SANDROCK RIDGE CARE & REHABILITATION

A revisit survey was completed on 10/15/24 for all previous deficiencies cited on 8/8/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 10/15/24 for all previous deficiencies cited on 8/8/24. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO37200 was completed on 8/6/24 to 8/7/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for three (#1, #2 and #3) of six residents reviewed for abuse out of six sample residents. Resident #1, who had a diagnosis of Alzheimer's disease and a tendency to wander, had a plan of care which documented the resident had impaired safety awareness and wandered aimlessly. The interventions were to offer Resident #1 pleasant diversions, structured activities, food, conversation, television and card games. On 2/28/24 Resident #1 wandered into Resident #2's room. Resident #2 told Resident #1 he was in the wrong room and told him to leave. Resident #1 refused to leave the room which caused Resident #2 to push Resident #1 to the floor. A staff member, who was informed that Resident #1 went to the wrong room, rushed to the room but she was unable to open the door. Resident #1 was on the floor in front of the door and was moaning in pain. The staff member eventually opened the door. Resident #1 and Resident #2's roommate informed the staff member that Resident #2 pushed Resident #1. Resident #1 was sent to the hospital and was diagnosed with a fracture to his right femoral neck (the thigh bone below the hip joint). Resident #1 was admitted to the hospital and required surgical repair to heal the fracture. On 3/8/24 Resident #1 re-admitted to the facility. The resident was placed on 15-minute checks for supervision related to Resident #1 being non-weight bearing when he returned to the facility. On 7/9/24 Resident #1, who remained on 15-minute safety checks, went into Resident #3's room. Resident #3 and his roommate asked Resident #1 to leave the room. Resident #1 refused and Resident #3 attempted to push Resident #1's wheelchair out of the room. Resident #1 hit Resident #3 in the face and pulled Resident #3's hair. A staff member intervened and removed Resident #1 from the room after the altercation occurred. Due to the facility's failure to prevent Resident #1 from wandering into another resident's room, Resident #1 was involved in a resident to resident altercation with Resident #2, which resulted in Resident #1 sustaining a right hip fracture and being sent to the hospital for surgical repair of his hip. Additionally, after the resident to resident altercation with Resident #2, the facility again failed to implement person-centered interventions to prevent Resident #1 from wandering into other resident's rooms, which resulted in a resident to resident altercation between Resident #1 and Resident #3. Findings include:I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 3:00 p.m. It read in pertinent part,"Residents have the right to be free from abuse. The resident abuse prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:-Identify and investigate all possible incident of abuse;-Investigate and report any allegations within timeframes required by federal requirements;-Protect residents from any further harm during investigations;-Establish and implement a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or findings of abuse; and,-Involved the resident council in monitoring and evaluating the facility's abuse prevention program."The Abuse and Neglect Clinical protocol, revised March 2018, was provided by the NHA on 8/6/24 at 3:00 p.m. It read in pertinent part,"The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician and staff will order measures required to address the consequence of an abuse situation. The physician and staff will address appropriately causes of problematic resident behavior where possible. The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. The medical director will advise facility management and staff about ways to ensure that basic medical, functional and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process."II. Incident of physical abuse between Resident #1 and Resident #2 on 2/28/24The facility abuse investigation documented that on 2/28/24 at 7:08 p.m. a resident informed the nurse that Resident #1 wandered into Resident #2's room. Resident #2 and his roommate asked Resident #1 to leave the room. Resident #1 refused to leave the room. Resident #2 got out of his recliner, walked over to Resident #1 and pushed Resident #1 to the floor. When staff arrived to the room, Resident #1 was on the floor in front of the room door moaning in pain. Resident #2 said Resident #1 fell. Resident #2's roommate and Resident #1 motioned that Resident #2 pushed Resident #1. The summary of the incident documented Resident #1 had a history of wandering and wandered into Resident #2's room and refused to leave. Resident #1 was sent to the hospital via an emergency ambulance. Resident #1 sustained a right femur fracture and required surgery to repair the injury. Upon Resident #1's return to the facility on 3/8/24, 15-minute safety checks were implemented for Resident #1. The facility substantiated the incident. III. Incident of physical abuse between Resident #1 and Resident #3 on 7/9/24The 7/29/24 facility abuse investigation documented Resident #1 ambulated via his wheelchair into Resident #3's room. Resident #3 and his roommate told Resident #1 he was in the wrong room, but Resident #1 refused to leave. Resident #3 attempted to push Resident #1's wheelchair backwards out the door. Resident #1 swung at Resident #3 with his hands and hit Resident #3 in the face. Resident #1 then pulled Resident #3's hair. Resident #3 yelled out and staff entered Resident #3's room. Resident #1 was sitting in his wheelchair with his head down and Resident #3 was standing next to Resident #1. Both residents were assessed and no injuries were noted. Resident #1 did not answer questions about the incident. Resident #3 and his roommate were interviewed on 7/29/24 and said Resident #1 wandered into their room and refused to leave. Resident #3 and his roommate said Resident #1 hit Resident #3 and pulled Resident #3's hair before staff entered the room. The investigation documented the previous interventions included Resident #1 was on 15-minute safety checks. The investigation documented no new recommendations or interventions were implemented. -The facility failed to implement a new effective person-centered intervention to prevent Resident #1 from wandering into other resident's rooms in order to prevent an additional resident to resident altercation. The facility did not substantiate this allegation because it was not identified as abuse.-However, physical abuse occurred due to Resident #1 willfully hitting and pulling Resident #3's hair. IV. ObservationsDuring a continuous observation on 8/7/24, beginning at 10:50 a.m. and ending at 11:15 a.m. The following was observed:At 10:50 a.m., Resident #1 was laying on his bed with his head under a blanket. At 10:52 a.m., licensed practical nurse (LPN) #1 walked down one of the two hallways and completed 15-minute checks on other residents. LPN #1 failed to go down the hallway where Resident #1's room was located to complete a 15-minute check for the resident. At 11:00 a.m., Resident #1 was laying on his bed with his head under a blanket. At 11:05 a.m. LPN #1 assisted a resident and passed by Resident #1's room but did not look in Resident #1's room. At 11:15 a.m., Resident #1 was laying on his bed with his head under a blanket. Staff did notcomplete a 15-minute check.-The facility failed to complete a 15-minute check on Resident #1 from 10:50 a.m. to 11:15 a.m. V. Resident #1A. Resident statusResident #1, age 89, was admitted on 7/19/21. According to the August 2024 computerized physician orders (CPO), diagnosis included Alzheimer's disease. The 6/19/24 facility assessment revealed Resident #1 was rarely understood, had moderate cognitive impairments, and was unable to identify the current season, the location of his room and staff names or faces. B. Resident #1's representative interview Resident #1's representative was interviewed on 8/7/24 at 11:58 a.m. The resident's representative said he understood the facility was not able to provide one on one attention to each resident but he felt Resident #1 needed a little more supervision. He said Resident #1 worked his entire life and did not like to sit still. The resident's representative said Resident #1 needed fulfilling activities such as being helpful instead of arts, crafts or games. The resident's representative said when he visited Resident #1 he took the resident outside on walks and it helped with limiting the resident from attempting to self-transfer. The resident's representative said he felt the supervision the facility provided for the resident could have been better. He said he was not sure what the facility did for Resident #1 when he was not at the facility visiting regarding care, activities and supervision. The resident's representative said he did not see staff complete 15- minute checks when he visited the facility. He said he felt Resident #1 did not get enough activities that he enjoyed or to keep him busy. C. Record reviewThe elopement care plan, revised 2/5/24, revealed Resident #1 was an elopement risk and wandered. The intervention included Resident #1 had a wander guard for safety. -The facility failed to update Resident #1's care plan to include an intervention to keep Resident #1 from wandering into other residents' rooms after the resident to resident altercations on 2/28/24 and 7/29/24. The behavior care plan, revised 7/25/24, revealed the resident had behavioral issues that were due to his diagnosis of dementia, aggression and exit seeking behaviors. Interventions included the following: administering medications as ordered (7/26/21), anticipating and meeting the resident's needs (7/26/24), being aware of the resident's triggers and which of his behaviors triggered other residents (5/9/22), providing the opportunity for positive interactions and attention (8/18/22), explaining all procedures to the resident before starting cares and allowing him a few minutes to adjust to changes (7/26/21), intervening as necessary to protect the rights and safety of others (7/26/21), monitoring behavior episodes and attempting to determine an underlying cause (7/26/21) and providing an activities program that was of interest and accommodated the resident's status. -However, the facility failed to implement new interventions following the resident to resident altercations on 2/28/24 and 7/9/24. The care plan last had new interventions implemented on 6/18/22. The intervention documented on 7/25/24 had was already been implemented on 6/18/22. The 2/28/24 progress note documented the NHA was notified of an incident and arrived at the facility to start an investigation. The 2/29/24 progress note documented the staff were directed to a resident's room that Resident #1 had entered. Resident #1 was on the floor in front of the room door and was yelling out in pain. The staff opened the door and Resident #2's roommate pointed at Resident #2 and motioned that the resident pushed Resident #1. Resident #1 said Resident #2 pushed him to the floor. Resident #2 denied pushing Resident #1. The staff called 911 and Resident #1 was transferred to the emergency room for medical treatment. The 2/29/24 progress note documented the hospital notified the facility that Resident #1 had fractured his right hip and the resident was being admitted to the hospital. The 3/8/24 progress note documented the resident was admitted back to the facility. VI. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 12/22/23 and discharged to a hospital on 4/14/24. According to the April 2024 CPO, diagnoses included heart failure and dementia. The 4/15/24 facility assessment documented Resident #2 had a memory problem, experienced inattention and disorganized thinking. The assessment documented Resident #2 had physical behaviors directed towards others and verbal behaviors directed at others. B. Record reviewResident #2's cognitive care plan, revised 3/5/24, revealed he was at risk for impaired thought process due to dementia. Interventions included asking yes or no questions to determine the resident's needs, communicating with the resident and his family regarding his capabilities and needs and monitoring for changes in his cognitive function. Resident #2's behavioral care plan, revised 3/5/24, revealed the resident displayed conflictual and difficult behaviors with other residents due to adjusting to his living situation and his diagnosis of dementia. Interventions included intervening when the resident demonstrated inappropriate behaviors, helping the resident identify his stressors which led to behaviors and referring to counseling as needed.-The facility failed to update Resident #2's care plan after the resident to resident incident occurred on 2/28/24 and failed to inform staff the resident had a problem with other residents wandering into his room. A review of Resident #2's electronic medical record (EMR) did not reveal documentation regarding the resident to resident altercation with Resident #1 on 2/28/24. VII. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 1/13/24. According to the August 2024 CPO, diagnoses included Huntington's disease (neurological disorder that causes nerve cells in the brain to break down), muscle weakness and abnormalities of gait and mobility. According to the 7/18/24 facility assessment, Resident #3 was cognitively intact. B. Record reviewResident #3's communication care plan, revised 7/12/19, documented he had a communication problem due to Huntington's disease and was slow to find his words. Interventions included anticipating and meeting the resident's needs, being conscious of the resident's position when in groups to promote proper communication with others, discussing the resident's concerns or feelings regarding his communication difficulty and validating Resident #3's message by repeating what he said out loud. Resident #3's cognitive care plan, revised 7/12/19, documented he had an impaired thought process due to Huntington's disease. Interventions included administering medications as ordered, asking yes or no questions in order to determine the resident's needs and presenting just one thought at a time. Resident #3's neurological care plan, revised 7/16/19, documented he had an alteration in his neurological status due to Huntington's disease. Interventions included completing assessments for side effects of psychotropic medications, cueing and reorienting the resident as needed, giving medications as ordered and obtaining and monitoring lab or diagnostic work as ordered.-A review of Resident #3's EMR did not reveal documentation regarding the resident to resident altercation with Resident #1 on 7/9/24. VIII. Staff interviewsThe NHA was interviewed on 8/7/24 at 10:00 a.m. The NHA said Resident #1 constantly wandered. She said Resident #1 wandered into the storage closet in the NHA's office when Resident #1 had to use the restroom. The NHA said she wondered if Resident #1 wandered into other rooms when he needed to use the restroom. The NHA said Resident #1 was placed on 15-minute checks when he returned from the hospital on 3/8/24. She said the facility felt 15-minute checks were a good intervention for Resident #1's wandering and because he was a high fall risk because it provided increased rounding and supervision for the resident. The activity director (AD) was interviewed on 8/7/24 at 1:43 p.m. The AD said she updated the activity calendar for each month and scheduled four to five group activities each day. She said she updated the activity care plans but she was pretty far behind. The AD said she reviewed the residents' diagnoses and cognitive levels to determine if a resident was independent or dependent upon staff of activities. The AD said Resident #1 was dependent upon staff to meet his emotional, intellectual, physical and social needs. The AD said she had not updated Resident #1's care plan. The AD said she was not aware Resident #1 enjoyed working. She said she planned to update his preferred activities to job-like activities. She said Resident #1 enjoyed participating in the ball toss groups but other activities did not interest him. The director of nursing (DON) and the NHA were interviewed together on 8/7/24 at 1:59 p.m. The DON said if a resident sustained several falls the facility implemented 15-minute safety checks. The DON said Resident #1 was a high fall risk and wandered which was why he was placed on an enhanced supervision level. The DON said the nurses and the CNAs completed the 15-minute checks. She said all of the staff were aware of the supervision levels for each resident and which residents were on 15-minute safety checks. The DON said the staff included Resident #1 in as many activities as possible and Resident #1 enjoyed walking. She said the staff were told if Resident #1 started walking then staff needed to follow behind him with his wheelchair. The DON said she was not aware Resident #1's care plan was not updated. The NHA said Resident #1 understood English but preferred speaking Spanish. The NHA said the facility had quite a few staff members who were fluent in Spanish and it helped when communicating with Resident #1. She said Resident #1 did not respond well to female staff whether the female staff spoke Spanish or not. She said Resident #1 usually only spoke to male staff who spoke Spanish. The NHA said she was not aware the staff who did not speak Spanish did not attempt to communicate with Resident #1 at all and just asked the male staff to translate for them. She said all staff needed to attempt to communicate with the resident. The NHA said she did not think to add the resident's preferred communication and staff to the resident's care plan. The DON said she was not aware the staff signed off on the 15-minute checks without looking at the residents each time. The NHA said she was not aware the staff signed off on the15-minute checks without looking at the residents each time.

