LIFE CARE CENTER OF STONEGATE

This structure is one (1) story, Type V (111) construction based upon independent testing results of the various ceiling/roof assemblies installed throughout the building. The facility is licensed for 120 beds, and the census on the survey date was 56. The facility was constructed in 2012. The facility's first floor is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The attic areas and exterior drive-through canopy are protected by 4 dry-pipe valve sprinkler systems. A non-combustible crawl space is not protected and is only accessible from the exterior and mechanical spaces through floor access hatches. The facility is classified as Fully Sprinkled. The facility is divided into four (4) compartments, each separated by two-hour rated construction that is continuous throughout the crawl space and attic areas. The four (4) compartments serve as the smoke compartments, with the fire alarm and fire sprinkler system initiating devices zoned by each compartment. Emergency backup power is supplied by a 500 kW diesel-powered generator which is located outside the building. The facility is also equipped throughout with a piped medical gas system. This survey was conducted on October 29, 2024, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."The results of this survey were discussed with the Director of Maintenance and the Facility Administrator during the exit conference.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. Fridge dry barrel head needs trim replacedNFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the facility. The administrator discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain wiring in accordance with NFPA 99 and NFPA 70. Therapy delayed egress keypad needs a plateNFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. This deficiency can potentially affect occupants, including residents, staff, and visitors to this area of the smoke compartment of the facility. The administrator and maintenance director discussed deficient items at the exit conference.

Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire drills closer than an hour apart, not at varied times 2. Missing DecemberNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 ofthe Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8.1. Battery electrolyte levels / Voltage Monthly 110-2010; 8.3.7.1 Specific Gravity or Battery Conductance - need 2. Missing monthly December NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. NFPA 110-8.3.7.1 Maintenance of lead acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in leu of the testing of specific gravity when applicable or warranted. This deficiency can potentially affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference.

A recertification survey with complaint #CO35479, #CO36231, #CO37439, #CO37596, #CO37602, #CO37615, #CO37620 and #CO37805 was conducted on 9/30/24 to 10/3/24. Seven deficiencies were cited.

An Emergency Preparedness survey was conducted from 9/30/24 to 10/3/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to honor resident choices for four (#71, #130, #183, and #186) of eight residents reviewed for self-determination out of 35 sample residents. Specifically, the facility failed to provide bathing for Resident #71, #130, #183 and #186 per their preferences. Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADL) policy, reviewed 9/10/24, was provided by the nursing home administrator (NHA) on 10/9/24 at 4:13 p.m. It read in pertinent part, "The resident will receive assistance as needed to complete activities of daily living (ADLs). The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: bathing, dressing, grooming, and oral care. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene."II. Resident #71A. Resident statusResident #71, age greater than 65, was admitted on 9/2/24. According to the October 2024 computerized physician orders (CPO), diagnoses included fracture of left lower tibia and fibula (leg bone), chronic embolism and thrombosis of deep veins of lower extremities (blood clots), type 2 diabetes mellitus, chronic kidney disease stage 4, depression and anxiety disorder. The 9/9/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial/maximal assistance with shower/bathe, upper/lower body dressing, putting on/taking off footwear, sit to stand and toilet transfers. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interview Resident #71 was interviewed on 10/3/24 at 4:03 p.m. Resident #71 said she felt good, fresh, cozy and clean when she got her regular showers. She said when she got her showers her hair felt good. Resident #71 said she did not feel as clean and comfortable when she did not get her regular showers. Resident #71 said she refused a shower one time. She said because there was a new certified nurse aide (CNA), her therapy had run late, it was after 4:00 pm and approaching dinner so she told the CNA she did not want her shower but unfortunately the shower did not get rescheduled. Resident #71 said she preferred a shower two times per week. C. Record reviewA review of Resident #71's ADL care plan, initiated 9/2/24, revealed it did not address the resident's specific shower/bathing preferences or needs. The care plan revealed to assist with mobility and ADLs as needed and therapy services as ordered. The Kardex (a tool utilized by staff to provide consistent care for residents) report, dated 10/3/24, revealed no specific references to the residents shower/bathing preferences or needs. Resident #71's bathing task records were reviewed from 9/2/24 to 10/3/24. The records revealed the resident preferred to receive a shower twice per week on Tuesdays and Fridays. The bathing task records further revealed the following:According to review of Resident #71's bathing task records from 9/2/24 to 10/3/24 the resident received a shower on 9/10/24, 9/13/24, 9/24/24 and 10/1/24. The resident received a sponge bath on 9/27/24. The resident received a shower four out of nine opportunities. From 9/2/24 to 9/9/24 (eight days) there were no showers documented for Resident #71. The documentation revealed the resident refused a shower on 9/17/24, however there was not a progress note to document why or the circumstances. III. Resident #130A. Resident statusResident #130, age greater than 65, was admitted on 7/23/24 and discharged on 8/2/24. According to the August 2024 CPO, diagnoses included metabolic encephalopathy (brain dysfunction), urinary catheter infection, congestive heart failure and dementia. The 7/30/24 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. He was dependent on staff assistance with eating, hygiene, shower/bath and upper/lower body dressing. He required substantial/maximal assistance with bed mobility, sit to stand and transfers. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Record reviewA review of Resident #130's ADL care plan, initiated 7/24/24, revealed it did not address the resident's specific shower/bathing preferences or needs. The care plan revealed to assist with mobility and ADLs as needed and therapy services as ordered. Resident #130's bathing task records were reviewed from 7/23/24 to 8/2/24. The records revealed the resident preferred a shower twice per week on Tuesdays and Fridays. From 7/23/24 to 8/1/24 (ten days) there was no documentation indicating the resident had received or been offered a shower. Documentation revealed the resident had one shower on 8/2/24 the day of his discharge. IV. Staff interviewsLicensed practical nurse (LPN) #5 was interviewed on 10/3/24 at 1:52 p.m. LPN #5 said it was important for the residents to have regular showers to prevent infections, it felt good, it promoted a good mood and it was good for the skin. LPN #5 said she would also do a skin check during a shower if the CNA would tell her there was something she needed to look at. LPN #5 said if a resident refused a shower she would give them time and offer again many times. She said she also talked to a supervisor if the resident did refuse and charted in the progress notes. CNA #4 was interviewed on 10/3/24 at 2:01 p.m. CNA #4 said it was important for the residents to have regular showers because it promoted good hygiene, so they would feel good and it gave them energy. CNA #4 said if a resident refused a shower she tried to encourage them. She said if they continued to refuse the resident would sign a paper and she would sign a paper and put it in the bath book. CNA #4 said she documented the refusal in the task section of the medical record and she would tell the nurse who would chart the refusal reason in the progress notes. V. Resident #183A. Resident statusResident #183, age greater than 65, was admitted on 9/25/24. According to the September 2024 CPO, the diagnoses included paraplegia (paralysis of the lower body), high blood pressure, pressure ulcer, muscle weakness and a complication of an internal fixation device (surgical implant) of the vertebrae. The 10/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He was dependent on staff for assistance with toileting hygiene, lower body dressing and transfers; he needed substantial/maximum assistance for bed mobility (movement back and forth in bed, sitting to lying/lying to sitting) and set-up help only with eating. The MDS assessment documented the resident's shower/bathing had not occurred due to a medical condition or safety concerns. B. Resident interviewResident #183 was interviewed on 10/1/24 at 9:12 a.m. Resident #183 said he had not been offered a shower since he was admitted to the facility on 9/25/24. The resident said he needed assistance bathing because he was unable to use his legs and was unsure of his scheduled shower days. C. Record reviewResident #183's comprehensive care plan, initiated 9/25/24, included focus areas for falls, pain medication, nutrition, skin integrity, and urinary incontinence. The care plan failed to address the resident's preferred or scheduled shower days as well as his needed level of assistance. Resident #183's bathing task sheet in his electronic medical record (EMR) failed to specify the resident's bathing schedule or his preferred bathing days,.-Review of the resident's EMR did not reveal documentation indicating the resident had been offered or provided a shower from 9/25/24 to 10/1/24Resident #183's Kardex as of 10/2/24 documented to assist the resident with ADL's as needed and did not include his bathing schedule, preferences or level of assistance needed. On 10/2/24 the residents bathing records stored in a binder at the nurses were reviewed and there was no record Resident #183 was offered a shower or bath since his admission on 9/25/24. VI. Resident #186A. Resident statusResident #186, age greater than 65, was admitted on 11/24/23 and discharged on 12/15/23. According to the December 2023 CPO, the diagnoses included encephalopathy (brain dysfunction), high blood pressure, dementia, dysphagia and weakness. The 12/15/23 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of two out of 15. She was dependent on maximum assistance for toileting hygiene, and needed substantial to maximum assistance with bathing, lower body dressing, transfers and all bed mobility, and supervision only with eating and oral hygiene. B. Record reviewResient #186's ADL care plan documented she had self-care performance deficit due to a recent hospitalization, a recent urinary tract infection, weakness, decreased mobility, dementia and incontinence. -However, the resident's comprehensive care plan and ADL care plan focus failed to include Resident #186's staff level of assistance required for bathing or her preferred or scheduled bathing days. Resident #186's ADL task report was provided by the divisional director of clinical services (DDCS) on 10/2/24 at 11:00 a.m. The task report revealed the resident's bathing schedule was Tuesday and Friday. -However, the task sheet did not include if the showers were provided and a review of the resident's electronic medical record revealed the facility did not document the resident refusing any showers or baths offered. VII. Staff interviewsCNA #2 was interviewed on 10/2/24 at 11:30 a.m. CNA #2 said she provided Resident #183 a shower on 10/1/24 six days after his admission and documented the shower in the resident's EMR. -However, CNA #2 was unable to show where Resident #183's shower was documented. CNA #2 said if a resident refused a shower the staff will ask the resident again if they would like a shower, and if the resident continued to refuse a nurse was then notified of the resident's refusal. CNA #2 said if a could also be offered a bed bath if they did not want to take a shower or bath, and if the resident refused altogether the resigned signed the paper copy of their daily bathing record. LPN #1 said she assisted transferring Resident #183 out of his bed on either 9/30/24 or 10/1/24 so he could have a shower. LPN #1 said the staff should record in the residents EMR if they received any kind of shower or bath, and a bathing record should also be stored in the binder. LPN #1 said she was unable to see where Resident #183's shower was recorded. The director of nursing (DON) and the DDCS were interviewed together on 10/3/24 at 3:08 p.m. The DON said the shower schedule for residents was set according to the room numbers of the residents, so specific rooms numbers were scheduled for specific days, and the schedule was on the binder at the nurses station containing the residents bathing records. The DON said she had not yet identified any gaps that residents had not received their showers as scheduled. She said some residents preferred different bathing days of the week than their scheduled days and the facility could accommodate that, and residents could bathe more frequently if they preferred. The DDCS said once the resident was admitted the facility should immediately have the resident on the bathing schedule. The DDCS said the facility did audits and pulled shower reports out of the EMRs for all residents in the facility to ensure residents were getting showers as scheduled. The DDCS said the facility had previous shower documentation issues and have had to retrain staff on bathing documentation. The DDCS said the facility did not have a record of Resident #186's shower schedule as offered by the facility or documentation Resident #186 was provided a shower or bath as scheduled.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three ( #181, #177 and #240) of nine residents reviewed out of 35 sample residents. Specifically, the facility failed to:-Ensure Resident #181 and Resident #177 received skin care as ordered by the physician; and,-Ensure Resident #240's provider was notified timely of a delay in starting antibiotics and ensure the resident's vital signs were monitored during a change in condition. Findings include:I. Failure to ensure Resident #181 and Resident #177 received skin care as ordered by the physicianA. Facility policy and procedureThe Skin Integrity and Pressure Ulcer/Injury Prevention and Management policy, revised 7/9/24, was provided by the nursing home administrator (NHA) on 10/2/24 at 5:00 p.m. It revealed in pertinent part, "The policy provides associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and (WOCN) Wound, Ostomy, Continent Nurses Society. "Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. All residents upon admission are considered to be at risk for pressure injury development due to medical issues requiring nursing care related to disease process and illness or need for rehabilitation services. Upon admission and throughout stay at a minimum pressure redistribution surface is in use with turning and repositioning with ADL care/assistance, incontinent care if needed to include skin barriers application as needed, and preventative wheelchair cushion if indicated. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident."B. Resident #1811. Resident statusResident #181, age greater than 65, was admitted on 9/22/24. According to the September 2024 computerized physician orders (CPO), diagnoses included congestive heart failure, acute respiratory failure and osteoarthritis. The 9/30/24 hospice assessment and care plan revealed the resident was bed bound due to weakness and her inability to get out of bed and bear weight. She needed assistance for all ADLs including bathing, dressing, feeding, transfers, and toileting (incontinence of bowel and bladder). 2. Record reviewThe 9/22/24 nursing admission collection tool for skin condition documented Resident #181 had a skin alteration of blanchable redness on her coccyx (base of the spine). Resident #181's hospice care plan revealed a physician's order for the hospice nurse to provide instructions related to the prevention and management of skin breakdown. Barrier cream was initiated for redness on the resident's coccyx on 9/24/24. A review of Resident #181's September 2024 CPO revealed a physician's order to apply barrier cream to the resident's buttocks twice a day and as needed for moisture associated skin damage (MASD), ordered on 9/24/24.-However, a review of Resident #181's September 2024 treatment administration record (TAR) revealed the barrier cream was documented as administered only once a day instead of twice a day on 9/25/24, 9/26/24, 9/27/24 and 9/29/24. C. Resident #1771. Resident statusResident #177, age less than 65, was admitted on 9/26/24. According to the September 2024 CPO, diagnoses included lower left limb cellulitis (skin infection), major depressive disorder, pruritus (itching), bullous disorder (skin disorder causing blisters), benign prostatic hyperplasia (enlarged prostate) and anxiety. Resident #177's minimum data set assessment (MDS) was still in progress at the time of the survey. The 9/27/24 progress notes in the resident's electronic medical record (EMR) documented the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15.2. Record reviewThe 9/27/24 nursing admission collection tool for skin condition documented Resident #177 had a skin alteration of an open area on his buttocks. Resident #177's EMR revealed documentation on 9/27/24 that the resident likely would need a follow up appointment with an infectious disease specialist and the resident was at high risk for readmission to the hospital due to his significant wounds. A review of Resident #177's physician orders revealed an order on 9/27/24 to cleanse the area with normal saline (NS), pat dry, and apply triad cream (sterile coating for broken skin) three times a day and additionally as needed for MASD.-However, a review of Resident #177's September 2024 TAR revealed treatments were not documented as provided on the evening shift of 9/27/24 and 9/29/24 and only administered two times each day instead of three. D. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/3/24 at 11:30 a.m. LPN #1 said she was unsure why Resident #177 and #181 had missing documentation in their TARs and she would have to follow up as to why the physician's orders were not documented as completed on those dates (see dates above). The director of nursing (DON) and the divisional director of clinical services (DDCS) were interviewed together on 10/3/24 at 3:08 p.m. The DON said Resident #177 refused some of his care and wound dressing changes which the nursing staff reported to her. The DON said the residents did have the right to decline any treatment and she spoke to the Resident #177 about his refusal of care because she wanted to address the refusals as soon as possible.-However, a review of Resident #177's EMR revealed the first documented refusal of triad cream applied to his buttocks was on 9/30/24. There were no refusals of the treatment documented on 9/27/24 and 9/29/24. The DON said the nurse should have documented a refusal of care or treatment administration in the TAR on 9/27/24 and 9/29/24. The DON said refusals of wound care or dressing changes could negatively impact a resident's healing. The DDCS said, for any treatment listed in the TAR, the staff should have documented if the treatment was administered or not, including if a resident refused, and the TAR should not have blank spaces left on it. II. Failure to ensure Resident #240's provider was notified timely of a delay in starting antibiotics and ensure the resident's vital signs were monitored during a change in conditionA. Professional referencesAccording to Kizior, R. J., Hodgson, K. J. (2023). Ampicillin. Saunders Nursing Drug Handbook. Elsevier. Pp. 66-67, "Continue antibiotics for the full length of treatment. Space doses evenly."According to Brekke, I. J., et al. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. National Institute of Health (NIH), National Library of Medicine (NLM), retrieved on 10/10/24 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333367/, "Changes in vital signs prior to clinical deterioration are well documented and early detection of preventable outcomes is key to timely intervention."B. Facility policy and procedureThe Changes in Resident's Condition or Status policy and procedure, reviewed 9/5/24, was provided by the NHA on 10/2/24 at 5:55 p.m. It read in pertinent part,"A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical, mental or psychosocial status in either life threatening conditions or clinical complications."When making notification, the facility must ensure that all pertinent information is available and provided upon request to the physician."C. Resident #2401. Resident statusResident #240, age 86, was admitted on 8/21/24 and expired at the facility on 8/27/24. According to the August 2024 CPO, diagnoses included infection of right hip prosthesis and thrombosis (blood clot) of right femoral and popliteal vein. The 8/25/24 MDS assessment revealed the resident's short and long term memory were intact and he was independent in his daily decision making. The resident was dependent with mobility and transfers. 2. Delayed antibiotic administrationa. Record reviewReview of Resident #240's 8/21/24 hospital records documented active medications on discharge from the hospital included Ampicillin sodium (antibiotic) 2 grams (gms) intravenously (IV) every four hours. The August 2024 CPO documented a physician's order for Ampicillin sodium 2 gms IV every four hours for hip infection and abscess, ordered 8/21/24. Resident #240's August 2024 medication administration record (MAR) documented the following:-On 8/21/24 at 8:00 p.m. Ampicillin was unavailable for administration;-On 8/22/24 at 12:00 a.m. Ampicillin was unavailable for administration;-On 8/22/24 at 4:00 a.m. Ampicillin was unavailable for administration; and,-On 8/22/24 at 8:00 a.m. Ampicillin was unavailable for administration. A comprehensive review of Resident #240's EMR failed to reveal documentation that indicated the provider was notified that four doses of Ampicillin were missed after Resident #240 was admitted to the facility.b. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/3/24 at 11:40 a.m. RN #1 said the facility had some antibiotics in the automated manual medication dispensing system (a system used for emergency medications). She said if antibiotics were not in the automated manual medication dispensing system, they were ordered from the pharmacy and were received the same day with the last delivery occurring around 9:00 p.m. She said if there was a delay in receiving an antibiotic from the pharmacy, the provider should be notified. She said residents on antibiotic therapy should receive their doses of medications on time so that their infections did not come back. The DON and the DDCS were interviewed on 10/3/24 at 3:39 p.m. The DDCS said antibiotics for newly admitted residents should be received on the same day the resident was admitted from the pharmacy. She said the pharmacy's last delivery every day was at approximately 9:00 p.m. She said if there was any delay in a resident's antibiotic therapy, the provider should be notified. She said she did not know why Resident #240's antibiotic therapy was not started timely. The DON said report should have been received by the facility's admitting nurse from the hospital regarding what antibiotics the resident was on and when the next dose of antibiotic was due. 3. Vital sign monitoringa. Record reviewA nursing progress note, dated 8/25/24 at 4:00 p.m., documented Resident #240 was more somnolent (drowsy, sleepy) and sitting up in a wheelchair. He was still speaking with the nurse and waiting to be put back in bed. His dose of pain medication was held (due to his somnolence) and his IV (intravenous) was started. The nurse called the provider regarding his current condition and orders were received for laboratory (lab) blood work to be done stat (immediately). If the lab work could not be done immediately, staff was to give a Fleet enema one time, monitor the resident and await a rounding provider to evaluate the resident in the morning. Staff was in the room putting the resident back into bed and the nurse returned to the family to explain what the provider wanted. The family, who were at the bedside, called the resident's name and said to the nursing staff they needed to call 911. The nurse supervisor was asked to call 911 because that was what the family wanted. The nurse then entered the room and the resident was lying flat and the nurse instructed the resident to breathe. The resident was able to grasp and squeeze the nurse's hand while they were waiting for paramedics to arrive. The paramedics arrived and as a report was being given to them by the facility nurse, the resident became unresponsive, despite paramedics calling his name. The paramedics started cardiopulmonary resuscitation (CPR) and the resident was pronounced deceased at 6:24 p.m. The 8/25/24 vital signs documentation revealed Resident #240's oxygen saturation levels (measure of oxygen in the blood) were as follows:-At 9:03 a.m. the resident's oxygen saturation level was 90% (percent) on room air;-At 9:57 a.m. the resident's oxygen saturation level was 90% via nasal cannula (no flow rate);-At 1:23 p.m. the resident's oxygen saturation level was 91% on room air; and,-At 4:30 p.m. the resident's oxygen saturation level was 95% on room air.-A comprehensive review of Resident #240's EMR failed to reveal documentation of any other vital signs (blood pressure, pulse, respirations) taken on 8/25/24.-However, according to the 8/25/24 progress note, the resident was somnolent, the provider was notified of the resident's condition but the EMR failed to reveal documentation of a head to toe physical assessment conducted on the resident to assess his change of condition or of the resident's current vital signs prior to the provider being notified of the change of condition. Furthermore, the EMR failed to reveal any resident monitoring, documentation of vital signs or a physical assessment of the resident after the family requested 911 and before the paramedics arrived.b. Staff interviewsRN #1 was interviewed on 10/3/24 at 11:40 a.m. RN #1 said when a resident was having a change or suspected change of condition, a head to toe physical assessment should be done and vital signs should be taken. She said the provider should be notified of the change of condition, the physical assessment and the vital signs. She said the change of condition, physical assessment and vital signs should all be documented in the EMR.The director of nursing (DON) and the DDCS were interviewed on 10/3/24 at 3:39. The DDCS said when a resident had a change of condition, nurses should complete a head to toe physical assessment with vital signs. She said the provider should be notified with the change of condition, the results of the physical assessment and the vital signs. She said this all should be documented in the resident's EMR.

