VITAE CARE INC

Initial comments, identified under ID Prefix Tag K0000, are informational in nature and are intended to reflect the general characteristics of the facility. This Life Safety Code survey was conducted in accordance with the Federal Register, 42 CFR §483.90(a). The facility is a 30,414 square foot, one-story structure of Type V (111) construction divided into 3 smoke compartments. The facility is licensed for 36 beds, with a resident census of 36 at the time of the survey. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry fire sprinkler system. The facility is classified as fully sprinklered. The survey was conducted on April 16, 2026, to determine compliance with the following applicable codes and standards: NFPA 101 (2012 Edition), Life Safety Code, Chapter 19 — Existing Health Care OccupanciesNFPA 99 (2012 Edition), Health Care Facilities CodeAll other applicable referenced codes and standardsDeficiency findings identified during the survey were reviewed on-site and were subsequently discussed during the exit conference with the Nursing Home Administrator (NHA).

Based on record review, and staff interviews, the facility failed to maintain emergency lighting in accordance with NFPA 101 (2012), Life Safety Code, Chapter 19 (Existing Health Care Occupancies), and Chapter 7 (Means of Egress). Specifically, no records were provided at time of survey to verify that the emergency lighting system had been tested for 90 minutes annually. This deficient practice had the potential to affect three of three smoke compartments, and to impact visitors, staff, and 36 of 36 residents. The nursing home administrator (NHA) was present during the survey. Findings Include:No ITM records were provided at time of survey to verify that the emergency lighting system had been tested for 90 minutes annually. Regulatory References:NFPA 101 (2012)§ 19.2 Means of Egress Requirements.§ 19.2.9 Emergency Lighting.§ 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9. § 7.9 Emergency Lighting.§ 7.9.3 Periodic Testing of Emergency Lighting Equipment.§ 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.§ 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2). The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered. The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3). Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.§ 7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator. A visual inspection shall be performed at intervals not exceeding 30 days. Functional testing shall be conducted annually for a minimum of 11/2 hours. Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 11/2-hour test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.§ 7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided. Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine. The emergency lighting equipment shall automatically perform annually a test for a minimum of 11/2 hours. The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3). The computer-based system shall be capable of providing a report of the history of tests and failures at all times. Deficiency findings were discussed during the survey and again at the exit conference with the NHA.

Based on observation and staff interviews, the facility failed to maintain exit and directional signs in accordance with NFPA 101 (2012), Life Safety Code, Chapter 19 (Existing Health Care Occupancies), and Chapter 7 (Means of Egress). Specifically, we identified one corridor that was missing exit signage. This deficient practice had the potential to affect one of three smoke compartments, and to impact visitors, staff, and 28 of 36 residents. The nursing home administrator (NHA) was present during the survey. Findings Include:Observations within the corridor in the “Long Hall” in Area 3 Smoke Compartment revealed missing exit signage. Specifically, the distance between the two exit signs in the hallway was measured at 137 feet. 37 feet greater than the distance allowed by code of 100 feet. One additional exit sign is required in the middle of the corridor. Regulatory References:NFPA 101 (2012)§ 19.2 Means of Egress Requirements.§ 19.2.10 Marking of Means of Egress.§ 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.§ 7.10 Marking Means of Egress.§ 7.10.1.5.2* New sign placement shall be such that no point in an exit access corridor is in excess of the rated viewing distance or 100 ft (30 m), whichever is less, from the nearest sign. Deficiency findings were discussed during the survey and again at the exit conference with the NHA.

Based on observation and staff interviews, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 (2012), NFPA 13 (2010), and NFPA 25 (2011). Specifically, the facility failed to provide a current and accurate sprinkler head identification list within the sprinkler cabinet located in the fire riser room. This deficient practice had the potential to affect three of three smoke compartments, and to impact visitors, staff, and 36 of 36 residents. The nursing home administrator (NHA) was present during the survey. Findings Include:Observation of the sprinkler cabinet located in the fire riser room revealed that some spare sprinkler heads were present; however, a sprinkler head identification list was not provided inside the cabinet. During interviews at that time, facility staff confirmed that a current sprinkler head list identifying the correct quantity of each type, manufacturer, model, temperature rating, and K-factor for installed sprinkler heads was not available in the cabinet or in the facility. Regulatory References:NFPA 13 (2010)§ 6.2.9.7 A list of the sprinklers installed in the property shall be posted in the sprinkler cabinet.§ 6.2.9.7.1* The list shall include the following:Sprinkler Identification Number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure ratingGeneral descriptionQuantity of each type to be contained in the cabinetIssue or revision date of the listNFPA 25 (2011) § 5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5A sprinkler wrench for each type of sprinkler as required by 5.4.1.6 § 5.4.1.4* A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.§ 5.4.1.4.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.§ 5.4.1.4.2 The sprinklers shall be kept in a cabinet located where the temperature in which they are subjected will at no time exceed 100°F (38°C).§ 5.4.1.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:For protected facilities having under 300 sprinklers — no fewer than 6 sprinklersFor protected facilities having 300 to 1000 sprinklers — no fewer than 12 sprinklersFor protected facilities having over 1000 sprinklers — no fewer than 24 sprinklers§ 5.4.1.6* A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers.§ 5.4.1.6.1 One sprinkler wrench shall be provided for each type of sprinkler installed. Deficiency findings were discussed during the survey and again at the exit conference with the NHA.