A complaint survey, prompted by Incident #36869 was conducted on 8/6/24 to 8/7/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for three (#1, #2 and #3) of six residents reviewed for abuse out of six sample residents. Resident #1, who had a diagnosis of Alzheimer's disease and a tendency to wander, had a plan of care which documented the resident had impaired safety awareness and wandered aimlessly. The interventions were to offer Resident #1 pleasant diversions, structured activities, food, conversation, television and card games. On 2/28/24 Resident #1 wandered into Resident #2's room. Resident #2 told Resident #1 he was in the wrong room and told him to leave. Resident #1 refused to leave the room which caused Resident #2 to push Resident #1 to the floor. A staff member, who was informed that Resident #1 went to the wrong room, rushed to the room but she was unable to open the door. Resident #1 was on the floor in front of the door and was moaning in pain. The staff member eventually opened the door. Resident #1 and Resident #2's roommate informed the staff member that Resident #2 pushed Resident #1. Resident #1 was sent to the hospital and was diagnosed with a fracture to his right femoral neck (the thigh bone below the hip joint). Resident #1 was admitted to the hospital and required surgical repair to heal the fracture. On 3/8/24 Resident #1 re-admitted to the facility. The resident was placed on 15-minute checks for supervision related to Resident #1 being non-weight bearing when he returned to the facility. On 7/9/24 Resident #1, who remained on 15-minute safety checks, went into Resident #3's room. Resident #3 and his roommate asked Resident #1 to leave the room. Resident #1 refused and Resident #3 attempted to push Resident #1's wheelchair out of the room. Resident #1 hit Resident #3 in the face and pulled Resident #3's hair. A staff member intervened and removed Resident #1 from the room after the altercation occurred. Due to the facility's failure to prevent Resident #1 from wandering into another resident's room, Resident #1 was involved in a resident to resident altercation with Resident #2, which resulted in Resident #1 sustaining a right hip fracture and being sent to the hospital for surgical repair of his hip. Additionally, after the resident to resident altercation with Resident #2, the facility again failed to implement person-centered interventions to prevent Resident #1 from wandering into other resident's rooms, which resulted in a resident to resident altercation between Resident #1 and Resident #3. Findings include:I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 3:00 p.m. It read in pertinent part,"Residents have the right to be free from abuse. The resident abuse prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:-Identify and investigate all possible incident of abuse;-Investigate and report any allegations within timeframes required by federal requirements;-Protect residents from any further harm during investigations;-Establish and implement a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or findings of abuse; and,-Involved the resident council in monitoring and evaluating the facility's abuse prevention program."The Abuse and Neglect Clinical protocol, revised March 2018, was provided by the NHA on 8/6/24 at 3:00 p.m. It read in pertinent part,"The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician and staff will order measures required to address the consequence of an abuse situation. The physician and staff will address appropriately causes of problematic resident behavior where possible. The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. The medical director will advise facility management and staff about ways to ensure that basic medical, functional and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process."II. Incident of physical abuse between Resident #1 and Resident #2 on 2/28/24The facility abuse investigation documented that on 2/28/24 at 7:08 p.m. a resident informed the nurse that Resident #1 wandered into Resident #2's room. Resident #2 and his roommate asked Resident #1 to leave the room. Resident #1 refused to leave the room. Resident #2 got out of his recliner, walked over to Resident #1 and pushed Resident #1 to the floor. When staff arrived to the room, Resident #1 was on the floor in front of the room door moaning in pain. Resident #2 said Resident #1 fell. Resident #2's roommate and Resident #1 motioned that Resident #2 pushed Resident #1. The summary of the incident documented Resident #1 had a history of wandering and wandered into Resident #2's room and refused to leave. Resident #1 was sent to the hospital via an emergency ambulance. Resident #1 sustained a right femur fracture and required surgery to repair the injury. Upon Resident #1's return to the facility on 3/8/24, 15-minute safety checks were implemented for Resident #1. The facility substantiated the incident. III. Incident of physical abuse between Resident #1 and Resident #3 on 7/9/24The 7/29/24 facility abuse investigation documented Resident #1 ambulated via his wheelchair into Resident #3's room. Resident #3 and his roommate told Resident #1 he was in the wrong room, but Resident #1 refused to leave. Resident #3 attempted to push Resident #1's wheelchair backwards out the door. Resident #1 swung at Resident #3 with his hands and hit Resident #3 in the face. Resident #1 then pulled Resident #3's hair. Resident #3 yelled out and staff entered Resident #3's room. Resident #1 was sitting in his wheelchair with his head down and Resident #3 was standing next to Resident #1. Both residents were assessed and no injuries were noted. Resident #1 did not answer questions about the incident. Resident #3 and his roommate were interviewed on 7/29/24 and said Resident #1 wandered into their room and refused to leave. Resident #3 and his roommate said Resident #1 hit Resident #3 and pulled Resident #3's hair before staff entered the room. The investigation documented the previous interventions included Resident #1 was on 15-minute safety checks. The investigation documented no new recommendations or interventions were implemented. -The facility failed to implement a new effective person-centered intervention to prevent Resident #1 from wandering into other resident's rooms in order to prevent an additional resident to resident altercation. The facility did not substantiate this allegation because it was not identified as abuse.-However, physical abuse occurred due to Resident #1 willfully hitting and pulling Resident #3's hair. IV. ObservationsDuring a continuous observation on 8/7/24, beginning at 10:50 a.m. and ending at 11:15 a.m. The following was observed:At 10:50 a.m., Resident #1 was laying on his bed with his head under a blanket. At 10:52 a.m., licensed practical nurse (LPN) #1 walked down one of the two hallways and completed 15-minute checks on other residents. LPN #1 failed to go down the hallway where Resident #1's room was located to complete a 15-minute check for the resident. At 11:00 a.m., Resident #1 was laying on his bed with his head under a blanket. At 11:05 a.m. LPN #1 assisted a resident and passed by Resident #1's room but did not look in Resident #1's room. At 11:15 a.m., Resident #1 was laying on his bed with his head under a blanket. Staff did notcomplete a 15-minute check.-The facility failed to complete a 15-minute check on Resident #1 from 10:50 a.m. to 11:15 a.m. V. Resident #1A. Resident statusResident #1, age 89, was admitted on 7/19/21. According to the August 2024 computerized physician orders (CPO), diagnosis included Alzheimer's disease. The 6/19/24 minimum data set (MDS) assessment revealed Resident #1 was unable to complete a brief interview for mental status (BIMS). A staff assessment for mental status revealed the resident was rarely understood, had moderate cognitive impairments, and was unable to identify the current season, the location of his room and staff names or faces. B. Resident #1's representative interview Resident #1's representative was interviewed on 8/7/24 at 11:58 a.m. The resident's representative said he understood the facility was not able to provide one on one attention to each resident but he felt Resident #1 needed a little more supervision. He said Resident #1 worked his entire life and did not like to sit still. The resident's representative said Resident #1 needed fulfilling activities such as being helpful instead of arts, crafts or games. The resident's representative said when he visited Resident #1 he took the resident outside on walks and it helped with limiting the resident from attempting to self-transfer. The resident's representative said he felt the supervision the facility provided for the resident could have been better. He said he was not sure what the facility did for Resident #1 when he was not at the facility visiting regarding care, activities and supervision. The resident's representative said he did not see staff complete 15- minute checks when he visited the facility. He said he felt Resident #1 did not get enough activities that he enjoyed or to keep him busy. C. Record reviewThe elopement care plan, revised 2/5/24, revealed Resident #1 was an elopement risk and wandered. The intervention included Resident #1 had a wander guard for safety. -The facility failed to update Resident #1's care plan to include an intervention to keep Resident #1 from wandering into other residents' rooms after the resident to resident altercations on 2/28/24 and 7/29/24. The behavior care plan, revised 7/25/24, revealed the resident had behavioral issues that were due to his diagnosis of dementia, aggression and exit seeking behaviors. Interventions included the following: administering medications as ordered (7/26/21), anticipating and meeting the resident's needs (7/26/24), being aware of the resident's triggers and which of his behaviors triggered other residents (5/9/22), providing the opportunity for positive interactions and attention (8/18/22), explaining all procedures to the resident before starting cares and allowing him a few minutes to adjust to changes (7/26/21), intervening as necessary to protect the rights and safety of others (7/26/21), monitoring behavior episodes and attempting to determine an underlying cause (7/26/21) and providing an activities program that was of interest and accommodated the resident's status. -However, the facility failed to implement new interventions following the resident to resident altercations on 2/28/24 and 7/9/24. The care plan last had new interventions implemented on 6/18/22. The intervention documented on 7/25/24 had was already been implemented on 6/18/22. The 2/28/24 progress note documented the NHA was notified of an incident and arrived at the facility to start an investigation. The 2/29/24 progress note documented the staff were directed to a resident's room that Resident #1 had entered. Resident #1 was on the floor in front of the room door and was yelling out in pain. The staff opened the door and Resident #2's roommate pointed at Resident #2 and motioned that the resident pushed Resident #1. Resident #1 said Resident #2 pushed him to the floor. Resident #2 denied pushing Resident #1. The staff called 911 and Resident #1 was transferred to the emergency room for medical treatment. The 2/29/24 progress note documented the hospital notified the facility that Resident #1 had fractured his right hip and the resident was being admitted to the hospital. The 3/8/24 progress note documented the resident was admitted back to the facility. VI. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 12/22/23 and discharged to a hospital on 4/14/24. According to the April 2024 CPO, diagnoses included heart failure and dementia. The 4/15/24 MDS assessment documented, based on staff assessment, the resident had a memory problem, experienced inattention and disorganized thinking. The assessment documented Resident #2 had physical behaviors directed towards others and verbal behaviors directed at others. B. Record reviewResident #2's cognitive care plan, revised 3/5/24, revealed he was at risk for impaired thought process due to dementia. Interventions included asking yes or no questions to determine the resident's needs, communicating with the resident and his family regarding his capabilities and needs and monitoring for changes in his cognitive function. Resident #2's behavioral care plan, revised 3/5/24, revealed the resident displayed conflictual and difficult behaviors with other residents due to adjusting to his living situation and his diagnosis of dementia. Interventions included intervening when the resident demonstrated inappropriate behaviors, helping the resident identify his stressors which led to behaviors and referring to counseling as needed.-The facility failed to update Resident #2's care plan after the resident to resident incident occurred on 2/28/24 and failed to inform staff the resident had a problem with other residents wandering into his room. A review of Resident #2's electronic medical record (EMR) did not reveal documentation regarding the resident to resident altercation with Resident #1 on 2/28/24. VII. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 1/13/24. According to the August 2024 CPO, diagnoses included Huntington's disease (neurological disorder that causes nerve cells in the brain to break down), muscle weakness and abnormalities of gait and mobility. According to the 7/18/24 MDS assessment, Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Record reviewResident #3's communication care plan, revised 7/12/19, documented he had a communication problem due to Huntington's disease and was slow to find his words. Interventions included anticipating and meeting the resident's needs, being conscious of the resident's position when in groups to promote proper communication with others, discussing the resident's concerns or feelings regarding his communication difficulty and validating Resident #3's message by repeating what he said out loud. Resident #3's cognitive care plan, revised 7/12/19, documented he had an impaired thought process due to Huntington's disease. Interventions included administering medications as ordered, asking yes or no questions in order to determine the resident's needs and presenting just one thought at a time. Resident #3's neurological care plan, revised 7/16/19, documented he had an alteration in his neurological status due to Huntington's disease. Interventions included completing assessments for side effects of psychotropic medications, cueing and reorienting the resident as needed, giving medications as ordered and obtaining and monitoring lab or diagnostic work as ordered.-A review of Resident #3's EMR did not reveal documentation regarding the resident to resident altercation with Resident #1 on 7/9/24. VIII. Staff interviewsThe NHA was interviewed on 8/7/24 at 10:00 a.m. The NHA said Resident #1 constantly wandered. She said Resident #1 wandered into the storage closet in the NHA's office when Resident #1 had to use the restroom. The NHA said she wondered if Resident #1 wandered into other rooms when he needed to use the restroom. The NHA said Resident #1 was placed on 15-minute checks when he returned from the hospital on 3/8/24. She said the facility felt 15-minute checks were a good intervention for Resident #1's wandering and because he was a high fall risk because it provided increased rounding and supervision for the resident. The activity director (AD) was interviewed on 8/7/24 at 1:43 p.m. The AD said she updated the activity calendar for each month and scheduled four to five group activities each day. She said she updated the activity care plans but she was pretty far behind. The AD said she reviewed the residents' diagnoses and cognitive levels to determine if a resident was independent or dependent upon staff of activities. The AD said Resident #1 was dependent upon staff to meet his emotional, intellectual, physical and social needs. The AD said she had not updated Resident #1's care plan. The AD said she was not aware Resident #1 enjoyed working. She said she planned to update his preferred activities to job-like activities. She said Resident #1 enjoyed participating in the ball toss groups but other activities did not interest him. The director of nursing (DON) and the NHA were interviewed together on 8/7/24 at 1:59 p.m. The DON said if a resident sustained several falls the facility implemented 15-minute safety checks. The DON said Resident #1 was a high fall risk and wandered which was why he was placed on an enhanced supervision level. The DON said the nurses and the CNAs completed the 15-minute checks. She said all of the staff were aware of the supervision levels for each resident and which residents were on 15-minute safety checks. The DON said the staff included Resident #1 in as many activities as possible and Resident #1 enjoyed walking. She said the staff were told if Resident #1 started walking then staff needed to follow behind him with his wheelchair. The DON said she was not aware Resident #1's care plan was not updated. The NHA said Resident #1 understood English but preferred speaking Spanish. The NHA said the facility had quite a few staff members who were fluent in Spanish and it helped when communicating with Resident #1. She said Resident #1 did not respond well to female staff whether the female staff spoke Spanish or not. She said Resident #1 usually only spoke to male staff who spoke Spanish. The NHA said she was not aware the staff who did not speak Spanish did not attempt to communicate with Resident #1 at all and just asked the male staff to translate for them. She said all staff needed to attempt to communicate with the resident. The NHA said she did not think to add the resident's preferred communication and staff to the resident's care plan. The DON said she was not aware the staff signed off on the 15-minute checks without looking at the residents each time. The NHA said she was not aware the staff signed off on the15-minute checks without looking at the residents each time.

A revisit survey was completed on 4/22/24 and 4/23/24 for all previous deficiencies cited on 02/09/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 4/22/24 and 4/23/24 for all previous deficiencies cited on 02/09/24. The facility is in compliance with all regulations surveyed

A survey prompted by complaint #CO35213 was completed 2/1/24 to 2/9/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 25 sample residents. Resident #11 was at nutritional risk with diagnoses of gastroesophageal reflux disease, muscle weakness and dementia. The registered dietitian (RD) implemented measures for the resident's nutrition risk and weight. Observations during the survey revealed the resident was not provided finger foods or fortified foods at meals, a brightly colored plate and alternatives offered when Resident #11's intake was poor. The facility failed to implement nutritional recommendations at mealtimes. Furthermore, the nutritional recommendations were for the interdisciplinary (IDT) team to follow up with the physician regarding her weight loss on multiple occasions and a reweight when Resident #11 lost weight and those recommendations were not followed up on. Due to the facility's failure to implement the nutritional recommendations, Resident #11 sustained a weight loss of eight pounds between 11/3/23 and 11/17/23, 6.8% which was considered significant weight loss. In addition, the resident continued to lose weight in total of 14 pounds in two months, 11.9% which was considered significant weight loss. Findings include: I. Facility policiesThe Weight Assessment and Intervention policy, revised March 2022, was provided by the nursing home administrator (NHA) on 2/8/24 at 8:57 a.m. It documented in pertinent part, "Any weight change of 5% or more since the last weight assessed is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing." The Nutrition/unplanned Weight Loss policy, revised September 2017, was provided by the NHA on 2/8/24 at 8:57 a.m. It documented in pertinent part, "The staff will report to the physician significant weight losses or any abrupt or persistent change from baseline appetite or food. The physician will review medical causes of anorexia and weight loss before ordering interventions. The staff and physician will identify pertinent interventions based on identified causes and resident conditions. The physician and staff will monitor nutritional status and response to interventions."II. Resident #11A. Resident statusResident #11, age 89, was admitted on 4/11/23. According to the February 2024 computerized physician orders, diagnoses included glaucoma (eyesight problem), gastro-esophageal reflux disease (backflow of stomach acid into to the esophagus), muscle weakness, vascular dementia (impaired blood flow to brain causing problems with memory, reasoning, judgment and planning) and psychotic and mood disturbances. The facility assessment from 1/10/24 documented Resident #11 was rarely/never understood. The facility assessment showed the resident required substantial/maximal assistance with activities of daily living (ADLs), which included eating, dressing, toileting and mobility. The resident was 68 inches tall (five foot eight inches) and weighed 108 pounds. B. ObservationResident #11 was observed continuously on 2/5/24 from 4:40 p.m. to 6:30 p.m. The observations were as follows:-At 4:55 p.m. the resident was assisted to the dining room table. -At 5:30 p.m. the resident received her meal. The food was served on white plates and not on bright colored plates (see care plan below). The meal consisted of a vegetable soup, cottage cheese with fruit and dessert. There was no supplement or cranberry juice served with the meal. There were no finger foods or fortified foods that she was supposed to be served (see record review below).-At 5:40 p.m. an unidentified certified nurse aide (CNA) assisted the resident with her meal. She took two bites of her dinner. She then took two bites of her dessert.-There were no other food choices offered to the resident for having eaten less than 50% of her meal. Resident #11 was observed continuously on 2/6/24 from 11:30 a.m. to 1:15 p.m. The observations were as follows:-At 12:24 p.m. the resident received her meal. The food was served on white plates and there was no cranberry juice served with the meal. The meal consisted of mashed potatoes, broccoli, a pork chop and slice of cake. There were no finger foods or fortified foods served to her.-At 12:30 p.m. an unidentified CNA assisted Resident #11 with her eating her meal.-The resident ate one bite of food and pushed the plate away from her.-There was no other food offered to this resident.-The interventions from the care plan were not followed based on these observations (see below). B. Facility assessment of resident's nutritional status on admissionThe care plan, updated on 11/21/23, identified that this resident had a nutritional problem related to dementia. Pertinent interventions included encouraging the resident to have snacks in the dining room, provide fortified foods, drinks and desserts, bright colored plates used to encourage intake and cranberry juice served at meals. The RD assessed this resident on 12/20/24. She assessed the resident's weight was trending downwards. She documented the resident's low intake of meals at 55%. C. Resident's weight recordResident #11's weight record showed the resident lost eight pounds which occurred between 11/3/23 and 11/17/23, 6.8% which was considered significant. The resident's weight on 11/3/23 was 118 pounds and the weight recorded on 11/17/23 was 110 pounds. The wheelchair scale was used in each weight. -There was no reweigh documented for confirmation of a loss the following day (as indicated by the RD assessment). The next weight entered was 108 pounds on 11/30/23. The resident's current weight was 104 pounds on 1/30/24. The resident lost 14 pounds over a two month period, 11.9% which was considered sginficant weight loss. D. Registered dietitian recommendations The registered dietitian (RD) recommended the resident was offered fortified foods and desserts, offered a supplement twice daily, had meals served on brightly colored plates, had meal assistance from nursing staff, was offered a sweet snack between meals (ice cream, cookies), was offered cranberry juice at meals and was brought out of her room for snacks and activities. This RD note was documented on 11/17/23. The progress note from nutrition/dietary services dated 11/17/23 documented this resident had a 12 pound weight loss in two weeks and meal intake was low at 52%. A reweigh was requested. The nursing team was going to discuss it with the physician. The nursing team was to continue with the recommendations (see above) from the RD.-However, the reweigh was not documented. -There was no documentation that the nursing staff had this discussion with the physician in the medical record. The nutrition/dietary services progress note dated on 12/15/23 showed nursing staff was to inform the physician of additional weight loss and to discuss appetite-stimulating medications. The nutrition/dietary services progress note on 12/22/23 documented nursing staff was to follow up with the physician on appetite stimulants. The nutrition/dietary services progress note on 1/5/24 documented the nursing staff was to discuss the resident with the physician.-There was no documentation in the medical record the nursing staff had discussions with the physician. III. Staff interviewsThe cook was interviewed on 2/6/24 at 12:30 p.m. The cook said that the tray line did not have any food which contained fortified food (powder protein). -An observation of the puree vegetable during the interview revealed there was no protein added to the pureed vegetables when they were supposed to be fortified. The dietary manager (DM) was interviewed on 2/6/24 at 12:40 p.m. The DM said the whey protein powder was added to the resident's meal (who consumed fortified foods) after the meal was served. The corporate registered dietitian (CRD) was interviewed on 2/8/24 at 9:50 a.m. She said residents with weight loss were reviewed weekly in nutrition risk meetings by a registered dietitian (RD). She said the RD was onsite typically for one day each month. She said she did not know Resident #11's nutrition plan of care. The director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said there was an offsite dietitian who completed the weekly nutrition assessment report (NAR) for at-risk residents. She said it was the dietary manager's responsibility to follow up and ensure the fortified foods were in place for the appropriate residents. She said every resident should always be offered an alternative to their meal if they ate less than 50%. She said nurses were to enter progress notes of when and what they have communicated with physicians about.

A complaint survey, prompted by #CO34707 was conducted on 2/1/24 to 2/9/24. Eleven deficiencies were cited.

Based on observation and interviews, the facility failed to ensure residents received notice orally and in writing which included a written description of their legal rights. Specifically, the facility failed to:-Information of how to file a complaint with the State Agency;-Post local contact agency for information about returning to the community;-Post information on Medicaid fraud; and, -Post a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies in the facility. Findings include: I. Resident group interviewThe resident group interview was conducted on 2/7/24 at 9:30 a.m. The group consisted of six alert and oriented residents selected by the facility. All six residents (#9, #10, #17, #20, #21 and #22) said they did not know where the facility posted information in regard to State Agencies contact information. II. ObservationsObservations throughout the building on 2/7/24 at approximately 1:30 p.m. revealed there was no statement for how a resident could file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation. There was no email address for the State Survey Agency included in the posting. The posting included a mailing address and phone number for the State Survey Agency and was in a glass compartment which was over six feet high in approximately a font of 12. The posting did include the phone number to the Center of Medicare and Medicaid. The posting failed to have the Adult Protective Services, where State law provides jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and Medicaid fraud unit and a statement that the resident may file a complaint with the State Survey agency concerning and suspected violation of State or Federal nursing facility regulations. III. Staff interviewThe social worker (SW) was interviewed on 2/7/24 at 2:00 p.m. The SW said she was unsure who originally made the posting on how to get in touch with the State Agencies because it was long before she had worked there. She said she was not aware of what specifically was required for the postings.

