CENTER AT CENTENNIAL, THE

A complaint survey, prompted by #CO39102 and #CO39448 was conducted on 3/5/25. No deficiencies were cited.

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 11/21/24 for all previous deficiencies cited on 10/23/24. The facility is in compliance with all regulations surveyed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is three story, Type II (111), construction. The facility is protected throughout by National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 2007 and is license for 80 beds. All beds are located on the second and third floors. This facility has no emergency or stand-by generator power system. Emergency exit lighting is comprised of battery unit lighting integral to the existing lay-in fluorescent fixtures. This re-certification survey conducted on November 13, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies". The deficiency cited was discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

STANDARD was not met based on observation and staff interviews regarding the emergency lighting. The facility failed to maintain the battery-powered emergency lights per 7.9.3 and 19.2.9.1. This deficiency could affect all residents and staff throughout the facility during primary power loss. During the record review of the facility-required testing of the battery-powered emergency lighting system, no documentation was available to confirm that each light testing was conducted at 30-day intervals for a minimum of 30 seconds each month or for at least 1.5 hours annually. 2012 Life Safety Code 101-7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for at least 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The maintenance director acknowledges the need for emergency lighting testing during the facility tour.

STANDARD not met: Through observation and discussion during the facility tour, it was determined that the facility failed to install and maintain fire-rated doors per NFPA 101 2012 Edition Chapter 9 Section 9.5 and 19.5.4. Failure to maintain fire-rated doors and assemblies in hazardous areas has the potential to harm all occupants, staff, and visitors in the building if the fire-rated doors fail to operate if a fire was to occur. The roll-down fire door on the second-floor elevator does not close automatically, compromising its one-hour fire protection rating. 19.5.4.1Existing rubbish chutes or linen chutes, including pneumatic rubbish and linen systems, that open directly onto any corridor shall be sealed by fire-resistive construction to prevent further use or shall be provided with a fire door assembly having a minimum 1-hour fire protection rating. All new chutes shall comply with Section 9.5. During a facility tour, the Director of Maintenance acknowledged the enclosure and door condition.

STANDARD is not met as evidenced by the following: During the review of the facility records with the staff, documentation was unavailable to confirm that the facility had a kitchen-hood-exhaust system cleaned as required by NFPA 96 (Chapter 11, Section 11.6.1). This deficient practice could affect all residents and staff should a fire occur due to failure to exhaust system shall be cleaned by a properly trained, qualified, and certified person(s). 1. The facility could not provide further documentation indicating that the kitchen hood system is cleaned every six months. 2. Upon inspection, the exhaust system was contaminated with deposits from grease-laden vapors. 3. The up-blast fan on the kitchen hood exhaust system is not equipped with a hinged and flexible cable system to access for inspection and cleaning. NFPA 96- Chapter 11, Section 11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction. NFPA 96-2011 section 7.8.2.1 Rooftop terminations shall be arranged with or provided with the following: (8) Hinged-up blast fan supplied with flexible weatherproof electrical cable and service hold-open retainer to permit inspection and cleaning that is listed for commercial cooking equipment. The Maintenance Director acknowledged the system's lack of inspections and servicing and stated they were not aware that it had to be inspected every six months and cleaned annually.

STANDARD not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alarm system failed to operate if a fire was to occur. 1. At the time of the survey, no documentation was available to indicate the Annual Testing of the fire alarm system had occurred in the past year. 2. No documentation was available during the survey to indicate that the fire alarm system had been tested semiannually in the past year. 3. During the review of the records, documentation was unavailable to verify the smoke detectors' sensitivity testing. 2012 Life Safety Code 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. The Director of Maintenance acknowledge the lack of testing of the fire alarm system in the past year during the tour of the facility.

STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. There is one painted pendent sprinkler head located in the maintenance hall. Per NFPA 13 section 3.2.6.3, "Unless applied by the manufacturer, sprinkler shall not be painted. The Director of Maintenance acknowledged the painted sprinkler head during the facility's tour.

The standard was not met. During the record review, it was determined that the facility did not comply with the corridor door requirements as outlined by NFPA 101 and NFPA 80 (2010). This deficiency could potentially impact occupants, including residents, staff, and visitors within the affected smoke compartments in the event of a fire emergency. At the time of the survey, no written record for each fire door's annual inspection, testing, or maintenance report. NFPA 101 4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance. -Referenced Publications 2.2* NFPA Publications. NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition. Door deficiencies items were discussed during the survey with the Director of Maintenance and again during the exit conference.

STANDARD is not met as evidenced by the: It was determined by record review and staff interview during the survey the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, per NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This deficient practice could affect all residents, staff, and visitors if the smoke dampers malfunction due to improper maintenance should a fire occur. Records were unavailable at the time of the survey to document the inspection and testing operation of the fire dampers installed in the facility as required every four years. NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. The issue of smoke and fire dampers' deficiency was discussed with the Director of Maintenance during the record review of required documentation.

A recertification survey with complaint #CO38023 was completed on 10/21/24 to 10/23/24. One deficiency was cited.

An Emergency Preparedness survey was conducted from 10/21/24 to 10/23/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#25 and #31) of three residents reviewed for antibiotic use out of 33 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #25 and Resident #31. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC) Antibiotic Prescribing and Usage in Hospitals and Long-term Care, dated 2019, was retrieved on 10/24/24 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html. It read in pertinent part,"Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections."II. Facility policy and procedureThe Antibiotic Stewardship Program (ASP) policy and procedure, revised 2/8/21, was received from the director of nursing (DON) on 10/23/24 at 12:43 p.m. It revealed in pertinent part"ASP will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting. "It is mandatory that all antibiotics are tracked using a facility spreadsheet. McGeer Criteria Surveillance Data Collection is to be used for all patients that are prescribed an antibiotic and determine if the patient meets criteria."The Infection Criteria Checklist, undated, was received from the infection preventionist (IP) on 10/23/24 at 11:35 a.m. It revealed in pertinent part, "Symptomatic urinary tract infections (UTI) must have three of the following: fever (greater than 100.4 degrees fahrenheit), new or increased pain on urinations, frequency or urgency, new flank or suprapubic pain or tenderness, change in character of urine (bloody, foul smell, sediment, pyuria), worsening of mental or functional status (may be new or increased incontinence)."III. Resident #25A. Resident statusResident #25, age greater than 65, was admitted on 9/27/24. According to the October 2024 computerized physician orders (CPO), diagnoses included compression fracture of vertebra (bone in the spine), urinary tract infection and hypertension (high blood pressure). The 10/1/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview of mental status (BIMS) score of 11 out of 15. The resident was incontinent of urine and prescribed an antibiotic. B. Resident interviewResident #25 was interviewed on 10/21/24 at 10:55 a.m. Resident #25 said she was on her second round of antibiotics for a UTI since coming to the facility. Resident #25 was not sure why she required another round of antibiotics for the same UTI. C. Record reviewReview of Resident #25's October 2024 CPO revealed the following physician's orders:Urinalysis (UA - a urine test) for urinary frequency, ordered 10/9/24. Keflex (antibiotic) 500 milligrams (mg) three times a day for three days for UTI, ordered 10/10/24. Bactrim DS (antibiotic) 800-160 mg, give two times a day for five days for UTI, ordered 10/18/24. The preliminary UA test result dated 10/12/24 read sensitivity report (a report which indicates what antibiotics a bacteria is susceptible to) was to follow. The UA sensitivity results report, dated 10/14/24, revealed Resident #25 had two microorganisms in her urine. According to the report, one organism was resistant to Keflex, the first antibiotic prescribed on 10/10/24 prior to the results report being completed (see physician's orders above).-Keflex was not the correct antibiotic to treat the whole infection. According to the UA sensitivity results report, both microorganisms were susceptible to the Bactrim that was started on 10/18/24.-Due to the facility's failure to wait for the UA sensitivity report results prior to starting Resident #25 on an antibiotic to treat her UTI, the resident was prescribed an antibiotic that was not effective for treating both microorganisms, which required a second antibiotic to treat the infection effectively. D. Staff interviewRegistered nurse (RN) #1 was interviewed on 10/23/24 at 8:58 a.m. RN #1 said if a resident presented with a new onset of symptoms, such as dark, cloudy urine or confusion, she suspected a possible UTI. RN #1 said she would contact the physician to obtain a UA test with culture and sensitivity. RN #1 said, depending on the physician, some would start a resident on an antibiotic before the culture and sensitivity test results were back from the laboratory (lab). RN #1 said when the culture and sensitivity test results came back, the physician would sometimes have to change the resident to a different antibiotic. IV. Resident #31A. Resident statusResident #31, age greater than 65, was admitted on 10/2/24. According to the October 2024 CPO, diagnosis included fracture of the neck of the left femur (thigh bone), dementia, cirrhosis of the liver, chronic viral hepatitis C, acute kidney failure, personal history of other infectious parasitic diseases and long term current use of antibiotics. The 10/8/24 MDS assessment revealed, the resident had severe cognitive impairment with a BIMS of five out of 15. He used a walker and a wheelchair and had impairment to one side of his lower extremities. He required maximal assistance with toilet hygiene and was dependent on staff for lower body dressing and putting on/off footwear. He was frequently incontinent of bowel and bladder. He had a surgical wound and moisture associated skin damage. He received an antibiotic. B. Record reviewA nurse's note dated 10/3/24 at 10:24 a.m. revealed Resident #31 had dark urine and an order was received to collect a urine sample via straight catheter and send it to the lab for evaluation. A 10/3/24 physician's order read to collect a urine sample for a UA and C&S (culture and sensitivity) if indicated due to dark urine. A 10/4/24 physician's order read Amoxicillin (antibiotic) oral tablet 875 mg (milligrams) give one tablet by mouth two times a day for urinary tract infection for six days. A 10/4/24 physician's risk/benefit assessment revealed the antibiotic use did not meet the McGeer criteria. -However, Resident #31 was prescribed the antibiotic despite the antibiotic use not meeting the criteria. A 10/15/24 physician's order read to collect a UA with culture and sensitivity. -The facility failed to identify any symptoms or reason for the request of the urinalysis. A 10/17/24 physician's order read Keflex (antibiotic) oral capsule 500 mg by mouth three times a day for UTI for three days. A nurse's note dated 10/18/24 at 2:17 p.m. revealed Resident #31t was started on Keflex 500 mg three times a day for five days while awaiting the sensitivity results. A 10/20/24 physician's order read Levaquin (antibiotic) oral tablet 500 mg by mouth one time a day for UTI for six days.-The facility failed to follow the Mcgeer Criteria when obtaining urinalysis and treating suspected urinary tract infections, which resulted in Resident #31 being prescribed three different antibiotics. C. Staff interviewLicensed practical nurse (LPN) #1 was interviewed on 10/22/24 at 9:40 a.m. LPN #1 said the nurses assessed the residents everyday. She said if the resident had a history of UTIs or symptoms, they would call the physician. She said if the physician ordered aurinalysis, the nurse would report it to the IP who would ensure it met the Mcgeer Criteria. LPN #1 said the nurse did not follow the McGeer Criteria when requesting an order for a urinalysis from the physician for Resident #31. V. Additional interviewsThe infection preventionist (IP) and the DON were interviewed on 10/23/24 at 11:05 a.m. The IP said the facility used Mcgeer criteria for UTIs before prescribing an antibiotic for a resident. The IP said staff looked for a change in the character of urine, such as color, smell, burning, frequency, incontinence, fever, or change in a residents' mental status. The IP said it was the responsibility of the nurse to observe, or if a certified nurse aide (CNA) reported any changes, to call the physician to be able to send out a UA.The IP said the nurse who collected the UA on 10/9/24 for Resident #25 only documented urinary frequency as a symptom, so the nurse did not follow Mcgeer criteria for Resident #25. The IP said Resident #25's antibiotic had to be changed when the culture and sensitivity came back in order to treat the UTI effectively. The IP said Resident #31 did not meet the criteria for antibiotic treatment on 10/4/24 and should not have been treated with an antibiotic. The DON said physicians could choose to start an antibiotic or wait for the culture and sensitivity results to come back. However, the DON said starting an antibiotic before the culture and sensitivity results came back did not follow the antibiotic stewardship program the facility had in place. The DON said the facility would immediately educate the nurses and physicians on following the Mcgeer Criteria for antibiotic use. The physician (PH) was interviewed on 10/25/24 at 11:20 a.m. The PH said he followed Mcgeer criteria most of the time if the resident was symptomatic for a UTI. The PH said he had to change the antibiotic after the culture and sensitivity results came back for Resident #25 in order to effectively treat her UTI because he had prescribed an antibiotic that was not effective to treat both microorganisms prior to receiving the sensitivity results. The PH said Resident #31 was symptomatic for a UTI on 10/3/24, with dark urine and altered mental status, so he ordered a urinalysis and started the resident on Amoxicillin on 10/4/24 while awaiting the culture and sensitivity results. The PH said Resident #31 was started on an antibiotic a second time after the UA was collected on 10/15/24 before receiving the sensitivity results. The PH said after the sensitivity results from the 10/15/24 UA were received, Resident #31's antibiotic had to be changed to effectively treat the bacteria growing in the urine.