A recertification survey with Incident #2741002 and Incident#2806889 was completed on 3/16/26 to 3/19/26. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/16/26 to 3/19/26. No deficiencies were cited.

Based on record review and interviews the facility failed to ensure one (#8) of five residents received treatment and care in accordance with professional standards of practice out of 35 sample residents. Specifically, the facility failed to:-Ensure Resident #8’s blood sugar levels were being monitored consistently per physician’s orders; and,-Ensure the physician was notified, per physician’s orders, when Resident #8’s blood sugar levels were out of range. Findings include:I. Facility policy and procedureThe Blood Glucose Testing policy and procedure, dated 9/11/23, was provided by the nursing home administrator (NHA) on 3/23/26 at 12:53 p.m. The policy read in pertinent part, “Blood glucose testing will be performed by a licensed nurse or nursing assistant per physician order. Appropriate infection control practices will be utilized by staff when performing blood glucose.“Knock and gain permission before entering the resident’s room. “Verify the identity of the resident.“Identify yourself and ask the resident’s permission to perform blood sampling.“If the resident refuses the care, explain the risks of not receiving care, the benefits of receiving care and acceptable alternatives to suggested treatment.“If permission is obtained from the resident, explain the procedure to the resident, including treatment process and expected sensations. Answer any questions and proceed. “If the resident refuses testing, document it in the medical record.”II. Resident #8A. Resident statusResident #8, age 67, was admitted on 2/19/26. According to the March 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with ketoacidosis without coma (life-threatening acute metabolic crisis where high blood sugar and elevated ketones cause blood acidity without leading to unconsciousness) and chronic kidney disease. The 2/25/26 minimum data set (MDS) assessment revealed that the resident was cognitively intact and with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was independent in indoor mobility and required some help with self care. B. Record review Review of the March 2026 CPO revealed the following physician's order:Check blood sugar twice a day. If blood glucose is greater than 250 milligrams/deciliter (mg/dl) and a sliding scale has not been ordered, notify the physician. If blood glucose is less than 60 mg/dl, follow hypoglycemia (low blood sugar level) procedure. Review of Resident #8’s February 2026 and March 2026 vital signs report revealed Resident #8’s blood sugar was checked on 2/25/26 at 8:45 p.m. Resident #8’s blood sugar was 302 mg/dl. -However, there was no documentation in #8’s electronic medical record (EMR) to indicate the physician was notified of the high blood glucose level, despite the physician’s order to notify if the blood sugar level was greater than 250 mg/dl (see physician’s order above). Review of Resident #8’s February 2026 and March 2026 medication administration records (MAR), from 2/18/26 to 3/18/26, revealed there was no blood sugar documented on the afternoon of 2/19/26, 2/20/26, 2/24/26 and 3/9/26. The MARs revealed documentation indicating the resident was unavailable (on 2/19/26, 2/24/26 and 3/9/26) and the resident refused (on 2/20/26). The documentation on all four dates was completed by registered nurse (RN) #2.-However, there was no further documentation in the resident’s EMR to indicate why the resident was unavailable or why the resident refused the blood sugar or what education was provided to the resident regarding the refusal. Review of Resident #8’s February 2026 and March 2026 MARs, from 2/18/26 to 3/18/26, revealed there was no blood sugar documented on 2/22/26. -However, there was no documentation in the resident’s EMR to indicate why a blood sugar was not checked. III. Staff interviewsRN #2 was interviewed on 3/19/26 at 3:28 p.m. RN #2 said when documenting that a resident was unavailable, it would mean a resident was out of the building,at an appointment, at the hospital, or at therapy. RN #2 said normally, nurses could go back and complete the assigned task at a later time if the resident was unavailable prior. RN #2 said he was not sure what Resident #8 was doing on the dates it was charted that Resident #8 was unavailable. The director of nursing (DON) was interviewed on 3/19/26 at 6:55 p.m. The DON said diabetic ketoacidosis was a complication of diabetes and was caused by high blood sugar and insufficient insulin. The DON said diabetes management was up to the physician’s discretion on how often to check blood sugars, but they were typically checked two to three times a day before meals and there could be a late evening blood sugar check as well. The DON said nurses checked blood sugars on residents with diabetes to make sure their blood sugar level was not too high or too low and to make sure they were giving the correct amount of insulin. The DON said if blood sugars were too high, it could cause increased thirst, frequent urination, fatigue and blurry vision. The DON said staff should notify the physician immediately if a blood sugar was out of range. The DON said it would not be appropriate to chart that a resident was unavailable. The DON said the nurse should have been explaining why the resident was not available because otherwise it did not give a good picture of what was going on. The DON said there was a spot in the MAR where nursing staff could click the option of “other” and then be able to provide a better description. The DON said if the resident was at an appointment or out of the building, she would still expect the nurse to check the resident’s blood sugar level when they returned. The DON said the nurse could have documented a note in Resident #8’s MAR that the resident was out of the facility. The DON said she was not sure where Resident #8 was when he was documented as being unavailable for a blood sugar check on 2/19/26, 2/24/26 and 3/9/26 (see record review above).