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Based on observations, record review and interviews, the facility failed to ensure one (#23) of two residents reviewed for dialysis care out of 35 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to consistently complete the pre- and post-dialysis facility assessment section on dialysis communication forms for Resident #23. Findings include:I. Facility policy and procedureThe Hemodialysis policy, reviewed 9/6/24, was received from the nursing home administrator (NHA) on 9/30/24 at 1:00 p.m. It revealed in pertinent part, "The facility assures that each resident receives care and services for the provision of offsite hemodialysis consistent with the professional standards of practice. This includes ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility, and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services."Day of dialysis: follow physician orders regarding medication administration pre- and post-dialysis. Observe the vascular access site prior to dialysis and initiate the pre/post dialysis communication form to be sent to the dialysis clinic with the resident. Post-dialysis: obtain vital signs of the resident upon return from dialysis and complete the pre-post dialysis communication form. Maintain dialysis transfer forms in the resident's record-do not destroy."II. Resident #23A. Resident statusResident #23, age greater than 65, was admitted on 5/19/24. According to the September 2024 computerized physician orders (CPO), diagnoses included end stage renal disease (decreased kidney function), dependence on renal dialysis, anemia in chronic kidney disease and protein-calorie malnutrition. The 9/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed substantial assistance with transfers, and partial/moderate assistance with bathing, lower body dressing, and toileting hygiene. She was independent with eating and oral hygiene. The MDS assessment documented the resident received dialysis care. B. Record reviewReview of Resident #23's September 2024 CPO revealed a physician's order for Resident #23 to receive dialysis on Tuesdays, Thursdays and Saturdays, ordered 8/17/24. Review of Resident #23's pre- and post-dialysis communication forms located in the dialysis communication binder, revealed the communication forms had three sections which were to be filled out on dialysis days. The pre-dialysis section on the dialysis communication form was to be completed by the facility with the resident's vital signs, including temperature, pulse, respirations and blood pressure. The section included comments to identify any assessment concerns or medication changes which the facility wished to be communicated with the dialysis center, the condition of the access/site, and whether a meal was given to the resident to take to the dialysis center. A signature, staff title, date and time the assessment was completed were to be filled in by the facility staff. The second section on the dialysis communication form was to be completed by the dialysis center after the resident completed their dialysis session. The section included vital signs, pre-weight, post-weight, condition of the access site, whether any medications were given at the dialysis center and any recommendations or follow up from the dialysis center. A signature and date were to be filled in by the dialysis center nurse. The post-dialysis section on the dialysis communication form was to be completed by the facility with the resident's vital signs, including temperature, pulse, respirations and blood pressure and the condition of the access site. A signature, staff title, date and time the assessment was completed were to be filled in by the facility staff. Review of Resident #23's dialysis communication forms from 8/31/24 to 9/26/24 revealed the communication form was not completed appropriately on the following dates:-On 8/31/24 the facility did not complete the pre-dialysis or post-dialysis sections of the dialysis communication form.-On 9/3/24 the facility did not complete the pre-dialysis section of the dialysis communication form.-On 9/5/24 the facility did not complete the pre-dialysis section of the dialysis communication form.-On 9/14/24 the facility did not complete the vital signs information in the pre-dialysis section, sign the pre-dialysis section or complete the post-dialysis section of the dialysis communication form.-On 9/17/24 the facility did not complete the vital signs information in the pre-dialysis section, sign the pre-dialysis section or complete the post-dialysis section of the dialysis communication form.-On 9/19/24 the facility did not document the resident's pre-dialysis weight in the dialysis communication form or complete the post-dialysis section of the dialysis communication form. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/3/24 at 11:30 a.m. LPN #1 said Resident #23's vital signs should have been checked prior to the resident going to dialysis. LPN #1 said usually a certified nurse aide (CNA) checked vital signs but a nurse was also able to check vital signs. LPN #1 said staff should get the resident's vital signs the day of their dialysis appointment by 10:45 a.m. LPN #1 said she was not aware there was missing documentation on Resident #23's dialysis paperwork but she said, at times, Resident #23's blood pressure could get low and could explain some of the missing documentation in the dialysis binder if the resident did not attend the dialysis treatment. LPN #1 said the staff was supposed to weigh the resident at the facility prior to the resident going to dialysis. She said the vital signs and weights should be recorded on the dialysis communication forms in the binder prior to the resident going to dialysis. The director of nursing (DON) and the divisional director of clinical services (DDCS) were interviewed together on 10/3/24 at 3:08 p.m. The DDCS said the dialysis communication forms should be filled out consistently, including the pre-dialysis section, prior to the residents going to their dialysis appointments. The DON said when a resident returned to the facility from dialysis with the communication binder, the facility nurse should call the dialysis center to follow up and get a report for how much fluid was taken off the resident at dialysis and document the information in the resident's electronic medical record (EMR). The DON said the dialysis communication forms should include the necessary information because it could indicate the resident experienced a fluid volume loss that affected the resident's blood pressure and the physician might make further recommendations based on that information.