A revisit survey was completed on 9/24/24 for all previous deficiencies cited on 7/31/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 9/24/24 for all previous deficiencies cited on 7/31/24. The facility is in compliance with all regulations surveyed.

A health survey prompted by complaints #CO33821 and #CO33824 was completed 7/29/24 to 7/31/24. No response is necessary.

A survey prompted by complaint #CO37051 was completed on 7/29/24 to 7/31/24. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 15 sample residents received adequate supervision and services to prevent an accident. Resident #1 was admitted to the facility on 4/13/24 with a traumatic subdural hemorrhage with loss of consciousness (intracranial bleeding between the brain and the skull), muscle weakness, aphasia (loss of the power of speech), hemiplegia (paralysis affecting one side of the body), Parkinson's disease (a condition that affects muscle control and movement), acute pain due to trauma and a history of falling. Resident #1 was status post burr holes (small holes that a neurosurgeon makes in the skull to help relieve pressure on the brain when fluid, such as blood, builds up and compresses brain tissue) of subdural hematoma with surgical incision on the left side of his head with staples in place. On 4/15/24, certified nurse aide (CNA) #1 and CNA #2 transferred Resident #1 via the hoyer lift (mechanical lift). During the transfer, Resident #1 fell from the lift to the floor, striking his head. Resident #1 began vomiting after the fall and was immediately transferred to the hospital where he was diagnosed with a large posterior scalp hematoma (bleeding under the skin) and left ankle trauma with pain and mild soft tissue swelling. The facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review the use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. Due to the facility's failure to transfer a dependent resident safely, Resident #1 sustained a new head injury and required hospitalization for three days. Resident #1 was discharged from the hospital to his home on hospice care due to the families concern for the resident's safety at the facility. Findings include:I. Facility policy and procedureThe Mechanical Lifts policy and procedure, revised 2/1/23, was provided by the nursing home administrator (NHA) on 7/31/24 at 10:22 a.m. It read in pertinent part, "(Facility name) utilizes mechanical lifts when appropriate to ensure safe patient handling during transfers and employee safety when providing patient care. Direct care staff will receive training upon hire and as needed for proper preparation of the patient, equipment, and environment during utilization of mechanical lifts."II. Mechanical lift manualThe user manual for the Span model: F500P full body patient lift was provided by the NHA on 7/31/24 at 10:35 a.m. It read in pertinent part, "Special care must be taken with users/patients who cannot themselves provide assistance while being lifted (patients who are comatose, spastic, agitated, or otherwise severely handicapped)."The patient lift should be used solely for transferring a user/patient from one utility (beds, chairs, toilets) to another. The patient lift should not be used for transporting or moving any patient from one location to another location."During lifting or lowering, whenever possible, always keep the base of the lift in the widest position."The base of the lift should be closed before moving the lift."Do not roll casters over any object while the user/patient is in the sling."Do not lock casters during lifting."While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lifter."Never leave the user/patient unattended during lifting."III. Resident # 1A. Resident statusResident #1, age 65, was admitted on 4/13/24 and discharged to the hospital on 4/15/24. According to the April 2024 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness, muscle weakness, aphasia, hemiplegia Parkinson's disease, acute pain due to trauma and history of falling. The 4/15/24 facility assessment revealed the resident had short and long-term memory problems and had severely impaired cognitive skills for daily decision making. He was dependent on staff for transfers, and required substantial/maximal assistance with bed mobility. The facility assessment indicated the resident had one fall since admission and documented there was no injury. -However, the resident sustained a head injury with a hematoma, per the hospital records. B. Facility investigation of Resident #1's fall on 4/15/24The fall investigation was provided by the director of nursing (DON) on 7/30/24 at 5:29 p.m. The 4/16/24 post fall investigation revealed the following in pertinent part:On 4/15/24 at 6:30 p.m. licensed practical nurse (LPN) #1 heard a loud bang and ran into the resident's room. Resident #1 was on the floor. CNA #1 and CNA #2 were using the hoyer lift to transfer the resident when Resident #1 slipped through the middle of the sling. Resident #1 hit the back of his head. The resident's vital signs were within normal limits. The physician and the resident's daughter were notified of the fall. The resident was evaluated by registered nurse (RN) #1 and she made the decision to send the resident to the emergency department (ED) as he had hit his head. The resident's vital signs were stable when the resident left the facility with emergency medical services via stretcher to the hospital ED.An undated statement was obtained from CNA #1. CNA #1 said she was sitting at the computer charting and giving a report to the next oncoming shift. She had asked CNA #2 if she would like her to help lay Resident #1 down and she replied "sure." CNA #1 said the hoyer lift sling appeared to be properly in place. CNA #1 said she hooked the resident's sling up to the hoyer lift and began to lift him to the bed. She said Resident #1 suddenly began to slip out of the sling and onto the floor. An undated statement was obtained from CNA #2. CNA #2 said she worked on the night shift at (facility name). CNA #2 said she started her shift at 6:00 p.m. on 4/15/24. CNA #2 said after report was given from the day shift, one of the day shift CNAs offered to help get Resident #1 into bed before she left for the day. CNA #2 said they went to Resident #1's room and he was sitting in his wheelchair by the window side and was leaning towards his right side. CNA #2 said they adjusted Resident #1 the best they could. CNA #2 said they tucked in the hoyer lift sling and criss-crossed the sling between his legs and moved the wheelchair closer to the hoyer lift machine. CNA #2 said they then lowered the hoyer lift machine down to wheelchair level and proceeded to hook up the sling to the machine. CNA #2 said they used the first hook on all six hookups (three on left, three on right). CNA #2 said she had control of the hoyer lift and the other CNA (CNA #1) was guiding Resident #1 towards the bed. CNA #2 said the wheelchair was removed once he was high enough, then she proceeded to move towards the bed. CNA #2 said they were in position moving towards the bed when Resident #1 slipped out of the sling through the bottom. CNA #2 said Resident #1's bottom went through the sling and he landed on his bottom, and then fell backwards and hit his head. CNA #2 said at that point she was in a state of shock. CNA #2 said she had been doing that job for more than 10 years and that had never happened. CNA #2 said they went to Resident #1 and he was still awake, aware and trying to speak. CNA #2 said the nurse rushed in and called 911. CNA #2 said she stayed with Resident #1 until the ambulance and fire department came to help him off the floor. She said Resident #1 was then sent out to the hospital for further evaluation. An undated statement from the DON said CNA #1 and CNA #2 had both been through skills check-offs to include mechanical lifts, and both followed facility protocol for hoyer lift use. The statement said this had been an unfortunate, isolated event. The resident was evaluated at the hospital and the head computed tomography (CT) scan did not show any new bleeds. -However, according to the emergency progress note Resident #1 sustained a large posterior scalp hematoma (see record review below). C. Record reviewThe baseline (admission) care plan, dated 4/13/24, revealed the resident required two person assistance with transfers, bathing, grooming, locomotion and toileting. The resident was at risk for falls related to impaired mobility secondary to weakness and debility and related to current drug regimen. The resident had acute and chronic pain. The 4/13/24 admission skin assessment revealed an actual surgical wound with dressing changes per physician orders. A review of the April 2024 CPO revealed a physician's order was set up to follow up with a neurological surgeon to remove the staples from the resident in five days, ordered on 4/14/24. The 4/16/24 nursing progress note, documented at 1:49 a.m., revealed the nurse heard a loud bang and the nurse ran into Resident #1's room. The resident was on the floor. The CNAs were using the hoyer lift and the resident slipped through the middle of the sling. The resident hit the back of his head. RN #1 came and evaluated the resident. The 4/16/24 change in condition note, documented at 2:42 a.m., revealed the resident's vital signs were within normal limits. The resident was vomiting after the fall. The note documented the physician and family were notified of the fall at 6:30 p.m. on 4/15/24. The 4/16/24 bed hold progress note, documented at 8:18 a.m., revealed the DON spoke with the resident's spouse who stated the resident would not be returning to the facility. The post fall evaluation, completed by the DON on 4/16/24, revealed the resident sustained a witnessed fall on 4/15/24. The resident hit his head and was transferred to the hospital. Neurological checks were initiated per facility protocol. A skin evaluation was not completed. The resident did not have pain from the fall and did not receive pain medication. The resident fell during a transfer in the resident's room with a hoyer lift and sling. The assessment documented the probable cause of the fall was the resident's buttocks slid through the sling onto the floor and the staff expressed that it was properly placed and the appropriate size sling was used. The IDT (interdisciplinary team) discussed the resident's fall. The resident was on the fall program with his bed in a locked and low position, received assistance from two persons at all times for hoyer lift transfers and to assure the sling fit correctly. The evaluation documented the care plan was revised on 4/16/24. It documented the physician and family were notified on 4/15/24. The 4/15/24 hospital progress note documented a 65 year old male with a history of Parkinson's disease and recent subdural hemorrhage status post burr holes brought in to the emergency department from a rehabilitation facility after he was accidentally dropped out of a hoyer lift and hit his head once again. He was not on an anticoagulant and was nonverbal at baseline. He was noted to have a large posterior scalp hematoma that was new since prior exam. A review of the resident revealed he had pain to his left ankle with mild soft tissue swelling. X-rays were obtained and were negative. The hospital progress note documented the plan was for the resident to return to the rehabilitation facility, however the patient's wife had serious concerns about the safety of this facility and did not wish him to go back there. The note documented the resident's spouse was going to contact hospice and palliative care services tomorrow morning as her desire was to take him home on hospice care. The resident was discharged home on hospice from the hospital on 4/17/24.-Following Resident #1's fall on 4/15/24 from the hoyer lift, the facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. D. Staff interviewsThe DON was interviewed on 7/30/24 at 5:05 p.m. The DON said Resident #1 sustained a fall on 4/15/24 at 6:30 p.m. The DON said CNA #1 and CNA #2 witnessed the fall. She said CNA #1 and CNA #2 alerted LPN #2 after the fall. The DON said CNA #1 and CNA #2 were transferring Resident #1, via a hoyer lift, from his wheelchair to the bed and had lifted the resident up in the sling and out of the wheelchair and began to lift him to the bed and that was when Resident #1 fell. The DON said she felt it was a freak accident. The DON said the hoyer lift sling was placed correctly because staff had expressed that it was properly placed and the appropriate size. She said when the CNAs started moving Resident #1 toward the bed, he slipped through the sling. The DON said since Resident #1's admission he had required two person assistance with the hoyer lift. The DON said the comprehensive care plan was still being developed on the day the resident sustained the fall. She said the resident's care plan was not updated after the fall because the resident did not return to the facility. The DON said there was a communication board in the resident's room to let the caregivers know what assistance level the resident required. The DON said no further re-education training was provided to CNA #1 and CNA #2 after the fall because they were both very competent with transfers and she did not know what further instruction or information she could have told them on how they could have corrected the situation. The DON reiterated that she had never seen this type of accident before so there had not been specific training or corrective action given to the direct care staff after the fall. The DON said CNA #1 and CNA #2 had had training on the hoyer lift in February 2024 and had completed the skills competency checklist. The DON said the facility did not do any other training for all the staff after the fall on 4/15/24 because she did not think it was needed as they had just completed the annual skills checklist and there was nothing identified in the fall incident that could have improved the situation. CNA #2 was interviewed on 7/30/24 at 5:40 p.m. CNA #2 said Resident #1 fell on 4/15/24 when she had just come on shift. She said Resident #1 was in his wheelchair and CNA #1 had offered to help put him into bed. CNA #2 said it was dinner time and sometimes it got busy, so she was glad for the help. CNA #2 said the hoyer lift sling was under Resident #1 and the moment she moved the hoyer lift away from the wheelchair, the resident fell and hit his head on the floor. CNA #2 said she screamed and could not believe what happened. CNA #2 said she ran and got the nurse and the resident was sent to the hospital. CNA #2 said she could not pinpoint what went wrong with the transfer since the sling was already under him. CNA #1 was interviewed on 7/30/24 at 5:44 p.m. CNA #1 said she and CNA #2 went in to transfer Resident #1 on 4/15/24 via a hoyer lift. She said he fell out of the sling during the transfer. CNA #1 said Resident #1 was in his wheelchair and she and CNA #2 went to hook the hoyer lift sling up and put him to bed for the evening. CNA #1 said she hooked up the sling and he slipped out of the sling. CNA #1 said she and CNA #2 had put the hoyer lift sling underneath the resident. CNA #1 said she remembered that because she had been working with Resident #1 all day on the day shift. CNA #1 said Resident #1 had just finished eating his dinner. CNA #1 said when Resident #1 was lifted up with the hoyer lift, they were turning the hoyer lift to go to the bed and that was when Resident #1 slid out of the sling and hit the floor. CNA #1 said she was completely shocked and did not know what could have gone wrong. CNA #1 said she was trying to be extra careful with the hoyer lift transfers she was now doing but said she did not receive any new training after the resident's fall. LPN #2 was interviewed on 7/30/24 at 5:55 p.m. LPN #2 said when she entered Resident #1's room on 4/15/24, he was on his back on the floor. She said the resident was conscious. LPN #2 said she checked his vital signs and went to get RN #1. LPN #2 said Resident #1 started vomiting when the emergency medical technicians (EMT) arrived. RN #1 was interviewed on 7/30/24 at 6:00 p.m. RN #1 said another RN, who had since retired, came in to assess Resident #1. RN #1 said the nurse on the floor would typically complete a fall progress note. RN #1 said a progress note was not documented by the RN in the resident's EMR. RN #1 said she decided not to move the resident until the EMT's arrived. RN #1 said she came in later to check on the situation, the resident was still on the floor and the EMTs had arrived. RN #1 said she heard the CNAs say they had hooked the hoyer lift up and they were not sure what had happened or how he fell. She said the CNAs did not say the hooks fell off but the resident fell out of the sling. The DON was interviewed again on 7/30/24 at 6:13 p.m. The DON said she had put an education book about the different types of hoyer lift slings to use, how to know which size to use as a guide and placed them at the CNAs desk stations. The DON said she was not sure if any of the CNAs had looked at it or read it. The DON said the facility had not had any further incidents of hoyer lift falls, but said she had not done any official education with staff following the fall. E. Facility follow-upOn 7/30/24 at 6:04 p.m. the DON provided documentation that CNA #1 had completed a skills competency checklist on 2/13/24 and CNA #2 had completed skills competency checklist on 2/17/24. The competency nurse aide skill checklist included 53 personal care skills, including hoyer use, with a date passed by demonstration and a signature.-However, the facility did not have CNA #1 and CNA #2 complete a new skills competency checklist following Resident #1's fall from the hoyer lift on 4/15/24. On 7/31/24 at 10:30 a.m. the NHA provided documentation that the facility had conducted weekly ongoing maintenance and hoyer lift inspections from January 2024 to present. On 7/31/24 at 1:09 p.m. the DON provided documentation of an audit that was performed by therapy on 7/31/24 (during the survey) to ensure residents who required hoyer lifts had the appropriate sling sizes and types and felt safe with them. The audit included five residents who were currently transferred by nursing staff using the hoyer lifts. On 8/2/24 at 9:45 a.m. the NHA sent an email which revealed in pertinent part, the NHA further reviewed the case (of the hoyer lift fall with Resident #1) with the facility medical director and the DON. The NHA said the chart reflected that when Resident #1 was returned to acute care post-fall, no significant changes from the prior studies were identified (attached were the before and after CT/neurology consult notes). The NHA said, specifically, Resident #1 had a previous history of brain injury/bleeds and that the staples identified in Resident #1's head were present upon admission to the facility. The NHA said no additional injuries or signs and symptoms of pain were noted by staff as a result of the fall. The in-services, audits sheets began and he would provide (see below).-However the hospital notes revealed after the facility fall Resident #1 sustained a new large posterior scalp hematoma (not subdural), and a new left ankle trauma with pain and mild soft tissue swelling (see record review above). In addition Resident #1 exhibited vomiting after the fall. On 8/2/24 at 2:21 p.m. the DON provided a signature page for the hoyer lift in-service. The hoyer lift in-service was dated 7/31/24 (during the survey). -However, the document revealed CNA #1 had the in-service emailed to her and CNA #2 did not participate in the in-service.-Additionally, the facility only provided the signature page, not the curriculum for the hoyer lift in-service.

