ADARA LIVING — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

July 15, 2026

Last Inspection

S/S D/E/F Potential for harmS/S G/H Actual harmS/S J Immediate jeopardy

The most recent inspection of ADARA LIVING on record is dated July 15, 2026. Across 35 published inspections, state surveyors cited 78 deficiencies, 4 of which reached actual harm or immediate jeopardy.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status

Active

Facility Type

SNF/NF Dual Certification

Administrator

Donegan, Caitlyn Carey

Owner

BROOMFIELD SKILLED NURSING AND REHABILITATION CENTER LLC

Phone

(303) 785-5800

Payor Source

Medicare, Medicaid, Private Pay

City

BROOMFIELD

ZIP

80020-1477

Inspections & Citations

35 inspections · 78 deficiencies

7/15/2026Licensure Complaint Survey · ID 28551A-H1No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A survey with #CO3003247 was completed on 7/15/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

7/15/2026Complaint Survey · ID 285517-H1No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO3003246, #CO3094704, Incident #3025818, Incident #3025843, Incident #3025873, Incident #3025967, Incident #3025970, Incident #3025975, Incident #3064382 and Incident #3073857 was completed on 7/15/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

4/29/2026Complaint Survey · ID 230047-H1No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO2970498, Incident #2972059, Incident #2972107, Incident #2972121, Incident #2972228, Incident #2972287, Incident #2972330, Incident #2972352 & Incident #2972399 was conducted on 4/28/26 to 4/29/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

4/29/2026Licensure Complaint Survey · ID 230049-H1No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A survey with #CO2970499 was completed on 4/28/26 to 4/29/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1/29/2026Complaint Survey · ID 1E29BF-H1No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO2643736 and #CO2694768 was conducted on 1/28/26 to 1/29/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1/29/2026Licensure Complaint Survey · ID 1E29C1-H1No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A survey with complaint #CO2694770 was completed on 1/28/26 to1/29/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

12/8/2025Complaint Survey · ID 1D8E61-H12 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO2618449, #CO2629409, Incident #2621345 and Incident #2639376 was conducted on 10/7/25 to 12/8/25. Two deficiencies were cited. The actual survey exit date was 10/8/25. Per AHFSA guidance from CMS on 11/17/25, the end date was adjusted to the date the CMS-2567 was issued to the provider, on 12/8/25.

Plan of correction

The state did not require a plan of correction for this citation.

0689Free of Accident Hazards/Supervision/Devices▼

Findings

Based on observation, record review and interviews, the facility failed to prevent an accident for one (#12) of six residents out of 22 sample residents. Specifically, the facility failed to ensure certified nurse aide (CNA) #4 transferred Resident #12 appropriately, which resulted in a fall for the resident. Findings include:I. Facility policy and procedureThe Fall Risk Assessment and Management policy, revised 9/24/25, was provided by the nursing home administrator (NHA) on 10/8/25 at 3:00 p.m. The policy read in pertinent part, “The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.”II. Resident #12A. Resident statusResident #12, age 79, was admitted on 2/4/21 and re-admitted on 7/6/22. According to the October 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), wedge compression fracture of the first lumbar vertebrae, displaced fracture of the lateral malleolus of the right fibula, age-related osteoporosis, dementia with mood disturbance, left hemiplegia and diabetes mellitus type 2. The 7/18/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She required a Sara lift (mechanical lift) with two-person assistance for transfers, assistance on and off the toilet, and with clothing management, and she turned side to side in bed with staff assistance. B. Record reviewThe 8/5/25 incident report documented Resident #12 was being transferred from her bed to a wheelchair by CNA #4, who was unable to complete the transfer, which caused the resident to fall. As a result of the incident, Resident #12 sustained a 7 centimeter (cm) skin tear to the left lower leg, with active bleeding noted at the time of assessment. According to the incident report, a predisposing factor was gait imbalance, and CNA #4 was unaware that the resident needed a Hoyer lift and assistance from an extra person for transfers. The 8/8/25 recapitulation of events revealed that Resident #12 refused to be transferred with the Sara lift and requested a stand pivot transfer. CNA #4 performed the stand pivot transfer which led to the fall. The activities of daily living care plan, initiated 2/16/21, documented Resident #12 had impaired physical mobility due to left-sided hemiplegia and contracture of the left hand following a stroke. She required a Sara lift and two-person assistance for transfers and used a wheelchair for mobility. The 8/5/25 progress note, documented after the incident, revealed Resident #12 sustained an approximately 7 cm skin tear located on the anterior left lower leg with active bleeding noted at the time of assessment. The surrounding skin was thin and bruised. Resident #12 was oriented and denied pain or dizziness. The nurse on duty assessed the wound, and the staff reported the incident to the resident’s physician and family, as well as to the unit manager. III. Staff interviewsCNA #5 was interviewed on 10/7/25 at 4:22 p.m. CNA #5 said the staff were sup the resident with two people using the Hoyer lift. CNA #5 said after the fall on 8/5/25, Resident #12 got a skin tear. CNA #5 said the NHA regularly organized meetings with staff to discuss accident prevention. CNA #4 was interviewed via phone on 10/8/25 at 12:40 p.m. CNA #4 said she was a new employee and before the incident with Resident #12, a registered nurse (RN) told her that Resident #12 was a one-person assistance and was able to stand up and pivot. CNA #4 said she tried to stand-pivot Resident #12 but the resident fell. CNA #4 said after the incident, two staff members came to help, and they put the resident in bed using a Hoyer lift. She said the RN took care of the bleeding on the resident’s left leg. CNA #4 said she did not know anything about Resident #12 prior to transferring the resident and she did not take care of the resident after the incident on 8/5/25. RN #2 was interviewed on 10/8/25 at 10:05 a.m. RN #2 said she did not remember anything else about Resident #12’s fall because it happened months ago. She said nurses should communicate changes in care plans and transfer statuses to CNAs during rounds. The director of nursing (DON) was interviewed on 10/8/25 at 3:20 p.m. The DON said the best way to determine how to transfer a resident was a multidisciplinary decision between previous facilities' orders, physical therapy (PT) and nursing. The DON said that the statuses for transfers and mechanical lift assistance were in the residents’ care plans; however, CNAs did not have access to the entire care plan. She said CNAs could see what they needed to know for resident care or ask a nurse if they needed further information on a resident’s transfer status. The DON said CNA #4 transferred Resident #12 by herself because the resident refused the mechanical lift, which caused the resident to fall and sustain a skin tear. The DON said CNA #4 did not ask the nurse how to perform the resident’s transfer. The DON said she did not know that an RN told CNA #4 that Resident #1 was a one-person assist for transfers and was able to stand up and pivot. The DON said after the incident, personalized education was provided to CNA #4. The NHA was interviewed on 10/8/25 at 4:30 p.m. The NHA said CNA #4 and the RN on duty at the time of the incident received safe transfer education after the incident. The NHA said she told CNA #4 and the RN that if a resident refused to use a mechanical lift, they needed to communicate with PT because PTs were the only ones allowed to transfer residents without using a Hoyer lift if the resident required a mechanical lift.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency:Follow-up was completed with CNA (certified nurse aide) #4 who transferred resident #12 inappropriately, which resulted in a fall. CNA #4 and the nurse on duty were educated on safe transfer techniques, appropriate transfer methods and appropriate actions when a resident refuses lift transfers. Identifying Other Residents Affected:A whole-house audit was completed to verify that all residents’ transfer orders were current and accurately reflected in the EMR (electronic medical record) and on corresponding room signage. Any discrepancies were corrected immediately, and staff were notified of updated transfer statuses. Systemic Changes to Prevent Recurrence:Mandatory nursing staff training to include appropriate transfers, signage in room, resident rights, resident safety and notification of nurse/management upon resident refusal. Staff education to be completed on or before the date of compliance. Monitoring to Ensure Compliance:The Therapy Director/designee will conduct weekly observational rounds on 5 residents for 12 weeks to review transfer order, correct room signage and appropriate transfer completion and technique by floor staff. Audit to be completed on spreadsheet. Findings will be reported to the QAPI Committee monthly for three months. Any concerns identified will be corrected immediately.

0760Residents are Free of Significant Med Errors▼

Findings

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

Plan of correction

The state did not require a plan of correction for this citation.

6/23/2025Complaint Survey · ID 9UXN111 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO40253, Incident #40153 and Incident #40317 was conducted on 6/23/25. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0600Free from Abuse and NeglectS/S D2 building records▼

Findings · record 1 of 2

Based on record review and interviews, the facility failed to ensure two (#4 and #2) of three residents reviewed for abuse were kept free from sexual abuse out of five sample residents. Specifically, the facility failed to: -Protect Resident #4 from sexual abuse by Resident #3; and, -Protect Resident #2 from sexual abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse policy, dated 1/30/25, was provided by the nursing home administrator (NHA) on 6/23/25 at 4:00 p.m. It read in pertinent part, "It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. "Identifying physical or psychosocial indicators of abuse (including injuries from an unknown source), neglect, exploitation, and misappropriation of resident property from situations of verbal, mental, sexual or physical abuse. "The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have the knowledge of individual care needs. "In cases of abuse, the quality assurance committee will review the circumstances of the abuse to determine if changes in policies and procedures are necessary to provide further preventative measures." II. Incident of sexual abuse towards Resident #4 by Resident #3 on 5/2/25 A. Facility investigation The 5/2/25 facility investigation was provided by the NHA on 6/23/25 at 4:00 p.m. The investigation revealed Resident #3 grabbed Resident #4's shirt and upper chest area. The investigation revealed the NHA interviewed Resident #4 on 5/2/25 at 10:15 a.m. Resident #4 said she went to talk to Resident #3. Resident #1 said Resident #3 shook her hand and with his other hand tried to reach down her shirt. Resident #4 said Resident #3 touched her skin and grazed her breast while holding her other hand. Resident #4 said Resident #3 shook her hand with his right hand and touched her breast with his left hand. Resident #4 said she did not welcome the touch, but was alright. Resident #4 said she felt safe because the nurse saw it and stopped it right away. Resident #4 said she did not feel totally safe because she was unsure what Resident #3 was up to and she did not want him on her unit. Resident #4 said she was not in pain. The investigation documented the director of nursing (DON) interviewed certified nurse aide (CNA) #4 on 5/2/25 at 10:40 a.m. regarding the incident between Resident #3 and Resident #4. CNA #1 said around 10:00 a.m. he was walking from the dining room on the second floor. CNA #1 said he saw Resident #3 near the nurses' station with his hand out towards Resident #4. He said he then saw Resident #3's hand pull at Resident #4's shirt by the collar. CNA #1 said he told Resident #3 that he could not do that. CNA #1 said he alerted one of the three CNAs sitting at the nurses' station. CNA #1 said one of the CNAs immediately took Resident #3 back to the third floor. CNA #1 said Resident #4 told him that Resident #3 was trying to touch her. CNA #1 said when he first saw Resident #3 reaching towards Resident #4 and pulling at her shirt, Resident #4 did not appear to have any reaction. CNA #1 said he immediately reported what happened to the nurse assigned to Resident #4. The assistant nursing home administrator (ANHA) and the DON interviewed a dietary aide (DA) on 5/2/25 at 4:30 p.m. The DA said she was in the dining room taking meal orders. She said Resident #4 was by the ice machine. The DA said she started walking out of the dining room and saw Resident #3 near Resident #4 with his hand on her shirt at the top. The DA said a CNA went to Resident #4 and Resident #3 right away and separated them. The DA said the CNA told Resident #3 that he could not touch other residents. The DA said Resident #4 did not appear to be upset

Findings · record 2 of 2

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

Plan of correction

The state did not require a plan of correction for this citation.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency:Resident #3, was placed on a 1:1 and given a 30-day discharge notice. He was successfully discharged to a more appropriate facility/setting. Resident #4 and #2, were followed by SS (social services) and offered psychosocial/behavior health support. Identifying Other Residents Affected:Residents living in the facility were interviewed to ensure no incidents of sexual or physical abuse have occurred or have reports of potential concerns. Social Services will audit care plans to ensure they include appropriate interventions for managing any sexual behaviorsThe audit will be completed before the compliance date 7/29/25 of to confirm that interventions align with best practices. Systemic Changes to Prevent Recurrence:Mandatory staff education on the residents' right to be free from physical and sexual abuse will be provided by the Abuse Coordinator / designee on or before the date of compliance. Education to include identifying signs of sexual inappropriateness that could lead to abuse or incidents and to be completed on or before the date of compliance of 7/29/25. Monitoring to Ensure Compliance:Any identified sexually inappropriate behaviors will be discussed at clinical meetings five days a week for 12 weeks on behavior tracking form. Findings will be reported to the QAPI Committee monthly for three months. Areas of concern identified, will be corrected upon discovery.

5/14/2025Complaint Survey · ID U90911No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO39769 was conducted on 5/14/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

3/31/2025Revisit: Recertification Survey · ID DBHI22No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required. A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required. A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

Plan of correction

The state did not require a plan of correction for this citation.

3/17/2025Complaint Survey · ID UKIY11No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A survey for Incident #CO39327 was conducted on 3/17/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

2/27/2025Revisit: Complaint, Recertification Survey · ID DBHI12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 2/27/25 for all previous deficiencies cited on 1/16/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

2/4/2025Recertification Survey · ID DBHI2112 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

INITIAL COMMENTS (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 4, 2025, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a three (3) story, Type II (111) protected, non-combustible construction with no basement. The suspended grid ceiling provides one hour of rated protection to the building structure and must remain intact. This original facility was constructed in 2002. The 2005 & 2008 additions are both one (1) story, Type II (111) protected non-combustible construction and are not separated from the original building by fire-rated construction. The facility is licensed for 210 beds, and the census on the survey date was 161. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The wet-pipe system protects all interior levels. There is a non-combustible limited access attic space in both the 2005 & 2008 additions that are not protected by automatic fire sprinklers. The facility is classified as fully-sprinklered.

Plan of correction

The state did not require a plan of correction for this citation.

0291Emergency LightingS/S F▼

Findings

Based on observation and staff interviews during the record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101. The deficient practice affected all smoke compartments. 1. Emergency lighting: no annual 90-minute inspection report available for review 2. Emergency lighting missing February 30-minute inspection report available for reviewNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The deficient practice could affect all smoke zones, 161 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Functional testing of emergency lighting system will be completed before substantial compliance date for both the 30 seconds and 90 minute required tests and documented to ensure compliance. Identifying Other Residents Affected: Facility wide audit of all emergency lighting will be completed by Maintenance director/designee by date of substantial compliance to ensure all were in good working order. Systemic Changes to Prevent Recurrence: Maintenance director/designee will be educated by date of substantial compliance on regulatory compliance of emergency lighting system testing to be completed monthly and annually. Monthly and annual checks to be entered into TELS system to be tracked and monitored regularly Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0293Exit SignageS/S F▼

Findings

Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. The deficient practice affected all smoke compartments. 1. There is no exit sign on the patio. 2. No Exit sign testing at the time of inspection. 3. 3 floor, but supply needs the north side of the exit sign blanked off 4. Dining shall remove the exit sign on the 3rd floor. Not an exitNFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 4.5.3.3 Awareness of Egress System. Every exit shall be clearly visible, or the route to reach every exit shall be conspicuously indicated. Each means of egress, in its entirety, shall be arranged or marked so that the way to a place of safety is indicated in a clear manner. NFPA 101, 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. The deficient practice could affect all smoke zones, 161 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency were completed on 2/16/25: Exit sign placed on fence in patio area Exit sign testing completed 3rd floor exit sign blanked off for appropriate direction of egress Exit sign removed from 3rd floor dining room Identifying Other Residents Affected: Maintenance director/designee completed full building audit on 2/14/25 and test of exit signs, no other areas of concern identified. Systemic Changes to Prevent Recurrence: Maintenance director will be educated by ANHA/ designee by date of substantial compliance on regulatory compliance of functional testing to be conducted monthly Exit signs to be included in TELS system to ensure regulatory compliance and continued tracking and monitoring Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0321Hazardous Areas - EnclosureS/S F▼

Findings

Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain hazard areas in accordance with NFPA 101, 99, and 58. The deficient practice affected all smoke compartments. 1. The supply room is missing ceiling tile and whole in the firewall2. MOD office missing ceiling tiles 3. The dish room on the second floor is missing ceiling tiles 4. Propane storage in an appropriate area 5. Laundry floor chute second 2 fire foam needs to be replaced with fire resistive system 6 . Management office 2-second floor whole in ceiling tile 7. No annual fire door report at the time of inspection. 8. Laundry chute 3rd floor fire door not attached 9. The fire door by the memory care dining doesn ' t latch 10. The memory care entrance fire door doesn ' t latchNFPA 588.4 Storage Outside of Buildings. 8.4.1* Location of Storage Outside of buildings. 8.4.1.1 Storage outside of building for cylinders awaiting use or resale or that are part of a cylinder exchange point shall be located as follows:At least 5 ft (1.5 m) from any doorway or opening in a building frequented by the public way where occupants have at least two means of egress defined by NFPA 101, Life safety codeAt least 10 ft (3m) from any doorway or opening in a building or section of a building that has only one means of egress8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3Protecting the area with automatic extinguishing systems in accordance with Section 9.7Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 4319.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B.NFPA 101 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code5.2.3 Functional Testing. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of doorbeing subject to testing5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting. NFPA 80 5.2* Inspections. 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.The deficient practice could affect all smoke zones, 161 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: - All identified ceiling tiles in the statement of deficiencies were replaced by Maintenance assistant on 2/15/25 - Propane stored in appropriate area on 2/16/25 - Fire service contractor contacted to obtain report of fire door inspection on 2/6/25. - Laundry chute contractor contacted on 2/6/25 to re-attach door to laundry chute on 3rd floor. - Fire doors fixed to latch on 2/6/25 by maintenance director. Identifying Other Residents Affected: An audit was conducted by the Maintenance director / Designee on 2/6/25 with no further areas of deficiency found. Systemic Changes to Prevent Recurrence: Maintenance director/designee will audit full building once a month to identify areas requiring replacement of ceiling tiles Maintenance director/designee will audit all fire doors in the building once a month to ensure proper latching/closing of fire door Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0324Cooking FacilitiesS/S F▼

Findings

Based on observation, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. The deficient practice affected all smoke compartments. No Semi-Annual Hood Inspection reports available for review NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months. 11.4* Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction and in accordance with Table 11.4. 11.4 Table Systems serving moderate-volume cooking operations SemiannuallyThe deficient practice could affect all smoke zones, 161 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Fire protection Service Company provided semi-annual hood inspection report, which showed compliance. Identifying Other Residents Affected: There are no other kitchen hoods in the facility Systemic Changes to Prevent Recurrence: Maintenance director/designee will collaborate with the fire prevention service company to obtain records once work has been completed. Maintenance director/designee will enter report into TELS system to ensure regulatory compliance of inspections and repairs Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0345Fire Alarm System - Testing and MaintenanceS/S F▼

Findings

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. The deficient practice affected all smoke compartments. 1. Missing two (2) year smoke detector sensitivity report. 2. Missing semi-annual report 3. Medical room 3 floor missing strobe capped off wires exposed 4. Magnet door hold not hooked up to fire alarm The door was held open with magnets not hooked up to fire alarm rm 333, 332, beauty salon, Memory care all rooms 5. Removed alarm device exposed wires storage second-floor storage NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72. NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:(1) Calibrated test method(2) Manufacturer's calibrated sensitivity test instrument(3) Listed control equipment arranged for the purpose(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range(5) Other calibrated sensitivity test methods approved by the authority having jurisdictionNFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes21.8.4 Magnetic door holders that allow doors to close upon loss of operating power shall not be required to have a secondary power source. The deficient practice could affect all smoke zones, 161 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Fire protection company contacted provided documentation, for two-year smoke detector sensitivity report and missing semiannual report. Magnet door holders removed from rooms 333, 332, beauty salon, and all memory care rooms on 2/17/25 Exposed wires in medication room 3rd floor and 2nd floor storage have been covered on 2/16/25 Identifying Other Residents Affected: A facility wide audit will be completed by maintenance director/ designee by date of substantial compliance to ensure there were no obstructions, no areas of concern were identified Systemic Changes to Prevent Recurrence: Maintenance director/designee will conduct monthly audits of facility to ensure fire alarm system components and devices are in place and have no obstructions Maintenance director/ designee will collaborate with fire protection company to obtain reports timely at time of service Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0355Portable Fire ExtinguishersS/S D▼

Findings

Based on observations and a review of records, it was determined that the facility did not maintain fire extinguishers in accordance with NFPA 10. The deficient practice affected 1 of 6 smoke compartments1. K class hydro due to no sign2. ABC kitchen due 6 year 3. No monthly inspection was done in the kitchen and maintenance shop. Inspection card blankLife Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers6.6 Installations for Class K Hazards. 6.6.1 Class K fire extinguishers shall be provided for hazards where there is a potential for fires involving combustible cooking media (vegetable or animal oils and fats). 6.6.2 Maximum travel distance shall not exceed 30 ft (9.15 m) from the hazard to the extinguishers. 6.6.3 All solid fuel cooking appliances (whether or not under a hood) with fire boxes of 5 ft3 (0.14 m3) volume or less shall have at least a listed 2-A rated water-type fire extinguisher or a 1.6 gal (6 L) wet chemical fire extinguisher that is listed for Class K fires. The deficient practice could affect all smoke zones, 25 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Fire protection contractor will replace fire extinguishers kitchen by substantial date of compliance, K Class hyrdo and ABC kitchen. A time limited waiver will be requested to ensure that fire extinguishers identified in statement of deficiencies can be remedied. Monthly inspection of kitchen and maintenance shop completed by maintenance assistant on 2/16/25, with no further deficiencies noted. Identifying Other Residents Affected: Maintenance director/designee to audit all fire extinguishers in facility to ensure that the fire extinguishers are maintained in accordance with regulatory requirements. Audit completed by date of substantial compliance, no other deficient fire extinguishers noted. Systemic Changes to Prevent Recurrence: Maintenance director/designee will enter report into TELS system to ensure regulatory compliance of inspections of fire extinguishers to be tracked and monitored regularly Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0363Corridor - DoorsS/S E▼

Findings

Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. The deficient practice affected 4 of 6 smoke compartments 1. Rm#130 door not latching all the way 2. Rm #362 door not latching 3. Rm#234 door not latching 4. Rm#243 door not closing all the way 5. Rm#341 door hardware falling off doors doesn ' t latch properly 6. The fire door by rm 347 doesn ' t latch 7. Rm #344 door not latching NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. The deficient practice could affect all smoke zones, 100 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: - Resident rooms doors for #130, #234, #243, #344, #362 were adjusted accordingly on 2/5/25 and now latch. Fire door by resident room #347 was adjusted on 2/5/25 and now latches. Identifying Other Residents Affected: Maintenance director/designee will audit building by date of substantial compliance to ensure all doors close and latch properly Systemic Changes to Prevent Recurrence: Maintenance director/designee will incorporate door monitoring within TELS system for preventative maintenance to ensure regulatory tracking and monitoring Monitoring to Ensure Compliance: Maintenance director/designee will audit 10 rooms a month to ensure proper closure and latching when door is closed. The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0511Utilities - Gas and ElectricS/S E▼

Findings

Based on observation and staff interviews, it was determined that the facility failed to maintain wiring in accordance with NFPA 99 and NFPA 70. The deficient practice affected 4 of 6 smoke compartments1.331 broken outlet cover behind a bed 2. Exposed wires above the door in 3 dining memory care 3. Activities office broken outlet cover by fridges exposed wires above the door 4. Maintenance room outlet cover 5. Dishroom second-floor fire alarm j boxes openNFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. The deficient practice could affect all smoke zones, 100 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency was completed for the following on 2/15/25: 1.331 broken outlet cover behind a bed. 2. Exposed wires above the door in 3rd dining memory care 3. Activities office broken outlet cover by fridges exposed wires above the door 4. Maintenance room outlet cover 5. Dish room second-floor fire alarm j boxes open Identifying Other Residents Affected: Maintenance director/designee conducted a facility wide audit by date of substantial compliance to identify other areas of exposed wires. Deficient areas were fixed when identified. Systemic Changes to Prevent Recurrence: Maintenance director/designee will complete monthly audit of different unit each month for exposed wires and broken outlet covers and fix upon discovery. Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0541Rubbish Chutes, Incinerators, and Laundry ChuS/S E▼

Findings

Through observation during the survey, it was determined that the facility failed to meet the rubbish chutes, incinerators, and laundry chute requirements in accordance with NFPA 101. The deficient practice affected 3 of 6 smoke compartmentsTrash Chute - No Inspection report available NFPA 82 (2009) 10.2.2 Waste and linen chutes and transport systems including chute loading and discharge doors shall be inspected and maintained not less than annually in accordance with manufacturers' instructions. Life Safety Code Section 19.5.4.1 Existing 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. NFPA 101 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 80 Section 15.1.3 Door assemblies shall be installed in accordance with their listing. NFPA 80 Section 5.2.14.1 Self-closing devices shall be kept in working condition at all times. The deficient practice could affect all smoke zones, 75 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Inspection of trash chute report requested from contractor on 2/6/25. Contractor will be completing work by substantial compliance date. Identifying Other Residents Affected: Facility wide audit completed by Maintenance assistant on 2/6/25 to ensure laundry chutes are compliant with regulatory requirements Systemic Changes to Prevent Recurrence: Maintenance director/designee will collaborate with company to obtain reports timely at time of service Annual inspection of laundry chutes will be incorporated into TELS system to be monitored and tracked regularly Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0712Fire DrillsS/S F▼

Findings

Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6. The deficient practice affected all smoke compartments. 1. Missing January and February drills 2. Fire drills closer than an hour apart, not at varied timesNFPA 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. The deficient practice could affect all smoke zones, 161 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: fire drill was conducted on 2/17/25 at 3 pm to ensure facility completed fire drills at varying times greater than an hour apart. Identifying Other Residents Affected: Maintenance Director / designee will conduct fire drills at unexpected times greater than an hour apart under varying conditions, at least quarterly Systemic Changes to Prevent Recurrence: Maintenance director will be educated by ANHA/ designee by date of substantial compliance on requirements of fire drill per regulations to familiarize all facility personnel of signals and emergency action required under varied conditions Monthly fire drills to be entered into TELS system to be tracked and monitored regularly Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0907Gas and Vacuum Piped Systems - Maintenance PrS/S D▼

Findings

Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. The deficient practice affected 1 of 6 smoke compartments 1. Rm 348 has 2 concentrators11.7.4.2 One liquid oxygen portable container [limited to 1.5 L (0.396 gal) capacity] per patient is permitted to be stored or used in a patient bed location or patient care room without having to meet the fire separation requirements of 11.7.4.1. The deficient practice could affect all smoke zones, 25 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Removal of both concentrators was completed by respiratory company on 2/5/25. Identifying Other Residents Affected: Complete building audit was conducted by Maintenance Director / designee on 2/5/25 to ensure oxygen storage is in accordance with regulatory requirements. No other areas identified at time of audit. Systemic Changes to Prevent Recurrence: Education to staff regarding oxygen storage regulatory requirements was conducted by ANHA on or before compliance date. Monitoring to Ensure Compliance: Maintenance director/designee will conduct monthly audits of resident rooms to ensure proper oxygen storage The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

0914Electrical Systems - Maintenance and TestingS/S F▼

Findings

Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). The deficient practice affected all smoke compartments. No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). The deficient practice could affect all smoke zones, 161 of 161 residents, and an indeterminable number of staff and visitors. Deficient items were discussed with the administrator at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Polarity and retention for outlets testing was completed for full building on 2/16/25. Identifying Other Residents Affected: All residents could be affected. Polarity and retention for outlets testing completed for full building by maintenance assistant on 2/16/25. Systemic Changes to Prevent Recurrence: Testing will be completed annually by Maintenance Director / designee. education provided to maintenance director on regulatory requirements by ANHA / Designee by date of compliance. Findings and work order for polarity and retention testing to be entered into TELS system by Maintenance Director / designee. Monitoring to Ensure Compliance: The administrator/designee will report findings from audit to QA for three months to assess effectiveness and identify if further monitoring is required.

1/16/2025Complaint, Recertification Survey · ID DBHI1111 deficiencies▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A recertification survey with complaint #CO36740 and Incident #38939, Incident #38982 and Incident #39940 was completed on 1/13/25 to 1/16/25. Eleven deficiencies were cited.

Findings · record 2 of 2

An Emergency Preparedness survey was conducted from 1/13/25 to 1/16/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0550Resident Rights/Exercise of RightsS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure care for residents in a manager and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one of four residents out of 53 sample residents reviewed for respect and dignity. Specifically, the facility failed to ensure a resident was provided privacy while using the restroom. Findings include:I. Resident statusResident #7, age greater than 65, was admitted on 9/27/19. According to the January 2025 computerized physician orders (CPO), diagnoses included schizophrenia, post traumatic stress disorder (PTSD) and history of falls. The 12/10/24 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. He was dependent on total assistance from staff for toileting hygiene, transfers, and lower body dressing. He needed substantial to maximal assistance with bed mobility and bathing, and needed set up help only with eating, oral and personal hygiene. II. Record reviewResident #7's activities of daily living (ADL) care plan documented Resident #7 haD an ADL self-care performance deficit due to impaired balance, muscle weakness, decreased endurance, poor trunk control, cognitive impairments and decreased motivation to perform tasks. Pertinent interventions included Resident #7 needed assistance from two people for transferring. Resident #7 had incontinent episodes of bowel and bladder and required assistance with incontinence care and clothing management after an episode. Resident #7 transferred onto the toilet for bowel movements occasionally. III. ObservationsOn 1/14/25 at 5:15 p.m. Resident #7 was sitting on the toilet in his room. The door to Resident #7's room and bathroom were both open, and the bathroom was immediately to the left of the room entrance. The bathroom door was opened at an angle so Resident #7 was visible from the hallway. Resident #7 was seated on the toilet, his pants were around his legs and he was holding a grab bar on the wall of the bathroom. Resident #7 grunted loudly twice and then yelled' here it comes' while seated on the toilet. An unidentified certified nurse aide (CNA) walked past Resident #7's room while Resident #7 was on the toilet with the door open, looked at the doors and continued to walk down the hallway. The unidentified CNA did not check on the resident or close the door to the room while the resident was using the restroom and was exposed to the facility hallway. Immediately after the unidentified CNA passed Resident #7's room, CNA #4 exited Resident #7's room with a clear bag of trash in her hand while Resident #7 was still in the bathroom and exposed to the facility hallway. She did not close the door to Resident #7's room, walked across the hallway and placed the clear trash bag inside a refuse container. CNA #4 walked back toward Resident #7's room and closed the door to the room. IV. Staff interviewsCNA #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said if a resident was able to independently sit in the bathroom without assistance either the bathroom door or room door should be closed for privacy. CNA #5 said she was trained to ensure the residents' room doors were closed for privacy unless the resident was claustrophobic and needed the door open. CNA #5 said if a resident needed the door open, the resident should still be shielded for privacy. CNA #4 was interviewed on 1/16/25 at 2:15 p.m. CNA #4 said she thought she was in Resident #7's room with his roommate on 1/15/25. CNA #4 said sometimes Resident #7 did use the bathroom himself with the bathroom door open so he could call someone when he needed help. CNA #4 said if a resident wanted the bathroom door open while they used the bathroom then the door to the resident's room should be closed or the resident should be provided another form of privacy. The director of nursing (DON) was interviewed on 1/16/25 at 10:15 a.m. The DON said Resident #7 was fine with his bathroom door open unless his roommate's family or visitors were in the room and then he would want the door closed.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Follow-up was completed for Resident #7 on 1/15/24 to ensure no further incidents involving privacy violations occurred. Additionally, the resident was educated on their right to privacy during toileting and personal care. Identifying Other Residents Affected: Each resident/family received a copy of their Resident Rights, along with contact information for the State Ombudsman, the Colorado Department of Public Health, and the NHA (nursing home administrator)/DON (director of nursing). Systemic Changes to Prevent Recurrence: Mandatory staff education on resident rights and dignity/privacy during activities of daily living (ADLs) and personal care will be completed on or before the compliance date. Monitoring to Ensure Compliance: The interdisciplinary team will conduct weekly rounds on assigned units, engaging with five residents to address concerns related to resident rights, dignity, and, if needed, assistance in contacting the ombudsman. This will be documented on an audit tool spreadsheet. Audit will take place weekly for 12 weeks. The NHA or designee will report findings and results to the QAPI committee monthly for three months or until substantial compliance is achieved. Areas of concern identified, will be corrected upon discovery.

0561Self-DeterminationS/S D▼

Findings

Based on observations, record review, and interviews, the facility failed to honor a resident's choice for laundry services, for one (#113) out of 33 residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #113's laundry was consistently saved and stored for his wife to launder due to his multiple allergies. Findings include:I. Facility policy and procedureThe facility's Promoting/Maintaining Resident Self-Determination policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 10:53 a.m. It read in pertinent part, "It is the practice of this facility to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. "Policy compliance guidelines included: -All staff members involved in providing care to residents will promote and facilitate resident self-determination;-Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident;-All aspects of care and services will be discussed in the care plan meeting and documented as such;-The care plan will reflect resident choices when applicable; and,-The facility will accommodate the resident's preferences to the extent possible and as agreed upon by the resident's sponsor and physician." II. Resident #113A. Resident statusResident #113, age greater than 65, was admitted on 8/26/22. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral/psychotic/mood disturbance and anxiety, post-traumatic stress disorder (PTSD) and gout (a type of arthritis). The 11/11/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of two out of 15. He was independent with bed mobility, transfers and locomotion. He required partial assistance with oral/toileting hygiene and showering, and supervision with dressing. B. Resident representative interview and observationsResident #113's representative was interviewed on 1/13/25 at 2:28 p.m. The representative said a bunch of Resident #113's clothes were previously missing and she was working with one of the facility's social workers regarding the issue. She said Resident #113 was previously exposed to Agent Orange (tactical herbicide) which caused him to develop a lot of allergies. The representative said Resident #113 had gotten rashes in the past if the wrong soap or laundry detergent was used. She said she had requested Resident #113's dirty laundry to be stored and saved for her to launder due to his allergy to most commercial laundry products. She said there was a lot of turnover with the nurses and the certified nurse aides (CNA) in the facility, so she felt like she had to micromanage his care. She said she did not understand why it was so difficult for the facility's staff to ensure his laundry was in his closet for her to collect. There was a sign taped to Resident #113's bathroom door stating he was allergic to aloe and to only use the shampoo that was in his closet. Another laminated sign was taped to Resident #113's closet door stating his wife wanted to do his laundry and facility staff should store his dirty laundry in the laundry basket inside the closet. A laundry basket was inside his closet. C. Record reviewA grievance form, dated 12/23/24, revealed Resident #113's wife reported the resident was missing pants, pajama pants and multiple shirts. She reported often finding other resident's clothing in Resident #113's room and not his clothing. An investigation was conducted by a facility administrator on 12/23/24, and five pairs of pants and five shirts were found in his closet. The administrator left a voicemail for Resident #113's wife on 12/27/24. The facility administrator reported his clothes were located in the facility laundry and other resident's clothing were removed from Resident #113's room. A review of Resident #113's electronic medical record (EMR) documented he had allergies to hydrocodone (pain medication), valproic acid (seizure medication, penicillins (antibiotics), milk and milk products, pork, aloe, corn and lavender. A skin integrity care plan, initiated on 9/7/22 and revised on 8/6/24, revealed Resident #113 was at risk for impaired skin integrity due to anticoagulant (blood thinner) use. He had fragile skin and poor safety awareness. Interventions included encouraging good nutrition and hydration to promote healthier skin, assessing his risk of skin breakdown quarterly and as needed, and completing skin assessments weekly. -Review of Resident #113's EMR did not reveal documentation addressing his allergies, skin issues with topical products and detergents, or laundry preferences. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 1/16/25 at 9:34 a.m. CNA #1 said Resident #113's wife did his laundry. She said he was frequently incontinent and would sometimes go through all of his clean clothes, so his clothes would be sent to the facility's laundry room. She said the laundry department was aware of Resident #113's allergies and did his laundry different from the other residents. Licensed practical nurse (LPN) #2 was interviewed on 1/16/25 at 9:48 a.m. LPN #2 said Resident #113's wife did his laundry. She said his wife did allow the facility to do his laundry when she was sick, but otherwise she wanted to primarily do it. She said she would ask Resident #113's wife to bring additional clothing in for him due to his incontinence. The director of nursing (DON) was interviewed on 1/16/25 at 1:51 p.m. The DON said if a resident's family asked to do their laundry, the facility had signs posted for staff to place on their closet and laundry bins they could put inside the closet. She said it was important to follow a resident's request because it was their right and the facility should honor their preferences, especially if they affect their health. The DON was interviewed again on 1/16/25 at approximately 5:45 p.m.. The DON said the facility had begun providing education with the facility's staff to discuss the resident's laundry and laundry preferences.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: The room signage and setup for Resident #113 were reviewed to ensure clear signage and a designated laundry basket were in place. Education on 1/31/25 was provided to floor staff regarding resident and family preferences by unit manager/social worker. Identifying Other Residents Affected:A facility-wide audit was completed on 1/31/25 to identify residents with self-laundry preferences. Systemic Changes to Prevent Recurrence: Education provided by SDC (staff development coordinator)/designee on Promoting / Maintaining Resident Self-Determination policy and updated signage will be provided to staff on or before the compliance date. Monitoring to Ensure Compliance: Social services will meet/call resident/representative/families who prefer to self-launder clothes 1x month for 6 months to ensure family/resident laundry preferences are being upheld. Results will be documented on an audit tool spreadsheet. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 6 months. Areas of concern identified, will be corrected upon discovery.

0600Free from Abuse and NeglectS/S E▼

Findings

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Residents #98, #16, #106, #127, #116, and #67 remain at the facility and are currently at their cognitive baselines. Social Services assessed resident behavior by 2/15/25 to ensure there were no concerns r/t (related to) alleged deficient practice. Care plans for all identified residents were reviewed by IDT to ensure accurate and appropriate interventions in place. Identifying Other Residents Affected: Residents living with dementia have the potential to have behavioral changes due to the cognitive changes predicted of Alzheimer’s or dementia. It is the goal of the facility to keep this population free from any form of abuse. Social services will continue to look for and address any noted changes in these residents’ behavior; if a change is noted, the physician will be notified for guidance and oversight of said changes. An audit will be conducted prior to the date of compliance by the social services department/designee. The audit will identify residents with the diagnosis of Alzheimer's or dementia and ensure they have effective care plans that assisted in the facility's ability to monitor and redirect residents with aggressive-like behaviors. Systemic Changes to Prevent Recurrence: Mandatory staff education on the residents' right to be free from physical abuse will be provided by the Abuse Coordinator / designee on or before the date of compliance. Abuse coordinator and or anyone involved with abuse investigations will be educated by nurse consultant/LCSW (licensed social worker) consultant on when abuse is substantiated vs. unsubstantiated, willful vs intentional etc. by 2/19/25. Monitoring to Ensure Compliance: The Psychopharmacological Committee will review any residents experiencing behavioral changes monthly to determine whether medication adjustments are needed x 6 months on behavior tracking summary form. Any identified markers will be discussed at clinical meetings five days a week for 12 weeks on behavior tracking form. Findings will be reported to the QAPI Committee monthly for three months. Areas of concern identified, will be corrected upon discovery. Abuse investigations will be monitored by the abuse coordinator to ensure they are appropriately designated (substantiated/unsubstituted) prior to final report being submitted.

0641Accuracy of AssessmentsS/S D▼

Findings

Based on observations, record review and interviews the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the residents'status based on the criteria outlined in the resident assessment instrument (RAI) for one (#83) of 18 residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #83's MDS accurately indicated the resident was receiving hospice services. Findings include:I. Facility policy and procedureThe Documentation of Medical Record policy and procedure, undated, was received from the nursing home administrator (NHA) on 1/16/25 at 1:47 p.m. It revealed in pertinent part, "Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy."II. Resident #83A. Resident statusResident #83, age 66, was admitted on 4/6/22. According to the January 2025 computerized physician's orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. The 11/26/24 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. She was dependent with toileting, personal hygiene, bed mobility and required set up assistance with eating. The assessment indicated Resident #83 was receiving hospice care.-However, review of Resident #83's EMR did not reveal the resident was receiving hospice services (see record review below). B. Record reviewA comprehensive review of the EMR failed to reveal a physician's order for hospice, progress notes of hospice services or care planned interventions of hospice services being provided. III. Staff interviewThe NHA was interviewed by email communication on 1/15/25 at 1:20 p.m. She said the hospice services coded for Resident #83 on the MDS assessment was incorrect and would be corrected. The minimum data set coordinator (MDSC) was interviewed on 1/16/25 at 2:15 p.m. The MDSC said she was responsible for completing the MDS assessments for the residents. The MDSC said she would assess a resident in their room and speak with staff about resident cares to complete the MDS assessment. The MDSC said she double checked the MDS assessment and read through alerts at the end prior to signing it. The MDSC said alerts could come from a new change on the MDS assessment that was different from the previous MDS assessment if it was available. She said if an alert came up, she could change the response at that time. The MSDC said the MDS assessment could be modified at any time if an error was found. The MDSC said Resident #83 was not on hospice services and that was coded in error. The MDSC said that the MDS assessment for Resident #83 had been corrected when it was brought to her attention (during the survey). The MDSC said she planned to slow down when reading through the alerts in the future to ensure that MDS assessments were coded correctly.

Plan of correction · submitted by the facility

How the corrective action will be accomplished for those issues identified by the alleged deficient practice?A chart review was completed by MDS Coordinator for resident #83 on 1/16/25 to ensure the identified errors were corrected and submitted. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?MDS Coordinator / designee completed an audit of residents on hospice on 1/20/25 to ensure correct coding and a reset was completed on the to determine if there were any incorrectly coded MDS assessments. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?PCC (Point Click Care) Assessment Validation tool engaged to alert staff completing MDS of any warnings, discrepancies and triggers and education provided to staff completing MDS assessments on accuracy of coding and Assessment Validation tool usage to be completed on or before the date of compliance. Education will be provided by NHA/DON to both MDS coordinators, on or before the date of compliance, regarding the importance of accurate and complete assessments as well as use of the PCC Assessment Validation Tool on or before the date of compliance. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?MDS coordinator/designee to audit accuracy of hospice coding biweekly for 12 weeks and 5 complete MDS assessments will be audited monthly for 6 months to ensure coding accuracy of each assessment. This will be documented on an audit tool spreadsheet. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 and 6 months respectively to ensure compliance and sustainability. Areas of concern identified, will be corrected upon discovery.