Based on record review and interviews, the facility failed to ensure one (#287) of five residents out of 35 sample residents was free from significant medication errors. Resident #287 was admitted to the facility on 6/20/24 for skilled nursing care after a failed left total knee revision. Secondary diagnoses included hypertension (high blood pressure), post-procedural pain and a history of heart failure. Resident #287's physician's orders for medications, upon his admission to the facility from the hospital on 6/20/24, included an order for carvedilol (a medication used to treat high blood pressure and heart failure) 6.25 milligrams (mg) twice daily for heart rate and blood pressure (BP). The hospital's list of physician ordered medications was verified by the facility's physician. The medication orders were entered into Resident #287's electronic medical record (EMR) by licensed practical nurse (LPN) #2 on 6/20/24 at 3:55 p.m. and confirmed by LPN #3 on 6/20/24 at 4:51 pm. However, LPN #2 incorrectly entered the physician's order for carvedilol as 25 mg by mouth two times a day for hypertension, if systolic blood pressure was under 100 mm/hg (millimeters of mercury), notify the physician and document in a progress note. LPN #2 incorrectly entered the dose of the carvedilol as 25 mg instead of the physician ordered 6.25 mg, four times the dose the resident was ordered to receive. LPN #3 failed to catch the discrepancy when confirming the entered physician's orders one hour after they were entered into Resident #287's EMR.Resident #287 was administered the 25 mg dose of carvedilol on the evening of 6/20/24 and the morning of 6/21/24. As a result of LPN #2's and LPN #3's failure to accurately transcribe and confirm a physician's medication order, Resident #287 received two doses of the medication that were excessively high. He sustained hypotension (low blood pressure) and was transferred to the hospital intensive care unit on 6/21/24. He was treated for a medication overdose that required intravenous medications to support his blood pressure and circulation. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/30/24 to 10/3/24, resulting in the deficiency being cited as past noncompliance with a correction date of 6/28/24. I. Incident on 6/20/24 and 6/21/24On 6/20/24 at 7:28 pm, Resident #287's BP was 112/59 mm/hg and the nurse administered the carvedilol medication to the resident. -The resident was administered an incorrect dose of carvedilol 25 milligrams (mg) instead of the correct dose of 6.25 mg. On 6/21/24 at 7:05 am, Resident #287's BP was 102/52 mm/hg and the nurse administered the carvedilol medication to the resident. -The resident was administered an incorrect dose of carvedilol 25 mg instead of the correct dose of 6.25 mg. At 1:59 p.m., Resident #287's blood pressure was 73/94 [sic] mm/hg. -LPN #2 and LPN #3 failed to follow professional standards of nursing practice when entering and confirming physician's medication orders into the EMR.As a result of LPN #2 and LPN #3's failure to accurately transcribe and confirm a physician's medication order, Resident #287 received two doses of the medication that were excessively high. He sustained hypotension (low blood pressure) and was transferred to the hospital intensive care unit on 6/21/24. He was treated for a medication overdose that required intravenous medications to support his blood pressure and circulation. Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/30/24 to 10/3/24, resulting in the deficiency being cited as past noncompliance with a correction date of 6/28/24. II. Facility's plan of correctionThe corrective action plan implemented by the facility in response to Resident #287's medication administration failure on 6/20/24 and 6/21/24 was provided by the nursing home administrator (NHA) on 10/3/24 at 6:15 p.m. The plan revealed the following: A. Corrective actionResident #287 was assessed following the administration of the two larger doses of carvedilol. The physician was promptly notified and new orders for the correct dose were obtained. The resident was notified of the error and sent to the hospital for further evaluation. The resident's primary care physician at the facility reviewed the medical record and supplied the facility with his findings. Education was done with the two nurses who transcribed and verified the medication order upon admission. A root cause analysis was completed with the involved nurses, and corrective action was implemented based on the findings. B. Identification of othersThe facility reviewed hospital discharge medication orders and facility admission medication orders. Out of 41 admissions that were reviewed, there was one other error noted. That error had no adverse outcomes. The physician was notified and corrective action was implemented. C. Systemic changesAdmission orders education was conducted from 6/25/24-6/28/24 and included the following:-All admission orders will have a second check completed by a nurse-The second check should consist of verifying the correct admission orders were entered by the first nurse-Orders should not be confirmed unless they meet the 10 rights of medication administration: right patient, medication, time, dose, route, right education/advice, right to refuse, right assessment, right evaluation/response and right documentation.-52 staff completed education on admission orders.-112 staff completed education regarding double checking blood pressures if abnormal results were obtained the first time. D. Monitoring-Review of medications will be done by the pharmacist upon admission and as needed.-Admission orders from the hospital are reviewed and entered by a nurse. A second nurse reviews the orders, comparing them to the transfer orders from the hospital.-If a medication error is identified, the process for medication variance will be followed, including prompt action to maintain safety for the resident, communicating with the physician, and implementing any provided orders. Additional education will be done with the nurses involved. This will be done within 24 hours of admission, and for two weeks or longer based on the level of compliance. The DON or designee, will conduct this review 3-5 (three to five) times per week for two weeks.-If significant abnormal vital signs are obtained, a second check will be completed using a manual cuff (for blood pressures). The DON will identify significantly abnormal vital signs and determine if re-checks have been completed. This will be done 3-5 (three to five) times per week for four weeks, and based on the results, additional training will be done with nurses. -The DON or designee will report audit findings and medication regimen review findings to the Facility quality assurance process improvement (QAPI) committee. The committee will review the findings and determine if the facility has achieved substantial compliance. The frequency of ongoing monitoring will be determined by the facility QAPI committee.-Education for nurses will be done upon hire and as needed regarding the facility process for transcribing and checking medication orders upon admission, rechecking abnormal vital signs, and the policy/procedure related to medication administration and errors. Date of correction was 6/28/24. III. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607, retrieved on 10/7/24, "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."IV. Resident #287A. Resident statusResident #287, age 75, was admitted on 6/20/24 and transferred to the hospital on 6/21/24. According to the June 2024 computerized physician orders (CPO), diagnoses included a failed left total knee revision, post-procedural pain and hypertension. The minimum data set (MDS) assessment was not completed on the resident due to being in progress at the time of the resident's discharge. B. Record reviewA review of Resident #287's BP documentation revealed the following:-On 6/20/24 at 5:51 p.m. the resident's BP was 160/94; -On 6/20/24 at 7:28 p.m. the resident's BP was 112/59;-On 6/21/24 at 7:05 a.m. the resident's BP was 102/52;-On 6/21/24 at 8:56 a.m. the resident's BP was 112/60; and, -On 6/21/24 at 1:59 p.m. the resident's BP was 73/94 [sic]. A nursing progress note dated 6/21/24 at 10:55 a.m. documented that Resident #287 received two doses of carvedilol 25 mg per the admission order, which was transcribed incorrectly. There were no adverse effects noted. The nurses were educated, the order was corrected, the physician was notified, and a new order was received to monitor vital signs every four hours for 24 hours. The resident was informed of the error. The June 2024 CPO revealed a new physician's order for carvedilol oral tablet 6.25 mg was entered on 6/21/24 at 10:23 a.m. The June 2024 CPO revealed a physician's order for vital signs every four hours for one day, entered on 6/21/24 at 12:00 p.m. A medical provider note dated 6/21/24 at 12:26 p.m. documented the medication error resulted in significant hypotension. The resident was seen laying in bed and was easily arousable, but lethargic and mildly dizzy. Staff was unable to establish an intravenous (IV) line to give him fluids, so the recommendation was to send him to the emergency room (ER). An order for a one time dose of Midodrine HCL (a medication used to treat low blood pressure) oral tablet 2.5 mg for hypotension, was entered on 6/21/24 at 1:15 p.m. A hospital transfer summary note, dated 6/21/24 at 3:15 p.m., documented that nursing gave Resident #287 Midodrine HCL 2.5 mg at 1:00 pm for hypotension as ordered by the physician. A nurse could not start an IV on Resident #287, so the resident was transferred to the hospital. The resident's wife and daughter, the DON, and the hospital emergency room were notified. An emergency room clinician note, dated 6/21/24 at 4:50 p.m., revealed Resident #287 received approximately 1400 milliliters (mls) of IV fluids. Given the resident's history of heart failure, the ER clinician started IV blood pressure medications, put in a central IV catheter, and admitted him to the intensive care unit. The medical director's investigation, not dated, was provided by the divisional director of clinical services (DDCS) on 10/3/24 at 5:38 p.m. The investigation revealed that the resident's prior hospital discharge summary showed he was on carvedilol (Coreg) 6.25 mg twice a day. The investigation documented the initial error was in the transcription of this order during admission to the facility of carvedilol as a 25 mg dose. The resident received two doses (an evening dose on 6/20/24 and morning dose on 6/21/24), with a first BP of 112/59 mm/hg and a second of 102/52 mm/hg. The investigation documented other medications that could have contributed to the low blood pressure were diazepam, furosemide, hydromorphone, loratadine, losartan, methocarbamol, mirtazapine, pramipexole and spironolactone. V. Staff interviewsLPN #1 and LPN #4 were interviewed on 10/3/24 at 9:36 a.m. LPN #1 and LPN #4 said, when a resident was admitted from the hospital, the facility received the resident's discharge summary before they arrived. They said the admissions department entered the discharge summary information into the EMR, including the list of the resident's medications given by the hospital. LPN #1 and LPN #4 said the facility nurses looked at that information, the physician verified it, and then the nurses entered the orders into the computer. The director of nursing (DON) and the DDCS were interviewed together on 10/3/24 at 3:13 p.m. The DON said the new facility procedure for entering residents' admission medications was for the physician, the DON, and the unit manager to check orders for new residents. The DON said, previously, staff had not been doing adequate admissions for new residents and that staff should have triple checked new admission physician orders as part of the admission process. The DON revealed that now the facility had a nurse who audited resident charts and ensured all the assessments, plans, diagnoses and physician's orders were entered correctly. The DDCS was interviewed again on 10/3/24 at 5:27 p.m. The DDCS said Resident #287 was at the facility for a very short time. She said there was a medication error that occurred which resulted in the resident receiving an incorrect dose of his blood pressure medication. She said the resident was admitted to the hospital's intensive care unit following the medication error. The DDCS said when the error occurred, the nurses responsible for entering the order, LPN #2 and LPN #3, admitted the error immediately. She said LPN #1, who administered the medication to the resident, took the resident's vital signs and then the resident was sent out for evaluation. The DDCS said she wrote a summary recommending the medical director review the resident's EMR, and if there were any concerns he should share them. She said the facility wrote a variance, reported the error, and called the doctor. She said the pharmacist reviewed the resident's medications and found the error. The DDCS said the physician and the resident were notified promptly that he got two doses of the 25 mg dose of the medication. She said vital signs equipment was checked to make sure it worked and the blood pressures were accurate. The DDCS said education was done with the two LPNs who were responsible for entering the physician's order and verifying it incorrectly and a plan of correction was done to ensure the error would not occur again.

