ADVANCED HEALTH CARE OF COLORADO SPRINGS

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

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 05/29/2023 and 06/04/2023, 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 revisit survey was completed on 6/2/23 for all previous deficiencies cited on 3/16/23. The facility is in compliance with all regulations surveyed.

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

The Initial Comments (ID Tag K0000) are informational only and are a representation of the facility's general characteristics. The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70 (a). The building is a one story wood framed structure, Type V (111). The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. The facility 's fire sprinkler system is a wet and a dry system. This survey of the 34 bed facility was conducted on April 10, 2023 for compliance with the NFPA 101 Life Safety Code, Chapter 19 Existing Health Care Occupancies and Referenced Publications. The facility will meet these requirements with the correction of the deficiencies listed herein. The following deficiencies were discussed with the facility Administrator during the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. Chalks in kitchen on stove wheels | Kitchen stove wheels do not have devices installed to return to same position after pulling out for cleaningNFPA 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.

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 Dry Valve full trip report available during inspectionSprinkler freezer/refrigerator corrosion | Sprinkler heads both freezer/fridge corroded Also unable to identify temperature of headNFPA 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 record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code NFPA 101. Fire Drills not compliant | No Fire Drill 3rd shift (4th qrt)/2nd shift (2nd qrt)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. NFPA 101, 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. 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 maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:Written records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade for receptacles in patient care need to be updated to verify all areas accounted for. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

A recertification survey was conducted 3/13/23-3/16/23. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/13/23 to 3/16/23. No deficiencies were cited.