A complaint survey, prompted by complaint #CO36658 and #CO36742 was conducted on 7/29/24 to 7/31/24. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for two (#2 and #3) of three residents reviewed for medication errors out of 15 sample residents. Specifically, the facility failed to ensure Residents #2 and #3 received medications as scheduled according to the physician's orders which resulted in significant medications errors. Findings include:I. Facility policyThe 6 (six) Medication Administration Rights policy, undated, was received from the nursing home administrator (NHA) on 7/30/24 at 1:28 p.m. It read in pertinent part, "Medications should be administered at the time indicated by the prescribing physician. Acceptable practice is to use a one-hour window time frame. Medications can be given one hour before or one hour after the prescribed time."II. Resident #2A. Resident statusResident #2, age 72, was admitted to the facility on 6/18/24. According to the July 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body), muscle spasms, and anxiety. The 7/1/24 minimum data assessment (MDS) assessment revealed the resident was moderately cognitively impaired. A brief interview for mental status (BIMS) was not conducted as the resident was rarely or never understood. The resident was dependent for all activities of daily living (ADL). B. Record reviewThe July 2024 CPO revealed a physician's order for Alprazolam (anti-anxiety medication) 0.25 milligrams (mg) with instructions to give one tablet via PEG-tube (percutaneous endoscopic gastrostomy feeding tube) three times a day for anxiety, ordered on 7/16/24. The 6/18/24 care plan, revised 7/11/24, revealed Resident #2 could experience adverse reactions from his psychotropic medications, including Alprazolam for his anxiety. Pertinent interventions included monitoring Resident #2 for mood disturbances and using non-pharmacological interventions. The 7/19/24 care plan revealed Resident #2 was at risk for adverse side effects from the use of anti-anxiety medication. Pertinent interventions included administering medications per physician's orders. Resident #2's July 2024 medication administration record (MAR) revealed the resident's Alprazolam 0.25 mg was not administered timely on the following dates:-On 7/17/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:21 p.m. (21 minutes after the allowed administration time).-On 7/18/24 the medication was scheduled for administration at 3:00 p.m. and administered at 5:24 p.m. (one hour and 24 minutes after the allowed administration time).-On 7/18/24 the medication was scheduled for administration at 9:00 p.m. and administered at 10:07 p.m. (seven minutes after the allowed administration time).-On 7/19/24 the medication was scheduled for administration at 9:00 a.m. and administered at 10:20 a.m. (20 minutes after the allowed administration time).-On 7/21/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:23 p.m. (23 minutes after the allowed administration time).-On 7/22/24 the medication was scheduled for administration at 9:00 a.m. and administered at 10:48 a.m. (48 minutes after the allowed administration time).-On 7/23/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:52 p.m. (52 minutes after the allowed administration time).-On 7/26/24 the medication was scheduled for administration at 9:00 a.m. and administered at 11:20 a.m. (one hour and 20 minutes after the allowed administration time).-On 7/28/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:46 p.m. (46 minutes after the allowed administration time).-On 7/29/24 the medication was scheduled for administration at 3:00 p.m. and administered at 4:33 p.m. (33 minutes after the allowed administration time). III. Resident #3A. Resident statusResident #3, age 70, was admitted on 6/12/24 and discharged on 6/21/24. According to the June 2024 CPO, diagnoses included malignant neoplasm (cancer) of the lung, lower back pain, and epigastric pain. The 6/18/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required supervision to partial/moderate assistance with most activities of daily living. The resident was on a scheduled pain medication regimen and had pain almost constantly that interfered with her day-to-day activities. B. Resident interviewResident #3 was interviewed via phone on 7/31/24 at 10:39 a.m. Resident #3 said the morphine to treat her pain associated with lung cancer was administered later than it was scheduled. She said occasionally it was over two hours late. Resident #3 said the delay in administration had caused her to be in pain. Resident #3 said she had laid in bed and suffered. Resident #3 said she had used her call bell to alert the certified nurse aides (CNAs) that she was in pain but the CNAs had told her they had already alerted her nurse. C. Record reviewThe June 2024 CPO revealed a physician's order for morphine sulfate oral solution 20 mg/milliliter (ml) with instructions to give 0.5 ml by mouth every four hours for pain management, ordered on 6/12/24. The 6/12/24 care plan, revised 6/13/24, revealed Resident #3 had acute/chronic pain risk due to her conditions, which included neoplasm of the lung, lower back pain, epigastric pain, and headaches. Pertinent interventions included administering pain medications per physician order and noting effectiveness. Review of Resident #3's June 2024 MAR revealed the resident's morphine sulfate 0.5 ml was not administered timely on the following dates:-On 6/14/24 the medication was scheduled for administration at 4:00 a.m. and administered at 5:27 a.m. (27 minutes after the allowed administration time).-On 6/15/24 the medication was scheduled for administration at 4:00 a.m. and administered at 5:12 a.m. (12 minutes after the allowed administration time).-On 6/15/24 the medication was scheduled for administration at 8:00 a.m. and administered at 10:09 a.m. (one hour and nine minutes after the allowed administration time).-On 6/21/24 the medication was scheduled for administration at 8:00 a.m. and administered at 10:15 a.m. (one hour and 15 minutes after the allowed administration time). Review of Resident #3's June 2024 pain level summary revealed the following:-On 6/14/24 at 5:23 a.m. Resident #3's pain was rated as a 6 out of 10 on a scale of 1-10;-On 6/15/24 at 10:09 a.m. Resident #3's pain was rated as an 8 out of 10; and,-On 6/21/24 at 10:15 a.m. Resident #3's pain was rated as a 6 out of 10. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 7/31/24 at 9:37 a.m. LPN #1 said medication administration was conducted each day by splitting the residents between two nurses and going down each hall, leaving about 20 residents for each nurse to administer medications to. LPN #1 said the facility's computer system notified nurses one hour before each medication cycle was due. He said, for example, for 10:00 a.m. medications, the computer system alerted them at 9:00 a.m.. LPN #1 said the nursing staff had a one hour window before and after a medication was due to administer the medication on time. LPN #1 said it was important to administer medications as scheduled in order to avoid interactions with other medications and to have an appropriate interval before or after meal times. LPN #1 said pain medications needed to be administered when they were scheduled to avoid over-sedating the resident. The director of nursing (DON) was interviewed on 7/31/24 at 11:11 a.m. The DON said medication administration was divided between the nurses, and that each hall had staggered medication administration schedules in order to keep the nursing staff on schedule. The DON said medications were considered to be given on-time if they were administered within an hour window before or after the medication was scheduled. The DON said most medications, especially pain medication, needed to be administered as scheduled. The DON said unforeseen circumstances could come up that could cause delays. The DON said Resident #2 may have had some delays in medication administration on the dates his medication was late due to being out of the facility for an appointment. The DON said, for Resident #3, on 6/21/24 the nurse who had administered the resident's pain medication over an hour late had been overwhelmed during the shift. The DON said the nurse in question had been counseled on timely administration of medications and later left the facility. The DON was interviewed again on 7/31/24 at 11:45 a.m. The DON said Resident #2 did not have any appointments scheduled on the days in which his medications were not administered as scheduled.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 15 sample residents received adequate supervision and services to prevent an accident. Resident #1 was admitted to the facility on 4/13/24 with a traumatic subdural hemorrhage with loss of consciousness (intracranial bleeding between the brain and the skull), muscle weakness, aphasia (loss of the power of speech), hemiplegia (paralysis affecting one side of the body), Parkinson's disease (a condition that affects muscle control and movement), acute pain due to trauma and a history of falling. Resident #1 was status post burr holes (small holes that a neurosurgeon makes in the skull to help relieve pressure on the brain when fluid, such as blood, builds up and compresses brain tissue) of subdural hematoma with surgical incision on the left side of his head with staples in place. On 4/15/24, certified nurse aide (CNA) #1 and CNA #2 transferred Resident #1 via the hoyer lift (mechanical lift). During the transfer, Resident #1 fell from the lift to the floor, striking his head. Resident #1 began vomiting after the fall and was immediately transferred to the hospital where he was diagnosed with a large posterior scalp hematoma (bleeding under the skin) and left ankle trauma with pain and mild soft tissue swelling. The facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review the use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. Due to the facility's failure to transfer a dependent resident safely, Resident #1 sustained a new head injury and required hospitalization for three days. Resident #1 was discharged from the hospital to his home on hospice care due to the families concern for the resident's safety at the facility. Findings include:I. Facility policy and procedureThe Mechanical Lifts policy and procedure, revised 2/1/23, was provided by the nursing home administrator (NHA) on 7/31/24 at 10:22 a.m. It read in pertinent part, "(Facility name) utilizes mechanical lifts when appropriate to ensure safe patient handling during transfers and employee safety when providing patient care. Direct care staff will receive training upon hire and as needed for proper preparation of the patient, equipment, and environment during utilization of mechanical lifts."II. Mechanical lift manualThe user manual for the Span model: F500P full body patient lift was provided by the NHA on 7/31/24 at 10:35 a.m. It read in pertinent part, "Special care must be taken with users/patients who cannot themselves provide assistance while being lifted (patients who are comatose, spastic, agitated, or otherwise severely handicapped)."The patient lift should be used solely for transferring a user/patient from one utility (beds, chairs, toilets) to another. The patient lift should not be used for transporting or moving any patient from one location to another location."During lifting or lowering, whenever possible, always keep the base of the lift in the widest position."The base of the lift should be closed before moving the lift."Do not roll casters over any object while the user/patient is in the sling."Do not lock casters during lifting."While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lifter."Never leave the user/patient unattended during lifting."III. Resident # 1A. Resident statusResident #1, age 65, was admitted on 4/13/24 and discharged to the hospital on 4/15/24. According to the April 2024 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness, muscle weakness, aphasia, hemiplegia Parkinson's disease, acute pain due to trauma and history of falling. The 4/15/24 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interviewfor mental status (BIMS). The staff assessment for mental status was completed and revealed the resident had short and long-term memory problems and had severely impaired cognitive skills for daily decision making. He was dependent on staff for transfers, and required substantial/maximal assistance with bed mobility. The MDS assessment indicated the resident had one fall since admission and documented there was no injury. -However, the resident sustained a head injury with a hematoma, per the hospital records. B. Facility investigation of Resident #1's fall on 4/15/24The fall investigation was provided by the director of nursing (DON) on 7/30/24 at 5:29 p.m. The 4/16/24 post fall investigation revealed the following in pertinent part:On 4/15/24 at 6:30 p.m. licensed practical nurse (LPN) #1 heard a loud bang and ran into the resident's room. Resident #1 was on the floor. CNA #1 and CNA #2 were using the hoyer lift to transfer the resident when Resident #1 slipped through the middle of the sling. Resident #1 hit the back of his head. The resident's vital signs were within normal limits. The physician and the resident's daughter were notified of the fall. The resident was evaluated by registered nurse (RN) #1 and she made the decision to send the resident to the emergency department (ED) as he had hit his head. The resident's vital signs were stable when the resident left the facility with emergency medical services via stretcher to the hospital ED.An undated statement was obtained from CNA #1. CNA #1 said she was sitting at the computer charting and giving a report to the next oncoming shift. She had asked CNA #2 if she would like her to help lay Resident #1 down and she replied "sure." CNA #1 said the hoyer lift sling appeared to be properly in place. CNA #1 said she hooked the resident's sling up to the hoyer lift and began to lift him to the bed. She said Resident #1 suddenly began to slip out of