could not understand Resident #10. CNA #4 said she was not aware of interpreter services being available. CNA #4 was not aware of any activities in the Spanish language being provided to Resident #10. RN #1 was interviewed on 2/29/24 at 3:42 p.m. RN #1 said that she was not aware of any activities planned in the Spanish language for Resident #10. RN #1 said that she would ask housekeepers that spoke Spanish for help if she could not understand Resident #10. RN #1 was not sure how she would speak with Resident #10 if bilingual housekeeping staff were not present. The activities director (AD) was interviewed on 2/29/24 at 6:21 p.m. The AD said she communicated with Resident #10 by looking up words in Spanish on her phone. The AD said she had provided Resident #10 with Spanish crossword puzzle books and Spanish word finding books, however, she said she had not planned any other activities for Resident #10 in the Spanish language. The AD said residents should have the opportunity to participate in activities in their primary language. IV. Resident #29A. Resident statusResident #29, over the age of 65, was admitted on 12/30/22. According to the February 2024 CPO, diagnoses included dementia, abdominal aortic aneurysm (AAA) (an enlarged area in the lower part of the aorta, the body's main artery) and high blood pressure (hypertension). According to the 12/6/23 MDS assessment, Resident #29 had significant cognitive impairment and was unable to complete the BIMS.The 1/6/23 MDS assessment documented it was very important for the Resident #29 to be able to do his favorite activities. B. ObservationsOn 02/26/24 at 9:55 a.m., Resident #29 was sitting in the common dining area eating breakfast. A moving and grooving activity, scheduled for 9:00 a.m., was going on, however, Resident #29 was unable to participate because he was still eating. -Nursing staff did not invite Resident #29 to participate in activities after he finished breakfast. On 02/27/24 at 2:56 p.m., a hot cocoa and snacks activity was scheduled to start at 2:30 p.m. for the afternoon activity. Music was playing in the dining room, and some residents were gathered for the activity. -Resident #29 was in his room for the duration of the activity, and was not observed to be invited to participate in the activity. On 02/28/24 at 10:06 a.m., a 9:00 a.m. moving and grooving activity was scheduled. Music was playing while Resident #29 continued to eat his breakfast throughout the scheduled morning activity time. -Resident #29 was not offered activities after finishing his breakfast. C. Record ReviewResident #29's activity care plan, initiated 1/12/24, documented Resident #29 was at risk for social isolation, required one on one assistance with all activities, should be asked about his interests so he could plan his day and that he could not focus on activities for long periods of time. His documented interests included western music and television, animals, the outdoors, and sorting papers. V. Resident #20A. Resident statusResident #20, age 81, was admitted on 6/7/21. According to the February 2024 CPO, diagnoses included visual loss in both eyes, unspecified anxiety disorder, generalized muscle weakness, lack of coordination and other unspecified depressive disorders. The MDS assessment revealed Resident #20 was cognitively intact with a BIMS score of 14 out of 15. Resident #20 required partial or moderate staff assistance for toileting, bathing, personal hygiene and dressing. She required extensive assistance with all surface transfers. He required setup and clean-up assistance with eating and oral hygiene. B. Resident interviewResident #20 was interviewed on 2/26/24 at 9:28 a.m. Resident #20 said the facility offered too many group social activities which she did not like to participate in. She said she enjoyed talking with staff, listening to music, football being outside and animals. She said it was too cold to go outside but when it warmed up she looked forward to going outside even if she just sat there. She said she felt forgotten by the staff because she did not participate in group activities. She said the facility failed to offer enough independent activities, especially for her, because she was legally blind. She said she wished she could do animal therapy and maybe animal therapy would help with her anxiety and depression. Resident #20 said she felt alone at the facility. C. ObservationsOn 2/28/24, during a continuous observation beginning at 8:16 a.m. and ending at 11:30 a.m., the following observations were made:At 8:16 a.m., Resident #20 was in her room with her door closed. At 9:29 a.m., the activity director (AD) went to the residents' rooms and offered a donut and a drink. The AD did not stop at Resident #20's room. Resident #20 was not offered a donut or drink, or a substitution due to her gluten and lactose allergy. At 9:37 a.m., an unidentified certified nurse aide (CNA) checked on Resident #20 and asked if she wanted a snack. Resident #20 declined. At 11:22 a.m., the AD invited a handful of residents to a group activity but did not invite Resident #20. D. Record reviewResident #20's care plan, revised 6/19/23, documented the resident was at risk for social isolation due to her preference not to participate in group activities. The care plan documented Resident #20 liked music, animals, the outdoors and her favorite sport was Nascar and she enjoyed watching the races. Interventions included:"-Ask the resident about her activity preferences and help her plan;-Assist Resident #20 with mail and phone calls as needed;-Help Resident #20 visit with family and friends in a private location;-Provide Resident #20 with a monthly calendar of scheduled activities;-Respect Resident #20's right to refuse, privacy and spiritual choices;-Resident #20 does not see well enough to watch television (TV) but she enjoys listening to the TV;-Resident #20 enjoys spending most of her day in her room listening to Alexa (blue tooth speaker);-Resident #20 enjoys country music;-Resident #20 gets upset with invites to group activities;-Resident #20 has an Alexa that she uses almost daily;-Resident #20 has a low tolerance for activities;-Resident #20 has poor vision, assist her as needed;-Resident #20 is able to vote. Assist the resident with voting needs as needed;-Resident #20 is unable to have gluten and is lactose intolerant, offer her foods that fit her diet;-Resident #20 prefers not to participate in group activities; and-Resident #20 states she enjoys the outdoors but declines invites to go outdoors."-The care plan did not include animal therapy as an activity intervention for Resident #20. A review of the activity progress notes revealed Resident #20 had multiple one-on-one activity visits between 8/1/23 and 11/24/23.-However, there were no one-on-one activity progress notes documented from 11/24/23 through 2/22/24.-There were no one-on-one activity progress notes documented from 2/25/23 through 3/1/24. D. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/29/24 at 11:50 a.m. RN #1 said Resident #20 could not see very well which caused her not to participate in activities outside of her room. RN #1 said the resident enjoyed watching football with staff and another resident, but when football season ended she stayed in her room listening to music on her Alexa speaker. Certified nurse aide (CNA) #4 was interviewed on 2/29/24 at 12:45 p.m. CNA #4 said Resident #20 was visually impaired but could see objects that were close to her. She said the resident recognized staff by their voices. She said Resident #20 enjoyed spending time with animals. CNA #4 said she brought her bearded dragon to work and Resident #20 loved spending time with it. The social services director (SSD) was interviewed on 2/29/24 at 5:41 p.m. The SSD said she was previously the AD before she switched departments. She said Resident #20 was legally blind but she could see shapes. The SSD said Resident #20 preferred to visit with male staff. She said the facility provided a talking book to the resident and she did not really like using it but the SSD said she could offer it again. The SSD said Resident #20 talked to her Alexa speaker. The SSD said she provided guidance to the AD and would provide more as needed. The AD was interviewed on 2/29/24 at 6:05 p.m. The AD said the activity staff, including herself, invited and encouraged Resident #20 to attend activity groups. She attended one-on-one activities in her room. She said when the weather was nice Resident #20 sat outside and enjoyed a glass of wine. She said Resident #20 had a friend who visited with an animal and Resident #20 loved animals. The AD said animal therapy was not offered to Resident #20 because the AD had not thought of that as an activity. She agreed the resident would benefit from animal therapy or animal visits. 2The AD said she did not offer Resident #20 a donut on 2/28/24 because the resident could not have it and often declined a substitution snack because it was different from what the other residents received. The AD said she should have offered a gluten and lactose-free donut to the resident so she was not left out of the activity. She said she bought Resident #20 gluten-free snacks but the resident refused to eat them because she believed the items still had gluten in them. The AD said the facility used to provide homemade gluten-free snacks to Resident #20 but stopped because she got burnt out on the items but she was willing to start making the gluten-free snacks again. VI. Resident #28A. Resident statusResident #28, age 86, was admitted on 12/7/22. According to the February 2024 CPO, diagnoses included unspecified dementia with other behavioral disturbances, delusional disorders and generalized muscle weakness. The 12/13/23 MDS assessment revealed Resident #28 was cognitively intact with a BIMS score of 15 out of 15. B. ObservationsOn 2/26/24 at 12:59 p.m. Resident #28 had a chair blocking her bedroom door from being opened and said she was busy. Her room was dark and quiet. Resident #28 allowed certain staff into her bedroom. On 2/28/24, during a continuous observation beginning at 8:16 a.m. and ending at 11:30 a.m., the following observations were made:At 8:16 a.m., Resident #28 had her bedroom door closed. At 9:29 a.m., the AD offered Resident #28 a donut and asked if she wanted something to drink. At 9:38 a.m., the NHA brought Resident #28 a cup of coffee. At 9:51 a.m., the NHA left Resident #28's room. At 11:22 a.m., the AD invited residents to a group activity but did not invite Resident #28. C. Record reviewResident #28's care plan, revised 12/27/22, documented the resident was at risk for isolation without invites or encouragement to activities. Resident #28 enjoyed reading, walking around, socializing, card games, TV and movies and arts and crafts. Interventions were documented as:"-Assist Resident #28 with mail and phone calls as needed;-Help the resident visit with family and friends in a private location;-Resident #28 enjoys doing her makeup and hair;-Resident #28 enjoys having phone calls with family and friends;-Resident #28 enjoys outdoor activities like going for walks when the weather is nice;-Resident #28enjoys independent activities like watching TV or movies, visiting with staff and other residents and reading books or magazines;-Resident #28 enjoys inviting people to come help her in her room and to carry her stuff around if she needs the help;-Resident #28 enjoys shopping trips;-Resident #28 enjoys socializing with staff and other residents;-Resident #28 likes to walk around the halls while pushing her wheelchair to help carry stuff;-Resident #28 watches TV and movies in her room and occasionally comes out to the activity room to watch movies with other residents;-Provide Resident #28 with a monthly calendar of scheduled activities;-Remind and encourage Resident #28 to do group activities daily and offer assistance while in group activities;-Remind Resident #28 when activities are scheduled;-The resident enjoys spending most of her day in her room watching TV and movies, cleaning and sometimes wandering around the halls of the facility;-Respect Resident #28's right to refuse, privacy and spiritual choices; and-Resident #28's most important activities are reading books or magazines, visiting with staff and residents and making phone calls to her family. On 4/30/23, an activity progress note documented the resident talked about the History Channel and true crime while the activity aide painted the resident's nails for 20 minutes. On 5/20/23, an activity progress note documented the resident talked about her problems and asked for help from the activity aide for 15 minutes. On 11/17/23, a nursing progress note documented Resident #28 was at Walmart with activity staff.-There were no activity progress notes documented from 11/17/23 to 3/1/24. D. Staff interviewsRN #1 was interviewed on 2/29/24 at 11:50 a.m. RN #1 said Resident #28 was afraid of germs and often stayed in her room. She said Resident #28 did not participate in activities outside of her room. RN #1 said the resident enjoyed doing her hair and makeup and cleaning her room. RN #1 said the resident did not participate in activities in her room except for flipping through magazines. The AD was interviewed on 2/29/24 at 6:05 p.m. The AD said ADLs counted as an activity for Resident #28. She said the facility offered a "rise and shine program" where the nursing staff assisted residents with getting ready for the day and making their beds. The AD said Resident #28 preferred a particular activity staff member, however the staff member was on leave. She said Resident #28 had had a decline in activity participation since her preferred activity staff member went on leave. The AD said she offered the resident magazines, newspapers, word searches and other supplies for independent activities but the resident refused the items. The AD said she had not tried other activities for Resident #28 that assisted with her fears and delusions.

Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional referenceAccording to the National Certification Council of Activity Professionals (NCCAP) (2023), retrieved on 3/13/24 from www.nccap.org, "An activity director must meet specific qualifications in education, certification and/or experience."The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist; or an activities professional who is licensed or registered, if applicable, by the State in which practicing; and,"-Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or"-Has two (2) years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or"-Is a qualified occupational therapist or occupational therapy assistant; or"-Has completed a training course approved by the State."An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes completion of the activities component of the comprehensive assessment; contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident." II. Record review Review of the staff list revealed an activity director (AD). According to the nursing home administrator (NHA), the activity director was currently in charge of activities (see interviews below). III. Staff interviewsThe AD was interviewed on 2/28/24 at approximately 11:00 a.m. The AD said she was the current director of activities. She said she planned the activities for the facility. She said she was not certified as an activity director. She said the social services director (SSD) was her mentor as she had previously worked as the AD. The SSD was interviewed on 2/29/24 at 5:41 p.m. The SSD said she used to be the activity director however, she changed positions and she no longer was the AD. The SSD said the facility's AD was not certified and she provided support to the AD. The SSD said she was no longer certified as an AD because she let her certification expire. The NHA was interviewed on 3/1/24 at 3:30 p.m. The NHA said she was not aware the SSD's activity certification had expired.

Based on record review, observations and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for four (#1, #27, #25 and #6) of four residents reviewed for accident hazards out of 35 sample residents. Specifically, the facility failed to:-Implement appropriate safety devices when assisting Resident #1 and Resident #25 in their wheelchairs; -Safely transfer Resident #27 and Resident #1 using an appropriate transfer device; and, -Ensure speech therapy recommendations were implemented for Resident #6. Findings include:I. Resident #1A. Resident statusResident #1, age 93, was admitted to the facility on 4/30/14. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia, osteoarthritis and intervertebral disk disorder. The 1/16/24 minimum data assessment (MDS) assessment revealed the resident was severely cognitively impaired. The resident was dependent and required supervision and assistance with all activities of daily living. B. ObservationsOn 2/26/24 at 11:10 a.m. Resident #1 was assisted to her room in her wheelchair by an unidentified staff member. Resident #1's wheelchair did not have foot pedals nor a footboard in place and her feet dragged along the ground as they moved. At 11:18 a.m. Resident #1 was assisted in her wheelchair back to the activities room. Resident #1's wheelchair did not have foot pedals nor a footboard in place and her feet dragged along the ground as they moved. On 2/28/24 at 9:00 a.m. certified nurse aide (CNA) #5 and #3 assisted the resident to her room. CNA #5 placed the gait belt around the resident's waist. The two CNAs lifted the resident, with one arm under each of the resident's arms and they held onto her pants while they lifted the resident. The resident did not stand on her own. The transfer was a total lift, and the gait belt was not utilized. At 4:38 p.m. the resident was assisted by the activity director (AD) to the television area. No pedals were used, as the resident's feet dragged on the floor. On 2/29/24 at 9:32 a.m. Resident #1 was assisted in her wheelchair by an unidentified certified nurse aide (CNA) from the activities room to the hallway outside of her room. Resident #1's wheelchair did not have foot pedals nor a footboard in place and her feet dragged along the ground as they moved. At 9:40 a.m. Resident #1 was assisted in her wheelchair from the hallway to her room. Resident #1's wheelchair did not have foot pedals nor a footboard in place, and her feet dragged along the ground as they moved. C. Record reviewThe 1/31/2020 care plan, revised on 1/15/24, revealed that Resident #1 was at risk of skin breakdown due to her decreased mobility and fragile skin. Pertinent interventions included having foot pedals and a foot board on her wheelchair to protect her feet. The 1/31/2020 care plan, revised on 1/15/24, revealed that Resident #1 required up to extensive assist of (1-2) staff. However, the care plan failed to direct the staff to use a gait belt. A fall risk evaluation, performed on 1/14/24, revealed that Resident #1 was a low fall risk. The evaluation indicated that Resident #1 was chair-bound and was disoriented at all times. -The resident's medical record failed to show that the resident was assessed for the proper technique to be used for the resident's transfers. D. Staff interviewsCNA #5 was interviewed on 2/28/24 at 9:15 a.m. The CNA said that Resident #1 was transferred daily in the same manner (see above). She said some days she stood better than she did during observation. The CNA said a mechanical lift was not utilized with this resident. The director of nurses (DON) was interviewed on 2/28/24 at 5:21 p.m. The DON said a gait belt should always be used when transferring a resident. She said that therapy did a screen on the resident to determine the transfer method. She said that when Resident #1 was transferred the gait belt should be held and under the arms was just support. She said she would get therapy to screen the resident. The DON said pedals should be used on resident wheel chairs so their feet did not drag when being propelled. However, if a resident self propelled the pedals could cause some problems so therefore the chairs did not have pedals. The DON said the pedals could be removed if the resident was being transported. She said injury could occur when a resident was being pushed by a staff member without foot pedals. II. Resident #25A. Resident statusResident #25, age 81, was admitted to the facility on 9/21/22. According to the February 2024 CPO, diagnoses included mild cognitive impairment, mild hypoxic ischemic encephalopathy (a form of brain damage caused by lack of oxygen to the brain during or just after birth), muscle weakness and repeated falls. The 12/26/23 MDS assessment revealed the resident was moderately cognitively impaired. The resident required assistance with all activities of daily living. B. ObservationsOn 2/27/24 at approximately 9:00 a.m. Resident #25 was assisted to her room in her wheelchair by an unidentified staff member. Resident #25's wheelchair did not have foot pedals. The resident was told to lift her legs while she was pushed in the wheelchair. On 2/28/24 at 4:46 p.m. CNA #6 assisted the resident from her room to the dining room. The CNA asked the resident to pick up her feet as he pushed the resident. C. Record reviewThe 10/5/22 care plan, revised on 12/18/23, revealed that Resident #25 had deficits in her ability to perform activities of daily living due to her impaired balance. Pertinent interventions included Resident #25 using a wheelchair with staff assistance in order to move around the facility and one staff member for all transfers between surfaces. A fall risk evaluation, performed on 12/23/23, revealed that Resident #25 was a high fall risk. This evaluation indicated that Resident #25 was chair-bound and intermittently confused. D. Staff interviewCNA #6 was interviewed on 2/28/24 at 4:50 p.m. The CNA said he asked the resident to pick up her feet when he pushed her in the wheelchair. He said he did not know if she had foot pedals. He said therapy would know if the resident was to have foot pedals on the wheelchair. III. Resident #27A. Resident statusResident #27, over the age of 65, was admitted on 10/20/23. According to the February 2024 CPO, diagnoses included metabolic encephalopathy (temporary or permanent brain damage resulting from a blood chemical imbalance), kidney failure, dementia, atrial fibrillation and high blood pressure (hypertension). According to the 1/30/24 MDS assessment Resident #27 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) score evaluation. According to the MDS assessment dated 11/1/23, Resident #27 required assistance with transferring, toileting, walking and incontinence care. B. ObservationsOn 2/26/24 at 10:27 a.m. general nurse aide (GNA) #1 and certified nurse aide (CNA) #2 were transferring Resident #27 from the wheelchair to the recliner without the use of a transfer device. Resident #27 pushed away from the staff while being lifted by her upper arms and shoulders. C. Record review-A review of the comprehensive care plan failed to document the transfer assistance needs of the resident. C. Staff interviewsCNA #2 was interviewed on 2/27/24 at 10:02 a.m. CNA #2 said that gait belts should be used to transfer residents from a wheelchair to a recliner chair. The director of nursing (DON) was interviewed on 3/1/24 at 12:55 p.m. The DON said Resident #27 required one to two person assistance and transferring Resident #27 without a gait belt was inappropriate. IV. Resident #6A. Resident statusResident #6, over the age of 65, was admitted on 6/19/23. According to the February 2024 CPO, diagnoses included vascular dementia, obsessive-compulsive disorder and depression. According to the 1/30/24 MDS assessment Resident #6 had significant cognitive impairment and was unableto complete the BIMS assessment. B. Observation On 2/29/24 at 5:36 p.m. Resident #6's bed was approximately at a 45 degree incline after set-up meal assistance was completed by certified nurse aide (CNA) #1. The resident began coughing after eating one bite of food. CNA #1 and licensed practical nurse (LPN) #2 entered the room and assisted the resident to sit up at 90 degrees. Resident #6 stopped coughing following this intervention. C. Record reviewThe speech therapy evaluation dated 7/22/23 documented the need for Resident #6 to sit up at 90 degrees for all meals. According to the care plan dated 2/23/24, Resident #6 required assistance with transferring, toileting, walking and incontinence care.-The care plan did not include the speech therapy evaluation intervention which documented the need for Resident #6 to sit up at 90 degrees for all meals. Cross-reference F656 for care planning. D. Staff interviewsCNA #1 was interviewed on 2/29/24 at 5:46 p.m. CNA #1 said that Resident #6 needed to be at 75-90 degrees to eat. CNA #1 stated the resident was not sitting at the correct angle when she began coughing. The speech and language pathologist (SLP) was interviewed on 3/1/24 at 11:48 a.m. The SLP said Resident #6 needed to sit up at 90 degrees for all meals. The SLP said the swallow study evaluation recommendations to be followed by the facility and it should be reflected in the plan of care.