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically the facility’s medication error rate was 6.5%, or three errors out of 31 opportunities. Findings include:I. Facility policy and procedureThe Administration of Medication policy and procedure, dated 5/5/26, was provided by the nursing home administrator (NHA) on 3/23/26 at 12:53 p.m. The policy read in pertinent part, “Licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications.“Compare the prescription label to the order on the electronic medication administration record (eMAR).“Verify the six medication administration rights: right patient, right drug, right dose, right dosage form, right route, right time.”II. ObservationsOn 3/18/26 at approximately 8:20 a.m. licensed practical nurse (LPN) #1 was preparing to administer a lidocaine (topical medication used to treat pain) 4% patch to Resident #19. Review of Resident #19’s March 2026 computerized physician orders (CPO) revealed the following physician’s order: Lidocaine 4% adhesive patch. Apply to lower back in the morning and remove every night at bedtime, ordered 3/13/26. LPN#1 told Resident #19 that she had a lidocaine pain patch for her lower back. Resident #19 said she had pain in both her lower back and her right shoulder. LPN #1 placed the lidocaine patch on Resident #19’s upper right shoulder.-However, the resident did not have an active physician’s order to apply the pain patch to her right shoulder (see physician’s orders above). LPN #1 went back to the medication cart and retrieved another lidocaine 4% patch. LPN #1 placed the second lidocaine 4% patch on Resident #19’s lower back. On 3/18/26 at 8:28 a.m. LPN #1 was preparing to administer medications to Resident #44. Review of Resident #44’s March 2026 CPO revealed the following physician’s order:Amlodipine (medication to treat high blood pressure) tablet 2.5 milligrams (mg). Amount to administer: 5 mg orally every day. Hold for systolic blood pressure less than 100 millimeters of mercury (mm/Hg). LPN #1 dispensed Resident #44’s medications into a medication cup. LPN #1 dispensed one 2.5 mg amlodipine tablet into the medication instead of two tablets (in order to equal the 5 mg dose). LPN #1 administered the medications to Resident #44, including the one tablet of amlodipine. -LPN#1 failed to administer the correct dose of amlodipine to Resident #44 (see physician’s orders above). III. Staff interviewsLPN #1 was interviewed on 3/18/26 at 8:28 a.m., after administering the incorrect dose of amlodipine to Resident #44. LPN #1 said she did not realize she needed to give 5 mg of amlodipine to the resident. LPN #1 said she should have administered another 2.5 mg tablet of amlodipine to Resident #44 in order to equal the full dose ordered. LPN #1 retrieved a second 2.5 mg tablet of amlodipine from the medication cart and administered it to the resident.-However, LPN #1 failed to identify her medication error prior to the interview. LPN #1 was interviewed a second time on 3/19/26 at 2:04 p.m. LPN #1 said staff should make sure they had the right medication, the right dose and administered the medication at the right time. LPN #1 said it was important to make sure all information was accurate before going into a resident’s room to administer medications. LPN #1 said it was important to have all medication information correct, in order to prevent medication errors. LPN #1 said Resident #19 had a physician’s order for a lidocaine patch to her lower back only. LPN #1 said Resident #19 said her shoulder was hurting so she administered the patch on her shoulder and then got the physician’s order for the second pain patch to be placed on the shoulder right away. LPN #1 said she should have called the physician to obtain the physician’s order for the second lidocaine patch before placing the patch on the resident’s shoulder. The director of nursing (DON) was interviewed on 3/19/26 at 7:52 p.m. The DON said the seven rights of medication administration were the right resident, right medication, right dose, right time, right route, right reason and right documentation. The DON said nurses should always have a physician’s order in the resident’s electronic medical record (EMR) before administering a medication to a resident. The DON said LPN #1 should have told Resident #19 that she needed to talk to the physician to get another physician’s order for an additional lidocaine patch for her shoulder. The DON said LPN #1 should have offered the resident a non-pharmacological intervention for her shoulder pain while waiting for the physician’s order to be obtained for the lidocaine patch for her shoulder. The DON said amlodipine was given to ensure a resident’s blood pressure did not get too high. The DON said if blood pressure got too high it could lead to health issues of heart attacks, strokes, or vision loss. The DON said nurses should be following the seven rights of medication administration. IV. Facility follow-upA second review of Resident #19’s March 2026 CPO on 3/19/26 revealed the following physician’s order:Lidocaine 4% adhesive patch. Special instructions: apply one patch to the lower back and over the top of the right shoulder in the morning and remove every night at bedtime.-However, the physician’s order to place apply the lidocaine patch to the resident’s shoulder was not obtained until the medication error made by LPN #1 was brought to the attention of the facility (see observations above).