0695Respiratory/Tracheostomy Care and SuctioningS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure two (#45 and and #95) of five residents who required respiratory care received the care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to:-Implement a routine cleaning schedule for the care of Resident #45's continuous positive airway pressure (CPAP) machine;-Ensure a care plan was in place and implemented for Resident #45's CPAP machine to include route of administration, oxygen supplementation, storage, cleaning and machine settings; and,-Ensure a functional continuous positive airway pressure (CPAP) machine was available, cleansed, stored, and maintained for Resident #45 and Resident #95. Findings include:I. Professional referenceThe Legionella Toolkit (12/26/24) retrieved on 1/22/25 from the Centers for Disease Control (CDC) https://www.cdc.gov/control-legionella/php/toolkit/control-toolkit.html. It read in pertinent part, "In the absence of control, Legionella can grow in almost any system or equipment containing non sterile water, such as tap water, at temperatures favorable to Legionella growth. Devices that may grow Legionella in the absence of control include the following: dental and medical equipment such as scalers, CPAP, bronchoscopes, and heater-cooler units. Dental and medical equipment should be cleaned regularly per manufacturer recommendations and use distilled water in respiratory equipment such as CPAP machines, heater-cooler units, and bronchoscopes (page 8)."II. Facility policy and procedureThe CPAP policy, revised November 2021, was provided by the nursing home administrator (NHA) on 1/16/25 at 1:47 p.m. The policy read in pertinent part, "A CPAP or BiPAP's purpose is to improve oxygenation, assist in reducing pulmonary edema, decrease the work of breathing and for use with residents who do not require assistance in maintaining adequate minute volume."Cleaning the CPAP and BiPAP machines: wash the mask daily in fragrance-free soap, mild and warm water or with designated sanitation wipes, then rinse in warm water and air dry. The frame of the mask should be cleaned weekly in warm soapy water or with a designated sanitation wipe. The CPAP/BiPAP humidifier uses distilled water only and should be emptied and refilled daily. The humidification chamber should be washed daily using mild soap and warm water and air dried."III. Resident #45A. Resident statusResident #45, age greater than 65, was admitted on 10/13/22. According to the January 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes, chronic respiratory failure with hypoxia, chronic kidney disease stage 2 and dependence on supplemental oxygen. The 12/3/24 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. The resident was dependent on assistance with transfers and bed mobility and needed substantial assistance with bathing. He needed set up help with upper body dressing and oral hygiene and was independent at meal time. The MDS assessment documented the resident used a non-invasive mechanical ventilator. B. Resident interview and observationResident #45 was interviewed on 1/13/25 at 11:05 a.m. Resident #45 said his CPAP machine did not get cleaned at the facility and he used his CPAP every night. Resident #45 said he cleaned his own CPAP machine himself. Resident #45's CPAP mask and tubing were on his nightstand during the interview on 1/13/25. C. Record reviewA review of Resident #45's January 2025 CPO revealed a physician's order to apply the CPAP at bedtime for sleep with two liters of oxygen bled in, one time a day starting 4/23/23. A review of Resident #45's care plan documented he had altered respiratory status and difficulty breathing related to sleep apnea and had coronary heart failure. Pertinent interventions included the use of the CPAP machine as ordered. -However, further review of the resident's electronic medical record (EMR) revealed Resident #45 did not have a physician's order that included the storage of the machine and/or settings of the device. Additionally, review of the resident's EMR revealed Resident #45 did not have a physician's order for cleaning his CPAP machine.-The use of a CPAP machine was not on Resident #45's care plan as an active problem area, and the care plan did not have goals and interventions listed for the CPAP machine, to include route of administration, frequency, oxygen supplementation, storage and/or settings and a cleaning schedule. IV. Resident #95A. Resident statusResident #95, age greater than 65, was admitted on 12/10/22 and readmitted on 3/12/24. According to the January 2025 CPO, diagnoses included obstructive sleep apnea (OSA), primary pulmonary hypertension (high lung pressure) and chronic obstructive pulmonary disease (COPD). The 12/3/24 MDS assessment revealed the resident was cognitively intact with a BIMSscore of 15 out of 15. She required partial assistance with bed mobility. She was dependent on staff for toileting hygiene, lower body dressing, applying/removing footwear, transfers, and locomotion. The assessment indicated the resident used a non-invasive mechanical ventilator. B. ObservationsOn 1/13/25 at 10:26 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor. On 1/14/25 at 9:39 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor with a floor fan on top of the mask's two straps. On 1/15/25 at 8:10 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor with a floor fan on top of one of the mask's straps. On 1/16/25 at 10:38 a.m. Resident 95's CPAP mask was stored in a plastic bag hanging on the resident's bed rail. C. Resident interviewsResident #95 was interviewed on 1/15/25 at 8:10 a.m. Resident #95 said she had not used her CPAP machine in two to three years. She said her CPAP machine was not functional and the power cord had been lost when she moved to a different room in the facility. She said the unit manager (UM) ordered a new power cord one month ago (December 2024) and she was still waiting for it to arrive. Resident #95 was interviewed on 1/15/25 at 9:05 a.m. Resident #95 said her CPAP mask and machine had not been cleaned since she moved in. Resident #95 was interviewed a second time on 1/16/25 at 10:38 a.m. Resident #95 said she contacted her service provider about the power cord for her CPAP machine and she was told they would provide an update at her next appointment. She said she did not use her CPAP machine the previous night (1/15/25) and she thought the UM stored it in a bag on 1/15/25 after he was looking at her machine. D. Record reviewA physician's order, dated 11/12/24, revealed staff should cleanse Resident #95's CPAP every night with provided cleansing wipes. A physician's order, dated 10/25/24, revealed staff should bleed in two liters of oxygen, then assist Resident #95 with her CPAP machine at bedtime for OSA.The respiratory care plan, initiated on 6/27/23 and revised on 11/4/24, revealed Resident #95 was at risk of respiratory distress due to COPD and OSA. It documented Resident #95 had a CPAP machine and often declined to use it. Interventions included a mask fitting, on 11/5/24, to promote CPAP compliance, administering medications/inhalers as ordered, cleansing and sanitizing Resident #95's CPAP machine with CPAP wipes as directed and monitoring for signs and symptoms of respiratory distress. A nurse progress note, dated 11/5/24 at 4:22 p.m., revealed Resident #95's provider was notified she was not using her CPAP machine due to mask fit. It documented a new mask was on order and should come soon. -Review of Resident #95's EMR failed to reveal documentation to indicate the facility had addressed the resident's non-functional CPAP machine or what interventions were put in place to repair/replace it. V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 1/15/25 at 9:42 a.m. RN #1 said the night nurse was responsible for cleaning and storing the CPAP machines/masks for residents. She said she was unsure how CPAP masks should be stored or how often the tubing should be changed. She said she would find the answer by asking the facility's infection control nurse, respiratory therapist, and/or the UM. The respiratory vendor (RV) was interviewed on 1/15/25 at 10:18 a.m. The RV said the respiratory company provided respiratory equipment for residents' needs. He said he came weekly to the facility to service equipment and replace supplies per schedule or as needed. He said if a resident/family used their personal respiratory equipment, the company would service them upon request and bill whoever initiated the request. The RV said the CPAP mask and tubing should be changed every three months. He said the mask should be stored in a bag or a resident's top nightstand drawer. He said it was important to keep it off of the ground. He said the respiratory company recommended CPAP machine supplies to be cleansed daily. UM #1 was interviewed on 1/16/25 at 11:56 a.m. UM #1 said the night shift nurses were responsible for cleaning residents' CPAP masks daily. He said he needed to check the facility's policy and procedure to verify how often CPAP machines should be cleansed. He said CPAP masks should be stored in plastic bags hung at the resident's bedside and the tubing should be draped over the bed rail. He said he requested a power cord for Resident #95's CPAP machine the previous month (December 2024) during a meeting with her care provider. He said he had left multiple voicemails, without a response or update, and advised Resident #95 to ask her care provider for an update. He said he was unsure if the CPAP mask and tubing in the plastic bag at Resident #95's bedside were new. UM #1 said he would discard the mask and tubing at Resident #95's bedside and replace it. -On 11/16/25 at 12:20 p.m., UM #1 was observed in Resident #95's room. He discarded the CPAP mask and tubing at her bedside. He said he would replace supplies with those from the facility's stock and order additional supplies from Resident #95's care provider. The director of nursing (DON) was interviewed on 1/16/25 at 1:51 p.m. The DON said the night nurses were historically responsible for cleansing CPAP supplies, however, the facility had recently given the UMs the ability to adjust the time cleansing occurred. She said the facility bulk-ordered wipes specifically used to cleanse respiratory supplies. She said the cleansing/maintenance schedule and orders/machine settings were resident-specific, and should be documented in the resident's orders and care plan. The DON said she was not sure how often CPAP machines/masks should be cleansed and how often the tubing should be replaced. She said CPAP masks should be stored in a plastic bag hung at the resident's bedside or in a bag in the top drawer of the resident's nightstand. She said she was unaware Resident #95's CPAP machine was non-functional and did not know the length of time since it was last used. The DON said cardiac issues were a potential risk for a resident not using the CPAP machine as ordered and respiratory illnesses were a risk if CPAP masks/machines were not stored and cleansed correctly.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Personal CPAP (continuous positive airway pressure) machines for Residents #45 and #95 were removed and replaced on 1/16/25 with units provided by the facility’s oxygen provider. Identifying Other Residents Affected: A facility-wide audit will be conducted by NHA/nurse manager before the compliance date to ensure that CPAP/trilogy machine users have proper equipment and updated physician orders. Systemic Changes to Prevent Recurrence: Mandatory staff education provided by SDC / designee on CPAP and respiratory machine policies will be completed on or before the compliance date. Monitoring to Ensure Compliance: Audits of 3 residents with CPAP/trilogy machines will be completed by Nurse Manager/designee 1x/ week for 12 weeks to ensure proper equipment in place, orders are in and up to date and machines are appropriately cleaned. This will be documented on an audit tool spreadsheet. Findings will be reported to the QAPI Committee monthly for three months. Areas of concern identified, will be corrected upon discovery.

0700BedrailsS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure that a consent and a safety bed rail evaluation was in place for one (#151) of five residents with bed rails out of 53 residents. Specifically, the facility failed to:-Ensure a signed consent was obtained from Resident #151 or the resident's representative prior to the initiation of side rails;-Ensure a physical therapy or occupational therapy (PT/OT) safety evaluation was conducted for Resident #151 prior to the use of half bed rails on a new bed; -Ensure the least restrictive alternatives were tried and documented prior to the use of half rails; and,-Ensure a physician's order was obtained for Resident #151 prior to the use of bed rails. Findings include:I. Professional referenceAccording to the U. S. Food and Drug Administration (FDA) (2023), Recommendations for Health Care Providers Using Adult Portable Bed Rails, retrieved on 1/22/25 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails, "Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment."Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient."II. Facility policy and procedureThe Physical Restraint policy and procedure, revised December 2019, was provided by the nursing home administrator (NHA) on 1/16/25 at 3:12 p.m. It read in pertinent part,"Physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident can not easily remove and that restricts freedom of movement or normal access to his/her body part."Does a resident have a device that can be considered a restraint? If yes, complete a physical restraint evaluation form, complete the physical restraint elimination usage form if the resident is a candidate for restraint reduction, elimination or usage."Physical therapy/Occupational therapy (PT/OT) consultation for least restrictive physical restraint."Obtain physician's order for restraint including medical symptoms for restraint usage, type of restraint, time of use and duration."Discuss restraint alternatives, risks and benefits with resident or legal representative upon initiation and annually."Complete physical restraint evaluation upon initial use and quarterly or with significant change."Document on care plan."III. Resident #151A. Resident statusResident #151, age less than 65, was admitted on 10/7/24. According to the January 2025 computerized physician orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs) and pressure ulcers. The 10/14/24 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 was dependent on staff with toileting, personal hygiene, bed mobility, transfers and required substantial/maximal assistance with eating. The assessment indicated physical restraints, including bed rails were not used. B. Observations and resident interviewOn 1/13/25 at 2:29 p.m. Resident #151 was lying in bed with two half rails in the up position on the bed. On 1/15/25 at 3:04 p.m. Resident #151 was lying in bed with two half rails in the up position on the bed. On 1/16/25 at 9:22 a.m. Resident #151 was lying in bed with two half rails in the up position on the bed. Resident #151 was interviewed on 1/16/25 at 9:23 a.m. Resident #151 said the nursing staff used the half rails when they were doing wound care in the mornings to prevent him from rolling out and put them down after they were done using them. He said he was able to use the controls on the bed rails to put his head up and down. He said he was not mobile enough to be able to get trapped between the bed rails and the bed. C. Record reviewThe January 2025 CPO revealed a physician's order to put opposite rail for legs up when turning resident in bed and have two people to do any care that required turning in bed, ordered 10/10/24.-However, the physician's order did not indicate that the resident's bed rails were to be in the up position when staff was not repositioning the resident. The 10/30/24 nursing physical restraint evaluation identified the use of half rails needed for positioning and to promote independence. It documented the side rails were not a restraint because the resident was paralyzed. It documented the use of half rails was requested by nursing staff and the resident.-However, Resident #151 was totally dependent on staff for bed mobility and therefore was unable to use the bed rails independently.-However, the evaluation failed to document if a PT/OT screening had been done for the bed rails to assess for safety. The 10/30/24 nursing physical restraint elimination/usage evaluation documented a score of 19 out of 20, which indicated the potential elimination of the restraint and to attempt alternatives for restraint.-However, a comprehensive review of the nursing physical restraint elimination evaluation and Resident #151's electronic medical record (EMR) did not document that potential alternatives to the bed rails had been attempted by the facility or that discussion had taken place regarding the potential elimination of the side rails. The activities of daily living (ADL) care plan, initiated on 10/7/24, indicated Resident #151 was dependent with bed mobility. Interventions included using bed canes to promote independence for repositioning and turning in bed.-However, Resident #151 was totally dependent on staff for bed mobility and therefore was unable to use the bed rails independently.-A comprehensive review of the care plan failed to reveal documentation of the use of bed rails or other least restrictive alternatives. A comprehensive review of Resident #151's EMR failed to reveal documentation of a signed consent, a physical restraint evaluation, a physical restraint elimination evaluation, a PT/OT safety screening or a physician's order prior to the implementation of a new bed and initiation of the half side rails. IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 9:30 a.m. LPN #3 said bed rails were a physical restraint and should have an evaluation for risk versus benefit. He said the bed rails should be assessed for proper functioning. He said prior to initiating any physical restraint, a consent needed to be obtained and a physician's order. He said Resident #151 had side rails to help prevent falls out of bed during repositioning. He said Resident #151 also used side rails for safety because he had seizures.-However, there was no documentation in Resident #151's EMR to indicate the resident used the bed rails due to seizures. The NHA was interviewed on 1/15/25 at 3:00 p.m. The NHA said Resident #151 should not have half bed rails up on his bed. She said the bed he was using should have the bed rails zip locked down to prevent their use. She said she was not aware that bed rails were being used for Resident #151. Unit manager (UM) #2 was interviewed on 1/16/25 at 10:20 a.m. UM #2 said she was new to the physical restraint evaluation process. She said before bed rails were used, nursing staff should evaluate the need for them, obtain a consent and a physician's order. She said the nursing staff obtained a consent for the use of Resident #151's bed rails on 1/15/25 (during the survey) on the new bed from the resident. She said Resident #151 had been on a different bed with a dolphin mattress (a pressure redistribution specialty air mattress used to treat pressure wounds) and had recently switched to the current hospital type bed with the half bed rails. She said nursing staff used the bed rails to help with repositioning the resident. She said the resident was able to use the control on the bed rails himself. The director of nursing (DON) was interviewed on 1/16/25 at 3:00 p.m. The DON said that any potential restraint should be assessed to determine if it was a true restraint. She said PT/OT was involved in evaluating bed rails. She said there was a restraint assessment done when Resident #151 was admitted to the facility for his bed rails on the old bed. The DON said therapy had determined there was no benefit to having the side rails up and Resident #151 had agreed to having the side rails zip locked down so they could not be used. The DON said there were other things the facility could try for repositioning the resident, including bolsters, that were not bed rails. She said Resident #151's old bed had a dolphin mattress which he did not like. She said it was discovered, during survey, that Resident #151 had arranged for a new bed from the veterans administration (VA) and had it delivered to the facility. She said she and the NHA had not been aware Resident #151 had a new bed delivered and had been using it since approximately November 2024 or December 2024. The DON said therapy had done an evaluation on the new bed for the bed rails, after it was brought to their attention, during the survey. She said it was not a practice of the facility to use bed rails. She said medical equipment, such as hospital beds, should not be brought into the facility and used by staff and residents without notifying the DON and the NHA.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Resident #151 was assessed for bedrail use by therapy on 1/15/25. Physician orders and consent were obtained on 1/16/25. Identifying Other Residents Affected: A facility-wide audit was completed by therapy/SDC on 2/6/25 to ensure bedrail users had proper consents, orders, and functional assessments. Systemic Changes to Prevent Recurrence:Staff education on bedrail risks, policies, and appropriate use will be completed by SDC/designee on or before the compliance date. Monitoring to Ensure Compliance: The Therapy Director/designee will audit the entire facility monthly for three months to ensure compliance with bedrail policies. This will be documented on an audit tool spreadsheet. Findings will be reported to the QAPI Committee monthly. Areas of concern identified, will be corrected upon discovery.

0805Food in Form to Meet Individual NeedsS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs in one of five dining rooms. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to the resident's diet orders of mechanical soft as indicated on their meal tray cards. Findings include:I. Facility policy and procedureThe Therapeutic Diet Orders policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:55 p.m. It read in pertinent part, "The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. "A mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: inadequate nutrition, nutritional deficits, weight loss, medical conditions such as diabetes, renal disease, or heart disease and swallowing difficulty."Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed."II. Meal service observationsMeal Service was continuously observed on 1/15/25 from 4:30 p.m. to 6:00 p.m. The posted menu documented the dinner meal as quiche, zucchini and onions, oven roasted potatoes, an apple cinnamon muffin and a fruit cup. At 5:20 p.m. meal tray assembly started for the long hall. A meal ticket indicated a resident was prescribed a mechanical soft diet order. The plate was assembled with a soft shell taco and ground beef, zucchini and potato wedges. The potato wedges served had skin on the potato. The meal tray was placed in the room delivery cart for service. At 5:45 p.m. a meal was assembled for a resident who's meal ticketed documented a mechanical soft diet. Written on the meal ticket was "soft taco and sides." The plate was assembled with a soft shell taco and ground beef and potatoes wedges. The potato wedges served had skin on the potato and the plate was delivered to the resident in the dining room.-However, according to the diet manual description (see below) potato skins were restricted for residents prescribed a mechanically alerted diet. Both plates contained potatoes with the skin on the potatoes. At 5:52 p.m. the human resources director (HRD), who was the previous dietary manager was notified the oven roasted potatoes contained skins and were served to residents on a mechanical soft diet. The HRD said residents on mechanical soft diets should not have potato skins. III. Record reviewThe fall/winter 2024-2025 diet spreadsheets were provided by the NHA on 1/13/25 at 1:00 p.m. The spreadsheet for dinner on 1/15/25 documented oven roasted potatoes could be served to a resident on a mechanical soft diet.-However, according to the diet manual description (see below) potato skins were restricted for residents prescribed a mechanically alerted diet. Both plates contained potatoes with the skin on the potatoes. The Dysphagia Mechanically Altered Diet Consistency Alteration Diet Manual , undated, was provided by the NHA on 1/16/25 at 1:30 p.m. It read in pertinent part, "Avoid dry tough meats, or any other whole pieces of meat, cheese slices or cues, peanut butter sandwiches or pizza, potato chips, skins, fried or french fried potatoes. Please pay close attention to the menu extensions provided. Be sure that all planned foods are prepared. It is imperative to post a copy of the current day's menu extension on the tray line for easy reference during meal service." (page 71). The recipe for red fresh oven roasted potatoes, dated 11/7/23, was provided by the NHA on 1/16/25 at 1:30 p.m. The recipe instructions documented the following production steps: 1. Cut the red potatoes into quarters and steam or boil until tender. Drain off the excess liquid. 2. Melt the margarine with garlic and salt and toss the potatoes with seasoned margarine. Bake in the oven at 400 degrees fahrenheit (F) for 35 to 40 minutes or until lightly browned and tender. Hold or serve hot food at or above 135 degrees F.-The recipe did not include any further instructions on how to modify red fresh oven roasted potatoes for mechanically altered diets. IV. Staff interviewsThe HRD was interviewed on 1/15/25 at 5:56 p.m. The HRD said she was not sure what happened but the potatoes sent and served to the other dining rooms in the building all had potatoes without skins. She said she brought the potatoes without skins to the first floor dining room for service and removed the roasted potatoes with skin from the steam table. The dietary manager (DM) and the NHA were interviewed together on 1/16/25 at 11:30 a.m. The DM said the speech therapy department reviewed food items the residents could or could not have. The NHA said she spoke to the speech therapist for the facility. The NHA said she asked the speech therapist if they had reviewed the recipe for the oven roasted potatoes, and the speech therapist replied to the NHA that residents on a mechanical soft diet could have potato skins. The NHA said she requested a resource from the speech therapist that indicated a resident on a mechanical soft diet was able to have potato skins. -However according to the facility's diet manual (see above) potato skins were restricted from the mechanical soft diet.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Fall/Winter 2024-2025 diet extensions were updated 1/31/25 to ensure potatoes with skins were removed from the mechanical soft menu. Education was provided 2/6/25 to the dietary manager, cooks, and dietary servers on proper mechanical soft diet preparation, emphasizing the removal of potato skins. Identifying Other Residents Affected: The Interdisciplinary Team (IDT) will review the current menu cycle and diet extensions to ensure that potato dishes align with appropriate diet textures. Systemic Changes to Prevent Recurrence: The IDT, including the dietary manager, registered dietitian (RD), and speech-language pathologist (SLP), will review menus and recipes to ensure compliance with mechanically altered diet requirements. Education by SDC/designee will be provided to the dietary manager and cooks before the compliance date on approved items and foods to avoid, following the Diet Manual guidelines. Monitoring to Ensure Compliance: The IDT team (dietary manager, RD, SLP) will review menu cycles weekly for 5 weeks to confirm adherence to mechanical soft diet standards. This will be documented on an audit tool spreadsheet. Findings will be reported to the QAPI committee by the NHA/designee to ensure compliance and sustainability. Areas of concern identified, will be corrected upon discovery.

0812Food Procurement,Store/Prepare/Serve-SanitaryS/S F▼

Findings

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in five of five nourishment refrigerators. Specifically, the facility failed to ensure safe and appropriate storage of food items in the nourishment refrigerators. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 1/21/25, read in pertinent part, "Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety." (Chapter 3-28). The Hormel Handling Information product guide, (2025), retrieved on 1/21/25, read in pertinent part: "For Med-Pass products: Shelf life is up to four days refrigerated after opening." (Page 5)II. Facility policy and procedureThe Safe Handling of Foods From Visitors policy, undated, was provided by the nursing home administrator (NHA) on 1/13/25 at 1:00 p.m. The policy read in pertinent part, "Facility staff will request that visitors bringing in food, and or residents that received food, must notify a member of the nursing or activities departments. The responsible facility staff member will determine whether the food item is for immediate consumption or to be stored for later use. When food items are intended for later consumption, the responsible facility staff member will. Ensure that the food is stored separate or easily distinguishable from the facility food in a unit refrigerator/freezer or resident's personal regenerator in their room and labeled with the resident name and current date. Refrigerators/freezer storage of foods brought in by visitors will be properly maintained and equipped with thermometers, have temperatures monitors daily for refrigerators equal to or less than 41 degrees fahrenheit and equal to or less than ten degrees fahrenheit; daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more three or more days; and cleaned weekly."III. ObservationsOn 1/15/25 at 9:52 a.m. a refrigerator was observed on the first floor behind the nurses station. The refrigerator contained a container of Med-Pass (liquid supplement) approximately a quarter full and an unopened Monster energy drink. A sticky light brown substance with long black hair was in the bottom of the refrigerator.-The facility failed to label the Med-Pass with an opened or expiration date according to the product's handling instructions (see recommendations above) and the Monster energy drink was not labeled with a resident's information to differentiate it from the staff's food. On 1/15/25 at 10:04 a.m. a refrigerator was observed in the second floor dining room. The refrigerator contained a container of Med-Pass approximately a quarter full.-The facility failed to label the Med-Pass with an opened or expiration date according to the products' handling instructions (see recommendations above). On 1/15/25 at 10:09 a.m. a refrigerator was observed on the third floor. The refrigerator contained three Nestle Boost supplements with a use by date of 12/26/24. On 1/15/25 at 10:22 a.m. in the first floor secure unit freezer, there was a clear plastic one ounce (oz) medication cup with a frozen white substance in the cup. There were small light pink pieces on top of the white substance with a small white spoon frozen inside the cup. The cup was not labeled or covered. On 1/15/25 at 10:35 a.m. a refrigerator was observed on the third floor secure unit. The refrigerator contained the following:-A container of Med-Pass approximately a quarter full and the facility failed to label the Med-Pass with an opened or expiration date according to the product's handling instructions (see recommendations above).-A clear plastic container topped with a red lid that contained fresh blueberries was not labeled with a resident's name or date on the container.-An opened, two quart container of coffee mate creamer that was not labeled with a resident's name or expiration date on the container.-One 16 ounce pump bottle of hand sanitizer.-A clear, two quart plastic container of salsa with no resident's name or expiration date on the container.-A disposable Starbucks cup with a sticker dated 1/12/25 at 9:11 a.m. with no residents name on the cup-One can of unopened Red Bull that was not labeled to differentiate it from the staff's food. A typed sign was posted on the refrigerator that read in pertinent part: Residents only. All items must have a resident name and date. All employee items will be removed. IV. Staff interviewsDietary aide (DA) #1 was interviewed on 1/15/25 at 10:05 a.m. DA #1 said a resident's family member could bring and keep a resident's food in the nourishment refrigerator. DA#1 said she asked the family to put the resident's name, room number and date on the item. DA #1 said the nurses used Med-Pass and should label the Med-Pass container upon opening it. Certified nurse aide (CNA) #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said if a resident's family brought in food and asked facility staff to store the food, CNA #5 labeled the container with the date food was brought to the facility and then placed the food in the resident's refrigerator. CNA #5 said if a family brought in food that was placed in a nourishment refrigerator at the nurses station she would label the item with the resident's name also. The NHA and the director of nursing (DON) were interviewed together on 1/16/25 at 11:30 a.m. The NHA said the dietary staff monitored temperatures of the nourishment refrigerators and checked for expired products . The NHA said the nursing staff used the refrigerators as well. The NHA said the nursing staff and the dietary staff could remove expired items from the refrigerators. The DON said the Med-Pass was not a widely used supplement but the containers were usually placed in the refrigerators after being opened. The NHA said a staff drink or food in a resident refrigerator would be discarded because the nourishments refrigerators were for resident food only.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Nourishment refrigerators (first-floor nurse station, second-floor dining room, third-floor dining room, first-floor memory care, and third-floor memory care) were cleaned and cleared of opened and unlabeled items on 1/29/25. Signage was placed on nourishment refrigerators stating: “Resident items only. Please date and label items" on 1/29/25. Identifying Other Residents Affected: A facility-wide audit was conducted by SDC/IP (infection preventionist) on 2/6/25 on nourishment refrigerators to verify cleanliness, labeling compliance, and resident-only use. Systemic Changes to Prevent Recurrence: Mandatory education on safe food handling will be provided to staff SDC/designee on or before the compliance date to ensure adherence to food safety protocols. Monitoring to Ensure Compliance: Biweekly audits for 12 weeks will be done by SDC/IP or designee to ensure that nourishment refrigerators remain clean and compliant with facility policies. This will be documented on an audit tool spreadsheet. Findings will be reported to the QAPI committee monthly for 3 months. Areas of concern identified, will be corrected upon discovery.

0813Personal Food PolicyS/S E▼

Findings

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on two of three floors. Specifically, the facility failed to ensure safe and appropriate storage of food items in resident's personal refrigerators. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 1/21/25 read in pertinent part: "Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety." (Chapter 3-28). II. Facility policy and procedureThe Safe Handling of Foods From Visitors policy, undated, was provided by the nursing home administrator (NHA) on 1/13/25 at 1:00 p.m. The policy read in pertinent part, "Facility staff will request that visitors bringing in food, and or residents that received food, must notify a member of the nursing or activities departments. The responsible facility staff member will determine whether the food item is for immediate consumption or to be stored for later use. When food items are intended for later consumption, the responsible facility staff member will: Ensure that the food is stored separate or easily distinguishable from the facility food in a unit refrigerator/freezer or resident's personal regenerator (sic) in their room and labeled with the resident name and current date. Refrigerators/freezer storage of foods brought in by visitors will be properly maintained and equipped with thermometers, have temperatures monitors daily for refrigerators equal to or less than 41 degrees fahrenheit and equal to or less than ten degrees fahrenheit; daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more three or more days; and cleaned weekly."III. Observations On 1/13/25 at 11:00 a.m. the following observations were made in room #138:Two personal refrigerators each belonging to the residents who resided in Room #138 were inspected. One refrigerator contained two packages of cheese and two containers of meat were stored in the refrigerator. The refrigerator did not have an internal thermometer. A resident who resided in room #138 was interviewed and said facility staff did not check the temperature of her refrigerator but her husband checked the refrigerator daily and kept it clean. The second personal refrigerator in room #138 was inspected and did not have an internal thermometer. On 1/13/25 at 1:40 p.m. the personal refrigerator in room #142 far was inspected and did not have an internal thermometer. IV. Record reviewPersonal refrigerator monitoring logs from December 2024 (12/1/24 to 12/31/24) and January 2025 (1/1/25 to 1/13/25) were reviewed. On 12/23/25, there were no temperatures recorded for refrigerators in room #130, #131, #133, #134, #135, #137, #138 or the two refrigerators in room #142. Temperatures were recorded once daily each day on 12/5, 12/26, and 12/27/25 for residents personal refrigerators and were as follows:A refrigerator in room #131 was documented as having temperatures of 42 F, 42 F, and 44 F. A refrigerator in room #133 was documented as having a temperature of 42F, 45, and 41 F.A refrigerator in room #135 was documented as having temperatures of 41 F, 45 F and 44 F.A refrigerator in room #142 was documented as having temperatures of 41 F, 43 F, and 43 F.A second refrigerator in room #142 was documented as having temperatures of 42 F, 41 F, and 44 F.-However, neither refrigerator in room #142 was labeled to indicate which resident's refrigerator was being monitored or what corrective actions were taken when the temperatures were out of range. Temperature logs for 1/13/25 through 1/16/25 revealed the following:A refrigerator in room #355 was documented once daily as having a temperature of 45 F, 45 F, 45 F and 45 F each day. A refrigerator in room #358 was documented once daily as having a temperature of 43 F, 43 F, 43 F, 43 F each day.-However, corrective actions were not indicated for the refrigerators in rooms #355 and #358 when they were documented as having temperatures out of the acceptable range. V. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said she was not sure who monitored the temperatures of the resident's personal refrigerators. CNA #5 said if a resident's family brought in food and asked facility staff to store the food, she labeled the container with the date food was brought to the facility and then placed the food in the resident's refrigerator. The NHA was interviewed on 1/16/25 at 11:00 a.m. The NHA said the housekeeping staff monitored and recorded the temperatures of resident's personal refrigerators when the rooms were cleaned. The NHA said the housekeeping staff kept a binder of all temperature logs for the residents personal refrigerators. The NHA said she was unsure if the facility staff provided education to the residents or their representatives regarding the food from outside sources policy. The NHA said she talked to the residents and families about the appropriate plugs and placement of the refrigerators. The environmental services director (ESD) and the NHA were interviewed together on 1/16/25 at 1:00 p.m. The ESD said each housekeeper brought a refrigerator monitoring log with them when they cleaned the resident's room. The ESD said there was a monitoring log for each hallway and when a housekeeper cleaned a resident's room, the personal refrigerator was checked and the temperature of the resident's personal refrigerator was recorded on the log. The ESD said if the temperature was above 40 degrees fahrenheit on the thermometer, that meant the refrigerator's temperature was out of range and the housekeeping staff should inform her. The ESD said she recently ordered thermometers and gave them to housekeeping staff on 1/15/25 to replace any refrigerators that needed them. The ESD said housekeeping staff carried extra thermometers with them. The NHA said if a resident's personal refrigerator was out of temperature range the facility would replace the refrigerator and discard the perishable food from the room. VI. Resident interviews and observations The resident who resided in room #134 was interviewed on 1/13/25 at 10:29 a.m. The resident said she had lived in the facility for two years and her refrigerator had not been cleaned since she moved in. The refrigerator in room #134 was observed. The refrigerator had a small amount of food spills that were red and brown in color and the freezer was half-full of packed ice crystals. A thermometer was found inside that read 40 degrees. Temperature logs were not seen in Resident #66's room. Room #134's refrigerator was observed again on 1/15/25 at 8:09 a.m. The refrigerator had one wrapped, undated, dessert inside. The refrigerator had a small amount of food spills that were red and brown in color and the freezer was half-full of packed ice crystals. The thermometer inside read 42 degrees. The refrigerator in room #130 was observed on 1/13/25 at 10:15 a.m. The refrigerator did not have a thermometer inside. There were two open, undated, cups of fluids inside the refrigerator. The refrigerator had a small amount of food spots that were brown in color and had some built up ice-crystals present. The refrigerator in room #130 was observed again on 1/15/25 at 8:19 a.m. The refrigerator had a small amount of food spots that were brown in color. There was not a thermometer inside the refrigerator. The freezer had some built-up ice crystals present.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Refrigerators in Rooms #138 and #142 were inspected, and internal thermometers were installed 1/16/25. Temperature logs were placed in rooms with personal refrigerators on 2/3/25. Housekeeping staff received education on 2/6/25 by SDC/designee on safe temperature maintenance and procedures for addressing unsafe temperature readings. Identifying Other Residents Affected: A facility-wide audit by therapy identified resident-owned refrigerators, ensuring the presence of internal thermometers, temperature logs, and cleanliness. Systemic Changes to Prevent Recurrence: Families and residents were provided the facility’s Safe Food Handling of Foods from Visitors Policy by Social Services on or before the compliance date. Monitoring to Ensure Compliance: Housekeeping manager / designee will perform 5 personal refrigerators for 12 weeks to verify refrigerator cleanliness and temperature log completion. This will be documented on an audit tool spreadsheet. Findings will be reported to the QAPI committee monthly for 3 months. Areas of concern identified, will be corrected upon discovery.

0842Resident Records - Identifiable InformationS/S D▼

Findings

Based on record review and interviews, the facility failed to maintain accurately documented medical records for one (#114) of four residents out of 53 sample residents. Specifically, the facility failed to ensure Resident #114's wound orders and treatment records were accurate. Findings include:I. Facility policy and procedureThe Documentation of Medical Record policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:30 p.m. It read in pertinent part, "Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy. Documentation may be performed manually or as per the facility's specific electronic medical record software program. Principles of documentation include but are not limited to: Documentation shall be factual, objective and resident centered; documentation shall be accurate, relevant and complete, containing sufficient details about the residents' care and/or responses to care; documentation shall be timely and in chronological order. Record date and time of entry. When documentation occurs after the fact, outside of acceptable time limits, the entry shall be clearly indicated as' late entry.' Corrections to a medical record shall be made to clarify inaccurate information. Contradictory information may be clarified by a new entry in the medical record."II. Resident statusResident #114, age greater than 65, was admitted on 12/11/24. According to the January 2025 computerized physician orders (CPO), diagnoses included post surgical aftercare of the skin and subcutaneous tissue and multiple pressure ulcers. The 11/18/24 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. He was dependent on total assistance from staff for toileting hygiene and lower body dressing, needed substantial assistance with bed mobility and bathing, supervision with personal hygiene and set up help only for eating. The MDS assessment documented the resident had one or more pressure ulcers. III. Record reviewA review of Resident #114's electronic medical record (EMR) revealed the following: A 12/11/24 admission nursing data collection documented in the skin assessment section documented to "See wound note." A corresponding note in the resident's EMR documented a skin assessment was completed by the wound nurse, see wound note.-However a skin/wound was not documented until 12/17/24 (see below). A skin/wound note documented on 12/17/24 revealed wound assessments were completed for Resident #114 on 12/13/24, upon admission. The note documented a right upper buttock unstageable pressure injury. A skin/wound note documented on 12/19/24 revealed a left buttock unstageable pressure injury "(corrected from previously documented right buttock)."A review of Resident #114's treatment administration record (TAR) revealed treatment orders for a right upper buttock pressure ulcer started 12/12/24 and discontinued 1/13/25. The treatment administration record documented treatment was administered or attempted to be administered as ordered on the right buttock during this time.-However, the facility failed to update Resident #114's wound treatment orders until 1/13/25 (during the survey) to indicate Resident #114 had a left buttock wound instead of a right buttock wound. Resident #114's admission wound location chart was provided by the NHA on 1/14/25 at 1:38 p.m. The wound location chart documented Resident #114 had a wound on his right buttock and no wound on his left buttock. The wound location chart was not dated.-However, the resident's wound was on his left buttock (see interview below). IV. Staff interviewsThe director of nursing (DON) was interviewed on 1/16/25. The DON said she talked to the two nurses who primarily performed Resident #114's wound treatments. The DON said both nurses knew Resident #114's wound was on his left buttock and not his right buttock. The DON said the nurses did not recognize Resident #114's wound treatment orders were incorrect. The DON said she did provide education to the assistant director of nursing (during the survey) on correct wound documentation in the resident's EMR.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Resident #114’s order was updated 1/13/25 to reflect accurate information and wound location. Identifying Other Residents Affected: The Wound Nurse / designee and DON/ADON (assistant director of nursing)/designee conducted an audit 2/5/25 of residents requiring wound care to ensure accurate documentation and treatment orders. Systemic Changes to Prevent Recurrence: Mandatory education on accurate documentation will be provided by SDC/designee to nurses and nurse managers on or before the compliance date. Monitoring to Ensure Compliance: The Wound Nurse/designee will review order listings at weekly wound meetings for 12 weeks to track updates and corrections. This will be documented on audit tool spreadsheet. Findings will be reported to the QAPI committee monthly for 3 months. Areas of concern identified, will be corrected upon discovery.

0943Abuse, Neglect, and Exploitation TrainingS/S E▼

Findings

Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident dementia abuse prevention. Specifically the facility failed to: -Provide annual resident abuse prevention training/education to 46 out of 212 staff members; and,-Provide annual dementia management education/training for 42 out of 212 staff members. Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, revised 12/17/18 was received from the nursing home administrator (NHA) on 1/13/25 at 1:10 p.m. It revealed in pertinent part, "It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals."Educating staff on factors related to dementia care and abuse prevention, such as understanding that expressions or indications of distress of residents with dementia are often attempts to communicate an unmet need, discomfort or thoughts that they can no longer articulate with words. However, they may be perceived as challenging behaviors to staff and could increase the risk of resident abuse and neglect."II. Staff training recordsA request was made for the facility's annual abuse and dementia training records for all active staff members on 1/14/25. On 1/15/25 at 3:32 p.m. the staff development coordinator (SDC) provided the records for all active staff members who had completed annual abuse and dementia training. The records revealed 46 out of 212 staff members had not completed the facility's annual abuse training. Additionally, the records revealed 38 out of 212 staff members had not completed the facility's annual dementia training. On 1/16/25 at 2:35 p.m. the NHA provided a revised copy of all active staff members training records for annual abuse and dementia training (see NHA interview below). The revised records revealed 42 (not 38) of 212 staff members had not completed the facility's annual dementia training.-The facility failed to ensure all active staff members completed the annual training for abuse and dementia. III. Staff interviewsThe NHA was interviewed on 1/15/25 at 3:13 p.m. The NHA said the facility had acquired a new SDC in May 2024 who was also the infection preventionist (IP) due to the facility identifying issues with training completion. The NHA said the facility put a performance improvement plan (PIP) in place for human resources. However, the NHA said the PIP did not include annual abuse and dementia education. The NHA said the electronic education platform previously used by the facility was not being completed by staff and they had opted into a new training platform that was started on 1/1/25. The NHA said it was important to ensure all staff members were able to provide care and be aware of signs of abuse and dementia care. The NHA was interviewed a second time on 1/16/25 at 12:45 p.m. The NHA said the staff were reviewing employee files to ensure accurate counts for training were given. She said the facility would not be able to provide documentation for all staff members for abuse and dementia training. The NHA said moving forward the SDC would be responsible for auditing and ensuring all abuse and dementia training was completed on hire and annually and it was to be added to the new hire checklist. On 1/16/25 at 3:20 p.m. the director of nursing (DON) was interviewed. The DON said abuse and dementia training for all employees was important for safety and knowledge of how to handle resident situations that could arise, especially with dementia residents in the facility.

Plan of correction · submitted by the facility

Corrective Action for Identified Deficiency: Employees not having completed facility abuse and dementia training completed necessary trainings on or before the date of compliance. Identifying Other Residents Affected: A new education platform was implemented on 1/1/25 to allow real-time tracking of staff completion of required courses. Human Resources will mandate completion of abuse and dementia training before new hires begin working. Systemic Changes to Prevent Recurrence: Education on the importance of abuse and dementia training will be provided to staff on or before the compliance date by SDC or designee. Monitoring to Ensure Compliance: Human Resources/Staff Development Coordinator (SDC) will pull training completion reports monthly for 6 months. Findings will be reported to the QAPI committee monthly for 6 months. Areas of concern identified, will be corrected upon discovery.

4/29/2024Revisit: Complaint Survey · ID FU3722No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

3/12/2024Complaint Survey · ID FU37215 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

Abbreviated Life Safety Code survey prompted by #CO35250 was conducted on 3/12/2024. Six deficiencies were cited. 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). An Abbreviated Life Safety Code survey prompted by #CO35250, conducted on March 12, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a three (3) story, Type II (111) protected non-combustible construction with no basement. The suspended grid ceiling provides the one-hour rated protection to the building structure and must remain intact. This original facility was constructed in 2002. The 2005 & 2008 additions are both one (1) story, Type II (111) protected non-combustible construction and are not separated from the original building by fire rated construction. The facility is licensed for 210 beds. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The wet-pipe system protects all interior levels. There is a non-combustible limited access attic space in both the 2005 & 2008 additions that are not protected by automatic fire sprinklers. The facility is classified as fully-sprinklered.

Plan of correction

The state did not require a plan of correction for this citation.

0331Interior Wall and Ceiling FinishS/S F▼

Findings

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire protection rating of the building structure in accordance with Life Safety Code Section 19.3.3.2. This deficient practice could affect all residents should the fire protection rating of the building structure not be adequate to withstand fire exposure, as originally designed. This was evidenced by the following:Damaged suspension ceiling tiles were noted through-out the kitchen, dish and storage room. A one-hour fire rated suspended ceiling system must be maintained as a continuous assembly throughout the building. 2012 NFPA 101 Section 19.3.3.2* Interior Wall and Ceiling Finish. Existing interior wall and ceiling finish materials complying with Section 10.2 shall be permitted to be Class A or Class B. The Maintenance Director acknowledge the missing ceiling tiles during the walk through of the facility.

Plan of correction · submitted by the facility

1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Maintenance Director installing new ceiling tiles replacing damaged tiles by 4/17/24. Education to be provided to all staff related to use of TELS 2. Address how the facility will identify other residents in having the potential to be affected by the same deficient practice. ANHA and Maintenance Director completed audit of damaged ceiling tiles which showed no other affected areas. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Staff will be reeducated on the use of TELS for required repairs to be scheduled. All inspections and findings will be reviewed by the Administrator to ensure compliance. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Ceiling tiles will be audited monthly for three months as part of the preventative maintenance rounding by Maintenance Director or designee. The Administrator or designee will report findings from audit to QA for three months to determine effectiveness of plan and reassess if further monitoring and evaluation is required.

0353Sprinkler System - Maintenance and TestingS/S F▼

Findings

STANDARD not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with 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 in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following. 1) Walk-in freezers dry pendent sprinkler head has been removed2) Walk-in freezer fire suppression supply line is disconnected and caped off due to freezing damage. 3) Pendent sprinkler shows signs of foreign materials around the working parts of the head. NFPA 101 2012 Edition Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are installed, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during the tour of the facility.

Plan of correction · submitted by the facility

1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. - Facility contracted with Frontier Fire to repair automatic sprinkler system in kitchen, completed work on 3/28/24.- Fire watch implemented pending repair time.- Education provided to all staff pertaining to fire watch 2. Address how the facility will identify other residents in having the potential to be affected by the same deficient practice.-Maintenance Director completed audit of building sprinkler system which showed no other areas of concern. - Staff reminded of maintenance related requests to be placed into TELS system for proper follow up. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. - Vendor in place for repair and rerouting of sprinkler system in refrigerated area to be moved outside of refrigerated area to decrease likelihood of frozen pipes during winter, work completed on 3/28/24.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. -Preventative maintenance rounds will be conducted monthly by the maintenance director or designated staff member with review from NHA to ensure compliance. - The Administrator or designee will report findings from audit to QA for three months to determine effectiveness of plan and reassess if further monitoring and evaluation is required.

0521HVACS/S F▼

Findings

STANDARD not met as evidenced by: It was determined through observation and interview, the facility failed to install the air conditioning system as required. (2012 NFPA 101 Section 19.5.2.1, 9.2.1) (NFPA 90A Section 4.3.12.1.1 Egress corridors in health care, detention and correctional and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas). This deficient practice could affect the entire facility, residents, visitors and staff and should a fire occur. During the survey, conducted on March 12, 2024 the building was found to be using portable air conditioners with flexed lines vented into the attic plume spaces in the following locations, Second and Third floor dish room, MC and LPN offices, Beauty shop and IT-room 5. (2012 NFPA 101 Section 19.5.2.1, 9.2.1) (NFPA 90A Section 4.3.12.1.1 Egress corridors in health care, detention and correctional and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas). The Administrator and Maintenance Director acknowledged improper installation of the air conditioning system during a tour of the facility and again at the exit conference.

Plan of correction · submitted by the facility

1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Vendor contacted to complete inspection of facility to identify source of air conditioning in facility. AC units with flexed lines venting into the attic plume spaces will be removed from identified offices and spaces by 4/17/24. 2. Address how the facility will identify other residents in having the potential to be affected by the same deficient practice. An audit was conducted by ANHA and Maintenance Director to identify location of portable ac units in the facility which identified ac units in the medication storage rooms. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Fans will be placed in identified areas to allow for air flow and cooler temperatures. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Maintenance Director or designee will conduct audits monthly for three months of air conditioning system in facility, NHA will ensure compliance. The Administrator or designee will report findings from audit to QA for three months to determine effectiveness of plan and reassess if further monitoring and evaluation is required.

0911Electrical Systems - OtherS/S F▼

Findings

STANDARD not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents in all smoke compartments due to increased potential hazards of electrical fire. The facility failed to maintain electrical equipment. 1. Electric hospital beds have frayed cords exposing energized electrical connections in resident's rooms 03, 07, 11,18,25,30,256,333,343 and 250.2. Missing or broken outlet covers in 300 long hall and residents 343. NFPA 70, National Electrical Code Article 370-25. Covers and Canopies in completed installations, each box shall have a cover, faceplate, or fixture canopy. The Maintenance Director acknowledged the electrical hazard during a tour of the facility.

Plan of correction · submitted by the facility

1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. All manufacturer cords have been ordered. All frayed cords from hospital beds will be replaced with the manufacturer cords by 4/17/24. Broken outlet covers have been replaced. Education will be provided to all staff regarding TELS system. Education to be provided to maintenance, central supply, and housekeeping to order manufacturer cords to replace frayed cords. 2. Address how the facility will identify other residents in having the potential to be affected by the same deficient practice. ANHA and Maintenance Director completed audit of frayed cords 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. All staff will be educated on the regulations regarding these electrical system requirements. Rounds and observations will be done routinely, during cleaning and Preventative maintenance rounds. Administrator to ensure compliance. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Maintenance Director or delegated staff will complete a monthly audit on bed cords for three months. The Administrator or designee will report findings from audit to QA for three months to determine effectiveness of plan and reassess if further monitoring and evaluation is required.