Based on observation, record review and interviews, the facility failed to ensure one (#29) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 35 sample residents. Resident #29 was at nutritional risk with a diagnosis of dementia. Interventions were implemented by the registered dietitian due to the resident's nutritional risk and history of weight loss, however, these interventions were not consistently evaluated for effectiveness. Observations during the survey revealed the resident's intake of nutritional supplements were not accurately documented. When the resident sustained a significant weight loss from 1/2/24 to 2/2/24, the intervention of offering fortified foods was not added until 20 days later. Due to the facility's failure to implement timely nutritional interventions and evaluate the effectiveness of nutritional interventions in place, the resident sustained a 16.3 pound (lbs) weight loss from 1/2/24 to 2/2/24, 10.7% which was considered significant. Findings include: I. Resident statusResident #29, over the age of 65, was admitted on 12/30/22. According to the February 2024 computerized physician order (CPO), diagnoses included dementia, abdominal aortic aneurysm (an enlarged area in the lower portion of the aorta, the body's main artery) and high blood pressure (hypertension). According to the 12/6/23 minimum data set (MDS) assessment, Resident #29 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS). The assessment documented Resident #29 required set-up or cleaning assistance with meals and maximal assistance with bathing, toileting and dressing. The resident was able to eat independently after set-up assistance was completed. The assessment did not identify weight loss. II. ObservationOn 2/28/24 at 9:46 a.m., Resident #29 was administered 237 milliliters (ml) of a nutritional supplement. Licensed practical nurse (LPN) #1 documented 237 ml of nutritional supplement consumed while the resident was actively drinking the supplement at 9:46 a.m. When the resident stopped drinking the nutritional supplement at 9:54 a.m., the MDS coordinator (MDSC) cleared Resident #29's tray, including the nutritional supplement. -The MDSC failed to observe or measure for any remaining nutritional supplement and did not communicate the amount of nutritional supplement consumed by Resident #29 to LPN #1. It was unknown how much nutritional supplement was consumed by Resident #29. At 4:16 p.m., LPN #1 discarded a nutritional supplement bottle in which medications were added for medication administration. Some remaining nutritional supplement and pill fragments were in the bottle. LPN #1 documented Resident #29 consumed 237 milliliters of nutritional supplement. III. Record review Review of Resident #29's electronic medical record (EMR) revealed the following documented weights: -On 8/16/23, the resident weighed 157.6 lbs;-On 9/8/23, the resident weighed 154.4 lbs;-On 10/25/23, the resident weighed 147.8 lbs;-On 12/2/23, the resident weighed 150.0 lbs;-On 1/2/24, the resident weighed 152.3 lbs;-On 2/2/24, the resident weighed 136.0 lbs;-On 2/15/24, the resident weighed 137.1 lbs; and, -On 2/23/24, the resident weighed 137.0 lbs. Resident #29's weight record showed the resident lost 16.3 pounds between 1/2/24 and 2/2/24. This was considered significant weight loss of 10.7% of the resident's body weight in one month. The care plan, dated 12/14/23, identified that Resident #29 was at risk for nutritional concerns and he required set-up assistance and a high back chair for all meals. Pertinent interventions included monitoring for decreased oral intake with meals and snacks, set up and supervision while eating, additional time to complete the meal, cueing to remain focused on eating and snacks throughout the day. The dietary quarterly assessment dated 2/19/24 documented a significant weight loss of 10.7%. -The dietary quarterly assessment failed to identify or implement additional nutritional interventions. The Dietary Nutritional assessment, dated 2/22/24, documented Resident #29 had a height of 73 inches and a weight of 137.1 pounds. It documented a significant weight loss of 10.7% in a month and 13.7% weight loss since 8/16/23. The nutritional assessment documented interventions including nutritional supplements three times a day, fortified food and allowing him extra time to finish meals. The nutritional assessment documented the resident did not refuse the nutritional supplements and consumed 100% of nutritional supplements three times a day. -The intervention to offer finger foods to the resident was added 2/22/24, however, this was 20 days after the significant weight loss was identified. The January 2024 and February 2024 medication administration record (MAR) documented nutritional supplements ordered 6/8/23 to be administered three times per day. There were 174 nutritional supplement administration opportunities between 1/1/24 and 2/27/24, of which 30 administrations were not given because the resident was sleeping. There was no documentation to indicate the nutritional supplement was re-offered to the resident when he was awake. The remaining 144 nutritional supplement administrations documented Resident #29 consumed 237 milliliters (ml) or 100% of the nutritional supplement.-However, observations revealed the resident did not consistently consume 100% of the supplement (see observations above). IV. Staff interviewsLPN #1 was interviewed on 2/28/24 at 4:19 p.m. LPN #1 said nutritional supplements should be observed, measured and then appropriately charted. LPN #1 said the resident's MAR should accurately document how many milliliters of nutritional supplements were consumed. LPN #1 said the nutritional supplements were ordered to prevent weight loss for Resident #29. The corporate registered dietitian (CRD) was interviewed on 2/29/24 at 10:30 a.m. The CRD said she had not witnessed Resident #29 consume a nutritional supplement. The CRD said she relied on the milliliters documented to know how much of the nutritional supplement residents' consumed. The CRD said staff should roughly estimate how much of the nutritional supplement had been consumed by a resident. The CRD said she was not aware of Resident #29 not receiving nutritional supplements because he was asleep. The CRD said she was not aware of nursing staff charting nutritional supplement totals before the resident finished consuming them. The director of nursing (DON) was interviewed on 3/1/24 at 12:55 p.m. The DON said if a resident was sleeping staff should re-offer nutritional supplements later in the day and document this. The DON said nutritional supplements should be measured after residents finished consuming them to accurately document the volume consumed. The DON said nursing staff, the CRD and the DON were all responsible for identifying if residents needed additional interventions for weight loss.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 17.86%, which was five errors out of 28 opportunities for error. Findings include: I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607, retrieved on 3/8/24, "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment."Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication."II. Facility policy and procedureThe Pharmacy Services Overview policy, undated, was received from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. It documented in pertinent part:"Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice."Manufacturer's instructions or user manuals related to any medication administration devices are kept with the devices or at the nurses station."III. Manufacturer's guidelinesThe How to Use your Lantus Solostar Pen manufacturer's procedure guide, dated 2022, was received from the NHA on 2/28/24 at 5:46 p.m. It documented in pertinent part:"-Dial a test dose of two units.-Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needs. This will help you get the most accurate dose.-Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.-If no insulin comes out, repeat the test two more times. If there's still no insulin coming out, use a new needle and do the safety test again.-Always perform the safety test before each injection-Never use the pen if no insulin comes out after using a second needle."IV. ObservationsOn 2/28/24 at 12:47 p.m. licensed practical nurse (LPN) #1 administered medication to Resident #31. LPN #1 reviewed the physician order and obtained Tylenol from the medication cart. LPN #1 added a small amount of the meal Resident #31 was currently eating and administered the medication. After administering the medication, LPN #1 asked Resident #31 if she had any pain or discomfort. -LPN #1 failed to assess Resident #31's pain before administering the physician ordered as-needed pain medication. According to the medication administration record (MAR), Resident #31 had a physician order for Tylenol every eight hours as needed for her pain. On 2/28/24 at 4:16 p.m. LPN #1 administered medications to Resident #29. Three ordered medications were crushed together and placed into a nutritional supplement. After Resident #29 consumed the nutritional supplement, the nursing staff emptied the remaining volume into the sink which contained several pill fragments. It was not known what dose of each medication Resident #10 received. -LPN #1 failed to ensure Resident #29 received the physician ordered dose of these three medications. The MAR documented that Resident #29 was to receive Trazodone 50 milligrams (mg) twice daily by mouth (an antidepressant), Tylenol 500mg twice daily by mouth and Seroquel 50mg twice daily by mouth (an antipsychotic). The physician orders documented the medications may be crushed and placed in an appropriate vehicle for medication administration for Resident #29. Resident #19 was observed on 2/28/24 at 4:59 p.m. receiving insulin medication administered by registered nurse (RN) #1. RN #1 took the resident's blood sugar. According to the sliding scale physician order, the resident was to receive six units of Lispro insulin. RN #1 obtained the six units of Lispro insulin from the medication cart. RN #1 administered the Lispro insulin to Resident #19. -RN #1 failed to complete the insulin pen safety check including priming with two units of insulin prior to administering the insulin. The MAR documented Resident #19 had ordered Lispro insulin to be administered subcutaneously per a sliding scale dose that varied depending on Resident #19's blood glucose reading. V. Staff interviewsLPN #1 was interviewed on 2/28/24 at 12:49 p.m. LPN #1 said he should have asked Resident #31 about her pain before obtaining the pain medication from the medication cart. LPN #1 was interviewed on 2/28/24 at 4:16 p.m. LPN #1 said he had an order to place crushed medications in an appropriate vehicle. LPN #1 said that the nutritional supplement was not an appropriate vehicle for the medications because pill fragments remained in the supplement after medication administration. LPN #1 said he should have used pudding or applesauce as an appropriate vehicle for medication administration. The director of nursing (DON) was interviewed on 2/28/24 at 6:13 p.m. The DON said she was not aware insulin pens needed a safety check performed including priming the pen needle. The DON said medication orders by the physician should always be followed. The DON said applesauce or pudding was considered an appropriate vehicle for medication administration. The pharmacist was interviewed on 2/29/24 at 3:46 p.m. The pharmacist said Resident #19 had two different kinds of multi-dose insulin pens and the safety check process for administering the two kinds of insulin was the same for the bedside nurse. The pharmacist said every insulin pen should be primed with two units of insulin before medication administration.