Based on interviews and record review, the facility failed to protect one (#23) resident from abuse out of 25 sample residents. Specifically, the facility failed to:-Ensure Resident #23 was protected from physical abuse by Resident #24 on 11/25/23; and, -Conduct a thorough investigation of a resident to resident altercation, including documentation of staff interviewed, which resulted in the appropriate authorities not being notified of physical abuse of Resident #23. Findings include:I. Facility policyThe Abuse and Neglect policy, revised March 2018, was received on 2/9/24 at 9:07 a.m by the corporate nurse consultant. The policy read in pertinent part, "Abuse is defined as the willful infliction of injury. The nurse will report findings to the physician."The Abuse, Neglect, Exploitation and Misappropriation Prevention program, revised April 2021, was received on 2/9/24 at 9:07 a.m. by the corporate nurse consultant. The policy read in pertinent parts, "the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives. Protect residents from abuse by anyone including facility staff, other residents."II. 11/25/23 incident between Resident #23 and Resident #24A. Facility investigationThe 11/25/23 investigation summary documented Resident #23 was in Resident #24's room going through his belongings. Resident #24 requested for the resident to leave the room. Resident #24 said he did not push the resident, but he placed his hand on her back and walked her out of his room. Once out of the room, Resident #23 was walking in the hallway going towards the nurses station stumbled and fell onto the floor. The summary documented after speaking with staff and residents it was determined that Resident #23 did fall in the hallway witnessed by a resident who stated Resident #24 was in his room when she fell. Interventions were to educate the resident on not entering other resident rooms and use handrails while walking down the hallway. Resident #23 had a small cut over left eye, a bump below right knee and a small abrasion on left. elbow.-However, according to staff interviews during the survey (see interviews below), Resident #24 admitted at the time of the incident on 11/25/23, he had pushed Resident #23 because she was in his room and would not leave. III. Resident #23A. Resident statusResident #23, age 75, was admitted to the facility on 10/13/23 and discharged on 12/13/23. According to the December 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances and generalized anxiety. The 10/13/23 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a score of eight out of 15 on the brief interview for mental status (BIMS). The resident was independent in ambulation and showed no behaviors. B. Record reviewThe care plan, initiated on 10/15/23, identified the resident was a high risk for elopement and wandering related to being disoriented to place. She had attempted to leave the facility unattended, wandered aimlessly and significantly intruded on the privacy of others by searching through and removing personal belongings. Pertinent interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, television and books and to monitor location every 15 minutes. The 10/24/23 progress note documented the resident had been confused all evening and trying to find her dog, she kept wandering into other residents' rooms. IV. Resident #24A. Resident statusResident #24, age 65, was admitted on 12/2/22. According to the February 2024 CPO, diagnoses included schizophrenia and bipolar disorder. The 1/23/24 MDS assessment documented the resident had a score of 15 out of 15 for the BIMS. The resident was independent in activities of daily living. The resident had no behavior problems. B. Record review The 10/30/23 progress note documented the resident had an altercation with another resident. Both residents were redirected. The care plan, updated 11/30/23, identified the resident had behavior problems. The resident care plan documented his diagnosis put him at risk for abusing others and being abused by others. He became aggravated with loud noises. Pertinent interventions included, his behavior was deescalated by taking him to a quiet environment, encourage him to write poetry, go outside and listen to music. The progress note dated 1/22/24 documented the resident returned to the facility from the facility van, he was very manic and out of sorts related to having a roommate. The progress note dated 1/23/24 showed the resident was saying inappropriate statements to the roommate. Redirected the resident and moved the roommate to another room. V. Staff interviewsThe social worker (SW) was interviewed on 2/8/24 at 10:26 a.m. The SW said Resident #23 no longer resided in the facility. She said the resident had dementia and that she would wander throughout the building and exit seek. She said she was not involved with the investigation. She said Resident #24 did not like for other residents to enter his room. She said she had heard that it was a verbal altercation between the two residents and not physical. She said verbal altercations were to have a thorough investigation. Registered nurse (RN) #1 was interviewed on 2/8/24 at 1:52 p.m. RN #1 said he was the charge nurse when the resident to resident incident occurred. The RN said he heard screaming and saw Resident #23 laying on the floor in the hallway on her left side. Resident #24 was standing in the doorway and said he shoved Resident #23 because she was in his room and would not leave. He said the resident's injury on her knee showed force and the skin tear showed the direction she fell with force. A staff member, who wished to be anonymous, was interviewed on 2/7/24. The staff member said they had heard Resident #24 admit to pushing Resident #23 as she would not leave his room. Licensed practical nurse (LPN) #2 was interviewed on 2/9/24 at 11:00 a.m. LPN #2 said Resident #24 had a history of not getting along with other residents. She said he had a history of manic behavior. She said he did not like having a roommate or other residents entering his room and he would not get physical with the roommate but he would say mean and inappropriate things to the resident. The nursing home administrator (NHA) was interviewed on 2/9/24 at approximately 10:00 a.m. The NHA said she was notified of the incident. She said she came into the building and she asked Resident #24 if he pushed Resident #23 and he denied it. The NHA said she had spoken to the staff working, however, it was not included in the investigation. The NHA said she did not substantiate it as abuse. She said she viewed the cameras and did not see anything which indicated abuse. The NHA said she had no record of the video recordings.

IV. Resident #10A. Resident statusResident #10, age 95, was admitted on 12/29/21. According to the February 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), anxiety and generalized muscle weakness. The 2/1/24 minimum data set (MDS) assessment revealed the resident had no noted cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behavior symptoms were noted. She required assistance for transfers, personal hygiene and toilet use, medications, and had no rejection of care. She was rarely incontinent of bowel or bladder. B. Resident interviewResident #10 was interviewed on 2/6/24 at 10:51 a.m. Resident #10 said she would like to have three showers per week, but would consider two showers per week acceptable. Resident #10 said she personally informed the nursing home administrator (NHA) that on one occasion she was not bathed for three weeks. Resident #10 recounts that it took another week after that conversation to receive a shower. C. Record reviewThe care plan dated 11/18/23 identified the resident was to receive one person assistance with showers. The bathing record from 1/9/24 to 2/5/24 showed the resident received only two showers out of 17 opportunities. V. Resident #9 A. Resident status Resident # 9, over the age of 65, was admitted on 12/13/22. According to the Februray 2024 CPO, diagnoses included myasthenia gravis (chronic autoimmune disorder), heart disease, osteoarthritis, osteoporosis and generalized muscle weakness. The 12/16/22 minimum data set (MDS) assessment revealed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She had no behaviors. She required assistance for transfers, and personal hygiene. B. Resident interviewResident #9 was interviewed on 2/5/24 at 4:10 p.m. Resident #9 said she was not getting regular showers. Resident #9 said she would like to be bathed three times per week, however would receive one bath per week. Resident #9 explained one time that staff was so short on one busy bath day, she told staff not to worry about her bath so someone else who needed it more could get it. Resident #9 explained she felt forgotten and unimportant when the promised twice a week showers did not happen. C. Record reviewThe bathing record from 1/9/24 to 2/5/24 showed the resident received only four showers out of 19 opportunities. The care plan, dated 12/11/23, identified the resident was to receive one person assistance with showers, or a sponge bath if the resident cannot tolerate a shower. VI. Staff interviewsA staff member who wished to stay anonymous was interviewed on 2/6/24. The staff member said showers were not provided to residents as there was not enough staff. Licensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 9:51 a.m. LPN #2 said regular care, such as showers and wound care for residents were not being done consistently. A staff member who wished to stay anonymous was interviewed on 2/7/24. The staff member said they had to skip showers because there was not enough staff. A staff member who wished to stay anonymous was interviewed on 2/8/24. The staff member said there was not enough staff to assist residents with showers. The director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said residents were scheduled to receive showers two times a week, unless otherwise requested. She said the nursing staff used shower sheets that documented showers were completed. -When the shower sheets were requested for Residents #3, #13, #20, #10 and #9, the DON did not provide the documentation by the exit of the survey on 2/9/24. Based on observations, interviews and record review, the facility failed to ensure five (#3, #13, #20, #10 and #9) of six residents reviewed for activities of daily living (ADLs) out of 25 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failedto ensure Residents #33, #13, #20, #10 and #9, who were dependent on staff for bathing care, were provided bathing consistently with their plan of care. Findings include: I. Resident #3A. Resident statusResident #3, under age 65, was admitted on 8/3/23. According to the February 2024 computerized orders (CPO), diagnoses included chronic pain, hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one side of the body) following cerebral infarction (stroke) that affected her left side. The 11/4/23 minimum data (MDS) assessment showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required total assistance of two with activities of daily living which included showers. She had no behaviors or refusal of care. B. Resident interviewResident #3 was interviewed on 2/8/24 at 9:00 a.m. Resident #3 said she wanted to receive two showers each week, however, she received only one a week and sometimes less than that. She said her family had never showered her (as indicated by the record, see below). C. Record review The care plan, initiated 8/14/23, identified the resident had an ADL self-care performance deficit related to activity intolerance, impaired balance, and chronic pain. Pertinent interventions included the resident required extensive assistance for bathing/showering and was to receive two showers/baths a week and as needed. The bathing record from 1/9/24 to 2/5/24 showed the resident received only two showers out of eight opportunities. The shower record showed the activity of bathing did not occur or family and/or non-licensed facility staff provided care 100% of the time for the missed opportunities. II. Resident #13A. Resident status Resident #13, over age 65, was admitted on 12/20/23. According to the February 2024 CPO, diagnoses included muscle weakness, lack of coordination and unspecified abnormalities of gait (walking) and mobility. The 1/2/24 MDS assessment documented the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident required substantial/maximal assistance with bathing and showering. She had no behaviors or refusal of care. B. Resident interviewResident #13 was interviewed on 2/6/24 at 1:35 p.m. She said she had showers scheduled twice weekly in the morning. She said she was not offered showers that frequently. She said she preferred to take showers in the morning when she was not tired. Instead, the nursing staff only offered showers to her late afternoon or during the evening. The resident said her family had never showered her in this facility (as indicated by the record, see below). C. Record review The bathing record from 1/9/23 to 2/5/24 showed the resident received only one shower out of eight opportunities. The shower record showed the activity itself did not occur or family and/or non-licensed facility staff provided care 100% of the time for the missed opportunities. III. Resident #20A. Resident statusResident #20, age 76, was admitted on 11/28/23. According to the February 2024 CPO diagnoses included chronic pulmonary embolism and chronic obstructive pulmonary disease. The 12/5/23 MDS assessment documented the resident had moderate cognitive impairment with a score of nine out of 15. The MDS coded the resident as requiring partial to moderate assistance with activities of daily living which included bathing. She had no behaviors. B. Resident interviewThe resident was interviewed on 2/5/24 at 3:00 p.m. The resident said there was not enough staff and she did not receive her showers as scheduled. She said she would prefer to have three showers a week. The resident's palms of her hands had dark substance on them, from wheeling her wheelchair. C. Record reviewThe care plan, updated on 10/26/23, identified the resident had activities of daily living (ADL) self care performance related to dementia, confusion. Pertinent interventions included the resident required a one person assist with bathing/showering two times a week and as necessary. The bathing record from 1/9/24 to 2/5/24 showed the resident received only three showers out of eight opportunities.

Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#18 and #4) of four residents reviewed for pressure injuries out of 25 sample residents. Specifically, the facility failed to:-Consistently assess and document a pressure injury for Resident #18;-Obtain physician orders for the treatment of a pressure injury Resident #18;-Consistently assess and document a wound for Resident #4; -Obtain physician orders for the treatment of a wound for Resident #4; and,-Conduct weekly skin assessments for Resident #4. Findings include:I. Professional ReferenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/12/24, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)"Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin Loss"Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage 2 should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin Loss"Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue Loss"Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable."Unstageable: Depth Unknown"Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed."Suspected Deep Tissue Injury: Depth Unknown"Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment."II. Facility PolicyThe Pressure Ulcers/Skin Breakdown policy was obtained from the corporate nurse consultant (CNC) on 2/8/24 at 9:12 a.m. The policy documented in pertinent part:"The Nurse shall describe and document pressure sore location, stage, length, width, depth, and presence of exudates or necrotic tissue; and,"The physician will guide care when new wounds develop."III. Resident #18A. Resident statusResident #18, age 80, was admitted on 1/17/24. According to the February 2024 computerized physician orders (CPO) diagnoses included macular degeneration, legal blindness and displaced fracture of the greater trochanter (top of the femur). The 1/24/24 minimum data set (MDS) assessment showed the resident had cognitive impairments. The resident had both short and long term memory impairments and had moderate impairment for decision making. He required substantial assistance with activities of daily living. He was at risk for pressure injury. -The MDS failed to code that the resident had a pressure injury. B. ObservationsOn 2/8/24 at 2:52 p.m., Resident #18 was observed to have a dressing in place over his lower medial spine. The dressing was dated 2/7/24. The resident had a gauze bandage on his right foot. C. Record reviewThe care plan, revised on 1/31/24, identified the resident had a potential for pressure ulcer development. Pertinent interventions included administering treatments as ordered and monitoring for and informing the resident and his family and care givers of any new skin breakdown. Review of Resident #18's February 2024 CPO revealed the following physician's order for the resident's right heel:Cleanse with normal saline or soap and water and pat dry with gauze. Apply sure prep to peri wound area. Apply collagen to bed of wound and cover with foam dressing. Change dressing three days a week or if accidentally removed or soiled. The start date of the order was 1/22/24.-The February 2024 CPO failed to have an order for the treatment of the lower medial spine wound. The 2/2/24 skilled charting documentations showed the resident had a right heel pressure ulcer. -However there were no measurements documented for the wound. The 2/7/24 skilled charting documentation included a skin condition section, however, there was nothing documented regarding Resident #4's right heel wound or the medial spine wound. D. Director of nursing (DON) interviewThe DON was interviewed on 2/9/24 at 9:09 a.m. The DON said Resident #18 had a pressure injury on his right heel. She said the dressing was scheduled every three days and as needed. The DON reviewed the medical record and confirmed there were no recent skin assessments which documented the measurements or the assessment of the pressure ulcer. She said that the resident had not been seen by a wound physician. The DON said Resident #18 had a pressure injury on his medial spine. She said he had a foam padded dressing to help protect the wound. She said any type of wound treatments needed to have a physician's order. The DON confirmed there was no assessment in Resident #18's EMR about the pressure wound on his medial spine. The DON said she had documented the measurements of the wound on the resident's right heel, however, she said the documentation did not save in the EMR. IV. Resident #4A. Resident StatusResident #4, age 80, was admitted to the facility on 7/5/23. According to the February 2024 CPO, diagnoses included dementia, type 2 diabetes and glaucoma. The 7/12/23 MDS assessment revealed the resident was significantly cognitively impaired and unable to complete all aspects of the brief interview for mental status (BIMS). The resident required one person assistance with eating, hygiene, dressing, bathing, turning in bed and two person assistance with toileting and transfers. The assessment documented the resident had no pressure ulcer wounds on admission and required interventions to prevent pressure ulcers. B. ObservationOn 2/7/24 at 1:17 p.m., Resident #4's skin was observed with a staff member who wished to remain anonymous. The resident had an open wound on his medial scrotum. The wound was approximately 1.5 centimeters (cm) long by 1 cm wide by 0.1 cm deep. -There was no dressing covering the wound. C. Record reviewThe Braden scale assessment (a tool utilized to predict pressure injury risk), completed on 1/3/24, showed the resident was at risk for developing a pressure injury. The care plan, initiated 12/7/23, identified the resident was at risk for pressure injury due to requiring assistance with turning and transfers. Pertinent interventions included assisting the resident with positioning and repositioning the resident in bed every two hours. A weekly skin check, dated 1/3/24, documented Resident #4's skin was warm, dry and intact. -Review of the resident's electronic medical record (EMR) failed to show any other weekly skin checks were completed after 1/3/24.-The February 2024 CPO failed to show Resident #4 had a physician's order for treatment for the pressure injury on the resident's medial scrotum. -Review of the resident's EMR contained no documentation to indicate the pressure injury was being monitored. D. Staff InterviewsA staff member, who wished to remain anonymous, was interviewed on 2/7/24 at 9:51 a.m. The anonymous staff member said the resident had a wound on his scrotum. The staff member said the wound had been present for several weeks. The DON was interviewed on 2/8/24 at 1:21 p.m. The DON said she was personally involved in wound care for all residents in the facility. The DON said she had briefly assessed the skin of Resident #4 in January 2023 but the resident did not want her involved in his skin care and therefore she did not pursue further evaluations of his skin. She did not follow up with any other nurses to ensure they were assessing his skin consistently. The DON said weekly skin checks needed to be documented for all wounds. She said she preferred for one nurse to perform wound measurements. She said she was the nurse responsible for measuring all wounds currently. The DON said the nurses should document and monitor wounds and pressure injuries on a consistent basis. She confirmed weekly wound assessments with measurements were not completed for Resident #4. The DON was interviewed a second time on 2/9/24 at 9:09 a.m. The DON said the facility did not have a wound physician but could call for a consultation if a wound was not healing. The DON said all wound treatments needed to have a physician's order. The nursing home administrator (NHA) was interviewed on 2/9/24 at approximately 10:00 a.m. The NHA said the facility had no pressure injuries. -However, the DON said Resident #18 had two pressure injuries (see DON interview regarding Resident #18 above).