Based on observations, record review and interviews, the facility failed to maintain accurately documented medical records for one (#45) of two residents reviewed out of 35 sample residents. Specifically, the facility failed to ensure the administration of Resident #45’s as needed (PRN) hydromorphone (opioid analgesic used to treat moderate-to-severe pain when other options are inadequate) on 3/12/26 and 3/13/26 was documented in the resident’s electronic medication administration record (eMAR). Findings include:I. Facility policy and procedureThe Administration of Medication policy, updated 5/5/25, was provided by the nursing home administrator (NHA) on 3/23/26 at 1:59 p.m. It read in pertinent part, “Licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications.“Identify each resident before administering any medication. Use picture identification located in the resident’s eMAR and/or verify by asking the resident to state his/her full name, checking with a family member or another staff member.“Identify the medication on the eMAR. Compare the prescription label to the order on the eMAR.“As you pour each pill into the medication cup, prepare the medication on the eMAR. After administering the medication, return to the eMAR and immediately chart the administration.“If a resident does not take a medication for any reason, document the refusal on the eMAR identifying the reason the medication was not received.“Logout of the eMAR before leaving the medication cart.”II. Resident #45A. Resident statusResident #45, age greater than 65, was admitted on 3/11/26. According to the March 2026 computerized physician orders (CPO), diagnoses included encounter for surgical aftercare following surgery on the digestive system, esophageal obstruction, gastro-esophageal reflux disease (GERD) with esophagitis (irritation and swelling of the esophagus, the tube that carries food from mouth to stomach) without bleeding and dysphagia (difficulty swallowing). The 3/17/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was able to walk independently with a walker. She needed some help completing the activities of daily living (ADLs). The MDS assessment indicated the resident complained of difficulty or pain in swallowing. B. Resident interviewResident #45 was interviewed on 3/18/26 at 11:34 a.m. Resident #45 said she did not receive her as needed pain medication timely after requesting it from licensed practical nurse (LPN) #2 on 3/13/26.. Resident #45 said her pain worsened on 3/13/26 because she did not receive the as needed pain medication quickly enough. C. Record reviewResident #45's pain care plan, revised 3/16/26, revealed the resident had acute and/or chronic pain related to general aches and pains. Interventions included administering medication per physician’s order, encouraging the resident to express concerns or fears regarding pain management, establishing an acceptable level of pain and notifying the physician if the current regimen was ineffective in managing pain. A physician’s order, dated 3/12/26, revealed to administer hydromorphone 4 milligrams (mg) tablet orally every four hours as needed (PRN) for pain on a scale of 6 to 10. The controlled drug record sheet for Resident #45’s hydromorphone 4 mg, dated 3/11/26, documented LPN #2 administered hydromorphone to Resident #45 as follows:-One 4 mg tablet was administered by LPN #2 on 3/12/26 at 10:30 a.m.;-One 4 mg tablet was administered by LPN #2 on 3/12/26 at 5:30 p.m.;-One 4 mg tablet was administered by LPN #2 on 3/13/26 at 6:30 a.m.;-One 4 mg tablet was administered by LPN #2 on 3/13/26 at 11:30 a.m.; and;-One 4 mg tablet was administered by LPN #2 on 3/13/26 at 5:00 p.m.-However, review of Resident #45’s March 2026 eMAR revealed no documentation of the 4 mg hydromorphone administration by LPN #2to the resident on 3/12/26 and 3/13/26. III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 3/19/26 at 4:08 p.m. CNA #2 said if a resident complained of pain, she would notify the nurse and let the resident know the nurse would be with them shortly. CNA #2 said she would not interrupt the nurse during lunch break. CNA #2 said on 3/13/26 at approximately 4:00 p.m. she did not notify LPN #2 when Resident #45 complained of pain because LPN #2 was on lunch break. CNA #2 said Resident #45 pressed the call light a second time before she told LPN #2 about the resident’s pain complaint. LPN #2 was interviewed on 3/19/26 at 12:43 p.m. LPN #2 said she usually let CNAs know when she was going on lunch break. She said CNAs could come get her if something was going on with a resident. LPN #2 said she should document all PRN medication in the eMAR after administration. She said on 3/13/26 she went on lunch break at 4:30 p.m. She said when she came back at approximately 5:00 p.m., she was on the phone with the physician regarding a critical laboratory result for another resident. LPN #2 said she administered the hydromorphone to Resident #45 shortly after 5:00 p.m. She said she documented the pain medication administration in Resident #45’s eMAR. -However, review of Resident #45’s March 2026 eMAR revealed no documentation of the hydromorphone administration by LPN #2 on 3/13/26 at 5:00 p.m. Additionally, several other administrations of the medication by LPN #2 on 3/12/26 and 3/13/26 were not documented in the eMAR(see record review above). The director of nursing (DON) was interviewed on 3/19/26 at 7:10 p.m. The DON said CNAs should notify her if a resident complained of pain and needed pain medication while the floor nurses were on lunch break. The DON said nurses should document all narcotic medications after administration in the resident’s eMAR and on the narcotic sheet. The DON said she was unable to locate documentation of hydromorphone administration by LPN #2 in Resident #45’s eMAR on 3/12/26 and 3/13/26.

