SLOAN'S LAKE REHABILITATION CENTER

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

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on February 13, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is an eight (8) story, Type I (332) (1-A) construction with a full basement. This facility is equipped with piped medical gas that is being utilized by residents. The facility was constructed in 1962 and 1967. This facility is licensed for 42 beds. The census on the date of the survey was 42. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The facility utilizes a fire pump located in the basement. This facility is classified as fully-sprinklered.

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 101One painted sprinkler head in the women's restroom, 6th floor. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. 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 record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied times. February and March: are 15 minutes apart. January and July: twenty minutes apart. Need to be an hour apart. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A recertification survey with complaint #CO34407 and #CO34552 was completed on 1/17/24 to 1/23/24. Seven deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/17/24 to 1/23/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services and assistance for bathing for two (#108 and #96) of four sample residents reviewed out of 30 sample residents. Specifically, the facility failed to provide bathing for Resident #108 and #96 to maintain personal hygiene. Findings include:I. Facility policy and procedureThe Activity of Daily Living policy, dated October 2023, was provided by the nursing home administrator (NHA) on 1/23/24/at 10:50 a.m. It read in pertinent part, "It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support to maintain. ADL documentation will be maintained in the electronic health record under tasks, care plan, assessments, or therapy documentation. ADL's will be care planned to reflect the resident specific needs."II. Resident #108A. Resident statusResident #108, age 79, was admitted on 1/4/24 and discharged on 1/17/24. According to the January 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), multiple fractures of pelvis (sacrum, and pubis), type 2 diabetes mellitus and chronic kidney disease. The 1/4/23 minimum data set (MDS) assessment was in progress. The 1/11/23 interdisciplinary (IDT) brief interview for mental status (BIMS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The 1/5/23 functional performance observation assessment revealed he required substantial/maximal assistance with one person for eating, toileting, personal hygiene, transfers and bed mobility. He was dependent for sit to stand. Shower/bathing was not assessed. B. Resident interview and observationResident #108 was interviewed along with the resident's representative on 1/17/24 at 3:05 p.m. Resident #108's hair was disheveled and long, uncombed and greasy. The resident's representative said she complained to the facility about his lack of showers and hygiene because he had been there for two weeks before the staff finally gave him a sponge bath. Resident #108 said he wanted a shower at least two to three times per week. C. Record reviewResident #108's ADL self care performance deficit care plan, revised 1/8/24, revealed the resident had self care performance deficits related to showers/bathing. Pertinent interventions were to assist with his bathing on Monday and Thursday evenings and as necessary or requested. The shower preference sheet dated 1/4/24 revealed the resident preferred a shower three days per week. The Kardex (a tool utilized by staff to provide consistent care for residents) report, dated 1/4/24, revealed the resident needed assistance with his bathing on Monday and Thursday evenings and as necessary or requested. Resident #108's bathing task records were reviewed from 1/4/24 to 1/17/24. The records revealed the resident was scheduled for two showers per week on Tuesday and Friday day shifts, per patient preference. Resident #108 was documented in the electronic health record (EHR) to have received no showers from 1/4/24 to his discharge on 1/17/24. The resident was documented to have refused bathing on 1/8/24 and 1/12/24 and one sponge bath on 1/16/24. -However, there was no documentation in the progress notes or CNA task records why the resident refused or documentation of assessment or follow up. -The resident missed all of his scheduled showers. D. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 1/18/24 at 3:00 p.m. She said she had worked at the facility for about one year and the staff mainly did showers, not bed baths, at the facility. CNA #3 said she documented the showers in the EHR, including the type of shower and any resident refusals. CNA #3 said the process for resident refusals was to document in the EHR and she would put in a comment about why the resident refused. CNA #3 said she asked the resident three times and then documented the refusal and put it in the note. CNA #3 said she was not required to tell the nurse about the refusal since she added a comment in the task section. Licensed practical nurse (LPN) #2 was interviewed on 1/18/24 at 03:07 p.m. She said the CNAs completed the showers and sometimes occupational therapy (OT) worked on that as part of therapy. LPN #2 said the CNAs documented in the EHR task section. LPN #2 said the CNAs let the nurses know of shower refusals and how many refusals because they should try a couple of times to get the resident to take a shower. LPN #2 said the CNAs needed to let the nurses know if a resident was not getting showers because of infection control concerns. LPN #2 said it was important for the residents to receive regular showers for good hygiene, cleanliness, to feel good, promote healing and infection control especially for those who were post surgical residents. The director of nursing (DON) was interviewed on 1/22/24 at 3:33 p.m. She said the CNAs completed the showers and if OT did the showers she asked the CNAs to chart that. The DON said on admission the residents were asked about their shower preferences and she noted that Resident #108's preference was for three times per week. The DON said she would recommend a minimum of two showers