Based on observation and interviews, the facility failed to ensure residents were free from significant medication errors for one (#19) of 11 residents reviewed for medication errors out of 35 sample residents. Specifically, the facility failed to ensure Resident #19 was administered insulin according to the manufacturer's guidelines. Findings include:I. Manufacturer's guidelinesThe How to Use your Lantus Solostar Pen manufacturer's procedure guide, dated 2022, was received from the nursing home administrator (NHA) on 2/28/24 at 5:30 p.m. It documented in pertinent part:"-Dial a test dose of two units.-Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needs. This will help you get the most accurate dose.-Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test.-If no insulin comes out, repeat the test two more times. If there's still no insulin coming out, use a new needle and do the safety test again.-Always perform the safety test before each injection-Never use the pen if no insulin comes out after using a second needle."II. ObservationResident #19 was observed on 2/28/24 at 4:59 p.m. receiving insulin medication being administered by registered nurse ( RN) #1. RN #1 was took the resident's blood sugar. According to the sliding scale physician order, the resident was to receive six units of Lispro insulin. RN #1 obtained the six units of Lispro insulin from the medication cart. RN #1 administered the Lispro insulin to Resident #19, however, the insulin pen safety check was not completed including priming with two units of insulin prior to administering the insulin. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/28/24 at 5:12 p.m. RN #1 said she did not know insulin pens had to be primed as part of their safety check before administration. RN #1 did not know where the manufacturer's guidelines for administering insulin were located in the facility. The NHA was interviewed on 2/28/24 at 5:14 p.m. The NHA did not know where the manufacturer's guidelines were kept for insulin pens in the facility. The NHA said she would have to contact the pharmacist to have that information available for bedside nursing staff. The director of nursing (DON) was interviewed on 2/28/24 at 6:13 p.m. The DON said she was not aware insulin pens needed a safety check performed including priming the pen needle. The DON said medication orders by the physician should always be followed. The DON said training on insulin pens was performed in initial orientation only and continuing education on multi-dose insulin pens had not been provided to nursing staff. The pharmacist (PH) was interviewed on 2/29/24 at 3:46 p.m. The PH said Resident #19 had two different kinds of multi-dose insulin pens and the safety check process for administering the two kinds of insulin was the same for the bedside nurse. The PH said every insulin pen sent to the facility should be primed with two units of insulin before administering the medication to the resident.

Based on record review and interviews, the facility failed to employ dietary staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 38 census residents. Specifically, the facility failed to: -Provide dietary competencies and skill tests to ensure staff could carry out the functions of the food and nutrition service according to professional standards of practice; and-Ensure the dietary supervisor was trained and certified as a dietary manager. Cross-reference F803 for dietary menus to meet residents' needs. Cross-reference F804 for food palatability and proper temperature. Cross-reference F805 for food prepared in a form to meet residents' needs. Cross-reference F806 for food prepared to accommodate residents' allergies. Cross-reference F812 for failure to prepare and serve food in a sanitary manner. Findings include:I. Record review-The dietary supervisor (DS) was unable to provide documentation that indicated she was a certified dietary manager.-The dietary supervisor (DS) was unable to provide copies of training and competencies completed for the dietary staff, including herself. II. Staff interviewsCook (CK) #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said she served smaller portions to certain residents because some residents did not eat as much and she wanted to limit food waste. She said the residents who were on a pureed diet got fruit and cottage cheese instead of the main meal because the foods were easier to blend. CK #1 said she was unaware foods served on a mechanical soft diet needed to be either one-inch by one-inch pieces or half-inch by half-inch sized pieces. She said she was educated that mechanical soft foods only needed to be soft. She said she had not completed additional training but had been a cook at long-term care facilities for over 20 years. CK #1 said she substituted items on the menu if they were not thawed in time or if the items were not in the kitchen. She said she omitted vegetables at dinner every day because "the residents did not like vegetables with dinner." CK #1 said she did not replace the omitted items with food of similar nutritional value or calories. The DS was interviewed on 2/29/24 at 11:12 a.m. The DS said the dietary staff, including herself, completed annual training. She said when new dietary staff were hired she relied on a cook to train the new cooks and a dietary aide to train the new dietary aides. The DS said the dietary staff needed more training, especially for texturizing food for residents on altered diets. The DS said she was previously a cook for 20 years in long-term care facilities and had been at the current facility for two years as the dietary supervisor. The DS said she had completed school and was expected to take her test on 3/5/24 to become a certified dietary manager. The DS said she was unaware of bread alterations required for mechanical soft textured diets. The DS said she did not know hand sanitizer was not allowed to be used in the kitchen and that staff needed to wash their hands with soap and water only while they were in the kitchen. The DS said the menus used at the facility were confusing and the cooks needed to follow what was on the menu for meals. The DS said she believed cold foods were to be held at a temperature of 34 to 46 degrees Fahrenheit (F) and hot foods needed to be held at a temperature over 65 degrees F. She said she tried to complete food temperature training every year. The DS said she provided menus to the kitchen staff with the dates blacked out and had mixed up the menus for February 2024. The DS said she was informed CK #1 did not serve vegetables at dinner time but was unaware it happened every night. She said she thought the cook omitted items occasionally. The DS said she was unaware the cook served half or small portions of food servings to the residents without a physician's order. She said if the resident wasted the food it was their right and CK #1needed to serve the portions according to the menu and recipes. The DS said the kitchen staff needed more training and guidance. She said she did not observe meals as much as she needed to because she was tied up in meetings every day. She said she felt the kitchen had enough staff but lacked adequate education. The DS said she called her registered dietitian (RD) if she had questions or needed help, however, she said she needed more support. The nursing home administrator (NHA) was interviewed on 2/29/24 at 9:02 p.m. The NHA said the facility was in the process of switching from the National Dysphagia Diet to the International Dysphagia Diet Standardization Initiative. She said all residents who were on a mechanical soft diet were on a level three mechanical soft diet. She said the DS was in charge of the kitchen and all dietary staff. -The facility failed to provide any follow-up documentation that included training completed by the dietary staff and the DS by the end of the survey on 3/1/24.