0920Electrical Equipment - Power Cords and ExtensS/S F▼

Findings

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents throughout the center core smoke compartments due to increased potential hazards of electrical fire. This was evidence by the following:The facility is utilizing a power strips as a substitute for fixed wiring to supply power appliances (refrigerator's) in rooms 261 and 262. The power strip is only rated for 15 amps and is not for connecting to higher amperage appliance. NFPA 70, National Electrical Code section 400-8 requires, in part, that flexible cords and cables not use as a substitute for the fixed wiring of a structure, and that they not be attached to a building surface. The Maintenance Director acknowledged the electrical installations during a tour of the facility.

Plan of correction · submitted by the facility

1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. - Flexible cords and cables will not be used as a substitute for the fixed wiring of a structure by 4/17/24.- Power appliances will be plugged into the wall outlets.- Education provided to residents and staff pertaining to life safety and regulations surrounding electrical equipment. 2. Address how the facility will identify other residents in having the potential to be affected by the same deficient practice.- An audit was conducted by NHA, ANHA, and Maintenance Director to identify residents utilizing power strips in rooms. - Maintenance Director will secure power strips to wall- Maintenance Director/designee will then coordinate with individual residents with identified noncompliance to meet their preferences in their rooms while continuing to meet regulations. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Electrical outlet and cooking appliances policy will be implemented and placed in admission packet including regulations outlining electrical equipment allowed in residential areas and the use of power cords and strips being utilized in patient care areas. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. All staff will be educated on the regulations regarding these electrical system requirements. Monthly audits will be completed for three months by Maintenance Director or designee to ensure compliance with electrical equipment. Administrator to ensure compliance. The Administrator or designee will report findings from audit to QA for three months to determine effectiveness of plan and reassess if further monitoring and evaluation is required.

12/3/2023Revisit: Recertification Survey · ID V0FR22No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

10/5/2023Revisit: Complaint, Recertification Survey · ID V0FR12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 10/4/23 to 10/5/23 for all previous deficiencies cited on 8/8/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

10/5/2023Revisit: Licensure Complaint Survey · ID N3ZP12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 10/4/23 to 10/5/23 for all previous deficiencies cited on 8/8/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

9/5/2023Recertification Survey · ID V0FR217 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

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 Sept 5, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a three (3) story, Type II (111) protected non-combustible construction with no basement. The suspended grid ceiling provides the one-hour rated protection to the building structure and must remain intact. This original facility was constructed in 2002. The 2005 & 2008 additions are both one (1) story, Type II (111) protected non-combustible construction and are not separated from the original building by fire rated construction. The facility is licensed for 210 beds and the census on the date of the survey was 151. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. The wet-pipe system protects all interior levels. There is a non-combustible limited access attic space in both the 2005 & 2008 additions that are not protected by automatic fire sprinklers. The facility is classified as fully-sprinklered.

Plan of correction

The state did not require a plan of correction for this citation.

0324Cooking FacilitiesS/S D▼

Findings

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96.. Hood suppression: - Only one inspection report available for previous 12 months (July 2023) this is a required semi annual inspectionNFPA 96, 11.2.2* All actuation and control components, including remote manual pull stations, mechanical and electrical devices, detectors, and actuators, shall be tested for proper operation during the inspection in accordance with the manufacturer ' s procedures. 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.

Plan of correction · submitted by the facility

1. Documentation of semi-annual hood suppression test was found and showed compliance with the regulation. 2. All residents have the potential to be affected. Maintenance Director / designee conducted a facility wide audit to ensure other hood suppression tests were completed. 3. Maintenance department was educated on or before date of substantial compliance regarding the importance of completing this test in a timely manner. Facility will incorporate these tests into its preventative maintenance and regulatory tracking system to ensure compliance with this regulation. 4. The NHA / Designee will conduct an annual audit and report findings to QAPI committee annually to evaluate and determine effectiveness of audit as well as the need for on-going monitoring.

0363Corridor - DoorsS/S E▼

Findings

Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101. Room door for 356 did not close Penetration in 3rd floor nurses storage room above lockNFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesNFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. 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.

Plan of correction · submitted by the facility

1. The door for room #356 has been fixed to ensure proper closure. The penetration in 3rdfloor nurse storage room above lock has been corrected. Both corrections were completed on or before date of substantial compliance. 2. All residents have the potential to be affected. Maintenance director / designee conducted a facility wide audit to ensure all resident room doors properly close. Maintenance director / designee conducted a facility wide audit to ensure any door penetrations are corrected. 3. Maintenance department was educated on or before date of substantial compliance regarding the importance of ensuring resident doors close per regulation as well as the importance of ensuring compliance with door penetrations. Resident door closure tests and spot checks of potential door penetrations will be incorporated into the facility’s preventative maintenance and regulatory tracking system to ensure compliance with this regulation. 4. The NHA / Designee will conduct monthly audits of 40 resident room doors monthly and spot checks of door penetrations. The findings of these audits will be reported to the QAPI committee on a monthly basis to evaluate and determine effectiveness of audit as well as the need for on-going monitoring.

0372Subdivision of Building Spaces - Smoke BarrieS/S E▼

Findings

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:Fire Barrier penetrations by room 152 and 147 NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. 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.

Plan of correction · submitted by the facility

1. The fire barrier penetrations by room #152 and #147 have been corrected on or before date of substantial compliance. 2. All residents have the potential to be affected. The Maintenance Director / designee conducted a facility wide audit to ensure any resident room fire barrier penetrations have been corrected. 3. Maintenance department was educated on or before date of substantial compliance regarding compliance with this regulation. Monthly resident room checks for fire barrier penetrations will be incorporated into the facility’s preventative maintenance and regulatory tracking system to ensure compliance with this regulation. 4. The NHA / Designee will conduct monthly audits of potential penetrations by residents rooms. The findings of these audits will be reported to the QAPI committee on a monthly basis to evaluate and determine effectiveness of audit as well as the need for on-going monitoring.

0541Rubbish Chutes, Incinerators, and Laundry ChuS/S E▼

Findings

Based on record review, it was determined that the facility failed to maintain the facility laundry chute in accordance with NFPA 101 and NFPA 82. Laundry chute: No annual inspection report for laundry chute components to include fusible linkNFPA 101 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless such installations are approved existing installations, which shall be permitted to be continued in service. 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.

Plan of correction · submitted by the facility

1. Facility contacted a licensed professional to complete the annual inspection with any noted corrections of laundry chute components to include fusible link. Any noted corrections were completed on or before date of substantial compliance. 2. All residents have the potential to be affected. The Maintenance Director / designee conducted a facility wide audit to ensure all laundry chutes are compliant with this regulation. 3. Maintenance department was educated on or before date of substantial compliance regarding compliance with this regulation. Annual inspections of laundry room chutes and fusible links will be incorporated into facility’s preventative maintenance and regulatory tracking system to ensure compliance with this regulation. 4. The NHA / Designee will conduct semi-annual audits to ensure laundry room chutes are compliant. The findings of these audits will be reported to the QAPI committee on a semi-annual basis to evaluate and determine effectiveness of audit as well as the need for on-going monitoring.

0712Fire DrillsS/S F▼

Findings

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 hour apart not at varied timesNFPA 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.

Plan of correction · submitted by the facility

1. Fire drills tracking system was created on or before date of substantial compliance. 2. All residents have the potential to be affected. The Maintenance Director / designee conducted an audit to ensure any necessary fire drills were completed at various times and with greater than one hour time difference between each drill. 3. Maintenance department was educated on or before date of substantial compliance regarding compliance with this regulation. Conducting fire drills at various times with greater than one hour between each drill will be incorporated into the facility’s preventative maintenance and regulatory tracking system to ensure compliance with this regulation. 4. The NHA / Designee will conduct quarterly audits to ensure compliance with this regulation. The findings of these audits will be reported to the QAPI committee on a semi-annual basis to evaluate and determine effectiveness of audit as well as the need for on-going monitoring.

0914Electrical Systems - Maintenance and TestingS/S F▼

Findings

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

Plan of correction · submitted by the facility

1. A tracking tool was created to show that there is receptacle testing in resident rooms. Specifically, the tool shows physical integrity of each receptacle is confirmed by visual inspection, the continuity of the grounding circuit in each electrical receptacle is verified, correct polarity of the hot and neutral connections is confirmed, and the retention force of the grounding blade is not less than 115 g (4 oz). No specific resident room receptacle was noted. 2. All residents have the potential to be affected. The Maintenance Director / designee conducted a facility wide audit to ensure all other similarly affected residents receptacles are appropriately tested and compliant. 3. Maintenance department was educated on or before date of substantial compliance regarding compliance with this regulation. Monthly checks of resident rooms will be incorporated into the maintenance department’s routine rooms inspections ensure compliance with this regulation. 4. The NHA / Designee will conduct monthly audits to ensure compliance with this regulation. The findings of these audits will be reported to the QAPI committee on a monthly basis to evaluate and determine effectiveness of audit as well as the need for on-going monitoring.

0918Electrical Systems - Essential Electric SysteS/S F▼

Findings

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: Generator Weekly inspections - No weekly inspection reports available for generator Generator Battery Conductance - No reports available to show monthly tracking 8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe 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.

Plan of correction · submitted by the facility

1. The weekly generator test was completed on or before date of substantial compliance and has been documented. The generator battery conductance was also tested on or before date of substantial compliance. The documented compliance is noted in the appropriate report located at the facility. 2. All residents have the potential to be affected. The Maintenance Director / designee conducted an audit to ensure all generator tests were completed timely in a compliant fashion. All documentation showing compliance is located at facility upon request. 3. The Maintenance Department was educated or before date of substantial compliance to ensure compliance with this regulation. Weekly generator tests and monthly generator battery conductance tracking were incorporated into the facility’s preventative maintenance and regulatory tracking system to ensure compliance with this regulation. 4. The NHA / Designee will conduct weekly audits for generator to ensure generator inspections are being completed accordingly. Monthly audits showing tracking of battery generator conductance will be completed by designee to ensure compliance with this regulation. The findings of these audits will be reported to the QAPI committee on a monthly basis to evaluate and determine effectiveness of audit as well as the need for on-going monitoring.

8/8/2023Licensure Complaint Survey · ID N3ZP113 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A survey prompted by complaint #CO33410 was completed 7/19/23 to 8/8/23. Three deficiencies were/were not cited.

Plan of correction

The state did not require a plan of correction for this citation.

0303Governing Body-Quality Assurance of Gov Body▼

Findings

Based on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to significant medications errors and residents were provided respect and dignity by staff that caused a pattern of psychosocial harm. Findings include: I. Facility policy and procedure The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the director of nursing (DON) on 8/8/23 at 2:30 p.m. It revealed, in pertinent part, "Purpose: to evaluate facility quality indicators, identify quality issues, develop corrective action plans and evaluate any action plans for continuous quality improvement. "Any concerns, trends or clusters identified should be listed on the QA Concerns List. Document the concern, goal and approaches and interventions to correct the concern on the QA Concern Action Plan. Review monthly any ongoing concerns until resolved. Develop new interventions as needed." II. Cross-reference citationsCross reference S0923: the facility failed ensure Resident #156, who was recently hospitalized for an acute embolism and was a high risk for deep vein thrombosis (DVT), was administered anticoagulant medication (Eliquis) as ordered upon discharge from the hospital. The facility failed to ensure the transcription of medications from the hospital records was accurate, which resulted in a failure to provide anticoagulant medication, which led to the resident developing a pulmonary embolism resulting in cardiac arrest. The facility's failure to administer the anticoagulant therapy, as was indicated by the hospital discharge records, led to the resident's change of condition and ultimately, his death, from cardiac arrest due to a pulmonary embolism. The failure to ensure the accurate transcription of physician's orders placed residents at risk for serious harm or death if it was not immediately corrected. Cross reference S1515: the facility failed to provide a culture and environment that promoted residents being treated with dignity and respect. Several residents reported psychosocial harm of feeling humiliated, disrespected and treated like children. These concerns were reported in resident council meetings. III. Staff interviews The director of nursing (DON) was interviewed on 7/25/23 at 8:15 p.m. She said the QAPI meetings were only required to be held every quarter, but the facility held them monthly. She said the nursing home administrator (NHA,) herself, assistant director of nursing (ADON), unit managers, social services, dietary manager, pharmacist and other members of the interdisciplinary team attended the meeting. She said each department presented a scheduled set of reports at each meeting and the facility attempted to identify the issues throughout the facility and discover trends. The DON said if new areas of concern were identified, performance improvement plans (PIP) would be developed and discussed during the next QAPI meeting. The DON said she remembered Resident #156's change of condition and being sent to the hospital but she could not remember the circumstances surrounding the change of condition. She said the facility had not identified that the facility's failure to transcribe the hospital discharge orders correctly directly related to Resident #156's change of condition and ultimately, his death. The DON said she was unaware many residents had concerns that staff did not treat them with dignity and respect. She said she was not aware residents had brought up the concerns during resident council. She said she had nurse managers on duty seven days per week to address concerns, but was not aware that the program had not been successful based on multiple resident interviews. The DON said the concerns identified during the survey process had not been previously identified by the facility staff and brought to the QAPI meeting.

Plan of correction · submitted by the facility

F8671. Corrective ActionThe facility will contract with a quality improvement specialist (QIS) with nursing home administrator and/or director of nursing experience (see requirements below) to provide consultation and oversight for quality assurance and performance improvement activities. The facility will immediately implement an appropriate quality assurance and process improvement plans consistent with the requirements of §483.75(d) in order to address facility failures in Resident Rights §483.10 and Pharmacy Services §483.45. The nursing home administrator (NHA), director of nursing (DON), nursing leadership, and interdisciplinary team (IDT) members, in conjunction with the QIS, shall review quality assurance performance improvement activities and create performance improvement plans related to resident rights and pharmacy services. Such action plans will, at minimum, include:(1) Ensuring each resident is treated with dignity and respect, and that each staff provides dignified resident care, in accordance with the requirements of F550.(2) Ensuring each resident's medication regimen is free from significant medication errors, in accordance with the requirements of F760.2. Identification of OthersThe NHA, DON, and applicable members of the IDT, in accordance with the QIS consultant, shall audit all current performance improvement plans not specific to those mentioned above in "1. Corrective Action" to determine the efficacy of each plan. Plans identified as ineffective will be reviewed and revised with the assistance of the QIS consultant. The QIS consultant will assist the facility leadership with identifying in the root causes of the inefficacy for those plans identified as ineffective. 3. System ChangesOn or before 9/6/2023 the facility shall hire a QIS consultant with experience consulting or directing nursing services or nursing home administration duties within nursing facilities. The QIS consultant shall exercise independent judgement in the performance of all duties under the consultant contract. The QIS consultant shall meet the independent judgement requirement if the consultant is not currently an employee of the facility or its corporate organization and has not within a five (5) year period immediately preceding 9/6/2023 been directly or indirectly affiliated with the facility, facility's owner(s), agent(s), or employee(s). In the performance of all services provided, the QIS consultant's status shall be that of an independent contractor and not that of an agent, employee, or representative of the facility, applicant or owner. The QIS consultant shall exercise professional, independent judgment in the performance of all such services and shall not be directly or indirectly instructed, guided, influenced or otherwise interfered with by the facility, applicant or owners, agents, employees or assigns. No oral understandings, statements, promises, or inducements contrary to the terms of this plan of correction (POC) shall be entered into during the term of this contract. Quality Improvement Specialist Consultant QualificationsPrior to engagement, the QIS consultant shall be a nursing home administrator and/or registered nurse with nurse leader experience, in possession of a valid occupational license in good standing with the State of Colorado. The QIS consultant must demonstrate recent (within the last five years) experience in providing administrative and care management or consulting services within nursing facilities, as approved by the Department [via Chad Fear at 303-815-8604]. Quality Improvement Specialist Consultant DutiesIn conjunction with the nursing home administrator (NHA), director of nursing (DON), nursing leadership, and other interdisciplinary team members, the QIS consultant shall oversee the development and implementation of an effective quality assurance and performance improvement program. This should include but not be limited to:(1) Developing, implementing, and monitoring effective, specific action plans for each of the 21 other deficiencies (F574, F584, F585, F600, F625, F626, F676, F677, F679, F684, F686, F689, F692, F695, F725, F730, F761, F806, F812, F880, F881) identified in the current deficiency list. (2) Revising any ineffective or underperforming action plan, in accordance with the established performance measures.(3) Educating applicable staff on:a. Their respective roles in completing each action plan developed to address deficient practice identified in the current survey.b. Methods for developing, implementing, and tracking the effectiveness of performance improvement plans.c. Methods of effectively utilizing scheduled and ad hoc performance improvement meetings to promote quality and prevent performance concerns.d. Techniques for identifying potential Quality Assurance and Assessment activities to prevent and remediate quality and performance concerns.e. Utilizing the state's quality improvement network/quality improvement organization for assistance with quality improvement projects.f. Utilizing any resident and/or family group to identify quality and performance improvement opportunities. 4. MonitoringMonitoring of approaches to ensure compliance with quality assurance and performance improvement activities:(1) At least weekly, for no less than twelve weeks, across all shifts and units, facility leadership or suitable designees, in conjunction with the QIS consultant, will complete validation audits/observations and record reviews to ensure the following:a. Quality assurance activities are conducted to verify all staff treat each resident with respect and dignity, in accordance with F550.b. Quality assurance activities are conducted to verify each resident's medication regimen is free from significant medication errors, in accordance with the requirements of F760. Such monitoring will be documented on a monitoring log. Staff will receive on-the-spot education when deviation from policy procedure is identified. The education will be documented on the monitoring log. Validation audits/observations and record reviews will reduce from weekly to monthly when the facility has demonstrated twelve consecutive weeks with no errors in implementing quality assurance activities that attain and maintain compliance with Medicare requirements of participation. Monthly validation audits will continue until the facility has demonstrated no less than three consecutive months with no errors in implementing quality assurance activities that attain and maintain compliance with Medicare requirements of participation.(2) The NHA, with the assistance of the QIS consultant, shall track and trend the success of all quality assurance performance improvement activities. Such tracking and trending data shall be reported to the quality assurance process improvement committee monthly for no less than three months and shall continue until all performance plan objectives related to maintaining an effective quality assurance performance improvement program are consistently demonstrated. The QIS consultant shall make weekly written reports for the first twelve weeks to the Department on all plan implementation, education, training, and monitoring related to quality assurance and performance improvement. Such reports shall be provided to the Department via email, [chad.fear@state.co.us and jo.tansey@state.co.us] beginning 9/8/2023 then each following Friday with the final weekly report being submitted on Friday, 11/24/2023. After the first twelve weeks, with Department approval, reports shall be due on the 15th of each month. Reporting shall then continue to be due monthly on the 15th for a minimum of three months and shall only be discontinued when the facility has demonstrated consistent implementation of all requirements of §483.75(d).

0923Nursing Services - Medication Administration▼

Findings

Based on interviews, observation and record review, the facility failed to ensure one (#156) out of 71 sample residents were free from significant medication errors. Specifically, the facility failed ensure Resident #156, who was recently hospitalized for an acute embolism and was a high risk for deep vein thrombosis (DVT), was administered anticoagulant medication (Eliquis) as ordered upon discharge from the hospital. The facility failed to ensure the transcription of medications from the hospital records was accurate, which resulted in a failure to provide anticoagulant medication, which led to the resident developing a pulmonary embolism resulting in cardiac arrest. The facility's failure to administer the anticoagulant therapy, as was indicated by the hospital discharge records, led to the resident's change of condition and ultimately, his death, from cardiac arrest due to a pulmonary embolism. The failure to ensure the accurate transcription of physician's orders placed residents at risk for serious harm or death if not corrected immediately. Findings include:I. Significant medication errors failuresThe facility failed to ensure the transcription of medications from the hospital records for Resident #156 were accurate upon his admission to the facility. This resulted in the facility's failure to ensure Resident #156 received anticoagulant therapy, as indicated by the hospital discharge physician. Resident #156 had been recently hospitalized for an acute embolism and was a high risk for DVT. The facility's failure led to Resident #156 developing a pulmonary embolism, resulting in cardiac arrest, and ultimately, his death. On 8/4/23 at 9:11 a.m., the nursing home administrator (NHA) and director of nursing (DON) were notified of the facility's failure to ensure Resident #156 received anticoagulant therapy. On 8/4/23 at 12:15 p.m., the facility submitted a plan which read:1. Corrective action The interdisciplinary team will conduct an audit of all new admissions and readmissions discharge orders that have been admitted to the facility within the past 30 days from today's date. The audit will be headed by the assistant director of nursing/designee. This audit will be completed by 8/7/23.2. Identification of others The discharge orders from the hospital will be initially reviewed by the admitting nurse. The admitting nurse will then verify the continuation of the discharge orders from the discharging facility with the admissions primary care physician or mid-level provider. The admitting nurse will have a second nurse verify the orders. The second nurse and the admitting nurse will sign off on the admitting orders together. The unit manager/designee will review both nurses and verify that the orders that are in place are the correct and most appropriate orders for the admitted resident and the unit manager/designee will make changes as needed. 3. Systemic changesFor all medication order changes, a second nurse will verify that medication changes to ensure that the new order (s) have been received and transcribed correctly for accurate administration of medication. This process will be reviewed five days a week by way of the order listing report during clinical meetings. Each member of the interdisciplinary team will initial off on this report to ensure compliance with this new process. Education will be provided to all licensed/registered nurses who are on duty today (8/4/23), and a continuing education will be provided to all licensed.registered nurses by 8/7/23 and all new nurses and agency staff prior to their first shift. Education will be provided by the DON (director of nursing)/designee. 3. MonitoringResults of this systemic change will be presented to the quality assurance improvement committee monthly, and as needed to ensure compliance with the new process. If a break in this process is identified, an immediate form of corrective action will be applied and a formal response will be completed. II. Failure to ensure anticoagulant medication was administered according to physician's ordersA. Resident #156 statusResident #156, age 77, was admitted on 5/10/23 and discharged to the hospital on 6/2/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included pulmonary embolism (blockage in heart arteries) and acute embolism and thrombosis of right femoral vein (blood clot in the vein in the leg). The 5/16/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with one person assistance with all activities of daily living. It indicated the resident had medically complex conditions, pulmonary embolism, DVT, PE (pulmonary embolism) or PTE (pulmonary thromboendarterectomy: surgery to remove blood clots and scar tissue from the arteries in the lungs). B. Record reviewThe anticoagulant therapy care plan, initiated and revised on 5/22/23, documented the resident received anticoagulant therapy due to a bilateral PE. The interventions included administering anticoagulant medications as ordered by the physician; monitoring for side effects and effectiveness; following up with the physician regarding medication dosing, lab draw scheduling and abnormal test results as ordered. The 5/10/23 admission summary documented the resident was admitted to the facility due to an acute pulmonary embolism. The 5/10/23 physician history and physical documented on 5/4/23, the resident was sent to the hospital with acute complaints of chest pain and shortness of breath. The resident was found to have bilateral pulmonary artery thrombus and subsequently underwent bilateral pulmonary artery thrombectomy with the majority of the thrombus cleared from the right and a partial thrombus cleared from the left.-The physician's assessment and plan included anticoagulant therapy to include Eliquis 10 MG twice daily through 5/16/23, then Eliquis 5 MG twice daily and to monitor for any acute respiratory complications. 1. Resident #156's history of acute embolismThe 5/5/23 hospital interventional radiology inpatient progress notes documented the resident was admitted to the hospital on 5/4/23 with a history of PE in 2022 and presenting with chest pain in the center of his chest and difficulty breathing as if "someone were on top of him." The resident was found to be tachypneic (rapid, shallow breathing) and mildly hypoxic (low oxygen level). The CTA (computed tomography angiography with contrast) indicated the resident had a large bilateral pulmonary embolus with image evidence of a right heart strain. Due to the resident's intermediate high risk of PE, the resident was recommended for a thrombectomy. On 5/4/23, a bilateral pulmonary artery thrombectomy with majority of thrombus cleared from right and partial thrombus cleared from the left. Following the procedure, it was recommended the resident receive continued anticoagulation. The 5/10/23 discharge physician orders documented the following:-Apixaban (Eliquis) 5 MG (milligram)-take two tablets (10 MG) twice daily for seven days (5/9/23-5/16/23) followed by one tab (5 MG) twice daily thereafter. 2. Failure of the facility to ensure Resident #156 received the correct anticoagulant therapyThe 5/10/23 physician's order note documented the following order was entered into the resident's electronic medical record:Eliquis Oral Tablet 5 MG-give 10 mg by mouth two times a day for PE until 5/16/23 and give 5 MG by mouth two times a day.-The CPO from the hospital (documented above) indicated the resident should receive 10 MG twice per day until 5/16/23 and then 5 MG twice per day thereafter, not receive 10 MG and 5 MG.The 5/11/23 physician's order note documented that the order was clarified to read: Eliquis 5 MG-give 10 MG by mouth two times a day for PE until 5/18/23.-However, the resident was still not receiving the correct dosage of Eliquis according to the 5/10/23 physician notes and the hospital discharge orders. According tothe May 2023 MAR (medication administration record), the resident did not receive any anticoagulant therapy after 5/18/23.-The hospital discharge orders indicate the resident should receive long term anticoagulant therapy with a dose of Eliquis 5 MG twice per day, with no stop date indicated. 3. Resident #156's change of conditionThe 6/2/23 nursing progress note documented a certified nurse aide (CNA) altered the nursing at 12:15 p.m. the resident was slumped over in the wheelchair, drool coming from his mouth, his pupils dilated, was slurring his speech and was diaphoretic (sweating heavily). The resident displayed seizure activity for 30 seconds with convulsing. The resident had a blood pressure of 74/42 (with normal being 120/80) and had an oxygen saturation of 82% (percent) on room air (normal range 95 to 100 %). The resident was placed on a non-re-breather at 15 LPM (liters per minute) which brought the resident to 88% oxygen saturation. The resident was sent to the hospital via 911 ambulance. The 6/2/23 emergency room notes documented the resident was brought into the emergency room unresponsive. The resuscitation efforts were not successful and were terminated at 1:12 p.m. It indicated Resident #156 had a life threatening clotting disease and upon his arrival to the hospital from the facility, the medication list showed no use of anticoagulants. According to the hospital notes, the coroner determined that the resident suffered from cardiac arrest due to a pulmonary embolism from a lack of anticoagulation. The 6/27/23 certificate of death documented the resident's cause of death was cardiac arrest due to a pulmonary embolism. The facility failed to ensure the medications indicated on the hospital discharge list were properly transcribed to the resident's medical record. This failure led to the resident's lack of anticoagulant therapy, which ultimately, caused a pulmonary embolism which resulted in Resident #156's death. C. Staff interviewsRegistered nurse (RN) #3 was interviewed on 7/25/23 at 3:06 p.m. She said anticoagulant therapy assisted in preventing DVTs and PEs. She said blood clots could travel throughout the body and cause serious health problems, even death. She said the nurse on duty was responsible for reviewing the discharge orders for an admitting resident. She said that the nurse was responsible to read over the medications, inform the attending physician at the facility and transcribe the medications into the resident's medical record. She said she was not aware of a system in place at the facility where the facility double checked the discharge orders from the hospital and the orders transcribed into the resident's medical record. She said if a resident was a high risk for PE, then not receiving anticoagulant therapy could cause the resident to suffer from an acute PE.The director of nursing (DON) was interviewed on 7/25/23 at 3:29 p.m. She said each resident who was admitted to the facility from the hospital had their medication reviewed by two nurses and the physician. She said the nurse would contact the physician to verify the medications. She said the admitting nurse was responsible for entering the medications into the resident's electronic medical record. She said the interdisciplinary team, which consisted of nursing management, did not review the admission orders to ensure the medications had been entered into the resident's medical record correctly. She said she remembered Resident #156's change of condition and being sent to the hospital but she could not remember the circumstances surrounding the change of condition. She acknowledged the orders from the hospital documented the resident should have been taking Eliquis 10 MG twice per day until 5/16/23 and then 5 MG twice per day thereafter. She confirmed the orders from the hospital were input incorrectly into the resident's medical record. She confirmed that the resident did not receive any anticoagulant therapy after 5/18/23. She confirmed the resident wasa high risk for embolism and DVT. She said a lack of anticoagulant therapy could cause the resident to throw another PE and lead to serious health complications, such as death. The pharmacist and the physician were unavailable for an interview during the survey process.

Plan of correction · submitted by the facility

F760 Abated 8/4/2023 1. Resident #156 no longer resides at the facility. 2. Any resident on anticoagulant therapy has the potential to be affected. An audit of all other residents on anticoagulant therapy was conducted on 9/8/2023 to ensure orders were correct and administered as ordered. No other residents were identified. Root cause analysis revealed a transcription error of anticoagulant medication for resident #156.3. Education was provided to all licensed nurses on 8/4/2023 to include the dual verification process of new admission/readmission of anticoagulant orders. Agency nurses will be educated prior to working their shift. During the new hire orientation process education will be provided to licensed nurses. Clinical competency validations of medication administration are completed for 2 nurses, once a week (to include agency staff), for 12 weeks. 4. The DON/designee will conduct audits of any resident on anticoagulant therapy 5 times per week for a period of no less than 12 weeks or until sustained compliance is achieved. This audit includes reviewing the current anticoagulant order. The provider will be notified for any missed doses and orders for any changes will be obtained at that time including lab work as determined by the provider. Results of this systematic change will be presented to the quality assurance improvement committee monthly for at least three months or until sustained compliance is achieved. Any deviation from the process will be corrected when identified.

1515Resident Rights - Statement of Rights▼

Findings

Based on interviews, observations and record review, the facility failed to ensure residents had the right to a dignified experience. The facility failed to ensure Resident #113 did not experience feeling humiliation during an episode of incontinence. The facility failed to treat Resident #127 with respect and dignity when the staff used foul language toward him and told him to clean his own bathroom. Additionally, the facility failed to provide a culture and environment that promoted residents being treated with dignity and respect. Findings include:I. Facility policy and procedureThe Resident Rights and Facility Responsibilities policy and procedure, undated, was provided by the administrator in training (AIT) on 7/26/23 at 1:30 p.m. It revealed, in pertinent part, "It is the facility's policy to abide by all resident rights, and to communicate these rights to residents and their designated representative in a language that they can understand."A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident."II. Failure to ensure Resident #113 did not experience humiliation during an incontinence episodeA. Resident statusResident #113, age 63, was admitted on 6/6/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included lung cancer, schizoaffective disorder, anxiety and insomnia. The 6/15/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He was independent with all activities of daily living. It indicated the resident had mild depression with a score of six out of 27 on the PHQ-9 (patient health questionnaire for depression). B. Resident interviewResident #113 was interviewed on 7/20/23 at 12:09 p.m. He said when he was first admitted, he had walked into the hallway to ask the nurse for pain medication. He said while he was walking back to his room, he realized he had an episode of diarrhea and it had run up his back and down his legs. He said he walked into his room, activated the call light and then walked into the bathroom. He said a certified nurse aide (CNA) entered his room and gasped. He said she looked horrified and disgusted. He said he was already embarrassed but that made him feel humiliated. He said he asked her to help him and she just stood there and stared at him. He said he told her if she was not going to help then to please grab him some towels out of the wardrobe but she left the room instead. He said he yelled at her because she was refusing to help him when it was her job. He said he did not know her name because the staff at the facility did not wear name tags. He said the CNA got the nurse and the nurse came to assist him in getting cleaned up. He said the social worker had talked to him about the incident, however he felt the facility had not done anything about it and was still very upset. C. Record reviewThe behavior care plan, initiated and revised on 7/6/23, documented Resident #133 tended to perseverate on things due to a diagnosis of anxiety and schizoaffective disorder. The interventions included anticipating the resident's needs, assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express feelings appropriately, explaining all procedures to the resident and allowing time to adjust and monitoring behavioral episodes and attempting to determine the underlying cause. The 6/9/23 nursing progress notes documented at approximately 2:30 a.m. the resident said he was walking with the walker out of his room and became incontinent of bowel. The nurse noted she had observed bowel incontinence. The resident needed assistance getting cleaned up and provided supervision while the resident showered. It indicated the resident said he was angry and very embarrassed. The 6/9/23 satisfaction and concern form documented that the resident had been admitted to the facility and said his needs had not been taken care of and wanted to file a formal complaint. The resident reported he felt like he was ignored by the CNA and felt it was a dereliction (abandonment) of duty. He said the CNA told him that it was too early to help him, left the room and did not assist him when he had an episode of diarrhea. He said the nurse assisted him but the CNA ignored him the rest of the day and did not offer him an apology. It indicated that the nurse was spoken with and obtained a timeline, however did not indicate that the CNA had been spoken with or what was done to rectify the situation with the resident. The 6/21/23 care conference note documented the resident was still upset about the incident in the shower. Social services staff offered to talk to the director of nursing (DON), however the resident declined saying, "no, I am not going to do that. What would that do."D. Staff interviews The DON was interviewed on 7/25/23 at 3:29 p.m. She said she was unaware of the situation with Resident #113. She said she was unaware if the CNA had been identified or spoken with regarding the resident's concerns. She said she was unsure why it indicated the resident was happy with the resolution when the grievance did not document a resolution. Social worker (SW) #1 was interviewed on 7/25/23 at 4:50 p.m. She said she was the social worker for Resident #113. She said the resident was very nice, upfront and knew what he was talking about. She said he was very social and walked around the facility interacting with the staff and other residents. She said she was not at the facility during the incident with the CNA. She said she was aware he was upset about the situation. She said she had suggestions to ensure this instance did not happen again, however she was unable to provide those suggestions. She said she was unsure if the CNA was talked to about the resident's concern. She said she thought the director of social services (DSS) met with the resident. The DSS was interviewed on 7/25/23 at 6:32 p.m. She said she was just the keeper of the grievances but did not actually read them. She said she never met with Resident #113 following the incident he reported. III. Failure to ensure Resident #127 was treat with respect and dignityA. Resident statusResident #127, age 79 was admitted on 5/5/21. According to the July 2023 CPO, diagnoses included anxiety, depressive episodes and malignant neoplasm (cancer) of the colon. The 6/8/23 facility assessment indicated the resident had moderate cognitive impairment with a score of nine out of 15 for the BIMS. The resident was primarily independent with activities of daily living and required setup help by staff. B. Observations and interviewOn 7/19/23 at 9:05 a.m., housekeeper (HSKP) #1 was observed upon entry to the third floor memory care unit. HSKP #1 said, "It's this (explicit word) guy again."Resident #127 was interviewed on 7/19/23 at approximately 11:00 a.m. He said housekeeping staff in particular use foul language in his room which makes him feel disrespected. Resident #127 said they even brought him cleaning supplies and left them in the resident's room and told him "you should clean the (explicit word) in the toilet yourself and you should clean your room yourself." The resident said housekeeping staff utilized a fork to scrape off dried feces in the toilet bowl and left the fork in the resident's bathroom in order for him to scrape off dried feces himself because housekeeping staff were sick of cleaning his room. At approximately 11:00 a.m. a fork with dried fecal matter on top of a three drawer plastic cart was observed in the resident's bathroom. The resident's bathroom was observed with streaks of brown hardened substance stuck to the outside of the toilet bowl. The inside of the toilet bowl contained dried fecal matter. The resident's room contained Scrubbing Bubbles (bathroom cleaner) and Ajax (all purpose powder cleaner). C. Staff interviewsSocial worker (SW) #1 was interviewed on 7/19/23 at 3:15 p.m. She said foul language should not be used in the facility, because the facility was a resident's home and the use of foul language was disrespectful. Registered nurse unit manager (RNUM) #1 was interviewed on 7/19/23 at 3:22 p.m. She said foul language should not be used in the resident's home because it could create a negative environment for a resident. The use of profanity could negatively impact a resident which could make them feel unsafe in their own home. The DON was interviewed on 7/19/23 at approximately 3:30 p.m. The DON said foul language in the care area was not professional and should not be used in the workplace by staff. IV. Failure to create a culture and environment that promoted treating residents with dignity and respectA. Resident interviewsResident #130's family member was interviewed on 7/19/23 at 3:55 p.m. He said the facility had been using agency staff members for a while and he felt they did not treat the residents at the facility with dignity and respect. He said he was assisting his mother one day when an agency staff member told him to stop and leave. He said she was argumentative with him while he was just trying to help because his mother became "slappy" with staff members she did not know. He said he worried about his mom all night long that night. Resident #75 was interviewed on 7/20/23 at 9:39 a.m. Resident #75 stated that staff talked down to her and other residents at least twice a day. She said, "They talk to us like we are children and it makes me very angry and I cannot do anything about it." Resident #48 was interviewed on 7/20/23 at 1:40 p.m. Resident #48 said the administration did not treat residents nicely. She said the NHA told her "don't you want to move to another facility." She said she became very upset when the NHA told her that. Resident #48 said other residents have needed help and staff have told them they needed to wait and the residents had to wait a long time, sometimes up to an hour before being helped. Resident #7 was interviewed on 7/20/23 at 10:39 a.m. She said she felt the facility staff were not respectful. She said the staff were quick to come into her room, complete their task and leave without speaking. She said she felt like they did not care and felt like a bother to them. Resident #86 was interviewed on 7/20/23 at 12:09 p.m. He said he felt the staff did not think the residents at the facility were a priority. He said they would enter the room, take care of the task and then leave. He said oftentimes staff would enter his room and ask, "What do you want now?"He said the facility staff would often enter his room without knocking. He said he felt it was rude for staff to walk into his home without knocking and receiving permission to enter. Resident #113 was interviewed on 7/24/23 at 3:35 p.m. He said he felt the facility staff had an attitude. He said it was like pulling teeth to get them to help. He said the staff will talk on their cell phones instead of answering the call lights. He said he felt like the staff did not care for them and was just there to get a paycheck. He said they do not have a sense of urgency and just meander down the hallway. Resident #75 was interviewed on 7/24/23 at 4:48 p.m. She said the certified nurse aide (CNA) #7 yelled at her while using the sink in her room. She said CNA #7 told her she needed to move because her roommate was getting ready to get a sponge bath. Resident #75 said she was upset that CNA #7 yelled at her. B. ObservationsOn 7/20/23 at 10:18 a.m. an unidentified CNA exited Resident #128's room with used incontinence supplies. A loud noise was observed and the unidentified CNA returned to Resident #128's room. The CNA asked the resident, "what do you want now?" Resident #128 said he wanted to stand up. The CNA said, "why do you want to stand up, you don't need to stand up."Resident #128 said, "I need to go." The CNA responded, "You aren't going anywhere and you need to calm down." The CNA then wheeled Resident #128 out to the nursing station and then left him to go into the break room. At 12:58 p.m. an unidentified CNA entered resident room #139 carrying a meal tray. She did not knock prior to entering the room, delivered the meal tray and left the room. She did not talk to the resident or set up the meal for the resident. C. Record reviewThe March 2023 resident council minutes documented the residents felt their needs were not taken seriously. The April 2023 resident council minutes documented the resident would like the administrator to be more involved and would like more of the management team represented in the meetings. The June 2023 resident council minutes documented one resident overheard some CNAs state the residents treat them badly and that was why the staff did not stay. The residents voiced concerns the CNAs should be professional and had concerns regarding agency staff. The July 2023 resident council minutes documented residents had concerns regarding communication around the facility, call lights not being put within reach when their beds and CNAs complained they did not have time. IV. Staff interviewsCNA #17 was interviewed on 7/25/23 at 3:10 p.m. She said all residents should be treated with dignity and respect. She said all staff were responsible for the care needs of each resident. The DON was interviewed on 7/25/23 at 3:29 p.m. She said facility staff should treat all residents with respect and dignity. She said each concern should be addressed with the resident who had the concern and all staff members involved. She said she had a nurse manager in the facility seven days per week to assist in handling any resident or family concerns. She said any concerns should be brought to the unit manager and with the social worker, work to resolve each resident's concerns. She said the nursing management had been pushing customer service and trying to have positive interactions with residents.

Plan of correction · submitted by the facility

How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. A follow-up was completed with resident #113 and #127. The follow-up was to ensure that no other event of alleged humiliation related to an incontinence episode of resident #113 occurred since the date of the event. Follow-up with resident #127 to ensure no foul language was used toward him or within his hearing range since the completion of the survey. The CNA in the incident with resident 113 was identified as an agency CNA and she was removed from our facility list and will not work here again. Social services has addressed the concerns of resident 75, 48, 7, 86, follow up completed with a family member of resident 130. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. DON/ designee met with all residents to discuss resident rights. Director of activities and social services provided each resident with a copy of the resident rights, contact information for the state ombudsman, the Colorado department of public health, and the NHA/DON of the facility. Facility adopted a partner program and IDT completed a house wide audit of any concerns that residents had. The concerns were identified and addressed with NHA. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur? 3. Staff will be educated, on or before the date of compliance, by NHA/designee on resident rights and the use of professional language in the workplace/resident homes. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. A member of the interdisciplinary team will round once a week and interview 5 residents, for twelve weeks, regarding any concerns they may have related to resident rights/dignity and if the need arises assistance with contacting the ombudsman. Concerns will be reviewed by IDT in daily morning meeting, M-F, to ensure resolution is completed. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and suitability. If there is any area of concern identified, it will be corrected immediately upon discovery.

8/8/2023Complaint, Recertification Survey · ID V0FR1124 deficiencies▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A recertification survey with complaints #CO32895 and #CO32979 and Incident #32643 was completed on 7/19/23-8/8/23. Twenty-four deficiencies were cited.