Based on observations, interviews and record review, 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 disease on three of three units. Specifically, the facility failed to:-Ensure hand hygiene was consistently performed during wound care;-Ensure enhanced barrier precautions (EBP) were followed during wound care and for residents with an indwelling medical device (foley catheter) and/or a wound;-Ensure a suction canister containing oral secretions was handled in a sanitary manner;-Ensure blood glucose meters were cleaned in a sanitary manner after each use according to manufacturer recommendations; and,-Ensure vital sign machines were cleaned in a sanitary manner. Findings include:I. Facility policy and procedureThe Infection Prevention and Control Program (IPCP) and Plan, revised 6/13/24, was provided by the nursing home administrator (NHA) on 9/30/24 at 1:30 p.m. It revealed in pertinent part, "The facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. "The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment and following accepted national standards; written standards, policies, and procedures for the program, which must include, but are not limited to: standard and transmission-based precautions to be followed to prevent spread of infections; and the hand hygiene procedures to be followed by staff involved in direct resident contact. General procedures included to ensure staff followed the IPCP's standards, policies and procedures (hand hygiene and appropriate use of PPE)."II. Hand hygiene and EBP failures during wound care. A. Professional referencesAccording to the Centers for Disease Control and Prevention (CDC) Hand Hygiene for Healthcare Workers, updated 2/27/24, retrieved on 10/10/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html,"Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device 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 patient's surroundings, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal."Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings, always clean your hands after removing gloves, remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil your hands."According to the CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, updated 4/2/24, retrieved on 10/10/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,"Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities. "EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO."Examples of high contact resident are activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing)."B. ObservationsOn 10/2/24 at 3:10 p.m. infection preventionist, who was also the facility's wound nurse, (IP) and the director of nursing (DON) entered Resident #38's room to perform wound care for the resident. The following observations were made:The IP performed hand hygiene and put on a gown and gloves before entering the resident's room. The DON performed hand hygiene and donned (put on) a pair of gloves. The DON proceeded to assist the IP with positioning Resident #38 onto his side and held him in place during the wound care. -The DON did not don a gown prior to entering the resident's room and assisting with the resident's wound care. The IP cleansed the resident's upper back wound with normal saline soaked gauze, then removed her gloves and disposed of them in trash. She immediately put on a pair of new gloves and placed medi-honey (a wound treatment) with a cotton swab into the wound bed. -The IP did not perform hand hygiene after the removal and disposal of her old gloves and before donning new gloves. On 10/2/24 at 3:20 p.m. the IP and the DON entered Resident #36's room to perform wound care for the resident.was The following observations were made:The IP performed hand hygiene and put on a gown and gloves before entering the resident's room. The DON performed hand hygiene and donned (put on) a pair of gloves. The DON proceeded to assist the IP with positioning Resident #36 onto his side and held him in place during the wound care. -The DON did not don a gown prior to entering the resident's room and assisting with the resident's wound care. The IP measured Resident #36's coccyx wound and removed her gloves. She immediately donned new gloves and cleaned the wound with normal saline soaked gauze. -The IP did not perform hand hygiene after removal of her old gloves and before donning new gloves. C. Staff interviewsThe DON and the IP were interviewed on 10/2/24 at 3:30 p.m. The DON said she was not the one who usually assisted the IP with wound care. She said she was not aware that she still needed to don a gown when coming into close contact with Resident #38 and Resident #36 during wound care, even if she was not directly providing the wound care. The DON said now that it had been brought to her attention, she would put on a gown, per EBP guidelines, when assisting with wound care. The IP said hand hygiene should be performed before and after resident contact with hand sanitizer. She said hands should be washed with soap and water if they were visibly soiled. She said hand hygiene should be performed after the removal of gloves and before putting on a new pair of gloves to help prevent the contamination of hands by the soiled gloves. III. Suction canister failureA. ObservationsOn 9/30/24 at 1:39 p.m. room #223-A was observed to have a used suction canister at the bedside. The suction canister was less than half full of yellow tinged clear to white liquid. The suction canister was undated. A suction tubing and an uncovered yankauer suction device were connected to the suction canister and hanging off the edge of the resident's bedside table. On 10/1/24 at 12:00 p.m. the used suction canister in room #223-A was observed in the same position on the resident's bedside table as it was the day prior. The suction canister contained the to have the same level of oral secretions in it. The suction canister continued to be undated and the suction tubing and yankauer suction device continued to hang off the edge of the bedside table. B. Staff interviewsLicensed practical nurse (LPN) #6 was interviewed on 10/2/24 at 12:20 p.m. LPN #6 said she did not know how long the suction canister had been sitting on the resident's bedside table. She said therapy had been working with the resident for approximately one week prior to suctioning out her oral secretions. She said, once a suction canister was used, it should be disposed of at the end of the shift. She said the yankauer suction device should have a cover on it to keep it clean. She said the oral secretions in the suction canister contained microorganisms which could be a medium for growth of other infectious microorganisms. The DON was interviewed on 10/2/24 at 1:00 p.m. The DON said the resident in room #223A did not have a current physician's order to be suctioned. She said it was difficult to determine how long the suction canister had been sitting at the bedside. She said the soiled suction canister should have been disposed of as it was a source of microorganisms. IV. Additional EBP failuresA. ObservationsOn 9/30/24 at 2:13 p.m. an unidentified staff member knocked on the door to Resident #177's room. Resident #177 had an indwelling foley catheter. Prior to entering the resident's room, the staff member donned a surgical mask, opened the door, entered Resident #177's room and told the resident he was going to have wound care. A second unidentified staff member then entered room Resident #177's room. At 2:23 p.m. the two unidentified staff members exited Resident #177's room. One staff member exited with a clear trash bag of disposable items. At 2:25 p.m. another unidentified staff member knocked on Resident #177's door, entered the resident's room holding a stack of clean, folded bedding and told the resident they were there to change the resident's bedding. A second staff member, certified nurse aide (CNA) #3, donned a yellow gown, a surgical mask and gloves and entered Resident #177's room. At 2:30 p.m. the unidentified staff member exited Resident #177's room with crumpled bedding in a clear trash bag. At 2:44 p.m. CNA #3 exited Resident #177's room. CNA #3 was no longer wearing PPE and was carrying two full clear trash bags, one of which contained a crumpled yellow gown. At 4:45 p.m. an EBP sign was observed posted outside Resident #177's door. The sign revealed in pertinent part, "Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use."On 10/2/24 at 9:26 a.m. an EBP sign was posted next to Resident #183's door to his room. The sign revealed in pertinent part, "Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use."On 10/2/24 at 10:21 a.m. an unidentified staff member knocked on the door to Resident #183's room and entered. At 10:22 a.m. CNA #1 entered Resident #183's room. Neither staff member donned a gown or surgical face mask prior to entering Resident #183's room. While in Resident #183's room, one of the staff members told Resident #183 he was going to be transferred into his chair. At 10:29 a.m. CNA #1 exited the resident's room. At 10:31 a.m. the unidentified staff member exited the room. B. Staff interviewsCNA #3 was interviewed on 9/30/24 at 2:26 p.m., prior to entering Resident #177's room. CNA #3 said there were no gowns in Resident #177's room and gloves were the only PPE in his room. CNA #3 said the PPE was outside the door for residents who received wound care. CNA #1 was interviewed on 10/2/24 at 10:29 a.m., immediately after she exited Resident #183's room. CNA #1 said she and another CNA transferred the resident from his bed to a chair. CNA #1 said the resident was unable to use his legs, so both CNAs held the resident under his arms while they transferred him from his bed to the chair. CNA #1 said she was not aware the EBP sign posted outside Resident #183's room provided instructions to don a gown to transfer a resident with EBP. CNA #1 said she knew staff had to don a gown, gloves and mask to change a resident's bedding using EBP.-However, observation revealed CNA #1 did not don the appropriate PPE prior to transferring Resident #183 to his chair (see observations above). LPN #1 was interviewed on 10/3/24 at 11:30 a.m. LPN #1 said staff should don a gown and PPE according to the EBP sign and when doing wound care, bathing or transferring the residents with EBP. The DON) was interviewed on 10/3/24 at 3:08 p.m. The DON said the IP provided staff training on EBP, and followed up to ensure that all residents who required EBP had signs posted correctly. The DON said staff should don a gown for resident contact during transfers or lifting and changing residents bedding. V. Glucometer and vital signs machine disinfecting failuresA. Professional referenceThe Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Healthcare Facilities (2019), was retrieved on 10/10/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/index.html. It read in pertinent part, "Careful cleaning of patient rooms and medical equipment contributes substantially to the overall control of Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-intermediate Staphylococcus aureus (VISA) and Vancomycin-resistant Enterococci (VRE) transmission. "Direct patient-care items (blood pressure cuffs) should be disposable whenever possible when used in contact isolation settings for patients with multiply resistant microorganisms."Non-critical items (those that come in contact with intact skin but not mucous membranes), are divided into noncritical resident care items (blood pressure cuffs, stethoscopes, wheelchairs, therapy equipment) and noncritical environmental surfaces (bed rails, bedside tables). They require cleaning followed by either low or intermediate level disinfection following manufacturers' instructions. Disinfection should be performed with an Environmental Protection Agency (EPA)-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products must be followed (use-dilution, shelf life, storage, material compatibility, safe use and disposal). B. Facility policy and procedureThe Cleaning and Disinfecting The Glucometer policy, revised 9/23/24, was provided by the nursing home administrator (NHA) on 10/2/24 at 5:34 p.m. It read in pertinent part,"To prevent the spread of infection, specifically blood borne pathogens through the use of point of care blood glucose monitoring, by cleaning and disinfecting glucometers after each resident use."C. ObservationsDuring a continuous observation on 10/2/24, beginning at 8:54 a.m. and ending at 10:51 a.m., the following was observed: One glucometer was observed in the top drawer of the medication cart. RN #2 took the glucometer into room #231. -At 9:24 a.m., after using the glucometer for the resident in room #231, RN #2 placed the glucometer on top of the medication cart and did not disinfect it. -At 9:28 a.m. she took the glucometer back into the same resident's room to do another blood sugar check. Upon returning to her cart, RN #2 placed the glucometer on top of the medication cart and did not disinfect it.-10:51 a.m., after another blood sugar check on the same resident in room #231, RN #2 put the glucometer in her pocket and left the area. She did not disinfect the glucometer. At 10:07 a.m. RN #2 took a vital signs machine into room #230. At 10:08 a.m. RN #2 brought the machine out of room #230. At 10:09 a.m. RN #2 took the vital signs machine into room #231.-RN #2 did not disinfect the vital signs machine in between residents At 10:13 a.m., an unidentified male CNA brought the vital signs machine out of room #231 and placed it in the hall near the Beaver Creek nurses' station.-The unidentified CNA did not disinfect the vital signs after removing it from room #231. At 10:16 a.m., the same unidentified male CNA took another vital signs machine, which had also been in room #231, out of the room and placed it in the hallway near room #227.-The unidentified CNA did not disinfect the vital signs after removing it from room #231. At 10:40 a.m., the same male CNA took the vital signs machine from near room #227 and brought it around the corner to sit next to the other vital signs machine near the Beaver Creek nurses' station. One of the blood pressure (BP) cuffs fell on the floor and the CNA picked it up and placed it back in the basket attached to the machine. -The BP cuff and the vital signs machine were not cleaned. C. Staff interviewsRN #2 was interviewed on 10/2/24 at 2:04 p.m. RN #2 said she was not taught the facility's policy for cleaning glucometers. RN #2 said there was only one resident who used the glucometer for blood sugar checks. She said she should have disinfected the vital signs machine in between residents but she forgot. The DON and divisional director clinical services (DDCS) were interviewed together on 10/3/24 at 3:13 p.m. The DDCS said the facility's policy was to use the glucometers for one patient and disinfect it according to the manufacturer's guidance, ideally as soon as it was used for the resident. The DON said that vital signs machines should be cleaned after each use on a resident to prevent the spread of any infection.

Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff, including contract agency staff, based on the facility assessment and resident population. Specifically, the facility failed to complete orientation skills checklists and receipt of orientation packets, which included information for general orientation of the facility, medication administration, electronic medical record access, laundry procedures, resident transfers, gait belt usage and information on nursing documentation and admission of residents, for agency nursing staff. Findings include:I. Record reviewReview of agency nurse and certified nurse aide (CNA) records who were working in the facility revealed the following: Registered nurse (RN) #3 had an orientation packet receipt, signed 4/24/23. -RN #3 did not have an orientation skills checklist. CNA #7 had an orientation packet receipt, signed 2/10/23. -CNA #7 did not have an orientation skills checklist.-CNA #8 did not have an orientation packet receipt or a completed orientation skills checklist. CNA #9 had a skills orientation checklist, completed 8/15/23.-CNA #9 did not have an orientation packet receipt.-RN #4 did not have an orientation packet receipt or a skills orientation checklist.-Licensed practical nurse (LPN ) #7 did not have an orientation packet receipt or a skills orientation checklist. RN #2 had an orientation packet receipt, signed in February 2023. -RN #2 did not have a completed skills orientation checklist. II. Staff interviewsRN #2 was interviewed on 10/2/24 at 1:00 p.m. She said she had been working at the facility for a year and did not recall any formal orientation to the facility. She said she did not receive a packet or an orientation skills checklist. She said she figured out what she needed to do or know on her own. RN #2 said she was not formally assigned to a mentor or preceptor but she asked other staff members and management if she had any questions.-However, a signed receipt of the orientation packet was provided by the staffing coordinator (SC) (see above). The director of nursing (DON) was interviewed on 10/2/24 at 1:09 p.m. The DON said she was new to the facility in the last two weeks and she did not know the process to orient outside agency nursing staff to the facility. She said the SC was in charge of ensuring agency staff received orientation. The SC and the DON were interviewed together on 10/2/24 at 1:20 p.m. The SC said she had taken over the role of orienting agency staff members in the last week due to an abrupt resignation of another staff member that had previously been in charge of orienting agency staff to the facility. She said agency staff should be given an orientation packet and assigned to a mentor. The SC said agency staff were given an orientation skills checklist to complete. She said the orientation skills checklist was not started until May of 2023. The SC said the facility had not used any outside agency staff again until recently within the last two weeks. She said if the facility had any changes to their existing policies, agency staff would be given a refresher of the information. The SC said she did not know why agency staff that currently worked at the facility, and had worked at the facility a year prior, did not have completed orientation packet receipts and orientation skills checklists.

A revisit survey was completed on 2/26/24 for all previous deficiencies cited on 12/13/23. The facility is in compliance with all regulations surveyed.

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

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

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/15/2024 and 01/21/2024, 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 complaint survey, prompted by #CO34246, #CO34233, #CO34371 and #CO34372 was conducted on 12/7/23 to 12/13/23. One deficiency was cited.