per week for basic hygiene and cleanliness. The DON said if a resident refused a shower she would expect the CNA to tell the nurse so they could help encourage the resident and chart that in the progress notes. The DON said it was important for Resident #108 to receive his showers per his preference in addition to maintaining his dignity and cleanliness. III. Resident #96 A. Resident status Resident #96, age greater than 65, was admitted on 1/1/23 and discharged on 2/24/23. According to the February 2023 CPO, diagnoses included major depressive disorder, anxiety disorder, fracture of the upper and lower end of right fibula, muscle weakness, moderate obesity and presence of an artificial knee joint. The 1/8/23 MDS assessment revealed the resident was cognitively intact with a BIM) score of 15 out of 15. The resident required supervision with oral hygiene, dependent with bed mobility, toileting, and maximal assistance with personal hygiene which included showers. He had no behaviors or refusals of care. B. Record review Resident #96's comprehensive care plan, initiated on 1/2/2023, identified the resident had an ADL self-care performance deficit related to toe-touch weight bearing (TTWB), open reduction and internal fixation (ORIF) of the left ankle. Interventions included one to two staff assistance with personal hygiene including showers. -The Kardex did not indicate shower days for Resident #96. The bathing record from 1/1/23 to 2/24/23 revealed the resident received one shower in a 55 day time frame. Documentation showed that the facility charted his showers as "not applicable" for 46 days from 1/4/23 to 2/24/23. Eight days were documented as the resident was"unavailable". C. Staff interviews CNA #2 was interviewed on 1/22/24 at approximately 2:00 p.m. The CNA said the resident's showers were assigned each day. She said each resident's shower days were assigned per the resident's preference. She said each CNA verified from the EHR who their assigned showers were in order to plan accordingly. The CNA said all refusals were reported to the unit nurse. CNA #2 said residents who were not bathed regularly could be at risk for infections, itchiness, and dry skin. Registered nurse (RN) #1 was interviewed on 1/22/24 at 2:10 p.m. The RN said the CNAs completed showers during their shift and reported all refusals to the nurse. The RN said the nurses usually attempted to find out the reason for the refusal and provided education to the resident about the importance of regular showers. The RN said regular showers were important to avoid the spread of infectious diseases.

Based on resident observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#12) of four residents reviewed for supplemental oxygen use out of 30 sample residents. Specifically, the facility failed to:-Ensure a physician's order was in place for Resident #12's continuous oxygen use. Findings include: I. Facility policy The Oxygen Administration Policy, revised March 2019, was provided by the nursing home administrator (NHA) on 1/23/24 at 10:47 a.m. It read in pertinent part, "The purpose of the oxygen policy is to provide sufficient oxygen to the bloodstream and tissues. The oxygen administration procedure included obtaining the appropriate physician's order." II. Resident #12 A. Resident status Resident #12, over age 65, was admitted on 12/10/23. According to the January 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation, hyperlipidemia, cardiac arrhythmia, hypoxia (low blood oxygen) and traumatic brain injury (TBI). According to the 12/30/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He was dependent on staff for bed mobility, transfers, grooming, and toilet use. The resident received oxygen therapy. B. Record review Resident #12's oxygen care plan, initiated on 12/11/23, identified the resident had oxygen therapy related to ineffective gas exchange. Interventions included administering medication as ordered by the physician, monitoring for signs and symptoms of respiratory distress and reporting any signs to a medical provider, and applying oxygen via nasal cannula up to 2 liters per minute (LPM) to keep oxygen saturations (oxygen blood levels) at or above 90% and titrating LPM (adjusting up and down) as indicated. -The January 2024 CPO did not include an order for the continued use of oxygen for the resident. C. Observation On 1/17/24 at 2:20 p.m., Resident #12 was seated in his wheelchair in his room with an oxygen cannula in his nostrils. The resident's oxygen concentrator was set to 1 LPM. On 1/18/24 at 9:59 a.m., Resident #12 was lying in his bed with an oxygen cannula in his nostrils. The oxygen concentrator was set to 2 LPM. On 1/18/24 at 1:05 p.m., the resident was seated in his wheelchair in his room with his oxygen cannula in his nostrils set at 2 LPM. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/18/24 at 3:19 p.m. CNA #1 said Resident #12 used oxygen continuously via nasal cannula at 2 LPM. The CNA said the resident was currently on 2 LPM and had been on oxygen since the beginning of her shift. Licensed practical nurse (LPN) #1 was interviewed on 1/18/23 at 3:36 p.m. The LPN said oxygen was considered a medication and required a physician's order before administration to any resident. LPN #1 said the resident had a physician's order in place but she could not locate the order in the resident's medical records. LPN #1 said a negative outcome of not having a physician's order for oxygen therapy could be the resident receiving too much oxygen causing hypercapnia (too much carbon dioxide in the bloodstream) or less oxygen causing respiratory distress such as hypoxia (insufficient level of oxygen to the bloodstream). The director of nursing (DON) was interviewed on 1/18/24 at 3:50 p.m. The DON said it was important for the nursing staff to ensure a physician's order was in place for every resident who required oxygen therapy. She said she was not sure why the resident did not have the required physician's order, however, she immediately ordered staff to call the physician's office to obtain an order for oxygen use for the resident. The DON said negative outcomes from administering oxygen without proper physician orderscould be altered mental status, dizziness, falls and hypoxic events and could have put the resident in respiratory distress.