Based on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed. Specifically, small portions were served to all residents and menu items were omitted without substitutions being made. Findings include:I. ObservationsA. Dinner on 2/28/24 At 4:35 p.m. cook (CK) #1 prepared a bacon, egg and cheese quiche for residents on a regular textured diet and an egg and cheese quiche for residents on a mechanical soft textured diet. The menu called for a bacon and cheddar quiche with oven-browned potatoes and parslied cauliflower and a tropical fruit parfait, however, CK #1 served peaches and omitted the cauliflower and said the residents did not like vegetables with dinner.-Resident #31 was served half of a portion of the mechanical soft quiche, although she did not have a physician's order for small portions. The vegetables were omitted.-Resident #15 was served half of a portion of the mechanical soft quiche, although he had a physician's order for extra portions. The vegetables were omitted.-Resident #8 was served half of a portion of the mechanical soft quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #16 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #14 was served half of a portion of the mechanical soft quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #30 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #33 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #23 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #22 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #21 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted.-Resident #3 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate.-Resident #4 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate.-Resident #25 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. She had a severe cognitive impairment and was unable to order her meal. CK #1 said fruit and cottage cheese were easier to puree than the main meal.-Resident #1 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. She had a severe cognitive impairment and was unable to order her meal. CK #1 said fruit and cottage cheese were easier to puree than the main meal. II. Staff interviewsCK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said Resident #3 and Resident #4 were the only residents who ordered the alternative meal of fruit and cottage cheese. She said she served fruit and cottage cheese to Resident #1 and Resident #25 because it was easier to puree and the residents could not order their meals due to their cognitive levels. CK #1 said she served half or small portions to the residents who did not eat much because she did not want food to be wasted. The corporate registered dietitian (CRD) was interviewed on 2/29/24 at 10:30 a.m. The CRD said meals needed to be served based on the physician's orders, therapeutic diets, residents' care plans and meal tickets. She said residents were to receive the full portion unless they had a physician's order documented for small portions. The CRD said the kitchen needed to serve the residents a full portion even if they wasted the food. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the cook needed to serve the meals based on the menu and recipes. She said residents had the right to waste food and CK #1 was not supposed to omit items or serve small portions to prevent food waste. She said if the meal ticket did not say "small portion" the resident needed to be served the full portion. The DS said the menu called for the quiche to be made in a pie pan and a regular portion needed to be one-sixth of the quiche and a small portion was one-eighth of the quiche. She said the facility only had one or two residents who had physician's orders for small portions. The DS said she needed to talk to CK #1 to tell her not to omit items from the menu without replacing the items with something of similar nutritional value.

Based on observations, interviews and record review, the facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature. Specifically, the facility failed to:-Ensure food was palatable and attractive when delivered to residents; and, -Ensure food was served at the appropriate temperature. Findings include:I. Resident interviewsResident #5 was interviewed on 2/26/24 at 3:50 p.m. Resident #5 said the kitchen mainly prepared eggs, chicken and pork. She said she rarely received beef. Resident #5 said she did not like the eggs the kitchen prepared and the eggs were served as the main source of protein. She said she told the kitchen not to serve her eggs because she disliked them. Resident #5 said the facility served french fries, potatoes and corn a lot. She said she was not provided with salt and pepper and the meals were often served not seasoned. The resident said her food was ice cold when she received it. Resident #8 was interviewed on 2/26/23 at 2:11 p.m. Resident #8 said the food was often served cold and the staff did not warm it up for the residents. Resident #20 was interviewed on 2/26/24 at 9:46 a.m. Resident #20 said the facility served a lot of canned or frozen vegetables. She said she wanted more fresh fruits and vegetables. She said she would eat a plain piece of lettuce if it was fresh. II. Resident group interviewResidents who frequently attend monthly resident council meetings and the resident council president were interviewed on 2/28/24 at 10:38 a.m. One resident said the food was "mediocre". Another resident who typically ate in her room said the food was sometimes cold. III. Test trayA test tray was evaluated by four surveyors on 2/28/24 at 5:30 p.m. The test tray consisted of an egg and cheese mechanical soft texture quiche and oven-fried potatoes. -The fruit that had been served to the residents was not sampled because the kitchen ran out of the fruit.-The egg and cheese quiche was 129.9 degrees Fahrenheit and the potatoes were 110.8 degrees Fahrenheit. -The crust on the bottom of the quiche was soggy and under-baked. -The quiche was cold, rubbery and flavorless. -The oven-fried potatoes tasted like frozen potatoes. The food on the test tray lacked seasoning. IV. Staff interviewsCook (CK) #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said she seasoned the meals based on what she knew the residents liked and disliked. She said she did not completely follow the recipes because she knew her residents. She said the residents disliked vegetables with dinner and she always omitted the vegetables and did not replace them with something of similar nutritional value. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the cooks needed to follow the menus and the recipes. She said the meals needed to be seasoned based on the recipe, not based on how well CK #1 knew the residents. The dietary manager (DM) from a sister facility was interviewed on 3/1/24 at 10:15 a.m. The DM said the cooks needed to follow the recipes and season the meals. She said items from the menu needed to be served and if they were omitted they needed to be replaced with something of similar nutritional value. She said residents each liked or disliked items and their meal tickets needed to be updated to reflect their likes/dislikes. The DM said the cooks should not season meals the same for everyone because a handful of the residents disliked seasonings.

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

Based on observations, record review and interviews, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (#20) of three residents reviewed for dietary preferences out of 35 sample residents. Specifically, the facility failed to provide meals and snacks according to Resident #20's lactose and gluten allergy. Findings includeI. Resident statusResident #20, age over 65, was admitted on 6/7/21. According to the February 2024 computerized physician order (CPO), diagnoses included unspecified anxiety disorder, other unspecified depressive disorder and underweight. According to the 11/28/23 minimum data set (MDS) assessment, Resident #20 had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. II. Resident interviewResident #20 was interviewed on 2/26/24 at 9:28 a.m. Resident #20 said one cook at the facility was good at accommodating her lactose and gluten allergies. She said she needed to gain weight because she was under 100 pounds. She said when her food contained lactose or gluten it gave her horrible diarrhea and made her not want to eat. Resident #20 said she received items she could not eat mainly at dinner time. III. ObservationsA. Dinner on 2/28/24At 4:35 p.m. cook (CK) #1 prepared a bacon, egg and cheese quiche. CK #1 served Resident #20 a piece of the quiche without the side crust.-The bottom crust was left on the quiche.-The quiche contained regular cheese. -CK #1 did not prepare a quiche without gluten or dairy. III. Record reviewResident #20's care plan, revised 11/9/23, documented the resident had a gluten and lactose-free diet. Interventions were documented as:"-Every Saturday night Resident #20 gets a special gluten-free pizza made for her;-Offer Resident #20 regular menu foods, if she declines that food offer her foods off of the specialized menu;-Assist Resident #20 with meal intake as needed;-Provide the necessary level of assistance for meal participation and to maximize intake;-Offer and encourage snacks between meals and as needed upon request;-Provide ordered diet;-Serve meals in individual bowls due to poor eyesight;-Resident #20 prefers to eat small portions at meals; and-Resident #20 likes egg salad stuffed tomatoes and gluten-free biscuits."The care plan further documented Resident #20 had an alteration in gastro-intestinal status which referred to gastroesophageal reflux disorder and diarrhea associated with gluten sensitivity. The intervention was documented as:"The resident is sensitive to food products with gluten. Monitor intake of non-gluten products and associated increase in diarrhea concerns. Report to the dietary manager if increased concerns arise and encourage decreased intake of gluten foods when exacerbation of diarrhea arises."IV. Staff interviewsCK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said Resident #20 wanted to try the quiche but she did not make a separate quiche without gluten or lactose. She said she removed the side crust to remove the gluten but did not think about the cheese that was in the quiche. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the cooks needed to prepare a separate dish for residents with allergies at each meal. She said CK #1 should not have served the regular quiche to Resident #20 even if the side crust was removed because the bottom crust was not gluten-free and the cheese in the quiche was not dairy-free.