Based on observations, interviews and record review, the facility failed to ensure residents and or their representatives were provided prompt efforts by the facility to resolve grievances for three (#1, #2 and #6) of three residents reviewed out of five sample residents. Specifically, the facility failed to address, resolve, document and follow up on grievances for:-Resident #1 regarding cold shower temperatures;-Resident #2 regarding cold shower temperatures and call light response times; and,-Resident #6 regarding call light response times.-Additionally, unnamed residents in the resident council complained of call light response times with no follow up documented by the facility. Findings include:I. Facility policy and procedureThe facility policy on grievances was requested from the director of nursing (DON) on 12/13/23 at 12:04 p.m. -The facility did not provide the requested policy by the end of the survey. II. Resident and resident representative interviewsResident #1 was interviewed on 12/7/23 1:14 p.m. He said the shower water temperatures were too cold. Resident #1 said he had reported it to the nursing staff multiple times in the last two weeks. Resident #1 said the nursing staff told him maintenance would fix the water temperatures but he had not heard anything back and the water temperature was still cold. Resident #2 was interviewed on 12/13/23 at 9:46 a.m. He said the water temperatures in the shower rooms were cold. He said he had reported this to the activity director (AD) since they were in charge of the resident council. He said he had begun refusing showers due to the water temperatures. He said he had reported about three weeks ago that the water temperature coming from the faucet in his room was very hot and he had to pull his hands out of the water due to the temperature. He said he thought the water temperatures may have been turned down at that time. Resident #2 said he had spoken with other residents in the facility who had concerns with the shower water being too cold. He said some of these residents had already moved out of the facility due to the cold shower water temperatures. Additionally, Resident #2 said call light wait times were a concern. He said this had been reported at the resident council meeting. Resident #2 said he had to wait over 30 minutes for his call light to be answered at times. He said it was difficult to wait when he needed to go to the bathroom or was uncomfortable in his wheelchair and needed to get back in bed. The resident representative for Resident #6 was interviewed on 12/14/23 at 11:51 a.m. She said her mother waited for her call light to be answered for over an hour and a half. She said she reported this to the admissions director (AMD) and the nursing home administrator (NHA). The resident representative said her mother was usually continent of urine but had occasional urine leakage. She said her mother waited so long for the call light to be answered she was soaked with urine through her clothing. The representative said the certified nurse aides (CNA) told her they were short staffed and therefore had not been able to get to her mother timely. The representative said she had reported this to the NHA. The NHA told the representative this was not true and they were not short staffed. The representative said the next day the nursing staff told her there was a staff meeting and the nursing staff were told not to talk to families about staffing concerns. III. ObservationsThe shower temperatures in the facility's two shower rooms were checked with the MTD on 12/12/23 at 9:12 a.m. The MTD did not know the location of the shower rooms and asked the nurse at the nurse station to show him where the shower room was. The Winter Park shower temperature after three minutes on hot was 102.9 degrees F. The Steam Boat shower temperature after three minutes on hot was 92.5 degrees F. The MTD said the shower temperature was too cool and someone must be doing laundry. IV. Staff InterviewsThe social services director (SSD) was interviewed on 12/07/23 at 12:42 p.m. She said she was not responsible for the grievance program. She said the NHA was responsible. The SSD said anyone could fill out a grievance. She said all grievances went to the NHA and then were reviewed in the daily morning meeting with the department leaders. She said if a concern was brought up in resident council a grievance card should be completed and the same process was followed. The NHA was interviewed on 12/7/23 at 12:47 p.m. She said grievance cards could be filled out by staff, residents or families. She said all grievances came to her and she reviewed them with the department leaders in the morning meeting. She said the department involved in the grievance should follow up on the grievance within three days and follow up with the person who submitted the grievance. See said the same process was followed if a grievance was brought up in resident council. Grievances related to call light response times and shower water temperatures for September 2023, October 2023 and November 2023 were requested from the NHA. The NHA was interviewed again on 12/7/23 at 1:30 p.m. She said she knew of one concern from Resident #1 regarding shower temperatures but she did not have a grievance card. The NHA said a grievance should have been filled out and completed for the residents concerned with water temperatures. The NHA said she had one grievance from October 2023 regarding call light response times and she would provide a copy. The NHA provided the September and October 2023 resident council notes on 12/7/23 at 12:23 p.m. She said she did not have any resident council notes for November 2023 because the activity coordinator (AC) was on vacation and had not provided the notes from that month. The maintenance director (MTD) was interviewed on 12/12/23 at 8:50 a.m. with the NHA The MTD said about a month ago (November 2023) he got a call in the evening from a nurse who said the water temperatures were cold in the evening. He said he came in that evening and the shower temperature was 90 degrees Fahrenheit (F) in one shower room and 98 degrees F in the second shower room. He said he adjusted the temperature. He said he did not know which resident was concerned or which nurse called him or on what day. The NHA said had heard about it from the unit manager but she had no documentation of the concern or follow up. She said there should have been a grievance completed. The MTD said he checked the shower temperatures daily at 6:00 a.m. but he had no record of the checks. He said ideally he liked to keep the showers at a temperature of 110 degrees F to 116 degrees F. The DON was interviewed on 12/12/23 at 2:54 p.m. She said she did not have any documentation of call light audits. She said there was no formal process for auditing the call lights, she said the nurse managers checked them on their rounds. V. Record reviewThe September and October 2023 resident council notes were reviewed on 12/7/23/ at 12:23 p.m. There were no November 2023 resident council notes. On 9/27/23 at 1:30 p.m. the resident council notes documented the residents were concerned with call light response times. The facility documented on the notes a call light audit would be done. On 10/25/23 at 1:30 p.m. the resident council notes documented the residents were concerned with call light response time again. The notes documented the DON responded and said she was waiting on the results of call light audits. On 12/7/23 at 2:02 p.m., the NHA provided a grievance form she said she had found on call light response times. On 10/26/23 a Comment and Concern form documented a resident representative reported concerns with call light response time. On 10/26/23, the NHA documented that this was at the beginning of the resident's stay and had improved since the resident moved to a new area of the facility.-There were no call light audits for review based on the September 2023 and October 2023 resident council notes..-There was no documentation of shower temperature audits by maintenance for review. III. ObservationsThe shower temperatures in the facility's two shower rooms were checked with the MTD on 12/12/23 at 9:12 a.m. The MTD did not know the location of the shower rooms and asked the nurse at the nurse station to show him where the shower room was. The Winter Park shower temperature after three minutes on hot was 102.9 degrees F. The Steam Boat shower temperature after three minutes on hot was 92.5 degrees F. The MTD said the shower temperature was too cool and someone must be doing laundry.

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 10/09/2023 and 10/15/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/02/2023 and 10/08/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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

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

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

A survey prompted by #CO32528, #CO33589 and #CO33606 was conducted on 9/11/23 to 9/13/23. No deficiencies were cited.

A revisit survey was completed on 7/10/23 for all previous deficiencies cited on 4/13/23. The facility is in compliance with all regulations surveyed.

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

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/15/2023 and 05/21/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/08/2023 and 05/14/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

This structure is one (1) story, Type V (111) construction based upon independent testing results of the various ceiling/roof assemblies installed throughout the building. The facility is licensed for 120 beds and the census on the date of the survey was 56. The facility was constructed in 2012. The facility ' s first floor is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The attic areas and exterior drive through canopy are protected by 4 dry-pipe valve sprinkler systems. There is a non-combustible crawl space that is not protected, and is only accessible from the exterior and mechanical spaces through floor access hatches. The facility is classified as Fully Sprinklered. The facility is divided into four (4) compartments, with each compartment separated by two-hour rated construction that is continuous throughout the crawl space and attic areas. The four (4) compartments serve as the smoke compartments, with the fire alarm and fire sprinkler system initiating devices zoned by each compartment. Emergency back-up power is supplied by a 500 kW diesel powered generator which is located outside the building. The facility is also equipped throughout with a piped medical gas system. This survey was conducted on March 27, 2022 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."The results of this survey were discussed with the Director of Maintenance and the Facility Administrator during the exit conference.

Through observation, it was determined that the facility failed to meet the emergency management requirements in accordance with NFPA 101. This was evidenced by:1. Egress paths were partially obstructed in kitchen and east/storage room. NFPA 101 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Through documentation review, it was determined that the facility failed to meet the emergency and exit light testing requirements in accordance with NFPA 101. This was evidenced by:1. Missing annual/90-minute emergency and exit light inspection/testing/maintenance report. 2. Missing monthly/30-second emergency and exit light inspection/testing/maintenance reports. NFPA 101 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). (2) *The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. (3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

During documentation review, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101 and NFPA 96 (2011). This was evidenced by:1. Missing semi-annual hood suppression system inspection/testing/maintenance report. 2. Missing hood system cleaning inspection/testing/maintenance report. NFPA 96 12.1.4.2 Records of compliance with 12.4.2 shall be maintained and shall be available to the authority having jurisdiction. 12.5 Inspection, Testing, and Maintenance of Listed Hoods Containing Mechanical, Water Spray, or Ultraviolet Devices. Listed hoods containing mechanical or fire-actuated dampers, internal washing components, or other mechanically operated devices shall be inspected and tested by properly trained, qualified, and certified persons every 6 months or at frequencies recommended by the manufacturer in accordance with their listings. NFPA 96 11.6.13 When an exhaust cleaning service is used, a certificate showing the name of the servicing company, the name of the person performing the work, and the date of inspection or cleaning shall be maintained on the premises. 11.6.14 After cleaning or inspection is completed, the exhaust cleaning company and the person performing the workat the location shall provide the owner of the system with a written report that also specifies areas that were inaccessible or not cleaned. 11.6.15 Where required, certificates of inspection and cleaning and reports of areas not cleaned shall be submitted to the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

During record review, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 101 and NFPA 72 (2010). This was evidenced by the following:1. Deficiencies on annual fire alarm inspection/testing/maintenance report were not corrected (four power supply batteries failed testing). 2. Missing semi-annual fire alarm inspection/testing/maintenance report. 3. Missing two (2) year smoke detector sensitivity inspection/testing/maintenance report. NFPA 72 (2010) 14.2.1.2.2 System defects and malfunctions shall be corrected. 14.2.1.2.3 If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours. 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 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 the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by the authority having jurisdictionThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Through documentation review and observation, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, NFPA 25 (2011) and NFPA 13 (2010). This was evidenced by:1. Missing annual, quarterly and semi-annual fire suppression inspection/testing/maintenance reports. 2. Missing annual backflow assembly inspection/testing/maintenance report. 3. Missing five (5) year internal obstruction inspection/testing/maintenance report for wet fire suppression system risers (4 total). 4. Fire sprinklers loaded or damaged in the following locations: Winter Park Dining Room has loaded sprinklers, SE wing dry fire riser/mechanical room has painted fire sprinklers, escutcheons missing for kitchen cooler/freezer heads and several sprinklers were loaded in kitchen. 5. Missing fire sprinkler inventory lists on spare parts cabinets. NFPA 101 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 13.6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end ofone main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. NFPA 25 5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.- NFPA 13 (2010) 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. NFPA 13 6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet. 6.2.9.7.1* The list shall include the following: (1) Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating (2) General description (3) Quantity of each type to be contained in the cabinet &n

Through documentation review, it was determined that the facility failed to meet the fire extinguisher maintenance requirements in accordance with NFPA 101 and NFPA 10 (2010). This was evidenced by:1. Missing annual fire extinguisher inspection/testing/maintenance report. NFPA 101 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Through documentation review, it was determined that the facility failed to meet the fire and smoke door inspection/testing/maintenance requirements in accordance with NFPA 101, NFPA 80 (2010) and NFPA 105 (2010). This was evidenced by:1. Missing dated annual fire/smoke rated door inspection/testing/maintenance report. NFPA 101 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction. -NFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. -NFPA 105 5.2.1.1 Smoke door assemblies shall be inspected annually. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Through observation, it was determined that the facility failed to meet the fire and smoke resistive construction requirements in accordance with NFPA 101. This was evidenced by:1. HVAC ductwork assembly in Winter Park Wing mechanical room did not meet rated assembly requirements. 2. SE Dry Fire Riser/Mechanical room had penetrations in drywall. NFPA 101 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."-NFPA 101 8.3.1.2* Fire barriers shall comply with one of the following:(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from thefloor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Through documentation review, it was determined that the facility failed to meet the emergency management requirements in accordance with NFPA 101 and NFPA 99 (2012). This was evidenced by:1. Missing documentation of required annual community-based emergency exercise. NFPA 99 12.5.3.3.8.1 The facility shall test its EOP [Emergency Operations Plan] at least twice annually, either through functional or full-scale exercises or actual events. 12.5.3.3.8.4 Annual table top, functional, or full-scale exercises shall include the following:(1) Community integration(2) Assessment of stand-alone capabilityThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

During documentation review, it was determined that the facility failed to meet the operating features requirements in accordance with NFPA 101. This was evidenced by: 1. Fire drills were not at varied times (1st Shift and 2nd Shift during 1st and 2nd Quarters) 2. Missing fire drills for 2nd Shift/1st Quarter. NFPA 101 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the operating procedures requirements in accordance with NFPA 101. This was evidenced by: 1. Missing written smoking policy. 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Based on field observations, it was determined that the facility failed to maintain oxygen equipment and operating procedures according to NFPA 101 and NFPA 99 (2012). This was evidenced by the following: 1. Main piped medical gas room had stored combustible materials. 2. Oxygen bottles were not secured from tipping in main piped medical gas room. NFPA 99 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:(1) Minimum distance of 6.1 m (20 ft)(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hourNFPA 99 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.(3) Cylinders shall be protected from tampering by unauthorized individuals.(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.(5) Safety relief devices in valves or cylinders shall not be tampered with.(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.(8) Sparks and flame shall be kept away from cylinders.(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

During documentation review, it was determined that the facility failed to maintain oxygen equipment and operating procedures according to NFPA 101 and NFPA 99 (2012). This was evidenced by the following: 1. Missing annual piped medical gas alarm inspection/testing/maintenance report. NFPA 99 5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:(1) They shall be inspected annually.(2) They shall be maintained by a qualified representative of the equipment owner.(3) A record of the annual inspection shall be available for review by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to meet the requirements for fire drills in accordance with NFPA 101 (2012) and NFPA 110 (2010). This was evidenced by the following:1. Missing monthly diesel generator inspection/testing/maintenance reports. 2. Generator missing back up emergency lighting. NFPA 110 8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 110 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. Thisrequirement shall not apply to units located outdoors in en-closures that do not include walk-in access. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Based on field observations, it was determined that the facility failed to maintain oxygen equipment and operating procedures according to NFPA 101 and NFPA 99 (2012). This was evidenced by the following: 1. Full and empty oxygen containers in Winter Park Wing transfill room were not separated. NFPA 99 11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

Based on field observations, it was determined that the facility failed to maintain oxygen equipment and operating procedures according to NFPA 101 and NFPA 99 (2012). This was evidenced by the following: 1. Missing Personal Protective Equipment in Winter Park Wing transfill room. 2. Staff were observed transfilling oxygen containers without using proper Personal Protective Equipment. NFPA 99 11.5.2.3 Transfilling Liquid Oxygen. Transfilling of liquid oxygen shall comply with 11.5.2.3.1 or 11.5.2.3.2, as applicable. 11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa(50 psi) shall include the following:(1) A designated area separated from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction.(2) The area is mechanically ventilated, is sprinklered, and has ceramic or concrete flooring.(3) The area is posted with signs indicating that transfilling is occurring and that smoking in the immediate area is not permitted.(4) The individual transfilling the container(s) has been properly trained in the transfilling procedures. 11.5.2.3.2 Transfilling to liquid oxygen portable containers at 344.74 kPa (50 psi) and under shall include the following:(1) The area is well ventilated and has noncombustible flooring.(2) The area is posted with signs indicating that smoking in the area is not permitted.(3) The individual transfilling the liquid oxygen portable container has been properly trained in the transfilling procedure.(4) The guidelines of CGA P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, are met. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Executive Director and Director of Maintenance during the exit conference.

A recertification survey with complaints #CO31539 and #CO31602 was completed from 4/10/23 to 4/13/23. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/10/23 to 4/13/23. Three deficiencies were cited.