Based on observations, interviews and record review, the facility failed to establish parameters for pain medication for one (#105) of five residents in a manner consistent with professional standards of practice out of 30 sample residents. Specifically, the facility failed to:-Ensure pain parameters were established and implemented for physician ordered as needed (PRN) pain medications; and,-Ensure non pharmacological interventions were implemented before administration of an opioid pain medication. Findings include:I. Facility policy and procedureThe Pain Management policy, revised November 2019, was provided by the nursing home administrator (NHA) on 1/22/24 at 10:52 a.m. It read in pertinent part, "Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome."The facility assists each resident with pain to maintain or achieve the highest practicable level of well being and functioning by: screening to determine if the resident has been experiencing pain; comprehensive evaluation of the pain; licensed nurse will complete the licensed evaluation in Point Click Care; and utilizing pharmacologic and/or non pharmacologic interventions to manage and/or try to prevent the pain consistent with the resident's goals."II. Resident #105A. Resident statusResident #105, age 84, was admitted on 1/11/24. According to the January 2024 computerized physician orders (CPO), diagnoses included rheumatoid arthritis (RA) and sacral fracture. The 1/16/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He required setup assistance with eating, supervision with personal hygiene, partial/moderate assistance with bed mobility and substantial/maximal assistance with toileting.-The assessment failed to indicate if the resident was on scheduled pain medication program, received as necessary (PRN) pain medications or received non pharmacological interventions for pain management. B. ObservationsOn 1/22/24 at 7:35 a.m., certified nurse aide with medication authority (CNA/MA) #1 entered Resident #105's room and asked what number his pain was on the pain scale. Resident #105 rated his pain a 6 out of 10. She asked Resident #105 if he wanted Tramadol or Oxycodone. CNA/MA #1 checked the Resident #105's medication orders and administered Oxycodone 2.5 milligrams (mg) to Resident #105.-She did not verify on the medication administration record (MAR) pain medication parameters or obtain guidance from licensed nursing partners regarding pain medications without ordered parameters.-She did not offer a non pharmacological intervention before administration of an opioid pain medication. C. Record reviewThe pain management care plan, initiated on 1/12/24, indicated Resident #105 was at risk for pain from a pelvic fracture. Interventions included to administer pain medications as ordered, anticipate need for pain relief, follow pain scale to medicate as ordered, monitor/report to nurse resident complaints of pain or requests for pain treatment and pain assessment every shift.-A review of Resident #105's comprehensive care plan did not reveal a person centered approach with identification of location, type or intensity of pain the resident experienced. -The care plan did not include personalized non pharmacological interventions to address the resident's pain. It did not identify a baseline assessment of pain or person centered pain management goals. Review of Resident #105's January 2024 CPO revealed the following physician orders related to pain management:Acetaminophen 1000 mg every six hours as needed for pain management. The date of the order was 1/19/24. Tramadol 50 mg every six hours as needed for severe pain. The date of the order was 1/19/24. Oxycodone 2.5 mg every eight hours as needed for acute pain. The date of the order was 1/18/24. Monitor level of pain every shift using a 1-10 scale, ordered 1/11/24, where:-0 indicated no pain;-1 to 3 indicated mild pain;-4 to 5 indicated moderate pain;-6 to 9 indicated severe pain; and,-10 indicated excruciating pain.-A review of the January 2024 CPO failed to reveal documentation regarding the location and type of the resident's pain being treated by Acetaminophen, Tramadol or Oxycodone. -The physician orders did not include specific pain scale parameters for the PRN Acetaminophen and Oxycodone. D. Staff interviewsCNA/MA #1 was interviewed on 1/22/24 at 7:40 a.m. CNA/MA #1 said the Oxycodone did not have specific ordered pain parameters and the Tramadol was ordered for severe pain. She said she let the resident decide which pain medication would be effective for his pain. Registered nurse (RN) #3 was interviewed on 1/22/24 at 9:30 a.m. RN #3 said when a resident was experiencing pain, non pharmacological approaches should be tried first. She said if pain medication was needed a pain assessment should be done first. She said a pain parameter should be ordered. She said Acetaminophen was administered for mild to moderate pain and opioid pain medication was administered for severe pain. RN #3 said if a pain parameter was not ordered for a pain medication the physician should be consulted to obtain pain parameters. The director of nursing (DON) was interviewed on 1/23/24 at 11:00 a.m. She said non pharmacological approaches should be tried first before pain medication was administered. She said pain assessments should be done before administration of a pain medication. She said which pain medication to give was based on physician ordered pain parameters. She said opioid pain medications should have pain medication parameters ordered. She said CNA/MA's should follow the physician ordered parameters for which pain medication to give. She said CNA/MA's should consult their licensed nursing partners if pain parameters were not ordered or not clear. She said she would review Resident #105's MAR for unclear or missing pain medication parameters.