Based on observations, record review and 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;-Expired dry goods were disposed of;-Proper hand hygiene was performed during meal service;-Kitchen refrigerators were held at the appropriate temperature; and,-Food items were labeled with use-by dates. Findings includeI. Food storageA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/9/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, "A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request." B. Initial kitchen tour observations on 2/26/24At 8:40 a.m. the initial tour of the kitchen was conducted. The following items were found:-A case of cranberry juice was stored on the same shelf with bottles of two different kinds of cleaning solutions and bottles of bleach in the pantry.-A bucket of chocolate chips was dated to be used by 3/16/21 and had a lid that was only partially on the bucket, exposing the chocolate chips.-A bucket of red velvet cake mix was dated to be used by 7/17/23 and had a lid that was only partially on the bucket, exposing the cake mix.-A bucket of thickener powder was dated to be used by 10/13/23 and had a lid that was only partially on the bucket, exposing the thickener powder.-A refrigerator/freezer appliance in the refrigerated cold storage room had significant amounts of spilled grime on the seals and the doors.-Two reusable grocery bags were sitting on the floor by the refrigerator/freezer appliance. The bags contained lettuce, cheese, queso, mixed vegetables and smoked salmon. -The food items in the bags were not dated or labeled and the bag of lettuce, cheese and mixed vegetables had condensation present inside the bag.-A large white refrigerator contained a bucket of pickle slices that were dated to be used by 8/1/23.-Six dozen eggs in the refrigerator were unlabeled.-The refrigerator labeled "Fridge #2" had an internal thermometer that read 38 degrees Fahrenheit and the spare thermometer in the refrigerator read 42 degrees Fahrenheit. The refrigerator felt warm and contained dairy items. -A bucket of whipped margarine was dated to be used by 2/8/24.-An opened box of cream of wheat was dated to be used by 12/29/23.-An opened box of corn muffin mix was dated to be used by 12/22/23.-An opened box of biscuit mix was dated to be used by 2/22/24. C. Staff interviewsCook (CK) #1 was interviewed on 2/26/24 at 8:40 a.m. CK #1 said she had just put the six dozen eggs in the refrigerator and had not had time to date and label them when she put them in the refrigerator.-However, 13 eggs out of the six dozen eggs had been used and served to the residents. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the food needed to have a date labeled on each item to indicate when the items were received and when the items needed to be used by. She said the cooks were responsible for going through the leftover cooked meals and checking the dates. She said she was responsible for the rest of the food inventory. The DS said she was unaware there were chemicals in the pantry with food items. The DS said she did not know what "use by" date she needed to put on different food types because the list she used was outdated. The DS said she tried not to use buckets to store foods, however, she said she was aware they were in the pantries and that the lids did not always fit. II. Food temperaturesA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/9/24 from:https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view revealed in pertinent part, "Except during preparation, cooking or cooling, food shall be maintained at 135 degrees Fahrenheit or above for ready-to-eat hot foods and 41 degrees Fahrenheit or below for ready-to-eat cold foods."B. Dinner observations on 2/28/24At 4:35 p.m. CK #1 prepared dinner. CK #1 took the temperature of the meal before she plated it for the residents. -The temperature of the pureed peaches was 42 degrees Fahrenheit (F) and the temperature of the pureed cottage cheese was 41.8 degrees F. -Both food items were above the recommended safe serving temperature of 41 degrees for ready to eat cold foods.-Despite the peaches and cottage cheese having temperatures above the safe zone, CK #1 proceeded to serve the five residents peaches and cottage cheese. C. Staff interviewsCK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said when she took the temperature of the peaches and the cottage cheese they both registered at 41 degrees F. She said the cold foods needed to be 41 degrees F or lower when she served them.-However, the thermometer had indicated the temperature of the peaches was 42 degrees F and the cottage cheese temperature was 41.8 degrees F (see observations above). The DS was interviewed on 2/29/24 at 11:12 a.m. The DS said the kitchen staff needed more education regarding safe food serving temperatures. The DS said cold foods needed to be 34 to 46 degrees F and hot foods needed to be anything above 65 degrees Fahrenheit.-However, cold foods needed to be served at temperatures below 41 degrees F or below and hot foods needed to be served at 135 degrees F or higher (see professional reference above). III. Hand hygiene in the kitchenA. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/9/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, "Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink."B. Dinner observations on 2/28/24At 4:35 p.m., CK #1 prepared plates for the residents for dinner. At 4:44 p.m., CK #1 used hand sanitizer and grabbed plates for the residents' dinner. At 4:47 p.m., CK #1 prepared five residents' plates and used hand sanitizer. At 4:50 p.m.. CK #1 prepared two residents' plates and used hand sanitizer. At 4:54 p.m., CK #1 prepared two residents' plates and used hand sanitizer. At 4:56 p.m., CK #1 put a meal tray in the meal cart, closed the meal cart door and used hand sanitizer. At 4:57 p.m., CK #1 prepared four residents' plates and used hand sanitizer. At 4:58 p.m., CK #1 prepared one resident's plate and used hand sanitizer. At 4:59 p.m., CK #1 touched the meal cart and used hand sanitizer. At 5:02 p.m., CK #1 prepared one resident's plate and used hand sanitizer. At 5:06 p.m., CK #1 prepared three residents' plates and used hand sanitizer. At 5:10 p.m., CK #1 washed her hands with soap and water after she picked something up from the floor. At 5:15 p.m., CK #1 prepared five residents' plates and used hand sanitizer. At 5:16 p.m., CK #1 used hand sanitizer. At 5:20 p.m., CK #1 prepared seven residents' plates and used hand sanitizer. At 5:22 p.m., CK #1 used hand sanitizer after putting platecovers on two residents' plates.-During the dinner service observation, CK #1 performed hand hygiene with soap and water instead of hand sanitizer only one time between 4:35 p.m. and 5:22 p.m. C. Lunch observations on 3/1/24The DS assisted CK #1 with preparing a chocolate cake with frosting for residents on a mechanical soft diet. At 11:47 a.m., the DS cut up a piece of cake and stirred the frosting throughout the chunks of cake. -The DS licked her fingers and prepared another piece of cake for another resident. At 12:05 p.m., the DS cut up a couple more pieces of cake and stirred the frosting throughout the chunks of cake. -The DS licked her fingers again and prepared more cake for the residents. D. Staff interviewsCK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said the facility installed hand sanitizer dispensers in the kitchen and she was unaware soap and water needed to be used instead of hand sanitizer in the kitchen. The DS was interviewed on 2/29/24 at 11:12 a.m. The DS said she was unaware the kitchen staff could not use hand sanitizer in the kitchen. She said the facility installed the hand sanitizer dispensers and was confused as to why the facility would do that if staff needed to use soap and water instead of hand sanitizer for hand hygiene in the kitchen.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, food and nutrition services and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to food and nutrition services, quality of care, resident safety and infection control. Findings include:I. Facility policyThe Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action was received from the nursing home administrator (NHA) on 2/26/24. The policy read in pertinent part, "Quality deficiencies that are identified through feedback and data and will undergo appropriate corrective action. Corrective actins are monitored against established goals and benchmarks by the QAPI committee. The QAPI program overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive scope and severity."II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correctF689 Accident hazardsDuring the recertification survey on 7/29/21 F689 was cited at a D scope and severity, a potential for more than minimal harm, isolated. During the abbreviated survey on 11/3/22 F689 was cited at a D scope and severity, a potential for more than minimal harm, isolated. During the recertification survey on 3/1/24 F689 was cited at an E scope and severity, a potential for more than minimal harm, pattern. F692 Nutrition parametersDuring the abbreviated survey on 11/3/22 F692 was cited at a G scope and severity, actual harm. During the recertification survey on 3/1/24 F692 was cited at a G scope and severity, actual harm. F867 Quality assurance program During an abbreviated survey on 6/15/22 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. During the abbreviated survey on 11/3/22 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. During the recertification survey on 3/1/24 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. F880 Infection controlDuring an abbreviated survey on 3/9/22 F880 was cited at an E scope and severity, a potential for more than minimal harm, pattern. During the recertification survey on 3/1/24 F880 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. III. Cross-reference citationsCross-reference F805 food in form to meet resident needs: The facility failed to implement the residents' therapeutic diet orders for mechanical soft textures and/or thickened liquids. Cross-reference F692 nutrition parameters: The facility failed to implement timely nutritional interventions and evaluate the effectiveness of nutritional interventions in place. IV. Staff interviewsThe nursing home administrator (NHA) and the director of nurses (DON) were interviewed on 3/1/24 at 3:23 p.m. The NHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and the medical director in attendance. The NHA said the meeting had an agenda. She said the agenda changed monthly. The NHA said the IDT met daily to discuss any issues from the previous night and answered the "Five Whys" in order to determine the root cause (an interative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question "Why?" five times). The QAPI committee looked for trends and then root causes and then put a performance improvement plan in place. \The NHA said the dietary manager (DM) attended the QAPI meetings as part of the IDT. She said prior to the survey, the DM was in school and needed to receive training. She said they did have a performance improvement plan for food temperatures and the dish machine not registering correctly, however, that was resolved. She said the kitchen has had turnover of two cooks and has had an issue on retaining staff. She said the the menu had been switched and there was lack of training and education provided to the kitchen staff on how to read and understand the menus. The DON said the nursing staff were trained to use proper transfer techniques. However, staff turnover and consistent solid staff were attributed to the deficient practice. The DON said the QAPI committee did discuss weights for both weight loss and gain at each meeting. She said they had identified that once weight loss was identified then the resident was placed on weekly weights and would be followed which included watching meal intakes and who required eating assistance. She said she was aware resident's weight loss continued to be addressed. She said multiple interventions were attempted with Resident #29. The DON said infection control was something they were always working on. She said the infection preventionist was performing hand hygiene audits and trainings. The NHA said since her employment from November 2023, she did recognize there were a lot of areas that needed changes. She said she was involving the IDT with recognizing and putting solutions in place.