the sling and onto the floor. An undated statement was obtained from CNA #2. CNA #2 said she worked on the night shift at (facility name). CNA #2 said she started her shift at 6:00 p.m. on 4/15/24. CNA #2 said after report was given from the day shift, one of the day shift CNAs offered to help get Resident #1 into bed before she left for the day. CNA #2 said they went to Resident #1's room and he was sitting in his wheelchair by the window side and was leaning towards his right side. CNA #2 said they adjusted Resident #1 the best they could. CNA #2 said they tucked in the hoyer lift sling and criss-crossed the sling between his legs and moved the wheelchair closer to the hoyer lift machine. CNA #2 said they then lowered the hoyer lift machine down to wheelchair level and proceeded to hook up the sling to the machine. CNA #2 said they used the first hook on all six hookups (three on left, three on right). CNA #2 said she had control of the hoyer lift and the other CNA (CNA #1) was guiding Resident #1 towards the bed. CNA #2 said the wheelchair was removed once he was high enough, then she proceeded to move towards the bed. CNA #2 said they were in position moving towards the bed when Resident #1 slipped out of the sling through the bottom. CNA #2 said Resident #1's bottom went through the sling and he landed on his bottom, and then fell backwards and hit his head. CNA #2 said at that point she was in a state of shock. CNA #2 said she had been doing that job for more than 10 years and that had never happened. CNA #2 said they went to Resident #1 and he was still awake, aware and trying to speak. CNA #2 said the nurse rushed in and called 911. CNA #2 said she stayed with Resident #1 until the ambulance and fire department came to help him off the floor. She said Resident #1 was then sent out to the hospital for further evaluation. An undated statement from the DON said CNA #1 and CNA #2 had both been through skills check-offs to include mechanical lifts, and both followed facility protocol for hoyer lift use. The statement said this had been an unfortunate, isolated event. The resident was evaluated at the hospital and the head computed tomography (CT) scan did not show any new bleeds. -However, according to the emergency progress note Resident #1 sustained a large posterior scalp hematoma (see record review below). C. Record reviewThe baseline (admission) care plan, dated 4/13/24, revealed the resident required two person assistance with transfers, bathing, grooming, locomotion and toileting. The resident was at risk for falls related to impaired mobility secondary to weakness and debility and related to current drug regimen. The resident had acute and chronic pain. The 4/13/24 admission skin assessment revealed an actual surgical wound with dressing changes per physician orders. A review of the April 2024 CPO revealed a physician's order was set up to follow up with a neurological surgeon to remove the staples from the resident in five days, ordered on 4/14/24. The 4/16/24 nursing progress note, documented at 1:49 a.m., revealed the nurse heard a loud bang and the nurse ran into Resident #1's room. The resident was on the floor. The CNAs were using the hoyer lift and the resident slipped through the middle of the sling. The resident hit the back of his head. RN #1 came and evaluated the resident. The 4/16/24 change in condition note, documented at 2:42 a.m., revealed the resident's vital signs were within normal limits. The resident was vomiting after the fall. The note documented the physician and family were notified of the fall at 6:30 p.m. on 4/15/24. The 4/16/24 bed hold progress note, documented at 8:18 a.m., revealed the DON spoke with the resident's spouse who stated the resident would not be returning to the facility. The post fall evaluation, completed by the DON on 4/16/24, revealed the resident sustained a witnessed fall on 4/15/24. The resident hit his head and was transferred to the hospital. Neurological checks were initiated per facility protocol. A skin evaluation was not completed. The resident did not have pain from the fall and did not receive pain medication. The resident fell during a transfer in the resident's room with a hoyer lift and sling. The assessment documented the probable cause of the fall was the resident's buttocks slid through the sling onto the floor and the staff expressed that it was properly placed and the appropriate size sling was used. The IDT (interdisciplinary team) discussed the resident's fall. The resident was on the fall program with his bed in a locked and low position, received assistance from two persons at all times for hoyer lift transfers and to assure the sling fit correctly. The evaluation documented the care plan was revised on 4/16/24. It documented the physician and family were notified on 4/15/24. The 4/15/24 hospital progress note documented a 65 year old male with a history of Parkinson's disease and recent subdural hemorrhage status post burr holes brought in to the emergency department from a rehabilitation facility after he was accidentally dropped out of a hoyer lift and hit his head once again. He was not on an anticoagulant and was nonverbal at baseline. He was noted to have a large posterior scalp hematoma that was new since prior exam. A review of the resident revealed he had pain to his left ankle with mild soft tissue swelling. X-rays were obtained and were negative. The hospital progress note documented the plan was for the resident to return to the rehabilitation facility, however the patient's wife had serious concerns about the safety of this facility and did not wish him to go back there. The note documented the resident's spouse was going to contact hospice and palliative care services tomorrow morning as her desire was to take him home on hospice care. The resident was discharged home on hospice from the hospital on 4/17/24.-Following Resident #1's fall on 4/15/24 from the hoyer lift, the facility failed to identify the root cause of Resident #1's fall, conduct staff re-education to prevent future falls, review transfer training techniques, or review use of the hoyer lift procedures with CNA #1 and CNA #2, who were involved with the fall. D. Staff interviewsThe DON was interviewed on 7/30/24 at 5:05 p.m. The DON said Resident #1 sustained a fall on 4/15/24 at 6:30 p.m. The DON said CNA #1 and CNA #2 witnessed the fall. She said CNA #1 and CNA #2 alerted LPN #2 after the fall. The DON said CNA #1 and CNA #2 were transferring Resident #1, via a hoyer lift, from his wheelchair to the bed and had lifted the resident up in the sling and out of the wheelchair and began to lift him to the bed and that was when Resident #1 fell. The DON said she felt it was a freak accident. The DON said the hoyer lift sling was placed correctly because staff had expressed that it was properly placed and the appropriate size. She said when the CNAs started moving Resident #1 toward the bed, he slipped through the sling. The DON said since Resident #1's admission he had required two person assistance with the hoyer lift. The DON said the comprehensive care plan was still being developed on the day the resident sustained the fall. She said the resident's care plan was not updated after the fall because the resident did not return to the facility. The DON said there was a communication board in the resident's room to let the caregivers know what assistance level the resident required. The DON said no further re-education training was provided to CNA #1 and CNA #2 after the fall because they were both very competent with transfers and she did not know what further instruction or information she could have told them on how they could have corrected the situation. The DON reiterated that she had never seen this type of accident before so there had not been specific training or corrective action given to the direct care staff after the fall. The DON said CNA #1 and CNA #2 had had training on the hoyer lift in February 2024 and had completed the skills competency checklist. The DON said the facility did not do any other training for all the staff after the fall on 4/15/24 because she did not think it was needed as they had just completed the annual skills checklist and there was nothing identified in the fall incident that could have improved the situation. CNA #2 was interviewed on 7/30/24 at 5:40 p.m. CNA #2 said Resident #1 fell on 4/15/24 when she had just come on shift. She said Resident #1 was in his wheelchair and CNA #1 had offered to help put him into bed. CNA #2 said it was dinner time and sometimes it got busy, so she was glad for the help. CNA #2 said the hoyer lift sling was under Resident #1 and the moment she moved the hoyer lift away from the wheelchair, the resident fell and hit his head on the floor. CNA #2 said she screamed and could not believe what happened. CNA #2 said she ran and got the nurse and the resident was sent to the hospital. CNA #2 said she could not pinpoint what went wrong with the transfer since the sling was already under him. CNA #1 was interviewed on 7/30/24 at 5:44 p.m. CNA #1 said she and CNA #2 went in to transfer Resident #1 on 4/15/24 via a hoyer lift. She said he fell out of the sling during the transfer. CNA #1 said Resident #1 was in his wheelchair and she and CNA #2 went to hook the hoyer lift sling up and put him to bed for the evening. CNA #1 said she hooked up the sling and he slipped out of the sling. CNA #1 said she and CNA #2 had put the hoyer lift sling underneath the resident. CNA #1 said she remembered that because she had been working with Resident #1 all day on the day shift. CNA #1 said Resident #1 had just finished eating his dinner. CNA #1 said when Resident #1 was lifted up with the hoyer lift, they were turning the hoyer lift to go to the bed and that was when Resident #1 slid out of the sling and hit the floor. CNA #1 said she was completely shocked and did not know what could have gone wrong. CNA #1 said she was trying to be extra careful with the hoyer lift transfers she was now doing but said she did not receive any new training after the resident's fall. LPN #2 was interviewed on 7/30/24 at 5:55 p.m. LPN #2 said when she entered Resident #1's room on 4/15/24, he was on his back on the floor. She said the resident was conscious. LPN #2 said she checked his vital signs and went to get RN #1. LPN #2 said Resident #1 started vomiting when the emergency medical technicians (EMT) arrived. RN #1 was interviewed on 7/30/24 at 6:00 p.m. RN #1 said another RN, who had since retired, came in to assess Resident #1. RN #1 said the nurse on the floor would typically complete a fall progress note. RN #1 said a progress note was not documented by the RN in the resident's EMR. RN #1 said she decided not to move the resident until the EMT's arrived. RN #1 said she came in later to check on the situation, the resident was still on the floor and the EMTs had arrived. RN #1 said she heard the CNAs say they had hooked the hoyer lift up and they were not sure what had happened or how he fell. She said the CNAs did not say the hooks fell off but the resident fell out of the sling. The DON was interviewed again on 7/30/24 at 6:13 p.m. The DON said she had put an education book about the different types of hoyer lift slings to use, how to know which size to use as a guide and placed them at the CNAs desk stations. The DON said she was not sure if any of the CNAs had looked at it or read it. The DON said the facility had not had any further incidents of hoyer lift falls, but said she had not done any official education with staff following the fall. E. Facility follow-upOn 7/30/24 at 6:04 p.m. the DON provided documentation that CNA #1 had completed a skills competency checklist on 2/13/24 and CNA #2 had completed skills competency checklist on 2/17/24. The competency nurse aide skill checklist included 53 personal care skills, including hoyer use, with a date passed by demonstration and a signature.-However, the facility did not have CNA #1 and CNA #2 complete a new skills competency checklist following Resident #1's fall from the hoyer lift on 4/15/24. On 7/31/24 at 10:30 a.m. the NHA provided documentation that the facility had conducted weekly ongoing maintenance and hoyer lift inspections from January 2024 to present. On 7/31/24 at 1:09 p.m. the DON provided documentation of an audit that was performed by therapy on 7/31/24 (during the survey) to ensure residents who required hoyer lifts had the appropriate sling sizes and types and felt safe with them. The audit included five residents who were currently transferred by nursing staff using the hoyer lifts. On 8/2/24 at 9:45 a.m. the NHA sent an email which revealed in pertinent part, the NHA further reviewed the case (of the hoyer lift fall with Resident #1) with the facility medical director and the DON. The NHA said the chart reflected that when Resident #1 was returned to acute care post-fall, no significant changes from the prior studies were identified (attached were the before and after CT/neurology consult notes). The NHA said, specifically, Resident #1 had a previous history of brain injury/bleeds and that the staples identified in Resident #1's head were present upon admission to the facility. The NHA said no additional injuries or signs and symptoms of pain were noted by staff as a result of the fall. The in-services, audits sheets began and he would provide (see below).-However the hospital notes revealed after the facility fall Resident #1 sustained a new large posterior scalp hematoma (not subdural), and a new left ankle trauma with pain and mild soft tissue swelling (see record review above). In addition Resident #1 exhibited vomiting after the fall. On 8/2/24 at 2:21 p.m. the DON provided a signature page for the hoyer lift in-service. The hoyer lift in-service was dated 7/31/24 (during the survey). -However, the document revealed CNA #1 had the in-service emailed to her and CNA #2 did not participate in the in-service.-Additionally, the facility only provided the signature page, not the curriculum for the hoyer lift in-service.