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable interventions and objectives for one (#12) of three out of 18 sample residents. Specifically, the facility failed to develop a person centered care plan for Resident #12's mental illness that included interventions, behaviors, and non-pharmaceutical approaches. Findings include: I. Resident #12 A. Resident status Resident #12, age 74, was admitted to the facility on 2/8/23. According to the March 2023 computerized physician orders (CPO), diagnoses included bipolar II disorder and unspecified dementia without psychotic disturbance. The 2/11/22 minimum data set (MDS) assessment showed the resident had moderate cognitive impairment with a score of ten out of 15. No behaviors were indicated. B. Record review The mood care plan, revised on 2/17/23 revealed the resident was taking an anticonvulsant for bipolar II disorder. The goals were to be without injury related to use of an anticonvulsant. The approaches were to administer the medication as ordered and report to the medical director. There were no interventions, behaviors, or non-pharmaceutical approaches related to mood. The psychotropic drug usage care plan, revised on 2/17/23 revealed the resident required the use of an antipsychotic medication related to a diagnosis of psychosis. The goals were for the resident to not exhibit any adverse side effects related to the medication. The approaches were:-offer counseling-encourage resident to express needs, wants, and feelings-encourage family to visit-monitor for changes in behavior-educate family and resident on side effects-review regime and conduct gradual dose reduction as appropriate-review medication for appropriate does, diagnosis, and usage per psycho pharmacological review-administer medication as ordered. -The resident's care plan failed to identify individualized behaviors, person centered interventions, and non-pharmaceutical approaches. The March 2023 medication administration records (MAR) revealed the following physician orders for psychotropic medications:-Divalproex (Depakote) 250 MG one time a day for bipolar ordered on 2/8/23;-Divalproex (Depakote) 500 MG to equal 1000 MG one time a day at bedtime for bipolar ordered on 2/8/23;-Lamotrigine (Lamictal) 25 MG one time a day for bipolar ordered on 2/8/23; and,-Quetiapine (Seroquel) 25 MG to equal 75 MG at bedtime for psychosis ordered on 2/8/23. The hospital nursing record dated 2/6/23, two days prior to admission to the facility, revealed the resident was experiencing dysphoric mood (depression, irritability, aggression and anger). The resident was prescribed Depakote 500 MG for mania associated with bipolar disorder. Target behavior tracking from 2/12/23 to 3/13/23 revealed: -Divalproex and Lamictal for behaviors of erratic mood swings or erratic behaviors started on 2/8/23 with no behaviors marked. -Quetiapine for behaviors of hallucinations/auditory or visual started on 2/8/23 with no behaviors marked. -Review of resident's progress notes dated 3/15/23 through 2/8/23 failed to reveal any notes regarding care conferences or care planning. II. Resident interview and representative interview The resident was interviewed on 3/15/23 at 10:30 a.m. He acknowledged he has a diagnosis of bipolar disorder and stated that no therapy or counseling has been offered to him, and he would have liked for it to have been offered. He stated he had never been invited to a care conference meeting since being at the facility. The resident's representative was interviewed on 3/16/23 at 8:52 a.m. She stated that the resident had been receiving psychological services in the community but had not been offered since admitting to the facility. She was aware there were routine care conferences held but she had to ask to attend, but the resident nor her were invited. She said that the staff had interviewed the resident regarding if he was experiencing depression but they did not ask her about his history of behaviors, interventions, or what approaches had worked for him in the past. The last significant episode he had was two years prior. He had been experiencing manic behaviors and depression, resulting in a fall and hospitalization. While at the hospital, he had been treated with Prozac (depression medication) which increased his manic behaviors. He had another injury and required 24- hour supervision while at the hospital. Manic behaviors for him manifested as excessive energy, "bouncing off the walls", apathy, and chronic depression. III. Staff interviews Registered nurse (RN) #2 was interviewed on 3/14/23 at 10:47 a.m. RN #2 stated the resident did not have any behaviors that he knew of. RN #2 pulled up the resident's target behavior tracking and could not tell which behavior was being tracked for Lamotrigine and the Divalproex because the tracker was combined. He acknowledged he could effectively track the behavior with one tracker for two medications. He could not explain what behaviors he was to be watching for according to the behaviors listed on the target behavior tracker. CNA #1 was interviewed on 3/14/23 at 11:00 a.m. CNA #1 stated resident had behaviors of confusion but no other behaviors that she was aware of. The admissions coordinator (AC) was interviewed on 3/14/23 at 11:19 a.m. She stated she did the admission and intake with the new residents. She would interview the resident and their family regarding any behaviors and would look in the resident's hospital records. She included that information on their target behavior tracker. If a resident had started taking several psychotropic medications at the same time, then they would be included on the same tracker. She could not explain how the staff would know which behavior they were tracking for which medication. RN #1 was interviewed on 3/15/23 at 10:44 a.m. RN #1 stated the resident had memory problems but no other behaviors she was aware of and she could not explain the behaviors she was tracking the resident for. She said what she thought erratic behavior meant a person was dangerous, she did not know what mood swings or hallucinations looked like for the resident. Management had not elaborated what behaviors staff were to be watching for on the tracker or in the resident care plan. The DON was interviewed with the AC present on 3/15/23 at 11:03 a.m. The DON stated the behaviors management wanted nursing staff to track were on the target behavior tracker. These were the behaviors that have been determined to be associated with the medication on the tracker. The AC did the interview with the family and the resident at time of admission. She would ask what behaviors they have associated with their mental illness and what did that look like. When the information was vague, the DON or AC would contact the psychologist that came to the facility to meet with the resident to help determine what their behaviors were. The MDS coordinator entered the care plan in the resident's electronic medical record and gathered her information from the staff and the records, she worked remotely. They acknowledged that they had not contacted their psychologist to meet with Resident #12 for counseling, to clarify behaviors or interventions for the resident. The MDS coordinator was interviewed with DON on 3/15/23 at 1:29 p.m. The MDS coordinator stated that if a resident was stable with their mental illness, she dis not include their behaviors or interventions in the resident's care plan. The MDS coordinator did not indicate why the behaviors on the target behavior tracker had not been included in Resident #12's care plan. The DON stated that even if the resident had a diagnosis of mental illness, if they were not showing behaviors, had not had any episodes for years, and were reportedly stable then the care plan would not include behaviors, approaches or non-pharmacological interventions for that diagnosis. The DON and the MDS coordinator acknowledged Resident #12's care plan did not include person centered information regarding behaviors, interventions and approaches.