Findings · record 2 of 2

An Emergency Preparedness survey was conducted from 7/19/23 to 8/8/23. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0550Resident Rights/Exercise of RightsS/S H▼

Findings

Based on interviews, observations and record review, the facility failed to ensure residents had the right to a dignified experience. The facility failed to ensure Resident #113 did not experience feeling humiliation during an episode of incontinence. The facility failed to treat Resident #127 with respect and dignity when the staff used foul language toward him and told him to clean his own bathroom. Additionally, the facility failed to provide a culture and environment that promoted residents being treated with dignity and respect. Findings include:I. Facility policy and procedureThe Resident Rights and Facility Responsibilities policy and procedure, undated, was provided by the administrator in training (AIT) on 7/26/23 at 1:30 p.m. It revealed, in pertinent part, "It is the facility's policy to abide by all resident rights, and to communicate these rights to residents and their designated representative in a language that they can understand."A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident."II. Failure to ensure Resident #113 did not experience humiliation during an incontinence episodeA. Resident statusResident #113, age 63, was admitted on 6/6/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included lung cancer, schizoaffective disorder, anxiety and insomnia. The 6/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He was independent with all activities of daily living. It indicated the resident had mild depression with a score of six out of 27 on the PHQ-9 (patient health questionnaire for depression). B. Resident interviewResident #113 was interviewed on 7/20/23 at 12:09 p.m. He said when he was first admitted, he had walked into the hallway to ask the nurse for pain medication. He said while he was walking back to his room, he realized he had an episode of diarrhea and it had run up his back and down his legs. He said he walked into his room, activated the call light and then walked into the bathroom. He said a certified nurse aide (CNA) entered his room and gasped. He said she looked horrified and disgusted. He said he was already embarrassed but that made him feel humiliated. He said he asked her to help him and she just stood there and stared at him. He said he told her if she was not going to help then to please grab him some towels out of the wardrobe but she left the room instead. He said he yelled at her because she was refusing to help him when it was her job. He said he did not know her name because the staff at the facility did not wear name tags. He said the CNA got the nurse and the nurse came to assist him in getting cleaned up. He said the social worker had talked to him about the incident, however he felt the facility had not done anything about it and was still very upset. C. Record reviewThe behavior care plan, initiated and revised on 7/6/23, documented Resident #113 tended to perseverate on things due to a diagnosis of anxiety and schizoaffective disorder. The interventions included anticipating the resident's needs, assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express feelings appropriately, explaining all procedures to the resident and allowing time to adjust and monitoring behavioral episodes and attempting to determine the underlying cause. The 6/9/23 nursing progress notes documented at approximately 2:30 a.m. the resident said he was walking with the walker out of his room and became incontinent of bowel. The nurse noted she had observed bowel incontinence. The resident needed assistance getting cleaned up and provided supervision while the resident showered. It indicated the resident said he was angry and very embarrassed. The 6/9/23 satisfaction and concern form documented that the resident had been admitted to the facility and said his needs had not been taken care of and wanted to file a formal complaint. The resident reported he felt like he was ignored by the CNA and felt it was a dereliction (abandonment) of duty. He said the CNA told him that it was too early to help him, left the room and did not assist him when he had an episode of diarrhea. He said the nurse assisted him but the CNA ignored him the rest of the day and did not offer him an apology. It indicated that the nurse was spoken with and obtained a timeline, however did not indicate that the CNA had been spoken with or what was done to rectify the situation with the resident. The 6/21/23 care conference note documented the resident was still upset about the incident in the shower. Social services staff offered to talk to the director of nursing (DON), however the resident declined saying, "no, I am not going to do that. What would that do."D. Staff interviews The DON was interviewed on 7/25/23 at 3:29 p.m. She said she was unaware of the situation with Resident #113. She said she was unaware if the CNA had been identified or spoken with regarding the resident's concerns. She said she was unsure why it indicated the resident was happy with the resolution when the grievance did not document a resolution. Social worker (SW) #1 was interviewed on 7/25/23 at 4:50 p.m. She said she was the social worker for Resident #113. She said the resident was very nice, upfront and knew what he was talking about. She said he was very social and walked around the facility interacting with the staff and other residents. She said she was not at the facility during the incident with the CNA. She said she was aware he was upset about the situation. She said she had suggestions to ensure this instance did not happen again, however she was unable to provide those suggestions. She said she was unsure if the CNA was talked to about the resident's concern. She said she thought the director of social services (DSS) met with the resident. The DSS was interviewed on 7/25/23 at 6:32 p.m. She said she was just the keeper of the grievances but did not actually read them. She said she never met with Resident #113 following the incident he reported. III. Failure to ensure Resident #127 was treat with respect and dignityA. Resident statusResident #127, age 79 was admitted on 5/5/21. According to the July 2023 CPO, diagnoses included anxiety, depressive episodes and malignant neoplasm (cancer) of the colon. The 6/8/23 MDS assessment indicated the resident had moderate cognitive impairment with a score of nine out of 15 for the BIMS. The resident was primarily independent with activities of daily living and required setup help by staff. B. Observations and interviewOn 7/19/23 at 9:05 a.m., housekeeper (HSKP) #1 was observed upon entry to the third floor memory care unit. HSKP #1 said, "It's this (explicit word) guy again."Resident #127 was interviewed on 7/19/23 at approximately 11:00 a.m. He said housekeeping staff in particular use foul language in his room which makes him feel disrespected. Resident #127 said they even brought him cleaning supplies and left them in the resident's room and told him "you should clean the (explicit word) in the toilet yourself and you should clean your room yourself." The resident said housekeeping staff utilized a fork to scrape off dried feces in the toilet bowl and left the fork in the resident's bathroom in order for him to scrape off dried feces himself because housekeeping staff were sick of cleaning his room. At approximately 11:00 a.m. a fork with dried fecal matter on top of a three drawer plastic cart was observed in the resident's bathroom. Cross-reference F880 infection control for failure to appropriately clean the resident's room. The resident's bathroom was observed with streaks of brown hardened substance stuck to the outside of the toilet bowl. The inside of the toilet bowl contained dried fecal matter. The resident's room contained Scrubbing Bubbles (bathroom cleaner) and Ajax (all purpose powder cleaner). Cross-reference F689 accident/hazards for having unsecured chemicals. C. Staff interviewsSocial worker (SW) #1 was interviewed on 7/19/23 at 3:15 p.m. She said foul language should not be used in the facility, because the facility was a resident's home and the use of foul language was disrespectful. Registered nurse unit manager (RNUM) #1 was interviewed on 7/19/23 at 3:22 p.m. She said foul language should not be used in the resident's home because it could create a negative environment for a resident. The use of profanity could negatively impact a resident which could make them feel unsafe in their own home. The DON was interviewed on 7/19/23 at approximately 3:30 p.m. The DON said foul language in the care area was not professional and should not be used in the workplace by staff. IV. Failure to create a culture and environment that promoted treating residents with dignity and respectA. Resident interviewsResident #130's family member was interviewed on 7/19/23 at 3:55 p.m. He said the facility had been using agency staff members for a while and he felt they did not treat the residents at the facility with dignity and respect. He said he was assisting his mother one day when an agency staff member told him to stop and leave. He said she was argumentative with him while he was just trying to help because his mother became "slappy" with staff members she did not know. He said he worried about his mom all night long that night. Resident #75 was interviewed on 7/20/23 at 9:39 a.m. Resident #75 stated that staff talked down to her and other residents at least twice a day. She said, "They talk to us like we are children and it makes me very angry and I cannot do anything about it." Resident #48 was interviewed on 7/20/23 at 1:40 p.m. Resident #48 said the administration did not treat residents nicely. She said the NHA told her "don't you want to move to another facility." She said she became very upset when the NHA told her that. Resident #48 said other residents have needed help and staff have told them they needed to wait and the residents had to wait a long time, sometimes up to an hour before being helped. Resident #7 was interviewed on 7/20/23 at 10:39 a.m. She said she felt the facility staff were not respectful. She said the staff were quick to come into her room, complete their task and leave without speaking. She said she felt like they did not care and felt like a bother to them. Resident #86 was interviewed on 7/20/23 at 12:09 p.m. He said he felt the staff did not think the residents at the facility were a priority. He said they would enter the room, take care of the task and then leave. He said oftentimes staff would enter his room and ask, "What do you want now?"He said the facility staff would often enter his room without knocking. He said he felt it was rude for staff to walk into his home without knocking and receiving permission to enter. Resident #113 was interviewed on 7/24/23 at 3:35 p.m. He said he felt the facility staff had an attitude. He said it was like pulling teeth to get them to help. He said the staff will talk on their cell phones instead of answering the call lights. He said he felt like the staff did not care for them and was just there to get a paycheck. He said they do not have a sense of urgency and just meander down the hallway. Resident #75 was interviewed on 7/24/23 at 4:48 p.m. She said the certified nurse aide (CNA) #7 yelled at her while using the sink in her room. She said CNA #7 told her she needed to move because her roommate was getting ready to get a sponge bath. Resident #75 said she was upset that CNA #7 yelled at her. B. ObservationsOn 7/20/23 at 10:18 a.m. an unidentified CNA exited Resident #128's room with used incontinence supplies. A loud noise was observed and the unidentified CNA returned to Resident #128's room. The CNA asked the resident, "what do you want now?" Resident #128 said he wanted to stand up. The CNA said, "why do you want to stand up, you don't need to stand up."Resident #128 said, "I need to go." The CNA responded, "You aren't going anywhere and you need to calm down." The CNA then wheeled Resident #128 out to the nursing station and then left him to go into the break room. At 12:58 p.m. an unidentified CNA entered resident room #139 carrying a meal tray. She did not knock prior to entering the room, delivered the meal tray and left the room. She did not talk to the resident or set up the meal for the resident. C. Record reviewThe March 2023 resident council minutes documented the residents felt their needs were not taken seriously. The April 2023 resident council minutes documented the resident would like the administrator to be more involved and would like more of the management team represented in the meetings. The June 2023 resident council minutes documented one resident overheard some CNAs state the residents treat them badly and that was why the staff did not stay. The residents voiced concerns the CNAs should be professional and had concerns regarding agency staff. The July 2023 resident council minutes documented residents had concerns regarding communication around the facility, call lights not being put within reach when their beds and CNAs complained they did not have time. IV. Staff interviewsCNA #17 was interviewed on 7/25/23 at 3:10 p.m. She said all residents should be treated with dignity and respect. She said all staff were responsible for the care needs of each resident. The DON was interviewed on 7/25/23 at 3:29 p.m. She said facility staff should treat all residents with respect and dignity. She said each concern should be addressed with the resident who had the concern and all staff members involved. She said she had a nurse manager in the facility seven days per week to assist in handling any resident or family concerns. She said any concerns should be brought to the unit manager and with the social worker, work to resolve each resident's concerns. She said the nursing management had been pushing customer service and trying to have positive interactions with residents.

Plan of correction · submitted by the facility

F550How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. A follow-up was completed with resident #113 and #127. The follow-up was to ensure that no other event of alleged humiliation related to an incontinence episode of resident #113 occurred since the date of the event. Follow-up with resident #127 to ensure no foul language was used toward him or within his hearing range since the completion of the survey. The CNA in the incident with resident 113 was identified as an agency CNA and she was removed from our facility list and will not work here again. Social services has addressed the concerns of resident 75, 48, 7, 86, follow up completed with a family member of resident 130. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. DON/ designee met with all residents to discuss resident rights. Director of activities and social services provided each resident with a copy of the resident rights, contact information for the state ombudsman, the Colorado department of public health, and the NHA/DON of the facility. Facility adopted a partner program and IDT completed a house wide audit of any concerns that residents had. The concerns were identified and addressed with NHA.What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur? 3. Staff will be educated, on or before the date of compliance, by NHA/designee on resident rights and the use of professional language in the workplace/resident homes. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. A member of the interdisciplinary team will round once a week and interview 5 residents, for twelve weeks, regarding any concerns they may have related to resident rights/dignity and if the need arises assistance with contacting the ombudsman. Concerns will be reviewed by IDT in daily morning meeting, M-F, to ensure resolution is completed. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and suitability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0574Required Notices and Contact InformationS/S D▼

Findings

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to:-Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents. Findings include:I. Resident group interviewThe group interview was conducted on 7/24/23 at 10:36 p.m. with five residents (#10, #68, #91 #104 and #105) identified by assessment and the facility as interviewable. All five residents said they did not know they could file a complaint with the State Agency and they did not know where the facility posted information in regard to pertinent State Agencies' contact information and it was not reviewed in the resident council meeting. III. Staff interviews and observationOn 7/19/23 at 10:46 a.m. observation of the mandatory posting for the State Agency was made on the third floor across from the unit manager's office. An eight inch by 11 inch paper was stapled inside a glass bulletin board. The posting was hung approximately six feet up from the floor. The bulletin board contained a paper with the names, addresses and phone numbers of State Agencies. The font of the contact information was approximately size 11 font but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. On 7/20/23 at 8:36 a.m. observation of the mandatory posting for the State Agency was made upon entrance to the facility. An eight inch by 11 inch paper was stapled inside a glass bulletin board upon the entrance to the facility on the right hand side. The posting was hung approximately seven feet up from the floor. The bulletin board contained a paper with the names, addresses and phone numbers of State Agencies. The font of the contact information was approximately size 11 font but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. The posting was in an area that was not easily accessible to residents that were not mobile. Certified nurse aide (CNA) #1 was interviewed on 7/24/23 at 2:11 p.m. She said she was uncertain where the State Agencies' contact information was located. CNA #2 was interviewed on 7/24/23 at 2:15 p.m. She said she did not know where the State Agencies' contact information was located. Registered nurse unit manager (RNUM) #1 was interviewed on 7/2/423 at 2:19 p.m. She said she did not know where the State Agencies' contact information was located.

Plan of correction · submitted by the facility

F574How corrective action will be accomplished for those residents found to have been affected by the alleged deficient practice. The mandatory posting for the State Agency information, to include filing a grievance was posted in 19 point font and an adjusted height of 37 inches. Residents 10, 68, 91, 104, and 105, personally received this form and were educated on its purpose and use. How the facility will identify other residents having the potential to be affected by the same alleged deficient practice. All residents with cognitive capabilities will receive the required information via paper copy and personal communication to educate the purpose and use. The information is also posted on all floors of the facility and in every admissions packet. What measures will be put into place or systemic changes made to ensure the alleged deficient practice will not reoccur. Staff will be re-educated, on or before the date of compliance, by Social Services/designee as to the purpose of the State Agency's information and its location throughout the facility. Revised copies of the mandatory information will be put in Admissions packets to ensure residents/families have immediate access to it. New staff will be educated as to the purpose and locations of the State agency form. Reminders as to the purpose and locations of the State agency forms will be addressed in Resident Council. All residents will be informed that Social Services will have copies and can assist with contacts if requested. How the facility plans to monitor its performance to make sure that solutions are sustained. NHA/designee will complete an audit once per week, for 4 weeks, then once per month for two months, to ensure that posting remains in place and visible to residents. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and suitability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0584Safe/Clean/Comfortable/Homelike EnvironmentS/S E▼

Findings

Based on observations and interviews, the facility failed to ensure residents had safe, clean, comfortable and homelike environments in multiple areas of the facility. Specifically, the facility failed to ensure resident rooms and facility hallways. Findings include:I. Initial observationsThe following was observed during the initial walkthrough of entering the facility on 7/19/23 at 9:00 a.m. until 7/20/23 at 4:00 p.m. The third floor memory care was observed to have bugs (deceased) in multiple ceiling light fixtures throughout the unit. Room #16 and #17: The window blinds were observed to be broken, bent and missing. Room #231: The electrical outlet on wall behind head of bed was observed to be dislodged from wall and unusable. Room #259: Multiple holes and tears, ranging from approximately one inch to four inches were observed in the screen to the window. Room #263: Two vertical holes, approximately three inches in length and half an inch wide were observed in the wall behind the head of the bed; pieces of drywall and dust was observed on the floor below the holes. Room #261: Ants were observed on the floor nearest the window. II. Environmental tour and staff interviewThe environmental tour was conducted on 7/25/23 at 3:21 p.m. with the maintenance director (MTD). The above observations were reviewed and documented by the MTD. He said he did not know if it was the responsibility of the maintenance or housekeeping department to clean bugs from light fixtures on the ceiling, he said he would discuss with the housekeeping department. He said he was aware of the damaged blinds in room #16 and #17 and was awaiting delivery of more blinds. He said he was unaware of the damaged electrical outlet in room #231. He said he was unaware of the damage to the screen window in room #259 and suspected it was hail damage from a recent storm. He said he was unaware of the damage to the wall in room #263 but was familiar with the problem. He said it occurred with the bariatric beds and the design when the residents raise and lower the head of the bed. He said he was aware of the ants in room #261 and the problem has been resolved. He said the staff submitted work tickets through a web-based communication system to inform the maintenance department of needed repairs. He said the same system was used to track and complete general maintenance rounds in the facility. He said he would attend to repairs as soon as possible.

Plan of correction · submitted by the facility

F584#1 – How corrective action will be accomplished for those residents found to have been affected by the alleged deficient practice. Third Floor Memory Care: Bugs in the ceiling light fixtures were removed immediately. Rooms #16 and #17: New blinds have been installed. Room #231: The electrical outlet was replaced. Room #259: The torn window screen is on order and will be replaced upon arrival. Room #263: The holes in the wall were temporarily covered and secured. A professional repair will be scheduled. Room #261: Although there was no evidence of ants, the room underwent thorough treatment to prevent future infestations.#2 – How the facility will identify other residents having the potential to be affected by the same deficient practice. A facility-wide inspection will be conducted, focusing on resident rooms, common areas, and hallways. The Maintenance and Housekeeping teams will identify any areas requiring immediate attention and corrections will be completed.#3 – What measures will be put into place or systemic changes made to ensure the alleged deficient practice will not reoccur. TELS: The web-based system for submitting and tracking maintenance requests will be reviewed and optimized to ensure timely responses to issues. Preventative maintenance orders will be put in for one floor per Quarter or as needed if notified by staff or residents or as a room becomes empty. Training for Maintenance and Housekeeping Staff: Both departments will undergo training, on or before the date of compliance, to ensure clarity regarding responsibilities and procedures, especially concerning cleanliness and repairs.#4 – Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit of 10 rooms per week will be conducted once a week for 12 weeks. Results and findings of audits will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and suitability. If there is any area of concern identified, it will be corrected immediately upon discovery. 5. Completion/compliance date 9/8/23

0585GrievancesS/S E▼

Findings

Based on observations, interviews and record review, the facility failed to ensure seven (#19, #69, #90, #92, #25, #98 and #75) residents were provided prompt efforts by the facility to follow up on grievances out of 71 sample residents. Specifically, the facility failed to ensure grievances were followed up timely with a resolution in regards to missing property. Findings include:I. Facility policy and procedureThe Complaints and Grievances policy, revised 2/8/19, was provided by the nursing home administrator (NHA) on 7/26/23 at 11:03 p.m. It read in pertinent part "This facility encourages and requests that staff, residents, families, visitors, express their concerns, complaints and grievances. The facility will review, investigate and respond to all such concerns. A resident, his or her representative, family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members, theft of property, without fear of threat or reprisal in any form."II. Resident interviews All residents were identified by facility and assessment as interviewable. Resident #19 was interviewed on 7/19/23 at 1:54 p.m. She stated she lost one of her favorite clothing items shortly after coming to the facility. She said she filed a grievance and went directly to the laundry to try to locate the missing item but was unable to find it. She said she was not reimbursed for the item or offered any other kind of resolution. She said no staff or management had followed up with her. Resident #69 was interviewed on 7/19/23 at 12:47 p.m. She said she had several bras when she first admitted to the facility on 11/24/20. She said she no longer had any bras at all. She had reported the missing items to the certified nurse aides (CNA) and nurses; however, she had not heard anything back. Resident #69 said the facility had not located or replaced any of the missing bras resulting in her not having any bras to wear and this makes her uncomfortable. Resident #90 was interviewed on 7/19/23 at 1:41 p.m. He said he had a watch when he was in his initial room approximately one month ago, however, when he moved to his current room the watch did not make it there. He said he filed a grievance and one of the CNAs said she looked for it in his old room but did not see it. Resident #90 was not offered any compensation or a replacement watch. Resident #92 was interviewed on 7/19/23 at 11:00 a.m. Resident #92 said she ordered items online and often did not receive them. Most recently she said she ordered some Easter cards and two puzzles that she did not receive. She did file a grievance and although there was writing on the grievance that the items were found in her room, they were not located. She said the items were still missing and she was not offered any replacement items or reimbursement. Resident #25 was interviewed on 7/19/23 at approximately 12:00 p.m. She said her clothing went missing on 7/4/23 after she requested her clothing to be laundered; prior to the clothes being laundered the resident ensured her clothing was labeled to prevent them from getting lost. She notified a CNA on 7/4/23 that upon receipt of her clean laundry she was missing her husband's polo shirt and her shirt with ruffled sleeves. The resident said the CNA told her she would let laundry know and they would keep looking for the missing items until they showed up. The resident said no grievance and or complaint form was filled out and the resident has not received any resolution since 7/4/23 (21 days since verbal complaint was made to staff). Resident #98 was interviewed on 7/19/23 at 2:05 p.m. She said she had two blankets go missing shortly after her sister brought them to her approximately six months ago. She said she filed a grievance but the missing blankets were not found and she was not offered reimbursement or a replacement. She said if you have nice things at the facility they go missing. Resident #75 was interviewed on 7/20/23 at 9:49 a.m. She said within the last six months her clothes have gone missing. She said her phone has been missing for over a week. Resident #75's daughter was interviewed on 7/26/23 at 4:30 p.m. She said the facility staff threw clothes away all the time. She said she went to the laundry room asking about her mother's clothing and the laundry staff showed her that the floor staff constantly threw clothes away that were not marked. She said she brought in a bag of clothes for the resident and labeled it with the resident's name and room number. She said the clothes never made it to Resident #75. She said three weeks ago, Resident #75's bed spread went missing. She said she had physically taken it to the laundry room and handed it to the staff. She said they told her if the label fell off, then it would be thrown away. She said the laundry staff would not allow her to take the clothing out of the trash can for fear they would get into trouble. She said she has seen personal items and clothes go missing often and the facility did not ever replace them. III. Observations and record reviewOn 7/24/23 at approximately 11:30 a.m. the laundry room was observed. The laundry room contained a lost and found section which contained approximately 50 items of missing clothing. The grievances were requested from the facility on 7/24/23 for the residents (see above) and only one grievance was provided for Resident #92. However, according to Resident #92 the items were not located (see above). IV. Staff interviewsCNA #2 was interviewed on 7/25/23 at approximately 3:00 p.m. She said she would not fill out a complaint form if a resident complained about missing property. The director of nurses (DON) was interviewed on 7/25/23 at approximately 7:30 p.m. The DON said if a resident told a CNA property was missing then the staff should immediately fill out a grievance form. If staff were unable to locate the missing item then the resident would be reimbursed monetarily if they had a receipt or the missing items needed to be replaced.

Plan of correction · submitted by the facility

F585How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Resident #19, #69, #90, #92, #98, and #75 identified during the survey all had filed grievances relating to missing items. All grievances as of 9/8/23 have been resolved. Resident #25 has since been discharged from the facility. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents have the potential to be affected by this alleged deficient practice. An audit of grievances filed for the past 30 days related to missing items was conducted by the social services department. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be completed, on or before the date of compliance, with Social Services Director/designee which will outline the need to file grievances on behalf of residents timely and for a final resolution to be reached by day 5 along with follow-up with the resident who filed the complaint. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. Grievances will be reviewed by the NHA after they have been filed. The NHA will review resident grievances 5 days a week. The NHA will bring all grievances to the morning stand up meeting 5 days a week for 12 weeks to ensure timely resolution. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and suitability. If there is any area of concern identified, it will be corrected immediately upon discovery. 5. Compliance/completion date 9/8/23

0600Free from Abuse and NeglectS/S D▼

Findings

Based on record review and interviews the facility failed to keep two residents (#108 and #133) free from resident to resident physical abuse of two residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure there was an effective plan to monitor, or provide increased oversight and effective interventions to protect, Residents #108 and #133 from Resident #409's behavior. Resident #409 physically abused two residents on 7/9/23. Findings include:I. Facility policy and procedureThe Abuse, Neglect, & Exploitation Prevention policy and procedure, revised 12/17/18, documented in pertinent part:"It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facilities staff, other residents, consultants or volunteers, staff or other agencies serving the residents, family members or legal guardians, friends or other individuals. Educating staff on factors related to dementia care and abuse prevention, such as understanding that expressions or indications of distress of residents with dementia are often attempts to communicate an unmet need, discomfort or thoughts that they can no longer articulate with words. However, they may be perceived as challenging behavior to staff and could increase the risk of resident abuse and neglect. Expressions or indications of distress can include, but are not limited to aggressiveness, wandering or elopement, agitation, yelling out, or delusions."II. Resident to resident altercation between Resident #409 (assailant) and Residents #108 and #133The abuse investigation dated 7/9/23 revealed certified nurse aide (CNA) #16 observed Resident #409 "grab and punch" Resident #133 three times on the head while in the dining area of the secure unit. CNA #16 separated Resident #409 from Resident #133 and Resident #409 fell backwards and landed on the floor. Registered nurse (RN) #2 observed the altercation and witnessed Resident #409 attempting to stand from the floor and strike CNA #16. RN #2 assisted in separating Resident #409 and Resident #133 and assessed both for pain and/or injury. While RN #2 held the hand of Resident #409 and assisted him to walk away from the dining area, Resident #409 hit Resident #108 on the head as she was self propelling her wheelchair past them. CNA #17 observed Resident #409 hit Resident #108 on the head as Resident #409 was being escorted from other residents. III. Resident #409A. Resident status Resident #409, age 71, was admitted on 6/28/23 and discharged on 7/9/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia with other behavioral disturbances. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. He required extensive assistance for transfers, dressing, toilet use and personal hygiene. Resident #409 had behaviors of pacing, exit seeking and wandering. B. Record reviewThe 6/28/23 care plan revealed resident #409 used psychotropic medications (prescription medication that affect a person's mental state). Pertinent interventions included monitoring, documenting, and reporting any adverse events to include behavior symptoms not usual to the person.-Resident #409 did not have a care plan regarding physical aggression. The 6/28/23 progress note revealed Resident #409 was admitted to the facility on this day, he was Spanish speaking only. The 6/30/23 progress note revealed Resident #409 was observed attempting to exit the unit on multiple occasions and was transferred to the secure memory care neighborhood on the first floor of the facility. The 7/2/23 progress note revealed Resident #409 had been wandering into other residents' rooms. The 7/3/23progress note revealed Resident #409 entered the room of another resident twice and attempted to take their wheelchair and was observed with his suitcase attempting to exit the building. The 7/4/23 progress note revealed Resident #409 fell backwards against a wall while attempting to open a door to the outside. The 7/8/23 progress note revealed Resident #409 was observed trying to hit another resident and nursing staff intervened, Resident #409 then hit the nurse in the face with a napkin. The 7/9/23 progress note revealed at 10:00 a.m., Resident #409 was observed punching the air with closed fists and stating in Spanish (translated by Spanish speaking CNA) "I want to kill somebody." A second progress note on the same day was recorded at 2:05 p.m. It revealed Resident #409 had fallen backwards while attempting to swing at a CNA after striking two other residents (Resident #108 and #133). IV. Resident #133A. Resident statusResident #133, age 76, was admitted on 12/12/22. According to the July 2023 CPO, the diagnoses included dementia and anxiety. The 6/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She was independent with mobility, transfers, dressing, toilet use and personal hygiene. B. Record reviewThe 7/9/23 progress note revealed Resident #133 was being evaluated for pain and any negative emotional outcomes for aggression received by Resident #409. Resident #133 was observed to have increased anxiety, she pointed at Resident #409 and stated, "He's also trying to get my pants down; you know the same guy; the idiot." Resident #133 approached the nurses station concerned that food on her plate was not okay to eat; the progress note revealed it to be a familiar behavior and she was observed to be in distress. The 7/10/23 progress note revealed Resident #133 was not able to recall the altercation happening on the previous day. The 7/11/23 through 7/13/23 progress notes revealed Resident #133 was free from pain and distress. The care plan, with a revision date of 7/13/23, revealed Resident #133 had a traumatic life experience with being physically abused by her mother as a child and history of alcohol dependence, and due to the recent event of being hit by Resident #409 she was at risk for potential trauma. Interventions included Resident #133 should be monitored for any ongoing mood and behavioral symptoms and that a referral for counseling support be made if need be. V. Resident #108A. Resident statusResident #108, age 88, was admitted on 12/31/21. According to the July 2023 CPO, the diagnoses included dementia, anxiety and depression. The 6/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance from one staff member for dressing, toilet use and personal hygiene. B. Record reviewThe 7/9/23 progress note revealed Resident #108 was struck on the top of her head by another resident and was being evaluated for pain and any negative emotional outcomes. Resident #108 was free from pain and distress. The 7/10/23 and 7/11/23 progress notes revealed Resident #108 was free from pain and distress. The 7/12/23 progress note revealed Resident #108 was observed having anxious behavior, repeatedly telling at staff she "wanted out of here."The 7/13/23 progress note revealed the facility was in contact with Resident #108's decision maker and discussed psychological services being offered to Resident #108. The decision maker was in agreement and added that Resident #108 had lived with an abusive son in her past. The care plan, with a revision date of 7/13/23, revealed Resident #108 was at risk for potential trauma related to the recent event of being hit by Resident #409, and that the resident had a history of trauma related to living with an abusive son. Interventions included promoting feelingsof safety as much as possible and providing the resident with reassurance when appropriate. VI. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 7/25/23 at 10:29 a.m. She said she was not working on the day of the altercation but had worked with Resident #409 while he was admitted to the secure unit. She said Resident #409 was restless, would wander into other residents' rooms, and would ask her how he could leave. She said she was fluent in Spanish and being that Resident #409 was Spanish speaking only she would inquire about his unmet needs. She said he would respond by asking how he could leave. Licensed practical nurse (LPN) #1 was interviewed on 7/25/23 at 10:29 a.m. She said she was not working on the day of the altercation but had worked with Resident #409 while he was admitted to the secure unit. She said he was restless and needed to be continuously monitored as he would wander into other residents' rooms and try to open every door on the secure unit. CNA #5 was interviewed on 7/25/23 at 11:00 a.m. She said she was working on the day of the altercation but did not witness the event. She said Resident #409 was to be observed by staff every 15 minutes for location and needs. She said she had checked in on Resident #409 as she was fluent in Spanish and he expressed no needs. She said she left for her break and was informed of an altercation upon her arrival. The administrator in training (AIT) was interviewed on 7/25/23 at 2:00 p.m. She said she met with the son of Resident #409 prior to admission. She said the terms of the admission was for Resident #409 to move in on a one month trial period, as there was dissatisfaction with his other facility. The AIT said Resident #409 was first admitted to the third floor of the facility and was quickly moved to the first floor secure unit after he was continuously opening and attempting to leave the unit through the emergency exits. She said the family was asked about any behavioral issues and the family denied any existed. She said she had not reached out to the managed care team of Resident #409 to ask about any behavioral issues.

Plan of correction · submitted by the facility

F600How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Residents #108, and #133 remain in the facility on a secure unit. Each resident is at their baseline and neither have had any further altercations and remain free from abuse. Resident #409 has been discharged from the facility. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents who reside on the memory care units have the potential to not remain at their baseline behavior due to cognitive changes based on the diagnosis of Alzheimer’s or dementia. It is the goal of the facility to keep this population free from any form of abuse. Social services will continue to look for and address any noted changes in these residents’ behavior; if a change is noted, the physician will be notified immediately for guidance and oversight of said changes. An audit will be conducted prior to the date of compliance by the social services department. The audit was to ensure that residents with the diagnosis of Alzheimer's or dementia had effective care plans that assisted in the facility's ability to monitor and redirect residents with aggressive-like behaviors. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be provided to line staff, on or before the date of compliance, by the staffing coordinator/designee of the residents' right to be free from harm. The education focused on the resident's right to be free from physical abuse. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. The interdisciplinary team will bring to the bi-weekly risk meeting any deviated behavioral residents for review. The committee at this time will decide if a medication intervention is required or if the behavior warrants a gradual dose reduction. Any identified markers will be brought to the clinical meeting 5 days a week for 12 weeks. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0625Notice of Bed Hold Policy Before/Upon TrnsfrS/S D▼

Findings

Based on interviews and record review, the facility failed to provide written information regarding the facility's bed-hold policy to a resident's representative for one (#409) resident reviewed for discharge out of 71 sample residents. Specifically, the the facility failed to provide Resident #409's representative with a written notice of the bed hold policy when he was transferred to the hospital. Findings include:I. Resident statusResident #409, age 71, was admitted on 6/28/23 and discharged to hospital on 7/9/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia with other behavioral disturbances. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. He required extensive assistance for transfers, dressing, toilet use and personal hygiene. II. Record reviewThe 7/9/23 nursing progress note revealed Resident #409 was sent to the emergency room to be evaluated for aggressive behaviors. Cross-reference F626 for not permitting a resident to return to the facility. A review of the resident's electronic medical record (EMR) did not reveal documentation to indicate that Resident #409's representative was contacted or provided written information regarding the resident's right to a bed hold at the time of Resident #409's transfer to the hospital. III. Staff interviewsThe director of nursing (DON) was interviewed on 7/25/23 at 8:00 p.m. She said, because Resident #409 was admitted for social respite, the facility was not obligated to provide written information regarding the facility's bed-hold policy. She said she was unaware of the federal requirement that a notice of bed hold had to be provided to the resident or resident representative upon transfer. IV. Additional informationOn 7/26/23 at 4:52 p.m. the administrator in training (AIT) provided a copy of the facility's bed hold policy, which was signed upon Resident #409's admission by the resident's representative. -However, the facility failed to provide the notice of the resident's right to a bed hold to Resident #409's representative upon the resident's transfer to the hospital.

Plan of correction · submitted by the facility

F 6251. How corrective action will be accomplished for those residents found to have been affected by the alleged deficient practice. Resident #409 was discharged home from hospital. 2. How the facility will identify other residents having the potential to be affected by the same alleged deficient practice. Residents transferred to the hospital will be provided with the required bed hold notice in a timely fashion. A review of discharges in the past 30 days will be completed to determine if bed hold policy was issued. Identified issues will be addressed through education.#3. What measures will be put into place or systemic changes made to ensure the alleged deficient practice will not reoccur. Staff were educated on ensuring the bed hold policy is sent with any transfers. Policy review completed to ensure respite residents have the same rights to return to the facility upon transfer as any resident admitted to the facility. Upon transfer the facility will provide a physical copy of the Bed Hold Policy.#4 – Indicate how the facility plans to monitor its performance to make sure that solutions are sustainedA transfer/discharge audit to be completed by the Medical Records Director/designee of all newly transferred out of facility residents will be conducted once a week for 12 weeks to ensure there is appropriate documentation to support the transfer. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and suitability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0626Permitting Residents to Return to FacilityS/S D▼

Findings

Based on interviews and record review, the facility failed to allow a resident to return to the facility after going to the hospital for one (#409) of one resident reviewed for discharge out of 71 sample residents. Specifically, the facility failed to assess Resident #409 when he went to the hospital to be stabilized to return to the facility. Findings include:I. Facility policy and procedureThe Involuntary Discharge policy and procedure, revised 2/14/19, was provided by the administrator in training (AIT) on 7/26/23. It read in pertinent part, "To assure residents will be transferred or discharged only for the resident's welfare, the resident's needs cannot be met in the facility, the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, the health and safety of individuals in the facility are endangered or for non-payment. "If the resident is being transferred due to the resident being a danger to self or others, there must be documentation to show that interdisciplinary interventions were tried and failed prior to discharge. The resident's physician must document in the medical record when the discharge is because the resident's needs cannot be met or the health of the resident is endangered. The facility will document in the resident's medical record: the basis for the transfer, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s)."II. Resident #409Resident #409, age 71, was admitted on 6/28/23 and discharged to hospital on 7/9/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia with other behavioral disturbances. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. He required extensive assistance for transfers, dressing, toilet use and personal hygiene. Resident #409 had behaviors of pacing, exit seeking and wandering. III. Record reviewThe 6/28/23 care plan revealed resident #409 used psychotropic medications (prescription medication that affect a person ' s mental state). Pertinent interventions included monitoring, documenting, and reporting any adverse events to include behavior symptoms not usual to the person. It also revealed Resident #409 was admitted for a social respite stay (provides short-term relief for primary caregivers) and would return home with family after the respite stay. -The 6/28/23 care plan failed to implement meaningful interventions to address the need for secure placement, use of psychotropic medications or that Resident #409 ' s primary language was Spanish. The July 2023 CPO revealed Resident #409 was to be monitored for agitation/aggression that presented as hitting, kicking, or verbal statements. Observed behaviors were to be documented in progress notes, to include description of behavior, non-pharmacological (medication administration), approaches and how Resident #409 responded. The July 2023 CPO revealed the following orders:Start date of 6/28/23 Seroquel (antipsychotic medication) oral tablet, give 200 milligrams (mg) by mouth one time a day for dementia with behaviors. Notify MD (medical doctor) if adverse effects are observed or reported. Start date of 6/29/23 Seroquel oral tablet, give 50 milligrams (mg) by mouth one time a day for dementia with behaviors. Notify MD if adverse effects are observed or reported. The 6/30/23 progress note revealed Resident #409 was observed attempting to exit the unit on multiple occasions and was transferred to the secure memory care unit on the first floor of the facility. The 7/2/23 progress note revealed Resident #409 had been wandering into other residents' rooms. The 7/3/23 progress note revealed Resident #409 entered the room of another resident twice and attempted to take their wheelchair and was observed withhis suitcase attempting to exit the building. The 7/4/23 progress note revealed Resident #409 fell backwards against a wall while attempting to open a door to the outside. The 7/8/23 progress note revealed Resident #409 was observed trying to hit another resident and nursing staff intervened, Resident #409 then hit the nurse in the face with a napkin. -The above progress notes, dated 7/2/23 to 7/8/23, failed to include what interventions were implemented and how Resident #409 responded. The 7/9/23 progress note revealed at 10:00 a.m., Resident #409 was observed punching the air with closed fists and stating in Spanish, translated by a Spanish speaking certified nurse aide (CNA), "I want to kill somebody." A female resident had approached the nurse station and stated Resident #409 was trying to get down her pants. The progress note revealed a CNA (unknown) stated Resident #409 believed Resident #133 to be his wife and would follow her. Resident #409 was kept close to the nurses station for one-to-one oversight and placed on 15 minute checks. The medical doctor, director of nursing, responsible party and weekend supervisor were informed. The 7/9/23 progress note revealed at 12:57 p.m., the facility received a one time order for Seroquel 100 milligrams (MG) to be administered for agitation. The 7/9/23 progress note revealed at 2:05 p.m., Resident #409 had fallen backwards while attempting to swing at a CNA after striking two other residents (Residents #108 and #133). Cross-reference F600 abuse. The 7/9/23 progress note revealed at 3:21 p.m., Resident #409 was sent to the emergency room for violent behavior. -However, prior to the facility sending the resident to the hospital, limited interventions were attempted to address his behaviors with him being moved to a secured unit on 6/30/23. The 7/10/23 progress note revealed the responsible party for Resident #409 was contacted by the administrator in training (AIT) and registered nurse (RN) #4 and informed of an interdisciplinary (IDT) facility decision of not accepting Resident #409 back after he was discharged from the facility to the hospital due to violent and aggressive behaviors. The responsible party for Resident #409 informed the AIT and RN #4 he had already been notified of this on 7/9/23 by a nurse on duty. The responsible party informed the facility that Resident #409 remained in the hospital as they were attempting to find a medication regimen that worked with his behaviors. -The facility failed to provide information to the resident on the bed hold policy at the time of transfer (cross-reference F625). The 7/9/23 discharge summary signed by the attending physician on 7/24/23 listed medically defined conditions as admitting diagnoses or current diagnoses to be: vascular dementia, unspecified severity, with other behavioral disturbances, complete loss of teeth, chronic obstructive pulmonary disease (COPD) (diseases that causes airflow blockage and breathing-related problems), vascular disease (condition that affects blood vessels), unspecified benign prostate hyperplasia without lower urinary tract symptoms (enlarged gland in men that carries semen and urine from body), lumbago with sciatica (lower back pain), heart disease, cerebrovascular disease (disease affecting blood flow to brain), hypertension (elevated pressure in blood vessels), personal history of malignant neoplasm of the bladder (bladder cancer). The final diagnoses listed were the same as above. The condition on discharge was listed as worsened, sent to the emergency room (ER); rehabilitation, potential and prognosis was listed as unknown. -The facility failed to have physician documentation in the medical record that Resident #409 ' s needs could not be met and what attempts had been made to meet his needs prior to initiating an involuntary discharge. -The facility failed to reassess the resident for return to the facility when the responsible party notified the facility the hospital was working on his medication regimen. -The facility failed to receive information from hospital on Resident #409 ' s condition and what services the facility would need to provide upon return to meet the resident needs. IV. Staff interviewsCNA #4 was interviewed on 7/25/23 at 10:29 a.m. She said Resident #409 was restless at baseline and required constant oversight by staff. She said she he went into other residents ' rooms and tried to open doors to the outside. She said she would redirect by walking with him and asking if she could help. She said she was fluent in Spanish and asked about his needs. She said he would ask how he could leave. She said walking and talking with him in Spanish was the only intervention she implemented with him. CNA #5 was interviewed on 7/25/23 at 11:00 a.m. She said Resident #409 required constant staff oversight as he went into other residents' rooms and tried to open doors. CNA #5 said she was fluent in Spanish and Resident #409 had made comments that he needed to find his wife and would ask where the exit was. She said walking and talking with him was the only intervention she implemented. The AIT was interviewed on 7/25/23 at 2:00 p.m. She said Resident #409 admitted as a social respite, as a trial, to see if facility would be a good fit for permanency. She said she was not aware of behaviors prior to his admission. She said if the facility had knowledge of behaviors associated with diagnoses those behaviors were to be documented in the care plan so that interventions could be implemented. She said she was instructed by the DON and nursing home administrator (NHA) to inform the family and the managed care team of Resident #409 the facility had decided to not readmit the resident from the hospital because of aggressive and violent behaviors. The admission coordinator (AC) was interviewed on 8/8/23 at 11:14 a.m. She said Resident #409 was hospitalized prior to admitting to the facility and the facility had declined to admit him. She said he was hospitalized for throwing a walker at his wife in their home. She said he was discharged back to their home and his managed care sent a referral for a respite stay. She said the managed care team assured her Resident #409 had only been aggressive towards his wife. She said Resident #409, his wife and their son had toured the facility prior to admission. She said Resident #409 was pleasant at this time. She said the facility contacted the managed care team for Resident #409 and they were told Resident #409 would not be readmitted because of violent and aggressive behaviors. She said when a resident was discharged to the hospital the facility awaited a call from the hospital or resident representative regarding readmission. She said she did not hear from the hospital regarding Resident #409 and she did not reach out to the hospital about his return. The DON was interviewed on 8/8/23 at 11:30 a.m. She said the facility was aware Resident #409 had been aggressive towards his wife prior to admitting to the facility. She said she would not expect this information to be added to a care plan. She said she was aware Resident #409 was sent to hospital for violent and aggressive behaviors over the weekend of 7/9/23. She said she received information from the hospital on 7/10/23 that Resident #409 remained unstable and the hospital was informed the facility would not readmit in that conversation. She was unable to provide documentation of a conversation between the facility and hospital regarding readmission. The son of Resident #409 was not available for an interview during the duration of the survey.

Plan of correction · submitted by the facility

F626How the corrective action will be accomplished for those issues identified by the alleged deficient practice?Resident #409 discharged to home from the hospital. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?An audit was conducted reviewing the previous 30 days of discharges, no one was involuntarily discharged. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?NHA, DON, SSD/ designees will discuss all discharges during morning meeting to ensure all regulatory guidelines are being met and bed hold policy is being followed. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?An audit of all discharges or transfers to ensure bed hold policy was provided indicating their right to return to the facility will be conducted five days a week for 90 days, any identified issues will be corrected at that time. Results and findings from audits will be reported to QAPI by NHA/designee to assure substantial compliance is achieved.