Based on record review and interviews, the facility failed to ensure one (#191) of two residents out of 30 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure consistent communication and documentation with the dialysis center regarding care and services was completed for Resident #191. Findings include:I. Facility policy and procedureThe Renal Dialysis, Care of Resident and Hemodialysis policy, revised December 2020, was provided by the nursing home administrator (NHA) on 1/22/24 at 10:00 a.m. It read in pertinent part,"Facility licensed nurses will complete the baseline information, pre and post dialysis section of the nurses dialysis communication record."Dialysis center licensed nurses will complete the dialysis center section of the nurses dialysis communication record."II. Resident #191A. Resident statusResident #191, age less than 65, was admitted on 1/4/24. According to the January 2024 computerized physician orders (CPO), diagnoses included end stage renal disease (ESRD). The 1/9/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial/maximal assistance with transfers, partial/moderate assistance with toileting and bed mobility and supervision with personal hygiene. B. Record reviewThe nutrition care plan, initiated 1/4/24, documented Resident #191 was at nutritional risk related to ESRD and dialysis. It indicated the resident received dialysis on Mondays, Wednesdays and Fridays. The fistula (an irregular connection between an artery and a vein created surgically to facilitate dialysis) care plan, initiated 1/8/24, documented the care of the fistula related to dialysis. Interventions included pressure reducing mattress, avoid scratching, good nutrition and hydration and facility protocols.-Further review of Resident #191's comprehensive care plan revealed the facility failed to initiate and implement a resident specific care plan focus for dialysis. On 1/18/24 a review of the hemodialysis communication record forms from 1/5/24 to 1/17/24 revealed the following:-On 1/8/24, a hemodialysis communication form was not on the chart;-On 1/10/24, a hemodialysis communication form was not on the chart; and,-On 1/15/24, a hemodialysis communication form was not on the chart.-Review of Resident #191's electronic medical record (EMR) failed to reveal documentation to indicate communication between the facility and the dialysis center had occurred on 1/8/24, 1/10/24 or 1/15/24. C. Staff interviewsRegistered nurse (RN) #2 was interviewed on 1/18/24 at 12:30 p.m. RN #2 said the facility nurse filled out the top portion of the nurses dialysis communication form, including vital signs, any medications to be administered during dialysis and other pertinent information. She said the form was sent to dialysis with the resident. RN #2 said the dialysis nurse filled out their portion of the form with information such as medications received, pre and post dialysis weights and other pertinent information. She said the form was supposed to be sent back to the facility with the resident after dialysis. She said this document was a permanent record on the resident's medical chart. RN #2 said if the form did not return to the facility with the resident, nurses should communicate with the dialysis center. She said there had been an issue with the dialysis center consistently not returning the hemodialysis communication form back to the facility with Resident #191 after dialysis. RN #2 said she did not know if nurses had communicated with the dialysis center regarding the missing communication forms. The director of nursing (DON) was interviewed on 1/23/24 at 11:00 a.m. She said the dialysis communication form should be filled out by the facility nurse prior to the resident going to dialysis with vital signs and medications. The dialysis nurse was to document pre and post dialysis weights, medications received and other pertinent information and return the form to the facility with the resident. She said nurses should communicate and document with the dialysis center if this form did not come back with the resident. She said the facility nurses were to check the resident's vital signs and fistula dressing upon the resident's return to the facility and document the information on the dialysis communication form. The DON said this communication should happen every time the resident went to dialysis and the communication form was a permanent part of the resident's medical record. She said receiving dialysis communication forms back from dialysis centers was an ongoing problem. She said Resident #191 had missing dialysis communication forms. She said the information from the forms was important for effective communication and the continuity of care between the facility and the dialysis center.