Based on observations, interviews and record review, the facility failed to provide an environment free from accident hazards for one (#3) out of 25 sample residents. Specifically, the facility failed to: -Investigate a fall Resident #3 on 1/17/24; -Properly secure Resident #3 in the facility van when going to an appointment on 1/24/24; -Ensure two staff assisted Resident #3 with a mechanical lift transfer. Findings include: I. Resident #3 Resident #3, under the age of 65, was admitted on 8/3/23. According to the February 2024 computerized orders (CPO), diagnoses included chronic pain, hemiplegia (paralysis to one side of the body), and hemiparesis (weakness to one side of the body) following cerebral infarction (stroke) that affected her left side. The 11/4/23 minimum data (MDS) assessment showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required total assistance of two staff with activities of daily living (ADLs) which included showers, positioning and transfers. She had no behaviors or refusal of care. II. Failure investigation a fall and properly secure Resident #3A. Resident interviewResident #3 was interviewed on 2/6/24 at 2:15 p.m. She said she suffered a fall on 1/17/24. She said two certified nursing aides (CNA) dropped her during a transfer and she fell on her left side. She said her left ankle was hurting and the director of nursing (DON) came in to assess her. Resident #3 said she was transported to a doctor's appointment via the facility van. She said during her van ride, she was not strapped in properly and there was an accident that occurred on 1/24/24. She said she suffered bruised ribs to her left side from the accident. B. Record review 1. 1/17/24-Review of the medical record revealed there was no documentation regarding the fall on 1/17/24. The fall occurred according to the resident and staff interview (see interviews). -Fall records for Resident #3 on 1/17/24 were requested from the nursing home administrator (NHA) on 2/7/24 and the facility failed to provide them by exit of the survey on 2/9/24.2. 1/24/24Records for facility van maintenance were requested on 2/7/24 at 3:00 p.m. and were not received by the exit on 2/9/24. The 1/24/24 investigation summary report and police report were obtained from the NHA on 2/8/24 at 11:00 a.m. The investigation summary included the name of the facility, date the incident occurred, resident name, description of what happened, interventions and signature of NHA. -However, the investigation was not included in the medical record. C. Staff interviewHospitality aide (HA) #1 was interviewed on 2/7/24 at 2:30 p.m. She said it was her first time driving the facility's van and she received a five minute training on the van from the facility maintenance director. The facility maintenance director showed her how to turn the van on and strap in the wheels of the wheelchair to the van. She said she felt pressured into signing the training form given to her by the nursing home administrator (NHA). HA #1 said while she was driving Resident #3 to a doctor appointment, the van was side swiped and as a result the resident flipped out of the wheelchair since she was not properly secured. She said the seatbelt to go across the chest of the resident in the wheelchair was broken and it was not fixed. The maintenance director was interviewed on 2/7/24 at 2:45 p.m. He said there were two seatbelts for the wheels on the wheelchair and one seatbelt that strapped across the chest of a resident in a wheelchair. He said he did the training course for staff operating the van that included utilizing the three belts when transporting a resident. He said the broken seatbelt was fixed right away after the accident on 1/24/24. He demonstrated the three working seatbelts for the wheelchair. An anonymous staff member was interviewed on 2/8/24 at 9:00 a.m. She said she was assisting in the transfer with Resident #3 when she was dropped and suffered a fall on 1/17/24. The resident fell on her left side and was complaining of left ankle pain. The staff member told the DON right away and the DON came in to assess Resident #3. III. Failure to use two staff for a mechanical lift transferA. Facility policy and procedureThe Mechanical Lifting Machine policy and procedure, dated July 2017, was provided by the director of nursing (DON) on 2/9/24 at approximately 9:00 a.m. It documented in pertinent part, "At least two nursing assistants are needed to safely move a resident with a mechanical lift."B. ObservationsOn 2/8/24 at 4:15 p.m. certified nurse aide CNA #6 operated a Hoyer (mechanical) lift to transfer Resident #3. There was no other staff member in the resident's room assisting with the transfer. C. Record review The 8/14/23 ADL care plan documented the resident had a self care deficit related to activity intolerance, impaired balance and chronic pain. Pertinent interventions included the resident requiring one person extensive assistance with all transfers. -However, based on observations and interviews, she required a mechanical lift for transfer with two staff. D. Staff interviewsCNA #4 was interviewed on 2/8/24 at 2:37 p.m. CNA #4 said she had heard of staff members using the Hoyer lift with one staff member instead of two as required. CNA #4 said she saw this with Resident #3 in the past. CNA #4 said she had seen the physical therapist transfer residents alone who required two person assistance. The physical therapist (PT) was interviewed on 2/8/24 at 5:10 p.m. The PT said staff should be using two staff members to transfer residents who require a mechanical lift.

Based on observations, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 25 sample residents. Resident #11 was at nutritional risk with diagnoses of gastroesophageal reflux disease, muscle weakness and dementia. The registered dietitian (RD) implemented measures for the resident's nutrition risk and weight. Observations during the survey revealed the resident was not provided finger foods or fortified foods at meals, a brightly colored plate and alternatives offered when Resident #11's intake was poor. The facility failed to implement nutritional recommendations at mealtimes. Furthermore, the nutritional recommendations were for the interdisciplinary (IDT) team to follow up with the physician regarding her weight loss on multiple occasions and a reweight when Resident #11 lost weight and those recommendations were not followed up on. Due to the facility's failure to implement the nutritional recommendations, Resident #11 sustained a weight loss of eight pounds between 11/3/23 and 11/17/23, 6.8% which was considered significant weight loss. In addition, the resident continued to lose weight in total of 14 pounds in two months, 11.9% which was considered significant weight loss. Findings include: I. Facility policiesThe Weight Assessment and Intervention policy, revised March 2022, was provided by the nursing home administrator (NHA) on 2/8/24 at 8:57 a.m. It documented in pertinent part, "Any weight change of 5% or more since the last weight assessed is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing." The Nutrition/unplanned Weight Loss policy, revised September 2017, was provided by the NHA on 2/8/24 at 8:57 a.m. It documented in pertinent part, "The staff will report to the physician significant weight losses or any abrupt or persistent change from baseline appetite or food. The physician will review medical causes of anorexia and weight loss before ordering interventions. The staff and physician will identify pertinent interventions based on identified causes and resident conditions. The physician and staff will monitor nutritional status and response to interventions."II. Resident #11A. Resident statusResident #11, age 89, was admitted on 4/11/23. According to the February 2024 computerized physician orders, diagnoses included glaucoma (eyesight problem), gastro-esophageal reflux disease (backflow of stomach acid into to the esophagus), muscle weakness, vascular dementia (impaired blood flow to brain causing problems with memory, reasoning, judgment and planning) and psychotic and mood disturbances. The minimum data set (MDS) from 1/10/24 documented Resident #11 was rarely/never understood. The MDS showed the resident required substantial/maximal assistance with activities of daily living (ADLs), which included eating, dressing, toileting and mobility. The resident was 68 inches tall (five foot eight inches) and weighed 108 pounds. B. ObservationResident #11 was observed continuously on 2/5/24 from 4:40 p.m. to 6:30 p.m. The observations were as follows:-At 4:55 p.m. the resident was assisted to the dining room table. -At 5:30 p.m. the resident received her meal. The food was served on white plates and not on bright colored plates (see care plan below). The meal consisted of a vegetable soup, cottage cheese with fruit and dessert. There was no supplement or cranberry juice served with the meal. There were no finger foods or fortified foods that she was supposed to be served (see record review below).-At 5:40 p.m. an unidentified certified nurse aide (CNA) assisted the resident with her meal. She took two bites of her dinner. She then took two bites of her dessert.-There were no other food choices offered to the resident for having eaten less than 50% of her meal. Resident #11 was observed continuously on 2/6/24 from 11:30 a.m. to 1:15 p.m. The observations were as follows:-At 12:24 p.m. the resident received her meal. The food was served on white plates and there was no cranberry juice served with the meal. The meal consisted of mashed potatoes, broccoli, a pork chop and slice of cake. There were no finger foods or fortified foods served to her.-At 12:30 p.m. an unidentified CNA assisted Resident #11 with her eating her meal.-The resident ate one bite of food and pushed the plate away from her.-There was no other food offered to this resident.-The interventions from the care plan were not followed based on these observations (see below). B. Facility assessment of resident's nutritional status on admissionThe care plan, updated on 11/21/23, identified that this resident had a nutritional problem related to dementia. Pertinent interventions included encouraging the resident to have snacks in the dining room, provide fortified foods, drinks and desserts, bright colored plates used to encourage intake and cranberry juice served at meals. The RD assessed this resident on 12/20/24. She assessed the resident's weight was trending downwards. She documented the resident's low intake of meals at 55%. C. Resident's weight recordResident #11's weight record showed the resident lost eight pounds which occurred between 11/3/23 and 11/17/23, 6.8% which was considered significant. The resident's weight on 11/3/23 was 118 pounds and the weight recorded on 11/17/23 was 110 pounds. The wheelchair scale was used in each weight. -There was no reweigh documented for confirmation of a loss the following day (as indicated by the RD assessment). The next weight entered was 108 pounds on 11/30/23. The resident's current weight was 104 pounds on 1/30/24. The resident lost 14 pounds over a two month period, 11.9% which was considered sginficant weight loss. D. Registered dietitian recommendations The registered dietitian (RD) recommended the resident was offered fortified foods and desserts, offered a supplement twice daily, had meals served on brightly colored plates, had meal assistance from nursing staff, was offered a sweet snack between meals (ice cream, cookies), was offered cranberry juice at meals and was brought out of her room for snacks and activities. This RD note was documented on 11/17/23. The progress note from nutrition/dietary services dated 11/17/23 documented this resident had a 12 pound weight loss in two weeks and meal intake was low at 52%. A reweigh was requested. The nursing team was going to discuss it with the physician. The nursing team was to continue with the recommendations (see above) from the RD.-However, the reweigh was not documented. -There was no documentation that the nursing staff had this discussion with the physician in the medical record. The nutrition/dietary services progress note dated on 12/15/23 showed nursing staff was to inform the physician of additional weight loss and to discuss appetite-stimulating medications. The nutrition/dietary services progress note on 12/22/23 documented nursing staff was to follow up with the physician on appetite stimulants. The nutrition/dietary services progress note on 1/5/24 documented the nursing staff was to discuss the resident with the physician.-There was no documentation in the medical record the nursing staff had discussions with the physician. III. Staff interviewsThe cook was interviewed on 2/6/24 at 12:30 p.m. The cook said that the tray line did not have any food which contained fortified food (powder protein). -An observation of the puree vegetable during the interview revealed there was no protein added to the pureed vegetables when they were supposed to be fortified. The dietary manager (DM) was interviewed on 2/6/24 at 12:40 p.m. The DM said the whey protein powder was added to the resident's meal (who consumed fortified foods) after the meal was served. The corporate registered dietitian (CRD) was interviewed on 2/8/24 at 9:50 a.m. She said residents with weight loss were reviewed weekly in nutrition risk meetings by a registered dietitian (RD). She said the RD was onsite typically for one day each month. She said she did not know Resident #11's nutrition plan of care. The director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said there was an offsite dietitian who completed the weekly nutrition assessment report (NAR) for at-risk residents. She said it was the dietary manager's responsibility to follow up and ensure the fortified foods were in place for the appropriate residents. She said every resident should always be offered an alternative to their meal if they ate less than 50%. She said nurses were to enter progress notes of when and what they have communicated with physicians about.

Based on interviews, observations and record review, the facility failed to ensure three (#25, #3 and #10) of three out of 25 sample residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to ensure oxygen concentrators had distilled water to humidify the oxygen concentrators for Resident #25, #3 and #10. Findings include:I. Professional referenceAccording to the Davis Advantage for Basic Nursing handbook, third edition, retrieved from Treas, Leslie S., et al. Davis Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. Davis Company, 2022., Key concepts of administering oxygen included, in relevant part, "Attach the flow meter to the oxygen source. Attach the humidifier to the flow meter. The humidifier is a small plastic container containing normal saline. The humidifier adds moisture in with the oxygen, which can dry the nasal or oral cavity."II. Facility policy and procedureThe Oxygen Administration policy and procedure, dated October 2010, was provided by the corporate nurse consultant (CNC) on 2/8/24 at 8:57 a.m., read in pertinent part, "Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check water level in the humidification jar. Documentation includes how the resident tolerated the procedure. III. Resident #25 statusResident #25, age 92, was admitted on 1/22/24. According to the January 2024 computerized physician orders (CPO), diagnoses included COVID-19, weight loss, mild dementia, hypertension (high blood pressure), and anxiety. The 2/2/24 minimum data set (MDS) assessment documented that the resident was cognitively intact with no short-term or long-term memory impairment. A. ObservationOn 2/6/24 at 4:00 p.m., Resident #25 was observed sitting on her bed in her room receiving oxygen therapy. The oxygen concentrator indicated that the resident was receiving oxygen at 3 liters per minute (LPM) by nasal cannula. The concentrator had a jar connected to it for distilled water, which was empty. B. Record reviewThe February 2024 CPO documented:-Oxygen by nasal cannula at 3 LPM continuously - ordered 1/22/24. A review of the resident's medical record did not indicate that a comprehensive care plan had been developed for the resident's use of oxygen therapy. IV. Resident #3 statusResident #3, under the age of 65, was admitted on 8/3/23. According to the February 2024 CPOs, diagnoses included chronic pain, hemiplegia (paralysis to one side of the body), and hemiparesis (weakness to one side of the body) following a cerebral infarction (stroke) that affected her left side. The 11/2/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required total assistance of two people with all activities of daily living. A. Resident interview and observationResident #3 was interviewed on 2/8/24 at 8:45 a.m. The resident said her nose felt dry and was hurting. She said the jar on her oxygen concentrator had been empty for a couple of days. Resident #3 had a nasal cannula in her nose and her oxygen concentrator was set to 2 LPM.. The oxygen concentrator had a jar for distilled water connected to it, however the jar was empty. B. Record reviewAccording to the February 2024 CPO, the resident's oxygen saturation was to be kept greater than 90% - ordered on 8/4/23. A review of Resident #3's medical record did not reveal documentation that a comprehensive care plan had been developed for the resident's use of oxygen therapy. V. Resident #10 statusResident #10, older than 65, was admitted on 12/29/21. According to the February 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, obstructive sleep apnea (OSA), generalized muscle weakness, and hypertension (high blood pressure). The 2/1/24 MDS assessment revealed the resident did not have cognitive impairment with a brief interview for mental status score of 15 out of 15. She required one person assistance for transfers, personal hygiene and toileting. It indicated that the resident required continuous oxygen. A. Resident interviewResident #10 was interviewed on 2/6/24 at 10:51 a.m. Resident #10 said that her oxygen concentrator was always out of water. She said that her oxygen concentrator had been empty for a week or longer. B. ObservationsOn 2/6/24 at 10:51 a.m., 2/7/24 at 2:58 p.m. and 2/8/24 at 8:12 a.m., Resident #10's oxygen concentrator was empty of distilled water. C. Record reviewThe February 2024 medication administration record (MAR) documented that the resident required oxygen via nasal cannula at 3 LPM related to her diagnosis of COPD - ordered on 11/23/2018. VI. Staff interviewsThe director of nursing (DON) was interviewed on 2/6/24 at 4:30 p.m. She said the nurses and certified nursing aides (CNA) were responsible for refilling the jars with distilled water for the oxygen concentrators. She observed the empty jar in Resident #25s room. She took the empty jar to the nurse's station, refilled the jar with distilled water and then reattached it to the oxygen concentrator. She said the facility did not have a process in place to ensure oxygen concentrator jars remained full of distilled water. She said the facility had eight gallons of distilled water, which was kept at the nurse's station. She said all residents wearing oxygen received humidification through the oxygen concentrators. The DON said there was an empty jar of distilled water on Resident #3's oxygen concentrator. She refilled the jar and connected it to the concentrator. CNA #6 was interviewed on 2/7/24 at 3:55 p.m. She said that CNAs or nurses were able to refill oxygen concentrators. CNA #6 said the supply room had several bottles of unopened distilled water intended for oxygen humidification containers. She said she did not know whose responsibility it was to ensure the oxygen concentrators had distilled water. The DON was interviewed on 2/8/24 at 9:00 a.m. She acknolwedged the empty jar of distilled water on Resident #3's oxygen concentrator. She refilled the jar and connected it to the concentrator.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference citations: -F677 activities of daily living for dependent residents; and, -F689 accident hazards. Findings include:I. Resident care needsThe facility census was 38 residents. Licensed practical nurse (LPN) #2 was interviewed on 2/9/24 at 10:30 a.m. LPN #2 said there were two residents who required a two person transfer using a mechanical Hoyer lift. She said there were five residents who required extensive assistance with eating. She said out of the 38 residents there were only five residents who required minimal assistance with activities of daily living. She said all 38 residents required supervision and assistance with showering. II. Staffing requirements for each station (east and west)The director of nurses (DON) was interviewed on 2/8/24 at 11:19 a.m. The DON said the facility had 38 residents. She said the staffing structure was two licensed nurses on the day shift and four certified nurse aides (CNAs) on the day shift. She said an extreme low would be three CNAs. Evening shift typically had two licensed nurses one of which was an registered nurse (RN) and three CNAs for the evening shift. The night shift one licensed nurse and one CNA. III. Resident council minutesThe 11/21/23 resident council meeting documented the residents had concerns in regards to call lights taking too long to be answered and showers not being completed timely. IV. Resident interviews Resident #8 was interviewed on 2/5/24 at 3:00 p.m. Resident #8 said the facility did not have enough staff. He said he had to wait a long period of time for assistance. V. Resident group interview A resident group interview was conducted on 2/7/24 at 9:30 a.m. with six alert and oriented residents (#9, #10, #17, #20, #21 and #22). All residents in the group interview said there was not enough nursing staff. Some of the comments were as follows:-Showers, making beds, brushing teeth and washing their faces got skipped because there was not enough staff.-Answering call lights took 25 minutes and longer.-There were typically two CNAs during the day, two during the evening and one at night during the week, which was not enough to take care of them. -There were typically two nurses during the day, one during the evening and one at night during the week, which was not enough to take care of them.-Weekends had even less staff than listed above. -When they brought this concern to the administration, they were told there was a "shortage of staff everywhere."-There was traveling nursing staff used in the past however, it was not used any longer.-Some of the residents have resorted to checking on one another when they have noticed call lights were on. VI. ObservationsOn 2/7/24 at 8:15 a.m. there was a certified nurse aide (CNA) and the restorative aide working the floor for 38 residents. At 8:35 a.m., there was only one CNA assisting five residents with their meals. The DON was working the mediation cart. On 2/8/24 at 8:05 a.m. three CNAs and one RN were scheduled. The DON was working the medication cart. At 4:00 p.m. the DON was working the medication cart. She said she had a nurse on vacation and therefore had to work the medication cart. On 2/9/24 at 8:00 a.m., the nursing home administrator, who was a RN, was working the floor as a CNA. The DON was working the medication cart. VII. InterviewsThe facility staff who were interviewed wished to stay anonymous. Numerous staff said they were told not to discuss staffing issues or other concerns with the survey team. The interviews were as follows:Anonymous staff member #1 was interviewed on 2/6/24. The staff member said the facility was always short on staff. The staff member said it was difficult to get all showers for residents completed and to provide timely meal assistance to dependent residents. Anonymous staff member #2 was interviewed on 2/7/24. The staff member said the past weekend there was only one CNA assigned on the day shift. Anonymous staff member #3 was interviewed on 2/7/24. The staff member said call lights were not answered timely because not enough staff. Lunch and dinner breaks were not taken as there was not enough time. Showers were not completed as scheduled and incontinence care was not performed timely. The facility had staffed five CNAs during the survey inspection on 2/6/24 which was not a normal situation. Anonymous staff member #4 was interviewed on 2/8/24. The staff member said it was difficult to perform good care to residents as they did not have enough time. The staff member said there was no one they felt comfortable talking to the administration. The staff member said Hoyer lifts were completed with one staff member when they were supposed to have two staff. Licensed practical nurse (LPN) #2 was interviewed on 2/9/24 at 8:40 a.m. The LPN said the facility currently had two CNAs on the floor and the NHA was working the floor. She said she could not leave only two CNAs on the floor to take care of all the residents. She said they had three scheduled, however, one CNA called and quit. The DON was interviewed on 2/8/24 at 11:18 a.m. The DON said three CNAs scheduled during the day was considered an extreme minimum. The DON said she started her employment 12/13/23. She said she did identify areas in nursing care which needed to be addressed, however, she did not have enough time to put together plans to fix them. She said she had been addressing the showers not happening as scheduled. She said she was always available to help the CNAs with care but if they did not ask she could not help. She said she had been working the medication cart a lot this past week as she had a nurse on vacation. She said the facility was actively working on hiring staff. The DON did not respond when asked how the CNAs were able to get the resident cares and responsibilities done during meal times with two CNAs. The corporate nurse consultant (CNC) was interviewed on 2/9/24 at 8:50 a.m. The CNC said the facility was attempting to hire two RNs and currently had four NA in the certification program.