0676Activities Daily Living (ADLs)/Mntn AbilitiesS/S D▼

Findings

Based on record review, observation, and interviews, the facility failed to ensure two of three residents (#41 and #136) reviewed for activities of daily living (ADLs) received the necessary care and services to maintain their abilities in ADLs out of 71 sample residents. Specifically, the facility failed to provide language communication tools in order for Resident #41 and #136 to effectively communicate their needs, requests, and opinions, as well as to participate in social conversation. Findings include:I. Resident #41 A. Resident statusResident #41, over the age of 65, was admitted on 6/11/14. According to the July 2023 Computerized Physician Orders (CPO), the resident's diagnoses included unspecified dementia, of unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The June 2023 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of four out of 15. She required supervised assistance with bed mobility, transfer, walking in room, walking in the corridor, dressing, eating, toilet use, and personal hygiene. B. ObservationOn 7/20/23 at 12:00 p.m. when an attempt was made to speak with Resident #41, staff reported the resident did not speak English but rather spoke Chinese. A communication board was not observed in the resident's room. On 7/25/23 at 10:30 a.m. another attempt to speak with the resident as she was exiting her room was unsuccessful; the resident kept walking, making hand gestures that could not be interpreted by the surveyor. C. Record review - failures The resident's communication care plan, revised on 6/21/23, documented Resident #41 did not speak the dominant language of the facility. Her primary language was Chinese and her family assisted with communication often. The plan read the resident was able to understand some English. Interventions included encouraging the resident to use signs/gestures(pointing)/sounds, and translator (family) when expressing self. It read the resident will often point to the phone to call her daughter if needed. It further read she had a communication board in her room with pictures to help with communication.-See staff interviews below; no staff indicated they used a communication board to help with communication and the care plan did not identify other means of communication and which means were most effective in addressing the resident's ability to express her needs, requests, opinions and to participate in social conversation. The activity care plan, revised on 6/27/23, documented Resident #41 had the following barriers to activity participation: non-English speaking, as the resident spoke Chinese. Interventions included: Staff using communication tools and family members to speak to the resident; using a direct and positive approach, speaking clearly while facing the resident, and being patient and understanding; using gestures and anticipating needs: respecting the resident's right to choose or refuse invitations to group participation; providing regular visits from activity staff to encourage, socialize, provide comfort and support as needed; referring to diet report and/or consult nurse before involvement in activities with food or drink; assessing individual needs, encourage active participation, escort to groups of choice as needed; assist as needed, and provide materials for independent pursuits.-See staff interviews below; no staff indicated they effectively communicated with the resident by speaking clearly and directly or were able to anticipate her needs or encourage active participation in activities; rather, staff reported communication with the resident was short and primarily through gesturing. An interdisciplinary team meeting note, dated 6/28/23, read the resident was able to answer yes or no questions, spoke only Chinese, but was able to communicate with gestures and make her needs known. D. Staff interviewsStaff interviews revealed the facility failed to ensure Resident #41 an effective means of communicating that promoted her ability to communicate her needs, requests, and opinions, as well as to participate in social conversation. Staff were unaware of and did not utilize communication tools to facilitate conversation. 1. The MDS coordinator was interviewed on 7/25/23 at 10:12 a.m. She said the resident communicates with her by pointing at objects. Resident #41 has an iPad (small computer) she uses to communicate with her daughter. She said her iPad is in Chinese. The MDS coordinator said the resident does not have a communication book because she uses her iPad. The MDS coordinator said they have an interpreter line they can use if they need it, but she said she has never used it. She said she was not sure if other staff had used the language line. 2. Certified nurse aide (CNA) #6 was interviewed on 7/25/23 at 10:29 a.m. CNA #6 said Resident #41 shows staff what she wants by pointing to things. She said Resident #41 sits with a male resident in the dining room and she will order whatever he orders. CNA #6 said the resident does not ask staff for anything. She said she has never been shown how to use the interpreter line or the resident's iPad. She said if she had a question about what the resident wanted, she would ask a nurse. 3. CNA #8 was interviewed on 7/25/23 at 11:03 a.m. She said she has not worked with Resident #41. She said if she worked with a resident who needed translation, she would ask other staff how they communicate with the resident. CNA #8 said she has used gestures with other residents and that helped. She also said she would go to the care plan and see what was written. 4. CNA #10 was interviewed on 7/25/23 at 11:15 a.m. She said she cannot understand Resident #41. She said the resident will point at things and they get those things for her. She said Resident #41 does not have a communication book or log. CNA #10 said there was no interpreter line at the facility. She said the staff let the resident "do her own thing "and if she needed something, she pointed to it. She said having Resident #41 point to things was not the right and effective way for the resident to have to communicate her needs. She said if the resident did not point at things, staff would not do anything for her. 5. The social services director (SSD) was interviewed on 7/25/23 at 11:42 a.m. She said she used gestures to address Resident #41's needs and requests. She said the resident pointed to things and that was how she knew what the resident needed. The SSD said the resident's daughter was available any time if staff had any questions or concerns. She said staff have google translate to communicate with residents who needed it and the CNAs use it more than other staff. She said staff have short interactions with Resident #41 as pothey are not able to communicate with resident. II. Resident #136 A. Resident #136's statusResident #136, age 66, was admitted on 3/23/22. According to the March 2022 CPO, the resident's diagnoses included unspecified dementia of unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The June 2023 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for mental status score of zero out of 15. She required total assistance with bed mobility, transfer, toilet use, and personal hygiene. B.. ObservationThe resident was continuously observed on 7/24/23 from 8:54 a.m. until 3:24 p.m. Observations revealed:-At 8:54 a.m., the resident sat in a Broda chair (a tilt-in-space positioning wheelchair) in the dayroom. -At 10:33 a.m., the resident sat in the dayroom, sleeping in her Broda chair. -At 10:51 a.m., staff wheeled the resident back to her room. Staff closed the door to her room. At 10:59 a.m., staff left the room with the resident and wheeled her back to the dayroom. -At 11:46 a.m., the resident had a visitor, and staff wheeled the resident in the Broda chair to a table in the dayroom.-At 11:58 a.m., almost three hours since the observation began, the resident had not been heard to talk or ask for anything.-At 12:10 p.m., family members showed up and helped feed the resident her lunch, speaking to the resident in Spanish. -At 3:09 p.m., staff in the dayroom got ready to wheel the resident in the Broda chair back to her room. Staff was overheard telling the resident in English that they were going to take her to her room and change her. At 3:24 p.m. staff wheeled the resident in the Broda chair back to the dayroom. C. Record review - failuresThe resident's cognitive care plan, revised on 7/3/23, documented the resident had an impaired communication problem as she was non-verbal. Interventions included, anticipating and meeting her needs, ensuring/providing a safe environment, call light in reach, and fall prevention measures in place. Monitoring/documenting physical/ nonverbal indicators of discomfort or distress, and follow-up as needed.-The care plan did not identify how to address her communication problem, did not identify that her primary language was Spanish (see below) or communicated to staff her physical/ nonverbal indicators of discomfort or stress. The activity care plan, revised on 6/20/23, documented barriers to activity participation as extreme ambulation and mobility limitations, language barrier (Spanish Speaking), difficulty understanding and communicating, and short attention span. Interventions included encouraging ongoing family involvement and inviting the resident's family to attend special events, activities, and meals. Staff will inform of activities, provide a calendar, escort to and assist during groups of choice as needed, assess individual needs, develop rapport with the resident, encourage nursing home involvement and group participation, as well as providing materials for independent pursuits. Be aware of limited mobility and endurance. Staff will refer to diet report and/or consult nurse before involvement in activities with food or drink, provide regular visits from activity staff to encourage, socialize, and provide comfort and support as needed.-See staff interviews below; no staff indicated they effectively communicated with the resident by speaking clearly and directly or were able to anticipate her needs or encourage active participation in activities; rather, staff reported communication with the resident was short and primarily through gesturing. D. InterviewsFamily interviews indicated they spoke to the resident in Spanish and, although minimal, did at times respond. Staff interviews indicated they spoke to the resident in English and were unsure the resident understood them. There was no indication that means to promote effective communication with the resident had been attempted. 1. The resident's husband was interviewed on 7/23/23 at 5:17 p.m. He said he comes in to feed his wife dinner every day. He said there is always a family member who comes in to feed her lunch or dinner. He said his wife does not speak anymore. He stated he talks to his wife in Spanish as he does not speak much English. 2. The resident's brother was interviewed on 7/24/23 at 11:50 a.m. He said he speaks to the resident in Spanish. He said she does not respond to him; stating she stopped talking about a year ago. He said he comes in every day to visit his sister and to feed her lunch. He said he is not sure how staff communicate with his sister as she does not speak. 3. The resident's niece was interviewed on 7/24/23 at 12:45 p.m. She said she speaks to her aunt in Spanish and she understands and will respond to cues like opening her mouth to eat. The niece said the resident would benefit from more Spanish programs on television and listening to Spanish music. 4. Certified nurse aide (CNA) #6 was interviewed on 7/25/23 at 10:29 a.m. CNA #6 said she tells the resident what she is going to do in English and the CNA said she was not sure if the resident comprehends what she has said. CNA #6 said she has never been shown how to use the interpreter line or if they have one. She said would ask the nurse if she had a question. 5. CNA #8 was interviewed on 7/25/23 at 11:03 a.m. She said she has not worked with Resident #136. She said she would ask staff how they communicate with the resident or see what works for them. 6. CNA #10 was interviewed on 7/25/23 at 11:15 a.m. She said Resident #136 did not say anything. She said she speaks in English to the resident and said she did not think the resident understands her. She said she did not think the resident communicates often. She said there is no interpreter line to communicate with residents whose primarily language was not English. 7. The social services director (SSD) was interviewed on 7/25/23 at 11:42 a.m. She said she has tried to talk to the resident in English and Spanish and said each time she has not gotten a response. The SSD said staff, CNAs more than other staff, use google translate to communicate with residents if they do not speak English a

Plan of correction · submitted by the facility

F676 previous submissionHow the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. For residents #41 and #136, communication sheets were provided by activities. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. Residents who do not speak English as a primary language have the potential to be affected by this alleged deficient practice. An audit was conducted on 9/5/23 to identify any resident who does not use English as a primary language. A communication sheet was provided to the resident in their native language. Any concern not listed on the communication sheet the facility has a language line available at each nurses station. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education was provided to staff on 7/26/23 regarding the use of the communication sheets and the language line. Any new admission will be assessed for primary language and receive a communication sheet if required. If the resident is non verbal and English is not the primary language the IDT will involve family to determine a plan to assist with communication. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. An audit will be completed by the SSD/designee for the next 12 weeks for all residents in the facility whose desired language of communication is not English. The information will be placed on the resident's face sheet for all who need to be made aware of the possible communication barrier. Any missing communication sheets in resident rooms will be promptly replaced. Additionally, regular checks will be instituted to ensure these sheets are consistently available. The facility's interpreter line telephone number will be placed in the admission packet and care plans. Auditing of staff to include ancillary staff utilizing the interpreter line and communication sheets effectively and availability of communication sheets are in once a week for 12 weeks. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0677ADL Care Provided for Dependent ResidentsS/S E▼

Findings

Based on observation, record review, and interviews, the facility failed to consistently provide activities of daily living (ADL) support for three (#27, #98 and #106) of six dependent residents reviewed for ADL care out of 71 sample residents. Specifically, the facility failed to:-Provide repositioning adjustments for Resident #27 and Resident #98 who were unable to reposition themselves; and, -Provide timely incontinence care for Resident #27 and Resident #106. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and servicesFindings include:I. Facility policy and proceduresA turning and repositioning document not dated or titled as a policy was provided by the nursing home administrator (NHA) on 7/26/23 at 11:05 p.m. It read in pertinent part, "Evaluate bed mobility and develop a turning schedule based on identified risk. Individualized positioning regime and repositioning schedule must be documented and displayed."If the patient is able to make large body movements easily and frequently: Monitor bed mobility and ensure adequate turning every 3-4 hours. If the patient is able to make small body shifts but is unable to make large body movements: Reposition every 2 hours. Use positioning devices to position the patient in a 30-degree laterally inclined position when repositioned to either side (see picture below). Avoid 90-degree side-lying position. If the patient is unable to make any independent movement: Turn every 2 hours or more frequently if indicated. May require therapeutic pressure management mattress. Please note that a patient on a therapeutic pressure management mattress should still be turned and repositioned regularly as per individualized positioning regime. Use positioning devices to prevent contact between bony prominences and completely relieve heel pressure when in bed. Support length of legs with a pillow and allow heels to drop off pillow."II. Resident #27A. Resident statusResident #27, age 78, was admitted to the facility on 5/7/21 and readmitted on 3/21/22. According to the July 2023 computerized physician orders (CPO), diagnoses included hypertensive heart disease with heart failure, diabetes mellitus type 2, morbid obesity, and chronic obstructive pulmonary disease. The 6/21/23 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 extensive assistance with two persons for bed mobility, toileting and transfers, and total dependence with one person for locomotion on unit, dressing and bathing. There were not any rejection of care behaviors exhibited. B. Record reviewThe resident's care plan, revised June 2023, revealed the resident had a self-care performance deficit related to muscle weakness, activity intolerance, decreased endurance, left knee pain, vision impairments and upper extremity tremors. The interventions revealed bed mobility required the assistance of one to two staff to sit up, lie down, turn, and reposition in bed. Pertinent interventions were to encourage and assist the resident to change positions frequently as tolerated, encourage her to shift her weight when in the wheelchair and to alternate from side to side while in bed using pillows and wedges for support. -However, see below; observations on 7/20, 7/24 and 7/25/23 revealed this was not being done. C. Resident observations 1. On 7/20/23 at 9:14 a.m., Resident #27 was observed in her bed, which had an air mattress, lying on her back and her call light was on outside of the room. She said she had pushed her call light at 8:30 a.m. to request to be cleaned up after an incontinence episode and was waiting for assistance. At 9:35 a.m. certified nurse aide (CNA) #13 and CNA #15 entered the room to reposition the resident. The CNAs moved the resident up further toward the head of the bed and more toward the center of the bed. They did not use any pillows or wedges for positioning or offloading the resident's heels and left the resident in the same position she had been in prior to being moved toward the head of the bed. Once the repositioning was completed, CNA #13 and CNA #15 started to leave the room. With prompting, Resident #27 said she had been waiting to be cleaned up after having an incontinence episode since she activated her call light at 8:30 a.m. During the observation, CNA #13 and CNA #15 had not asked Resident #27 why she had activated her call light. CNA #13 said she had to wait for another CNA to help her. CNA #15 said he could assist so they began the task at that time. CNA #14 entered the room and told CNA #15 he could leave and she would continue assisting. Resident #27 was placed back on her back, the same position she had been in since first observed at 9:14 a.m. 2. During a continuous observation on 7/24/23 that started at 9:40 a.m. and ended at 2:30 p.m., Resident #27 was observed in her bed lying on her back. The resident was not offered assistance with repositioning for five hours. -At 11:00 a.m., the resident remained in the same position, lying on her back in bed, looking out the window. The resident turned on the television (TV).-At 12:15 p.m., an unidentified CNA entered the resident's room and served her lunch. She did not offer to reposition the resident.-At 1:15 p.m., an unidentified CNA entered the resident's room and removed the resident's lunch tray. She did not offer to reposition the resident. -At 1:30 p.m., the resident began reading a magazine and writing with a pen. The resident remained in the same position. -At 2:30 p.m., the resident remained in the same position and was observed sleeping. 3. During a continuous observation on 7/25/23 that started at 9:35 a.m. and ended at 3:00 p.m. Resident #27 was observed in her bed lying on her back with her head elevated. The resident was not offered assistance with repositioning for seven hours. -At 9:45 a.m., the resident was talking on her phone while in her bed lying on her back with her head elevated. -At 11:15 a.m., the resident began reading a book and was in the same position as above. -At 12:30 p.m., the resident was served a lunch tray in her room while she lay in bed on her back. The CNA did not offer to reposition the resident. -At 1:15 p.m., an unidentified CNA entered the resident's room and removed the lunch tray. The CNA did not offer to reposition the resident. -At 2:30 p.m., the resident had the TV on and was in the same position as above. -At 4:00 p.m., the resident was talking on the phone and was in the same position as above. Resident #27 remained in the same position throughout the remainder of the day until the last observation at 4:30 p.m. D. Resident interviewResident #27 was interviewed on 7/20/23 at 9:55 a.m. Resident #27 said she frequently waited over an hour after she pushed her call light to get assistance. She said the CNAs rarely repositioned her unless she asked. This made her worry about her likelihood of developing a pressure injury. III. Resident #98A. Resident statusResident #98, age 64, was admitted on 2/7/19. According to the July 2023 CPO, diagnoses included type 2 diabetes mellitus with diabetic neuropathy, paroxysmal atrial fibrillation, morbid obesity, and chronic kidney disease. The 5/29/23 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. She required extensive assistance with two people for bed mobility and dressing. She required extensive assistance from two people for transfers. She did not have any rejection of care or verbal behaviors exhibited. B. Record reviewThe care plan revised 6/8/23, revealed self-care performance deficits related to muscle weakness, morbid obesity, activity intolerance and impaired mobility. The interventions revealed the resident required limited to extensive assistance to turn over, reposition and sit up in bed. C. Resident observations During a continuous observation on 7/20/23 that began at 10:40 a.m. and ended at 1:30 p.m., Resident #98 was observed lying in her bed, which had an air mattress, on her back with the head of the bed slightly elevated. She was not repositioned or offered to be assisted with repositioning for three hours. -At 11:00 a.m., the resident turned her TV on and remained in the same position on her back with the head of the bed slightly elevated. -At 12:15 p.m., an unidentified CNA entered the resident's room with a lunch tray. She did not offer to preposition the resident. -At 1:00 p.m., an unidentified CNA entered the resident's room and removed the lunch tray. She did not offer to reposition the resident. -At 1:30 p.m., the resident remained in the same position with her TV on and her eyes closed. D. Resident interviewResident #98 was interviewed on 7/24/23 at 3:35 p.m. She said the staff did not come in to remind her to reposition or assist her with repositioning. She said she was unable to reposition herself. This made her very worried about her skin and the status of her current pressure injuries. E. Staff interviewsCNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she turned in her notice to end her employment with the facility because there was not enough staff to help the residents in a timely manner. She said the facility was always short staffed and she did not have time to remind or help residents turn or reposition because she was always providing care for someone else. (Cross-reference F725)An anonymous nurse was interviewed on 7/25/23 at 1:55 p.m. The nurse said the facility needed more help. The nurse said they did not have time to remind or assist residents to turn or reposition. Tears began to roll down their cheeks as they described often going home and not wanting to come back to work at the facility because the staffing was so short. The nurse said it was not their intention to provide subpar care but they could only do what they had time to do. (Cross-reference F725)The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said residents who were unable or did not remember to reposition themselves should be reminded and/or assisted to reposition every two hours and as needed. She said the CNAs knew who needed to be reminded or assisted with repositioning by looking at the Kardex (a directive for care). IV. Resident #106A. Resident statusResident #106, age 80, was admitted to the facility on 7/1/21. According to the July 2023 CPO, diagnoses included dementia and benign prostatic hyperplasia with lower urinary tract symptoms (frequent need to urinate). According to the 5/17/23 MDS assessment, the resident was severely cognitively impaired with a brief interview for a mental status score of zero out of 15. The resident required extensive assistance of two persons with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident was incontinent of bowel and bladder and was at risk of pressure ulcers. B. Record reviewThe resident's care plan, revised on 5/30/23, revealed Resident #106 had an activity of daily living (ADL) self-care performance deficit for toileting related to cognitive and memory impairments. He required extensive assistance with toileting tasks and had incontinent episodes with urine and bowels. Interventions included assistance with toileting frequently and as needed. The care plan, revised on 5/30/23, revealed ResidentResient #106 had daily episodes of bladder and bowel incontinence related to confusion and diminished awareness of personal needs related to dementia. Interventions included assistance with toileting frequently, as he would allow and as needed. The care plan, revised 5/30/23, revealed Resident #106 had the potential for impaired skin integrity related to incontinence. Interventions failed to include assistance with incontinence care. C. ObservationsOn 7/19/23, during a continuous observation beginning at 10:30 a.m. and ending at 3:30 p.m., Resident #106 was observed in a Broda chair (wheelchair that can tilt, recline, and has adjustable footrest) in the main dining area with staff and other residents. At 2:30 p.m., Resident #106 was assisted to his room by CNA #5, positioned in his wheelchair, to look out the window and the care staff exited the room. Incontinence care for Resident #106 was not observed for five hours. On 7/20/23, during a continuous observation beginning at 10:00 a.m. and ending at 2:30 p.m., Resident #106 was observed in a Broda chair in the main dining area. At approximately 2:00 p.m., Resident #106 was assisted to his room by CNA #4 and CNA #5. Incontinence care was provided and Resident #106 returned to the main dining room. CNA #5 said the resident had been incontinent of urine. Incontinence care for Resident #106 was not observed for four and on-half hours. On 7/24/23, during a continuous observation beginning at 9:30 a.m. and ending at 3:00 p.m., Resident #106 was observed in a Broda chair in the dining room area. At approximately 1:30 p.m. Resident #106 was assisted to his room by CNA #3 and CNA #5 and was provided with incontinence care. The resident's brief was observed to be soiled with urine and yellow in color. Incontinence care for Resident #106 was not observed for four hours. D. Staff interviewCNA #3 was interviewed on 7/25/23 at approximately 11:00 a.m. She said she had worked in the building for only a couple days. She said Resident #106 was provided incontinence care after breakfast and lunch on the shift she worked. CNA #5 was interviewed on 7/25/23 at approximately 11:00 a.m. She said residents fully dependent on staff for incontinence care are assisted twice a shift. She said depending on the resident, incontinence care could be provided more or less often. She said Resident #106 was provided incontinence care after breakfast and lunch on her shifts. She said he was consistently incontinent of urine. The unit manager (UM) was interviewed on 7/25/23 at 2:48 p.m. She said for assisting fully dependent residents with incontinence care, it was provided after every meal, as needed and during overnight rounds. She said it was dependent on the resident's output, lack thereof, and tolerance of care provided. She said providing Resident #106 with incontinence care after meals during day shift hours was acceptable for his incontinence needs. -But see findings above; the resident had multiple risk factors for skin breakdown and interviews revealed he was consistently incontinent of urine. The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said that residents who were incontinent should be checked every two hours and as needed.

Plan of correction · submitted by the facility

F677How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Residents #98, and #106 were provided with incontinence care, and each resident was turned and repositioned. Resident #27 has expired. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents who are unable to turn and reposition themselves are at risk of alleged deficient practice. An audit will be conducted, on or before the date of compliance, to identify residents who are incontinent and require turning and repositioning. The audit was to ensure the timeliness of the required ADL. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be provided, on or before the date of compliance, to all line staff by the staff coordinator/designee, that emphasized the importance of turning and repositioning as well as prompt changing of incontinent residents. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. A check/change turn and repositioning audit of incontinence care for 5 residents will be conducted 3 days a week for 4 weeks, 2 times a week for 4 weeks, and then once a week for 4 weeks. The audit will be completed by members of the interdisciplinary team to ensure compliance for these ADL’s. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0679Activities Meet Interest/Needs Each ResidentS/S D▼

Findings

Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#69) of two residents out of 71 sample residents. Specifically, the facility failed to offer and provide activity programs for Resident #69 to meet her activity needs. Findings include:I. Facility policy and procedureThe Federal Resident Right and Facility Responsibilities document, not dated, was provided by the nursing home administrator (NHA) on 7/26/23 at 11:00 p.m. It read in pertinent part: "The resident has a right to choose activities, schedules (including sleeping and waking times), health care and provider of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part."II. Resident statusResident #69, age 73, was admitted on 11/24/2020. According to the July 2023 computerized physician orders (CPO) diagnoses included hemiplegia (total or nearly complete paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, type two diabetes mellitus with other diabetic kidney complications and polyneuropathy and major depressive disorder. The 7/4/23 minimum data set assessment documented the resident did not have memory or cognitive issues indicated by a score of 14 out of 15 on the brief interview for mental status (BIMS). The resident needed extensive assistance with bed mobility and activities of daily living (ADLs) and total dependence for transferring. The resident did not have any behaviors or rejection of care. It was very important for the resident to get outside to get fresh air when the weather was good and be able to keep up with the news. III. Resident interviewResident #69 was interviewed on 7/19/23 at 12:47 p.m. She said she would like to participate in some of the activities, however, staff would not get her up to participate in activities. She said she has asked multiple times to get up and go outside as this was her favorite thing to do and of utmost importance to her but was always told no because they did not have enough staff for someone to go with her. Instead, they just leave her in the bed. Resident #69 said this makes her very sad. IV. Observations The observations showed the resident was lying in bed with no meaningful activity. The resident resided on the third floor in a room by herself. Her bed was placed parallel to and against the long side of the wall with the head of the bed at the window end of the room disabling her from being able to look out of the window. There were books on a shelf on the opposite wall from the bed and out of the residents' reach. 7/19/23-At 12:47 p.m. Resident #69 was lying in bed with her eyes open with the television (TV) on. She appeared to be watching TV. -At 1:50 p.m. the resident continued to lay in bed with the TV on. -At 3:05 p.m. she continued to lay in bed with the TV on. -At 5:00 p.m. there were no changes. 7/20/23-At 11:29 a.m. Resident #69 was lying in bed with the TV on.-At 11:50 a.m. there were no changes.-At 12:38 p.m. there were no changes. V. Record reviewThe 1/9/22 activities assessment showed Resident #69 had general activity preferences of cards and other board games, current events, music, movies, dining out, reading and writing, outdoor games, painting, gardening, talking, cooking, word games, and visiting with animals. The care plan, revised 7/11/23, identified Resident #69 enjoyed cards and other games, music, reading, writing and watching TV (television). The goal documented the resident would participate in offered programs such as outings, personal shopper or restaurant dine-in as desired throughout the month. The resident would pursue independent leisure activities such as reading, watching TV, listening to music and visiting with others as desired. The interventions included: staff will honor references for daily activities and routines, inform of activities, provide calendar, escort to and assist during groups of choice as needed, assess individual needs, develop rapport with resident, encourage nursing home involvement and group participation, provide materials for independent pursuits, be aware of limited mobility and endurance, help locate and clean glasses as needed for all activities. The participation records were requested on 7/25/23 at 5:33 p.m. for Resident #69 and were not provided. VI. Staff interviewThe activities assistant (AA) was interviewed on 7/25/23 at 5:33 p.m. The AA said he was responsible for providing one-to-one interaction with residents that remain in their beds in their rooms. He said he was supposed to spend 15 minutes two to three times a week with them and the visits were logged. The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said residents that stay in their rooms have one-to-one visits in their rooms with the activities department staff. The activities director was interviewed on 8/8/23 at 10:00 a.m. She said she determined which residents needed one-to-one activity time based on criteria such as if they were bedbound or stayed in their room, if the resident was able to self-lead with activities and if the resident had any rejection of one-to-one time in the past. She said if residents refused activity offerings she had the activity staff try to ask what the resident would prefer to do. She said she could not always accommodate the residents ' requests because she did not have the staff to support those requests. She said she started a stroll group on Friday mornings and she tried to get Resident #69 to participate but the resident would typically agree the day before and then refuse on the day of the activity. -However, the AD did not provide documentation showing this pattern. The AD said she had tried to encourage the activity staff to document activity participation including refusals but she did not think they were doing so. The AD said she should provide a one-to-one activity 45 minutes three times a week for the residents with that program but she did not have the staffing to support it, so they provided 15 to 20 minutes two to three times a week to those on one-to-one activities.

Plan of correction · submitted by the facility

F679 How corrective action will be accomplished for those residents found to have been affected by the alleged deficient practice. Resident 69 was visited by the Activities department to review and refresh her preferences and how they can assist her in meeting her physical, mental, and psychosocial wellbeing. The Activities director developed a 1:1 program with resident 69 where they meet together weekly for outdoor activities, based on resident preferences and weather depending. Resident #69’s room was rearranged so she can see outdoors. How the facility will identify other residents having the potential to be affected by the alleged deficient practice. The facility provides 1:1 programming for residents that prefer not to leave their room. Activity Director is documenting 1:1 activities participation and refusals in PCC under activity participation notes and includes information about the activity and the residents participation level. Activities Director also has a monthly participation log for each resident for other activity participation, which is also summarized and documented in PCC quarterly. Activities Director/MDS Coordinator have identified residents who have a preference for outdoor activities. An outdoor activity is offered weekly. What measures will be put into place or systemic changes made to ensure the deficient practice will not re-occur. Education was provided on 9/5/2023 for activities staff regarding facilitating resident participation in desired activity programming, and the therapeutic 1:1 program and documentation of programs. Care plans were updated. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur? 4. Activity Director/designee will complete an audit of 15 residents per week for 3 months to include participation in group activities, going outside, and regularly scheduled activities to ensure that activities preferences are being honored based on active participation or refusals records. The Activity Director will send a message to unit managers every morning and Friday will include weekend activities, with a list of residents who wish to participate in activities that day so that the nursing staff can assist in preparing them to attend. Assistance will be provided to the residents as needed. Activities Department staff will no longer be assisting in transportation to appointments. The facility has also hired a new activity staff member.

0684Quality of CareS/S D▼

Findings

Based on interviews, observation and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#7) out of 71 sample residents. Specifically, the facility failed to ensure Resident #7, who was diagnosed with diabetes, had her fingernails cut by a licensed nurse. Resident #7 sustained a laceration on her finger when the certified nurse aide (CNA) cut her nails. Findings include:I. Resident #7 statusResident #7, age 84, was admitted on 4/18/19. According to the July 2023 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus and Parkinson's disease. The 5/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility, transfers, toileting and extensive assistance of one person with dressing and personal hygiene. A. Resident interviewResident #7 was interviewed on 7/20/23 at 11:18 a.m. She said she had asked a CNA for someone to cut her fingernails. She said the CNA told her she could do it. She said she did not think the CNA was able to cut her nails because she was diabetic, but believed her. She said the CNA cut her finger when she was cutting her fingernails. B. Record reviewThe diabetes mellitus care plan, initiated on 5/1/19 and revised on 5/29/23, documented the resident had a risk of complications related to elevated blood sugars due to a diagnosis of diabetes mellitus. It indicated the resident utilized insulin daily to manage her diabetes. The 1/27/23 nursing progress note documented the CNA accidentally cut the skin around the resident's nails to the right thumb. The laceration measured 0.6 centimeters (cm) in length. The area was cleansed with normal saline and a treatment was applied. The physician was notified. II. Staff interviewsRegistered nurse (RN) #3 was interviewed on 7/25/23 at 3:06 p.m. She said CNAs were able to cut resident fingernails, except those who had a diagnosis of diabetes. She said a licensed nurse should cut the fingernails of a diabetic resident and a podiatrist for toenails. She said residents who had a diagnosis of diabetes had a risk of slower healing with lacerations and wounds. The DON was interviewed on 7/25/23 at 3:29 p.m. She said a licensed nurse should be the one to cut the fingernails and provide nail care of a diabetic resident. She said she was unaware a CNA had cut Resident #7's fingernail that caused a laceration. She confirmed Resident #7 had a diagnosis of diabetes. She said lacerations and wounds could be slower to heal and had a higher risk of infections for diabetic residents.

Plan of correction · submitted by the facility

F684How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Resident #7 nails were in good condition as of 08/04/2023. Nails were filed by RN due to resident diabetic diagnosis. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents who have the diagnosis of diabetes have the potential to be affected by alleged deficient practice. An audit will be conducted, on or before the date of compliance, for residents who have the diagnosis of diabetes and require assistance with cutting their nails. Registered nurses will provide nail care to any residents identified to be in need of this service. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be completed, on or before the date of compliance, DON/designee to inform all line staff that only a licensed professional nurse should cut the fingernails of a resident with the diagnosis of diabetes. A task has been identified and placed in PCC to alert the CNA that nail care for diabetic residents is to be performed only by licensed and registered nurses only. A batch order, on the MAR, was created to identify residents with a diagnosis of diabetes who require a licensed or registered nurse to perform nail care. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not reoccur?4. Diabetic residents will have their nails assessed once a week by a licensed professional nurse. This assessment will be conducted once a week for 12 weeks. If the nail of the diabetic resident is in need of cutting and the professional nurse is able to do so safely, the nails of that individual will be cut. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0686Treatment/Svcs to Prevent/Heal Pressure UlcerS/S D▼

Findings

Based on record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for two (#23 and #85) of two residents in a sample of 71 residents. Specifically, the facility failed to implement or plan interventions to reduce pressure injury risk factors for Resident #23 and #85, both of whom had been identified at high risk for pressure injuries. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and servicesFindings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages, the National Pressure Injury Advisory Panel - NPIAP web. (2/4/18) accessed 8/2/23 from http://www.npiap.org/resources/educationaland-clinical-resources/npuap-pressure-injury-stages. read in pertinent part: "A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions:"Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized areas of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI (deep tissue pressure injury) to describe vascular, traumatic, neuropathic, or dermatologic conditions." II. Facility policy and procedureThe Prevention and Treatment of Pressure Ulcers policy, revised January 2020, was provided by the nursing home administrator (NHA) on 7/25/23 at 11:06 p.m. It read in pertinent part, "To ensure a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the clinical condition demonstrates it was unavoidable. To ensure a resident who has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection and prevent additional pressure ulcers."The Skin Management policy was provided by the NHA on 7/25/23 at 11:06 p.m. It read in pertinent part, "On admission/readmission all residents will have a head-to-toe skin observation completed by a licensed nurse and all skin issues identified, measured and documented on the Nursing Admission Data Collection. All skin issues identified will have a treatment plan in place and a care plan formulated for the areas."III. Resident #23A. Resident statusResident #23, age 86, was admitted to the facility on 8/12/22. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, atrial fibrillation, and chronic kidney disease. According to the 5/4/23 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of 14 out of 15 and did not have any cognitive impairments. The resident required extensive assistance with bed mobility, transfers, and toileting. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. The resident had an unstageable pressure injury presenting as a deep tissue pressure injury upon admission in August of 2022 that was coded as a Stage IV pressure ulcer on the May 2023 MDS. The resident did not have any behaviors or refusal of care. B. Record review - history of pressure injury and plans to prevent new pressure injury from developingThe Braden scale measuring pressure injury risk completed on 8/13/22 showed the resident was at high risk for pressure ulcers with a score of 17 because of the following risk factors: atrial fibrillation, chronic pain, poor mobility, chronic kidney disease, long-term anticoagulant use, and advanced age. The weekly skin observation tool completed on 8/13/22 did not identify any skin issues. The new admit report and aide checklist dated 8/12/22 identified discoloration to the right heel. The wound care note completed by the wound care provider on 8/18/22 identified an unstageable deep tissue injury to the right heel, healing, and orders to float heels in bed and skin prep once daily for 30 days. The wound care note for 8/24/22 showed the wound was getting larger, evidenced by an increased surface area. The same orders as previously implemented were continued. On 8/30/22, physician orders were entered for Prevalon boots to the heels when in bed if tolerated, otherwise continue to float heels. Wound care notes from 9/7/22 to 10/7/22 showed the wound improved as evidenced by a decrease in surface area. On 10/19/22 the wound care note identified a surgical debridement of the wound to remove necrotic tissue had been performed resulting in an increase in surface area. The orders were changed to use medihoney and cover with a gauze island with the dressing to be cleaned and redressed three times a week and as needed. The wound care note on 11/23/22 documented the wound was resolved as evidenced by epithelialized tissue. The procedure note dated 12/7/22 showed a scabbed area to the right heel without any signs or symptoms of infection and orders were to continue to offload heels at night. The procedure note dated 12/21/22 identified the wound as unstageable without drainage and new orders to cleanse, pat dry and apply puracol every other day with a dry dressing and offload the feet. The wound status was documented as healing. On 1/4/23 the procedure note orders were changed to apply medihoney and calcium alginate three times a week. The wound status was documented as worsening as evidenced by an increase in surface area. The treatment administration record (TAR) was revised March, 2023. This was the first time there was documentation of staff assisting with donning heel boot protectors at bedtime every night shift for skin integrity. The treatment continued until 4/18/23 and then it no longer appeared on the TAR.The wound care notes continued to show the wound worsening from 4/19/23 to 5/24/23 as evidenced by increased surface area. The resident's care plan, last revised on 5/31/23, identified the resident had a risk for impaired skin integrity related to an unstageable deep tissue injury upon admission due to atrial fibrillation, chronic pain, chronic kidney disease, long-time anticoagulant use, impaired mobility, and advanced age. The interventions included encouraging the resident to change positions frequently, shift weight while in the wheelchair and alternate sides while in bed, Prevalon boots provided and floating heels while in bed. C. Observations - failure to implement plans to prevent pressure injuryDuring continuous observations on 7/24/23 that started at 9:40 a.m. and ended at 3:30 p.m., Resident #23 sat in her wheelchair. Notwithstanding her high risk for pressure injury and history of actual pressure injury, need for extensive assistance with mobility, and incontinence, the resident was not approached by staff to toilet or reposition for six hours. -At 10:00 a.m., the resident was sitting in her wheelchair with the TV on. -At 11:30 a.m., the resident sorted through papers on her bedside table. She remained in her wheelchair. -At 12:00 p.m., the resident was taken to the dining room in her wheelchair for lunch. She was not offered toileting, repositioning or reminded to shift her weight. -At 12:15 p.m., an unidentified certified nurse aide (CNA) delivered the resident her lunch in the dining room. She did not remind the resident to shift her weight or offerassistance to reposition.-At 1:00 p.m., the resident was taken back to her room and remained in her wheelchair. She was not offered toileting or incontinence care. She was also not reminded to shift her weight or offered assistance to reposition.-At 1:30 p.m., the resident was in the same position in her wheelchair in her room. She had not been offered to reposition or lay down. IV. Resident #85A. Resident statusResident #85, age 86, was admitted on 9/27/22. According to the July 2023 CPO, diagnoses included heart failure, morbid obesity, artificial openings of urinary tract, and renal and ureteral calculous obstruction. According to the 6/26/23 MDS assessment, the resident had a brief interview for mental status (BIMS) score of 14 out of 15 and did not have any cognitive impairments. The resident required extensive assistance with toileting, dressing, and walking. The resident needed limited assistance with bed mobility and transfers. The resident was frequently incontinent of bowel and had an indwelling catheter. The resident did not have any behaviors or refusal of care. B. Record Review - history of pressure injury and plan to address pressure injury riskAccording to the 6/26/23 MDS, the resident had a stage IV (four) pressure injury to the coccyx upon admission in September of 2022 that was coded as a Stage four pressure ulcer in the June 2023 MDS.The Care Plan initiated on admission on 9/22/22 identified the resident as being at risk of impaired skin integrity with pertinent interventions to encourage the resident to change positions frequently, shift weight while in wheelchair, and to limit sitting to 60 minutes. The Care Plan, revised in July 2023, showed impaired skin integrity and had pertinent interventions to encourage the resident to change positions frequently, shift weight while in wheelchair, and to limit sitting to 60 minutes. The Kardex dated 7/25/23, under resident care, showed the resident needed to be limited to sitting for no longer than 60 minutes. C. Observations 1. During continuous observations on 7/20/23 that started at 9:14 a.m. and ended at 1:45 p.m. Resident #85 sat in her wheelchair and was not approached by staff to reposition or to move to the bed or recliner.-At 9:45 a.m., the resident was sitting in her wheelchair in her room with the TV on. -At 11:00 a.m., the resident continued to sit in her wheelchair while watching TV. -At 12:00 p.m., the resident wheeled herself to the dining room for lunch.-At 12:15 p.m. an unidentified CNA served lunch to the resident. She did not offer to reposition the resident. -At 12:45 p.m. the resident returned to her room and remained in her wheelchair. There was no evidence the resident had been repositioned or received incontinence care. At 1:45 p.m. an unidentified CNA assisted the resident to lie down in her bed. At this time, she had been sitting up in her wheelchair for four and one-half hours. 2. During continuous observations on 7/24/23, starting at 9:40 a.m. and ending at 2:30 p.m., the resident sat in her wheelchair and she was not approached to reposition or move to her bed or recliner.-At 9:55 a.m., the resident went downstairs in her wheelchair for an activity in the main dining room. -At 10:55 a.m., the resident returned upstairs to her room and she remained in her wheelchair.-At 11:55 a.m., the resident ambulated to the dining room in her wheelchair for lunch.-At 12:15 a.m., an unidentified CNA delivered the resident her lunch. The CNA did not offer to reposition the resident or remind her to shift her weight. -At 1:00 p.m., the resident went back to her room and picked up a small book from her bedside table. She remained seated in her wheelchair.-At 1:40 p.m., CNA #13 entered the resident's room and assisted the resident to stand. After the resident stood up she sat back down in her wheelchair. -At 2:15 p.m. CNA #13 and licensed practical nurse (LPN) #3 assisted the resident to her recliner chair. At this time, except for standing briefly at 1:40 p.m., the resident had been sitting upright in her wheelchair for five hours. V. InterviewsCNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she had turned in her notice to end her employment with the facility because there was not enough staff to help the residents in a timely manner. She said the facility was always short staffed and she did not have time to remind or help residents turn or reposition because she is always providing care for someone else. (Cross-reference F725)An anonymous nurse was interviewed on 7/25/23 at 1:55 p.m. The nurse said the facility needed more help. The nurse said they did not have time to remind or assist residents to turn or reposition. Tears began to roll down their cheeks as they described often going home and not wanting to come back to work at the facility because the staffing was so short. The nurse said it was not their intention to provide subpar care but they could only do what they had time to do. (Cross-reference F725)The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said residents who were unable or do not remember to reposition themselves should be reminded and/or assisted to reposition every two hours and as needed. She said the CNAs knew who needed to be reminded or assisted with repositioning by looking at the Kardex. She said that residents who are incontinent should be checked every two hours and as needed.

Plan of correction · submitted by the facility

F686How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Residents #23 and #85, both noted with present upon admission pressure ulcers. Treatment and dressing change orders are in place and are being completed per physician order. An order was created to appear on the MAR to ensure offloading and repositioning is being completed and documented in the resident record. Care plans updated as it related to pressure injuries. Wound physician visit completed. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. An audit was completed to determine all residents with a completed Braden assessment that indicates they are at risk of developing a pressure ulcer. No issues identified. Each resident has an active plan of care in place. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be completed, on or before the date of compliance, by DON/designee, to all nursing line staff. Education is based on the importance of completing a Braden assessment timely, turning and repositioning, active treatment orders, and wound physician visits, for the combined effort of preventing pressure ulcers from occurring. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. An audit will be completed, by DON/designee, on 5 residents 3 days a week for 4 weeks, two days a week for 4 weeks, and then once a week for 4 weeks. The audit is to ensure that all preventive measures are in place to aid in the prevention of an acquired pressure ulcer. The Braden assessment will then be completed once a week for 4 weeks on all new admissions and readmissions. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0689Free of Accident Hazards/Supervision/DevicesS/S E▼

Findings

II. Resident #89A. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pg 812. "If a patient was unable to cooperate or does not have sufficient upper or lower body strength, use ceiling, hydraulic floor, or power driven lift to transfer the patient from bed to chair. Use a minimum of two to three caregivers."B. Facility policy and procedureThe Mechanical Lift policy, reviewed 2/21/2020, was provided by the director of nursing (DON) on 7/25/23 at 11:06 p.m. It read in pertinent part, "Mechanical lifts should ALWAYS be used with two (2) or more trained staff members assisting in lift procedure from start to finish (including the placement of and removal of the sling)."C. Resident statusResident #89, age 75, was admitted on 8/23/22. According to the July 2023 computerized physician order (CPO) diagnoses included hemiplegia (total or nearly complete paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, type two diabetes mellitus and acquired absence of right and left leg above the knee. The 5/14/23 minimum data set (MDS) assessment showed the resident did not have cognitive impairment with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with bed mobility, transfers and all activities of daily living. The resident did not have any behaviors or rejection of care. D. Record reviewThe care plan updated on 5/29/23 identified the resident required two person assist with the mechanical lift for all transfers. E. Observations and interviewsOn 7/25/23 at 10:27 a.m., Resident #89 was observed in his wheelchair in his room with the call light on because he needed to use the restroom. CNA #2 brought the mechanical hoyer lift into the room, closed the door and turned off the call light. CNA #2 exited the room with the mechanical hoyer lift five minutes later at 10:23 a.m. with Resident #89 following her in his wheelchair. The resident was transferred via the mechanical lift with one CNA. Resident #89 was interviewed on 7/25/23 at 10:32 a.m. Resident #89 said CNA #2 used the mechanical hoyer lift by herself and no other staff were in the room when she moved him from his wheelchair to the toilet and back again. He said the CNAs transfer him by themselves more often than not. He said it was unusual for two CNAs to use the hoyer lift with him. CNA #2 was interviewed on 7/25/23 at 10:35 a.m. CNA #2 said she used the mechanical hoyer lift by herself when she transferred Resident #89 from the wheelchair to the toilet and then back to the wheelchair. She said she did not always remember who needs to be transferred with specific equipment so she often asked the nurses for guidance. She said she knew there was supposed to be two people using the hoyer lift but there was not always help available when it was needed so she did it by herself especially with residents that were able to help themselves some. (Cross-reference F725 for insufficient staffing)CNA #19 was interviewed on 7/25/23 at 3:15 p.m. She said she used the mechanical lift to transfer residents that were totally dependent on staff for care. She said she often transferred residents by herself using the mechanical lift because she was unable to find help. She said she was unaware that two staff members should be present when using a mechanical lift. (Cross-reference F725). The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said when the mechanical hoyer lift was used, it was always a two-person assist device and it was never authorized for only one CNA to use it. She said the staff had been provided training on proper use of the hoyer lift and the two person requirement as the facility had recently been cited for the same thing. III. Resident #127 A. Material Safety Data Sheet for chemicals 1. Ajax all purpose cleaning powderHazard IdentificationHealth Hazards (Acute and Chronic): This product contains a small amount of crystalline silica, a naturally occurring impurity in calcium carbonate. NTP has listed crystalline silica as an carcinogen. IARC has found limited evidence for carcinogenicity in humans. However, under normal conditions of product use, no significant health risk to humans is expected. Signs and Symptoms:Eye-Direct exposure to large amounts may cause eye irritation, but no permanent eye injury is expected. Skin-May cause irritation upon prolonged and excessive contact. However, no skin irritation is expected with normal use. Ingestion-May be harmful if swallowed. Inhalation-Overexposure to dust may cause respiratory tract irritation. Medical Conditions Generally Aggravated by Exposure: None known. 2. Scrubbing bubbles bathroom cleanerHazard identification:Principle routes of exposure: Eye contact. Skin contact. Inhalation. Eye contact: Severe eye irritation. Skin contact: Moderately irritating to the skin. Inhalation: May be irritating to nose, throat, and respiratory tract. Ingestion: May be irritating to mouth, throat and stomach. B. Resident statusResident #127, age 79, was admitted on 5/5/21. According to the July 2023 CPO diagnoses included anxiety, depressive episodes and malignant neoplasm (cancer) of the colon. According to the most recent MDS dated 6/8/23 the resident had moderate cognitive impairment with a score of nine out of 15 for the BIMS. The resident was primarily independent with activities of daily living and required setup help by staff. C. Observations and interviewsResident #127 was interviewed on 7/19/23 at approximately 11:00 a.m. Resident #127 said housekeeping staff brought him cleaning supplies and left them in his room and told him "you should clean the (explicit word) in the toilet yourself and you should clean your room yourself." The resident's room contained Scrubbing Bubbles (bathroom cleaner) and Ajax (all purpose powder cleaner). D. Staff interviewsHousekeeper (HSKP) #2 was interviewed on 7/19/23 at 2:35 p.m. She said Ajax and Scrubbing Bubbles were accidentally left there by her. She said housekeeping supplies should never be left in the room because a resident could eat or drink the chemicals or get the chemicals in their eyes. The environmental director (ED) was interviewed on 7/19/23 at approximately 3:00 p.m. She said she always had to correct and remind HSKP #2 that housekeeping supplies should never be left in a resident's room. Housekeeping supplies should never be given to a resident to clean their own room. Housekeeping staff were responsible for cleaning the room and not the resident. Housekeeping supplies should never be left in the room because it could potentially be harmful to a resident if they used it incorrectly. The ED said the facility's policies and procedures were not adhered to and that she had to educate all her staff. The director of nurses (DON) was interviewed on 7/25/23 at approximately 7:30 p.m. The DON said cleaning supplies should not be left in the resident's room. Cleaning supplies should enter the room with housekeeping staff and be secured by housekeeping staff upon exit of a resident's room. Based on observations, record review and interviews, the facility failed to ensure three (#78, #89 and #127) of five out of 71 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to:-Ensure Resident #78 did not receive another resident's medications;-Ensure Resident #89 was transferred with a mechanical lift according to professional standards of practice; and, -Ensure cleaning chemicals were not left in Resident #127's room unsecured. Findings include:I. Resident #78A. Resident statusResident #78, age 86, was admitted on 12/13/22. According to the July 2023 computerized physician orders (CPO), the diagnoses included hypertension and depression. The 6/19/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was independent with all activities of daily living. B. Resident interview and observationsResident #78 was interviewed on 7/19/23 at 3:34 p.m. She said the nurse came into her room and tried to give her pain medication. She said she told the nurse she did not get any pain medication, but that she was waiting for her Eliquis medication. She said the nurse had called her another resident's name. She said this was not the first time a nurse had tried to give her someone else's medication. She said she was glad she was of sound mind so she did not take the wrong medications, but was concerned for those residents who were not. During the interview, licensed practical nurse (LPN) #6 approached Resident #78 at the medication cart. Resident #78 asked LPN #6 why she called her by another resident's name and why she tried to give her the wrong medications. LPN #6 responded she was sorry and thought Resident #78 was another resident in the hallway. She said she had attempted to give Resident #78 a pain medication that was meant for another resident. C. Record reviewThe anticoagulant therapy care plan, initiated and revised on 6/29/23, documented the resident used anticoagulant therapy due to a diagnosis of atrial fibrillation (irregular and often very rapid heart rhythm). The interventions included administering anticoagulant medication as ordered by the physician. A review of the July 2023 CPO did not reveal a physician's order for Resident #7 to receive pain medication. D. Staff interviewsRegistered nurse (RN) #3 was interviewed on 7/25/23 at 3:06 p.m. She said prior to administering medication, each nurse should review the rights of medication use, which included ensuring the right patient, the right drug, the right time, the right dose and the right route. She said it could be very dangerous if a nurse administered medications without first verifying the rights of medication use. The director of nursing (DON) was interviewed on 7/25/23 at 3:29 p.m. She said prior to administering medications, the nurse should review the rights of medication use. She said administering the incorrect medication could be dangerous depending on the resident, their conditions and any other medications they may be taking. She said Resident #78 should have not had to tell the nurse that those were the wrong medications. She said the nurse should have verified who the resident was prior to attempting to administer medications. She said, if the nurse was new to that hallway, then she should have asked another staff member to verify who the resident was prior to attempting to administer medications.