Based on record review and interview, the facility failed to develop and maintain an up to date emergency preparedness training and testing program that was based on the facility's emergency preparedness (EP) program plan, annual risk assessment, facility EP policies and procedures, and the communication plan that was delivered to all staff annually. Specifically, the facility failed to:-Develop a written training and testing program based on the facility's updated EP program;-Provide annual education and instruction to all facility staff, contractors, and facility volunteers to ensure all individuals are aware of the facility's EP program; and,-Ensure EP training included, at a minimum, training related to the facility's EP policies and procedures. Findings include: I. Facility plan The emergency preparedness (EP) program was provided by the nursing home administrator (NHA) on 4/12/23 at 11:30 a.m. The facility did not have a written training and testing program with provisions to provide all staff, contractors, and facility volunteers received annual EP training specific to the facility's updated EP program. The Facility's Emergency preparedness policy revised 2/23/23, read in pertinent part: "The facility must comply with all applicable Federal, State and local emergency preparedness requirements. The facilities must establish and maintain and emergency preparedness program that meets the following requirements. The emergency preparedness program must include, but not be limited to, the elements below:"Training and testing. The (facility) must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(I) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually." -The above policy statement was an excerpt from the Federal regulation and not documentation of a policy and procedure for training employees about expectations and response to the facility's EP program. II. Staff interviews The maintenance director (MTD) was interviewed on 4/13/23 at 1:30 p.m. The MTD said the facility had a safety committee through quality assurance and performance improvement (QAP) meting were they discussed staff training needs and provided the above referenced document titled Emergency Preparedness Chapter 1: Emergency Management Plan. The MTD was not able to provide a policy that documented a procedure for how facility staff, contracted employees and volunteers would be trained on the specific procedure of the facility's EP program.

Based on record review and interview, the facility failed to provide all staff, contracted staff and volunteers received initial and annual emergency preparedness training and testing of the facility's EP program. Specifically, the facility failed to:-Provide initial and annual education and instruction to staff, contractors, and facility volunteers to ensure all individuals are aware of the facility's EP program;-Ensure the EP training encompasses the facility expected response to the annual risk and all hazards risk assessment;-Ensure EP training included, at a minimum, training related to the facility's EP policies and procedures; and,-Ensure staff were knowledgeable of the facility's EP program. Findings include: I. Facility plan The emergency preparedness (EP) program manual was provided by the nursing home administrator (NHA) on 4/12/23 at 11:30 a.m. The manual did not include documentation proof to show that all facility staff, contracted employees and volunteers were provided annual training on the updated policy and procedures specific to the staff's expected response in the event that the facility faced an emergency situation. II. Staff interviewsThe maintenance director (MTD) was interviewed on 4/13/23 at 1:30 p.m. The MTD acknowledged facility staff were assigned to take computerized training on emergency preparedness and fire drill response on an annual basis but the assigned training were not specific to the facility EP program policy and procedures for emergency situations. Additionally, staff participated in regularly scheduled fire drills; however, the facility did not conduct any drills to train staff in response to any of the other potential disaster situations as identified in the annual facility-based and community-based risk assessment.

Based on record review and interview, the facility failed to conduct two exercises annually to test the facility's emergency plan and maintain documentation of the facility's response to all drills, tabletop exercises, and emergency events, and then revise the facility's emergency plan, as needed. Specifically, the facility failed to conduct and document two full-scale exercises, individual facility based functional exercises, mock disaster drill, tabletop exercise or workshop in the last year (12-month cycle). Findings include: I. Testing participation The emergency preparedness (EP) program was provided by the nursing home administrator (NHA) on 4/12/23 at 11:30 a.m. The manual contained a document referencing the facility experienced an actual winter storm event on 1/17/23, where the facility had to enact the facility's EP program. Following the event, the facility assessed the emergency situation. -The facility was unable to provide documented proof of a second emergency activity had been conducted in the last 12 months, where the facility either enacted the facility EP program due to an actual emergency event or tested and assessed the EP program based on a mock drill or table top event. II. Staff interviews The maintenance director (MTD) was interviewed on 4/13/23 at 1:30 p.m. The MTD said he only had documentation of the one winter storm (actually occurring) event being reviewed as a test of the facility's test and assessment and response to the policy and procedures of the facility's EP program.

Based on observations, record review and interviews, the facility failed to promote self-determination for two (#36 and #205) of six residents reviewed for preferences and choices of 28 sample residents. Specifically, the facility failed to honor the resident preferences for bathing and implement bathing care based on the resident self-determined preferences. Identified resident preferences included:-Being able to take a bath when requested (Resident #36 and #205); and,-Being asked about daily routine and being able to have a plan for staff to follow particularly for bathing needs (Resident #36 and #205). Findings include:I. Facility policyThe Person Centered Care Planning policy, dated 8/16/22, was provided by the nursing home administrator (NHA) on 4/13/23 at 6:30 p.m. It read in pertinent part: "Policy: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs."The comprehensive care plan must describe the following: In consultation with the resident and the resident's representative(s)­: The resident's goals for admission and desired outcomes."The care plan will be developed and implemented to ensure consistency with implementation across all shifts."II. Resident #36A. Resident statusResident #36, over the age of 65, was admitted on 2/19/21. According to the April 2023 computerized physician's orders (CPO) diagnoses included hemiplegia and hemiparesis (loss of strength or paralysis on one side of the body) following cerebrovascular disease affecting the right dominant side, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). According to the 2/20/23 minimum data set (MDS) assessment, the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15; no mood or behavioral symptoms were documented. The resident needed extensive assistance from two staff for activities of daily living (ADL) such as personal hygiene and bathing due to weakness, limited range of motion, poor coordination, poor balance, visual impairment, and pain, and the use of a sit to stand device for transfers between surfaces. B. Resident interviewResident #36 was interviewed on 4/11/23 at 1:02 p.m. Resident #36 said it gets very cold in the shower and she would much rather take a hot bath than a shower; but the staff would not honor that request. Resident #36 said none of the staff she asked would let her have a tub bath when requested. C. Record reviewThe comprehensive care plan revised on 3/29/23, documented a care focus for bathing/showering preferences. Interventions included one staff to provide bathing/showering assistance on Monday evenings, to prepare the shower with a warming light, keep the bathroom door closed during showers and keep the resident warm prior to the resident getting into the shower. -The care plan did not document the resident preference for a tub bath. III. Resident #205A. Resident statusResident #205, age 82, was admitted on 3/31/23. According to the April 2023 CPO diagnoses included chronic respiratory failure with hypoxia, heart failure and depression. The 4/6/23 MDS assessment was not complete, but did reveal in part that the resident had intact cognitive ability with a BIMS score of 15 out of 15; no mood or behavioral symptoms were documented. The resident required limited assistance by one person for personal hygiene but the MDS document had not yet revealed details of the resident's bathing needs. B. Resident interviewResident #205 was interviewed on 4/11/23 at 10:26 a.m. Resident #205 said he has only had one shower since admission 3/31/23; and had asked staff about using the spa tub as he would like to have a tub bath instead of a shower at least occasionally but he was told by the staff that no one uses the bathtub in the spa. C. Record reviewThe comprehensive care plan initiated 4/6/23 documented a care focus for admission and depression needs. Interventions included "Provide opportunities for the resident and family to participate in care."-Neither the baseline care plan or the comprehensive care plan address the resident's daily living preferences. IV. Staff InterviewsCertified nurse aide (CNA) #1 was interviewed on 4/13/23 3:14 p.m.. CNA #1 said when each resident was admitted they were asked if they preferred a shower or a tub bath and preferred days of bathing; this information was uses to develop the resident bathing plan and used on bathing days; staff did not ask the residents each time if they would like a bath or shower each bathing day, instead staff followed exactly what was care planned. CNA #1 said residents could refuse their bath or showers if they did not want to bathe. CNA #1 said a bathtub is available in the spa on each unit if that was the resident's care plan choice. The social services director (SSD) was interviewed on 4/13/23 at 10:16 a.m. The SSD said residents had the right to determine daily preferences and change their minds about daily routine.

Based on observations, record review and interviews, the facility failed to provide activities that meet the interests and choices of residents for three (#32, #15 and #205) of four out of 28 sample residents. Specifically, the facility failed to to offer and provide personalized activity programs for Resident #32, #15 and #205. Findings include:I. Facility policy and procedureThe Therapeutic Activities Program policy and procedure, last revised 4/1/22, was provided by the director of nursing (DON) on 4/13/23. It read in pertinent part,"The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activity's component of the comprehensive assessment. Directing the activity program includes scheduling of activities, both individual and groups, implementing and/or delegating the implementation of the programs, monitoring the response and/or reviewing/evaluating the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary. The facility should implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning)." II. Resident #32A. Resident statusResident #32, age 78, was admitted on 8/15/22. According to the April 2023 computerized physician orders (CPO) diagnoses included anxiety disorder, insomnia and major depressive disorder. According to the 2/15/23 minimum data set (MDS) assessment, the resident had intact cognition as evidenced by a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with one person physical assistance for: bed mobility, transfers, walking and toilet use. Additionally, the resident required supervision assistance with one person physical assistance for personal hygiene, eating, and dressing. The resident was not having any behaviors or refusal of care. The MDS assessment documented that the resident said it was very important to engage in his favorite activities. B. Resident interviewResident #32 was interviewed on 4/12/23 at 9:22 a.m. Resident #32 said he would prefer to participate in activities such as playing cards and games; or get together with like minded individuals with similar cognitive ability who could have a conversation and socialize with her. The resident was not interested in most group activities hosted by the facility because the only options were bingo and television (TV), which made him feel warehoused. The resident was unaware of what options he had at the facility to find like minded peers and said none of the staff have offered him alternatives or made any attempts to meet his activities needs. C. ObservationsOn 4/12/23 from 8:43 a.m. until 12:00 p.m., Resident #32 was observed continuously. The resident was in his room watching television the entire time and no staff entered the resident room during this time. -Neither group or independent activities were offered to Resident #32 between 8:43 a.m. until 12:00 p.m., however, the activities schedule revealed a group activity of chapel was to take place on 4/12/22 at 11:00 a.m. D. Record reviewThe comprehensive care plan, last revised on 12/12/22, documented Resident #32 had little or no activity involvement in group activities. The resident continued to decline daily invitations to participate. Resident #32 preferred activities were: watching TV in his room, live music and chapel. The activities evaluation dated 8/16/22 revealed Resident #32 enjoyed playing cards, interacting with small groups of people and reading. -The care plan failed to incorporate individualized preferences as identified in the activities assessment. The resident confirmed in an interview that his activities preferences more accurately reflected the activities evaluation and the comprehensive care plan was not individualized to the resident preferred activities choices. The activity participation flow sheet for the month of April 2023 revealed Resident #32 refused all activities offered including activities held on 4/12/23, which was in contrast with observations (see above) as the resident was not offered the opportunity to accept or refuse attendance at the morning activity. Additionally, the resident was not given the opportunity to express his desire for an alternative activity. E. Staff interviews CNA #4 was interviewed on 4/13/23 at 11:41 a.m. The CNA said Resident #32 is independent and could make his needs known. The resident spent all day in his room watching television. The resident did not participate in activities because he did not enjoy the activities at the facility. CNA #4 said the resident watched TV or wanted to be in his room and get into his chair. CNA #4 said every Monday activities were not offered because the activity staff were busy charting, occasionally some Fridays, activities were not offered because activity staff were busy charting. The activities director (AD) was interviewed on 4/13/23 at 11:53 a.m. The AD said Resident #32 had intermittently participated in activities. The resident continued to be invited daily to encourage the resident to participate in activities. The facility provided and ordered reading material for the resident. The AD said Resident #32 had his own TV with on demand station selections. Resident #32 enjoyed connecting in a spiritual sense with things, book club, and acknowledged he seemed to want to connect more intellectually with people and play bridge. The AD would expect the resident's care plan to be individualized to the resident's preferred activities. If a resident refused activities the activity staff would re-approach the resident for a later offering. Activities staff should offer the resident an independent or alternative activity when the resident failed to show interest in group activities. If a resident refused activities on a habitual basis, the activity team would assess the resident daily and update the care plan to meet the resident's individual needs. The AD would expect residents to be offered individual interventions, daily encouragement, and to offer residents to do something independently. Activity staff should attempt to offer activities 45 minutes prior to group starting. The AD said Resident #32 was offered activities on 4/12/22 as evidenced by the documented refusal on the activity participation flow sheet. -The documentation the AD referred to was in contrast with the continuous observation of Resident #32 (see above). The AD acknowledged that the resident's care plan was not individualized. The resident's care plan failed to incorporate playing cards, intellectual development courses, reading and playing bridge. III. Resident #15A. Resident statusResident #15, over the age of 90, was admitted on 5/22/2020. According to the April 2023 CPO diagnoses included inclusion body myositis (chronic, progressive muscle inflammation accompanied by muscle weakness), Bell's palsy (paralysis or weakness on one side of the face) and congestive heart failure. The 2/9/23 MDS assessment documented the resident had intact cognitive ability with a brief interview for mental status (BIMS) score of 15 out of 15; no mood or behavioral symptoms were documented. The 5/16/22 annual MDS assessment interview for daily preferences documented the resident said it was very important to be able to choose to have books, newspapers and magazines available to read; music to listen to; keep up with the news; do things with groups of people; and do favorite activities. B. ObservationsOn 4/11/23 from 10:30 a.m to 2:30 p.m., observations revealed:-At 10:30 a.m. Resident #15 was sitting in her wheelchair in her room with the television on.-At 11:10 a.m. the resident remained in her room without change.-At 2:30 p.m. the resident was in her bed with the television on. -No staff approached the resident to offer any type of activity either independent activity or attendance to attend a scheduled group activity. On 4/12/23 from 10:25 a.m. to 2:21 p.m. the resident was up in a wheelchair with no activity provided except independent television watching. No staff approached the resident to offer any type of activity either independent activity or attendance to attend a scheduled group activity. On 4/13/23 form 9:53 a.m. to 2:17 p.m. the resident was up in a wheelchair with no activity provided except independent television watching. No staff approached the resident to offer any type of activity either independent activity or attendance to attend a scheduled group activity. C. Resident interviewResident #15 was interviewed on 4/11/23 at 11:44 a.m. Resident #15 said that she would like to participate in more activities but the activities that she would have been interested in did not occur on most days until 2:00 p.m. Most days the resident liked to go back to bed between 2:00 p.m. and 2:30 p.m. due to her health condition. The resident said she would really like it if the activities department would schedule more activities in the morning, so she could participate and she would really enjoy playing cards. D. Record reviewThe resident's comprehensive care plan, revised on 1/13/23, revealed Resident #15 enjoyed watching TV (television), doing word search puzzles, and reading. The care focus goal documented the resident would engage in self-directed activities daily. The interventions included: staff would invite, encourage and assist the resident to activities of assessed preference, with an emphasis on crafts, bingo, other games, trivia, movies and gardening. E. Staff InterviewLicensed practical nurse (LPN) #3 was interviewed on 4/13/23 at 3:40 p.m. LPN #3 said Resident #15 liked to go to bed very early in the afternoon, so the resident did not attend many group activities. LPN #3 was not aware that the resident would like to play cards. IV. Resident #205A. Resident statusResident #205, age 82, was admitted on 3/31/23. According to the April 2023 CPO diagnoses included chronic respiratory failure with hypoxia, heart failure and depression. According to the 4/6/23 MDS assessment, the resident had intact cognitive ability with a BIMS score of 15 out of 15; no mood or behavioral symptoms were documented. The resident had an inability to perform activities of daily living (ADL) without significant physical assistance. The 4/8/23 activity preferences section documented the resident enjoyed reading, small group activities, and visits from friends and family. B. ObservationsOn 4/11/23 at 10:23 a.m. Resident #205 was in his room with the television on and he was looking off towards the window and was unfocused on the television. On 4/12/23 from 1:00 p.m. to 4:48 p.m. Resident #205 was sitting in his room with the television on with no other options for activity. No staff approached the resident to offer any type of activity either independent activity or attendance to attend a scheduled group activity. On 4/13/23 from 10:05 a.m. to 11:00 a.m. Resident #205 was sitting in his room with the television on with no other options for activity. No staff approached the resident to offer any type of activity either independent activity or attendance to attend a scheduled group activity. C. Resident interviewResident #205 was interviewed on 4/11/23 at 10:24 a.m. Resident #205 said that he had not chosen to participate in activities because he would prefer to interact with people who were closer in age and cognition. The resident said staff had suggested the names of three other residents he could go and meet but did not offer to set up any introductions with the other residents. "I guess I would have to go and find these people on my own?" " I don't really feel comfortable going to a strangers' room on my own." Resident #205 said he would like to go to the dining room to eat his meals but he does not want to sit by himself and did not know who or if anyone in the dining room would be like minded and able to have a conversation with him. Resident #205 said he would like to play cards with other residents but was told no one else in the facility would be interested in card games. -However, in a previous interview with Resident #15 the resident said she was interested in a group to play cards (see Resident #15's interview above). D. Record reviewThe comprehensive care plan initiated on 4/6/23, documented a care focus management of depression symptoms related to adjustment to being newly admitted to the facility for previously living in a private home. Interventions included "Provide opportunities for the resident to participate in care."E. Staff InterviewLPN #3 was interviewed on 4/13/23 at 3:40 p.m. LPN #3 said the nursing staff gave Resident #205 the name of a few residents they felt would be appropriate for him to interact with. However, they did not set up the introductions and were not aware that he had not introduced himself to anyone yet.