A complaint survey, prompted by #CO2690954 was conducted on 1/5/26. No deficiencies were cited.

A complaint survey, prompted by #CO1946848 and #CO2690952 was conducted on 1/5/26. No deficiencies were cited.

A survey prompted by Incident #39375 was conducted 3/19/25. No deficiencies were cited.

A revisit to the 12/21/24 survey was completed on 3/27/24. The facility was in compliance with the regulation surveyed.

A revisit to the 12/21/24 survey was completed on 3/27/24. The facility was in compliance with the regulations surveyed.

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

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility's general characteristics. The facility is a one-story wood frame structure, approximately 41,000 sq. ft., Type V (111) construction, without a basement. The building is served by a piped medical gas system with a bulk Oxygen storage tank located to the rear of the facility. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The survey was conducted on January, 18 2024 for compliance to fire safety requirements of NFPA 101, Life Safety Code (LSC), 2012 edition, Chapter 18 for New Health Care Occupancies. and the requirements of NFPA 99, Health Care Facilities Code, 2012 edition, and referenced standards. The facility was licensed for 36 beds and operated as a non-secured facility at the time of this survey.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. Semi Annual Hood Inspection | Only 7/20/23 report available for review | no previous report available 2. Semi Annual Hood Cleaning | Only 11/9/23 report available for review | no previous report availableNFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.4 Table Systems serving moderate-volume cooking operations SemiannuallyThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Missing two (2) year smoke detector sensitivity report. 2. Cintas did not test all fire alarm devices. NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer's calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by the authority having jurisdictionNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashesThis deficiency has the potential to harm all occupants, staff and visitors in the building if the fire alarm system fails to operate. Deficient items were discussed with the Administrator during the exit conference.

Based on observations and records review, it was determined that the facility did not have Fire Alarm out of service guidance in accordance with NFPA 101. Out of Service Fire Alarm Guidance | Does not include verbiage for state notificationNFPA 101 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011) One (1) painted sprinkler head in the IT room. Per NFPA 13 section 3-2.6.3 "Unless applied by the manufacturer, sprinkler shall not be painted2) Main Entrance canopy sprinkler heads missing escutcheon plate. 3) Loaded sprinkler head in Clean linen roomNFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator at the exit conference.

Based on observations and records review, it was determined that the facility did not have Sprinkler System out of service guidance in accordance with NFPA 101 and NFPA 25Out of service Sprinkler Guidance - Not available at time of surveyNFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:(1) The extent and expected duration of the impairment have been determined.(2) The areas or buildings involved have been inspected and the increased risks determined.(3) Recommendations have been submitted to management or the property owner or designated representative.(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:(a) Evacuation of the building or portion of the building affected by the system out of service(b) *An approved fire watch(c)*Establishment of a temporary water supply(d)* Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire(5) The fire department has been notified.(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.(7) The supervisors in the areas to be affected have been notified.(8) A tag impairment system has been implemented. (See Section 15.3.)(9) All necessary tools and materials have been assembled on the impairment site. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70. Electrical receptacle in the kitchen next to the sink is needs to be a GFCI receptacle. NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105Records were not available at the time of the survey to document the inspection and testing operation of the fire dampers installed in the facility as required one year after initial inspection. NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills are required to be conducted on each shift quarterly; the facility failed to conduct a fire drill on the second shift in the fourth quarter. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator at the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:Oxygen transfill room - All combustible materials needs to be removed NFPA 99: .11.3.2* Storage for nonflammable gasses greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were identified during the survey and discussed with the Administrator and at the exit conference.

A recertification survey was conducted from 12/18/23 to 12/21/23. Seven deficiencies were cited.