Based on observation, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#196) of five residents reviewed for medication errors of 30 sample residents. Specifically, the facility failed to ensure that Resident #196 was administered an anticoagulant medication correctly by removing the medication from a capsule before administration to the resident. Findings include:I. Professional referenceBoehringer Ingelheim Pharmaceutical. (November 2023). Package insert. Pradaxa. U. S. Food and Drug Administration (FDA). https://content.boehringer-ingelheim.com/DAM/c669f898-0c4e-45a2-ba55-af1e011fdf63/pradaxa%20capsules-us-pi.pdf, retrieved on 1/24/24 at 10:07 a.m."Pradaxa capsules should be swallowed whole. Pradaxa capsules should be taken with a full glass of water. Breaking, chewing, or emptying the contents of the capsule can result in increased exposure (more of the drug in a shorter amount of time)."Amaraneni, A., Chippa, V., and Rettew, A. (2023). Anticoagulation Safety. Stat Pearls. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/30085567/#:~:text=Oral%20anticoagulants%20have%20been%20classified,for%20harm%20when%20used%20clinically, retrieved 1/25/24 at 11:38 a.m."Oral anticoagulants have been classified as high alert medications according to the Institute of Safe Medication Practices (ISMP) because they have the potential for harm when used clinically."II. Facility policy and procedureThe Therapeutic Research Center Medications That Should Not Be Crushed reference guide, revised February 2023, was provided by the director of nursing (DON) on 1/22/24 at 10:05 a.m. It revealed in pertinent part,"Pradaxa (Dabigatran) intact product must be taken to avoid increased exposure."III. Resident #196A. Resident statusResident #196, age 93, was admitted on 1/21/24. According to the January 2024 computerized physician orders (CPO), diagnoses included periprosthetic right hip fracture and atrial fibrillation (abnormal heart rhythm). The minimum data set assessment (MDS) was not completed due to the resident being recently admitted. According to the 1/22/24 nursing assessment the resident was alert to person, place and time. The nursing assessment revealed the resident had swallowing difficulties, was on a modified diet and required crushed medications to be administered. B. ObservationsOn 1/22/24 at 7:14 a.m. certified nurse aide with medication authority (CNA/MA) #1 opened the Pradaxa capsule and sprinkled the medication into applesauce. CNA/MA #1 entered Resident #196's room and administered the medication to the resident.-CNA/MA #1 did not verify or obtain guidance if medication was able to be removed from the capsule from reference material or licensed nursing staff prior to the administration of the medication. C. Record reviewThe 1/21/24 computerized physician order (CPO) revealed an order for Pradaxa (an anticoagulant medication) oral capsule 150 milligrams (mg). Give by mouth two times a day for atrial fibrillation. The 1/21/24 CPO revealed an order for anticoagulant bleeding monitoring including blood tinged or frank blood in urine, black tarry (sticky) or frank blood in stool, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status or significant or sudden change in vital signs every shift.-A comprehensive review of the CPO did not reveal Pradaxa could be removed from the capsule for administration. IV. Staff interviewsCNA/MA #1 was interviewed on 1/22/24 at 10:00 a.m. She said Resident #196 required his medications to be crushed because of a swallowing problem. She said she did not know if medication could be removed from the capsule. She said she had not thought to check to see if the medication could be removed from the capsule. She said medications that could not be crushed or removed from the capsule should be verified with thelicensed nursing staff. The DON was interviewed on 1/22/24 at 10:18 a.m. She said, upon consultation with the facility pharmacist, Pradaxa should not be removed from the capsule because the capsule was removed from the drug, more of the drug could be absorbed in a shorter amount of time which increased the risk of bleeding. She said Resident #196 would be monitored for bleeding but the physician provider did not want additional monitoring (blood work) at this time. She said the provider had changed Pradaxa to Eliquis (an anticoagulant), which could be crushed. She said, in consultation with the pharmacist, she had provided a list of updated medications that should not be crushed reference guide for the medication administration carts. She said staff that provided medication administration should reference this guide before crushing or removing medications from their capsules. She said the CNA/MA's should verify with their licensed nursing partners before crushing medications. She said if there were additional concerns by nursing staff the pharmacy should be consulted. The pharmacist was interviewed on 1/23/24 at 12:48 p.m. She said Pradaxa should not be removed from its capsule because of the increased risk of rapid absorption of the drug which increased the risk of bleeding. She said Resident #196 had only received two doses of Pradaxa since admission the risk of bleeding was not as high of a concern and did not require lab work. She said the provider had changed Resident #196 to an anticoagulant which could be crushed. She said she had provided nursing staff with education and reference materials for which medications could be crushed or removed from their capsules.