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

A focused infection control survey with complaint #CO33602 was conducted 9/26/23 to 9/27/23. No deficiencies were cited.

An Emergency Preparedness focused infection control survey was conducted 9/12/23 to 9/13/23. No deficiencies were cited.

A revisit survey was completed on 6/23/23 for all previous deficiencies cited on 4/13/23. The facility is in compliance with all regulations surveyed.

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

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is three story, Type II (111), construction. The facility is protected throughout by National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 2007 and is license for 80 beds. All beds are located on the second and third floors. This facility has no emergency or stand-by generator power system. Emergency exit lighting is comprised of battery unit lighting integral to the existing lay-in fluorescent fixtures. This re-certification survey conducted on April 26, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19,"Existing Health Care Occupancies". The deficiency cited was discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. Kitchen appliances on casters need method in place to ensure continued suppression system coverageNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location. 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 and Maintenance director at the exit conference.

Through documentation review, it was determined that the facility did not to meet the Fire Alarm testing and maintenance requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:No Semi Annual Fire Alarm report available at time of inspectionLife Safety Code 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 Section 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. 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 and Maintenance director 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 101No Semi Annual Sprinkler inspection available at the time of inspection NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12These 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 and Maintenance director at the 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. 1 hour firewall needs to be repaired in employee break roomNFPA 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. 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 and Maintenance director at the exit conference.

Through 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 Receptacle Polarity/Retention inspection available at the time of inspection 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). 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 and Maintenance director at the exit conference.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the transfilling of oxygen from one cylinder to another in accordance with NFPA 99 - Health Care Facilities, 11.5.2.3. The following evidenced this:Room ventilation fan not working at the time of inspection9.3.7.5.3 Mechanical Ventilation. 9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) normore than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers. 9.3.7.5.3.4 Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system. 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 and Maintenance director at the exit conference.

A recertification survey with complaints #CO31552, #CO31587, #CO31597, #CO31601 and #CO31683 was completed from 4/10/23 to 4/13/23. Eight deficiencies were cited.

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

Based on record review and interviews, the facility failed to have an annual review of the complete emergency preparedness plan (EPP). Specifically, the facility failed to have an annual review of the EPP.Findings include:I. Record reviewThe emergency preparedness plan (EPP) was provided by the director of nursing (DON) and the assistant director of nursing (ADON) on 4/13/23 at 11:15 a.m. Review of the EPP revealed the facility did not have an annual review of the EPP. II. Staff interviewThe EPP was reviewed with the DON on 4/13/23 at 11:15 a.m. She said she was unable to verify the emergency plan was updated annually. The ADON was interviewed on 4/13/23 at 12:19 p.m. She said it was important to update and maintain an emergency preparedness plan in case there was an emergency the facility would be prepared and able to keep everyone safe.

Based on record review and interview, the facility failed to have a complete emergency preparedness communication plan. Specifically, the facility failed to have a policy and procedure for the use of volunteers in an emergency or other emergency staffing strategies to address surge needs during an emergency. Findings include:I. Facility planThe emergency preparedness plan (EPP) was provided by the director of nursing (DON) and the assistant director of nursing (ADON) on 4/13/23 at 11:15 a.m. Review of the EPP revealed the facility did not have a policy and procedure for the use of volunteers in an emergency or other emergency staffing strategies to address surge needs during an emergency included in the EPP.II. Staff interviewThe ADON was interviewed on 4/13/23 at 12:19 p.m. She said it was important to update and maintain an emergency preparedness plan in case there was an emergency the facility would be prepared and able to keep everyone safe.

Based on record review and interviews, the facility failed to have a complete emergency preparedness communication plan. Specifically, the facility failed to include all contact information for staff, volunteers, and providers. Findings include:I. Facility planThe emergency preparedness plan (EPP) was provided by the director of nursing (DON) and the assistant director of nursing (ADON) on 4/13/23 at 11:15 a.m. Review of the EPP revealed the facility did not have contact information for staff, volunteers, and providers. II. Staff interviewThe ADON was interviewed on 4/13/23 at 12:19 p.m. She said it was important to update and maintain an emergency preparedness plan in case there was an emergency the facility would be prepared and able to keep everyone safe.

Based on record review and interviews, the facility failed to develop and implement an effective communication plan in the emergency plan. Specifically, the facility failed to have contact information for Federal, State, tribal, regional and local emergency preparedness staff. Findings include:I. Facility planThe emergency preparedness plan (EPP) was provided by the director of nursing (DON) and the assistant director of nursing (ADON) on 4/13/23 at 11:15 a.m. Review of the EPP revealed the facility did not have contact information for Federal, State, tribal, regional and local emergency preparedness staff. II. Staff interviewThe EPP was reviewed with the DON on 4/13/23 at 11:15 a.m. She said the facility did not have contact information for Federal, State, tribal, regional and local emergency preparedness officials to maintain an integrated response during a disaster or emergency situation. The ADON was interviewed on 4/13/23 at 12:19 p.m. She said it was important to update and maintain an emergency preparedness plan in case there was an emergency the facility would be prepared and able to keep everyone safe.

Based on record review and interviews, the facility failed to develop and maintain an emergency preparedness training and testing program. Specifically, the facility failed to have an emergency preparedness training and testing program for current and new staff. Findings include:I. Facility planThe emergency preparedness plan (EPP) was provided by the director of nursing (DON) and the assistant director of nursing (ADON) on 4/13/23 at 11:15 a.m. Review of the EPP revealed the facility did not have an emergency preparedness training and testing program for current and new staff. II. Staff interviewThe EPP was reviewed with the DON on 4/13/23 at 11:15 a.m. She said she was unable to locate the training and testing program. The ADON was interviewed on 4/13/23 at 12:19 p.m. She said it was important to update and maintain an emergency preparedness plan in case there was an emergency the facility would be prepared and able to keep everyone safe.