An Emergency Preparedness survey was conducted from 12/18/23 to 12/21/23. One deficiency was cited.

Based on record review and interview, the facility failed to complete an additional testing exercise of choice in addition to activating its emergency plan. Specifically, the facility failed to conduct an additional full-scale exercise, individual facility based functional exercise, mock disaster drill, table top exercise or workshop in the last year. Findings include: I. Testing The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) on 12/21/23 at 8:30 a.m. Review of the EPP revealed the facility had not conducted a second exercise of choice in the past year. II. Staff interview The EPP was reviewed with the NHA on 12/21/23 at 8:30 a.m. The NHA said the facility had not participated in a second exercise in the past year. The NHA said he was not aware a second exercise was required. He said in the last year the facility had not completed the second exercise required. The NHA said it was important to train and test the EPP annually to keep up with the requirements and ensure the EPP was effective.

Based on record review and interviews, the facility failed to honor resident choices for two (#22 and #94) of three residents reviewed for showers out of 21 sample residents. Specifically, the facility failed to ensure Resident #22 and Resident #94 received two showers a week and identified on the baseline care plan. Findings include: I. Resident #22A. Resident statusResident #22, age over 65, was admitted on 10/5/23 and readmitted on 12/3/23. According to the December 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, end stage renal disease and type II diabetes mellitus. The 12/9/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. She had no behaviors or rejections of care. The assessment identified dialysis care. B. Record reviewThe care plan, initiated 12/18/23, identified ADL functional status and rehabilitation potential. Interventions included staff to assist with showers twice a week and as needed per patient preference. The care plan, initiated 12/18/23, identified behavioral symptoms such as rejection of cares. Interventions included to document any refusals of care to the physician. The shower logs provided by the director of nursing (DON) on 12/21/23 at 9:02 a.m. The shower sheets for Resident #22 from readmission on 12/3/23 to 12/19/23 documented three showers in the last 16 days.-The resident's electronic chart did not document notification to the provider of any refusals. C. InterviewsCertified nurse aide (CNA) #6 was interviewed on 12/21/23 at 11:07 a.m. She said each resident was scheduled for two showers a week. The shower schedule was based on the room number and offered twice a week, except on Mondays when the shower aide was off. She said if a resident refused the shower aide, another aide would offer. She said if the resident continued to refuse, the aide would notify the nurse on duty, and complete a refusal form and have the resident sign it. CNA #7, who was the shower aide, was interviewed on 12/21/23 at 11:09 a.m. She said she assisted residents twice a week with showers. She said each room was scheduled twice a week. She said if a resident refused a shower she would write refuse on the shower sheet, report the refusal to the nurse and have the resident sign the refusal sheet. She said if a resident refused a shower they usually were not offered another shower until the next scheduled shower day. If a resident asked for another shower and if she had the time, she would give the shower. Licensed practical nurse (LPN) #1 was interviewed on 12/21/23 at 11:15 a.m. She said if a CNA reported a refused shower, she would go talk to the resident and try to persuade them to take the shower. She said if the resident refused a shower, the aide was to mark refusal on the shower sheet and the staff were to complete a refusal sheet for the resident to sign. She said the nurse would then complete a progress note and let the director of nursing (DON) know. The DON was interviewed on 12/21/23 at 11:20 a.m. She said Resident #22 had a history of refusing showers. She said there were no shower sheets or refusal sheets signed by the resident. She said the provider was not notified of the refusals. She said if a resident refused showers, the staff were to document on the shower sheet refused. She said not every refusal would be a progress note. She said she would provide more education with the staff on expectations for shower refusals. II. Resident #94A. Resident statusResident #94, age over 65, was admitted on 12/13/23. According to the December 2023 CPO, diagnoses included subarachnoid hemorrhage (brain bleed), chronic kidney disease and heart failure. The MDS assessment was not completed since the resident recently admitted to the facility. B. Resident interviewResident #94 was interviewed on 12/18/23 at 9:13 a.m. He said he had not had a shower since his admission and would like one. C. Record reviewThe baseline care plan, initiated on 12/13/23, identified the resident would receive two showers a week. The shower logs provided by the DON on 12/21/23 at 9:02 a.m. The two shower records, dated 12/19/23 and 12/20/23, did not identify if a shower was provided. One shower sheet had a refusal written on it and it had been signed by the resident. D. InterviewsThe DON was interviewed on 12/19/23 at 2:50 p.m. She said she did not know he had not received a shower. On 12/21/23 at 11:20 a.m. the DON said on one of the shower sheets dated 12/20/23 included the word refusal and CNA #7, LPN #1 and Resident #94's signatures. She said she would follow up with the resident and work to provide a shower for him.

Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (#22) of three residents out of 21 sample residents. Specifically, the facility failed to develop a person-centered baseline care plan for Resident #22 that included dialysis care and services. Findings include: I. Facility policyThe Baseline Person Centered Care Plan policy, revised 9/11/23, provided by the director of nursing (DON) on 12/21/23 at 9:02 a.m. included:"The baseline person centered care plan is developed during the admission process to direct patient care prior to the development of the comprehensive care plan."The baseline person centered care plan is written to include care to be given, goals to be accomplished, and actions necessary to attain the goals."This form covers the basic information utilized to disseminate information to provide care for a newly admitted or readmitted patient."II. Resident #22Resident #22, age over 65, was admitted on 10/5/23 and readmitted on 12/3/23. According to the December 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, end stage renal disease and type II diabetes mellitus. The 12/9/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. She had no behaviors or rejections of care. The assessment identified dialysis care. III. Record reviewThe baseline care plan, dated 10/5/23, did not include the resident received dialysis. The December 2023 CPO included: -Assess dialysis access for appearance, signs of infection, drainage, bleeding.-Three times a week weight post hemodialysis.-Assess vital signs pre and post dialysis.-No blood pressure on left arm, has a fistula for dialysis.-Patient has dialysis at (dialysis center) on Monday, Wednesday and Friday. VI. InterviewThe DON was interviewed on 12/19/23 at 2:50 p.m. She said Resident #22 received dialysis. She said upon admission the facility was aware the resident needed dialysis. She said dialysis was not included on the baseline care plan because there was not a section on the admission form that identified dialysis. She said dialysis should have been identified somewhere on the baseline care plan. She said she would update the admission form to include dialysis. V. Facility follow-upThe DON provided an updated admission form on 12/21/23 at 6:41 p.m. The updated admission form had a space for dialysis care.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#242) resident reviewed for discharge planning out of 21 sample residents. Specifically, the facility failed to ensure the discharge planning process was developed, communicated and documented in Resident #242's medical records. Findings include: I. Resident statusResident #242, age 74, was admitted on 12/7/23. According to the December 2023 computerized physician order (CPO), diagnoses included hypertension, cellulitis (skin infection) of right arm, spondylosis (abnormal wear on the cartilage and bones of the neck), heart disease with heart failure, type two diabetes mellitus with diabetic neuropathy, hyperlipidemia, sleep apnea, atrial fibrillation, anemia, depression, insomnia, weakness and fall. The 12/13/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. The resident required limited one person assistance with bed mobility, transfers and toileting. It indicated that the resident expected to be discharged to the community in a group home. II. Resident interview The resident was interviewed on 12/18/23 at 1:53 p.m. He said that no staff talked to him about his care plan and his discharge plans. He thought he would stay at the facility for two to three more weeks. III. Record review -A review of Resident #242's medical record did not reveal documentation that the resident's discharge plan was part of the resident's comprehensive plan of care. It did not document the resident's discharge goal, interventions used to achieve the resident's goals or the discharge planning process. -The 12/7/23 baseline care plan did not document if the resident wanted to stay in the facility long term or to return to the community. The discharge planning progress notes revealed that the resident planned to be discharged on 1/9/24 to a group home. It was added on 12/19/23 at 1:22 p.m. by the corporate nurse consultant (CNC). The 12/13/23 letter addressed to the resident documented the discharge time frame was three to four weeks. -No further documentation was in Resident #242's medical record regarding his discharge plan and goals. IV. Staff interviews The director of nursing (DON) was interviewed on 12/21/23 at 12:21 p.m. She said the discharge planner was responsible for discharge planning. She was unavailable to be interviewed. The DON said the CNC, the facility liaison and the DON provide backup support when the discharge planner was not available. The DON said discharge planning should start as soon as the resident was admitted. The discharge plan was reviewed weekly and more often as needed. The admission nurse explained the process at time of admission to reduce the questions from residents and family members on when the resident would be discharged. She said that discharge planning was reviewed with the resident and family members on a weekly basis by the discharge planner. The DON said discharge planning was documented in a spreadsheet that was not linked to the resident's medical record. The DON provided a letter regarding the discharge plan for Resident #242 on 12/21/23 at 12:40 p.m. She said the spreadsheet did not provide additional information about the discharge plan but was a tool to generate the discharge letter. -However, there was a lack of communication/documentation regarding Resident #242's discharge until identified during the survey when a discharge letter was provided.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNAs) reviewed. Specifically, the facility had not provided inservice education based on the outcome of the performance reviews for CNA #1, #2 and #4. Findings include: I. Record review CNA #1 (hired 8/10/22) had a performance review on 11/10/23. CNA #2 (hired 8/10/22) had a performance review on 11/11/23. CNA #4 (hired 8/10/22) had a performance review on 8/10/23.-The CNAs did not have an inservice education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 12/21/23 at 9:45 a.m. She said the facility had completed the annual performance reviews, but was not aware the performance reviews needed to develop regular inservice education based on the outcome of the performance reviews. She said the facility would develop a plan to complete the performance reviews going forward.