Based on observations, interviews and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (#7) of two residents reviewed for falls out of 18 sample residents. Specifically the facility failed to timely implement appropriate and effective interventions to prevent five falls in a two week period. Findings include: I. Facility policy The Fall Prevention policy, updated 9/28/22, was provided by the director of nursing (DON) on 3/15/23 at 4:30 p.m., read in part:"Safety interventions will be implemented and monitored with appropriate documentation as indicated ...Based upon the calculated score of the Fall Risk Assessment, the fall risk protocol and care plan will be completed and the appropriate interventions initiated. The admitting nurse/nurse manager will be responsible for insuring that interventions are initiated and communicated to appropriate staff for follow through ...The assigned licensed nurse will be responsible for ensuring safety checks are in place as care planned and will initial the TAR (treatment administration record) indicating checks are completed and document in nursing notes for verification." II. Resident #7 A. Resident status Resident #7, age 79, was admitted on 2/20/23. According to the March 2023 clinical physician orders (CPO) diagnoses included encounter for orthopedic aftercare following surgical amputation, right below knee amputation, diabetes mellitus and heart failure. The 2/26/23 minimum data set (MDS) assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score 15 out of 15. She required extensive assistance with bed mobility and dressing, limited assistance with transfers and toilet use, supervision with eating, and she was independent with personal hygiene. B. Record review The comprehensive care plan, dated 2/27/23, included the following: Patient will improve self-care and mobility function and achieve discharge goals as identified on MDS (minimum data set) section GG. Approaches included: functional performance will be evaluated with discharge from skilled services. Functional discharge goals will be determined on admission. Baseline functional performance will be determined upon admission. Patient identified at risk for falls related to: Mobility and/or functional deficits. Impaired safety awareness and balance deficits. Goal: Risk of falls and/or injury related to falls will be minimized throughout stay. Approaches included: Monitor for adverse side effects of medication regimen; consult with MD (physician) as needed. Ensure proper placement of call light and assistive devices for ease of access. PT (physical therapy) and/or OT (occupational therapy) evaluation and treatment to address functional deficits. Educate patient and/or family regarding fall risks and safety needs. Encourage patient to call for assistance with transfers and ambulation. Assist with transfers and ambulation as needed.-The risk for falls care plan was not revised with new interventions after Resident #7's falls. Patient requires/receives staff assist with ADL (activities of daily living) completion r/t (related to) limited mobility and generalized weakness due to s/p (status post) Rt BKA (right below knee amputation). Goal: Patient will increase strength and endurance to regain independence per skilled therapy goals throughout stay. Patient will present a clean and neat appearance, clean clothing, properly adjusted, hair combed and neat throughout stay. Approaches included: Oxygen as ordered. Monitor of s/s (signs and symptoms) of lethargy/fatigue/dizziness r/t (related to) medication use; notify MD (physician) if s/s (signs and symptoms) occur. Monitor labs as ordered; notify MD (physician) of abnormal results. Monitor vital signs as ordered; notify MD (physician) of abnormal results. Functional mobility is expected to improve throughout the patient's stay. More or less assistance may be needed depending on progress, acute illness, time of day and/or psychosocial needs. Ensure call light is within patient's reach. Assist with ambulation or wheelchair mobility as needed. Monitor for s/s (signs and symptoms) of pain; assess pain at least every shift and PRN (as needed). Encourage patient to rest in between activities. PT (physical therapy) & OT (occupational therapy) to evaluate and treat per MD (physician) order. Staff to allow for and encourage patient choices and preferences. Staff to encourage independence/participation with ADLs (activities of daily living) as able. Falls On 2/28/23 a nurse documented: "Pt (patient) stated she slipped out of w/c (wheelchair) and hit face on carpet, noted abrasion to bridge of nose, no other visible injuries noted. Given cool washcloth for abrasion. ROM (range of motion) good and neuro checks initiated d/t (due to) unwitnessed fall and are wnl (within normal limits). Pt (patient) on scheduled hydrocodone (pain medication). Pt (patient) is assisted back into bed with call light within reach. On call DON (director of nursing) notified of fall." On 3/4/23 a nurse documented: "pt (patient) was trying to transfer from w/c (wheelchair) to recliner. Pt (patient) has BKA (below knee amputation) and thought her leg was whole. When trying to 'step' out of w/c (wheelchair), she fell on her right side. She was found sitting up on the floor and was upset that she did this. No increased pain than pt (patient) already has. Assessment negative. Neuro's (neurological assessment) started and wnl (within normal limits) so far." On 3/9/23 a nurse documented: "Pt (patient) found sitting upright against the side of the sink in the bedroom. W/C (wheelchair) was in front of the bathroom door. She stated she slid from W/C (wheelchair)."Pt (patient) assessed for injury with no injuries noted at this time. Neurological assessment in place and are WNL (within normal limits), ROM (range of motion) intact. Assisted back to bed. Bed in lowest position with call light in reach. DON (director of nursing) notified." On 3/10/23 a nurse documented: "patient found sitting on floor by her room door. Assessed for injury and no noted. Patient denied any pain or discomfort, patient very drowsy. Assisted back to bed. Neuro checks commenced per facility policy." Follow-up note revealed: "Patient found sitting on floor by the door to her room. Her w/c (wheelchair) was noted to be in the bathroom. When asked what happened she stated that she was going to the bathroom."On 3/14/23 a nurse documented: "Pt (patient's) neuro checks are completed this shift. Pt (patient) continues to self-transfer, pt (patient) is seen hopping on 1 (one) leg with transfer and did not look safe. Encouraged pt (patient) to call for assistance with transfers and/or to use a slide board to which pt (patient) refuses. Notified pt (patient) that her scheduled pain medication was decreased this eve from 5mg to 2.5mg. Pharmacy also notified." On 3/15/23 a nurse documented: "Pt (patient) found sitting upright on the fall mat next to the bed. She stated she was trying to get into the W/C from the bed."Follow-up note revealed: "Assessed for injury with none noted at this time. Assisted back to bed. Neuros initiated and are WNL (within normal limits), ROM (range of motion) intact. DON (director of nursing) notified. Call light in reach, fall mats in place and bed in lowest position." C. Resident observations and interviewResident #7 was observed on 3/15/23 between 11:00 a.m. and 2:30 p.m. She was in her room seated in her wheelchair at the table. At 11:30 a.m. the resident brought a pillow from her bed and placed it on the table. At 12:00 p.m., Resident #7 was observed sleeping at the table, with her head on a pillow. Resident #7 was interviewed on 3/15/23 at 12:01 p.m. She said she fell last night and a "couple times" before that. She said she realized she was weak and needed help, however she did not remember to use the call light. The resident's lunch meal was delivered to her room by a certified nurse aide (CNA) #2, and the tray was placed on the table. The CNA removed the pillow and placed it on the bed. At 1:15 p.m. the resident was observed sleeping with head down on the table, her lunch meal tray was pushed back. The resident said she was not hungry. At 2:25 p.m. the resident closed the door to her room. CNA #1 was asked to check on the resident. At 2:30 p.m. the CNA said the resident was trying to transfer herself from wheelchair to bed. During the observations, the staff did not offer the resident assistance to use the restroom or if she needed to rest in bed. III. Staff interviews Registered nurse (RN) #1 was interviewed on 3/15/23 at 11:42 a.m. She said Resident #7 was very impatient and frequently transferred herself from her wheelchair to the toilet and to her bed. She said the resident did not remember to use the call light. She said the resident was not aware she was an amputee and was at high risk for falls. She said she was not aware of any new fall prevention approaches except for reminding the resident to use the call light. CNA #2 was interviewed on 3/15/23 at 11:45 a.m. She said the standard was to check on each resident every two hours. She said she was not aware of Resident #7 falls. She said she reminded the resident to use her call light when she needed help. The director of therapies (DOT) was interviewed on 3/15/23 at 2:12 p.m. She said the unit nurse communicated with the therapy team about residents' falls. She said the interdisciplinary team was reviewing falls during morning stand-up meeting and appropriate approaches were discussed. She said Resident #7 refused the "do not get up on your own - call for help" signs placement in her room. She said one of the approaches to prevent falls for Resident #7 was initiating a "check light," the call light system was automatically turned on every 15 minutes to alert staff to check on the resident. The DON was interviewed on 3/15/23 at 4:30 p.m. She said she was aware of the resident's frequent falls. She said the resident did not remember she had her right lower leg amputated and tried to transfer herself to and from the toilet, and to and from bed. She said the resident did not use her call light for assistance. She said the interdisciplinary team recommended the check light. She said the resident's call light should be set to activate at every 15 minutes intervals for the staff to check on her, however this was not initiated until this afternoon.