Based on record review and interviews, the facility failed to have a complete emergency preparedness training and testing plan. Specifically, the facility failed to provide initial training and annual training to new and existing staff on the emergency preparedness plan (EPP) policies and procedures, provide EPP training at least annually, and maintain documentation of EPP trainingFindings include:I. Facility planThe emergency preparedness plan (EPP) was provided by the director of nursing (DON) and the assistant director of nursing (ADON) on 4/13/23 at 11:15 a.m. Review of the EPP revealed the facility did not have a plan that provided initial training and annual training to new and existing staff on the EPP policies and procedures, provide EPP training at least annually, and maintain documentation of EPP training. II. Staff interviewThe EPP was reviewed with the DON on 4/13/23 at 11:15 a.m. She said she was unable to locate the training and testing plan that provided initial training and annual training to new and existing staff on the EPP policies and procedures, provide EPP training at least annually, and maintain documentation of EPP training. The ADON was interviewed on 4/13/23 at 12:19 p.m. She said it was important to update and maintain an emergency preparedness plan in case there was an emergency the facility would be prepared and able to keep everyone safe.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 10 of 25 resident rooms in four hallways. Specifically, the facility failed to ensure walls, halls, ceilings, and floors were repaired, painted and properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 4/12/23 at 1:03 p.m. revealed: Room #227: The toilet paper holder in the resident's restroom was falling off the wall with two dime sized holes. The wall next to the entrance had two dimes sized holes. The transition from the resident's room to the hallway was missingRoom #223: The resident's thermostat had been moved with the outline of the old thermostat visible. Room #219: There were two quarter sized holes on the wall next to the room's entrance. The ceiling outside of room #219 had two large water stains approximately 24 inches by 24 inches and the other was 20 inches by 20 inches. Room #202: The toilet holder was hanging off the wall in the resident's restroom. There were two nickel sized holes from the damaged toilet paper holder. Room #203: The toilet paper holder was hanging off the wall in the resident's restroom. Room #213: The toilet paper holder was hanging off the wall in the resident's restroom. Room #208: The floor tile next to the shower had an area approximately 12 inches long, which was lifted. The strip in front of the shower was missing a section approximately 36 inches long by three inches wide. The ceiling outside of room #319 had large water stains approximately 25 inches long by 14 inches wide. Room #310: The wall in the restroom had two quarter sized holes next to the commode. II. Environmental tour and staff interview The environmental tour was conducted with the housekeeping supervisor (HKS) and director of nursing (DON) on 4/13/23 at 9:50 a.m. The above detailed observations were reviewed. The DON documented the environmental concerns. The HKS said the facility utilized a computer system to identify environmental issues. The HKS said the maintenance supervisor (MS) was out on vacation and he was just filling in for MS while he was on vacation. The HKS said he did not have any repair requisition requests for the above-mentioned items. The HKS said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on record review, observations and interviews, the facility failed to ensure the facility was free from accidents and hazards. Specifically, the facility failed to ensure the exit doors to the second and third floor balconies were locked from the outside without allowing building re-entry if locked outside. Findings include:I. Facility policyThe Facility Assessment Tool, dated 10/19/22, was received on 4/10/23 from the director of nursing (DON). -The assessment tool did not include information on facility patio-balcony safety for exit and entry. II. ObservationsOn 4/10/23 at 1:15 p.m., on the third floor west hallway the patio door was propped wide open with a metal patio chair. There was a letter size notice at standing eye level on the inside wall to notify patio users the door would lock from the outside if the door was fully closed. A portable, wireless, doorbell button was observed at standing height attached to the outside door frame. On 4/11/23 at 8:45 a.m. the third floor west hallway patio was propped wide open with a metal patio chair. The third floor west hallway patio was observed outside to have no signage by the door frame to notify the door would lock after entering the patio area and was fully closed. The patio contained a standing height portable, wireless, doorbell button. At 1:27 p.m. a female resident was observed on the third floor, self-propelling her wheelchair using her lower extremities. She moved towards the elevator every time the elevator doors opened. Staff were observed three times as they re-directed the resident away from the elevator. The resident was heard telling the staff that she wanted to go home. At 1:38 p.m., the exit door to the patio on the west 200 hall was propped open with a metal patio chair. There was a remote, wireless, doorbell button attached to the door frame. The remote doorbell was pressed but no bell could be heard in the west hall. At 1:48 p.m., the exit door to the patio on the east 200 hall was propped open with a metal patio chair. The patio area did not have a sign that identified the door locked if closed. There was no doorbell outside attached to the metal door frame. At 2:00 p.m. the exit doors to the patios on the third floors were observed propped wide open with a metal chair. The east patio had a remote doorbell attached to the outside door frame but no signage that identified the door would lock when closed. The exit door on the west patio was propped wide opened with a metal chair. The west patio did not have signage that identified the door would lock when closed. The west patio did not have a remote door bell attached to the outside door frame. All remote doorbells were tested with no chime heard on receiver or located receiver at the nursing station or certified nurse station on all halls. The doorbell transmitter was pressed for one and a half minutes with no response from any facility staff. This was done on all three patios and no facility staff responded to an activated doorbell transmitter. III. Resident interviewResident #28 was sitting alone outside on the patio and was interviewed on 4/11/23 at 1:30 p.m. The resident said he had to leave his rollator walker inside the facility in the hallway because he could not push it around the metal chair in the doorway that held the door open. He said to access the chair he was sitting on he "sort of hobbled along," holding on to the doorway and back of the metal patio chairs. The resident said he was aware the door would lock if it closed because he saw the sign on the wall and he watched the door because it was a windy day and wanted the door to remain propped open. He said that he was unaware a doorbell button was attached to the exterior door frame. IV. Staff interviewsCertified nurse assistant (CNA) # 9 was interviewed on 4/10/23 at 1:27 p.m. CNA #9 said anyone was allowed to use the patio when they desired. She said all residents were told that they should notify a staff member prior to using the patio. CNA #9 said if a resident was locked out on the patio it would not be for long because a lot of staff members use the adjacent stairs during the day and they look to see if anyone was on the patio. She said a lot of staff members were in the hallways during the day and would hear or notice anyone locked out on the patio. CNA #1 was interviewed on 4/11/23 at 1:43 p.m. She said staff propped the patio doors open as it got too hot in the facility. She said the facility did not have residents that wandered. She said if any resident would go out the patio doors it would automatically lock behind them. She said if a resident would get locked out on the patio, "I wouldn't really check as it was at the end of the hall and I could not see if a resident was in the patio area." She said she did not know the location of the chime receiver or that the patio had a doorbell transmitter. CNA #2 was interviewed on 4/11/23 at 1:52 p.m. She said she did not know the patio doors would lock automatically when they were closed and she said she did not know they had doorbells. She said, "I have never really checked to see if any residents were using the patio area." She said she did not know where the doorbell receiver was located. Registered nurse (RN) # 4 was interviewed on 4/11/23 at 2:05 p.m. She said not just anyone was allowed to use the exterior patio balconies. She said the activity and therapy staff members took residents outside after they cleared the activity with the assigned registered nurse. RN #4 said they keep wandering residents in line of sight with the staff and no wandering residents would be able to make their way unattended outside. RN #4 was unaware where the doorbell transmitter was located and was unaware the patios had doorbell buttons outside. RN #4 said she was not concerned that the doorbells did not ring because she was unaware the facility had any incidents with residents or staff trapped outside. The director of nursing (DON) was interviewed on 4/11/23 at 3:48 p.m. She was told of observations above. She said the facility had an issue with their air conditioners. The DON said she had never seen any residents out on the patios as no residents went out there. She said the facility did not admit residents who wander to the facility. She said, "I suppose it would be possible a resident could get stuck out on the patio but not injured." She said the maintenance supervisor was out on vacation and she would have the housekeeping supervisor look into it immediately.-However, observations revealed there was a female resident that was trying to leave the facility to go home (see above). The housekeeping supervisor (HS) was interviewed on 4/12/23 at 10:01 a.m. He said he did not know why the patio doors locked automatically but he said the nursing home administrator (NHA) had said it was because of the high winds the facility had. He said all four patio areas have new signage on them and they were getting new doorbell transmitters and doorbell receivers. He said he did not know how often the doorbell transmitters and doorbell receivers were tested prior to yesterday, and he did not know if there were any logs documenting the monitoring of the doorbell devices. V. Record reviewA request was made for the battery monitoring logs of the patio doorbells and location of doorbell chime receivers on all floors, as well as follow up staff training on monitoring the patio areas. At time of exit on 4/13/23, no information requested was provided.