Based on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#242) of five residents reviewed for medication errors of 21 sample residents. Specifically, the facility failed to ensure that Resident #242 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include:I. Professional referenceAccording to the Lantus (glargine) manufacturer guidelines, updated 2022, retrieved fromhttps://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf on 12/28/23 included the following recommendations,"Perform a safety test. Dial a test dose of two units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle."II. ObservationOn 12/21/23 at 7:12 a.m. registered nurse (RN) #1 checked Resident #242's insulin order of glargine insulin 14 units to be administered in the morning. She obtained the resident's labeled glargine insulin pen and dialed 14 units into the pen. She then administered the insulin in the resident's right upper arm and disposed of the needle in the sharps container. She did not prime the pen prior to administration. III. Staff interviewsRN #1 was interviewed on 12/21/23 at 7:25 a.m. She said insulin pens were primed only when the pen was brand new prior to the first administration. She said she was not aware of insulin pens needing to be primed prior to every administration of insulin. The director of nursing (DON) was interviewed on 12/21/23 at 7:58 a.m. She said insulin pens should be primed by pushing two units through the pen prior to administering the ordered dose of insulin. She said this needed to be done to ensure air was eliminated in the pen and the resident received the correct dosage of insulin.

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included the use of an electronic elopement prevention system, dialysis services and hospice services. Findings include: I. Record review The facility assessment was provided by the nursing home administrator (NHA) on 12/19/23 at 11:27 a.m. The facility assessment was last reviewed on 10/17/23 by the NHA, director of nurses (DON) and the interdisciplinary team (IDT). The facility assessment failed to include the following:-The facility had an electronic elopement prevention system.-The facility offered contracted dialysis and hospice services. II. InterviewThe NHA was interviewed on 12/19/23 at 11:41 a.m. He said he was not aware the services identified were not included in the facility assessment. He said the facility assessment should be a reflection of all the services available to residents. III. Facility follow-upThe NHA provided an updated facility assessment to include an electronic elopement prevention system, dialysis services and hospice services on 12/19/23 at 2:09 p.m.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one out of one units. Specifically, the facility failed to:-Ensure an intravenous (IV) administration set was stored in a sanitary manner; and,-Ensure the hub of an insulin pen was cleaned off prior to the administration of insulinFindings include:I. Professional referenceVelasquez, J., Evans. B. (August 2022). Enhancing Peripheral Line Maintenance Practices Among Nurses in a Critical Care Setting: A Quality Improvement Project. University of New Hampshire. https://scholars.unh.edu/cgi/viewcontent.cgi?article=1700&context=honors, retrieved on 1/2/24."The Institute for Safe Medication Practices (ISMP) has identified that there are two common practices that continue to put patients at risk for infection including 1) failure to place a sterile cap on the end of a reusable intravenous (IV) administration set that has been removed from a saline lock or IV catheter hub and 2) failure to properly disinfect the IV port when accessing IV sets."The Centers for Disease Control (CDC). (June 2019). Frequently Asked Questions Regarding Safe Practices for Medical Injections. https://www.cdc.gov/injectionsafety/providers/provider_faqs_med-prep.html, retrieved on 1/2/24."Parenteral medications (medications that enter the body by injection) should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."II. ObservationsOn 12/19/23 at 12:20 p.m. Resident #193's IV administration tubing was observed without a sterile cap on the end of tubing disconnected from the resident and hanging on the IV pole. It was not dated or timed when the tubing was hung or changed. Resident #193's IV tubing was observed hanging in an unsanitary manner without a sterile cap over the end to ensure it remained free of contamination. On 12/21/23 at 7:18 a.m. registered nurse (RN) #1 was observed obtaining Resident #242's labeled insulin pen. RN #1 was observed placing a new sterile needle onto the hub of the insulin pen and dialing 14 units into the pen. RN #1 was observed not cleaning off the hub of the insulin pen with alcohol before applying the sterile needle. III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 12/19/23 at 12:25 p.m. He said IV administration tubing, after it is disconnected from the resident and stored for possible future use, should have a sterile cap placed on the end of the tubing to ensure it was kept free from contamination. RN #1 was interviewed on 12/21/23 at 7:25 a.m. She said the rubber stopper on the insulin pen should be cleaned off in an aseptic technique using an alcohol pad to ensure the stopper was not contaminated before applying a sterile needle. The director of nursing (DON) was interviewed on 12/21/23 at 7:58 a.m. She said IV administration tubing, after it was disconnected from the resident, should have a sterile cap placed on the end of the administration tubing to ensure the end of the tubing was not contaminated and stored in a sanitary manner. She said the rubber stoppers on insulin pens should be cleaned off with alcohol prior to being accessed with a sterile needle to prevent contamination of the sterile needle prior to insulin administration.

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