Plan of correction · submitted by the facility

F689How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Resident #78 medications were verified, and she was given the correct medications, #89 was transferred via lift with two person assist, and resident #127 room was inspected to ensure no unsecured chemicals were left in his room. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents have the potential to be placed at risk of alleged deficient practices. Therefore, audits completed of random medication administration pass, observations completed by unit managers of proper transfer via Hoyer lift for those residents that require it, and all resident rooms were inspected for unsecured chemicals, none found. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be completed, on or before the date of compliance, by DON/designee with licensed nurses. Education was on the 6 rights of medication administration, Hoyer lift transfers with two person assistance, and the dangers of leaving unsecured chemicals in resident rooms. The education included negative outcomes for failure to follow expectation and policies of the facility. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. The interdisciplinary team rounds two times a week to ensure that no unsecured chemicals are on unit/in rooms. This will continue twice a week for 12 weeks. Hoyer lift transfers require two-person assistance. An audit of 5 observations twice a week for 4 weeks, then once a week for 8 weeks, for residents identified for the usage of Hoyer lift transfers will be completed by the unit manager or designee. Medication administration using the 6 rights of medication administration 3 nurses will be observed three times a week for four weeks, two times a week for four weeks, and then once a week for four weeks. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0692Nutrition/Hydration Status MaintenanceS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure two (#130 and #92) of three out of 71 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically, the facility failed to:-Ensure Resident #130 received assistance to meet her nutrition and hydration needs; and,-Ensure Resident #92 received sufficient hydration. Findings include:I. Facility policy and procedureA. The Hydration policy and procedure, revised January 2020, was provided by the director of nursing (DON) on 7/25/23 at 6:30 p.m. It read in pertinent part, "Purpose: to identify residents at risk for dehydration. To evaluate the fluid requirement of each resident. To identify risk factors which lead to dehydration and develop an appropriate preventative care plan. To provide sufficient fluid intake to maintain proper hydration and health."B. The Facility Nutrition Program policy and procedure, revised April 2007, was provided by the DON on 7/25/23 at 6:30 p.m. It read in pertinent part, "Direct care staff, assisted by the facility's clinical dietician, will evaluate each individual's physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization."A facility dietician will help assess the nutritional needs and risks of all residents and patients in the facility, and help the facility assure that it provides appropriate meals and other nutritional interventions."II. Resident #130 A. Resident statusResident #130, age 89, was admitted on 11/3/21. According to the July 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, anxiety disorder, macular degeneration and legal blindness. The 5/29/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of one out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene. The resident required extensive, one person physical assistance with eating. It indicated the resident did not have weight loss of 5% or more in the last month or 10% or more in the past six months. B. Resident representative interviewResident #130's representative was interviewed on 7/19/23 at 4:05 p.m. He said he did not think the facility staff encouraged the resident to drink enough. He said she had two beverage containers, one filled with cranberry juice and the other with Sprite (soda) each day and when he arrived almost every day around 2:00 p.m. the containers were still filled to the top and not within her reach when she was sitting in the recliner. He said Resident #130 required assistance with drinking and eating, as well as encouragement. He said when she was thirsty she would call out for help, but she would only receive assistance when someone was around in the hallway, which was not very often. He said when he arrived at the facility, more often than not, her lunch was sitting on the over bed table, not within reach and still covered in clear wrapping. He said Resident #130 did not like going to the dining room to eat, because she was not a very social person. He said she needed to be assisted in her room, but he felt the staff were too busy or did not care to ensure she ate, because she required more attention. He said he felt that the resident did not get assistance with eating unless a family member was present. He said the facility often gave the resident food items that were not cut up. He said the resident was not able to cut up her food for her and he had made it clear that when possible to cut up items. He said sandwiches could be cut up into small sections to make it easier for the resident to handle. He said the resident was not able to pick up a whole hamburger or sandwich to eat. C. ObservationsDuring a continuous observation on 7/20/23 beginning at 9:30 a.m. and ending at 2:15 p.m., Resident #130 was observed sitting in the recliner chair, sleeping. A water pitcher (24 ounces) was observed filled to the top with ice and another beverage tumbler (26 ounces) with a red liquid (cranberry juice) filled to the top sitting on top of the over bed table. The table was not within reach of the resident, who was reclined in the recliner chair. The hospice certified nurse aide (CNA) was fixing the resident's blanket and then left the room.-At 9:48 a.m. the hospice CNA told the nurse she had provided a bed bath to Resident #130 and then left the facility.-At 10:09 a.m. two unidentified activity staff members entered the resident's room for the donuts and coffee activity. They entered the room and then immediately exited. One staff member said, "she is sleeping, just mark passive down cause she is asleep." The other staff member said, "well, they can't say we didn't offer her anything.-At 11:34 a.m. the over bed table was in the same position and not within reach of the resident. Staff were not observed entering the resident's room to offer her a drink.-At 11:51 a.m. an unidentified nurse entered the resident's room. She woke the resident up to take her medications. The resident said she was thirsty and the nurse held the drink tumbler containing the cranberry juice for the resident as she drank. The resident said, "thank you, I was so thirsty."-At 12:34 p.m. CNA #19 entered the resident's room with her lunch. The resident was served a cheeseburger, not cut up and the plate was wrapped in clear plastic. She did not wake up the resident to eat lunch. She placed it on the over bed table, which was still not within reach of the resident, who remained in the recliner chair. She did not provide any additional beverages for the resident.-At 2:07 p.m. the resident remained in the same position and her food was still wrapped, on the over bed table and not within reach of the resident. The facility staff had not returned to assist the resident with eating or set up her meal. Her water pitcher remained at the same level (full) and the tumbler with cranberry juice had been reduced by approximately six ounces. During a continuous observation on 7/24/23 beginning at 10:00 a.m. and ended at 2:50 p.m. Resident #130 was observed laying in the recliner chair. The hospice CNA exited the room after providing incontinence care and personal hygiene. The hospice CNA informed the nurse of the care she provided and then left the facility.-At 10:30 a.m. the resident was lying in the recliner chair with a water pitcher filled to the top on the over bed table, not within reach of the resident.-At 11:57 a.m. registered nurse (RN) #3 entered the room to administer medications. She entered with a cup of cranberry juice (six ounces). The resident took the medication and drank the entire cup.-At 12:57 p.m. a visitor entered the room and played music for the resident. The resident's water pitcher remained on the over bed table, not within reach.-At 1:06 p.m. CNA #19 entered the room and delivered her lunch, shrimp pasta.-At 1:13 p.m. an unidentified CNA entered the room with an eight ounce (oz) cup of cranberry juice and placed it on the over bed table. He did not move the table within reach of the resident.-At 1:23 p.m. RN #3 entered the room with a six oz cup of cranberry juice and medications. The resident drank the entire cup of cranberry juice. The nurse did not move the over bed table within reach of the resident.-At 1:46 p.m. CNA #19 was observed in the hallway cleaning off plates after residents were finished eating. She informed the nurse that she needed to feed Resident #130. The nurse said she needed her to lay another resident down before she assisted Resident #130 with her meal.-At 2:49 p.m. Resident #130 was observed sleeping in the recliner chair. The resident's lunch was observed on the over bed table, not within reach. The resident was served shrimp noodles with large pieces of cantaloupe on the side. It appeared as though the resident had eaten one to two bites of the shrimp noodles, the cantaloupe was untouched and still covered with plastic. The water pitcher was filled to the top and two glasses of cranberry juice were filled to the top, untouched. D. Record reviewThe memory impairment care plan, initiated on 11/10/21 and revised on 6/1/23, documented the resident had impaired short term and long term memory. The interventions included offering gentle cueing, reminders and redirection as needed; providing comfort when the resident is confused and does not know where she is; and contacting the family for assistance as needed. The dehydration care plan, initiated and revised on 6/12/23, documented the resident had a potential for dehydration or fluid deficits related to care needs and Alzheimer's disease. The interventions included encouraging the resident to drink fluids every shift and ensuring the resident had access to fluids. The nutrition care plan, initiated on 11/11/21 and revised on 6/12/23, documented the resident was at nutritional risk due to a diagnosis of Alzheimer's disease, advanced age and weight loss. It indicated the resident was receiving hospice care. The interventions included providing the resident's diet as ordered, offering meal alternatives if the resident's intake is poor, providing reminders that items are available from the a la carte menu, providing meal assistance as needed, putting the food into bowls so it is easier for the resident to hold/eat, monitoring weights monthly, encouraging fluids in between meals, and providing supplements as ordered. The comprehensive care plan documented that the resident often preferred to sit in her recliner chair, partially reclined when she was eating or drinking. It indicated she had been provided education about the risks associated with improper alignment, however because of the resident's dementia, it was unclear how much she was able to retain. It indicated she would often decline assistance with meals. The interventions included ensuring the resident has the diet necessary to make eating as safe as possible, raising the head of the recliner as much as she will allow, setting up the resident's meal and providing feeding assistance. The activities of daily living (ADL) care plan, initiated on 11/11/21 and revised on 6/12/23, documented the resident had a self-care performance deficit related to impaired balance, decreased endurance, blindness and dementia. It indicated the resident was unable to meet her own self care needs and was dependent upon staff for care. It indicated the resident had varying levels of feeding herself and staff should set up her meals and assist as needed (last revised 11/16/21). The 2/25/23 nutrition assessment documented Resident #130 received a regular, mechanical soft diet and had an average meal intake of 50-75% (percent). The resident received Ensure three times per day with an average intake of 50-100%.It indicated the resident required limited assistance with eating. The resident's estimated needs were documented as approximately 1500 calories, approximately 63 grams of protein and 1700-2100 ml (milliliters) of fluids. The July 2023 meal intakes documented the resident had a variable intake, but primarily between 50-75%, however, on multiple occurrences (11 out of 24), meal intakes were only documented once per day. Resident #130's weights were documented as follows:-1/13/23: 146.5 lbs (pounds)-2/10/23: 147.4 lbs-3/16/23: 143 lbs-4/3/23: 144.2 lbs-5/1/23: 142.4 lbs-6/5/23: 138.7 lbs (loss of 5.26% in six months); and-7/11/23: 134.4 (loss of 3.10% in one month).-A review of the resident's electronic medical record did not reveal any further nutrition documentation or interventions. E. Staff interviewsCNA #19 was interviewed on 3:15 p.m. She said Resident #130 required total assistance with all ADLs. She said the resident required assistance with eating. She said the resident could not pick up the food by herself. She said the resident required a lot of cueing and encouragement toeat. She said the resident was not able to pick up the water pitcher or tumbler by herself. She said staff should be offering her a beverage every one to two hours, but she got too busy and would forget. (Cross-reference F725 for insufficient staffing). She confirmed the resident's over bed table was not within reach of the resident. She said it was easier for the resident to eat her meals if it was cut up. She confirmed, during the survey process, the resident's food has sat in her room for an extended periods of time. She said she got really busy and it was hard to be able to assist her with her meal timely. (Cross-reference F725)She confirmed the shrimp noodles were cold when she tried to assist the resident. She said she did not think it probably tasted good cold and that could be why the resident did not take very many bites. The registered dietitian (RD) was interviewed on 7/25/23 at 6:15 p.m. She said Resident #130 was not her radar for weight loss. She said the resident received Ensure three times per day and had an average meal intake of 50-75%.She agreed the resident had a gradual weight loss over the past few months. She said the resident had lost 8% in the past six months. She said she had not been notified of the gradual weight loss because it was not considered significant. She said Resident #130 required assistance with eating and required a lot of cueing and encouragement. She said she conducted observations of feeding in the dining room, but did not observe residents in their rooms. She said she had not assessed the resident since May 2023. She said she did not have any additional interventions in place to address the resident's weight loss. She said the resident should be assisted when her meal was delivered to her room. She said the resident's meal should not be sitting in her room, not within reach and still covered. She said beverages should be offered to the residents throughout the day. She said she would recommend the resident receive 50 to 60 ounces of fluids per day (1479 ml to 1775 ml).-However, the amount the RD recommended varied from the 2/25/23 nutrition assessment where it was recommended she receive 1700-2100 ml. The DON was interviewed on 7/25/23 at 3:29 p.m. She said beverages should be offered throughout the day and night, every couple of hours. She said beverages should be placed within reach of the resident. She said any residents who required assistance and ate in their rooms, should have their meal trays passed at the same time to maintain food temperature. She said once their tray has been delivered, the staff member should sit and assist the resident with her meal. She said she was unsure of how much care Resident #130 required. She said the RD was responsible to identify weight loss trends and put interventions into place. III. Resident #92A. Resident statusResident #92, age 72, admitted to the facility on 12/7/21. According to the July 2023 CPO, diagnoses included chronic kidney disease, anemia in chronic kidney disease and morbid obesity. The 5/26/23 minimum data set (MDS) assessment, showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required total dependence for bed mobility and extensive assistance from two or more staff members for transfers and toilet use. The resident was independent with eating. B. Resident interviewResident #92 was interviewed on 7/19/23 at 11:00 a.m. She said she only received water with her meals and she was not offered water outside of meal times. She said she had to push her call light and wait over an hour to ask for water and most of the time she would not get it until the meal was served anyway. (Cross-reference F725)C. Observations During the continuous observation period on 7/24/23 at 9:00 a.m. to 11:40 a.m. and at 12:30 p.m. to 3:30 p.m. the resident was not offered water or other hydration. -At 9:00 a.m. the resident was laying in her bed. She did not have any fluids available at her bedside.-At 11:40 a.m. an unidentified CNA answered the resident's call light but did not offer the resident any water or other hydration. -At 12:45 p.m. an unidentified CNA removed the resident's lunch tray but did not offer the resident any additional beverages or water. -At 1:30 p.m. the resident did not have any water in her cup on the bedside table. -At 2:45 p.m. the resident did not have any water in her cup on the bedside table. -At 3:30 p.m. the resident did not have any water within reach. During the continuous observation period on 7/25/23 at 1:35 p.m. to 5:33 p.m. the resident was not offered any fluids outside of meal time.-At 1:35 p.m. the resident was in bed and she did not have any water in her cup on her bedside table. -At 3:00 p.m. her water cup remained empty. -At 5:30 p.m. an unidentified CNA served the resident a 240 ml cup of a red drink and a 240 ml cup of another beverage. The resident had not had any fluids since lunch. D. Record reviewThe nutrition assessment dated 12/9/22 indicated the resident was on a 3500 ml fluid requirement daily. The care plan initiated 6/14/23 had a focus for risk of nutrition deficit due to diuretic use and had an intervention to encourage fluid intake with and in between meals. For the month of July 2023 the fluid intake response form for Resident #92 showed the resident consumed anywhere from 340 milliliters (ml) of fluid to 1920 ml of fluid. Most days the resident consumed less than 1000 ml of fluid. The hydration sheets showed the following for July 2023:7/1/23 600 ml7/2/23 800 ml7/4/23 1920 ml7/5/23 400 ml7/6/23 800 ml7/7/23 340 ml7/8/23 960 ml7/9/23 350 ml7/10/23 980 ml7/11/23 600 ml7/13/23 680 ml7/14/23 780 ml7/16/23 960 ml7/17/23 520 ml7/19/23 960 ml7/22/23 1200 ml7/23/23 720 ml7/24/23 600 mlE. Staff interviewsCNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she did not have time to provide residents with water unless they asked for it. She said there was not enough staff and she spent her entire shift answering call lights. (Cross-reference F725)The RD was interviewed on 7/25/23 at 6:31 p.m. She said residents should be offered fluids not only during meal times but in between meals to meet their individual hydration needs.

Plan of correction · submitted by the facility

F692How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Resident #92 and resident #130 have been offered to eat meals in the assisted dining room. Assisted dining provides oversight during the meal. If the resident refuses assisted dining, 1:1 assistance with the meal will be provided to ensure adequate amounts of nutrition/hydration was consumed, as the resident allows. If assisted dining is not available, hydration is offered every shift and as needed via routine hydration pass, medication administration pass, and during social activities. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents who require assistance with eating and hydration are at risk of alleged deficient practices. An audit was conducted to identify residents who require assistance with eating and hydration. These residents will be identified by a blue bracelet. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be provided to nursing line staff, on or before the date of compliance, by DON/designee, on the importance of offering residents identified as needing assistance with hydration, their meals or beverages timely and to chart if meal/beverage was consumed or refused. Resident #92 is independent with eating and drinking and her estimated fluid needs are 2900-3000 ml per day. Resident #130 will continue to be offered to eat in the assisted dining room. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. Unit managers/designee will inspect the identified residents who require assistance with feeding/beverages, meal tray, and ADL sheet for reporting of meal and beverage consumption three times a week for four weeks, twice a week for four weeks, and then once a week for four weeks to ensure that the resident is being assisted. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0695Respiratory/Tracheostomy Care and SuctioningS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure one (#108) resident who required respiratory care received the care consistent with professional standards of practice out of 71 sample residents. Specifically, the facility failed to ensure a portable oxygen concentrator was in working condition for Resident #108. Findings include: I. Resident statusResident #108, age 88, was admitted on 12/12/22. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia, chronic obstructive pulmonary disease (COPD), emphysema (lung disease that causes breathlessness) and anxiety. The 6/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance from one staff member for dressing, toilet use and personal hygiene. She required oxygen therapy. II. Observations and interviewsOn 7/24/23 at 12:34 p.m. certified nurse aide (CNA) #3 approached Resident #108 with a rag and wiped a clear, liquid substance off the floor located directly under the portable oxygen tank hanging from back of wheelchair of Resident #108. On 7/25/23 at 10:02 a.m. Resident #108 was observed sitting in a wheelchair in her personal room, two puddles of a clear, liquid substance was observed on the floor under the wheelchair and portable oxygen tank, approximately four to six inches in diameter. CNA #3 entered the room, observed the clear, liquid substance and wiped it up. CNA #3 checked the portable oxygen tank level for fullness, the tank level was less than a quarter of the way full. CNA #3 used a pulse oximeter (device placed on fingertip to measure oxygen levels) to measure the oxygen level of Resident #108. Reading on the pulse oximeter revealed an oxygen level of 89 percent, she then provided Resident #108 with a nasal cannula (a device used to administer supplemental oxygen to those in need of oxygen therapy) from a stationary oxygen tank in the room. CNA #3 said she noticed a clear liquid substance dripping from the portable oxygen tank on 7/24/23 at 12:34 p.m. She said she took no further action past cleaning the substance from the floor. She said she was aware it had came from the portable oxygen tank of Resident #108. CNA #5 was entered the room of Resident #108. CNA #5 said she had filled the oxygen tank at 7:00 a.m. that morning (7/25/23). CNA #3 used the pulse oximeter for a second time 10:13 a.m. to check the oxygen levels of Resident #108, oxygen level was 96 percent. III. Record reviewResident #108 had a physician's order to receive oxygen via nasal cannula at 2 liters. The care plan with a revision date or 6/28/23 revealed Resident #108 required oxygen use for emphysema and COPD.IV. Staff interviewsCNA #3 was interviewed on 7/25/23 at 10:24 a.m. She said she noticed a liquid dripping from Resident #108's portable oxygen tank on 7/24/23. She said she did not inspect the tank for further defects. She said oxygen tanks not in good working condition should be switched out for equipment that was in working condition. CNA #5 was interviewed on 7/25/23 at 10:24 a.m. She said she was not aware Resident #108's portable oxygen tank had been dripping liquid. She said oxygen tanks not in good working condition should be switched out for equipment that was in working condition. The director of nursing was interviewed on 7/25/23 at 8:00 p.m. She said if a portable oxygen tank was observed to be leaking fluid it should be replaced by one in working condition. The facility took the concentrator that Resident #108 was using out of circulation.

Plan of correction · submitted by the facility

F695How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Resident #108 was noted to have a leak in her 02 portable concentrator. The portable concentrator was replaced during the survey. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. Resident who utilizes portable oxygen concentrators have the potential to be affected by the alleged deficient practice. An audit will be conducted, on or before the date of compliance, by the DON/designee of all portable oxygen concentrators to ensure they were working properly and free of leaks. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be provided, on or before the date of compliance, of nursing staff, by staff coordinator/designee, on the importance of inspecting portable oxygen concentrators for leaks to ensure they are properly performing. Education included if the tank is leaking, remove and replace it with a functioning tank, and place the leaking tank in the oxygen room with signage noting its leakage and to report leaking tank to Rocky Mountain Respiratory Resource for replacement. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. Portable oxygen concentrators will be inspected by the unit manager/ADON or designee three times a week for 4 weeks, then two times a week for 4 weeks, and then once a week for 4 weeks. If a concentrator is noted with leaks it will be removed out of service and Rocky Mountain Respiratory Resource will replace the broken unit. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0725Sufficient Nursing StaffS/S F▼

Findings

Based on record review, observations, and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required per their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to consistently provide adequate nursing staff given the acuity and diagnoses of the facility's population, resident census, and the residents' daily need for care and services. Cross-reference citations: -F677 for the failure to provide timely incontinence care and reposition to residents; -F686 for the failure to provide repositioning for residents with pressure injuries; -F689 for the failure to ensure two staff were utilized when transferring residents with mechanical lifts; and, -F692 for the failure to provide timely eating assistance and consistently provide fluids to residents between meals. Findings include:I. Resident census and conditionsAccording to the 7/19/23 Resident Census and Conditions of Residents report, the resident census was 158 and the following care needs were identified:-110 residents needed assistance of one or two staff members for bathing and 37 residents were dependent;11 residents were independent.-135 residents needed assistance of one or two staff members for dressing and seven residents were dependent;16 residents were independent.-134 residents needed assistance of one or two staff members for transferring and no residents were dependent; 24 residents were independent.-129 residents needed assistance of one or two staff members for toilet use and 11 residents were dependent; 18 residents were independent.-60 residents needed assistance of one or two staff members for eating and six residents were dependent; 92 residents were independent. II. Staff requirements for each floor/unitA. 1st Floor rehab- 18 residentsTwo licensed nurses for 12 hours for the day shift and four certified nurse aides (CNAs);The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and three CNAs. B. 2nd Floor - 25 residentsTwo licensed nurses 12 hours for the day shift and five CNAs;The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and three CNAs. The unit had a CNA medication aide who worked from 6:00 p.m. to 6:00 a.m. C. 3rd Floor - 23 residentsTwo licensed nurses 12 hours for the day shift and three CNAs;The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. D. 3rd Floor Memory Care - 12 residentsOne licensed nurse 12 hours for the day shift and one CNA;The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and one CNA.E. Memory unit- 27 residentsOne licensed nurse 12 hours for the day shift and three CNAs;The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. III. Resident Council minutesThe Resident Council minutes were reviewed on 7/24/23 at 4:42 p.m. A. Resident Council minutes dated 2/8/23 revealed residents complained staff said showers were being skipped because the staff did not have time. B. Resident Council minutes dated 5/10/23 revealed residents miss their old CNAs and have mixed reviews on agency staff; it was discussed the whole country was in a CNA shortage. C. Resident Council minutes dated 7/12/23 revealed residents complained about staff administering wrong medications or not receiving their medications and the nurses do not want to double check or they do not have time; the nurses just drop off the medications and leave them on the table where they are not seen, and therefore, are not being taken. The minutes further read, showering schedules were a mess. Residents complained the facility would not pay overtime for reliable CNAs but will pay for agency staff who leave early. IV. ObservationsA. Resident #130 was observed on 7/19/23 at 4:44 p.m. According to the comprehensive care plan, the resident needs more attention as she was not able to make her needs known. She cannot usethe call light as she did not know what it is. B. Resident #25 was observed continuously on 7/24/23 from 1:10 p.m. to 3:00 p.m.-At 1:15 p.m. Resident #25 engaged the call light and requested for her husband (Resident #110) to be transferred from his wheelchair to his recliner.-At 1:18 p.m. CNA #12 responded and said she would be back in 10 minutes. The CNA turned off the call light; she did not address the resident's request.-At 2:15 p.m. Resident # 25 engaged the call light, 60 minutes later. Her husband continued to sit in his wheelchair and Resident #25 again requested for her husband to be moved from his wheelchair to the recliner. Staff turned off the call light and at time transferred Resident #25's husband to his recliner. V. Resident interviewsResident interviews revealed delays, from 20 minutes to over an hour, in staff providing them requested assistance. A. Resident #127 was interviewed on 7/19/23 at 11:13 a.m. According to computerized physician's orders (CPO), the resident admitted on 5/5/21 and assessed on 6/8/23 as moderately impaired. The resident said he had to wait 45 minutes for his call light to be answered when there were fewer staff working. He said around 4:00 p.m. or 5:00 p.m. there were not a lot of staff working on the floor.. He said the evening and middle of the afternoon and weekends were the worst. B. Resident #43 was interviewed on 7/19/23 at 12:06 p.m. According to CPO, the resident was admitted on 6/28/22 and assessed on 6/21/23 as cognitively intact. She said during the evening shift, if you push your call light, you can wait a long time, anywhere from 30-45 minutes. She said this happened often and mainly in the evening. C. Resident #104 was interviewed on 7/19/23 at 1:16 p.m. According to CPO, the resident was admitted on 8/22/19 and assessed on 4/9/23 as cognitively intact. He said there was not enough staff here. He said he had had to fill his own cups with ice every day as staff did not offer to do so. D. Resident #98 was interviewed on 7/19/23 at 1:20 p.m. According to CPO, the resident was admitted on 12/24/19 and assessed on 5/29/23 as cognitively intact. He said he had never waited less than an hour for help when pushing the call light. E. Resident #130 was interviewed on 7/19/23 at 4:44 p.m. According to CPO, the resident was admitted 11/13/21 and assessed on 5/29/23 as moderately impaired. She said this past Monday her sister pushed the call button and no one came for an hour and 15 minutes. F. Resident #7 was interviewed on 7/20/23 at 10:44 a.m. According to CPO, the resident was admitted 4/18/19 and assessed on 5/15/23 as cognitively intact. She said she requires assistance from two staff with toileting, transfers, and bed mobility, and sometimes there was only one staff working the hallway and it was hard to get the care she needed. She said she had had to wait around 20 minutes to get help. She said two CNAs worked the hallway and she required a two person assist. She said sometimes they only have one CNA and it was hard for her to get the care she needs. G. Resident #85 was interviewed on 7/25/23 at 2:00 p.m. Record review revealed the resident was admitted 9/27/22 and assessed on 6/26/23 as cognitively intact. She requires, per MDS, extensive assistance with toileting. She said she had had to wait over an hour at times to get assistance to use the restroom for a bowel movement and she believed it was due to a lack of available staff. VI. Staff interviewsStaff interviews indicated staffing expectations (see above) were not being consistently met. Staff reported they had too many duties and it was difficult to keep an eye on all the residents. A. CNA #9 was interviewed on 7/23/23 at 5:47 p.m. She said she had been employed at the facility since 4/12/19 and usually worked the weekends. She said every weekend and especially on Sundays, the facility was very, very short-staffed. She said most of the time, the facility did not have enough staff coverage, so the facility had been working with agency staff most of the time, call-off. CNA #9 said this morning, they only had two CNAs for the second floor. She said at 10:00 a.m. a third CNA came in but she was a shower aide. B. CNA #11 was interviewed on 7/23/23 at 5:50 p.m. She said she had been employed at the facility since 7/2/13 and usually worked weekdays. She said due to staffing shortages, the residents do not get the care they need. She said the facility had only one Sara lift on the second floor and the majority of the residents on the second floor require a Sara lift. C. CNA #7 was interviewed on 7/24/23 at 9:55 a.m. She said she had been employed at the facility since 1/21/22 and usually worked weekdays. She said staffing issues were horrible and the weekends were the worst. She said the weekend supervisor did not tell anyone anything. She said this morning there were three CNAs because a CNA picked up an extra shift. She said there used to be five CNAs on the second floor and now, because the census was low, they pulled the fifth CNA and there were only four CNAs on the first shift. She said when the facility changed the schedule, reducing the number of CNAs each shift, a lot of staff left. She said the facility was using a lot of agency staff. D. CNA #12 was interviewed on 7/24/23 at 3:36 p.m. She said she had been employed at the facility since 6/5/23 and usually worked weekdays. She said the third floor Memory Care usually had three CNAs and two registered nurses (RNs) who worked the floor and it was not enough staff. She said it was difficult to keep an eye on all the residents in Memory Care, especially those with wandering behaviors and were a fall risk. She said sometimes the RN will help her with transfers but some of the other staff would not help. She said she could not provide the appropriate care with the amount of staff they currently have. She said since the survey began, there had been more staff help but after the survey, staff would get the help they need and the facility will be short-staffed again. She said she had never seen the director of nursing (DON) in the Memory Care unit except when the survey was going on. E. CNA #2 was interviewed on 7/24/23 at 3:47 p.m. She said she had been employed at the facility since 6/5/23 and usually worked weekdays. She said they usually have three CNAs and two RNs a shift who sometimes help her out. She said sometimes there was not enough staff, especially when two CNAs were helping a resident out, leaving one CNA to attend to the other residents. G. CNA #1 was interviewed on 7/24/23 at 3:59 p.m. She said she had been employed at the facility since 1/13/22 and usually worked weekdays. She said there were three CNAs and two RNs on her shift. She said depending on the day and how many requests the residents have, it would be helpful to have an extra CNA. She said when there were too few facility staff, the facility had agency staff come in to fill in for staffing shortages. H. CNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she had turned in her notice to end her employment with the facility because there was not enough staff to help the residents in a timely manner. She said the facility was always short staffed and she did not have time to remind or help residents turn or reposition because she was always providing care for someone else. Cross-reference F686. I. An anonymous nurse was interviewed on 7/25/23 at 1:55 p.m. The nurse said the facility needed more help. The nurse said they did not have time to remind or assist residents to turn or reposition. Tears began to roll down their cheeks as they described often going home and not wanting to come back to work at the facility because the staffing was so short. The nurse said it was not their intention to provide subpar care but they could only do what they had time to do. J. The DON was interviewed on 7/25/23 at 7:52 p.m. She said she had been employed at the facility since February 2023. She said the facility did not have a shortage of staff because the facility uses agency staff to supplement staffing. She said, on the first floor, they have three to four CNAs and two RNs and on the second floor, they have two RNs and anywhere from four to six CNAs. She said on the third floor, they have two RNs and three to four CNAs. She said every floor had a nurse manager. She said the nursing home administrator (NHA), DON, and scheduler were responsible for staffing concerns. She said she and the scheduler meet daily to discuss staffing concerns or issues. She said they staff according to the census, acuity level and medical necessity. The DON said if the acuity requires three-person assistance, then they would add another staff aide or nurse to make sure there was enough staff. The DON said if there was not enough staff to address residents' needs, then their needs would not be addressed. She said they try to staff as adequately as they can, but there was nobody jumping into health care and everyone was tired of doing this kind of work. She said they have tried to put out bonuses and did not work. She said they were competitive in their salaries and no one was jumping at the opportunity. She said they offered to pay training for new CNAs and no one had applied. K. The scheduler was interviewed on 8/8/23 at 2:30 p.m. She said she had received a directive from management to staff the units by census or she will get in trouble. She staffing should be as follows:The first floor should have three CNAs for day shift and night shift, two nurses on day shift and from 6:00 p.m. to 10:00 p.m. and 6:00 p.m. to 6:00 a.m., one nurse. The second floor should have four CNAs and two nurses. The first floor Memory Care unit should have one nurse and three CNAs. The third floor should have three CNAs and two nurses on day shift and from 6:00 p.m. to 10 :00 p.m., one nurse and two CNAs. The third floor Memory Care should have one CNA and one nurse on day shift. She said on the night shift, one nurse floats back and forth. The scheduler was interviewed again on 8/8/23 at 3:00 p.m. She said they have several CNA and nurse positions open. She said:-The first floor had open positions of three morning CNAs and one CNA at night. There was one full time nurse position open. -The second floor had six CNA positions open, one on day shift, two on night shift and two-part time CNAs. There were three nurse positions on day shift and two full time nurse positions open on night shift. -The third floor had one morning and one night CNA position open. There are three nurse positions open on day shift and two nurse positions open on night shift. The Memory Care unit on the third floor had two CNA positions open for an eight hour shift and one-part time CNA needed. There was one nurse position open for the night shift. She said the facility was not offering any hiring bonus. She said the facility would pay for new CNAs included $1500.00 toward training classes. The scheduler said they used to have PRN as needed when staff called off but she said staff do not answer their phones, so she said she stopped calling them. She said she had increased the bonus to $15.00 an hour for CNAs and $60.00 an hour for nurses. She said she was not supposed to increase the bonus as the bonuses need to be approved by the NHA. She said when there was a call-off, she would put a message to staff in care communication and it went out to all the staff. She said the call-offs vary on the weekdays, but there were more call-offs on the weekends. She said they changed the staff's schedule so staff rotate every other weekend off and every weekend on. She said they use agency staff to fill the gaps in open positions. She said if the agency staff called off they were suspended from care for seven days. She said she gave staff three chances to call-ff and if they continue to call-off she took them off the schedule and off the list for rehire. VII. Additional informationThe facility staffing policy was received on 8/8/23 at 2:35 p.m. It read, in pertinent part, "it was the goal of the facility to operate at the optimal level to meet the standards of care for our residents. The facility's daily staffing HPPD (hours per patient day) changes routinely, however, the facility will never operate below a minimum of 2.0 HPPD. The state of Colorado had no minimum staffing ratio for long-term care. However, the facility adhered to all state and federal regulations related to staffing and the guidance provided by such entities. The facility will adjust its staffing as needed based on census, acuity and the needs of the residents." The AIT was interviewed on 8/8/23 at 2:36 p.m. She said the policy was given to her by the DON and printed off by the DON today. The scheduler was interviewed on 8/8/23 at 2:45 p.m. She said she did not recognize the staffing policy when shown. The AIT was interviewed on 8/8/23 at 3:00 p.m. She said when she was not able to find a policy she would go to the DON and provide the copy. She said the policy that was provided was what the DON had printed off.

Plan of correction · submitted by the facility

F725How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. A comprehensive assessment of facility staffing levels was conducted and an updated staffing pattern has been established to meet residents’ needs. Facility staff is tracked and trended through the ADP system. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. The facility is diligently engaged in the implementation of comprehensive personnel retention strategies, which encompass wage enhancements, employee recognition initiatives, incentivization programs, and performance-based bonuses. Additionally, our recruitment and hiring procedures are being optimized through the utilization of the ADP platform, thus streamlining and enhancing our talent acquisition process. To further ensure adequate staffing levels, we have established a partnership with a staffing agency. Furthermore, we have conducted a meticulous review of our staffing policies through the lens of an acuity assessment, ensuring alignment with our commitment to delivering top-quality care. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. The Staff Coordinator conducted re-education sessions for unit managers and line staff, emphasizing timely eating assistance, the consistent provision of fluids to residents between meals, proper resident repositioning, pressure injury prevention, and correct procedures for mechanical lift transfers. Re-education addresses the potential of outcomes when staffing is not meeting care needs at the facility. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. Staffing schedules will be reviewed 5 times per week for 12 weeks by the scheduler/designee. During the staffing schedule review, the facility will address any coverage concerns as they arise. In the event any staff presents concerns of being overwhelmed with the workload they may speak with NHA, DON, or HR. Facility staffing will be tracked and trended and reported to the QA committee by NHA/designee.

0730Nurse Aide Peform Review-12 hr/yr In-ServiceS/S E▼

Findings

Based on record review and interview the facility failed to ensure certified nurse aides (CNAs) received 12 hours of training per year for seven (CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24, and CNA #25) out of 49 CNAs. Specifically, the facility failed to provide 12 hour training for CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24 and CNA #25. Findings include:I. Record reviewThe facility was unable to provide documentation CNA #20 (hire date of 1/11/19) , CNA #21 (hire date of 8/22/22), CNA #22 (hire date of 6/6/17), CNA #23 (hire date of 8/1/19), CNA #7 (hire date of 1/21/22), CNA #24 (hire date of 9/15/2020) and CNA #25 (hire date of 9/29/22) had completed 12 hours of training during the survey process. II. Staff interviewThe infection preventionist (IP) interviewed on 8/8/23 at 2:10 p.m. He said the system they use for tracking training records was through a computer based program. He said he had his own tracking spreadsheet for education. He said he did not have a list of mandatory training for the CNAs to complete. He said he would look at the list of classes from last year and go off of whatever was in the system. He said he was not sure what would happen if the CNAs did not meet their training expectations as he said he had not done it. He said he would give the CNAs a timeframe to get their training done.

Plan of correction · submitted by the facility

F730Deficiency: Failure to ensure all CNAs received the mandatory 12 hours of training per year. 1. Immediate Corrective Actions:Immediate Training: Arrange for immediate training sessions to ensure CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24, and CNA #25 complete the required 12 hours of training. Set a strict deadline for completion. Training Verification: Review the computer-based program's training records for all CNAs to verify completion of training. Cross-reference these records with the infection preventionist's (IP) tracking spreadsheet to identify any discrepancies or missed trainings. 2. Systemic Changes to Prevent Future Deficiencies:Mandatory Training List: Compile a clear and updated list of mandatory training for CNAs, detailing the content, duration, and frequency of each session. Training Calendar: Implement a yearly training calendar that outlines all training sessions required for CNAs. This will provide clear visibility and planning opportunities for CNAs and management alike. Regular Communication: Disseminate monthly training reminders to CNAs to keep them informed of upcoming sessions and any pending training hours they need to complete. 3. Monitoring Mechanism:Quarterly Audits: The infection preventionist (IP) or designated staff will conduct quarterly audits to check training records for all CNAs and ensure that they are on track to complete their 12 hours. Annual Training Review: At the end of each year, perform a comprehensive review of all training records to ensure that all CNAs have completed their required training. 4. Accountability and Reporting:The IP/designee will be responsible for overseeing the training records and ensuring the adherence of CNAs to the new protocols. He/she will provide a monthly update on training compliance to facility leadership and flag any CNAs at risk of not meeting the required training hours well in advance. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0760Residents are Free of Significant Med ErrorsS/S J▼

Findings

Based on interviews, observation and record review, the facility failed to ensure one (#156) out of 71 sample residents were free from significant medication errors. Specifically, the facility failed ensure Resident #156, who was recently hospitalized for an acute embolism and was a high risk for deep vein thrombosis (DVT), was administered anticoagulant medication (Eliquis) as ordered upon discharge from the hospital. The facility failed to ensure the transcription of medications from the hospital records was accurate, which resulted in a failure to provide anticoagulant medication, which led to the resident developing a pulmonary embolism resulting in cardiac arrest. The facility's failure to administer the anticoagulant therapy, as was indicated by the hospital discharge records, led to the resident's change of condition and ultimately, his death, from cardiac arrest due to a pulmonary embolism. The failure to ensure the accurate transcription of physician's orders placed residents at risk for serious harm or death if not corrected immediately. Findings include:I. Immediate JeopardyA. Situation of immediate jeopardyThe facility failed to ensure the transcription of medications from the hospital records for Resident #156 were accurate upon his admission to the facility. This resulted in the facility's failure to ensure Resident #156 received anticoagulant therapy, as indicated by the hospital discharge physician. Resident #156 had been recently hospitalized for an acute embolism and was a high risk for DVT. The facility's failure led to Resident #156 developing a pulmonary embolism, resulting in cardiac arrest, and ultimately, his death. B. Imposition of immediate jeopardyOn 8/4/23 at 9:11 a.m., the nursing home administrator (NHA) and director of nursing (DON) were notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #156 received anticoagulant therapy. C. Facility plan to remove immediate jeopardyOn 8/4/23 at 12:15 p.m., the facility submitted a plan for the immediate jeopardy. The plan read:1. Corrective action The interdisciplinary team will conduct an audit of all new admissions and readmissions discharge orders that have been admitted to the facility within the past 30 days from today's date. The audit will be headed by the assistant director of nursing/designee. This audit will be completed by 8/7/23.2. Identification of others The discharge orders from the hospital will be initially reviewed by the admitting nurse. The admitting nurse will then verify the continuation of the discharge orders from the discharging facility with the admissions primary care physician or mid-level provider. The admitting nurse will have a second nurse verify the orders. The second nurse and the admitting nurse will sign off on the admitting orders together. The unit manager/designee will review both nurses and verify that the orders that are in place are the correct and most appropriate orders for the admitted resident and the unit manager/designee will make changes as needed. 3. Systemic changesFor all medication order changes, a second nurse will verify that medication changes to ensure that the new order (s) have been received and transcribed correctly for accurate administration of medication. This process will be reviewed five days a week by way of the order listing report during clinical meetings. Each member of the interdisciplinary team will initial off on this report to ensure compliance with this new process. Education will be provided to all licensed/registered nurses who are on duty today (8/4/23), and a continuing education will be provided to all licensed.registered nurses by 8/7/23 and all new nurses and agency staff prior to their first shift. Education will be provided by the DON (director of nursing)/designee. 3. MonitoringResults of this systemic change will be presented to the quality assurance improvement committee monthly, and as needed to ensure compliance with the new process. If a break in this process is identified, an immediate form of corrective action will be applied and a formal response will be completed. D. Removal of the immediate jeopardyThe above plan was accepted on 8/4/23 at 12:34 p.m. and the immediate jeopardy removed. However, record review and interviews revealed deficient practice remained at a G level, actual harm that was isolated. II. Failure to ensure anticoagulant medication was administered according to physician's ordersA. Resident #156 statusResident #156, age 77, was admitted on 5/10/23 and discharged to the hospital on 6/2/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included pulmonary embolism (blockage in heart arteries) and acute embolism and thrombosis of right femoral vein (blood clot in the vein in the leg). The 5/16/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with one person assistance with all activities of daily living. It indicated the resident had medically complex conditions, pulmonary embolism, DVT, PE (pulmonary embolism) or PTE (pulmonary thromboendarterectomy: surgery to remove blood clots and scar tissue from the arteries in the lungs). B. Record reviewThe anticoagulant therapy care plan, initiated and revised on 5/22/23, documented the resident received anticoagulant therapy due to a bilateral PE. The interventions included administering anticoagulant medications as ordered by the physician; monitoring for side effects and effectiveness; following up with the physician regarding medication dosing, lab draw scheduling and abnormal test results as ordered. The 5/10/23 admission summary documented the resident was admitted to the facility due to an acute pulmonary embolism. The 5/10/23 physician history and physical documented on 5/4/23, the resident was sent to the hospital with acute complaints of chest pain and shortness of breath. The resident was found to have bilateral pulmonary artery thrombus and subsequently underwent bilateral pulmonary artery thrombectomy with the majority of the thrombus cleared from the right and a partial thrombus cleared from the left.-The physician's assessment and plan included anticoagulant therapy to include Eliquis 10 MG twice daily through 5/16/23, then Eliquis 5 MG twice daily and to monitor for any acute respiratory complications. 1. Resident #156's history of acute embolismThe 5/5/23 hospital interventional radiology inpatient progress notes documented the resident was admitted to the hospital on 5/4/23 with a history of PE in 2022 and presenting with chest pain in the center of his chest and difficulty breathing as if "someone were on top of him." The resident was found to be tachypneic (rapid, shallow breathing) and mildly hypoxic (low oxygen level). The CTA (computed tomography angiography with contrast) indicated the resident had a large bilateral pulmonary embolus with image evidence of a right heart strain. Due to the resident's intermediate high risk of PE, the resident was recommended for a thrombectomy. On 5/4/23, a bilateral pulmonary artery thrombectomy with majority of thrombus cleared from right and partial thrombus cleared from the left. Following the procedure, it was recommended the resident receive continued anticoagulation. The 5/10/23 discharge physician orders documented the following:-Apixaban (Eliquis) 5 MG (milligram)-take two tablets (10 MG) twice daily for seven days (5/9/23-5/16/23) followed by one tab (5 MG) twice daily thereafter. 2. Failure of the facility to ensure Resident #156 received the correct anticoagulant therapyThe 5/10/23 physician's order note documented the following order was entered into the resident's electronic medical record:Eliquis Oral Tablet 5 MG-give 10 mg by mouth two times a day for PE until 5/16/23 and give 5 MG by mouth two times a day.-The CPO from the hospital (documented above) indicated the resident should receive 10 MG twice per day until 5/16/23 and then 5 MG twice per day thereafter, not receive 10 MG and 5 MG.The 5/11/23 physician's order note documented that the order was clarified to read: Eliquis 5 MG-give 10 MG by mouth two times a day for PE until 5/18/23.-However, the resident was still not receiving the correct dosage of Eliquis according to the 5/10/23 physician notes and the hospital discharge orders. According to the May 2023 MAR (medication administration record), the resident did not receive any anticoagulant therapy after 5/18/23.-The hospital discharge orders indicate the resident should receive long term anticoagulant therapy with a dose of Eliquis 5 MG twice per day, with no stop date indicated. 3. Resident #156's change of conditionThe 6/2/23 nursing progress note documented a certified nurse aide (CNA) altered the nursing at 12:15 p.m. the resident was slumped over in the wheelchair, drool coming from his mouth, his pupils dilated, was slurring his speech and was diaphoretic (sweating heavily). The resident displayed seizure activity for 30 seconds with convulsing. The resident had a blood pressure of 74/42 (with normal being 120/80) and had an oxygen saturation of 82% (percent) on room air (normal range 95 to 100 %). The resident was placed on a non-re-breather at 15 LPM (liters per minute) which brought the resident to 88% oxygen saturation. The resident was sent to the hospital via 911 ambulance. The 6/2/23 emergency room notes documented the resident was brought into the emergency room unresponsive. The resuscitation efforts were not successful and were terminated at 1:12 p.m. It indicated Resident #156 had a life threatening clotting disease and upon his arrival to the hospital from the facility, the medication list showed no use of anticoagulants. According to the hospital notes, the coroner determined that the resident suffered from cardiac arrest due to a pulmonary embolism from a lack of anticoagulation. The 6/27/23 certificate of death documented the resident's cause of death was cardiac arrest due to a pulmonary embolism. The facility failed to ensure the medications indicated on the hospital discharge list were properly transcribed to the resident's medical record. This failure led to the resident's lack of anticoagulant therapy, which ultimately, caused a pulmonary embolism which resulted in Resident #156's death. C. Staff interviewsRegistered nurse (RN) #3 was interviewed on 7/25/23 at 3:06 p.m. She said anticoagulant therapy assisted in preventing DVTs and PEs. She said blood clots could travel throughout the body and cause serious health problems, even death. She said the nurse on duty was responsible for reviewing the discharge orders for an admitting resident. She said that the nurse was responsible to read over the medications, inform the attending physician at the facility and transcribe the medications into the resident's medical record. She said she was not aware of a system in place at the facility where the facility double checked the discharge orders from the hospital and the orders transcribed into the resident's medical record. She said if a resident was a high risk for PE, then not receiving anticoagulant therapy could cause the resident to suffer from an acute PE.The director of nursing (DON) was interviewed on 7/25/23 at 3:29 p.m. She said each resident who was admitted to the facility from the hospital had their medication reviewed by two nurses and the physician. She said the nurse would contact the physician to verify the medications. She said the admitting nurse was responsible for entering the medications into the resident's electronic medical record. She said the interdisciplinary team, which consisted of nursing management, did not review the admission orders to ensure the medications had been entered into the resident's medical record correctly. She said she remembered Resident #156's change of condition and being sent to the hospital but she could not remember the circumstances surrounding the change of condition. She acknowledged the orders from the hospital documented the resident should have been taking Eliquis 10 MG twice per day until 5/16/23 and then 5 MG twice per day thereafter. She confirmed the orders from the hospital were input incorrectly into the resident's medical record. She confirmed that the resident did not receive any anticoagulant therapy after 5/18/23. She confirmed the resident was a high risk for embolism and DVT. She said a lack of anticoagulant therapy could cause the resident to throw another PE and lead to serious health complications, such as death. The pharmacist and the physician were unavailable for an interview during the survey process.