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs that accommodated resident allergies, intolerances and preferences for two (#106 and #191) of six residents out of 30 sample residents. Specifically, the facility failed to:-Ensure Resident #106 was provided appropriate vegetarian meal items per the menu spreadsheets after the meat was eliminated;-Ensure Resident #191 was provided or offered a substitute meal when the resident did not like the lunch item provided;-Ensure Resident #191 was provided with dinner after a late dialysis appointment; and,-Follow the therapeutic dialysis diet for Resident #191. Findings include:I. Facility policy and procedureThe Resident Food Preferences and Meal Alternates policy, revised July 2021, was provided by the nursing home administrator (NHA) on 1/23/24 at 2:32 p.m. It read in pertinent part, "Specific food preferences, diet restrictions, and diet history will be gathered upon admission to inform the food service department of the resident's information. Appropriate alternate foods will be prepared and substituted for food dislikes, allergies, and/or intolerances. "Upon admission (within 48-72 hours) and periodically as needed, the food service manager or dietician, or designee, will interview the individual for the following information: acceptance of diet order, food preferences, intolerances, allergies, cultural and/or religious preferences, location where the meals are to be served and diet history. "Information is included in nutrition evaluation, care plan, and resident meal ticket. The information is kept on file to ensure that each individual's needs and desire for food are met. The food service staff are responsible for preparing and serving the alternates. The food service department will make reasonable accommodations to meet resident preferences and special requests. The food service staff will use the menu substitution lists and menu spreadsheets as a guideline for appropriate, nutritionally balanced substitutions."II. Resident #106A. Resident statusResident #106, age greater than 65, was admitted on 12/31/23, and discharged on 1/22/24. According to the January 2024 computerized physician orders (CPO), diagnoses included chronic embolism and thrombosis of deep veins of left leg (blood clot), chronic kidney disease, and cerebral infarction (stroke). The 1/7/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required substantial/maximal assistance with toileting hygiene and lower body dressing. She required partial/moderate assistance with bathing, bed mobility, and transfers. She was independent with eating. B. Resident observation and interviewResident #106 was interviewed on 1/17/24 at 2:11 p.m. She said she was a vegetarian. Resident #106 said the kitchen took the meat off her meals but did not substitute another protein. Resident #106 said it was a real struggle when she first admitted because they served her meat. She said the dietary manager (DM) had a meeting with her and now the meat was gone but she was still not receiving a substitute for the protein. She said she knew what was on the menu by the meal slip but she had not seen an always available menu for alternatives. Resident #106 said if she did not like what was on the menu then she was not able to eat. She said she liked peanut butter sandwiches but they were not offered. She said no one had offered her any type of protein shakes. Resident #106 was observed on 1/18/24 at 12:14 p.m. Her lunch tray had dill potatoes, chef's vegetable blend, cornbread and butter and a lemon bar. The resident said sometimes they offered almond milk but it was not offered that meal and she was drinking water. Resident #106 said the food service staff had not offered or provided a meatsubstitute for her meals. The 1/18/24 menu spreadsheet revealed "select vegetarian item to serve" in place of the "catch of the day." -However no vegetarian protein substitution had been provided to Resident #106. C. Record ReviewResident #106's nutritional care plan, initiated 12/31/23 and revised 1/16/24, revealed in pertinent part to honor residents rights to make personal dietary choices and provide dietary education as needed (initiated 1/2/24).-There was no documentation regarding the resident's preference for a vegetarian diet. A grievance was filed on 1/2/24 by Resident #106's representative. The resident's representative said the resident did not eat meat and wanted no meat on her tray. The DM responded on 1/3/24 and said she had spoken to the resident's representative and told her to give dietary services a list of proteins the resident wanted. The DM said she went out and got Resident #106 beans and told her about garbanzo beans. The DM said the resident's representative would provide some of the proteins and to give the resident whatever she would circle on her menu. Other foods requested were vegetable patties and avocados. The DM told the resident and her representative they already had these items in the kitchen. The DM told them if there was any other special request she would be happy to go and buy it.-The meat was eliminated from the resident's meals however no protein substitutions were provided or offered on the resident's meal ticket.-The vegetarian preference was added to the resident's meal ticket but not to the care plan. The 1/5/24 admission nutrition evaluation revealed the resident liked most foods, had no major dislikes and would order preferred foods off the daily menu.-However the evaluation was completed by a PRN (as needed) dietician off site and did not involve an interview with the resident, therefore it had not documented that the resident was a vegetarian. Review of Resident #106's meal ticket revealed the following information regarding the resident's meal and food preferences: -Vegetarian; -Regular portions;-Allergies: None; -Beverages: No preferences; -Dislikes: Eggs; -Prefers: No meats; -Refer to spreadsheet for portion sizes; and,-Note: No meats, make sure food is hot. The bottom of the meal ticket read in pertinent part,, "Remember to check the additional diet information above and make appropriate adjustments."-However the meal tickets had no notice for the kitchen to add a vegetarian protein substitute from the menu spreadsheet, therefore no appropriate vegetarian protein meal item was provided after the meat was eliminated. D. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 1/22/24 at 1:58 p.m. She said resident meal tickets came on a paper on the resident's meal tray to be filled out by the resident for the next day's meals. The papers were then taken back to the kitchen when the trays were picked up. CNA #4 said the residents filled out their own orders and she was not involved with the ordering or offering of alternate items. The registered dietician (RD) and corporate registered dietician (CRD) were interviewed on 1/22/24 at 2:11 p.m. The RD said the usual procedure for determining resident's preferences and therapeutic diets was to see all residents within five days of admission to interview the resident, gather information from the chart and to put dietary interventions in place on the care plan. The RD said she would typically see everyone in the facility however she had been off work for over a month and a PRN dietician was reviewing the residents charts remotely and there were no in-person interviews. The RD said the DM interviewed residents and updated the meal tray cards but Resident #106's meal ticket was not updated to a vegetarian diet until after the family filed a grievance with the facility. The RD said if a resident was a vegetarian it should be noted on the admission nutrition evaluation but it had not been done for Resident #106 because the PRN dietician had not interviewed the resident. The RD said if a vegetarian resident did not want the meat the dietary staff had menu extensions (menu spreadsheets) and would substitute a menu item that was similar in nutritional value. The RD said Resident #106's lunch on 1/18/24 was not a complete/healthful meal due to missing the protein substitute. The RD said it would be the kitchen's responsibility to select a vegetarian protein option. The CRD, after having viewed Resident #106's meal tickets from 1/14/24 to 1/19/24, said there should have been a spot for the protein substitution on the ticket for either the resident to write in a preference or for the kitchen to put in an appropriate vegetarian protein option. The CRD said the resident was not regularly getting a food group (protein) substitution which was a concern. The CRD said that was why the in-person interviews of residents were important. The CRD said there was a combination of systems that she needed to address to make the process better and she would do some additional training. III. Resident #191A. Resident statusResident #191, age less than 65, was admitted on 1/4/24. According to the January 2024 CPO, the diagnoses included end stage renal disease (ESRD). The 1/9/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial/maximal assistance with transfers, partial/moderate assistance with toileting and bed mobility and supervision with personal hygiene. B. Resident interviewResident #191 was interviewed on 1/17/24 at 1:50 p.m. He said he had not spoken to a dietitian since his admission on 1/4/24. He said he was on a renal diet. He said he had been receiving bananas and potatoes which he was not allowed to eat on a renal diet. Resident #191 said he went to dialysis in the evenings. He said the facility did not send dinner with him when he left the facility at 3:30 p.m. He said when he returned at 9:00 p.m., his dinner was usually waiting, cold, for him in his room. He said he was not comfortable eating food left out for an extended period of time. Resident #191 was interviewed again on 1/18/24 at 1:00 p.m. He said when he did not like what was served on the renal diet menu for lunch there was not another option on the menu for him to choose from. He said staff did not offer him an alternative. He said he did not like the alternatives in the always available menu book. He said his family was bringing food from home. C. ObservationsOn 1/18/24 at 12:30 p.m., Resident #191 was observed sitting in the dining area and refused his lunch tray. Staff did not offer an alternative lunch and provided the resident with a cupcake. Resident #191 returned to his room without eating lunch. D. Record reviewThe nutrition care plan, initiated 1/4/24, documented Resident #191 was an increased nutritional risk and was on a therapeutic diet for ESRD and dialysis. Interventions included a physician ordered renal diet, monitor weights and intakes, offer and encourage snacks and fluids and honor resident rights to make personal choices. The 1/9/24 nutrition evaluation documented Resident #191 was particular with the food he ate and he was having difficulty adjusting to the food in the facility. The 1/14/24 nutrition progress note recommendations documented to continue the resident's renal diet as ordered, offer a Prostat (protein supplement) every day for protein needs and to monitor weights and oral intakes. -The nutrition progress note failed to reveal a consultation with Resident #191 regarding therapeutic diet education, food choices, preferences and alternatives. E. Staff interviewsCNA #5 was interviewed on 1/22/24 at 2:10 p.m. She said residents were given a meal ticket at noon for the next day. She said if the resident did not like what was on the menu they would mark out what they did not want. A substitution or alternative was not automatically offered or provided in place of what the resident did not want. She said if residents did not like what was on the menu for their diet they could order from the always available menu. The DM was interviewed on 1/22/24 at 2:40 p.m. She said when residents were admitted they were provided education on how the meal ordering system worked. She said residents were also provided education on how to order from the always available menu. She said the RD rounded on every resident to find out resident preferences which were added in the care plan. She said an RD was to see every resident within five days of admission. She said for therapeutic diets, the diet was ordered by the physician on transfer from the hospital. The DM said the RD would round with the resident and review the diet, preferences and restrictions. She said she the facility's usual RD had recently been gone and a PRN RD was working remotely and had completed new resident nutritional evaluations through chart review. The DM said an RD had not seen Resident #191 since he was admitted. She said dialysis centers did not allow food to be sent with residents to dialysis. She said because of food safety Resident #191 should not have his tray left in his room until he returned from dialysis. She said education would be provided for staff to store his tray in the unit refrigerator until he returned from dialysis in the evening.