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. Specifically, the facility failed to:-Maintain how water temperatures coming out of the tap and showers in resident care areas for resident bathing and grooming tasks at a safe water temperature to avoid scalding and residents from sustained burns to the body; and -Ensure the Resident #36 was being assisted with the current methods of transfer assistance as documented in the resident's care plan. Findings include:I. Hot temperaturesA. Professional referenceAccording to the U.S. Consumer Product Safety Commission (CPSC) Avoiding Tap Water Scalds, Document #5098, retrieved from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cpsc.gov/s3fs-public/5098-Tap-Water-Scalds.pdf on 4/24/23: "All users are urged to lower water heaters to 120 degrees Fahrenheit. Most adults will suffer third-degree burns if exposed to 150-degree water for two seconds. Burns will also occur with a six-second exposure to 140-degree water or with a thirty second exposure to 130-degree water. Even if the temperature is 120 degrees; a five-minute exposure could result in third-degree burns."B. Facility policyThe Water Temperature Inspection policy, last reviewed 12/19/22, was provided by the nursing home administrator (NHA) on 4/13/23 at 3:25 p.m. It read in pertinent part, "Policy: The facility monitors all water temperatures on a weekly basis or more often, if needed. The facility will ensure the residents' environment remains as free from accident hazards as possible. "Procedure: Shower/faucet temperatures:1. Temperatures will be taken weekly from one resident's room on each wing on a rotating basis. To ensure safety, include a room close to the hot water tank and a room in which the residents are able to use the sink independently. 2. Satisfactory temperature range is maintained per state regulations."C. ObservationsWater temperatures from random rooms were checked on 4/10/23 the findings revealed:-At 5:43 p.m. the water temperature of room 107 was measured and found to be 136.3 degrees F.-At 5:45 p.m. the water temperature of room 106 was measured and found to be 136.4 degrees F.-At 5:47 p.m. the water temperature of room 135 was measured and found to be 135.6 degrees F.-At 5:49 p.m. the water temperature of the sink in the common area was measured and found to 138.6 degrees F.-At 5:51 p.m. the water temperature of room 203 was measured and found to be 122.1 degrees F.-At 6:33 p.m. the maintenance director (MTD) was observed adjusting the boiler room water holding tank temperature at the mixing valve. The MTD said the holding tank temperature needed to be adjusted for maintaining proper temperatures at the tap in the resident rooms. In order to do so he was using a screwdriver to make an adjustment of the mixing valve to allow more cold water into the system, which would lower the temperatures of the water in resident room faucets.-At 6:37 p.m. water temperatures at the resident's sink and shower in the same rooms as tested above were measured again with the MTD to confirm the findings. The water at the tap in resident room 135 was measured at 134.1 degrees F, the common area sink was measured at 134 degrees F, room 107 was measured at 133.1 degrees F and room 106 was measured at 132 degrees F.-The water temperatures were lowered but still were found to be unsafe for resident use. The MTD acknowledged it would take time to lower the temperatures to safe bathing temperatures and said he would continue to monitor the temperature until the water in the resident rooms tested at a safe level for resident use. D. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 4/10/23 at 6:20 p.m. CNA #1 said she tested the water temperature on her forearm and then instructed the residents to test the temperature with their arm or hand before she sprayed the water on their body. CNA #1 said there were a couple of residents that required minimal assistance but even in those situations the CNA adjusted the water temperature for the resident and remained in the room with the residents during their shower in case the resident needed any assistance. CNA #1 said most residents needed full assistance with bathing. The MTD and NHA were interviewed on 4/10/23 at 6:45 p.m. The MTD said he would remain on site this evening until the water temperature were safe for resident use and would return in the morning at 5:30 a.m. to conduct another test to the resident water to ensure the water was safe for the resident us as they started to get up in the morning to bath and dress for the day. The MTD said the facility had been having problems with one of the hot water holding tanks maintaining proper temperature for resident use. Additionally, the mixing valve which controlled the amount of hot and cold water flowing through the tank was not functioning properly; the holding tank was leaking water and black sludge was coming from the piping; and the plumbing system had a heavy build up calcification due to hard water. After several attempts by the MTD to maintain the holding temperature for safe hot water temperatures for resident use, and not being able to obtain and maintain safe bathing temperature (of 100 degrees F, see professional references above). The facility contracted a plumber to assess repairs and schedule a time for the system to be repaired. The MTD said the plumber scheduled a repair session but there was a 12 week wait time to get the repairs completed. Repairs were scheduled to occur 4/11/23, however when this survey started the repairs were delayed for one week, due to the facility not wanting the survey and plumbing repairs to be occurring simultaneously. The MTD said while waiting for the scheduled repairs to occur he was conducting weekly water tests since February 2023 so he could make necessary adjustments to keep the hot water from being too cold. Since the discovery of the excessive hot water temperature in resident rooms and until the contractor was available to complete the needed plumbing work the MTD planed to check water temperatures twice daily and adjust the mixing valve as indicated by the temperature checks to ensure none exceed 120 degrees F at the tap and have the holding tanks set between 150 and 170 degrees F.-The MTD was reminded that a person could sustain a burn from water coming out to the tap at 120 degrees F and that safe bathing temperatures were 100 degrees F (referring to professional reference above). The NHA was interviewed on 4/10/23 at 7:00 p.m. The NHA said as a precaution the evening and night time staff would be provided a thermometer so they could test the water temperatures if any resident wanted to take an evening night time shower, but was sure that no resident was scheduled to take a shower this evening. The MTD was required to staff on site until the hot water temperature lowered to a safe level for resident use and would be back at 5:30 a.m. to test the water temperatures in resident rooms to make sure the temperature did not rise overnight. It was unlikely for the temperatures to rise overnight because the problem was that the hot water holding tank was not maintaining temperature and had to be adjusted up to maintain hot water for resident showering and bathing. The NHA said water temperature would continue to be checked every shift to ensure safe water temperatures until the plumbing repairs were completed. Additionally, the NHA agreed that staff would receive education on safe water temperatures for resident use and education on how to check the temperature of the water in the showers. The MTD was interviewed on 4/12/23 at 10:12 a.m. The MTD said he contacted the contracted plumbing company and was able to reschedule them to complete a portion of the repair project. The plumber was scheduled to arrive later in the afternoon on 4/13/23 to repair the mixing valve so the hot water would be mixing to a safe temperature for resident use. II. Improper transferA. Resident statusResident #36, age over 65, was admitted on 2/19/21. According to the April 2023 computerized physician's orders (CPO) diagnoses included hemiplegia and hemiparesis (loss of strength or paralysis on one side of the body) following cerebrovascular disease affecting the right dominant side, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). According to the 2/20/23 minimum data set (MDS) assessment, the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15; no mood or behavioral symptoms were documented. The resident needed assistance from two staff to move between surfaces and the use of a sit to stand lift for transfers. B. Resident interviewResident #36 was interviewed on 4/13/23 at 11:05 a.m. Resident #36 said that she used a slide board for transfers between surfaces in the morning and used a sit to stand mechanical lift for transfers in the evening when getting into bed. Resident #36 said she did sustain injuries on both of her upper arms and left index finger when an agency certified nurse aide (CNA) transferred her using the bear hugger technique a few weeks ago. C. Transfer incident on 3/12/23The facility investigation dated 3/13/23 revealed on 3/12/23 at 10:00 p.m. Resident #36 was transferred from her wheelchair to her bed using a bear hugging technique. As described, the CNA assigned to provide care to the resident used an unprescribed transfer technique where the CNA placed her arm s under the resident's shoulders and wrapped her arms tightly around the resident's body and lifted the resident up from the wheelchair pivoting the resident's body from the seat of the wheelchair to a seated position onto the bed. The resident complained of pain during the transfer; however, the CNA did not stop the transfer process or call the floor nurse for assistance. Resident #36 said the CNA responded to her yelling out in pain by saying "you just think it hurts." The nurse on duty was not aware the resident had concerns and did not notice any bruises or redness on the resident's body. Resident #36 told investigators that the CNA on duty did not follow her directions when she told the CNA to provide a slide board for the transfer; instead the CNA responded by saying the slidboard was not needed and proceeded to "wrap her arms around me and squeezed so tightly that I screamed in pain." The resident said the CNA practically threw her on the bed and she did not want that CNA to take care of her anymore because he CNA did not listen to transfer instructions. The social services (SS) staff met with the resident on 3/13/23 at 9:15 a.m. The resident told the SS staff the night of the transfer in question she pointed out the transfer instruction that were posted on the closet door for the agency CNA to follow in order to perform the transfer from wheelchair to bed; the CNA told said she did not know how to use either transfer method posted (slide board method or the sit to stand mechanical lift) and she was not going to use either method. The CNA proceeded to a hug type transfer method to pull the resident up off the bed. The resident said she screamed in pain and the CNA disregarded her complaints of pain. The agency CNA (alleged assailant) was interviewed and acknowledged she did not follow the prescribed transfer method and the resident had complained of pain during the transfer. Other residents were interviewed during the course of the investigation to determine if he had a similar experience with staff. The male resident said some staff were very distant or business-like. There had been a couple of CNAs that were difficult to work with; those staff got upset if a resident disagreed with what they were saying. Another male resident said he had to give new CNAs some guidance with transfering assistance and felt "a sense of community was missing here." At the time of the investigation the resident's care plan documented the resident's transfer interventions included: transfer using a sit to stand lift only, due to a history of falling. As a result of the facility investigation the facility provided education for the CNAs to notify the nurse immediately with the resident complaint of pain. The CNA was terminated after the incident on 3/12/23. D. Record reviewThe comprehensive care plan, created 2/20/23, revealed the resident had activities of daily living (ADL) and self-care deficits. The care plan focus documented the resident required assistance by two staff to move between surfaces and the use of a sit to stand mechanical lift for transfers. E. Staff interviewsCNA #2 was interviewed on 4/13/23 at 11:11 a.m. CNA #2 said when she got Resident #36 up this morning she did not use a sit to stand device, instead she transferred the resident by herself using a slide board and a gait belt and did not ask for or receive assistance from any other staff members while transferring the resident. CNA #2 acknowledged she was aware of the transfer instruction posted in the resident's room which instructed staff to use a sit to stand device on all transfers; and still did not follow the posted transfer instructions.-CNA #2 made an independent decision to perform a transfer that was not the prescribed care plan intervention. The director of nursing (DON) was interviewed on 4/13/23 at 2:09 p.m. The DON said each resident was evaluated on admission and with a change of condition to determine their strength and ability to move safely in the facility. Nursing staff were able to refer to a resident's physical and occupational therapy notes for additional guidance on transferring recommendations. Transfer recommendations were documented in the resident's care plan and bedside Kardex care plan resource for CNA. The DON said staff were to refer to the resident care plan for reference prior to initiating care. The DON said safe procedures for transfer training and education was to all clinical staff upon hire and repeated annually. The nursing staff recently received annual transfer training this past February 2023. Additionally, staff would be provided resident specific transfer education if a resident had changes to their transfer ability; that information was provided during the shift change huddle that the entire interdisciplinary team (IDT) team attended. Agency staff were expected to walk each room with a seasoned facility CNA and receive a detailed report of expectations and care plan interventions for each resident. The DON said adherence to the resident's care plan was expected as a CNA was not permitted to determine how to transfer residents and only the nurses were allowed to downgrade a resident's transfer status after assessment. If a resident needed to be upgraded there would need to be a therapy assessment to reevaluate and determine the most appropriate method of transfer. The physical therapist (PT) was interviewed on 4/13/23 at 3:34 p.m. The PT said resident #36 was working with a therapist to strengthen her ability to perform safe transfers without the sit to stand mechanical lift. The slide board transfer method ring had not been determined safe for the CNAs to provide, because the resident had the tendency to become fatigued and could fall if not monitored and supported properly during the transfer. The CNA staff were to provide Resident #36 transfer assistance with two staff present, the sit to stand mechanical lift, a gait belt and never a stand pivot or slide board transfer. This was what was in the resident's care plan. These instructions were posted in the resident's room on the closet door for staff to read and follow. The PT said the slide board was removed from resident's room so staff would not be tempted to use it when assisting Resident #36 with transfers.