Based on record review and interviews, the facility failed to provide appropriate pharmaceutical services to meet the needs of residents for one (#1) of three residents reviewed for pharmacy services out of 25 sample residents. Specifically, the facility failed to ensure medications were available to prevent missed doses of Prostat liquid (a protein supplement for wound healing) for Resident #1. Findings include:I. Facility policy and procedureThe Medication Ordering and Receipt policy, revised June 2017, was received from the nursing home administrator (NHA) on 2/8/24 at 8:57 a.m. The policy documented in pertinent part, "Routine (tab/capsule) medication orders will be cycle filled every 24 hours and delivered to the facility on a daily basis. Unit dose bulk medications (liquids, creams, patches, ophthalmic, inhalers) and controlled substances must be reordered by the facility when there is no more than a four day supply of medication remaining."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 5/17/21. According to the February 2024 computerized physician orders (CPO), diagnoses included muscles weakness, Parkinson's disease (progressive disorder affecting the nervous system and parts of the body controlled by the nervous system) with dyskinesia (abnormal movements), gait (walking) abnormalities, muscle wasting and cerebral infarction (stroke). The 1/19/24 minimum data set (MDS) assessment documented the resident was rarely/never understood. It documented that the resident required substantial/maximal assistance for activities of daily living (ADLs) which included bathing, toileting, dressing and mobility. B. Record reviewReview of the January 2024 CPO revealed Resident #1 had a physician's order for Prostat liquid 30 milliliters (ml) to be given twice daily.-The medication had an order date of 12/15/23 and was discontinued on 1/31/24.-Review of Resident #1's January 2024 medication administration record (MAR) revealed the resident did not receive the Prostat liquid protein nutritional supplement from 1/2/24 through 1/13/24, 1/15/24, 1/23/24, 1/24/24, 1/28/24 and 1/29/24. The administration code for the dates of the missed medication doses was documented as "Other/See progress notes". The progress notes for the dates of the missed medication doses documented the following reasons for the missed doses:-Prostat liquid 30 ml two times a day for supplement was unavailable;-Waiting on order;-On order;-Waiting for medication from pharmacy;-Needs to be ordered; and,-Waiting on pharmacy.-There was no documentation in Resident #1's electronic medical record (EMR) to indicate the resident's family or physician was notified regarding the medication being unavailable and/or the resident missing several doses of medication. C. Staff interviewThe director of nursing (DON) was interviewed on 2/8/24 at 11:18 a.m. The DON said nurses were instructed to order medications in a timely fashion (two to three days before the medication ran out) so medication administration did not get missed. She said she was aware of Resident #1's missing Prostat. She said the Prostat was not ordered because the nursing staff was new and the nurse who used to order medications was no longer working at the facility. The DON said there was a "gap in communication that was never closed" on who was to reorder the medication. She said she did not know of a backup pharmacy the facility used when medications were unavailable. She said the bedside nurse should always notify the family of the resident and the physician when medications were not given.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#10 and #14) of two residents reviewed for medication errors out of 25 sample residents. Specifically, the facility failed to ensure:-Resident #10 was administered her chronic obstructive pulmonary disease (COPD) medications ordered for nearly a week; and, -Resident #14 was administered his medication for Huntington's disease. Findings include:I. Facility policy and procedureThe Medication Ordering and Receipt policy and procedure, dated 6/21/17, was provided by the director of nursing (DON) on 2/8/24 at 8:57 a.m. It documented in pertinent part, "Non-dose bulk medications such as inhalers, liquids, creams, and patches must be reordered by the facility when there is no more than a four day supply of medication remaining."II.. Resident #10A. Resident statusResident #10, age 95, was admitted on 12/29/21. According to the February 2024 computerized physician orders (CPO), diagnoses included COPD, anxiety, obstructive sleep apnea, generalized muscle weakness and hypertension (high blood pressure). The 2/1/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behavior symptoms were noted. She required assistance for transfers, personal hygiene and toilet use, medications and had no rejection of care. B. Resident interviewResident #10 was interviewed on 2/6/24 at 10:51 a.m. Resident #10 said she did not receive her medication for COPD for a week. Resident #10 said she remembered that not receiving her medication affected her by making her very tired. She did not participate in any activities all week as she usually did. Resident #10 said she just ate breakfast, lunch and dinner and laid down in her bed as she was too weak and tired to do anything else. C. Record reviewThe February 2024 CPO showed an order for Anoro Ellipta one inhalation. Inhale orally one time a day for COPD. Ordered 12/29/23. The January 2024 medication administration record (MAR) showed the Anoro Ellipta medication was not administered on 1/5/24, 1/7/24, 1/8/24, 1/9/24, 1/10/24, 1/11/24 and 1/12/24. -A review of the progress notes revealed the medication was not available from the pharmacy on each day. III. Resident #14 A. Resident statusResident #14, age 70, was admitted on 1/13/24. According to the February 2024 CPO, diagnoses included generalized weakness and Huntington's disease. The 1/26/24 MDS assessment showed the resident had no cognitive impairment with a score of 13 out of 15 on the BIMS assessment. The resident required partial to moderate assistance with activities of daily living. B. Record reviewThe February 2024 CPO documented the following orders:-Gabapentin 600 mg three times a day for Huntington's disease, ordered 7/5/19.-Tetrabenazine 25 mg two times a day for Huntington's disease, ordered 8/12/19. -Austedo 12 mg twice a day for Huntington's disease, ordered 1/14/24. The January and February 2024 MAR and progress notes revealed: -Two doses of Gabapentin out of five ordered doses were administered between 1/13/23 to 1/14/23.-A review of the progress notes revealed Gabapentin was not available from the pharmacy on 1/13/24 and 1/14/24.-Tetrabenazine 25mg was not administered out of three medication administration opportunities between 1/13/24 and 1/14/24.-A review of the progress notes revealed Tetrabenazine was not available from the pharmacy on each day.-Austedo 12mg was missed for a total of 10 doses on 1/17/24, 1/18/24, 1/9/24, 2/4/24, 2/5/24, 2/6/24 and 2/7/24. -A review of the progress notes documented the Austedo was not available from the pharmacy on 1/17/24, 1/18/24, 1/19/24, 2/4/24, 2/5/24, 2/6/24 and 2/7/24. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 2/7/24 at 8:51 a.m. LPN #2 said bedside nursing staff were not responsible for ordering medications. LPN #2 said the facility administration ordered medications for residents. The pharmacist was interviewed on 2/7/24 at 12:21 p.m. The pharmacist said Resident #14 had two fill orders for his Austedo on 1/17/24 and 2/3/24, both of which were filled on those days. The pharmacist said orders were not sent to the pharmacy for Resident #14's Gabapentin or Tetrabenazine. The director of nursing (DON) was interviewed on 2/7/24 at 2:06 p.m. The DON said medication orders by the physician should always be followed. The DON said that if a resident with Huntington's disease did not receive their medication, the doctor to be notified, the resident's family to be notified, herself to be notified and an assessment of the resident should be conducted. The DON said the information should be documented in the resident's progress notes. The medical director (MD) was interviewed on 2/7/24 at 2:52 p.m. The MD said Resident #10's Anoro Ellipta was an important medication for chronic obstructive pulmonary disorder (COPD) management and keeping the resident out of the hospital. The MD said he had not been notified the resident did not get this medication for six days and said he should be notified if a resident could not receive their Anoro Ellipta medication.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include:I. Resident group interviewA resident group interview was conducted on 2/7/24 at 9:30 a.m. with six cognitively intact residents (#9, #10, #17, #20, #21, and #22). All the residents in the group said the food was not palatable. Additional resident concerns and comments from the group interview included:-The food was not seasoned well, it was either not seasoned at all or very salty;-Residents had to bring their own seasoning to the dinner table;-The evening cook and weekend cook were inconsistent with the addition of seasoning and the food was worse on evenings and weekends;-One resident said she often bought her own ravioli and would ask for that for dinner if she did not like what was being served for dinner;-The food was always served cold;-The vegetables were cooked but served cold and there were always raw carrots in the mix of cooked vegetables; -Room trays did not always come with condiments; and, -Residents said they would like to have ice cream anytime rather than just on Saturdays.-The residents said they had been told for months by the food committee that they were "working on" the residents' complaints. II. Resident interviews Resident #8 was interviewed on 2/5/24 at 3:00 p.m. Resident #8 said that he had resided at the facility for a while. He said the food was not good. He said it was not seasoned and it was served cold. He said he purchased his own food so he could eat it if the meal was not palatable. Resident #19 was interviewed on 2/5/24 at approximately 3:30 p.m. Resident #19 said the food was served cold and the food did not have enough seasoning. III. Resident council minutesThe 11/21/23 food committee minutes showed the residents had concerns with the vegetables being served cold and not fully cooked. The residents requested ice cream more often and not just on Saturdays. The 12/19/23 resident council minutes showed the residents had concerns with vegetables being served cold. Residents requested to be served ice cream more often. IV. ObservationThe evening meal was observed on 2/6/24 beginning at 5:15 p.m. in the dining room. The plates used to serve the residents' food were only slightly warm. The chocolate pie did not have any mechanism to keep it cold such as refrigeration or ice. On 2/6/24 at 5:35 p.m., the room trays arrived on the floor. There were nine trays on the cart. -There was no salt, pepper or other condiments provided with the room trays. V. Test trayA test tray, regular diet was evaluated on 2/6/23 at 5:50 p.m. The following observations were made:-The steak sandwich was 105.6 degrees fahrenheit (F) and was cold to the palate;-The mixed vegetables were 112.6 degrees F and were cold to the palate; and,-The chocolate pudding was 62.6 degrees F and was lukewarm to the palate. VI. InterviewCook (CK) #1 was interviewed on 2/6/24 at 12:30 p.m. CK #1 said the facility no longer ordered ice cream in the small ready to serve containers. She said she had been told ice cream was not to be served except on Saturdays. The dietary manager (DM) was interviewed on 2/7/24 at 2:00 p.m. The DM said the facility did not have the heating element which went with the thermal plate cover. She said the plate warmer was not working properly and therefore the food was not put onto hot plates. She said she was aware of the residents' food complaints. She said she had been working with the cooks on knife skills and cooking standards. She said the cart with the room trays had condiments on it and the server needed to offer the condiments to the residents when the trays were delivered. The social worker (SW) was interviewed on 2/8/24 at 10:26 a.m. The SW said she had heard the food needed some improvement. The nursing home administrator (NHA) was interviewed on 2/9/24 at 10:04 a.m. The NHA said the reason ice cream was not being served to residents other than Saturdays, was because the residents were not eating their meals and eating too much ice cream. She said the facility was going through a gallon of ice cream a day. The NHA said ice cream floats or other treats were served during activities.

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

A revisit survey was completed on 8/09/23 for all previous deficiencies cited on 6/15/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 8/09/23 for all previous deficiencies cited on 6/15/23 . The facility is in compliance with all regulations surveyed.

This survey was conducted by the Colorado Division of Fire Prevention and Control in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility's general characteristics. The facility is a one (1) story Type V (111) protected wood frame structure which includes a complete National Fire Protection Association (NFPA) 13 automatic fire suppression system. Current census is 40 beds of a 58 bed facility and was surveyed on July 11, 2023 for compliance with chapter 19 "Existing Health Care Occupancies" of the 2012 edition of NFPA 101- Life Safety Code, and other referenced publications. The facility will meet these requirements when the following deficiencies are corrected. The survey concluded with an exit conference, a discussion of the deficiencies with the Administrator and the Maintenance Director

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit cannot be identified during an emergency. This was evidenced by the following: 1. Emergency lighting in rehab room not working 2. Exits signs needed for courtyard access and egress out of the courtyard NFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. The exit sign deficiencies were during the exit conference.

Through observation during the course of the survey, it was determined that the facility failed to maintain the oxygen-transfer-room in accordance with NFPA 99, 11.3.2.3. This deficient practice could affect all residents through-out the facility by failing to provide safeguards for the storage of non-flammable medical oxidizing gases. This was evident by the following:1. Flammable materials (plastic) stored in oxygen transfer rooms NFPA 101, 19.3.2.1.3 Doors. Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 21.2.2.4.2. 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: Cylinders shall be protected from damage by means of the following specific procedures:a. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.b. Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.c. Cylinders shall be protected from tampering by unauthorized individuals.d. Cylinders or cylinder valves shall not be repaired, painted, or altered.e. Safety relief devices in valves or cylinders shall not be tampered with.f. Valve outlets clogged with ice shall be thawed with warm - not boiling - water.g. A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.h. Sparks and flame shall be kept away from cylinders.i. 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.j. 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.k. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.l. Cylinders shall not be supported by radiators, steam pipes, or heat ducts. This deficiency has the potential to affect staff, visitors, and residents alike in the event of an emergency due to fire in a space that is enriched with oxygen. The oxygen storage and transfer room deficiency items were discussed with the Director of Maintenance and Administrator at the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25,5.2.1.1.1. This was evidence by the following. 1. Missing five year internalNFPA 25, 14.2.1 Inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one 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 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12, and NFPA 25, 5.2.1 NFPA 25, 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. NFPA 25, 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. The deficiencies were discussed during the exit

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3This was evidenced by the following: 1. Rms 31, 36 door won't close NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. This was discussed during exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Penetration in ceiling in mechanical room and vault NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. The smoke barrier deficiency has the potential to affect all residents, visitors, and staff within those smoke compartments. The deficiencies were discussed during the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. This was evidenced by the following:1. Gas orifice on dryer rated for 0-2000 feet in elevation in laundry room. NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer's installation instructions. This deficiency was discussed during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain proper electrical practices in accordance with Life Safety Code Section 19.5.and NFPA 70, 110.26. This was evidenced by the following:1. FACP breaker does not possess a lock out device in electrical panel NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical CodeNFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. NFPA 70, 110.26 Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. This deficient practice could affect all occupants and staff through-out the facility during an emergency. This deficiency was discussed during the exit conference.