Plan of correction · submitted by the facility

F760 1. Resident #156 no longer resides at the facility. 2. Any resident on anticoagulant therapy has the potential to be affected. An audit of all other residents on anticoagulant therapy was conducted on 9/8/2023 that orders were transcribed correctly and administered as ordered. No other residents were identified. Root cause analysis revealed a transcription error of anticoagulant medication for resident #156.3. Education was provided to all licensed nurses on 8/4/2023 to include the dual verification process of new admission/readmission of anticoagulant orders. Agency nurses will be educated prior to working their shift. During the new hire orientation process education will be provided to licensed nurses. Clinical competency validations of medication administration are completed for 2 nurses, once a week (to include agency staff), for 12 weeks. 4. The DON/designee will conduct audits of any resident on anticoagulant therapy 5 times per week for a period of no less than 12 weeks or until sustained compliance is achieved. This audit includes reviewing the current anticoagulant order. The provider will be notified for any missed doses and orders for any changes will be obtained at that time including lab work as determined by the provider. Results of this systematic change will be presented to the quality assurance improvement committee monthly for at least three months or until sustained compliance is achieved. Any deviation from the process will be corrected when identified.

0761Label/Store Drugs and BiologicalsS/S E▼

Findings

Based on observations and interviews the facility failed to ensure three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted professional standards. Specifically, the facility failed to ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Medication Storage policy was requested from the director of nursing (DON) on 7/25/23 but was not provided. II. Observations7/25/23 -At 10:34 a.m. the third floor medication room medication refrigerator was observed with licensed practical nurse (LPN) #4. The refrigerator was not locked and it contained a locked box to hold controlled medications needing refrigeration that could be picked up and removed from the refrigerator. The narcotic locked box was not permanently affixed to the refrigerator. The nurse confirmed the controlled substance locked box inside of the refrigerator contained Lorazepam.-At 10:50 a.m. the second floor medication room medication refrigerator was observed with registered nurse (RN) #1. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the controlled substance locked box inside of the refrigerator contained Lorazepam.-At 11:11 a.m. the first floor medication room medication refrigerator was observed with LPN #1. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the controlled substance locked box inside of the refrigerator contained Lorazepam. III. Staff interviewsThe director of nursing (DON) was interviewed on 7/25/23 at 8:05 p.m. The DON said the narcotic boxes in the refrigerators were in a locked box in a locked room and she was not aware the narcotic boxes needed to be permanently affixed to the refrigerator itself. She said the most commonly refrigerated controlled substance in the facility was Lorazepam.

Plan of correction · submitted by the facility

F761How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Narcotic storage boxes were replaced and secured within the refrigerator for 4 refrigerators. The narcotic box secured within the refrigerator is locked, as well as the door to the medication rooms. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. There are no other refrigerators for stored narcotics. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be completed, on or before the date of compliance, by staff coordinator/designee, with licensed nurses, on the importance of ensuring narcotic refrigerator boxes are secured. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. Licensed nursing staff will check daily that their designated refrigerator has a secured narcotic box within; this is a system change that will occur once daily. If a narcotic box becomes unsecured, licensed nursing staff will notify the maintenance department immediately. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0806Resident Allergies, Preferences, SubstitutesS/S E▼

Findings

Based on observations, record review and interviews; the facility failed to provide food that accommodated resident preferences for four (#13, #78, #79 and #86) of four residents out of 71 sample residents. Specifically the facility failed to offer food choices according to resident preferences for Residents #13, #78, #79 and #86. Findings include:I. Observations and record reviewOn 7/25/23 the noon kitchen line was observed continuously from 12:00 p.m. to 1:00 p.m. The trays were prepared using a resident list, which had the resident's preferences (likes and dislikes) and what the resident wanted to eat for their meal. At approximately 12:30 p.m. Resident #13 was served half of a serving of carrots.-Tray card for Resident #13 indicated that the resident disliked carrots. At approximately 12:30 p.m. Resident #78 was served a full serving of carrots.-Tray card for Resident #78 indicated that the resident disliked carrots. At approximately 12:30 p.m. Resident #79 was served gravy.-Tray card for Resident #79 indicated that the resident disliked gravy. At approximately 12:30 p.m. Resident #86 was served a full serving of carrots.-Tray card for Resident #86 indicated that the resident disliked carrots. II. Resident interviewsResident #13 was interviewed on 7/24/23 at 1:36 p.m. The resident said she did not like carrots although she was served them and she would not eat them. Resident #78 was interviewed on 7/24/23 at 1:40 p.m. The resident said she was bothered that she was served carrots because she did not like them at all. The resident said her meal ticket documented she did not like them. The resident said she only wanted potatoes but she always got carrots. Resident #79 was interviewed on 7/24/23 at 1:47 p.m. The resident said she received gravy on her potatoes but she did not want gravy and she did not like it and therefore she did not eat her potatoes. Resident #86 was interviewed on 7/24/23 at 1:50 p.m. The resident said he was bothered that he was served carrots because he did not like them at all, especially since they were half cooked and he could not stab them with a fork. The resident said the facility did not listen to the resident's preferences and it made him frustrated and angry. III. Staff interviewsThe dietary manager (DM) was interviewed on 7/24/23 at 7:04 p.m. The DM said the dietary staff were supposed to review the tray card prior to serving the resident. The tray card included hand written preferences, likes and dislikes and selections a resident would make prior to receiving their meal. Dietary staff should serve residents according to the tray card when they were plating the meal to ensure the residents were served what they ordered and to take into account the resident's preferences. The tray card listed the resident's preferences and the facility was supposed to honor the resident's preferences.

Plan of correction · submitted by the facility

806#1 – Address how corrective action will be accomplished for those residents found to have been affected by the alleged deficient practice. The Dietary Manager/designee met with resident 13, 78, 86 and 79 to review food preferences for accuracy. #2 – Address how the facility will identify other residents having the potential to be affected by the same alleged deficient practice. Monthly food committee meeting to address resident food preferences, and validation of tray cards, will ensure that resident choices are being honored. The dietary manager/designee will review all residents with food preferences, and will meet with all admissions and readmissions to determine if they have food preferences or updates. #3 – Address what measures will be put into place or systemic changes made to ensure the deficient practice will not reoccur. The dietary manager/designee will conduct consultations with new admissions to ascertain their food preferences and any dietary requirements that meet their nutritional needs. RD nutrition assessment addresses preferences for established residents quarterly and upon change of condition. Dietary manager/designee will in service all dietary staff, on or before the date of compliance, related to following resident food preferences.#4 – Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Dietary Manager/designee will interview 5 residents weekly for 12 weeks to ensure that their food preferences are being followed. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0812Food Procurement,Store/Prepare/Serve-SanitaryS/S F▼

Findings

Based on observations and interviews, the facility failed to prepare and serve food in a sanitary manner. Specifically, the facility failed to have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher. Findings include:I. Professional reference According to the Food and Drug Administration Food Code (2022) accessed on 8/16/23 from https://www.fda.gov/media/164194/download?attachment read in pertinent part,"Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water."A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160°F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160°). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160ºF."II. ObservationsOn 7/19/23 at 8:53 p.m. an unidentified dietary aide put a load of dishes through the dishwasher. She said the dishwasher was high temperature and indicated that the external display read 180 degrees F (Fahrenheit). She said she did not know how to check the internal temperature of the dishwasher to ensure the outside display was correct. She said the facility did not keep a log of the temperature of the dishwasher. III. Record reviewThe facility was unable to provide documentation that the internal temperature of the dishwasher was being monitored to ensure functionality. IV. Staff interviewsThe dietary manager was interviewed on 7/19/23 at 11:35 p.m. He said the facility did not have a way to check the internal temperature of the dishwashing machine. He said the outside gauge was sufficient. He said he would not know how to begin to check the internal temperature of a dishwasher. He said he did not have a waterproof thermometer and had never heard of temperature testing strips. He said he could not be certain the outside gauge was correct, but felt it probably was fine. He said he did not understand why he needed to ensure the internal temperature and the outside gage matched, when he felt as though it most likely did match. He said he did not have a policy on the dishwasher. He said he would not know where to look to even obtain a policy on the use of the dishwasher.

Plan of correction · submitted by the facility

F812Address how corrective action will be accomplished for those residents found to have been affected by the alleged deficient practice. 1. Test strips were purchased and in use. Address how the facility will identify other residents having the potential to be affected by the same alleged deficient practice. 2. The facility has two other dishwashers and strips were purchased for those. Address what measures will be put into place or systemic changes made to ensure the alleged deficient practice will not reoccur. 3. The dishwashers operate under the correct and required parameters. The gauges are NSF certified. The machine is routinely inspected for correct operation. Temperature logs are routinely and rigorously used. Dietary staff will be re-educated, on or before the date of compliance, by the dietary manager/designee, to use the surface strips. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. 4. An audit will be conducted once a week for 12 weeks, by dietary manager/designee, to ensure that test strips are being utilized. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and suitability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0867QAPI/QAA Improvement ActivitiesS/S H▼

Findings

Based on record review and interviews the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to significant medications errors that rose to the level of immediate jeopardy and residents were provided respect and dignity by staff that caused a pattern of psychosocial harm. Findings include: I. Facility policy and procedure The Quality Assessment and Assurance Committee policy and procedure, revised January 2018, was provided by the director of nursing (DON) on 8/8/23 at 2:30 p.m. It revealed, in pertinent part, "Purpose: to evaluate facility quality indicators, identify quality issues, develop corrective action plans and evaluate any action plans for continuous quality improvement. "Any concerns, trends or clusters identified should be listed on the QA Concerns List. Document the concern, goal and approaches and interventions to correct the concern on the QA Concern Action Plan. Review monthly any ongoing concerns until resolved. Develop new interventions as needed." II. Cross-reference citationsCross reference F760: the facility failed ensure Resident #156, who was recently hospitalized for an acute embolism and was a high risk for deep vein thrombosis (DVT), was administered anticoagulant medication (Eliquis) as ordered upon discharge from the hospital. The facility failed to ensure the transcription of medications from the hospital records was accurate, which resulted in a failure to provide anticoagulant medication, which led to the resident developing a pulmonary embolism resulting in cardiac arrest. The facility's failure to administer the anticoagulant therapy, as was indicated by the hospital discharge records, led to the resident's change of condition and ultimately, his death, from cardiac arrest due to a pulmonary embolism. The failure to ensure the accurate transcription of physician's orders placed residents at risk for serious harm or death if it was not immediately corrected. Cross reference F550: the facility failed to provide a culture and environment that promoted residents being treated with dignity and respect. Several residents reported psychosocial harm of feeling humiliated, disrespected and treated like children. These concerns were reported in resident council meetings. III. Staff interviews The director of nursing (DON) was interviewed on 7/25/23 at 8:15 p.m. She said the QAPI meetings were only required to be held every quarter, but the facility held them monthly. She said the nursing home administrator (NHA,) herself, assistant director of nursing (ADON), unit managers, social services, dietary manager, pharmacist and other members of the interdisciplinary team attended the meeting. She said each department presented a scheduled set of reports at each meeting and the facility attempted to identify the issues throughout the facility and discover trends. The DON said if new areas of concern were identified, performance improvement plans (PIP) would be developed and discussed during the next QAPI meeting. The DON said she remembered Resident #156's change of condition and being sent to the hospital but she could not remember the circumstances surrounding the change of condition. She said the facility had not identified that the facility's failure to transcribe the hospital discharge orders correctly directly related to Resident #156's change of condition and ultimately, his death. The DON said she was unaware many residents had concerns that staff did not treat them with dignity and respect. She said she was not aware residents had brought up the concerns during resident council. She said she had nurse managers on duty seven days per week to address concerns, but was not aware that the program had not been successful based on multiple resident interviews. The DON said the concerns identified during the survey process had not been previously identified by the facility staff and brought to the QAPI meeting.

Plan of correction · submitted by the facility

1. Corrective ActionThe facility will contract with a quality improvement specialist (QIS) with nursing home administrator and/or director of nursing experience (see requirements below) to provide consultation and oversight for quality assurance and performance improvement activities. The facility will immediately implement an appropriate quality assurance and process improvement plans consistent with the requirements of §483.75(d) in order to address facility failures in Resident Rights §483.10 and Pharmacy Services §483.45. The nursing home administrator (NHA), director of nursing (DON), nursing leadership, and interdisciplinary team (IDT) members, in conjunction with the QIS, shall review quality assurance performance improvement activities and create performance improvement plans related to resident rights and pharmacy services. Such action plans will, at minimum, include:(1) Ensuring each resident is treated with dignity and respect, and that each staff provides dignified resident care, in accordance with the requirements of F550.(2) Ensuring each resident's medication regimen is free from significant medication errors, in accordance with the requirements of F760.2. Identification of OthersThe NHA, DON, and applicable members of the IDT, in accordance with the QIS consultant, shall audit all current performance improvement plans not specific to those mentioned above in "1. Corrective Action" to determine the efficacy of each plan. Plans identified as ineffective will be reviewed and revised with the assistance of the QIS consultant. The QIS consultant will assist the facility leadership with identifying in the root causes of the inefficacy for those plans identified as ineffective. 3. System ChangesOn or before 9/6/2023 the facility shall hire a QIS consultant with experience consulting or directing nursing services or nursing home administration duties within nursing facilities. The QIS consultant shall exercise independent judgement in the performance of all duties under the consultant contract. The QIS consultant shall meet the independent judgement requirement if the consultant is not currently an employee of the facility or its corporate organization and has not within a five (5) year period immediately preceding 9/6/2023 been directly or indirectly affiliated with the facility, facility's owner(s), agent(s), or employee(s). In the performance of all services provided, the QIS consultant's status shall be that of an independent contractor and not that of an agent, employee, or representative of the facility, applicant or owner. The QIS consultant shall exercise professional, independent judgment in the performance of all such services and shall not be directly or indirectly instructed, guided, influenced or otherwise interfered with by the facility, applicant or owners, agents, employees or assigns. No oral understandings, statements, promises, or inducements contrary to the terms of this plan of correction (POC) shall be entered into during the term of this contract. Quality Improvement Specialist Consultant QualificationsPrior to engagement, the QIS consultant shall be a nursing home administrator and/or registered nurse with nurse leader experience, in possession of a valid occupational license in good standing with the State of Colorado. The QIS consultant must demonstrate recent (within the last five years) experience in providing administrative and care management or consulting services within nursing facilities, as approved by the Department [via Chad Fear at 303-815-8604]. Quality Improvement Specialist Consultant DutiesIn conjunction with the nursing home administrator (NHA), director of nursing (DON), nursing leadership, and other interdisciplinary team members, the QIS consultant shall oversee the development and implementation of an effective quality assurance and performance improvement program. This should include but not be limited to:(1) Developing, implementing, and monitoring effective, specific action plans for each of the 21 other deficiencies (F574, F584, F585, F600, F625, F626, F676, F677, F679, F684, F686, F689, F692, F695, F725, F730, F761, F806, F812, F880, F881) identified in the current deficiency list. (2) Revising any ineffective or underperforming action plan, in accordance with the established performance measures.(3) Educating applicable staff on:a. Their respective roles in completing each action plan developed to address deficient practice identified in the current survey.b. Methods for developing, implementing, and tracking the effectiveness of performance improvement plans.c. Methods of effectively utilizing scheduled and ad hoc performance improvement meetings to promote quality and prevent performance concerns.d. Techniques for identifying potential Quality Assurance and Assessment activities to prevent and remediate quality and performance concerns.e. Utilizing the state's quality improvement network/quality improvement organization for assistance with quality improvement projects.f. Utilizing any resident and/or family group to identify quality and performance improvement opportunities. 4. MonitoringMonitoring of approaches to ensure compliance with quality assurance and performance improvement activities:(1) At least weekly, for no less than twelve weeks, across all shifts and units, facility leadership or suitable designees, in conjunction with the QIS consultant, will complete validation audits/observations and record reviews to ensure the following:a. Quality assurance activities are conducted to verify all staff treat each resident with respect and dignity, in accordance with F550.b. Quality assurance activities are conducted to verify each resident's medication regimen is free from significant medication errors, in accordance with the requirements of F760. Such monitoring will be documented on a monitoring log. Staff will receive on-the-spot education when deviation from policy procedure is identified. The education will be documented on the monitoring log. Validation audits/observations and record reviews will reduce from weekly to monthly when the facility has demonstrated twelve consecutive weeks with no errors in implementing quality assurance activities that attain and maintain compliance with Medicare requirements of participation. Monthly validation audits will continue until the facility has demonstrated no less than three consecutive months with no errors in implementing quality assurance activities that attain and maintain compliance with Medicare requirements of participation.(2) The NHA, with the assistance of the QIS consultant, shall track and trend the success of all quality assurance performance improvement activities. Such tracking and trending data shall be reported to the quality assurance process improvement committee monthly for no less than three months and shall continue until all performance plan objectives related to maintaining an effective quality assurance performance improvement program are consistently demonstrated. The QIS consultant shall make weekly written reports for the first twelve weeks to the Department on all plan implementation, education, training, and monitoring related to quality assurance and performance improvement. Such reports shall be provided to the Department via email, [chad.fear@state.co.us and jo.tansey@state.co.us] beginning 9/8/2023 then each following Friday with the final weekly report being submitted on Friday, 11/24/2023. After the first twelve weeks, with Department approval, reports shall be due on the 15th of each month. Reporting shall then continue to be due monthly on the 15th for a minimum of three months and shall only be discontinued when the facility has demonstrated consistent implementation of all requirements of §483.75(d). 5. Correction Date9/6/2023Adara Living - DPOC 867 - V0FR11

0880Infection Prevention & ControlS/S E▼

Findings

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure:-Housekeeping staff engaged in appropriate infection control practices when cleaning a resident room;-Residents were provided with proper hand hygiene prior to meals; -Proper hand hygiene was conducted during medication pass; and, -Shared equipment was consistently sanitized between resident uses. Findings include:I. Facility policy and procedureA. The Infection Control policy and procedure manual, revised August 2015, was received by the administrator in training (AIT) on 7/26/23. It read in pertinent parts: "This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before preparing or handling medications and before and after assisting a resident with meals."B. The Infection Prevention Manual for Long-Term Care, specific to housekeeping services, was received by the AIT on 7/26/23. It read in pertinent parts: "To promote a safe and sanitary environment which is maintained by a contracted service, by employees of the facility, or a combination of both. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas."II. Failure to ensure housekeeping staff maintained infection control practices when cleaning a resident room. A. Resident interview and observationResident #127 was interviewed on 7/19/23 at 10:38 p.m. The resident said housekeeping staff have had trouble cleaning the toilet, especially the dried fecal matter in the bowl. Housekeeping staff used an eating utensil (fork) and a toilet brush to clean the toilet bowl. The resident complained that the fork and toilet brush had been left in his bathroom on top of his plastic organizer for three weeks and both cleaning tools were left with dried fecal matter. At 10:45 p.m. a fork and a toilet brush with dried fecal matter were observed in the resident's bathroom on top of a plastic organizer by the toilet. B. Staff InterviewLicensed practical nurse (LPN) #5 was interviewed on 7/19/23 at 11:01 a.m. She said she did not know why the fork with the dried fecal was in the resident's bathroom on top of the resident's plastic organizer. She said that she has never seen a fork before used as a cleaning tool and it was an infection control issue to leave the fork with fecal matter in the bathroom. Fecal matter harbored bacteria and other pathogens that could be potentially harmful to a person. The LPN removed the fork by disposing of it in the trash receptacle. -However, the LPN did not dispose of the toilet bowl cleaner with dried fecal matter on the resident's plastic organizer and or disinfect the surface where the fork was resting. The environmental director (ED) was interviewed on 7/19/23 at 2:52 p.m. She said the area where the fork was kept should have been disinfected after the LPN removed it and the housekeeping staff should have been notified. The resident needed a new brush and the brush should not have been kept on top of the plastic organizer but should have been stored in the appropriate container. The ED said the bathroom was not clean and needed to be cleaned by a housekeeping staff member. The ED said she would provide education to her housekeeping staff related to appropriate practices related to bathroom cleaning and cleaning tool storage. Registered nurse unit manager (RNUM) #1 was interviewed on 7/19/23 at 3:08 p.m. She said that the LPN should have called the housekeeping staff after she witnessed the fork situation and notified them to clean the room. The fork with the fecal matter was an infection control issue and it may cause many gastrointestinal problems if touched by the resident and he touched his face or if he accidently used the fork to eat. The toilet brush was an infection control issue to be left out with fecal matter and not stored in the appropriate storage container. RNUM #1 said she would have the toilet bowl cleaner thrown out, replaced with a new one and the entire bathroom would be disinfected. RNUM #1 said she would provide education to the LPN.The infection preventionist (IP) was interviewed on 7/25/23 at 5:19 p.m. He said the fork with dried fecal matter was an infection control issue. The fork should have never been used to clean the toilet. Staff should use appropriate cleaning materials and the cleaning materials should leave the room after the room was cleaned. The surface of the organizer in the resident's room should have been cleaned after the fork was removed. The toilet bowl cleaner should have been placed back into the housekeeping cart after it was used and if the resident wanted their own in the room then it should have been stored in the holder after it was used. III. Failure to ensure residents were provided with an opportunity to participate in hand hygiene prior to mealsOn 7/19/23 at 11:57 a.m. the dining room on the third floor was observed. Hand sanitizer was not offered to any of the seven residents in the dining room at any point prior to or during the meal. The resident room meal trays were delivered at 12:45 p.m. to the third floor and residents were not offered or encouraged hand hygiene prior to eating their meal. -At 12:45 p.m., a certified nurse aide (CNA) #2 delivered a room tray to room 346 and did not offer hand hygiene to the resident. No hand sanitizer and or cleaning wipes were provided on the meal trays.-At 12:47 p.m., CNA #1 delivered a room tray to a resident in room 347 and did not offer hand hygiene to the resident. No hand sanitizer and or cleaning wipes were provided on the meal trays.-At 12:50 p.m., CNA #2 delivered a room tray to a resident in room 342 and did not offer hand hygiene to the resident. No hand sanitizer and or cleaning wipes were provided on the meal trays. The third floor memory care dining room was observed continuously from 4:30 p.m. to 5:45 p.m. Nine residents were observed eating dinner in the dining room. The meal consisted of a hamburger or a ham and cheese sandwich. -88% of residents ate using their hands.-100% of residents were not offered or encouraged to engage in hand hygiene. Throughout the dinner meal service, no hand hygiene was offered by staff. Hand hygiene products were not available on any dining table. On 7/20/23 at 11:51 a.m. the dining room on the third floor was observed. There were six residents present for lunch service and hand sanitizer was not offered prior to or during the meal. On 7/24/23 at 11:48 a.m. the dining room on the third floor was observed. A resident was blowing his nose into the open air without a tissue while he was sitting at a dining table. Then he began wiping his nose with his bare hand and the sleeve of his shirt. At 11:50 a.m. trays began to be passed out and hand sanitizer was not offered to any residents. At 11:56 a.m. multiple staff were observed washing their hands at a sink in the dining room. Posted above the handwashing sink was a sign identifying the process for staff to wash their hands for at least 20 seconds. An unidentified CNA was observed washing her hands for six seconds. Another unidentified staff member washed her hands for 12 seconds. An unidentified CNA was observed washing her hands for three seconds. Another unidentified CNA was observed washing her hands for eight seconds. At 1:05 p.m. 11 resident room meal trays were delivered to the first floor and residents were not offered or encouraged hand hygiene prior to eating their meal. The meal consisted of fried chicken, carrots, mashed potatoes and gravy.-100% of the residents were not offered or encouraged to engage in hand hygiene prior to their meal for lunch. On 7/25/23 the lunch kitchen line was observed continuously from 12:00 p.m. to 1:00 p.m. At 12:15 p.m. 14 residents were observed in the dining room for lunch.-50% of the residents were eating their meals with their hands.-64% ate cookies with their hands.-100% of residents in the dining room were not offered or encouraged to engage in hand hygiene. Throughout the lunch meal service no hand hygiene was offered by staff. Hand hygiene products were not available on any dining table. IV. Failure to ensure hand hygiene was performed during medication pass On 7/25/23 at 9:57 a.m. the certified nurse aide with medication authority (CNA/MA) #1 was observed for medication pass. CNA/MA #1 exited a resident room and did not perform hand hygiene. CNA/MA #1 walked to the medication cart and unlocked the drawers with her keys that were on a key ring in her pocket. She unlocked her computer by typing on the keypad and unlocked the narcotic box and pulled medication from the drawer. She was confused about the expiration date so she closed the narcotic box, the medication cart drawer and took the medication in the box to show the unit manager who was in her office down the hall. After getting clarification, CNA/MA #1 returned to the medication cart, did not perform hand hygiene and unlocked the drawer to gather the remaining medications. CNA/MA #1 carried the medications to the resident's room and handed the medication cup to the resident. CNA/MA #1 put a syringe of oral morphine in the resident's mouth and administered it then she gave the resident the medicine cup of remaining medications for her to take. CNA/MA #1 returned to the medication cart without performing hand hygiene after exiting the resident's room and wrote in the narcotic log book on top of the medication cart with her pen that she removed from her pocket. V. Failure to ensure shared equipment was sanitizedOn 7/24/23 at approximately 10:30 a.m. LPN #1 was observed approaching Resident #143 with a portable vitals sign machine (vital signs measure the body's basic functions by objectively measuring body temperature, pulse rate, respiration rate, and blood pressures) and obtained vitals. At 12:34 p.m. CNA #3 approached Resident #108 with the same portable vital signs machine to check her oxygen levels (how much oxygen is in the blood). The portable vitals sign machine was not wiped down before or after it was used to obtain vitals for Resident #143 and Resident #108. CNA #3 was interviewed on 7/24/23 at 12:34 p.m. She said the portable vital signs machine was used on multiple residents throughout the day. She said cleaning between uses was necessary if the machine was visibly dirty. VI. Administrative interviewsThe IP was interviewed on 7/25/23 at 5:30 p.m. He said hand hygiene should be offered before meals staff should either offer residents to wash their hands or use hand sanitizer. The IP said he never saw any hand sanitizer wipes at the facility. He said staff were to perform hand hygiene (sanitizer) when entering and exiting resident rooms, while passing meal trays, and during medication passes. He said hand sanitizer gel should be rubbed over all surfaces of hands and fingers until the hands were dry. He said this duration should be 20-30 seconds. He said direct care staff are responsible for cleaning portable vital machines. He said machines were to be cleaned after each use and as needed. The director of nursing (DON) was interviewed on 7/25/23 at 8:00 p.m. She said all staff members should be performing when entering and exiting resident rooms, while passing meal trays and during medication pass. She said residents should be offered hand sanitizer prior to meals. She said hand sanitizer gel should be rubbed over all surfaces of hands and fingers until the hands were dry. She said this duration should be 20-30 seconds. She said direct care staff were to clean equipment (portable vitals machine and mechanical lifts) between each use.

Plan of correction · submitted by the facility

F880How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Housekeeping staff educated immediately on appropriate procedures for cleaning rooms via standard practices. Residents completed appropriate hand hygiene prior to the next meal, nurses utilized hand sanitizer in between residents while completing medication passes, equipment sanitized prior to next usage and continued to be sanitized in between residents. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents are at risk of alleged deficient practice. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be provided to housekeeping staff, on or before the date of compliance, by DON/designee, related to the proper steps of cleaning a resident room to prevent the spread of infection while maintaining a clean and safe environment. Education will be conducted, on or before the date of compliance, by DON/designee, with nursing staff on the importance of hand hygiene in between residents when passing medications, and the importance of cleaning equipment between residents to cut down on the spread of infection. Education will be conducted, on or before the date of compliance, by DON/designee, with all staff on the importance of hand hygiene for all residents prior to meal services. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. An observation audit will be completed by DON/designee of 10 residents weekly for 12 weeks on proper hand hygiene prior to meal services, 10 rooms weekly for 12 weeks for the appropriate process of cleaning in order to prevent the spread of infection while maintaining a clean and safe environment, 5 nurses a week for proper hand hygiene technique while passing medications in between residents, and 5 CNA’s weekly for proper cleaning of equipment between residents when providing services. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

0881Antibiotic Stewardship ProgramS/S D▼

Findings

Based on record review and interviews the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#143) resident reviewed for antibiotic stewardship out of 71 sample residents. Specifically, the facility failed to thoroughly assess and document clinical signs and symptoms of an infection to ensure the criteria of the infection was met prior to the administration of an antibiotic for Residents #143. Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (2019) The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX B: Measures of Antibiotic Prescribing, Use and Outcomes, retrieved 7/27/23 https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf. It read in pertinent part, "Incomplete assessment and documentation of a resident's clinical status, physical exam or laboratory findings at the time a resident is evaluated for infection can lead to uncertainty about the rationale and/or appropriateness of an antibiotic. Ongoing audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the nursing home or at a transferring facility, should verify that the antibiotic prescribing elements have been addressed and recorded."II. Facility procedureA Synopsis of McGeer's Definitions of Infection: Constitutional Criteria in Residents of Long-Term Care Facilities (LTCFs) was received by the infection (IP) preventionist on 7/26/23, it read in pertinent part:"FeverSingle oral temperature >37.8°C (>100°F)ORRepeated oral temperatures >37.2°C (99°F) or rectal temperatures >37.5°C (99.5°F)ORSingle temperature >1.1°C (2°F) over baseline from any site (oral, tympanic, axillary)"LeukocytosisNeutrophilia (>14,000 leukocytes/mm3)ORLeft shift (>6% bands or =1,500 bands/mm3)"Acute change in mental status from baseline (all criteria must be present)Acute onsetFluctuating courseInattention"ANDEither disorganized thinking or altered level of consciousnessAcute functional declineA new 3-point increase in total activities of daily living (ADL) score (range, 0-28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence)14Bed mobilityTransferLocomotion within LTCFDressingToilet usePersonal hygieneEating."III. Resident statusResident #143, over age 92, was admitted on 9/6/22. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia. The 5/20/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident required extensive assistance from staff for toilet use and personal hygiene. IV. Record reviewThe 7/13/23 progress note revealed Resident #143 had a temperature of 96.9, she was observed to have increased weakness while ambulating (walking) and she was incontinent with dark yellow urine that had an odor. The facility placed a call to the resident's nurse practitioner and received orders to obtain UA (urine analysis), C&S (culture and sensitivity test, to check which medicine would work best on germ if found), CMP (complete blood count lab) and CBC (complete blood count lab). -However, she did not meet the criteria for a urine analysis due her not meeting the McGreer's criteria. Although she had weakness and odor with her urine, she did not have the presence of a temperature or other symptoms to warrant further testing. The 7/13/23 lab results revealed Resident #143 had urine that was amber in color and cloudy in clarity with presence of bacteria. Resident #143 tested negative for leukocyte esterase (leukocyte esterase test is a urine test for the presence of white blood cells and other abnormalities associated with infection) and a further culture was not indicated (a culture would identify what type of bacteria may be causing an infection). -However, the resident was subsequently started on an antibiotic even though she did not meet the McGreers criteria. The 7/14/23 progress note revealed the nurse practitioner was notified on results for labs and a new order to start antibiotic Nitrofurantoin 100 milligram (mg) twice daily (TID) for urinary tract infection (UTI) for five days. The July 2023 CPO revealed the following order:-Nitrofurantoin Macrocrystal oral capsule 100 mg give 1 capsule by mouth two times a day for UTI for five days from 7/15/23 to 7/18/23. V. Staff interviewsThe infection preventionist was interviewed on 7/25/23 at 5:30 p.m. He said the facility used the McGeer Criteria for determining the need for a urinary analysis (UA) in regards to a urinary tract infection (UTI). He said Resident #143 displayed dark urine and foul smelling odor in her brief. He said, according to the McGeer Criteria, Resident #143 did not meet criteria for further testing. In addition, he acknowledged the resident was not supposed to be started on an antibiotic when she did not meet the McGreer criteria.

Plan of correction · submitted by the facility

F881How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Resident #143 completed antibiotics ordered by her physician on 07/18/2023. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. All residents with antibiotics ordered have the potential to be affected by this alleged deficient practice. An audit was conducted by the infection prevention nurse/Designee. A look back period from August 1st, 2023- September 5th, 2023 was conducted to make sure all residents received the proper antibiotic. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. Education will be completed, on or before date of compliance, by DON/designee, with prescribing providers and licensed nursing staff. They were trained in using the McGeer Criteria. The training detailed the clinical signs and symptoms that indicate an infection and how to determine if these align with the McGeer criteria. During identification audit Nursing/providers complete assessments and documentation based upon clinical signs and symptoms of an infection to determine if the McGeer criteria is met prior to antibiotic usage. Education included the use of unnecessary antibiotics and potential outcomes for failure to not document and assess prior to their use. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. The facility will audit all antibiotics prescribed for infections 5 days a week for 4 weeks, 3 days a week for 4 weeks, then 2 days a week for 4 weeks to ensure that the plan of treatment meets the McGeer criteria. Results and findings of this process change will be reported to the QAPI committee by the NHA or designee monthly for 3 months to ensure compliance and sustainability. If there is any area of concern identified, it will be corrected immediately upon discovery.

8/7/2023Focused Infection Control, Other-Fed Survey · ID ZUMJ111 deficiency▼

0884Reporting - National Health Safety NetworkS/S F▼

Findings

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 07/31/2023 and 08/06/2023, 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.

Plan of correction

The state did not require a plan of correction for this citation.

7/17/2023Revisit: Complaint Survey · ID 0UFT12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 7/17/23 for all previous deficiencies cited on 5/30/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

7/17/2023Revisit: Licensure Complaint Survey · ID WKYT12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 7/17/23 for all previous deficiencies cited on 5/30/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

5/30/2023Complaint Survey · ID 0UFT111 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A survey for Incident #32106 was conducted 5/30/23. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0689Free of Accident Hazards/Supervision/DevicesS/S G▼

Findings

Based on record review and interviews, the facility failed to ensure one (#4) of six residents reviewed for accidents out of six sample residents remained as free from accident hazards as possible. Resident #4 sustained head trauma (concussion) and extensive bruising to her legs, face and scalp when she was transferred by staff with a Hoyer (mechanical) lift. The facility staff did not assess the resident after the incident. Right after the incident, the resident was sent to her scheduled appointment with a cardiologist. The resident developed a headache, blurred vision and nausea where she was sent to the emergency room (ER) by a cardiologist and diagnosed with a concussion and scalp hematoma. Findings include: I. Facility policies and proceduresThe Falls Prevention and Management policy, revised 7/21/17, was provided on 5/30/23 by the director of nursing (DON). -The policy read did not include any information on injuries caused by the equipment. -The policy on accidents related to the equipment was requested at the time of the survey, however was not provided at the time of the survey with exit on 5/30/23 or 24 hours after the exit. II. Resident statusResident #4, age 78, was admitted on 3/21/22. According to the May 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), hypertension and bipolar disorder. The 2/28/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident required extensive assistance of two people with transfers, dressing, toileting and personal hygiene. The fall section revealed the resident did not have a fall in the last six months. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. III. Resident interview and observation Resident #4 was interviewed on 5/30/23 at 1:30 p.m. She said last Monday (5/22/23) she had a scheduled appointment with a cardiologist. Before the appointment, two certified nurse aides (CNAs) were transferring her using a Hoyer lift from the bed to the wheelchair. At the time of the transfer, when she was in the sling of the Hoyer in midair, something went wrong and the lift tilted. She landed abruptly into her wheelchair and the top metal bar of the Hoyer lift hit her on the head. Resident #4 stated she felt sudden pain in her head and back of her thighs. She said her pain at the time of the incident was 8 to 9 on the scale of 10 (with 10 being the worst pain on the scale). Both CNAs stated that Hoyer wheels did not turn properly and it caused the lift to tilt. She said right after the incident she was taken to the cardiology appointment and the nurse at the facility did not assess her for injuries. Resident #4 stated her headache got worse, she had blurred vision, felt lightheaded and nauseous by the time she arrived at her appointment. She reported her symptoms and incident to the cardiologist who sent her to the ER for evaluation. At the time of the interview, the resident was observed in her bed. On her left forehead she had four to five centimeters (cm) bruise that was black to yellow in color. Another bruise, dark red to black in color was observed at the top of the resident's head. The bruise was about one by two cm., with an elevated surface. Resident #4 parted her hair and pointed to the bruise. She said this was where the top bar of Hoyer lift hit her. She said she had bruises on both of her upper legs. She said she continued to have headaches and was fearful of transfers. She said she did not refuse any transfers as it was the only way for her to get out of the bed. Resident #4 said after she returned from the ER, unit manager (UM) #1 and her nurse (licensed practical nurse #1) told her the CNAs did not observe the lift touching or hitting her. She said they ignored her statement that she got hurt and "called me a liar." She said when bruises became visible a few days later, the nurses at the facility did not monitor them and "did nothing about it."IV. Skin assessmentThe resident's skin on her legs was inspected on 5/30/23 at 2:40 p.m. in the presence of licensed practical nurse (LPN) #2. A large blue to gray to yellow bruise was observed on the resident's left upper inner and back thigh. The bruise located slightly above the knee joint and extended to about two thirds of the resident's upper and inner thigh. The left thigh had a small red to blue bruise, approximately one cm by two cm. Both bruises appear to be healing. The resident stated that bruises on her thighs, face and head were the result of the Hoyer incident that took place several days ago. V. Record reviewThe comprehensive care plan, initiated on 5/19/21 and revised on 2/17/22, revealed the resident was using Hoyer lift for transfers and assistance of two people. The care plan for skin integrity, initiated on 6/20/21 and revised on 8/16/22, documented the resident was at risk for skin integrity due to multiple comorbidities including the use of anticoagulation medication (Coumadin). Interventions included to monitor her skin weekly and to report any abnormalities to the physician. -The skin integrity care plan was not updated with skin injuries the resident sustained on 5/23/23 during the transfer. The medication administration record (MAR) for May 2023 revealed that resident was receiving an anticoagulant medication:Coumadin four milligrams (mg) by mouth in the afternoon every Monday, Wednesday for atrial fibrillation. Start date 4/3/23. -The May 2023 MAR did not include any evidence that the resident was monitored for bleeding and bruising due to the use of anticoagulant. The cardiology report dated 5/23/23 documented the resident complained of nausea and jaw pain after the incident in the facility. The cardiologist sent the resident to the ER for a head scan and evaluation. The ER discharge summary dated 5/23/23 around 3:00 p.m. revealed the resident was admitted for nausea, headache and lightheadedness. Her head scan was negative for any acute findings and she was discharged back to the facility with a diagnosis of concussion and scalp hematoma. The initial progress note in resident's electronic medical record regarding the incident was documented on 5/23/23 at 3:03 p.m. documenting the resident reported an incident that occurred during the Hoyer transfer (before going) to the cardiologist and based on her symptoms such as nausea, headache and jaw pain, she was sent to the ER. -The note did not mention who communicated the message to the facility staff and what actions were taken after the resident returned from the ER.-The progress notes did not include the resident's assessment by a registered nurse and did not document the resident's vital signs at the time of her return. The incident report was provided by the assistant director of nursing (ADON) on 5/30/23 at 3:50 p.m. and included following information:An incident report dated 5/23/23 at 12:38 p.m., read "the resident was transferred from bed to her wheelchair with the Hoyer lift, but the lift was not turning around and all wheels raised and she fell on her chair and the Hoyer fell on the arms of both CNAs. Resident went to a doctor's appointment right after the incident."Further the note by the nurse read, as immediate actions taken "the resident was assessed at the doctors office." Under injuries, it was documented a bruise on top of the scalp. -Per interview with the ADON (see below), she added bruises later to the report. A handwritten note dated 5/23/23, with no time, by UM #1 read: "I spoke to (resident) who stated she hit her head when the Hoyer tipped over. (Head scan) was completed and the hospital and at the time of incident had no bruising to her head." -The note did not include the assessment of the resident's legs or her vital signs. A handwritten note with no initials, dated 5/23/23, with no time, mentioned CNA #1 and CNA #2 were interviewed at the same time. The note read: "We were transferring the resident off bed to the chair and the Hoyer did not want to turn around and all the wheels were raised and she fell on the chair and the Hoyer on the arms of (CNA #1) and (CNA #2). The resident did not hit anything nothing touched her."-The note did not include the signature or initials of the writer and it was unclear who wrote the note. Per interview with the ADON (see below) she said the note was most likely written by LPN #1, who was a treating nurse for Resident #4 at the time of the incident. A CT scan results showed no acute findings;A progress note by UM #1 on 5/23/23 at 3:16 p.m. (already mentioned above); andA note by the LPN #1 who worked with a resident on that date was completed 5/23/23 at 5:52 p.m. The note was identical to the note in the incident report (see above).-The note did not document if the resident was assessed by LPN #1 before she was sent to her appointment with the cardiologist or after she returned from the ER.-The incident report did not include the interview with Resident #4 who was alert and oriented to time, place and person and was able to provide a detailed recollection of events. -The incident report did not include a summary of findings or the conclusion. It did not specify what caused the lift to tilt, improper use or malfunction. The report did not specify what immediate actions were taken on 5/23/23 to ensure the lift was not used until inspected (the inspection was completed on 5/24/23, see under facility follow-up). -The CNAs that were involved in this incident were not checked for their competency and knowledge of Hoyer lift use, they were not provided additional education after the incident. The neurological checks were provided by ADON and revealed the resident's vital signs were first taken after the incident on 5/24/23 at 2:30 p.m.-The neurological checks were almost 24 hours after she returned from the ER on 5/23/23 around 3:30 p.m. The skin assessment on 5/24/23 (a day after the incident) documented the resident had discolorations on both of her arms and surgical dressing on the neck. -The skin assessment did not mention the resident's legs, face and scalp bruises. The skin assessment on 5/30/23 (completed at the time of the survey) documented that the resident had bruises on the left knee, right knee, right thigh and top of her scalp. The note read: "bruising occurred during back to bed transfer, back of both legs, forehead and scalp."-There was no evidence that bruises were monitored after the incident. VI. Staff interviewsLPN #2 was interviewed on 5/30/23 at 2:40 p.m. He said he was familiar with the resident and he was not aware of any recent falls. He said the resident had bruises on her head from the transfer a few days ago. He said he learned about her bruises today but he had no time to document that in the resident's progress notes. He said the resident was alert and oriented and was able to make needs known. CNA #3 was interviewed on 5/30/23 at 2:45 p.m. She said she knew the resident well, but was not working with her today. She said the resident was a Hoyer lift transfer with two person assistance all the time. She said she heard about the incident with the lift from the resident herself, but she did not work with her at the time of the incident or after. She said the resident was cooperative with care, alert, oriented and did not have refusals or other types of behaviors. She said she never had any accidents with Hoyer lifts with any residents in the building. CNA #1, CNA #2 and LPN #1 were not available for an interview at the time of the survey. UM #1 was interviewed on 5/30/23 at 2:48 p.m. She said she initially learned about the incident from the driver who was transporting the resident to the cardiologist appointment. She said the driver reported the resident was taken to the ER right from the appointment. UM #1 said she briefly spoke with both CNAs (CNA #1 and CNA #2) on5/23/23 and they both told her the resident was not hurt during the transfer. She said she talked to LPN #1 and told her to start the incident report for the resident. The ADON was first interviewed on 5/30/23 at 3:22 p.m. She said she was aware of the Hoyer lift incident with the resident. She did not recall from whom she initially learned about it, but she remembered discussing it with the interdisciplinary team (IDT) team. She said she did not know if LPN #1 was or was not notified by CNAs about the incident before resident left for an appointment and she could not say if resident was or was not assessed by LPN #1. She said her role was to make sure the investigation was complete. She said the Hoyer lift was inspected by the maintenance director (MTD), but she was not sure when. She said she was gathering the investigation information and could answer questions later when she gets it together. The MTD was interviewed on 5/30/23 at 4:10 p.m. He said he usually got reports about equipment from staff through the electronic system the facility was utilizing. He reviewed the records on his phone and stated he could not locate the exact time and date when he received the request to inspect the Hoyer lift. He said he would ask the NHA for assistance. He said when staff sent requests for inspection they did not specify which lift was involved, they would just say which floor the lift was on. He said he recalled getting the request to inspect the lift on the second floor a few days ago. He said he inspected all the lifts that were present on the second floor and they all were functioning appropriately. The ADON was interviewed a second time on 5/30/23 at 4:44 p.m. She said she gathered the report and provided it in the folder. She said the resident was sent to ER for the evaluation and her head scan revealed no acute findings. She said the neurological assessments were started late, on 5/24/23 because they could not decide if it was necessary since her head scan looked good. She said the handwritten note in the investigation folder was most likely completed by LPN #1. She said the incident report was completed by LPN #1 and she later added bruising to the incident report section. She said she was not aware the resident was diagnosed with concussion (as documented on hospital discharge summary). The DON was interviewed on 5/30/23 at 6:04 p.m. She said she was aware of the incident with the lift involving Resident #4. She said the incident was investigated and it was inconclusive what happened. She said the resident should be assessed as soon as staff become aware of the incident. She said she did not know about the incident until the resident returned from the ER. She said she did not know if CNAs notified LPN #1 about the incident before the resident left for an appointment. She said the investigation did not determine the CNAs, who operated the lift on 5/23/23,required competency check or additional training. She said the lift was inspected by MTD and was functioning properly. VII. Facility follow-upOn 5/30/23 at the time of the survey, the NHA submitted an email with a copy of work order #16449, dated 5/24/23 for "2-nd floor common area" Hoyer lift. The note under comments read all lifts were checked and were in working condition. -The date on the work order indicated that Hoyer lift that tilted during transfer with Resident #4 was still used by staff on 5/23/23.