Based on record review and interviews, the facility failed to ensure facility nurses and certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies prior to providing skilled services as ordered by the physician for three out of three nurses reviewed for competencies. Findings include: I. Facility acuity On 4/12/23, per the facility census and condition the facility had a census of 56 total residents; of those residents:-54 residents needed assistance of one to two staff to transfer from surface to surface;-42 residents needed assistance of one to two staff with bathing and an additional 11 residents were totally dependent on staff for bathing;-54 residents needed assistance of one to two staff with dressing;-52 residents needed assistance of one to two staff with use of the toilet and an additional two residents were totally dependent on staff for use of the toilet; and,-49 residents needed assistance from one to two staff with eating meals. II. Competency records The nursing facility held a competency fair on 12/20/22 to test the nursing staff skills for caring for residents. The training record documented nursing staff in attendance but did not include an accompanying check to show which tasks the nursing staff had successfully completed by return demonstration or if any of the nursing staff needed additional training in any of the areas tested. Training records also revealed: -Twenty-two facility hired certified nurse aides (CNAs) were reviewed for competencies; nine CNAs failed to participate in the skills fair. The facility did not have any additional records to show if the nine CNAs not in attendance participated in a skills check for competencies by return demonstration for direct care assistance within the scope of practice for a CNA, in the past 12 months of employment. -Fifteen nurses were reviewed for competencies, nine registered nurses (RNs) and six licensed practical nurses (LPNs); five nurses failed to participate in the skills fair. The facility did not have any additional records to show if the five nurses not in attendance participated in a skills check for competencies by return demonstration competencies performed by the nurses providing direct care to the residents as ordered by the provider and identified in the plan, in the past 12 months of employment. III. Interview The staff development coordinator (SDC) was interviewed on 4/13/23 at 2:37 p.m. The SDC said the facility had not held a skill fair to test the performance of nursing staff since December 2022; participation at the December 2022 skills fair had only approximately 80 percent of the nursing staff in attendance. The facility recognized that not all staff participated in the last skills fair and planned to hold a skills fair to test staff competence with return demonstration of nursing skills in the next month. The director of nurses (DON) was interviewed on 4/12/23 at 6:01 p.m. The DON acknowledged not all nursing staff had participated in an annual skills competence check within the last 12 months of employment and the facility planned to hold a skills fair to test nursing competencies for scope of practice in the coming months.

Based on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for one (#36) of five residents out of 28 sample residents. Specifically, the facility failed to ensure Resident #36 drug regimen must be free from unnecessary drugs, in excessive doses where there was potential for adverse consequences which indicate s the dose should be reduced or discontinued; and for excessive duration without clinical justification. Findings include:I. Facility policyA request was made to the director of nursing (DON) for the facility's policy on monthly pharmacy review or resident medication and for responding to pharmacy recommendation was made on 4/13/23; however the policy was not provided by the end of the survey. II. Resident #36A. Resident statusResident #36, over the age of 65, was admitted on 2/19/21. According to the April 2023 computerized physician's orders (CPO) diagnoses included hemiplegia and hemiparesis (loss of strength or paralysis on one side of the body) following cerebrovascular disease affecting the right dominant side, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). According to the 2/20/23 minimum data set (MDS) assessment, the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15; no mood or behavioral symptoms were documented. The resident needed assistance from two staff to move between surfaces and the use of a sit to stand lift for transfers. B. Record reviewAccording to the April 2023 CPO, the resident had the following orders:-Omeprazole 40 milligrams (mg), give by mouth once per day, as needed for GERD (gastroesophageal reflux disease), start date 8/5/22;-Guaifenesin liquid 100mg/5ml ( milliliters) give 10 ml,by mouth, every six hour as needed; for chronic cough guaifenesin (10ml Dose), start date 2/19/21; -Tessalon Perles capsule 100 mg, give one capsule by mouth, every eight hours, as needed, for for chronic cough, start date 5/2./21; and,-Zofran 4 mg disintegrating (crush and dissolve in water) given by mouth every six hours, , as needed for nausea and vomiting, start date 1/5/22. Monthly pharmacy review documentation dated 11/24/22, 12/27/22, 1/24/23, and 3/25/23 revealed the pharmacy had made repeated recommended since 11/24/22 that the dosage of prescribed omeprazole be reduced from 40 mg to 20 mg to reduce the risk of the resident developing clostridium difficile or C. difficile (a germ bacterium that causes diarrhea and colitis, an inflammation of the colon) infections, bone loss and fractures. The pharmacy recommendation read in part: "Rationale for Recommendation: Long-term PPI (proton pump inhibitors) use (greater than 8 weeks) is associated with increased risk of C. difficile infections, bone loss and fractures. References: 1) Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. STEADI - Stopping elderly accidents, deaths & injuries. 2019 Sep. 2) American Geriatrics Society 2019 updated AGS Beers Criteria."There was no physician response to the recommendation that had been made consistently since 11/24/23 and there were no changes in the resident CPO order for omeprazole per the pharmacy recommendations, as of 4/12/23. Monthly pharmacy review documentation dated dated 9/26/22, 10/24/22, 11/24/22, and 3/25/23 revealed the pharmacy had made repeated recommendation since 9/26/22 that prescribed medication guaifenesin, tessalon perles, and zofran be discontinued from the residents orders due to lack of use over the past 120 days. At the time of survey (4/10/13-4/13/13), none of these recommendations had been followed and the physician had not responded to the pharmacy recommendations. III.. Staff interviewThe director of nursing (DON) was interviewed on 4/13/23 at 2:09 p.m. The DON said she was new to the facility. When the pharmacist sends prescribing recommendations to the facility it is the DON's responsibility to provide the recommendation to the physician and ensure the physician's response to agree, disagree, or provide other prescribing orders were documented in the resident record and followed immediately. If the provider did not respond in a timely manner the DON would provide the pharmacy request to the facility medical director for review and a decision on the recommendation(s).

Based on observations and interviews the facility failed to ensure two out of three medication refrigerators stored and secured drugs and biologicals in accordance with accepted professional standards. Specifically, the facility failed to:-Ensure controlled medications were in a double locked storage area where the locked controlled substance medication containment unit was secured to the refrigerator;-Ensure each medication cart was locked when nurse was not at the cart;-Ensure alcohol for resident consumption was not stored in the same refrigerator as resident medications; and,-Ensure controlled medications for disposal were kept in a double locked area until disposal. Findings include:I. Facility policy and procedureThe Storage and Expiration Dating of Medications policy and procedure, last revised 7/21/22, was provided by the director of nursing (DON) on 4/13/23 at 4:35 p.m. It read in pertinent part; "Facility should ensure that only authorized Facility staff, as defined by Facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with Applicable Law."Facility should store Schedule II - V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device-Store all drugs and biologicals in locked compartments, including the storage of Schedule 11-V medications in separately locked, permanently affixed compartments, -Facility should ensure that Schedule II -V controlled substances are only accessible to licensed nursing, Pharmacy , and medical personnel designated by Facility."Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items."Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored."III. Observations and interviewsOn 4/10/23 at 2:33 p.m., a medication cart on the 200 hall was observed to be unlocked and the nurse was not within direct line of sight with the cart for several minutes. On 4/12/23 at 8:52 a.m. the medication room on the 200 unit did not have the box storing the refrigerated controlled medications permanently affixed inside the refrigerator. At 2:14 p.m. the 100 unit medication room was observed. Resident alcohol was stored in the medication refrigerator and the controlled medication box was not permanently affixed to the refrigerator. On 4/13/23 at 2:01 p.m. a medication cart on the 300 unit was observed unlocked, and there was no nurse within the vicinity of the cart. This medication cart was not in use, but had several unsecured medicions inside. This medication cart contained several medications including two bottles of calcium 600 mg (milligrams) with vitamin D-3 10 mg tablets; docusate sodium (stool softener) 100 mg; two bottles of tylenol 325 mg; aspirin 325 mg; omeprazole 20 mg; tums, insulin syringes and 3 milliliter (ml) syringes with needles. The controlled medication compartment was locked under single lock and unable to be viewed. IV. Staff interviewsThe DON was interviewed on 4/13/23 at 2:09 p.m. The DON acknowledged that narcotic medications needed to be in a double locked affixed compartment; the DON said she was responsible for moving the controlled medications scheduled for disposal when discontinued from the medication carts and medication rooms when the medications were no longer in use; medication for disposal was moved to a double locked filing cabinet in the DON office. In addition to the double lock the DON's office door was locked when DON was not in the office. The DON said she was behind on destroying the controlled medications and when she opened the drawer for observation several of the medications started to fall out of the back side of the drawer due to it being overfilled. The DON was advised of the medications in the unlocked medication cart on the 300 hall and when the interview ended she said she was going to remove the medications from the medication cart immediately.

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 record review and interview, the facility failed to provide training to their staff that at a minimum educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically, the facility failed to:-Provide annual abuse identification and prevention training for one of five certified nurse aides (CNA) and one of two nurses reviewed; and,-Provide initial hire orientation and/or annual dementia management training for three out of five CNAs and one of two nurses reviewed. Findings include: I. Facility policy and procedures The Protection of Residents: Reducing the Threat of Abuse and neglect policy, revised 2/27/2020, was provided by the nursing home administrator (NHA) on 4/10/23 at 11:12 a.m., read in part: "To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. "It is the policy of this facility to develop, implement, and maintain an effective training program on abuse prohibition including but not limited to the following topics:-Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation, including sexual abuse;-Identifying what constitutes abuse, neglect, exploitation and misappropriation of resident property;-Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property;-Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources;-Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. "Procedure: Refer to the In-Service Education Policy for complete training requirements."The facility policy on staff training was requested on 4/13/23; the policy was not provided by the end of the survey on 4/13/23. II. Training records A request was made for training records for the past 12 months (4/10/22 to 4/10/23) for six randomly selected CNAs that showed proof of the CNAs participation in orientation (new hire) or annual abuse identification, prevention, and reporting; and dementia management training. The facility staff development coordinator (SDC) provided employee records. The training records revealed not all reviewed employees were up to date with annual and new hire abuse identification, prevention, and reporting, and dementia management training. Training records revealed: -CNA #8 was hired on 12/15/22. CNA #8's training records revealed the CNA was not provided annual dementia management training in the last 12 months. -CNA #9 was hired on 2/2/23. CNA #9's training records revealed CNA #9 was not provided initial/annual dementia management training. -CNA #10 was hired on 7/22/22. CNA #10's training records revealed CNA #10 was not provided annual training for abuse identification, prevention, and reporting or dementia management training. -Registered nurse (RN) #2's training records revealed RN #2 was not provided annual training for abuse identification, prevention, and reporting or dementia management training. III. Staff interviews The staff development coordinator (SDC) was interviewed on 4/12/23 at 2:37 p.m. The SDC said she was in charge of staff training and she provided staff assignments on the expected training sessions. Training consisted of a composed based training developed by an outside vendor. Training content was composed of information based on nursing facilities industry standards and not specifically developed by the facility itself. Staff were assigned to attend regularly scheduled all staff meetings where leadership would present in-service topics as relevant tothe activities of the community. All staff meetings were usually presented on multiple topics and were not specific to one issue of concern. Staff were expected to complete the computerized training for abuse identification, prevention, and reporting or dementia management training upon her and annually thereafter. The SDC said she was responsible for assigning the training to staff; the human resources department maintained all training records. The human resource director (HRD) was interviewed on 4/13/23 at 4:15 p.m. The HRD said employee training records were tracked through a computerized program that provided course status reports for compliance of each employee's training records. The HRD looked in the training system and was unable to find proof of employee records to verify all staff were in compliance with the requirement for participation in annual abuse identification, prevention, and reporting or dementia management training.