A survey prompted by complaint #CO32715 was completed 6/12/23 to 6/15/23. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#20) of six residents reviewed for falls out of 24 sample residents. The facility failed to ensure Resident #20, who had nine falls within six months, had effective interventions, supervision and assistance in place to prevent further falls. Resident #20 suffered multiple falls with injuries including lacerations to his face and his head, including an emergency room visit where he received six stitches and he continued to fall. Findings include:I. Facility policyThe Nursing Services Policy and Procedure Manual for Long-Term Care, revised April 2018, was provided on 6/15/23 at 3:07 p.m. by the nursing home administrator (NHA). It read in pertinent part, "The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling."II. Resident #20A. Resident status Resident #20, age 73, was admitted on 2/10/2020. According to the June 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic pain, muscle weakness, lack of coordination, unspecified abnormalities of gait and mobility, dementia and other abnormalities of gait and mobility. The 6/6/23 facility assessment showed that Resident #20 had severe cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The facility assessment indicated Resident #20 required extensive assistance with transfers and toilet use and limited assistance from caregivers for walking around his room. His balance was unsteady and he needed assistance to balance himself. He used a walker or wheelchair for ambulation. Resident #20 was listed as having one fall since admission or most recent assessment.-However, Resident #20 had nine falls within a six-month period (see record review below). B. Resident interviewResident #20 was interviewed on 6/14/23 at 2:52 p.m. He stated he was supposed to use his call light when he wanted to get up. Resident #20 said the caregivers did not respond in a timely manner to call lights, especially when he had to use the restroom. "I got to do what I got to do, so I would walk to the bathroom alone and fall." Resident #20 had signage around his room that documented, "Please remember to use your wheelchair or walker at all times." He explained how previous falls led to his placement at the facility and he kept falling during his stay. He said staff kept his wheelchair out of reach so he would not use it without calling for assistance but he still got up anyway when he could not wait any longer to use the restroom. Resident #20 stated he used to have a walker but the facility did not want him to use it anymore due to falling a lot and removed it from his room.-The use of a wheelchair and no walker and keeping the wheelchair out of the resident's reach so he would ask for assistance was not included in the care plan (see below). C. ObservationsOn 6/12/23 at 2:00 p.m., Resident #20 was observed walking out of his room into the hallway. A staff person approached and asked him why he was walking, then helped him back into his room and closed the door. During the resident interview on 6/14/23 at 2:52 p.m. (above), no walker was observed in his room. He was in bed and his wheelchair was at the foot of his bed facing away from him toward the wall. Resident #20 was observed throughout the survey, from 12:00 p.m. to 6:00 p.m. on 6/12/23 and from 8:30 a.m. to 6:00 p.m. on 6/13, 6/14 and 6/15/23. He spent most of his time in his room with his door closed, except for meals and going outside to smoke. He ambulated in his wheelchair independently wheeling himself through the facility to the back door and received assistance from staff to exit the back door to the smoking area. D. Record reviewAccording to the fall risk care plan, initiated on 9/15/21 and most recently revised on 4/18/23, Resident #20 was listed as weight-bearing and he needed assistance from one staff member to ambulate. Resident #20 also needed limited assistance from one staff for when he walked around and as needed (PRN) in his wheelchair. Resident #20 was listed as a high fall risk due to a diagnosis of Parkinson's disease which would affect his coordination and gait. Interventions were the following:"-Anticipate and meet the resident's needs (9/15/21).-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (9/15/21).-Resident #20 forgets to use his walker or wheelchair and needs reminders to use his call light and allow staff to assist with transfers (undated).-Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (10/12/21).-Ensure proper positioning when in wheelchair (4/18/23).-Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair (9/15/21).-Follow facility fall protocol (9/15/21).- 'I like to get myself up and into my wheelchair, please make sure my wheelchair is within easy reach' (6/13/23, during the survey).-Offer frequent assistance to the bathroom, assist in keeping clean, dry, and comfortable (10/1/21 and 6/13/23).-Signage placed in room to remind resident to use his wheelchair and walker when ambulating (9/21/22).-Place signage around my room to remind me to use my call light and wait for assistance (11/15/22).-Place wheelchair wedge with support to help with falling (4/17/23).-Push wheelchair when outside (4/18/22)."-The resident's actual falls with injury were not documented in his care plan.-There was no evidence of tracking and trending the times of day or night the resident had fallen, in order to develop more effective fall prevention measures.-The care plan did not define how frequently the resident should be offered assistance to the bathroom.-New interventions following each fall were not added to the care plan.-No wedge cushion was observed in the resident's wheelchair during the survey.-No signage was observed in the resident's room to remind him to use his call light for assistance.-The resident's wheelchair was not within his reach in keeping with the care plan, per observation and resident interview. Review of nursing progress notes and fall investigations for the previous six months revealed:1. Unwitnessed fall on 1/17/23 Resident #20 had an unwitnessed fall on 1/17/23 at 1:49 a.m. He was found on the bed on his hands and knees, cursed at staff, and said he had fallen to the floor. No injuries were noted. -No fall investigation was provided. 2. Witnessed fall on 2/9/23Resident #20 had a witnessed fall on 2/9/23 at 4:45 p.m., with an injury that led to an emergency room visit. He had a laceration to the right eyebrow and received six stitches in the hospital. He had been ambulating in the hall behind his wheelchair, tripped and fell, hitting the right side of his face.-The facility failed to correct how Resident #20 was utilizing his wheelchair which resulted in an injury. The facility failed to provide limited assistance with walking due to the resident being unsteady and supervision to ensure timely assistance to prevent falls with injury. 3. Unwitnessed fall on 2/17/23Resident #20 had an unwitnessed fall on 2/17/23 at 5:15 p.m. (late entry documented at 9:28 p.m.) He came out of his room and told staff he fell while he was walking across the room. He had a laceration to the right side of his forehead, no bleeding or swelling and no other injuries. Witnessed fall, staff involved, on 3/16/23Resident #20 had a witnessed fall on 3/16/23 at 6:57 p.m. Staff were pushing him in after smoking, his wheelchair caught on the door threshold, pitching him from the wheelchair to his knees. He had abrasions on both knees. 4. Unwitnessed fall on 3/27/23Resident #20 had an unwitnessed fall on 3/27/23 at 9:33 p.m. according to nursing notes which documented no further details other than that neurological checks were initiated. No injuries were noted. 5. Witnessed fall on 4/13/23Resident #20 had a witnessed fall on 4/13/23 at 9:35 p.m. He was outside in his wheelchair, hit a groove in the concrete causing him to fall. He hit his head and suffered a laceration above his right eye. The nurse cleaned, steri-stripped, provided an ice pack and initiated neurological checks. The resident later had swelling to the right side of his face. Review of the facility investigation revealed the interdisciplinary team (IDT) recommendation for a new intervention was education. The facility documented in the report they updated the care plan to reflect the recommendation.-However, the care plan was not updated regarding education.-The type of education to be provided and to whom was not documented in the investigation.-The care plan intervention to supervise the resident for safety when he was outside was not updated until 4/18/23, five days later. 6. Unwitnessed fall on 4/16/23On 4/16/23 at 1:35 p.m., Resident #20 fell and sustained an abrasion to his hand. The fall investigation determined Resident #20 fell out of his chair onto his knees and scraped his hand. The previous intervention was listed as a wedge (cushion) for Resident #20's wheelchair. A new intervention was documented to ensure proper positioning in the wheelchair. The facility documented in the report they updated the care plan to reflect the recommendation.-The care plan was not updated until after the resident's second fall outside although the 4/16/23 fall was caused by staff. -The care plan was updated regarding the wedge cushion, but it was not observed in the resident's wheelchair (see observations above). 7. Unwitnessed fall on 5/17/23On 5/17/23 at 12:42 a.m., Resident #20 was found sitting on the floor in front of his bed. The fall investigation determined he was getting up to go to the bathroom, slipped, and fell onto his buttocks. Previous interventions were documented as education and signage. A new recommendation was entered as a referral to physical therapy (PT). The facility documented in the report they did not update the care plan based on the new intervention. He suffered two skin tears on his right hand.-Although, the resident was going to the bathroom without assistance, the care plan was not updated with specific interventions about anticipating the resident's bathroom assistance needs and how often to provide the assistance.-He was already receiving PT at the time of this fall according to therapy notes.-The care plan was not updated after the 5/17/23 fall. 8. Unwitnessed fall on 6/8/23On 6/8/23 at 9:28 p.m., Resident #20 was found sitting on the floor (with no noted injuries) in his room, holding his knees. The resident's roommate had to use his call light for assistance. The resident's wheelchair was four to five feet away from him. The fall investigation determined Resident #20 was headed to the bathroom when he slid down onto the floor off his bed. Previous interventions were documented as education and signage. A new recommendation was entered to maintain his wheelchair within easy reach of Resident #20. The facility documented in the report the care plan was updated with this recommendation.-However, observation and resident interview (above) revealed the resident's wheelchair was not consistently kept within his reach.-The care plan was not updated regarding timely bathroom assistance, although the resident fell attempting to go to the bathroom without assistance.-There was no recommendation for, or evidence of, PT or restorative services following this fall. Therapy notes revealed he was discharged from PT on 6/5/23, where he had been working on training in wheelchair propulsion and maneuvering within his environment. Resident #20's fall assessment completed 6/8/23 showed he had a fall risk score of 55, indicating high fall risk.-No further fall risk assessments were provided.-Review of the times Resident #20 fell revealed most of his falls happened late at night or early morning. However, there was no evidence the facility identified this trend to identify root causes, meet the resident's needs, and implement measures to meet those needs. Review of IDT notes on 6/13/23 revealed Resident #20 had many falls. Resident #20 utilized his wheelchair as a walker and agreed to utilize it how it was meant to be used. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/15/23 at 8:40 a.m. CNA #1 explained occasionally the facility was short staffed and they worked with what they had but it delayed the time it took to answer call lights. "We manage the best way we can when we are understaffed." CNA #1 said Resident #20 fell a lot due to his Parkinson's disease and not waiting for the nursing staff to answer his call light. CNA #1 explained Resident #20's fall precautions were signs posted in his room and that staff needed to stop him if they saw him ambulating. Staff located fall precautions and care instructions in the care plan but CNA #1 did not know how to find care plans so she relied on signs posted in the residents' rooms. Nurse aide (NA) #3 was interviewed on 6/15/23 at 9:14 a.m. NA #3 stated a lot of falls occurred because call lights were not answered in a timely manner and residents would get impatient waiting for a response. She stated the facility was usually understaffed therefore staff did not answer call lights. She explained Resident #20 would get up independently and staff constantly needed to remind him to use his call light and wheelchair. Resident #20 typically did not like to wait for staff to answer his call light so he would walk himself where he needed to go. He was on hourly checks and staff reminded him not to walk around on his own. NA #3 did not know how to look up care plans and relied on signs posted in the residents' rooms or asked other floor staff what each resident needed specifically. Physical therapy aide (PTA) #1 was interviewed on 6/15/23 at 3:30 p.m. regarding Resident #13's fall and recovery. PTA #1 stated Resident #20 had just been discharged from physical therapy (PT) in June 2023. He was still being treated by restorative therapy because he had reached his maximum physical capability due to his diagnosis of Parkinson's disease and there was nothing more to be done with PT.The nursing home administrator (NHA) was interviewed at 2:00 p.m. on 6/15/23 and Resident #20's fall investigations were requested. The NHA said it would be a "huge stack" of documentation since the resident had frequent falls. She did not say why the resident fell so frequently or what prevention measures the facility was taking. At 2:30 p.m. on 6/15/23 she provided only four fall investigations: for 4/13/23, 4/16/23, 5/17/23 and 6/8/23.

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

A recertification survey with complaint #CO32462, #CO32496 and #CO32504 was completed on 6/12/23-6/15/23. Seven deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/12/23 to 6/15/23. No deficiencies were cited.

Based on observations and interviews, the facility failed to ensure residents had safe, clean, comfortable and homelike environments in two of two resident hallways and one of two shower/tub rooms. Specifically, the facility failed to ensure:-Resident rooms were clean and in good repair;-Resident rooms were stocked with clean bath linens;-Room temperatures were maintained for resident comfort;-The shower room was safe, clean and in good repair; and,-The bath tub was in working order and available for resident use. Findings include:I. Facility policy and procedure Although requested on 6/15/23 from the maintenance director, the facility did not provide policies related to general maintenance, housekeeping or linens. II. ObservationsThe following was observed during the initial tour of the facility beginning at 12:35 p.m. on 6/12/23:A. East Hall Room 15: The temperature felt warm. Room 8: The closet smelled of urine, there were no linens in the room. The room temperature felt hot. Room 10: The floor was sticky with a yellow hue and the room smelled of urine. The bathroom floor and sink had spots and smudges and no linens were in the room. There were two televisions side by side. One television had no sound and words across the screen and the other television was loud. The resident by the window said the room was too noisy because of his roommate's television, his own television did not work and he could not find the remote. Room 7: The temperature felt hot. Room 6: The temperature felt hot and only one hand towel was in the bathroom. Room 3: There were no linens in the room and the room temperature felt hot. Room 2: There was one hand towel and one washcloth for two residents. The room temperature felt hot. B. West Hall Room 26: The room temperature felt warm and the resident's window had no screen. C. Additional observations6/13/23 at 9:11 a.m. room 10 smelled of urine and the floor was sticky and had a yellow hue. At 9:08 a.m. the temperature in room 25 felt hot. At 1:21 p.m. the temperature in room 23 felt hot. Throughout the survey, conducted from 12:30 p.m. to 6:00 p.m. on 6/12/23, and from 8:00 a.m. to 6:00 p.m. on 6/13, 6/14 and 6/15/23, it was observed throughout the facility that residents did not consistently have towels and washcloths in their rooms. Some rooms had no linens at all, only soap and paper towels. The shared rooms did not have sufficient linens according to observations during the survey. III. Resident interviewsResident #25 was interviewed on 6/12/23 at 1:53 p.m. He said his room was "too warm" and he would like something done about it. Resident #16 was interviewed on 6/12/23 at 2:22 p.m. He stated if he needed linens he had to call staff and request more linens. Resident #26 was interviewed on 6/12/23 at 2:50 p.m. She said her room was so hot, she had to borrow a fan from another resident. She said she had complained to staff about the temperature of the room but was told that "she just needed to go along with it." She said she had brought a small air conditioner but was waiting to have it installed in her window. She said she has to keep her door and window open for the airflow. She said her window did not currently have a screen in it. She said she was concerned that bugs may come into her room. The resident's window was observed not to have a screen. Resident #6 was interviewed on 6/12/23 at 4:35 p.m. She stated her room was 63 degrees Farenheit in the winter and she was freezing. "Now the temperature is too warm and I have to use a fan." She stated she had to purchase a window air conditioner and the facility would be installing it soon. Resident #30 was interviewed on 6/13/23 at 9:08 a.m. He had two fans going in his room. He said his room got very hot during the day. Resident #30 said he had told staff that his room was too hot. He said staff told him that they had the ability to cool the facility but then other residents would be too cold. He said he had to get his own fans for the room to help cool it down. Resident #13 was interviewed on 6/13/23 at 1:03 p.m. She said her room "gets really hot," especially if she had to close her door. Resident #3 was interviewed on 6/13/23 at 1:21 p.m. She said she liked to have her door closed but when the door was shut, her room got too hot. The resident requested the door be left partially open after the interview. IV. Resident group interviewThe resident group interview was conducted on 6/13/23 at 9:45 a.m. with five interviewable residents: #6, #11, #13, #24 and #25. Several residents said the facility did not provide sufficient towels and washcloths in their rooms. Resident #13 said she used her own towels and washcloths from home because she had asked for them and did not receive them from the facility. Resident #11 said she had one small towel in her room but no washcloths. Resident #24 said, "There seems to be a problem with sufficient linens." Regarding room temperatures, several residents said their rooms were too hot. Resident #6 said she just got her air conditioner installed that morning. Resident #25 asked how she got it and Resident #6 said she bought it herself. Resident #25 said the first thing people said to him when they visited him was, "Is your room always this hot?" Resident #11 said if she kept her door shut her room got too hot. Resident #25 said the heating system was the problem: "You can open the windows and it won't change the balance of the heat and cold." Resident #11 said it was cool in the hall but not in the rooms. V. Staff interviewsA housekeeper was interviewed on 6/12/23 at 1:54 p.m. She said the resident rooms were warm and she was not sure if the maintenance department had adjusted the thermostat. The maintenance director was interviewed on 6/14/23 at 9:30 a.m. He said he would install window air conditioner units in Resident #25's and Resident #3's rooms within the next hour and a half. He said he would also explore ways to turn off the heat during the day and back on at night or move the thermostat location so the heater would not be triggered by the swamp cooler vents, for the comfort of all the residents. During a follow-up interview at 10:00 a.m. he said the better solution was to turn down the thermostat to 60 degrees so it would not kick on during the day and would kick on at night for resident comfort since it was still getting down to 44 degrees at night. He said he did not have an ambient thermometer to measure the temperatures in residents' rooms. IV. Environmental tour observations and interviewsThe environmental tour was conducted on 6/15/23 at 9:00 a.m. with the MSD who was in charge of maintenance and housekeeping in the facility. Room 15The room was very hot and the newly installed air conditioner (AC) window unit was set at 90 degrees. The maintenance director (MSD) turned it to "high cool" when the resident said his room was too warm. The MSD said he did not have an ambient thermometer to check the room temperature. The two baseboard wall heater units were warm to the touch and the MSD said the heat was on because it was still 55 degrees outside. The MSD explained to the resident how to control the temperature in his room using the window AC unit. The resident told the MSD, "They have one bath tub here and it isn't working." The MSD confirmed it was not working, and said the mechanisms that sealed the tub were badly damaged. The lock that locked the tub down was stripped and broken. The MSD said the estimated time on getting the tub repaired was two to three weeks. The resident reiterated, "It's the only tub and it's broken." The resident said he could not use the showers (see observation of the shower below). Regarding the resident complaints about room temperatures being too hot, the MSD said the facility boiler was repaired around January 2023 to keep room temperatures comfortable when it was 38 degrees below zero outside. The MSD said the facility established temperatures were a problem when the therapy room was too cold at 68-69 degrees. He said the only ambient thermometer they had was in the therapy room. To ensure residents' rooms were comfortable, he said he was now installing AC units for residents who were too hot. He said residents should not have to pay for their own AC units or fans. He said he was going to install programmable thermostats next week so the heat would go on at night when needed, and go off during the day when needed. Room 13There was one hand towel and one washcloth for the two residents who lived in this room. The MSD said each resident should have a bath towel, hand towel and washcloth which staff should be checking and replacing at least once daily. Room 10The floors in the room and the bathroom were sticky underfoot. The bedside tables were soiled with dried fluids. There were no linens in the bathroom, only paper towels. There was one used, wadded and visibly soiled washcloth on a bedside table. The blinds did not close. The resident by the window was sleeping and the resident by the door said the blinds needed to be repaired because he did not like "being on display" especially at night when the lights were on in their room. Their room faced the front lawn and the street. The resident said it had been that way since he moved in a month ago. The MSD acknowledged the concerns and said the housekeeping staff needed to pay more attention to detail. He said he would replace the blinds. Room 9There were no towels or washcloths in the room or bathroom. One resident was sleeping and the other resident said the room was too hot. The MSD acknowledged the concerns and said their plan to repair the thermostat and provide AC units for resident rooms should help alleviate the problem. Room 11 There were two bath towels and one hand towel in the room where two residents lived. The MSD said the linen situation was better than in some rooms but not what the residents should have. Room 5There were no towels or washcloths in the room where two residents lived. Two unlabeled, undated urinals were hanging from the towel racks in the bathroom, one had a black substance in the bottom. One of the residents was in the room lying on his bed. He said he used paper towels to wipe his face. Room 2There were washcloths and two hand towels on the same rod. The resident said she shared the towels with her husband, who was her roommate. She said she had to use her own towels from home because the staff forgot to provide clean bath linens. The white window blinds were soiled with dark fingerprints and stains, and the wall near the head of the resident's bed by the window was damaged and needed touch-up paint. Room 23The resident in this single occupancy room said she got a window AC unit in her room yesterday and it was wonderful and her room was cool. However, she said her fan needed to be cleaned and it was observed to be covered with dusty. The MSD said he would take it to the shop and clean it for her. Room 25 There was only one hand towel for the two residents who lived in the room. One of the residents said the room was "too hot right now," which was observed. The MSD said the programmable thermostat and "maybe adding an air conditioner" would help. The resident said the internet and phone service were "a problem in this room." The MSD responded they had put something in place, but the resident responded, "It doesn't work." The MSD said, "It's been mentioned."Room 26The resident by the window said her room was hot and asked the MSD to turn on the window AC unit that the MSD had installed two days ago. The resident pointed out that her window coverings needed to be adjusted because the area above the newly-installed AC unit left half her window exposed. Her window faced the front yard and the street. The MSD said they would install curtains above the AC units so the windows would not be exposed. East hall shower roomThere were broken tiles at the entrance and by the drain where a resident could cut their toe. A black substance covered the bottom edges of the shower, where caulking was missing. The privacy curtain was soiled at the top and had a two-inch diameter brown spot in the middle. There was a gallon of disinfectant on the floor. The door to the sharps container on the wall was hanging open creating a safety hazard, as the container was full of disposable razors and could have fallen from the wall. The director of nursing (DON) was notified at 11:00 a.m. She removed the sharps container and instructed staff not to use the shower room until it was repaired. She said she thought the shower room needed to be "completely redone." The MSD said he would "repair it all."The MSD said their plan of correction would address all the concerns above in a timely manner. He said they used the TELS system where staff could notify him of concerns, but other than the room temperature issues, none of the above concerns had been brought to his attention via the TELS system. He said for housekeeping issues they had used more detailed checklists in the past and may need to go back to that. He said he would work on addressing as many of the AC window unit and privacy issues as soon as possible that day. He said they would do a linen audit to ensure residents had sufficient clean bath linens in their rooms available to them, because they had plenty of linens. "We will address all these items in our plan of correction."