Based on observations, record review and interviews, the facility failed to ensure the kitchen provided food that accommodated resident preferences for three (#27, #28 and #229) of six residents of 20 sample residents. Specifically, the facility failed to ensure Resident #27, #28 and #229 were receiving their menu choices. Findings include:I. Resident #27Resident #27, age 79, was admitted on 3/31/23. According to the April 2023 computerized physician orders (CPO), diagnoses included osteoarthritis and irregular heartbeat. The 4/4/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairments with a brief interview of mental status (BIMS) score of 14 out of 15. B. Resident interviewResident #27 was interviewed on 4/11/13 at 10:15 a.m. She said during her stay, she completed menus with her food choices but she rarely received the food that she requested. She said when she received food items she did not want, certified nursing assistants (CNA) were not helpful to replace the items. She stated she finally told a CNA she would accept any entrée except fish and then she received tilapia. She ordered scrambled eggs and a muffin for breakfast and instead received two boiled eggs and sausage, and when she requested a replacement she did not receive the breakfast items until lunchtime. She began to save her meal sheets that were included with each meal to show what she ordered was not the same as what she was receiving. One meal she received roasted turkey, poultry gravy, mashed potatoes, glazed carrots, baked roll, and cranberry crunch bar. What she ordered were pears, carrots, herb roasted potatoes, roll, and a cookie. Another meal she identified included lemon baked fish, orzo pilaf, vegetable blend, chocolate pudding, and tomato juice when she ordered carrots, pasta, pear, gravy and pound cake. C. Record reviewThe nutrition care plan dated 4/4/23 revealed the resident had the potential for an inability to maintain nutrition due to lactose intolerance and decreased appetite. Interventions were to provide and serve the resident ' s diet as ordered. The resident required the assistance of one staff member to set up her meals and she was independent with eating. The nutrition assessment dated 4/4/23 revealed the resident had a moderate decrease in food intake with a regular diet texture thin consistency. II. Resident #28A. Resident statusResident #28, age 82, was admitted on 3/21/23. According to the April 2023 computerized CPO, diagnoses included cellulitis (skin infection) and hypertension. The 3/23/23 MDS assessment revealed the resident had no cognitive impairments with a BIMS score of 15 out of 15. B. Resident interview Resident #28 was interviewed on 4/10/23 at 1:50 p.m. The resident stated she had problems with receiving the food she ordered four times a week for the last four weeks. She said she had complained to the dietary aides and CNAs but the issue has not improved. The resident said the dietary staff had told her it had to do with their new computer system for taking orders and they were working on it. C. Record reviewThe nutrition care plan dated 4/4/23 revealed the resident had potential for an inability to maintain nutrition due to underweight body mass index (BMI), decreased appetite with weight loss and meets criteria for malnourishment. Interventions were to provide and serve the resident ' s diet as ordered. The nutrition assessment dated 3/23/23 revealed the resident had a severe decrease in food intake, underweight body mass index (BMI), decreased appetite with weight loss and met criteria for malnourishment with a regular diet texture thin consistency. III. Resident #229A. Resident statusResident #229, age 94, was admitted on 4/3/23. According to the April 2023 CPO, diagnoses included fracture and kidney failure. The 4/5/23 MDS assessment revealed the resident had no cognitive impairment with a BIMS score of 13 out of 15. B. Resident interviewResident #229 was interviewed on 4/10/23 at 1:10 p.m. She stated she was not sure what she would get for her meals because she did not always get what she ordered. She filled out the menus provided to her by the kitchen staff but the kitchen would make substitutions and she would not know until she received her meal tray. C. Record reviewThe nutrition care plan dated 4/3/23 revealed the resident had the potential for an inability to maintain nutrition due diagnosis and past medical history of swallowing difficulty. Interventions were to provide and serve the resident ' s diet as ordered. The nutrition assessment dated 4/6/23 revealed the resident had occasional swallowing difficulty and met criteria for malnourishment with a regular diet texture thin consistency. IV. ObservationsOn 4/12/23 the tray line was observed from 12:01 p.m. through 1:50 p.m. The starch of the regular meal that day was southern style squash. This was substituted with zucchini. At 1:32 p.m cook (CK) #2 ran out of the zucchini and substituted it with a vegetable blend (zucchini, carrots, and cauliflower). At 1:32 p.m. the kitchen ran out of the puree dessert, cherry crisp. This was substituted with cherry Jello for the last six puree orders. V. Staff interviews The registered dietitian (RD) was interviewed on 4/13/23 at 9:38 a.m. She stated her role was to focus on clinical but was not involved in the meal planning. She would provide individual recommendations for residents and would review substitutions and sign off if appropriate. The RD did not know if the residents were notified when a menu item was replaced with a substitute. She acknowledged the substitutions from the 4/12/23 lunch were not ideal. The kitchen manager was using a new system for taking resident orders and the system was still not running smoothly. The food items on the menu provided to the facility by the distribution company did not always match what they wanted to serve to the residents. The meal tickets had the distribution companies menu items on it and this did not always match what the residents received on their order form to choose from. Dietary manager (DM) #1 was interviewed on 4/13/23 at 9:48 a.m. He stated the food items on the menu provided to the facility by the distribution company did not always match what they wanted to serve the residents. The dietary aides would go to the resident rooms and provide the residents with menus for the entire week to fill out. The dietary aides would return every day to enter that order into a tablet that would go into the kitchen system. He stated the RD did sign off on the substitutions for the 4/12/23 lunch but the kitchen had no system to notify residents of menu changes. He had been working with the distribution company daily for two months to resolve the discrepancies. DM #1 provided recipes on 4/12/23 at 3:00 pm. for the puree vegetables, chicken salad/tuna salad sandwiches, and the chef salad. He provided documents with the recipe typed up and he said he typed the recipes up that same day. -The recipes failed to show portion or scoop sizes. The RD interviewed on 4/13/23 at 3:34 p.m. She stated there were official recipes for the puree vegetables, chicken salad/tuna salad sandwiches, and the chef salad that included exact portions and measurements. She was not aware the dietary manager did not know about the recipes.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure food was labeled, dated, and monitored in refrigerators;-Ensure the kitchen equipment were clean and sanitary; -Ensure staff were utilizing proper personal hygiene practices;-Ensure holding temperatures of food were within the safe range; and, -Ensure systems were in place to prevent compromised food safety through proper staff training. Findings include: I. Failure to ensure food was labeled, dated and monitored correctly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view. It revealed in pertinent part, "A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request." (Retrieved 4/17/23). B. Facility policy and procedure The Food Storage policy, revised 2/8/21, was provided by the director of nursing (DON) on 4/13/23 at 1:58 p.m. It revealed in pertinent part, "Food from outside sources are to be stored in the refrigerators located on floors two and three with the correct date. Outside food sources should be labeled properly with the correct date and room number of the patient." C. ObservationsOn 4/12/23 at 4:19 p.m. a tour of the second floor nursing floor refrigerator was conducted with dietary manager (DM) #1 and the following was observed:-In the employee break room, a resident refrigerator containing a take-out food box with a resident room number was undated.-A kitchen bowl of oatmeal was undated.-An outside food container was dated 4/11/23 but not labeled. On 4:12 p.m. at 4:34 p.m. a tour of the third floor nursing floor refrigerator was conducted with DM#1 and the following was observed:-In the employee break room, a resident refrigerator containing an outside food container was dated but not labeled. D. Staff interviewsDM #1 was interviewed on 4/12/23 at 4:34 p.m. He stated foods kept inside of containers should have a date and a label. These food items should be thrown away after 24 hours. He said that the dietary clerks were responsible for maintaining and cleaning the resident refrigerators in the employee break rooms. II. Failure to ensure the kitchen equipment were clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, "For sanitation of equipment, food-contact surfaces and utensils, a contact time of at least 7 seconds for a chlorine solution or a contact time of at least 30 seconds for other chemical sanitizing solutions. Unless used immediately after sanitization, all equipment and utensils shall be air-dried." (Retrieved 4/17/23) B. Observations On 4/10/23 at 9:10 a.m. a stack of steam table pans on a shelf were wet in between the pans. On 4/12/23 at 12:10 p.m. cook (CK) #2 took a sharp knife out of the knife box and she went to the three compartment sink and rinsed it under water. She proceeded to go to the third sink and pumped out some sanitizer onto the knife, and immediately rinsed the knife off, not allowing the sanitizer to sit on the knife in order to sanitize it properly. She then used it to cut ham for lunch. At 1:42 p.m. a stack of steam table pans on a shelf were wet in between the pans. On 4/13/23 at 8:33 a.m. dietary aide (DA) #2 was observed pouring liquid from coffee and juice cups into a red sanitation bucket. At 1:25 p.m. two stacks of steam table pan on a shelf were wet in between the pans. C. Staff interviewsDA #2 was interviewed on 4/13/23 at 8:33 a.m. She said the kitchen staff used a designated red sanitation bucket to pour drink liquids into before putting them into the dishwasher. She said she had been employed with the facility less than a month and did not know how to fill the sanitation buckets with the chemical, how often the buckets should be changed or what chemical was used. DM #1 was interviewed on 4/13/23 at 10:30 a.m. He stated the kitchen had red sanitation buckets filled with an ammonia chemical solution and green buckets filled with a soap and water solution for cleaning the kitchen. The ammonia solution should be maintained between 300-400 parts per million (PPM) and tested every week to three days. He said the red sanitation bucket DA #2 was used for pouring liquids, such as coffee and juice, into the dishwasher. It was emptied down the drain when full. DM #1 was interviewed again on 4/13/23 at 1:35 p.m. He said dishes that come out of the dishwasher were still wet and set on a rack or on a cart to air tray. He was unaware there were steam table pans stacked while still wet and warm from the dishwasher. He acknowledged this was unsanitary due to the moisture between the pans could create bacteria. The registered dietitian (RD) was interviewed on 4/13/23 at 3:00 p.m. She stated the kitchen staff should be using the red sanitation buckets only for the sanitation chemical and not to drain liquids. She said that the chemical should be tested every two hours, as needed, and when changed out. III. Failure to ensure staff were utilizing proper personal hygiene practices A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view. It revealed in pertinent part, "Epidemiological outbreak data repeatedly identify a major risk factor related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: Poor personal hygiene. Food employees shall clean their hands and exposed portions of arms for at least 20 seconds, using a cleaning compound in a handwashing sink. Food employees shall clean their hands and exposed portions of their arms after touching bare human body parts other than clean hands". (Retrieved 4/17/23) B. Facility policy and procedureThe Handwashing for dietary staff policy, revised 2/8/21, was provided by the DON on 4/13/23 at 1:58 p.m. It revealed in pertinent part,"Hands should be washed after touching bare human body parts other than clean hands. Hand washing procedure is a 20-second process." C. ObservationsContinuous observations from 11:10 a.m. through 1:50 p.m. on 4/12/23 revealed: -At 11:45 a.m. DM #1 began washing dishes with gloves on.-At 12:36 p.m. DM #1 picked up clean trays and separated them out to dry while wearing the same gloves he wore to wash dirty dishes.-At 12:48 p.m. DM #1 moved clean blender parts with the same dirty gloves.-At 1:20 p.m., DM #1 put dirty dishes into the dishwasher and then pulled the clean rack out of the other side of the machine wearing the same gloves he wore to wash and load the dirty dishes. -During lunch service, CK #2 touched her surgical mask with her bare hands five separate times and failed to perform hand hygiene.-During lunch service, DA #1 touched his surgical mask with his bare hands seven separate times and failed to perform hand hygiene. On 4/13/23 at 10:08 a.m. CK #2 was observed washing her hands for less than ten seconds during meal preparation and after touching her surgical mask twice with her bare hands. At 10:47 a.m. DA #2 was observed touching her bare face with bare hands without performing hand hygiene. D. Staff interviews DM #2 was interviewed on 4/10/23 at 9:00 a.m. She stated that the staff were to only use the designated hand washing sink to wash their hands and needed to wash for no less than 20 seconds. The staff were to wash after using the bathroom, touching unclean body parts and any other time when their hands were exposed to bacteria. IV. Failure to ensure holding temperatures of food were within the correct range A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; "The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control." (Retrieved 4/17/23) B. Observations Continuous observations from 11:10 a.m. through 1:50 p.m. on 4/12/23 revealed:-At 11:30 a.m. cold sandwiches and salads were brought out and held on a pan rack next to the steam table and tray line. There were nine sandwiches (tuna, chicken and ham) and eleven chef salads (some containing egg and ham). The sandwiches and salads were covered with saran wrap but were not kept on ice or with any other means to maintain a cold temperature. The sandwiches and salads were left out on the rack during the entire lunch service without any mechanism to keep them cold.-At 11:37 a.m. temperatures were taken at the start of lunch service by CK #2. The temperatures were as follows:Puree hot corn- 115°FPuree hot ham- 111°FCold tuna salad sandwich- 56°FCold chef salad- 55°FCottage cheese- 48°F-At 11:40 a.m. CK #2 made another batch of puree corn and the temperature read at 129°F.-Service started at 11:58 a.m.-At 12:46 p.m. the chicken salad sandwich temperature was 67.4°F.-At 1:50 p.m. at the end of lunch service, the salad temperature was 76.9°F.On 4/12/23 at 4:19 p.m. a tour of the second floor nursing floor cart and refrigerator was conducted with DM #1 and the following was observed:-The second floor nursing medication cart held a metal container for dietary supplements and soft foods for medication administration. Within the metal container was an open six ounce cup of yogurt. The yogurt ' s internal temperature was 66°F and was sitting in water with no ice.-The second floor nursing floor refrigerator failed to contain a thermometer for the freezer section. The temperature inside the refrigerator section showed the internal temperature was 52°F.On 4:12 p.m. at 4:34 p.m. a tour of the third floor nursing floor refrigerator was conducted with DM #1 and the following was observed:-The third floor nursing medication cart held a metal container for dietary supplements and soft foods for medication administration. Within the metal container was an open 3.9 ounce cup of applesauce. The applesauce ' s internal temperature was 71°F and was sitting in water with no ice.-The third floor nursing floor refrigerator failed to contain a thermometer for the freezer section. C. Staff interviewsCK #1 was interviewed on 4/12/23 at 11:37 a.m. She said the internal holding temperature for hot foods should be no less than 135°F and no more than 41°F for cold foods. If hot foods such as pureed items did not meet that temperature, she would remake the puree. She did not know the procedure when the food was not within hot holding range. CK #1 stated that if cold foods exceed 41°F, she would put the item in the refrigerator to bring the temperature down. DM #1 was interviewed on 4/12/23 at 4:34 p.m. He stated food items kept on the nurses cart for residents should be kept on ice at a holding temperature of 41°F or below. Food kept inside of the employee break room resident refrigerator should have a holding temperature of 41°F or below. DM #1 did not know who was responsible for ensuring the nursing staff understood the holding temperatures. Licensed practical nurse (LPN) #2 was interviewed on 4/12/23 at 4:40 p.m. She stated the nurse filled the metal container on the medication cart with ice at the beginning of the shift. She stated she did not know what the holding temperature should be for food items inside the metal container. Registered nurse (RN) #2 was interviewed on 4/13/23 at 9:12 a.m. She stated the overnight nurse would restock the items in the metal container on the nurse ' s medication cart and fill the container with ice at the end of the shift. RN #2 would dump the container after her medication pass at 9:30 a.m. She stated she did not know what the holding temperature should be for food items inside the metal container. RN #3 was interviewed on 4/13/23 at 9:15 a.m. She stated she did not know what the holding temperature should be for food items inside the metal container. DM #1 was interviewed on 4/13/23 at 9:48 a.m. He stated cold foods, such as sandwiches and salads, should be kept at a holding temperature of 31°F. The kitchen staff should maintain the temperature by covering the food or using it immediately. V. Failure to ensure systems were in place to prevent compromised food safety through proper staff training. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; "The designated person in charge shall ensure that:-Food employees are properly trained in food safety." (Retrieved 4/17/23) B. Staff interviewsThe DON was interviewed on 4/13/23 at 1:10 p.m. She stated that the dietary manager consultant was the RD. The DON said she would produce proof of kitchen staff training on hand hygiene, sanitation and testing, and temperatures. The RD was interviewed on 4/13/23 at 3:00 p.m. She stated she only provided consultation to the dietary manager on the clinical and nutritional needs of the residents, not areas like sanitation or holding temperatures. The DON was interviewed again 4/13/23 at 3:23 p.m. She stated that she was unable to find any proof of kitchen staff training on sanitation, hand hygiene or temperatures. She was not able to provide proof of training in those areas for DM #1. DM #1 had started staff in-serving in those areas on 4/13/23. DM #1 was using the facility policies to in-service the kitchen staff. The DON acknowledged that the facility did not have a policy on sanitization or testing. C Facility follow-up A facility policy on kitchen temperature control was requested from the DON on 4/13/23 at 10:39 a.m. At time of exit, this policy had not been provided. Documentation of the kitchen staff in-service was requested from the DON on 4/13/23 at 4:15 p.m. An email was received on 4/13/23 at 4:43 p.m. from the DON stating an in-service to the kitchen staff regarding temperature testing, hand hygiene, and kitchen sanitation was initiated 4/13/23 and would be completed by 4/14/23. Documentation of this was not provided after exit date 4/13/23.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 in one of four halls including an isolation room. Specifically, the facility failed to ensure appropriate personal protective equipment (PPE) while providing care for Resident #136 who was positive for COVID.Findings include: I. The Centers for Disease Control (CDC) recommended guidelines The CDC, Preparing for COVID-19 in Nursing Homes, updated 9/27/22, retrieved on 4/19/22 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. It read in pertinent part,"HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). "In general, patients should continue to wear source control until symptoms resolve or, for those who never developed symptoms."II. Observations and interviews On 4/11/23 at 11:36 a.m. the activity director was observed entering Resident #136's room, who was on isolation for COVID-19. The AD was observed donning a gown and gloves. She was observed wearing a cloth mask and then placing a surgical mask over her cloth mask. She then walked into Resident #136's room. She stayed in the room approximately seven minutes and exited the room. She doffed her PPE inside the room and opened the door removing the second surgical mask and placing it in the trash can with her bare hand, which was overflowing in the resident's room. She then went into another resident's room and did not hand sanitize her hands prior to entering the room. She did not wear a N-95 mask and she did not wear a face shield or eye protection prior to entering Resident #136's room. She did not hand sanitize her hands after placing the second surgical mask into the trash can. At 1:57 p.m. an unknown staff member entered Resident #136's room. She was observed putting on a gown, gloves and placed a new surgical mask over her original surgical mask. She was in the room for approximately seven minutes. She exited the room wearing her surgical mask. She did not hand sanitize her hands prior to donning her PPE prior to entering the resident's rooms. She did not wear a N-95 mask or face shield or eye protection. At 2:13 p.m. a hospice caseworker was observed entering Resident #136's room. She donned her gown and gloves prior to entering the resident's room. She was in the room for approximately 15 minutes. She exited the resident room and doffed her PPE outside of the resident's room. She bent into the resident's room and placed the PPE in the trash can pushing her used PPE into the trash can as it was overflowing. The hospice caseworker (HCW) said she had received her PPE training and doffing from her hospice provider. She said she visited various facilities completing hospice assessments. The HCW did not hand sanitize her hands prior to donning her PPE. She did not wear an N95 mask or wear a face shield or eye protection. She doffed her PPE outside of the resident's room. At 3:02 p.m. registered nurse (RN) #1 was observed entering Resident #136's room. She donned her gown and gloves. She was in the resident's room for approximately five minutes. She exited the resident's room and returned to her medication cart. RN #1 said she did not have on a N95 mask and she did not wear a face shield or any eye protection when entering the resident's room. On 4/12/23 at 9:09 a.m. certified nurse aide (CNA) #4 was observed entering Resident #136's room. She donned her gown, gloves and N95 mask but placed the N95 mask over her surgical mask. She was in the resident's room for approximately five minutes. CNA #4 doffed all her PPE in the resident's room and exited with the resident's meal tray. CNA #4 walked to the CNA station on the east hall with the room tray and her face shield on. While CNA #4 was placing the meal tray into the meal cart. She spilled the resident's milk while picking up the glass. She placed the uncovered meal tray back into the meal cart. She then removed her face shield placing it into a lower drawer in the CNA station. CNA #4 said she should have not worn her N95 over her surgical mask and she should have sanitized her hand and face shield after removing the room tray from the COVID room, and she should have placed them into a bag. III. Administrative interviews The director of nursing (DON) was interviewed on 4/13/23 at 9:14 a.m. She said staff should wear full PPE, which would be a gown, gloves, N95, face shield or eye protection. Staff should hand sanitize prior to entering the residents' room. She said then staff should be doffing all PPE prior to exiting residents' rooms and placing their face shields into a paper bag. The DON was told of the observations above. She said all staff have been trained on doffing and donning PPE, and they know better than that. She said a negative outcome could be getting themselves sick and spreading COVID. The infection control nurse (ICN) was interviewed on 4/13/23 at 11:00 a.m. She said staff should wear full PPE, which would be a gown, gloves, N95, face shield or eye protection. Staff should hand sanitize prior to entering the residents' room. She said then staff should be doffing all PPE inside the residents' room prior to exiting residents' rooms. She said then staff should sanitize their face shield or eye protection placing them inside of a bag. She said staff should know better than that because they have all been trained on donning and doffing PPE.