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one out of two floors. Specifically, the facility failed to:-Ensure a resident's room was cleaned in a sanitary manner;-Ensure that the proper cleaning agent was used to clean a resident's room who was on transmission based precautions; and-Ensure appropriate personal protective equipment (PPE) was worn to clean a resident's room who was on transmission based precautions for Clostridium difficile. Findings include:I. HousekeepingA. Professional reference 1. The Centers for Disease Control (CDC) Frequently Asked Questions for Clinicians about Clostridium Difficile (10/25/22), https://www.cdc.gov/cdiff/clinicians/faq.html, retrieved on 1/25/24 at 10:26 a.m., read in pertinent part,"Wear gowns and gloves when entering Clostridium difficile infection (CDI) rooms and during their care."Ensure adequate cleaning and disinfection strategy, ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently."Use an Environmental Protection Agency (EPA) registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. (Note: only hospital surface disinfectants listed on EPA's List K are registered as effective against Clostridium difficile spores)."2. The CDC Environment Cleaning Procedures (5/4/23), https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118, retrieved on 1/25/24, read in pertinent part,"Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms."Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas."B. Manufacturer recommendationsAccording to the Clorox Healthcare Fuzion Cleaner Disinfectant (EPA List K registration #67619-30) manufacturer guidelines. January 2024, retrieved from https://www.cloroxpro.com/products/clorox-healthcare/fuzion/ on 1/25/24 at 11:05 a.m."Remove gross soil if visible, For Clostridium difficile spores and tuberculosis (TB), always clean the surface prior to disinfecting. Spray 6-8 inches from the surface until the surface is completely wet. Disinfect by leaving solution on surface for Clostridium difficile spores two minutes of contact time. Wipe with a clean damp cloth. Allow to air dry."C. Observation On 1/23/24 at 9:30 a.m., housekeeper (HS) #1 cleaned resident room #611 following the resident's discharge from the facility. The resident had been on transmission based precautions for Clostridium difficile. The following observations were made:HS #1 entered the resident's room after donning gloves and placed the resident's belongings into plastic bags. -HS #1 did not put a protective isolation gown on prior to entering the room. HS #1 sprayed the fall mats, bedside table, nightstand, bed and recliner chair in the room lightly with Oxivir, a disinfectant, and immediately began wiping the disinfectant off the surfaces without allowing the disinfectant to remain on the surface for an appropriate dwell time (the amount of time a disinfectant needs to remain on a surface without being wiped away or disturbed to effectively kill germs). -Oxivir is a disinfectant which is not on the EPA List K for disinfectants effective against Clostridium difficile. -She cleaned from a low area and proceeded to a high area. HS #1 sprayed the bathroom vanity, sink, toilet, shower and commode chair lightly with Oxivir. -The surfaces were not visibly wet. -HS #1 used Oxivir, a disinfectant not on the EPA List K for disinfectants effective against Clostridium difficile. HS #1 wiped the top of the toilet bowl, underneath the toilet seat, tank of the toilet and down the outside of the toilet bowl. -She cleaned the toilet from a dirty area to a clean area and from a low area to a high area without changing gloves, rags or performing hand hygiene. HS #1 turned on the shower and rinsed off the commode with water. -She did not use a disinfectant on the EPA List K for disinfectants effective against Clostridium difficile..D. Staff interviewsHS #1 was interviewed on 1/23/24 at 10:00 a.m. She said she did not know if there was anything she needed to do differently for residents who were on transmission based precautions with Clostridium difficile. She said she wore gloves for all residents' rooms that she cleaned but did not know if she needed to wear a gown for residents on isolation. She said she used Oxivir to clean residents' rooms and it needed to be visibly wet for one minute. HS #1 said she did not know if there were any other disinfectants she needed to use for Clostridium difficile. She said surfaces needed to be cleaned from clean to dirty and after cleaning a dirty area she should not return to a clean area. The director of nursing (DON) who was also the facility's infection preventionist (IP) was interviewed on 1/23/24 at 10:36. She said when a resident who was on transmission based precautions for Clostridium difficile was discharged they did a full deep cleaning of the room. She said the room should be cleaned with the Clorox Healthcare Fuzion Cleaner because it was an approved disinfectant for Clostridium difficile. The DON said surfaces should remain visibly wet for the manufacturer recommended time of two minutes. She said housekeepers should wear gowns and gloves to clean rooms with Clostridium difficile. She said it was important to start from clean to dirty and top to bottom to not track dirty particles back to clean areas as it could potentially spread infectious agents.

A survey prompted by #CO34074 was conducted on 11/16/23-11/21/23. No deficiencies were cited.

A complaint survey, prompted by #CO32431 was conducted on 6/12/23. No deficiencies were cited.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 05/01/2023 and 05/07/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/27/2023 and 03/05/2023, 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 #CO30656 was conducted on 1/31/23-2/1/23. No deficiencies were cited.

A survey prompted by complaint #CO30658 was completed 1/31/23-2/1/23. No deficiencies were cited.

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 01/09/2023 and 01/15/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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