Based on observation, record review and interviews, the facility failed to ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity which included proper licensure or certification. Specifically, the facility failed to ensure nurse aide (NA) #1 and NA #2 had the appropriate certifications to perform scheduled tasks for resident care. Findings include: I. Record reviewThe employee list was provided by the nursing home administrator (NHA) on 6/14/23 at 4:00 p.m. According to the employee list nurse aide (NA) #1 was a certified nurse aide (CNA). The employee list identified NA #2 as a NA. The June 2023 nursing staff working schedule was provided on 6/15/23 by the facility. The nursing staff schedule identified NA #1 worked as a CNA on 5/2/23, 5/3/23, 5/4/23, 5/5/23, 5/9/23, 5/10/23, 5/11/23, 5/12/23, 5/16/23, 5/17/23, 5/19/23, 5/24/23, 5/25/23, 5/26/23, 6/1/23, 6/6/23, 6/7/23, 6/10/23, 6/11/23, 6/12/23, 6/13/23 and 6/15/23. The nursing staff schedule identified NA #2 was scheduled as a CNA. NA #2 worked on 5/3/23, 5/5/23, 5/8/23, 5/9/23, 5/12/23, 5/13/23, 5/14/23, 5/16/23, 5/17/23, 5/18/23, 5/19/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/31/23, 6/1/23, 6/2/23, 6/3/23, 6/5/23, 6/8/23, 6/12/23, 6/13/23 and 6/14/23. According to Colorado Division of Professions and Occupations, NA #1's CNA license expired on 1/31/23 and NA #2 did not have a CNA license in the State of Colorado. II. Staff interviewNA #3 was interviewed on 6/15/23 at 9:14 a.m. NA #3 said she had been asked to perform CNA tasks when she had not been fully trained and was not certified for. She said she was afraid to fail her skills test to become certified because she had not been fully trained. The director of nursing (DON) was interviewed on 6/15/23 at 4:40 p.m. She said she was responsible for checking when licenses/certifications were about to expire and let the nurse/CNA know of the expiration date so it could be renewed. The DON said she missed the expiration date of NA #1 and was not aware NA #1's license had expired until 6/15/23, during the survey. The DON said NA #1 has been scheduled and completed duties as a CNA after her certification had expired. The DON said NA #2 had failed her skills certification test twice and was scheduled to take the test a third time. The DON said because she was scheduled to retest she could continue to perform duties as a CNA. She said NAs had 120 days from the time they get their NA certificate, to become a certified nursing aide. The DON said both NA #1 and NA #2 were suspended, effective 6/15/23. She said she needed a better system to check nursing staff licenses/certifications and was working on putting a new plan in place. She said she would do a complete nursing staff audit and start a tracking system. She said she would have a second verifier to make sure the licenses/certifications were up to date.

Based on observations, record review, and interviews, the facility failed to implement appropriate and timely interventions to ensure one (#17) of four residents reviewed for pressure ulcers out of 24 sample residents received the necessary care and treatment to prevent the development of a pressure injury to prevent reoccurring pressure ulcers. Specifically, the facility failed to implement precautions to prevent Resident #17's pressure ulcers from reoccurring on his heels and his bottom. Findings include:I. Professional referenceThe National Pressure Injury Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 6/28/23 read in pertinent part:"Pressure Injury:A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue."Stage 1 Pressure Injury:Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury."Stage 2 Pressure Injury:Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions)."Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions."The National Pressure Injury Advisory Panel (NPIAP), "Prevention and Treatment of Pressure Ulcers" reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time."The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing:-Positioning that places pressure on the pressure ulcer should be avoided.-The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented.-The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications.-Signs of deterioration in the wound should be addressed immediately.-The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order."II. Resident statusResident #17, age 80, was admitted on 2/24/22. According to the 6/14/23 computerized physician's order (CPO) diagnoses included dementia, depression, unspecified sequelae of cerebral infarction (depression/anxiety that is a residual effect of a stroke) and peripheral neuropathy (damage to the nerves around the brain and spinal cord). According to the 5/25/23 minimum data set (MDS) assessment showed that Resident #17 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Resident #17 needed extensive assistance from at least one staff member for activities of daily living (ADLs), repositioning and transfers. The resident utilized a wheelchair for mobility. Resident #17 was documented as at risk for pressure ulcers. He was documented as having the following:-Pressure reducing device for chair;-Pressure reducing device for bed;-Nutrition or hydration intervention to manage skin problems;-Pressure ulcer care; and, -Applications of ointments or medications other than to feet. III. Observations and interviewsOn 6/12/23 at 2:27 p.m. Resident #17 was sleeping supine (on his back) in his bed with both of his knees bent and both of his feet were on his mattress pad. No heel protectors were observed. On 6/14/23 at 9:00 a.m. Resident #17 was in the dining room eating breakfast. A blue heel protector was on his left foot; however, there was no heel protector on his right heel. He had a history of pressure wounds on his right heel (see record review below). Registered nurse (RN) #1 was providing wound care to Resident #17 at 10:28 a.m. His left heel (wound first documented on 4/27/23) had a reddened area approximately 1.5 inches in diameter. The wound was dry and not opened. RN #1 stated the wound occurred from the resident using his feet to propel himself in his wheelchair. A heel protector was applied and stayed on at all times. The resident's coccyx (tailbone) wound (first documented on 6/15/23) was approximately one centimeter (cm) in diameter and was a hardened, unopened scab. The gluteal cleft had a wound (first documented 5/3/23) that was around one inch in diameter with a white slough (dead tissue separated from the living tissue) documented on the wound. RN #1 stated pressure ulcer precautions included turning and incontinence care on a two-hour schedule; she said however, Resident #17 moved a lot in bed and did not stay in the positions staff placed him in. At 10:46 a.m. Resident #17 was changed and staff assisted him to the dining room in his wheelchair for lunch. A blue heel protector was observed on his left foot and not on his right heel. At 2:45 p.m. Resident #17 was sleeping supine in his bed with both of his heels on his mattress. No heel protectors were observed. At 5:20 p.m. Resident #17 was sitting in the dining room for dinner. His blue heel protector was on his left foot and not on his right heel. On 6/15/23 at 9:14 a.m. Resident #17 was sleeping supine with both of his knees bent. Both of his feet were on his mattress and no heel protectors were observed. IV. Record reviewAccording to the care plan, last revised 3/21/22, Resident #17 was documented as weight-bearing and independent with ambulation, however, it also documented he had limited physical mobility referring to his disease process. The facility implemented the following interventions for Resident #17's skin problems:-Keep resident clean and dry, encourage movement to promote perfusion (passage of fluid through the circulatory system), initiated 2/28/22 and revised 4/24/23;-Avoid scratching and keep hands and body parts free from excessive moisture. Keep fingernails short, initiated 2/28/22;-Encourage good nutrition and hydration in order to promote healthier skin, initiated 2/28/22;-Follow facility protocols for treatment of injuries, initiated 2/28/22;-Keep skin clean and dry. Use lotion on dry skin. Do not apply between toes, initiated 2/28/22 and revised 5/19/23;-Monitor or document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, to MD (medical doctor), initiated 2/28/22;-Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, initiated 2/28/22; and. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations, revised 2/28/22. Repositioning was indicated under the musculoskeletal focus of the care plan, due to the potential for alteration in musculoskeletal status, referring to weak or unsteady gait and falls. The intervention documented was to change positions frequently and alternate periods of rest with activity out of bed in order to prevent respiratory complications, dependent edema (swelling of body parts affected by gravity like hands, legs, and feet), flexion deformity (inability to full straighten the leg) and skin pressure areas. This was initiated on 2/28/22 and revised on 5/19/22. According to the Braden scale for predicting pressure sore risk, most recently completed 8/27/22, Resident #17 scored a 16 which indicated he was at risk for pressure ulcers. Resident #17 was marked for a potential problem referring to friction and shear since he moved feebly (moved without ensuring his feet were off the ground due to weakness) and during a move skin slid to some extent against other objects. Weekly skin assessments showed Resident #17 had numerous different pressure sores and were not documented as healed. On 2/23/23 at 6:18 p.m. a skin assessment documented a SDTI (suspected deep tissue injury) to the resident's right heel. On 3/9/23 at 3:45 p.m. a skin assessment documented a SDTI still present on the resident's right heel. On 3/16/23 at 6:34 p.m. a skin assessment documented a SDTI still present on the resident's right heel. On 3/23/23 at 8:38 p.m. a skin assessment documented a sDTI still present on the resident's right heel. On 4/6/23 at 9:14 p.m. a skin assessment documented a sDTI still present on the resident's right heel. On 4/13/23 at 12:52 p.m. a skin assessment documented Resident #17 had a stage I pressure ulcer wound to his right heel. Measurements were 1.0x0.6x0.0. No drainage was noted. The wound bed was red and almost healed. No odor was present. On 4/21/23 at 12:46 p.m. a skin assessment documented Resident #17 had a stage I pressure ulcer to his right heel. The wound measurements were 1.0x0.4x0.0. No drainage was noted. Wound bed was red and almost healed. No odor was present. The wound bed was cleaned and sure prep (ointment) was applied. Resident #17's heel was placed in a soft heel protector. On 4/27/23 at 10:03 p.m. a skin assessment documented a new SDTI to Resident #17's left heel that measured 2.5x2.0x0.0. On 5/3/23 at 11:45 a.m. a skin assessment documented a SDTI still present to Resident #17's left heel and a new stage 1 pressure wound to his right intergluteal cleft. On 5/4/23 at 10:23 p.m. a skin assessment documented a SDTI still present on the resident's left heel and a stage 1 pressure wound was still present on his right intergluteal cleft. On 5/11/23 at 9:22 p.m. a skin assessment documented a SDIT was still present on the resident's left heel and a stage 1 pressure wound was still present on his right intergluteal cleft. On 5/18/23 at 6:38 p.m. a skin assessment documented a SDIT was still present on the resident's left heel and a stage 1 pressure wound was still present on his right intergluteal cleft. On 5/25/23 at 9:35 p.m. a skin assessment documented a SDTI was still present on the resident's left heel and a stage 1 pressure wound was still present on his right intergluteal cleft. On 6/1/23 at 1:58 p.m. a skin assessment documented a SDIT was still present on the resident's left heel and a stage 1 pressure wound was still present on his right intergluteal cleft. On 6/8/23 at 2 p.m. a skin assessment documented a SDIT was still present on the resident's left heel and a stage 1 pressure wound was still present on his right intergluteal cleft. On 6/12/23 at 7:42 p.m. a skin assessment documented Resident #17's pressure wound on his left heel had healed. The hard protective layer was removed and the skin underneath was pink and viable. No discoloration or pain was noted. On 6/15/23 at 1:40 p.m. a skin assessment documented Resident #17's pressure wound on his left heel had healed. Sure prep (ointment) was applied to his left and right heel for preventative reasons. The nurse kept the resident's heel protector on his left heel until the tissue was no longer soft. No pain was noted and the resident handled the care provided well. The nurse provided education on heel floating (having heels kept off of surfaces) while in bed and his heel protector. The wound on his right intergluteal cleft was documented as a stage 2 pressure wound. Measurements were documented as 0.7x0.7x0.0. The wound was cleaned and opti-foam (bandage) was applied to the wound. Resident #17 had a pressure wound documented on his coccyx (tailbone) and the measurements were 1.5x0.8x0.0. Opti-foam was applied to wound on his coccyx. The peri area of the wounds were red and viable. No pain was documented and the resident did not complain of treatments. The nurse re-educated the resident on his wounds and treatments for them.-The facility failed to have an updated care plan for Resident #17's pressure wounds or treatments that were needed to treat/prevent the wounds from reoccurring. Based on observations (see above) the facility was not implementing intervention/preventative measures with his history of pressure ulcers. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/15/23 at 8:40 a.m. She said if she saw any sort of skin impairment she notified the nurse of it. Nurse aide (NA) #3 was interviewed on 6/15/23 at 9:14 a.m. NA #3 said pressure ulcers occurred due to staff not implementing measures put in place, such as heel protectors or floating heels. She said treatment for residents with pressure ulcers were inconsistent among the nurses. She said care plan interventions for prevention of resident pressure ulcers were not consistently followed. She said pressure ulcers were only treated when they developed.

Based on observations, record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#20) of six residents reviewed for falls out of 24 sample residents. The facility failed to ensure Resident #20, who had nine falls within six months, had effective interventions, supervision and assistance in place to prevent further falls. Resident #20 suffered multiple falls with injuries including lacerations to his face and his head, including an emergency room visit where he received six stitches and he continued to fall. Findings include:I. Facility policyThe Nursing Services Policy and Procedure Manual for Long-Term Care, revised April 2018, was provided on 6/15/23 at 3:07 p.m. by the nursing home administrator (NHA). It read in pertinent part, "The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling."II. Resident #20A. Resident status Resident #20, age 73, was admitted on 2/10/2020. According to the June 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic pain, muscle weakness, lack of coordination, unspecified abnormalities of gait and mobility, dementia and other abnormalities of gait and mobility. The 6/6/23 minimum data set (MDS) assessment showed that Resident #20 had severe cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment indicated Resident #20 required extensive assistance with transfers and toilet use and limited assistance from caregivers for walking around his room. His balance was unsteady and he needed assistance to balance himself. He used a walker or wheelchair for ambulation. Resident #20 was listed as having one fall since admission or most recent assessment.-However, Resident #20 had nine falls within a six-month period (see record review below). B. Resident interviewResident #20 was interviewed on 6/14/23 at 2:52 p.m. He stated he was supposed to use his call light when he wanted to get up. Resident #20 said the caregivers did not respond in a timely manner to call lights, especially when he had to use the restroom. "I got to do what I got to do, so I would walk to the bathroom alone and fall." Resident #20 had signage around his room that documented, "Please remember to use your wheelchair or walker at all times." He explained how previous falls led to his placement at the facility and he kept falling during his stay. He said staff kept his wheelchair out of reach so he would not use it without calling for assistance but he still got up anyway when he could not wait any longer to use the restroom. Resident #20 stated he used to have a walker but the facility did not want him to use it anymore due to falling a lot and removed it from his room.-The use of a wheelchair and no walker and keeping the wheelchair out of the resident's reach so he would ask for assistance was not included in the care plan (see below). C. ObservationsOn 6/12/23 at 2:00 p.m., Resident #20 was observed walking out of his room into the hallway. A staff person approached and asked him why he was walking, then helped him back into his room and closed the door. During the resident interview on 6/14/23 at 2:52 p.m. (above), no walker was observed in his room. He was in bed and his wheelchair was at the foot of his bed facing away from him toward the wall. Resident #20 was observed throughout the survey, from 12:00 p.m. to 6:00 p.m. on 6/12/23 and from 8:30 a.m. to 6:00 p.m. on 6/13, 6/14 and 6/15/23. He spent most of his time in his room with his door closed, except for meals and going outside to smoke. He ambulated in his wheelchair independently wheeling himself through the facility to the back door and received assistance from staff to exit the back door to the smoking area. D. Record reviewAccording to the fall risk care plan, initiated on 9/15/21 and most recently revised on 4/18/23, Resident #20 was listed as weight-bearing and he needed assistance from one staff member to ambulate. Resident #20 also needed limited assistance from one staff for when he walked around and as needed (PRN) in his wheelchair. Resident #20 was listed as a high fall risk due to a diagnosis of Parkinson's disease which would affect his coordination and gait. Interventions were the following:"-Anticipate and meet the resident's needs (9/15/21).-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (9/15/21).-Resident #20 forgets to use his walker or wheelchair and needs reminders to use his call light and allow staff to assist with transfers (undated).-Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (10/12/21).-Ensure proper positioning when in wheelchair (4/18/23).-Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair (9/15/21).-Follow facility fall protocol (9/15/21).- 'I like to get myself up and into my wheelchair, please make sure my wheelchair is within easy reach' (6/13/23, during the survey).-Offer frequent assistance to the bathroom, assist in keeping clean, dry, and comfortable (10/1/21 and 6/13/23).-Signage placed in room to remind resident to use his wheelchair and walker when ambulating (9/21/22).-Place signage around my room to remind me to use my call light and wait for assistance (11/15/22).-Place wheelchair wedge with support to help with falling (4/17/23).-Push wheelchair when outside (4/18/22)."-The resident's actual falls with injury were not documented in his care plan.-There was no evidence of tracking and trending the times of day or night the resident had fallen, in order to develop more effective fall prevention measures.-The care plan did not define how frequently the resident should be offered assistance to the bathroom.-New interventions following each fall were not added to the care plan.-No wedge cushion was observed in the resident's wheelchair during the survey.-No signage was observed in the resident's room to remind him to use his call light for assistance.-The resident's wheelchair was not within his reach in keeping with the care plan, per observation and resident interview. Review of nursing progress notes and fall investigations for the previous six months revealed:1. Unwitnessed fall on 1/17/23 Resident #20 had an unwitnessed fall on 1/17/23 at 1:49 a.m. He was found on the bed on his hands and knees, cursed at staff, and said he had fallen to the floor. No injuries were noted. -No fall investigation was provided. 2. Witnessed fall on 2/9/23Resident #20 had a witnessed fall on 2/9/23 at 4:45 p.m., with an injury that led to an emergency room visit. He had a laceration to the right eyebrow and received six stitches in the hospital. He had been ambulating in the hall behind his wheelchair, tripped and fell, hitting the right side of his face.-The facility failed to correct how Resident #20 was utilizing his wheelchair which resulted in an injury. The facility failed to provide limited assistance with walking due to the resident being unsteady and supervision to ensure timely assistance to prevent falls with injury. 3. Unwitnessed fall on 2/17/23Resident #20 had an unwitnessed fall on 2/17/23 at 5:15 p.m. (late entry documented at 9:28 p.m.) He came out of his room and told staff he fell while he was walking across the room. He had a laceration to the right side of his forehead, no bleeding or swelling and no other injuries. Witnessed fall, staff involved, on 3/16/23Resident #20 had a witnessed fall on 3/16/23 at 6:57 p.m. Staff were pushing him in after smoking, his wheelchair caught on the door threshold, pitching him from the wheelchair to his knees. He had abrasions on both knees. 4. Unwitnessed fall on 3/27/23Resident #20 had an unwitnessed fall on 3/27/23 at 9:33 p.m. according to nursing notes which documented no further details other than that neurological checks were initiated. No injuries were noted. 5. Witnessed fall on 4/13/23Resident #20 had a witnessed fall on 4/13/23 at 9:35 p.m. He was outside in his wheelchair, hit a groove in the concrete causing him to fall. He hit his head and suffered a laceration above his right eye. The nurse cleaned, steri-stripped, provided an ice pack and initiated neurological checks. The resident later had swelling to the right side of his face. Review of the facility investigation revealed the interdisciplinary team (IDT) recommendation for a new intervention was education. The facility documented in the report they updated the care plan to reflect the recommendation.-However, the care plan was not updated regarding education.-The type of education to be provided and to whom was not documented in the investigation.-The care plan intervention to supervise the resident for safety when he was outside was not updated until 4/18/23, five days later. 6. Unwitnessed fall on 4/16/23On 4/16/23 at 1:35 p.m., Resident #20 fell and sustained an abrasion to his hand. The fall investigation determined Resident #20 fell out of his chair onto his knees and scraped his hand. The previous intervention was listed as a wedge (cushion) for Resident #20's wheelchair. A new intervention was documented to ensure proper positioning in the wheelchair. The facility documented in the report they updated the care plan to reflect the recommendation.-The care plan was not updated until after the resident's second fall outside although the 4/16/23 fall was caused by staff. -The care plan was updated regarding the wedge cushion, but it was not observed in the resident's wheelchair (see observations above). 7. Unwitnessed fall on 5/17/23On 5/17/23 at 12:42 a.m., Resident #20 was found sitting on the floor in front of his bed. The fall investigation determined he was getting up to go to the bathroom, slipped, and fell onto his buttocks. Previous interventions were documented as education and signage. A new recommendation was entered as a referral to physical therapy (PT). The facility documented in the report they did not update the care plan based on the new intervention. He suffered two skin tears on his right hand.-Although, the resident was going to the bathroom without assistance, the care plan was not updated with specific interventions about anticipating the resident's bathroom assistance needs and how often to provide the assistance.-He was already receiving PT at the time of this fall according to therapy notes.-The care plan was not updated after the 5/17/23 fall. 8. Unwitnessed fall on 6/8/23On 6/8/23 at 9:28 p.m., Resident #20 was found sitting on the floor (with no noted injuries) in his room, holding his knees. The resident's roommate had to use his call light for assistance. The resident's wheelchair was four to five feet away from him. The fall investigation determined Resident #20 was headed to the bathroom when he slid down onto the floor off his bed. Previous interventions were documented as education and signage. A new recommendation was entered to maintain his wheelchair within easy reach of Resident #20. The facility documented in the report the care plan was updated with this recommendation.-However, observation and resident interview (above) revealed the resident's wheelchair was not consistently kept within his reach.-The care plan was not updated regarding timely bathroom assistance, although the resident fell attempting to go to the bathroom without assistance.-There was no recommendation for, or evidence of, PT or restorative services following this fall. Therapy notes revealed he was discharged from PT on 6/5/23, where he had been working on training in wheelchair propulsion and maneuvering within his environment. Resident #20's fall assessment completed 6/8/23 showed he had a fall risk score of 55, indicating high fall risk.-No furtherfall risk assessments were provided.-Review of the times Resident #20 fell revealed most of his falls happened late at night or early morning. However, there was no evidence the facility identified this trend to identify root causes, meet the resident's needs, and implement measures to meet those needs. Review of IDT notes on 6/13/23 revealed Resident #20 had many falls. Resident #20 utilized his wheelchair as a walker and agreed to utilize it how it was meant to be used. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 6/15/23 at 8:40 a.m. CNA #1 explained occasionally the facility was short staffed and they worked with what they had but it delayed the time it took to answer call lights. "We manage the best way we can when we are understaffed." CNA #1 said Resident #20 fell a lot due to his Parkinson's disease and not waiting for the nursing staff to answer his call light. CNA #1 explained Resident #20's fall precautions were signs posted in his room and that staff needed to stop him if they saw him ambulating. Staff located fall precautions and care instructions in the care plan but CNA #1 did not know how to find care plans so she relied on signs posted in the residents' rooms. Nurse aide (NA) #3 was interviewed on 6/15/23 at 9:14 a.m. NA #3 stated a lot of falls occurred because call lights were not answered in a timely manner and residents would get impatient waiting for a response. She stated the facility was usually understaffed therefore staff did not answer call lights. She explained Resident #20 would get up independently and staff constantly needed to remind him to use his call light and wheelchair. Resident #20 typically did not like to wait for staff to answer his call light so he would walk himself where he needed to go. He was on hourly checks and staff reminded him not to walk around on his own. NA #3 did not know how to look up care plans and relied on signs posted in the residents' rooms or asked other floor staff what each resident needed specifically. Physical therapy aide (PTA) #1 was interviewed on 6/15/23 at 3:30 p.m. regarding Resident #13's fall and recovery. PTA #1 stated Resident #20 had just been discharged from physical therapy (PT) in June 2023. He was still being treated by restorative therapy because he had reached his maximum physical capability due to his diagnosis of Parkinson's disease and there was nothing more to be done with PT.The nursing home administrator (NHA) was interviewed at 2:00 p.m. on 6/15/23 and Resident #20's fall investigations were requested. The NHA said it would be a "huge stack" of documentation since the resident had frequent falls. She did not say why the resident fell so frequently or what prevention measures the facility was taking. At 2:30 p.m. on 6/15/23 she provided only four fall investigations: for 4/13/23, 4/16/23, 5/17/23 and 6/8/23.