Based on observations and interviews, the facility failed to maintain emergency patient care equipment in safe operating condition and remove expired medical supplies from three of three emergency response crash carts. Specifically, the facility failed to perform daily quality readiness checks on the emergency response cart, to ensure the carts contained emergency equipment and expired items were removed and replaced. Findings include: I. Facility policyThe facility policy for maintaining patient care equipment was requested 4/12/23 at and was not received by exit on 4/13/23. II. ObservationsA. On 4/12/23 at 4:15 p.m. the second and third floor emergency response carts were observed with the director of nursing (DON). The DON acknowledged the following:Third floor emergency response cart:-Four pairs sterile examination gloves, expired June 2022, 286 days prior;-Four 100 militer (ml) Medline Sterile Water Solutions, expired December 2022, 102 days prior; and, -Three Medline Non-Conductive Suction Tubing - Sterile, expired December 2022, 102 days prior. There was a daily checklist on the cart that indicated facility staff failed to check the cart every day. The cart was not covered and was stored in the staff break room adjacent to the dining table. Second floor:-Two Medline Non-Conductive Suction Tubing - Sterile, expired December 2022, 102 days prior; and, -Five pairs of sterile examination gloves, expired June 2022, 286 days prior. B. On 4/13/23 at 11:15 a.m. the first floor emergency response cart was observed with the assistance director of nursing (ADON). The ADON confirmed the cart contained the following expired items: -Four sterile gloves, expired June 2022, 286 days prior; and, -Three 100 ml Medline Sterile Water Solutions, expired June 2022, 286 days prior. There was no inventory/quality checklist on the medication cart and it was missing a sterile oral suction yankauer and collection canister. The oxygen cylinder on the cart did not have a flow regulator properly attached for immediate use. The cart was not covered and was stored in a room and adjacent to the table where facility staff completed their individual COVID-19 testing. III. Interviews The DON was interviewed on 4/12/23 at 4:51 p.m. She stated it was the responsibility of the night shift nurse to check the items on the cart and ensure the oxygen canister was ready for use. She replaced the expired items on the second and third floor and had a staff member cover the carts with a bed sheet. The ADON was interviewed on 4/13/23 at 11:30 a.m. She acknowledged the first floor oxygen flow regulator was assembled incorrectly, where the flow regulator was not attached to the oxygen canister correctly. It took the ADON several attempts to adjust the regulator so that it was operational. The ADON acknowledged expired items were present. She said that it was the responsibility of the nursing department to maintain the equipment. She was unable to locate the daily checklist for the cart. She said the crash carts were to be checked after every use.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on hand held showers in 12 private shower rooms, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 4/12/23 at 1:03 p.m. revealed: The hand held shower head in rooms #227, #237, # 223, #219, #202, #203, #208, #340, #326, #331, #319 and #307 did not have a backflow prevention valve on them. The hand held showers were long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pans. II. Staff Interview The housekeeping supervisor (HKS) was interviewed on 4/13/23 at 9:50 a.m. He acknowledged he was not familiar with the backflow valve protocol. He said the hand held showers in all showers should have had a backflow prevention valve on them. He said he would install them immediately.

Based on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning on four resident hallways. Findings include: I. Observations An observation of the resident environment was completed on 4/12/23 at 1:03 p.m. Exhaust fans were installed in the ceiling of each bathroom. Bathroom fans in all rooms located on four of four hallways were not audible and did not create air movement with the switch turned on. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans did not function properly. Urine odors were observed during multiple observations in all halls, between 4/10/23 and 4/13/23. The bathroom exhaust fans were not functioning in all restrooms of the facility. II. Staff Interview The environmental tour was conducted with the housekeeping supervisor (HKS) and director of nursing (DON) on 4/13/23 at 9:50 a.m. The HSK confirmed the exhaust fans in all restrooms were not functioning. The HSK said the ventilation fans had been worked on previously. The HSK said he would have to check the motors on all halls to see why they were not functioning correctly. The HSK said the ventilation fans in every resident room should be in good working condition.

A revisit to the 1/5/2023 survey was completed on 3/2/2023. The facility was in compliance with the regulation surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/16/2023 and 01/22/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A complaint survey, prompted by complaints #CO30483 and #CO30464 was conducted on 1/4/23 to 1/5/23. One deficiency was cited.

Based on observations, record review and interview, the facility failed to ensure a residents' who were unable to carry out activities of daily living (ADLs) receives the necessary services and assistance during showers and baths for three (#7, #8 and #2) of four residents reviewed for hygiene assistance of nine sample residents. Specifically, the facility failed to provide scheduled showers and baths or offer an alternative for Resident #7, #8 and #2. Findings include: I. Facility policy The Activities of daily living (ADLs), and Mobility Care Need policy, reviewed on 2/8/21, was provided by the director of nursing (DON) on 1/6/23 at 8:51 a.m. The policy read in part, "Patient communication boards will be utilized to communicate assistance levels and important precautions/restrictions to enable direct care staff to promote functional independence while maintaining patient safety when providing care." II. Resident #7 A. Resident status Resident #7, age 93, was admitted on 12/22/22. According to the January 2023 computerized physician orders (CPO), diagnoses included wedge compression fracture, muscle weakness, acute kidney failure, chronic kidney disease, and history of falling. According to the 12/25/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming, bathing and toilet use. B. Observation/resident interview On 1/4/23 at 10:13 a.m., Resident #7 was sitting in her recliner with her pajamas on. She said I get tired of being in my pajamas. She said, "I prefer a shower but I have to get a sponge bath out of the sink. I have only received two showers since I have been here (12/22/22)." C. Record review The care plan, initiated 12/23/22 and revised 1/3/23, identified the resident was okay with receiving a shower, bed bath, and/or sponge bath per her preference. Interventions include the resident preferred showers. Bathing frequency was two times a week. The December 2022 point of care (POC) documentation utilized by the certified nurse assistants (CNAs), identified the bathing task to occur two times a week. The documentation identified the resident receiving one shower on 12/24/22 at 12:08 p.m. The occupational therapy shower sheets provided by the nursing home administrator (NHA) on 1/5/23 at 11:42 a.m. The shower sheets from the last 30 days documented one shower was given on 12/26/22, and 1/4/23 with no time given. III. Resident #8 A. Resident status Resident #8, age 80, was admitted on 12/12/23. According to the January 2023 CPO, diagnoses included metabolic encephalopathy (altered mental status), abnormal gait, dysphagia (swallowing difficulty), altered mental state, and history of falling. According to the 12/15/22 MDS assessment, the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming, bathing, and toilet use. B. Observation/resident interview On 1/4/23 at 11:30 a.m., Resident #8 was lying in her bed talking with her daughter. Resident #8's hair was disheveled and uncombed. Resident #8 and the resident's daughter were interviewed on 1/4/23 at 11:30 a.m. The daughter said Resident #8 was getting a shower once a week. She said, "I had to ask the staff to give her a shower on 12/20/22." The daughter said, "I requested she get a shower on 12/31/22 and again on 1/1/23 and requested again on 1/2/23." She said staff told her there were drain issues this weekend so no showers were given. C. Record review The care plan, initiated 12/22/22 and revised 12/28/22, identified the resident was okay with receiving a shower, bed bath, and/or sponge bath per her preference. Interventi