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 on two of two units. Specifically, the facility failed to:-Ensure staff followed proper hand hygiene procedures when moving from task to task; -Ensure frequently touched surfaces were cleaned; and, -Ensure surface disinfectant times were adhered to for disinfecting products by all staff. Findings include: I. Failed to ensure staff performed hand hygiene and residents were offered hand hygiene prior to meals. A. Professional referenceThe Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/30/2020), retrieved on 3/12/24 from https://www.cdc.gov/handhygiene/providers/guideline.html, included the following recommendations, in pertinent part for hand hygiene, "Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal."B. Facility policyThe Handwashing/Hand Hygiene policy, revised October 2023, was received from infection preventionist (IP) #1 on 2/29/24 at 5:15 p.m. The policy read in pertinent part, "This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility."C. ObservationsOn 2/26/24 at 12:30 p.m., general nurse aide (GNA) #1 was assisting Resident #31 during lunch. Resident #31 had dropped silverware into the middle of her plate and was eating food without utensils. GNA #1 picked up the serving utensils and redirected the resident to use them. -GNA #1 did not perform hand hygiene prior to picking up Resident #31's utensils from the middle of her plate..On 2/26/24 at 12:37 p.m., licensed practical nurse (LPN) #1 was clearing resident plates and discarding refuse from the lunch meal. After clearing the plates, LPN #1 proceeded to enter and exit a resident's room. -LPN #1 did not perform hand hygiene prior to entering the resident's room. On 2/28/24 at 9:00 a.m., certified nurse aide (CNA) #5 and CNA #3 assisted Resident #1 to her room. CNA #5 performed incontinence care for the resident. -CNA #5 failed to change her gloves after performing the care and proceeded to touch items in the resident's room, such as the door knob and personal items of the resident's. On 2/28/24 at 10:00 a.m., the activity director (AD) gave a hug to a resident. -The AD proceeded to touch the hands of another resident without performing hand hygiene. On 2/28/24 at 4:46 p.m., CNA #6 assisted a resident to the dining room.-CNA #6 failed to perform hand hygiene when he left the dining room and began to assist another resident to the dining room. On 2/29/24 at approximately 12:00 p.m., housekeeper (HSK) #2 was cleaning a shared room. -HSK #2 failed to perform hand hygiene after changing gloves between cleaning the toilet and cleaning the remainder of the room. D. Record reviewA 1/16/24 in-service education sheet documented staff were educated on proper handwashing. E. Staff interviewIP #1 and IP #2 were interviewed on 2/29/24 at 3:52 p.m. IP #2 said hand hygiene needed to be performed between tasks, after leaving a resident's room and when hands were visibly soiled. She said residents needed to be offered hand hygiene prior to consuming their meals. She said she performed hand hygiene audits and training on a regular basis. II. Failure to ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areasA. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (2021) Jul;113:104-114,retrieved on 3/12/24 revealed in pertinent part:"High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment." The CDC Environment Cleaning Procedures (5/4/23), retrieved on 3/12/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, read in pertinent part, "High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include:-bedrails-IV (intravenous) poles-sink handles-bedside tables-counters-edges of privacy curtains-patient monitoring equipment (keyboards, control panels)-call bells-door knobs."B. ObservationsOn 2/29/24 at approximately 12:00 p.m., HSK #2 cleaned room #110. THSK #2 failed to clean the door knobs, pull cords and light switches in the room. C. Staff interviewP#1 and IP #2 were interviewed on 2/29/24 at 3:52 p.m. IP #2 said the high touch areas included door knobs, light switches and pull cords. She said that it was important to ensure they were cleaned properly as it could pose a risk for infections to spread if they were not. III. Ensure surface disinfectant times were adhered to for disinfecting products by all staffA. Manufacturer recommendationsThe disinfectant in the facility was identified as HP202. The manufacturer's recommendations read in pertinent part, "This product contains hydrogen peroxide and is a one step hospital use germicidal cleaner and deodorant designed for general cleaning, disinfection and controlling mold and mildew odors on hard, non-porous surfaces. Effective against in one minute on hard, non-pourous surfaces. "For use as a one-step cleaner/disinfectant: All surfaces must remain visibly wet for 10 minutes."For use as a *virucide: All surfaces must remain visibly wet for 5 (five) minutes. A one minute contact time is required for *HIV-1 (AIDS virus), *Influenza Virus Type A (H1N1), *SARS-Related Coronavirus 2 (SARS CoV-2) (the virus that causes COVID-19)."B. ObservationsOn 2/29/24 at approximately 12:00 p.m., HSK #2 cleaned room #110. HSK #2 sprayed the toilet with the cleaner/disinfectant HP202. He also sprayed the sink. -HSK #2 left cleaner/disinfectant on the toilet and sink for less than three minutes. C. InterviewsHSK #2 was interviewed on 2/29/24 at 12:15 p.m. HSK #2 said he used HP 202 to clean and disinfect surfaces in residents' rooms. He said for COVID-19 disinfection the product had a dwell time of three minutes. He said for all other organisms, the dwell time was 10 minutes. CNA #4 was interviewed on 2/29/24 at approximately 10:00 a.m. CNA #4 said when she cleaned the shower chair between residents she would spray the chair with the HP202. She said she would imminently spray the chair off with water. IP#1 and IP #2 were interviewed on 2/29/24 at 3:52 p.m. Both IP #1 and IP #2 said they were not involved with the chemicals the housekeeping department used and were not sure what the dwell times for the chemicals were.

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 02/12/2024 and 02/18/2024, 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 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.

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

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 1/5/23 for all previous deficiencies cited on 11/3/22. Two deficiencies were cited.

A revisit survey was completed on 1/5/23 for all previous deficiencies cited on 11/3/22. One deficiency was cited.