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

Based on observations, record review and interviews the facility failed to ensure one (#10) of two residents reviewed for appropriate mental health services out of 24 sample residents received proper treatment and services to attain their highest practicable mental and psychosocial well-being. Specifically, the facility failed to:-Ensure alternative services were offered, besides only therapy when the resident refused it;-Assist the resident with positive coping skills and ensure staff members knew what positive coping skills versus negative coping skills looked like; and,-Ensure the care plan reflected the services for the resident's needs and how staff could better assist with her mental well-being. Findings include:I. Resident statusResident #10, under age 60, was admitted on 4/1/22. According to the June 2023 computerized physician orders (CPO), diagnoses included major depressive disorder, bipolar disorder and dissociative and conversion disorder. The 4/1/22 minimum data set (MDS) assessment showed Resident #10 had no cognitive impairment from a brief interview for mental status (BIMS) assessment completed with a score of 15 out of 15. She had verbal behavioral symptoms directed towards others (threatened others, screamed at others and cursed at others) and she wandered. II. Resident interviewResident #10 was interviewed on 6/14/23 at 1:02 p.m. She said she self-isolated due to "I get angry around too many people, as long as I am in here (in the bedroom) they (the other residents) are safe and I do not get in trouble." Resident #10 explained she yelled a lot when she was angry and the facility was helping by doing the "bare minimum." She said she did not want therapy but would vent to the nursing home administrator (NHA) and administrative assistant (AA) when they were available to listen. She enjoyed being able to vent to the NHA and AA but they appeared busier and she was unable to meet with them. Resident #10 said she was happy with her medication regimen because she had a say in what she received. Resident #10 said she slept a lot and stayed in her room due to her mental illnesses. She stated she had verbal outbursts and made threats in the heat of the moment too. She preferred to vent to someone she knew versus a psychiatrist or therapist. She said she tried to keep her mind busy by isolating herself in her room since she had no other options that interested her. III. Record reviewAccording to the care plan, initiated on 9/26/18 and last revised on 7/8/22, Resident #10 was independent in meeting her emotional, intellectual, physical, and social needs. One focus care planned for Resident #10 was that she had behavioral issues related to resisting care, verbal aggression, excessive sleeping (slept all day and up all night) and refused medications at scheduled times. Resident #10's condition placed her at risk of being abused and abusing other residents. This focus area was initiated on 10/16/2020 and last revised on 5/18/22. The facility implemented the following interventions for her behavioral issues:-One-to-one redirection when agitated (initiated on 4/30/21);-15-minute checks every shift for safety and as needed (initiated on 4/27/21 and revised on 1/11/23);-Administer medications as ordered. Monitor for/document for side effects and effectiveness (initiated on 10/16/2020);-Assist to develop more appropriate methods of coping and interacting by communicating with staff. Encourage to express feelings appropriately (initiated on 10/16/2020 and revised on 10/16/2020);-Be aware of triggers and which of her behaviors may trigger other residents around her. If any behaviors are observed, engage in activities of choice, assess for pain or other physical needs, offer food or fluids, provide items of comfort, etc (initiated on 10/16/2020);-Caregivers are to provide opportunities for positive interactions and attention. Stop and talk with him/her as passing by (initiated on 10/16/2020);-Explain all procedures before starting and allow her a few minutes to adjust to changed (initiated on 10/16/2020 and revised on 10/16/2020);-If reasonable, discuss the resident's behaviors and explain/reinforce why her behavior is inappropriate and/or unacceptable to her (initiated on 10/16/2020 and revised on 10/16/2020);-Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed (initiated on 10/16/2020);-Resident #10 enjoys to play games on Ipad or visit with staff reminiscing about family and animals (initiated on 4/30/21);-Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes (initiated on 10/16/2020);-Praise any indication of progress of improvements in behavior (initiated on 10/16/2020 and revised on 10/16/2020); and,-Provide a program of activities that is of interest and accommodates her status (initiated on 10/16/2020 and revised on 10/16/2020). Another focus care planned for Resident #10 documented she had a mood problem related to bipolar disorder and discharge was not indicated because she needed more assistance with daily care (initiated on 3/4/21 and revised on 7/7/22). The goal was documented as Resident #10 would have improved mood, calmer appearance, no signs or symptoms of depression, anxiety or sadness; and no anger or yelling episodes through the next review date of 4/17/23. -However, the care plan was not updated since 7/7/22. Resident #10's mental illness care plan documented she used psychotropic medications related to diagnoses of bipolar disorder and dissociative and conversion disorders. The medications utilized were listed as seroquel (an antipsychotic) and duloxetine (antidepressant). The goal was the resident would be free of psychotropic drugs related to complications like a movement disorder, discomfort, hypotension, gait disturbance, or cognitive/behavioral impairment through the next review date. This was initiated on 12/3/2020 and revised on 4/13/22. The goal date was set to be reviewed on 4/17/23.-However, the facility had not updated the care plan since 7/7/22.-The facility failed to implement a care plan that specifically guided caregivers on what Resident #10's triggers were, what type of reinforcement needed to be provided, guidance on positive and negative coping skills, how the facility helped the resident recognize positive coping skills, what Resident #10's diagnoses meant, what potential behaviors looked like besides yelling and angry outbursts. Guidance was not provided to caregivers for excessive sleeping and activities (outside of participation in independent activities in her bedroom) or programs were not documented in the resident's medical record. IV. Staff interviewNursing aide (NA) #3 was interviewed on 6/15/23 at 9:14 a.m. She stated the facility did not handle mental illness or Resident #10's behaviors adequately. Some staff would not explain what care tasks they needed to complete with Resident #10 and it increased her verbal aggression and verbal threats of aggression.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections for residents. Specifically, the facility failed to ensure:-Ensure staff offered residents hand hygiene appropriately; and, -Ensure proper hand hygiene standards were followed by staff during dining service. Findings include:I. Facility policies and proceduresThe Handwashing and Hand Hygiene policy, revised August 2019, provided by the nursing home administrator 6/15/23 at 3:07 p.m. read in part:"This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors."Use of alcohol-based (ABHR) hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents;-After contact with a resident ' s intact skin;-After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident;-Before and after eating or handling food;-Before and after assisting a resident with meals."II. ObservationsOn 6/12/23 at 12:40 p.m. an unidentified nurse aide (NA) was observed sitting between two residents and assisting them with eating. She wiped off a resident ' s mouth and used her same hand to pick up the spoon of the other resident and assisted her without sanitizing her hands in between residents. On 6/12/23 at 12:45 p.m. staff were observed passing out room trays. There were no hand wipes on the trays and staff stated they would have to find them in the kitchen. The residents were not offered hand hygiene at the time of room tray service. At 12:50 p.m. in the dining room, an unidentified certified nurse aide (CNA) was observed assisting two residents to eat and was touching her own face and hair in between assisting the residents without using alcohol-based hand rub (ABHR) in between assisting each resident. The CNA was observed gripping the top of the cup to assist the resident to drink. She assisted another resident at the table to eat and did not perform hand hygiene after assisting the previous resident. At 12:55 p.m. the same CNA opened a nutritional supplement bottle, unwrapped a straw, touched the drinking surface of the straw and began to assist a resident to drink without first performing hand hygiene. At 12:58 p.m. the CNA opened a nutritional supplement bottle, unwrapped the straw and held it in her hand before inserting it into the bottle and assisting the resident to drink. No hand hygiene was observed beforehand. She threw the straw paper in the trash and used ABHR on the wall after assisting the resident. She assisted a resident with a bite of food and offered a drink while holding the straw at the drinking surface with her fingers. She then offered food to another resident and assisted him with a drink without performing hand hygiene in between assisting residents. She pushed his plate away, picked up trash from the table, wiped the surface of the table with her hand, touched her hair and face, then assisted a resident at the table to eat with a spoon. No hand hygiene was observed after she cleaned the table with her hand. She then continued to alternate between feeding the two residents at the table without performing hand hygiene in between each resident. Resident room tray deliveries were observed during the breakfast meal on 6/14/23. The following breakfast trays were delivered by the dietary aide (DA) #1 and the registered dietitian (RD).-At 8:33 a.m. two room trays were delivered to the residents in room #25. The residents were not offered hand hygiene before they were offered their breakfast.-At 8:35 a.m. one room tray was delivered to the resident in room #27. The resident was not offered hand hygiene before he was offered his breakfast.-At 8:36 a.m. two room trays were delivered to the residents in room #30. The residents were not offered hand hygiene before they were offered their breakfast.-At 8:40 a.m. one room tray was delivered to the resident in room #23. The resident was not offered hand hygiene before she was offered her breakfast.-At 8:44 a.m. one room tray was delivered to the resident in room #21. The resident was not offered hand hygiene before she was offered her breakfast.-At 8:46 a.m. one room tray was delivered to the resident in room #26. The resident was not offered hand hygiene before she was offered her breakfast.-At 8:48 a.m. a certified nurse aide (CNA) delivered a room tray to a resident in room #7. The resident was not offered hand hygiene before she was offered her breakfast. At 8:53 a.m. DA #1 was observed preparing the delivery of three room trays in the kitchen. The DA scratched the side of her nose and proceeded to cover each plate with plate covers, touch the ice scoop, pour coffee in mugs, cover the tops of the beverages with small plastic bags/sleeves and place napkin rolled utensils on the trays. The DA placed the three room trays on the cart for room delivery in the West hall. The DA performed hand hygiene with ABHR when she entered the hallway. At 12:36 p.m. a CNA assisted two residents with eating and did not perform hand hygiene in between each resident. The CNA used a napkin to wipe a resident ' s mouth and then used the same hand to pick up a utensil and give a bite of food to another resident without performing hand hygiene. On 6/15/23 at 12:03 p.m. kitchen staff were serving bowls with their thumbs on the top edges. At 12:06 p.m. a CNA was observed wiping her hands on her pants while feeding two residents and did not perform hand hygiene between residents or after wiping her hands on her pants. III. Resident interviewsResident #6 was interviewed on 6/15/23 at 1:17 p.m. She said staff were not consistent in offering residents hand wipes or encouraging hand hygiene before meals unless the facility had a COVID outbreak. Resident #26 was interviewed on 6/15/23 at 1:23 p.m. Resident #26 was observed eating lunch in her room. She said she was not offered or encouraged before she was provided her meal. She said eats in her rooms sometimes but was only encouraged to clean her hands when she ate in the dining room but not when she ate in her room. IV. Staff interviewsNursing aide (NA) #4 was interviewed on 6/14/23 at 5:37 p.m. She said residents who eat in their rooms should be offered hand hygiene before they eat. The director of nursing (DON) was interviewed on 6/15/23 at 10:54 a.m. She stated staff should be using hand hygiene between serving each resident and after they touched any objects while assisting the resident to eat. Staff should offer residents handwashing or hand sanitizer prior to dining service. She stated she performed rounds to ensure hand hygiene protocol and procedures were being followed. She stated staff were provided hand hygiene training annually. She stated she would look for documentation for staff in-service and training, but did not usually document "on the spot" education for hand hygiene. She stated she would arrange further hand hygiene training for staff. CNA #1 was interviewed on 6/15/23 at 1:13 p.m. She said residents in the dining room should have hand hygiene provided to them before and after meals with hand wipes or ABHR. She said was not sure when residents who eat in their rooms were offered hand hygiene. She said some of the residents were independent and could perform their own hand hygiene. The RD was interviewed on 6/15/23 at 1:26 p.m. The RD identified herself as the current dietary manager. The RDsaid staff should perform hand hygiene before meals, between resident meal assistance and anytime they touch potential contaminated surfaces, to avoid potential cross-contamination. The RD said staff perform hand hygiene before and after entering resident rooms. She said residents should be offered hand hygiene before they are served their meal. The RD said residents were offered hand hygiene when the residents entered the dining room to eat. She said she did not know when residents were offered hand hygiene in their rooms. She said all residents should be offered hand hygiene. The RD said the kitchen staff had been responsible for delivering the breakfast and lunch room trays to the residents for the last two to three months. She said the CNAs used to pass out the room trays. The RD said the kitchen staff rely on nursing staff to assist and offer hand hygiene for residents before meals in the dining room and in the resident rooms. Observations of inconsistent hand hygiene were shared with the RD. She said she would collaborate with the nursing department to create a plan to improve staff and resident hand hygiene. She said the facility could look at placing ABHR at each table or offering staff pocket sized/personal ABHR for use in the dining room when assisting residents. The RD said she would look at hand wipes packets to be placed on the room trays for residents eating in their rooms. The RD said all staff received inservice training on the importance of hand hygiene. The RD said the dietary staff was trained to perform hand hygiene anytime their hands were visibly soiled, enter the kitchen, change a task, deliver meals or touch potentially contaminated surfaces such as anything on the face, body or skin. The RD said she would continue to review hand hygiene with the kitchen staff. She said she conducted a meal observation of the meals monthly, but could start weekly observations to ensure staff were following appropriate infection control practices. DA #1 was interviewed on 6/15/23 at approximately 1:45 p.m. The DA said the kitchen staff did not offer hand hygiene to residents when they delivered meals. She said she thought the nursing staff would provide the residents with hand hygiene. She said the kitchen staff ' s focus was to deliver the food timely so the food could maintain appropriate temperature. The DA said she had not been trained to offer or assist residents with hand hygiene when she passed room trays. She said she just delivered the room trays. DA #1 said she should perform hand hygiene anytime she touched potentially contaminated surfaces, including her face, when handling resident meals.

A complaint survey, prompted by #CO30738 was conducted on 2/14/23. No deficiencies were cited.