Based on record review, observation and interviews, the facility failed to provide supervision, assistance and services to prevent falls with injuries for two (#5 and #9) of three residents reviewed out of 15 sample residents. Resident #5 had a history of falls upon admission, cognitive impairment, used a walker, and needed limited physical assistance with ambulation and transfers. Between 12/13/22 and 1/5/23, Resident #5 experienced five falls: two unwitnessed and three witnessed. Resident #5 had a neurological condition change afterward and was hospitalized and diagnosed with a subdural hematoma (brain bleed). Afterward, Resident #5 was admitted to hospice care and became dependent for ambulation in a wheelchair pushed by staff. Newly admitted Resident #9 had dementia and lack of safety awareness. Between 12/13/22 and 1/5/23, Resident #9 had eight falls, four unwitnessed and four witnessed, resulting in skin tears, abrasions and bruising. Findings include: I. Facility policy The Fall Management policy, dated June 2022, was provided by the assistant director of nursing (ADON) via email on 1/6/23 at 1:23 p.m. The policy documented in part that the facility would assist residents to attain or maintain their highest practicable level of function by providing adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls.-Newly admitted residents were evaluated by the interdisciplinary team for fall risk, and were considered at high risk until the assessment was completed.-If a resident was determined to be at high risk for falls, the resident was referred to rehabilitation services. II. Facility resident status Review of the facility fall report, provided by the director of nursing (DON) on 1/5/23 at 10:19 a.m., revealed that between 12/13/22 and 1/5/23, residents had experienced 25 falls. Unwitnessed falls totaled 17, and witnessed falls totaled eight. All the unwitnessed falls, except one, involved Residents #5 and #9. III. Resident #5 A. Resident status Resident #5, age 80, was admitted on 9/21/22. According to the January 2023 computerized physician orders (CPO), diagnoses included mild hypoxic ischemic encephalopathy (brain injury), cognitive impairment, dysphagia (difficulty with swallowing), and mood disorder with depressive features. The 11/10/22 facility assessment documented Resident #5 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She required limited one-person assistance with bed mobility, transfers, locomotion in her room and on the unit. She needed extensive assistance with toileting and personal hygiene. A significant change facility assessment dated 12/28/22 was in progress and not yet completed. -Although the resident needed assistance with ambulation and transfers, the facility failed to consistently provide it, which contributed to her falls culminating in a major injury. B. Observation Resident #5 was observed during lunch on 1/5/23 from 11:50 a.m. to 12:25 p.m. She needed cueing and assistance from staff with eating, and staff pushed her wheelchair as she was unable to ambulate independently. C. Record review Resident #5's care plan, initiated on 10/5/22 and revised on 12/4/22, identified risk for falls related to history of falling at home and poor cognition. She was assessed at high risk for falls on 10/5/22, scoring 13. A score of 10 or more indicated high risk. Approaches were: Complete fall assessment upon admission, encourage resident to participate in activities of choice, encourage resident to wear appropriate non-skid footwear during transfers or ambulation, ensure that call light is within reach and give the resident encouragement to use when assist is needed, keep environment clutter free, physical and occupational therapy as ordered, place bed in lowest position, provide appropriate lighting, provide assist with ADLs (activities of daily living)as needed, provide resident and/or responsible party education on safety awareness and safety needs, review medications and identify medications that can increase fall risk. According to the fall report, nursing progress notes and fall investigations dated 12/13/22 through 1/5/23, the resident had five falls within less than a month, as follows. 1. Fall on 12/15/22 at 8:45 a.m. - witnessedThe resident attempted to sit on her front wheeled walker in the common area room and fell, hitting her left knee. She was given medication for pain and educated to sit in a chair, not on the seat of her front wheel walker. She was not injured, and was unable to describe the incident. Predisposing factors were incontinence and visual impairment. The care plan was updated as follows on 12/15/22: Resident's old walker was replaced with a walker that she can navigate better and not have issues running into things; remind resident to sit in a regular chair and not try to sit on the seat of her walker, she also needs reminders to lock her brakes on the walker. 2. Fall on 12/16/22 at 1:57 p.m. - witnessed The resident attempted to sit down in a chair in the activity room, missed the chair and dropped to her buttocks to the floor. She refused to accept help back to a standing or sitting position initially after the incident. She was allowed to remain on the floor and decompress under staff supervision for around five minutes, then allowed staff to assist her. She complained of pain in her left knee, and was assisted back to a recliner. She declined an offered Tylenol. No injuries were apparent.-No care plan approaches were added. 3. Fall on 12/17/22 at 12:56 p.m. - witnessedThe resident was walking through the door way from the lounge area to in front of nursing station, tripped over her walker and fell on her left side hitting her left temple and left shoulder on floor. The nurse witnessed this and ran to assist but did not get to Resident #5 before she fell on the floor. The resulting abrasion on the resident's left shoulder was red but not open. The raised area to her left temple had a 0.25 x 0.25 cm open area, which was not bleeding. The resident description was, "Ouch!" Nurses' notes at 12:32 and 1:10 p.m. on 12/17/22 documented Resident #5 had dark bruising to her left eye, and an ice pack was applied to reduce swelling. The resident was seated by two staff in a wheelchair in front of the nursing station so she could be observed at all times, as she was "not used to her new walker." Predisposing factors were gait imbalance, memory impairment, weakness/fainted, dementia, incontinence and ambulation without assistance. The resident's care plan approaches were updated on 12/17/22: Front wheeled walker removed placed in wheelchair until Resident #5 can navigate her new walker with ease and balance, referred to OT, staff to assist her with walker when she wants to ambulate. 4. Fall on 12/18/22 at 5:52 p.m. - found on floor A certified nurse aide (CNA) reported to the nurse that the resident was "sitting on her floor in her room by her bed, laughing." The nurse documented they assessed the resident and would tell the registered nurse (RN) on night shift to do the assessment. No injuries were documented. The resident said, "I sat on my butt. I'm not hurt." The predisposing factors were the same as the fall above. A 12/19/22 interdisciplinary team (IDT) meeting note documented they met to discuss Resident #5's frequent falling issues on 12/15, 12/16, 12/17/22 (and 12/18/22 which was not noted). "Multiple falls, related to her use of her walker. First intervention was to get her a walker that didn't have big wheels that she was tripping on. 2nd intervention was to work with staff to use her walker, and work with staff to ambulate safely, get used to it, refer to OT (occupational therapy)." The resident hit her head, had bruising to her left eye, an abrasion with bruising to her left shoulder, and received Tylenol and an ice pack. Her medical history was "DD (developmental disability) with dementia." The root cause was poor safety awareness and balance. The resident's care plan was revised on 12/19/22 with an approach to "refer to OT for evaluation for ambulation." -There was no evidence of a therapy assessment for the resident's new walker. -Resident #5 did not receive therapy services despite two notes and care plan updates documenting referrals would be made. The resident was found on the floor after a fall five days later. 5. Fall on 12/24/22 at 10:30 a.m. - found on floor After the resident was found on the floor by housekeeping staff, a nurse entered the room and observed Resident #5 sitting on the ground in front of her wheelchair. She had gotten out of her recliner and attempted to get in her wheelchair but missed it and landed on her buttock. She denied hitting her head. She was able to follow the nurse's commands, and had no complaints of pain or discomfort. Neurological checks were in place. A 12/24/22 late entry fall investigation IDT note documented the root cause was poor balance while trying to transfer from one surface to another. The immediate intervention was to remind Resident #5 to "square herself with the chair she's going to before she tries to transfer, and refer to therapy." -The resident did not receive therapy services after any of the above falls. On 12/25/22 at 8:46 p.m. a nurse documented a UA (urinalysis) dip was obtained in the facility related to emesis (vomiting), fatigue, and complaints of stomach pain. Results were faxed to the physician. On 12/26/22 at 12:59 p.m., the assistant director of nursing (ADON) documented "Reported resident with declines over past week and specifically within last 24 to 48 hours. Resident with several unwitnessed falls in past 2 weeks. Notably a fall on 12/17/22 where resident had obvious head injury with bruising to her left eye/temple region. Resident with some complaints of mouth pain starting approx. 12/22 as well. VSS (vital signs) and Neuros (neurological checks) following each fall have been stable and WNL (within normal limits). This weekend resident with c/o (complaints of) pain in stomach and head, vomiting several times on evening/NOC (night shift) of 12/24. This RN assessed resident yesterday with all VSS and WNL-resident stated she just didn't feel well. I assessed resident again this day and she shows significant change from yesterday. Resident unable to speak at baseline-responses are garbled and unintelligible overall. Appears lethargic and sleepy this day-does respond to touch easily. Pupillary response baseline for resident. Hand grips with increased weakness in last 24 hours as well. Contacted PCP (primary care physician) with information summary-agreed resident should be sent to ER (emergency room) for evaluation. POA (power of attorney) contacted-message left to return call to facility. Ambulance to be contacted for transport." On 12/26/22 at 9:41 p.m., a nursing note documented the resident returned to the facility via ambulance on a gurney. "Resident is resting in bed at this time. This nurse notified family of resident arrival and discharge orders and findings of Intraparenchymal hemorrhage of brain Subdural hematoma, Patient is comfort care measures only, Tylenol 500mg PO (by mouth) q (every) 4 hrs PRN for pain, follow up with Primary care physician within next 2-10 days and (hospital) to assist with additional resources for care." A 12/28/22 IDT note documented "Resident with multiple issues occurring/developing over past week. TX (treatment) initiated for UTI (urinary tract infection), recently diagnosed with subdural, changed in physical function secondary to subdural-resident all in all with refusals to participate in activity, eat or drink for better part of 4 days increasing declines since last review. Will begin fortifying all meals going forward as we anticipate resident meal intake to be highly variable as she attempts recovery from subdural. Family considering admission to hospice related to poor prognosis with subdural and residents' overall status. Will continue to monitor resident until triggers resolve and resident stabilizes." The fall risk care plan was updated on 12/31/22 with an approach to remind Resident #5 to "square herself with the chair she's going to before she tries to transfer, refer to therapy." -As of 1/5/23, the resident had not received therapy services. D. Staff interview The NHA, director of nursing (DON), assistant director of nursing (ADON) and social services director (SSD) were interviewed on 1/5/23 at 6:47 p.m. The ADON and NHA said all resident falls were essentially avoidable. The ADON said Resident #5 had needed assistance when ambulating with her walker, depending on whether or not she was having weakness or confusion. The NHA acknowledged that therapy, supervision, assistance, and engagement in life were necessary approaches to prevent falls for Resident #5. IV. Resident #9 A. Resident status Resident #9, age 83, was admitted on 11/25/22. According to the January 2023 CPO, diagnoses included an old myocardial infarction, chronic obstructive pulmonary disease, unspecified dementia, generalized muscle weakness, other lack of coordination and need for assistance with personal care. The 12/6/22 facility assessment documented severe cognitive impairment with a BIMS score of zero out of 15. He required extensive two-plus-person assistance with bed mobility, transfers, walking in his room, locomotion off unit, dressing, toileting, and personal hygiene. He had a history of falls within the last month prior to admission, and within the last two to six months prior to admission. B. Record review The 11/16/22 hospital admission history and physical, prior to the resident's admission to the facility, revealed advancing dementia, progressive memory impairment, repeated falls, and encounters with law enforcement after "wandering off." He was found down and unresponsive, and was no longer safe to be cared for at home. The resident's fall prevention care plan, initiated 12/4/22, identified high fall risk, history of frequent falls at home, frequent falls related to poor decision making, dementia, inability to self- evaluate own physical ability and resistance to staff assistance. Interventions included frequent monitoring in areas where he was not alone, staff assistance with ambulation as allowed, staff must take turns monitoring him while he was up in his chair, and referral to therapy. -The resident did not receive therapy services and there was insufficient evidence of frequent monitoring and assistance based on the resident's continued repeated falls (below). According to the fall report, nursing progress notes and fall investigations dated 12/13/22 through 1/5/23, the resident had eight falls within less than a month, as follows. 1. Fall on 12/20/22 at 8:55 a.m. - unwitnessedA nurse heard a resident yelling "someone just fell on the floor!" Resident #9 was rolling over to his hands and knees from his side, and said he had hit his head. He had fallen from the recliner. No injuries were found. 2. Fall on 12/21/22 at 6:45 p.m. - unwitnessed A nurse was called to the day room by CNAs and found the resident on the floor lying on his left side. Other residents were in the day room and stated he hit his head. No injuries were found. 3. Fall on 12/27/22 at 12:29 p.m. - witnessed A nurse was walking past the resident and aide and heard a thump. The resident was on the floor in the doorway of the nurses' station. The aide said the resident abruptly leaned to the right and went down, hitting his head on the corner of the wall. He sustained a skin tear to the back of his neck, a small bruise to the left side of his cheek and top of his head, and a small knot to the back of his head. The skin tear was treated and the resident complained of a headache. 4. Fall on 12/30/22 at 11:15 a.m. - witnessed A visitor approached a nurse and said a resident had just fallen. Resident #9 was on the floor of the day room. A witness stated he was pushing the bedside table and fell, hitting his shoulder on the corner of the entertainment center. No injuries were apparent. 5. Fall on 12/30/22 at 5:15 p.m. - unwitnessed The resident was found on the floor in front of the nurses' station and was helped back into his wheelchair by the social worker and a CNA. No visible injuries were found. An RN assessment revealed no injuries. Immediate action was documented as neurological checks continued. Root cause was poor cognition and the resident did not know his own capabilities. Staff were to help him ambulate to build strength and endurance. 6. Fall on 1/3/23 at 1:25 p.m. - witnessed A nurse was speaking to a CNA at the nurses' station and looked up to see the resident standing up from a chair, lose his balance, sit back on the arm of the chair, causing it to tip and throw him to the floor. He landed on his right hip and elbow, and hit his head on the floor. He indicated pain to his right elbow while lying on the floor. He was assisted to a wheelchair by an RN and CNA and assessed, then assisted to lie down in bed. He had bruising to his right elbow and the top of his right forearm. 7. Fall on 1/4/23 at 12:15 p.m. - witnessed Resident #9 slid slowly out of his chair at the dining room table and did not hit his head. No injuries were observed. 8. Fall on 1/5/23 at 12:19 p.m. - unwitnessed A nurse was called into the resident's room by the CNAs who had found Resident #9 on the floor by his roommate's dresser. No injuries were noted. The resident stated he had no pain during the assessment. He had been napping in his bed, when staff went in to take care of him, he was on the floor, apparently had crawled out of the low bed, over the mattress fall pad, and was making his way to the door. The resident was assisted back into his wheelchair and taken to the activity room for coffee and socialization. Documented predisposing factors for the resident's falls were gait imbalance, weakness/fainted, dementia, furniture, confusion, impaired memory, incontinence, and ambulating without assistance. -New approaches were not documented as attempted after each fall. No therapy services were provided. C. InterviewsThe resident council president was interviewed on 1/5/23 at 10:00 a.m. She said she had seen residents stand up and fall because there was not enough staff around to assist them. She said she tried to help by encouraging those residents to sit back down until staff could come to assist them. She said this happened frequently, in the day room and in the dining room, and she had seen a resident fall within the past couple of days. The NHA, director of nursing (DON), assistant director of nursing (ADON) and social services director (SSD) were interviewed on 1/5/23 at 6:47 p.m. The ADON and NHA said all resident falls were essentially avoidable. The NHA acknowledged that therapy, supervision, assistance, and engagement in life were necessary approaches to help prevent falls for Resident #9.