Plan of correction · submitted by the facility

“This Plan of Correction is prepared and submitted as required by law. By submitting this Plan of Correction, Adara Living does not admit that the deficiency listed on this form exist, nor does the facility admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiency. The Facility reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts, and conclusions that form the basis for the deficiency.“ F 689How the corrective action will be accomplished for those issues identified by the alleged deficient practice?Resident #4 assessed upon return from ED, neuro checks initiated upon discovery. Event placed into risk management system. CT report from ED negative for any acute findings. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. An audit of 3 months prior to complaint survey was completed on 06/13/2023. The audit was completed to ensure that all areas of risk events with major injury related to acute injury had been addressed in a timely manner for all other residents who had the potential to be affected by alleged deficient practice. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. All major risk events with acute injury that yields a major injury will be brought to clinical 5 days a week by the assistant director of nursing to be reviewed by Director of nursing/ designee and the interdisciplinary team. Education completed on 6/16/23 with the nursing staff and department heads as well as unit managers related to timely reporting of risk events with major injury, tag out of equipment, and transfers with use of the lift. Competencies started (6/19/23) with nursing staff in reference to injury free transfer procedures and performance checklist. Education was initiated to facility staff on the investigation process, including assessments, neuro checks, and appropriate notifications. Social Service Director initiated education to facility in regards to resident rights specifically related to respect, dignity, listening to residents, and remaining free from abuse and neglect . How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. Facility will review risk events with major injury related to acute injury 5 days a week. This process will be done weekly for four weeks, then bi-weekly for one month, and then monthly for one month. Results of the risk event with major injury related to acute injury will be reported to the Administrator and the Process Improvement Committee monthly and as needed to ensure compliance and timely responses. Date of Compliance 6/19/2023

5/30/2023Licensure Complaint Survey · ID WKYT111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A survey prompted by complaint #CO32536 was completed 5/30/23. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0704Res Care - Accident Prevention and Attention▼

Findings

Based on record review and interviews, the facility failed to ensure one (#4) of six residents reviewed for accidents out of six sample residents remained as free from accident hazards as possible. Resident #4 sustained head trauma (concussion) and extensive bruising to her legs, face and scalp when she was transferred by staff with a Hoyer (mechanical) lift. The facility staff did not assess the resident after the incident. Right after the incident, the resident was sent to her scheduled appointment with a cardiologist. The resident developed a headache, blurred vision and nausea where she was sent to the emergency room (ER) by a cardiologist and diagnosed with a concussion and scalp hematoma. Findings include: I. Facility policies and proceduresThe Falls Prevention and Management policy, revised 7/21/17, was provided on 5/30/23 by the director of nursing (DON). -The policy read did not include any information on injuries caused by the equipment. -The policy on accidents related to the equipment was requested at the time of the survey, however was not provided at the time of the survey with exit on 5/30/23 or 24 hours after the exit. II. Resident statusResident #4, age 78, was admitted on 3/21/22. According to the May 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), hypertension and bipolar disorder. The 2/28/23 facility assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident required extensive assistance of two people with transfers, dressing, toileting and personal hygiene. The fall section revealed the resident did not have a fall in the last six months. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. III. Resident interview and observation Resident #4 was interviewed on 5/30/23 at 1:30 p.m. She said last Monday (5/22/23) she had a scheduled appointment with a cardiologist. Before the appointment, two certified nurse aides (CNAs) were transferring her using a Hoyer lift from the bed to the wheelchair. At the time of the transfer, when she was in the sling of the Hoyer in midair, something went wrong and the lift tilted. She landed abruptly into her wheelchair and the top metal bar of the Hoyer lift hit her on the head. Resident #4 stated she felt sudden pain in her head and back of her thighs. She said her pain at the time of the incident was 8 to 9 on the scale of 10 (with 10 being the worst pain on the scale). Both CNAs stated that Hoyer wheels did not turn properly and it caused the lift to tilt. She said right after the incident she was taken to the cardiology appointment and the nurse at the facility did not assess her for injuries. Resident #4 stated her headache got worse, she had blurred vision, felt lightheaded and nauseous by the time she arrived at her appointment. She reported her symptoms and incident to the cardiologist who sent her to the ER for evaluation. At the time of the interview, the resident was observed in her bed. On her left forehead she had four to five centimeters (cm) bruise that was black to yellow in color. Another bruise, dark red to black in color was observed at the top of the resident's head. The bruise was about one by two cm., with an elevated surface. Resident #4 parted her hair and pointed to the bruise. She said this was where the top bar of Hoyer lift hit her. She said she had bruises on both of her upper legs. She said she continued to have headaches and was fearful of transfers. She said she did not refuse any transfers as it was the only way for her to get out of the bed. Resident #4 said after she returned from the ER, unit manager (UM) #1 and her nurse (licensed practical nurse #1) told her the CNAs did not observe the lift touching or hitting her. She said they ignored her statement that she got hurt and "called me a liar." She said when bruises became visible a few days later, the nurses at the facility did not monitor them and "did nothing about it."IV. Skin assessmentThe resident's skin on her legs was inspected on 5/30/23 at 2:40 p.m. in the presence of licensed practical nurse (LPN) #2. A large blue to gray to yellow bruise was observed on the resident's left upper inner and back thigh. The bruise located slightly above the knee joint and extended to about two thirds of the resident's upper and inner thigh. The left thigh had a small red to blue bruise, approximately one cm by two cm. Both bruises appear to be healing. The resident stated that bruises on her thighs, face and head were the result of the Hoyer incident that took place several days ago. V. Record reviewThe comprehensive care plan, initiated on 5/19/21 and revised on 2/17/22, revealed the resident was using Hoyer lift for transfers and assistance of two people. The care plan for skin integrity, initiated on 6/20/21 and revised on 8/16/22, documented the resident was at risk for skin integrity due to multiple comorbidities including the use of anticoagulation medication (Coumadin). Interventions included to monitor her skin weekly and to report any abnormalities to the physician. -The skin integrity care plan was not updated with skin injuries the resident sustained on 5/23/23 during the transfer. The medication administration record (MAR) for May 2023 revealed that resident was receiving an anticoagulant medication:Coumadin four milligrams (mg) by mouth in the afternoon every Monday, Wednesday for atrial fibrillation. Start date 4/3/23. -The May 2023 MAR did not include any evidence that the resident was monitored for bleeding and bruising due to the use of anticoagulant. The cardiology report dated 5/23/23 documented the resident complained of nausea and jaw pain after the incident in the facility. The cardiologist sent the resident to the ER for a head scan and evaluation. The ER discharge summary dated 5/23/23 around 3:00 p.m. revealed the resident was admitted for nausea, headache and lightheadedness. Her head scan was negative for any acute findings and she was discharged back to the facility with a diagnosis of concussion and scalp hematoma. The initial progress note in resident's electronic medical record regarding the incident was documented on 5/23/23 at 3:03 p.m. documenting the resident reported an incident that occurred during the Hoyer transfer (before going) to the cardiologist and based on her symptoms such as nausea, headache and jaw pain, she was sent to the ER. -The note did not mention who communicated the message to the facility staff and what actions were taken after the resident returned from the ER.-The progress notes did not include the resident's assessment by a registered nurse and did not document the resident's vital signs at the time of her return. The incident report was provided by the assistant director of nursing (ADON) on 5/30/23 at 3:50 p.m. and included following information:An incident report dated 5/23/23 at 12:38 p.m., read "the resident was transferred from bed to her wheelchair with the Hoyer lift, but the lift was not turning around and all wheels raised and she fell on her chair and the Hoyer fell on the arms of both CNAs. Resident went to a doctor's appointment right after the incident."Further the note by the nurse read, as immediate actions taken "the resident was assessed at the doctors office." Under injuries, it was documented a bruise on top of the scalp. -Per interview with the ADON (see below), she added bruises later to the report. A handwritten note dated 5/23/23, with no time, by UM #1 read: "I spoke to (resident) who stated she hit her head when the Hoyer tipped over. (Head scan) was completed and the hospital and at the time of incident had no bruising to her head." -The note did not include the assessment of the resident's legs or her vital signs. A handwritten note with no initials, dated 5/23/23, with no time, mentioned CNA #1 and CNA#2 were interviewed at the same time. The note read: "We were transferring the resident off bed to the chair and the Hoyer did not want to turn around and all the wheels were raised and she fell on the chair and the Hoyer on the arms of (CNA #1) and (CNA #2). The resident did not hit anything nothing touched her."-The note did not include the signature or initials of the writer and it was unclear who wrote the note. Per interview with the ADON (see below) she said the note was most likely written by LPN #1, who was a treating nurse for Resident #4 at the time of the incident. A CT scan results showed no acute findings;A progress note by UM #1 on 5/23/23 at 3:16 p.m. (already mentioned above); andA note by the LPN #1 who worked with a resident on that date was completed 5/23/23 at 5:52 p.m. The note was identical to the note in the incident report (see above).-The note did not document if the resident was assessed by LPN #1 before she was sent to her appointment with the cardiologist or after she returned from the ER.-The incident report did not include the interview with Resident #4 who was alert and oriented to time, place and person and was able to provide a detailed recollection of events. -The incident report did not include a summary of findings or the conclusion. It did not specify what caused the lift to tilt, improper use or malfunction. The report did not specify what immediate actions were taken on 5/23/23 to ensure the lift was not used until inspected (the inspection was completed on 5/24/23, see under facility follow-up). -The CNAs that were involved in this incident were not checked for their competency and knowledge of Hoyer lift use, they were not provided additional education after the incident. The neurological checks were provided by ADON and revealed the resident's vital signs were first taken after the incident on 5/24/23 at 2:30 p.m.-The neurological checks were almost 24 hours after she returned from the ER on 5/23/23 around 3:30 p.m. The skin assessment on 5/24/23 (a day after the incident) documented the resident had discolorations on both of her arms and surgical dressing on the neck. -The skin assessment did not mention the resident's legs, face and scalp bruises. The skin assessment on 5/30/23 (completed at the time of the survey) documented that the resident had bruises on the left knee, right knee, right thigh and top of her scalp. The note read: "bruising occurred during back to bed transfer, back of both legs, forehead and scalp."-There was no evidence that bruises were monitored after the incident. VI. Staff interviewsLPN #2 was interviewed on 5/30/23 at 2:40 p.m. He said he was familiar with the resident and he was not aware of any recent falls. He said the resident had bruises on her head from the transfer a few days ago. He said he learned about her bruises today but he had no time to document that in the resident's progress notes. He said the resident was alert and oriented and was able to make needs known. CNA #3 was interviewed on 5/30/23 at 2:45 p.m. She said she knew the resident well, but was not working with her today. She said the resident was a Hoyer lift transfer with two person assistance all the time. She said she heard about the incident with the lift from the resident herself, but she did not work with her at the time of the incident or after. She said the resident was cooperative with care, alert, oriented and did not have refusals or other types of behaviors. She said she never had any accidents with Hoyer lifts with any residents in the building. CNA #1, CNA #2 and LPN #1 were not available for an interview at the time of the survey. UM #1 was interviewed on 5/30/23 at 2:48 p.m. She said she initially learned about the incident from the driver who was transporting the resident to the cardiologist appointment. She said the driver reported the resident was taken to the ER right from the appointment. UM #1 said she briefly spoke with both CNAs (CNA #1 and CNA #2) on 5/23/23 and they both told her the resident was not hurt during the transfer. She said she talked to LPN #1 and told her to start the incident report for the resident. The ADON was first interviewed on 5/30/23 at 3:22 p.m. She said she was aware of the Hoyer lift incident with the resident. She did not recall from whom she initially learned about it, but she remembered discussing it with the interdisciplinary team (IDT) team. She said she did not know if LPN #1 was or was not notified by CNAs about the incident before resident left for an appointment and she could not say if resident was or was not assessed by LPN #1. She said her role was to make sure the investigation was complete. She said the Hoyer lift was inspected by the maintenance director (MTD), but she was not sure when. She said she was gathering the investigation information and could answer questions later when she gets it together. The MTD was interviewed on 5/30/23 at 4:10 p.m. He said he usually got reports about equipment from staff through the electronic system the facility was utilizing. He reviewed the records on his phone and stated he could not locate the exact time and date when he received the request to inspect the Hoyer lift. He said he would ask the NHA for assistance. He said when staff sent requests for inspection they did not specify which lift was involved, they would just say which floor the lift was on. He said he recalled getting the request to inspect the lift on the second floor a few days ago. He said he inspected all the lifts that were present on the second floor and they all were functioning appropriately. The ADON was interviewed a second time on 5/30/23 at 4:44 p.m. She said she gathered the report and provided it in the folder. She said the resident was sent to ER for the evaluation and her head scan revealed no acute findings. She said the neurological assessments were started late, on 5/24/23 because they could not decide if it was necessary since her head scan looked good. She said the handwritten note in the investigation folder was most likely completed by LPN #1. She said the incident report was completed by LPN #1 and she later added bruising to the incident report section. She said she was not aware the resident was diagnosed with concussion (as documented on hospital discharge summary). The DON was interviewed on 5/30/23 at 6:04 p.m. She said she was aware of the incident with the lift involving Resident #4. She said the incident was investigated and it was inconclusive what happened. She said the resident should be assessed as soon as staff become aware of the incident. She said she did not know about the incident until the resident returned from the ER. She said she did not know if CNAs notified LPN #1 about the incident before the resident left for an appointment. She said the investigation did not determine the CNAs, who operated the lift on 5/23/23,required competency check or additional training. She said the lift was inspected by MTD and was functioning properly. VII. Facility follow-upOn 5/30/23 at the time of the survey, the NHA submitted an email with a copy of work order #16449, dated 5/24/23 for "2-nd floor common area" Hoyer lift. The note under comments read all lifts were checked and were in working condition. -The date on the work order indicated that Hoyer lift that tilted during transfer with Resident #4 was still used by staff on 5/23/23.

Plan of correction · submitted by the facility

“This Plan of Correction is prepared and submitted as required by law. By submitting this Plan of Correction, Adara Living does not admit that the deficiency listed on this form exist, nor does the facility admit to any statements, findings, facts, or conclusions that form the basis for the alleged deficiency. The Facility reserves the right to challenge in legal and/or regulatory or administrative proceedings the deficiency, statements, facts, and conclusions that form the basis for the deficiency.“ F 689How the corrective action will be accomplished for those issues identified by the alleged deficient practice?Resident #4 assessed upon return from ED, neuro checks initiated upon discovery. Event placed into risk management system. CT report from ED negative for any acute findings How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?2. An audit of 3 months prior to complaint survey was completed on 06/13/2023. The audit was completed to ensure that all areas of risk events with major injury related to acute injury had been addressed in a timely manner for all other residents who had the potential to be affected by alleged deficient practice. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?3. All major risk events with acute injury that yields a major injury will be brought to clinical 5 days a week by the assistant director of nursing to be reviewed by Director of nursing/ designee and the interdisciplinary team. Education completed on 6/16/23 with the nursing staff and department heads as well as unit managers related to timely reporting of risk events with major injury, and tag out of equipment, transfers with use of the lift. Competencies started (6/19/23) with nursing staff in reference to injury free transfer procedures and performance checklist. Education was initiated to facility staff on the investigation process, including assessments, neuro checks, and appropriate notifications. Social Service Director initiated education to facility in regards to resident rights specifically related to respect, dignity, listening to residents, and remaining free from abuse and neglect . How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?4. Facility will review risk events with major injury related to acute injury 5 days a week. This process will be done weekly for four weeks, then bi-weekly for one month, and then monthly for one month. Results of the risk event with major injury related to acute injury will be reported to the Administrator and the Process Improvement Committee monthly and as needed to ensure compliance and timely responses. Date of Compliance 6/19/2023

5/24/2023Revisit: Complaint Survey · ID MYE712No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 5/24/23 for all previous deficiencies cited on 3/28/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/26/2023Complaint Survey · ID J48011No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A survey for Incident #31582 was conducted 4/26/23. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

3/28/2023Complaint Survey · ID MYE7117 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO31285 and #CO31374 was conducted on 3/22/23-3/28/23. Seven deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0585GrievancesS/S D▼

Findings

Based on interviews and record review, the facility failed to ensure one (#2) out of three sample residents reviewed out of 12 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically the facility failed to ensure Resident #2's concerns regarding incontinence care were resolved timely by the facility. Findings include: I. Facility policy and procedure The Grievance policy and procedure, revised 2/8/19, was provided by the director of nursing (DON) on 3/29/23. It read in pertinent part, "A resident, family member, staff member or visitor may file a grievance at any time with an appropriate staff member or supervisor. A resident, or person filling the grievance will be informed of the findings of the investigation within five (5) days and the actions that will be taken to correct the identified problems. The Grievance official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility and issuing written grievance decisions to the resident. All residents or persons acting on a resident's behalf that initiate a grievance are to be offered a written Resolution Summary." II. Resident #2 A. Resident status Resident #2, age 92, was admitted on 3/20/21. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance and malignant neoplasm (cancer) of the lung. The 2/20/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required one person physical assistance with all activities of daily living (ADLs) including toileting and personal hygiene. The resident was receiving hospice services. B. Resident representative interview Resident #2's power of attorney (POA) was interviewed on 3/23/23 at 1:25 p.m. The resident's POA said she visited almost daily and on several occasions she witnessed Resident #2 with a smell of urine because she was not changed for long periods of time. She said she had brought up concerns with several staff members on numerous occasions and had not received any written results of the investigation or plan how the care concerns would be resolved. She said she brought all concerns during the care conference and the response she received was that the facility was challenged by staffing shortage, and employed agency staff who were not familiar with residents' needs. She said this was given as an excuse for the care that Resident #2 did not receive daily. There was no resolution for the concerns she brought up to the management (Cross-reference to F677 incontinence care). C. Record review Review of the facility concern forms revealed one concern for Resident #2, dated 2/22/23. The concern form stated that POA reported to the hospice nurse that staff at the facility were not meeting the Resident #2's needs. Specifically, she was not changed timely and frequently found in dirty clothes. As a response from the facility, the care conference was scheduled for 3/2/23. Below the form was dated 3/2/23 the family was notified of the resolution and the family was "satisfied" with the resolution. D. Staff interviewUnit manager #1 was interviewed on 3/23/23 at 3:45 p.m. She said Resident #2's POA approached her on many occasions with many nursing concerns, such as the resident not getting assistance with meals and not getting incontinence care. She said she explained to the POA that they were doing their best with the staff they got. She said she passed POA's concerns to other team members during daily meetings. She said she did not recall if she filled out the grievance form. The social service director (SSD) was interviewed on 3/28/23 at 10:15 a.m. He said he did recall the resident bringing up concerns about several different things, butwas unsure of the time and date. She said since the change in the administration a few months ago the process of grievances changed. She said the grievances were no longer mainstreamed to her, but were submitted to any supervisors and then reviewed by the administrator. She said all grievances were investigated by the heads of the departments that they were pertinent to. After all the investigations and administrator's review, she logged the grievance. She said due to many agency nurses in the building the grievance process was not very smooth in the nursing department. She said it was the responsibility of DON to investigate grievances related to nursing care and the administrator was responsible for review and family communication. The DON was interviewed on 3/28/23 at 12:05 p.m. She said she was aware of the family concerns with care and believed all the concerns were resolved to the family satisfaction. The NHA was interviewed over the phone on 3/28/23 at 12:41 p.m. He said Resident #2's POA frequently visited the facility and he spoke with her about all the concerns she brought. He believed all her concerns were resolved. -However, according the the resident's POA interview (see above) the concerns with Resident #2 incontinence care were not resolved.

Plan of correction

The state did not require a plan of correction for this citation.

0623Notice Requirements Before Transfer/DischargeS/S D▼

Findings

Based on record review and interviews, the facility failed to permit resident to remain in the facility, and not transfer or discharge the resident from the facility for one (#6) of three residents reviewed for discharge out of 12 sample residents. Specifically, the facility failed to provide Resident #6 and their responsible parties, an appropriate notice of discharge that included:-The reason for transfer or discharge;-The effective date of transfer or discharge;-A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests;-Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and, -The name, address (mailing and email) and telephone number of the Office of the State. Findings include:I. Facility policy and procedureThe Involuntary discharge policy and procedure, revised 2/14/19, was provided by the director of nursing (DON) on 3/28/23 at 12:40 p.m. It read in pertinent part, "To assure residents will be transferred or discharged only for the residents welfare."Elements include a thirty day transfer/discharge notice."If the resident is being transferred due to the resident being a danger to self or others, there must be documentation to show that interdisciplinary interventions were tried and failed prior to discharge. "The resident physician must document in the medical record."The facility will document in the residents medical record: The basis for the transfer, the specific residents need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s)."The facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-term care (LTC) Ombudsman. Notice to the Office of the State LTC ombudsman must occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. A copy of the notice sent to the Ombudsman will be maintained in the medical record. The notice provided to the resident, family member, or representative must contain an explanation of the right to appeal the transfer to the state as well as the name, address, and phone number of the Ombudsman."The Thirty Day Transfer/Discharge notice, Nursing Home Notice of Involuntary Transfer or Discharge paperwork, dated 2/14/19, was provided by the DON on 3/28/23 at 12:40 p.m. It read in pertinent part, "This notice is for involuntary discharge or transfer. Fill out this notice for the resident you want to move. Give these papers to the resident - and to his or her representative. Also, send these pages to the State long term care (LTC) Ombudsman, and the Local LTC Ombudsman. "A nursing home can move a resident 30 days after it gives this page to the resident, provided a safe discharge has been arranged. The nursing home must document the exception. The doctor must also sign the fourth page or the nursing home must attach the doctor's written order. "The nursing home must tell you why they want you to move. Here is what they said, about the situation, their efforts to resolve the situation and other important information. You can appeal this. You can get help with your appeal. You have the right to appeal the nursing home's decision to transfer or discharge you."II. Frequent visitor interviewA frequent visitor, with knowledge of the facility, was interviewed on 3/23/23 at 4:00 p.m. He said he was not aware of facility initiated discharge for Resident #6. He said he was not notified verbally or in writing about this discharge. III. Resident #6A. Resident statusResident #6 age 72, was admitted on 3/28/22 and discharged 2/4/23. According to the February 2023 computerized physician orders (CPO) diagnoses include Parkinson's disease, depressive episodes, dementia with other behavioral disturbances, and insomnia. The 12/20/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment deficit with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required one person supervision for walking in the room, in the corridors, locomotion on and off the unit, toileting, and personal hygiene. There were no behaviors noted in the MDS assessment. B. Record reviewThe comprehensive care plan documented discharge was not feasible. Interventions include providing the resident with daily opportunities to participate in activities of interest, social services will assist the resident in finding safe and appropriate placement where which the resident can transfer, if the resident and/or responsible party indicates a desire to discharge. The care plan for behaviors documents the resident being verbally aggressive, such as yelling, can be combative, threatening to others with physical and/or invade others personal space related to dementia. Interventions included administering medications as ordered, analyzing key times, places, circumstances, triggers and what de-escalates behaviors, assess residents' coping skills and support system, and assess residents' understanding of the situation. The care plan for activities documents the resident enjoyed going outside, gardening, exercise, trips, and outdoor games. Interventions included provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility and to honor preferences. C. Progress notesNursing note dated 1/30/23 at 3:06 a.m. documented the resident was up and wandering the hallways and was in slight distress.-No additional information was in the note on why the resident was in distress and what was done to help the resident. Nursing note dated 1/24/23 at 7:00 a.m. documented the resident crying and banging on the window with her hands. -No additional documentation on potential causes of behavior or what was done to help the resident with behavior. Behavior note dated 2/4/23 at 1:50 p.m. documented staff hearing the door alarm at 11:30 a.m. and found the resident running outside the building. When the resident saw the staff she picked up a large rock, the staff intervened. Two certified nurse aides (CNAs) escorted the resident back into the building while she resisted. Once the resident was back in the building the resident obtained a leather belt and wrapped it around a handrail in the shower and tried to pull it off the wall. Behavior note dated 2/4/23 at 2:00 p.m. documented the resident behavior of yelling, cussing, attempting to hit staff members with a belt. After staff obtained the belt the resident attempted to hit her head on the window. Three CNAs prevented the resident from hurting herself. The resident left the facility at 12:30 p.m. via ambulance. The power of attorney (POA) was notified. Nursing note dated 2/4/23 at 1:16 p.m. documented that the resident's POA was notified over the phone that Resident #6 would not be accepted back to the facility, the "POA did not agree but was aware."A discharge summary from the nurse practitioner, dated 2/3/23 (a day prior to behaviors documented above), and signed on 2/21/23 documented the condition on discharge was: unstable at time of discharge, sent to the emergency room (ER) and not allowed to return to the facility.-The note did not include reasons or clarification why the resident was not allowed to return to the facility. Cross-reference F626 for permitting a resident to return from the hospital. -The POA was not given a written notice of the resident's discharge to include the information for the resident and/or representative to appeal the discharge from the facility. An after-visit summary from the hospital dated 2/4/23 document the resident was stable and "medically cleared to return to assisted living."-No documentation of interdisciplinary team (IDT) or social services notes was in the medical record. There was no documentation of the exact time of discharge to the hospital or physician order for discharge. -There were no additional notes by a primary care physician or medical director regarding discharge. There were no documented notes on what was done to manage resident's behavior in the facility. III. Staff interviewsCertified nurse assistant (CNA) #1 was interviewed on 3/27/23 at 2:21 p.m. The CNA said the resident was known to fixate on the doors and tried to get out of the unit. The CNA said the resident had tried to use a dinner knife to pry the doors open. She said the resident was known to get violent and the staff would give her space or contact family to help de-escalate the situation. The CNA said the resident had been discharged from the facility due to an elopement and being a danger to herself and others. Registered nurse (RN) #1 was interviewed on 3/28/23 at 10:26 a.m. The RN said Resident #6 always had some behaviors and sometimes one--one walking would help but not usually. The RN said the resident did not have triggers that would set her off. She said staff usually kept track of triggers so they could be avoided. The social services director (SSD) was interviewed on 3/28/23 at 11:02 a.m. The SSD said she was not familiar with Resident #6's triggers or the incident that caused the resident to be discharged from the facility. She said the DON and nursing home administrator (NHA) made the decision to discharge the resident and she was not part of the discharge process. The SSD said a note regarding the incident should be documented in the resident's medical record. The SSD said the social services department was not informed or involved with the discharge of Resident #6. The DON was interviewed on 3/28/23 at 11:19 a.m. The DON said in most resident discharges to the hospital there was no paperwork and it was done on an individual basis. The DON said Resident #6 had a history of behaviors. The DON said she and the NHA made the decision to transfer the resident to the hospital and not allow her to be readmitted to the facility. The DON said the family requested the resident be allowed to return to the facility and the request was considered by the IDT team. The DON said the IDT decided the resident was too dangerous to return based on her condition in the facility prior to being discharged to the hospital. The NHA was interviewed on 3/28/23 at 12:33 p.m. The NHA said the discharge of Resident #6 was facility initiated. He said he reviewed the situation and made the decision to not let the resident back. He said after the resident had been cleared by the hospital to return that the facility had no indication that she was stable and he did not think the hospital could stabilize her. He said the medical director was involved in the decision and there should be documentation of the decision.-However, there was no documentation provided from the medical director by the exit of the survey on 3/28/23.

Plan of correction · submitted by the facility

How the corrective action will be accomplished for those issues identified by the alleged deficient practice? Resident #6 that was identified during the complaint survey has been discharged from the facility. How the facility will identify other residents having the potential to be affected by the same alleged deficient practice. An audit was completed on 4/3/23 of current residents the audit identified no potential residents that would be affected by said deficient alleged practices. What measure will be put in place or systemic measures put in place to ensure that the deficient practice will not reoccur. The Social Service department was educated on 4/7/23 of the Involuntary Discharge Notice. Going forward, the Social Service department will make notifications in person of any potential Involuntary Discharge Notices. How the facility will monitor its corrective actions to ensure that the deficiency practice is being addressed and not reoccur. The facility prior to issuing an Involuntary Discharge Notice will meet as an Interdisciplinary Team to discuss current status of potential residents that could be discharged from the facility. Once it is established that the resident has the potential for involuntary discharge, the facility must follow the steps outlined on the Involuntary Discharge Notice Appeal process. The results of these findings will be reported to the administrator and to the process improvement committee monthly and as needed to ensure compliance and timely notification of Involuntary Discharge Notices.

0626Permitting Residents to Return to FacilityS/S D▼

Findings

Based on interviews, record review and observation the facility failed to allow resident to return to the facility after going to the hospital for one (#6) of three residents reviewed for discharge out of 12 sample residents. Specifically, the facility failed to allow the resident to return to the facility once stabilized at the hospital. Findings include:I. Facility policy and procedureThe Involuntary discharge policy and procedure, revised 2/14/19, was provided by the director of nursing (DON) on 3/28/23 at 12:40 p.m. It read in pertinent part, "To assure residents will be transferred or discharged only for the residents welfare."If the resident is being transferred due to the resident being a danger to self or others, there must be documentation to show that interdisciplinary interventions were tried and failed prior to discharge. "The resident's physician must document in the medical record."The facility will document in the residents medical record: The basis for the transfer, the specific residents need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s)."The notice provided to the resident, family member, or representative must contain an explanation of the right to appeal the transfer to the state as well as the name, address, and phone number of the Ombudsman."II. Resident #6A. Resident statusResident #6 age 72, was admitted on 3/28/22 and discharged on 2/4/23 to the hospital. According to the February 2023 computerized physician orders (CPO) diagnoses include Parkinson's disease, depressive episodes, dementia with other behavioral disturbances, and insomnia. The 12/20/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment deficit with a brief interview for mental status (BIMS) with a score of 10 out of 15. The resident required one person supervision for walking in the room, in the corridors, locomotion on and off the unit, toileting, and personal hygiene. There were no behaviors coded on the MDS assessment. III. Record reviewThe care plan for long term care (LTC) documented discharge was not feasible. Interventions include providing the resident with daily opportunities to participate in activities of interest, social services will assist the resident in finding safe and appropriate placement where which the resident can transfer, if the resident and/or responsible party indicates a desire to discharge. The care plan for behaviors documents the resident being verbally aggressive, such as yelling, can be combative, threatening to others with physical and/or invade others personal space related to dementia. Interventions include administering medications as ordered, analyzing key times, places, circumstances, triggers and what de-escalates behaviors, assess residents' coping skills and support system, and assess residents' understanding of the situation. A. Nursing notesBehavior note dated 2/4/23 at 2:00 p.m. documented the resident behavior of yelling, cussing, attempting to hit staff members with a belt. After staff obtained the belt the resident attempted to hit her head on the window. Three CNAs prevented the resident from hurting herself. The resident left the facility at 12:30 p.m. via ambulance. The power of attorney (POA) was notified. Nursing note dated 2/4/23 at 1:16 p.m. documented the resident's power of attorney (POA) would not be accepted back to the facility, the POA did not agree but was aware. Cross-reference F623 for discharge notice. A discharge summary dated 2/3/23 (dated a day prior to the resident's discharge to the hospital), signed on 2/21/23 documented the condition on discharge as: unstable at time of discharge, sent to the emergency room (ER) and not allowed to return to the facility. An after-visit summary from the hospital dated 2/4/23 document the resident was stable and "medically cleared to return to assisted living."-The resident was not accepted back to the facility for readmission after completion of hospital treatment where she was medically stable and cleared. IV. Staff interviewsThe social services director (SSD) was interviewed on 3/28/23 at 11:02 a.m. The SSD said she was not familiar with Resident #6's triggers or the incident that caused the resident to be discharged from the facility. She said the DON and nursing home administrator (NHA) made the decision to discharge the resident and she was not part of the discharge. The SSD said a note regarding the incident should be documented in the resident's medical record. The SSD said that social services was not informed or involved with the discharge of Resident #6. The DON was interviewed on 3/28/23 at 11:19 a.m. The DON said in most discharges to the hospital there was no paperwork and paperwork was done on an individual basis. The DON said Resident #6 had a history of behaviors. She and the NHA made the decision to transfer the resident to the hospital and not allow her to be readmitted to the facility. The DON said the family requested the resident be allowed to return to the facility and the request was considered by the facility. The DON said the interdisciplinary team (IDT) decided the resident was too dangerous to return based on her condition in the facility prior to being discharged to the hospital. The NHA was interviewed on 3/28/23 at 12:33 p.m. The NHA said the discharge of Resident #6 was facility initiated. He said he reviewed the situation and made the decision to not let the resident back. He said after the resident had been cleared by the hospital to return that the facility had no indication that she was stable and he did not think the hospital could stabilize her. He said the medical director was involved in the decision and there should be documentation of the decision. -However, there was no documentation provided from the medical director by the exit of the survey on 3/28/23.

Plan of correction · submitted by the facility

How the corrective action will be accomplished for those issues identified by the alleged deficient practice?1. Resident #6 that was identified during the complaint survey has been discharged from the facility on 2/4/23. How the facility will identify other residents having the potential to be affected by the same alleged deficient practice. 2. An audit was completed on 4/12/23 of current residents and the audit identified no potential residents that would be affected by said deficient alleged practice. What measure will be put in place or systemic measures put in place to ensure that the deficient practice will not reoccur. 3. The Admissions Director along with the Social Services Department has been educated on 4/7/23 of the facility bed hold policy. The bed hold policy will be provided at the time of transfer/discharge to an acute setting. How the facility will monitor its corrective actions to ensure that the deficiency practice is being addressed and not reoccur. 4. The Admissions Director/ Administrator or Administrator Designee will verify upon transfer/discharge that the bed hold policy was provided to the resident or responsible party. Once it is established that the bed hold policy was provided, the facility will comply with the standard set by CMS/The State of Colorado. The results of these findings will be reported to the administrator and to the process improvement committee monthly and as needed to ensure compliance and timely notification of bed hold policies. DOC: 04/26/23

0658Services Provided Meet Professional StandardsS/S D▼

Findings

Based on observations, and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were not left at the bedside in a resident's room. Findings include:I. Observations On 3/23/23 at 3:46 p.m. in room # 261 a medication cup with two orange medications (that were identified as Senna S) observed on the table. The resident was not in his room. The above observation was communicated to the licensed practical nurse (LPN) #2. II. Staff interviewsLPN #2 was interviewed on 3/23/23 at 3:55 p.m. She said she left medications at the bedside because the resident wanted to take medications later. She said she was not sure how to handle the situation since the resident was alert and wanted to take medications later. Unit manager (UM) #2 was interviewed on 3/23/23 at 4:05 p.m. She said medications should not be left at the bedside. She said if a resident wanted medications later, the nurse should have taken medications back and provided it to the resident when he was ready for it. The director of nursing (DON) was interviewed on 3/28/23 at 12:15 p.m. She said medications should not be left at the bedside for safety reasons. She said if a resident wanted to self administer medications he or she should be assessed for self administration of medications.

Plan of correction · submitted by the facility

How the corrective action will be accomplished for those issues identified by the alleged deficient practice?Medication removed from bedside table on 03/23/2023 for resident #12 identified during complaint survey. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?All nursing management completed a room to room search for any medications left at bedside on 03/23/2023. The search found no other medications left at bedside that could affect any other resident related to alleged deficient practice. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?Education provided to licensed and registered nurses on 03/23/2023 on the importance of not leaving medications at bedside under no circumstances. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?Nursing managers will complete random room searches three times week for one month, then twice a week for one month, then monthly for one month for medications left at bedside. Results of these searches will be reported to the Administrator or Director of Nursing as well as the Process Improvement Committee monthly and as needed to ensure compliance of no medication at bedside. An emergency QAPI was held on 03/23/2023 as a result of this complaint survey. DOC: 04/26/2023

0677ADL Care Provided for Dependent ResidentsS/S D▼

Findings

Based on observations, record review, and interviews, the facility failed to provide necessary care and services for residents who were unable to carry out activities of daily living for one (#2) out of three sample residents reviewed out of 12 sample residents. Specifically, the facility failed to provide incontinence care to Residents #2 after the meal. Findings include:I. Facility policy and procedure The Incontinence Management policy, revised 8/20/29, was provided by the director of nursing (DON) on 3/29/23. The policy included a "Passway to Incontinence Management." The passway read in pertinent part: "When a resident has no memory recall and is extensively dependent, manage the incontinence care with frequent changes."II. Resident #2A. Resident statusResident #2, age 92, was admitted on 3/20/21. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance and malignant neoplasm (cancer) of the lung. The 2/20/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required one person physical assistance with all activities of daily living (ADLs) including toileting and personal hygiene. Resident was always incontinent. The resident was receiving hospice services. B. ObservationsResident #2 was observed on 3/22/23 between 11:50 a.m. and 4:10 p.m.-At 11:50 a.m. the resident was brought to the dining room and served a meal.-At 12:55 p.m. the resident was taken by a certified nurse aide (CNA) to her room and put to bed without being provided incontinence care.-At 4:10 p.m. the resident was still in bed sleeping. According to the CNA toileting task documented in the resident's record, the resident was last toileted at 9:02 a.m. on 3/22/23. C. Resident representative interview Resident #2's power of attorney (POA) was interviewed on 3/22/23 at 1:25 p.m. The resident's POA said she visited almost daily and on several occasions she witnessed Resident #2 with a smell of urine because she was not changed for long periods of time. She said she brought all concerns during the care conference and the response she received was that the facility was challenged by staffing shortage, and employed agency staff who were not familiar with residents' needs. She said this was given as an excuse for the care that Resident #2 did not receive daily (Cross-reference to F585 grievances). D. Record reviewThe comprehensive care plan for the bowel and bladder was initiated on 5/5/21 and last revised on 5/31/22, revealing the resident was incontinent of bowel and bladder. Interventions included to observe patter of incontinence, and initiate toileting schedule if indicated. -The care plan did not include any specifics about the resident's individual needs. The resident's kardex (a directive for CNAs) included the following interventions: offer toileting upon rising, before and after meals and before bed time. III. Staff interviewsCNA #2 was interviewed on 3/22/23 at 3:26 p.m. She said she was agency CNA and she was not familiar with Resident #2's needs. She said she was not assigned to the unit where Resident #2 was residing, but she was helping on the unit to answer the call lights. CNA #3 was interviewed on 3/22/23 at 3:30 p.m. She said she was agency CNA and she was not familiar with Resident #2's needs. She said she was not assigned to the unit where Resident #2 was residing, but she was helping on the unit with call lights and transfers. Unit manager (UM) #1 was interviewed on 3/22/23 at 3:40 p.m. She said CNA #4 was assigned to the unit where Resident #2 was residing. She said she was not sure where CNA #4 was at the moment. CNA #4 was interviewed on 3/22/23 at 4:00 p.m. She said she was an agency CNA and took over the shift at 2:00 p.m. from the other CNA. The previous CNA was an agency CNA and she did not recall her name. She said she did notreceive a report from her on which resident was toileted and which residents were not. She said sometimes a report was given and sometimes not. She said she was not familiar with residents on the unit. She said she was given a printed page with resident's names and their transfer status. She said she was also assigned to provide showers to four residents on another unit and was absent from her assigned unit for a significant amount of time. She said she did not check on Resident #2 since her shift started and she did not provide any care to the resident. UM #1 was interviewed a second time on 3/22/23 at 4:10 p.m. She said the facility was fully staffed. The unit had three CNAs who were agency CNAs and she was helping them with transfers and care to make sure the care was provided. The DON was interviewed on 3/28/23 at 12:10 p.m. She said the incontinence care should be offered to all residents prior and after the meals. She said agency CNAs were working the unit, but they all received printed instructions for all residents in their care. She said Resident #2 should have been provided incontinence care after the meal prior to the nap.

Plan of correction

The state did not require a plan of correction for this citation.

0684Quality of CareS/S D▼

Findings

Based on record review and staff interviews, the facility failed to ensure two (#9 and #10) residents reviewed out of 12 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to administer morning medications to Resident #10 and afternoon insulin to Resident #9. Findings include:I. Resident #10A. Resident statusResident #10, age 80, was admitted on 10/19/19. According to the March 2023 computerized physician orders (CPO), diagnoses included dementia, heart failure, and depression. The 2/8/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. B. Medication administration observationsLicensed practical nurse (LPN) #3 was continuously observed on 3/23/23 from 10:58 a.m. to 1:00 p.m. LPN #3 was approached at 10:58 a.m. He said he was an agency nurse, it was his first time working on the unit and he was a bit late with his morning meds. He said Resident #10 was his last resident that he had to pass morning medications to. He pulled blister cards out of medication card and pulled the following medications: -Vitamin D 3 1,000 international units (IU)-Vitamin B 12 500 milligrams (mg)-Tylenol 650 mg for pain-Lasix 10 mg for edema-Sertraline 125 mg for depression-Oxycodone 5 mg for chronic painLPN #3 put all medications in a plastic sleeve and crushed them. He could not locate an order for administering crushed medications and reached out to unit manager (UM) #2. The UM #2 reviewed the resident's orders and could not locate the order to crush medications. He instructed LPN #3 to dispose of crushed medications and went to clarify the orders. LPN #3 disposed of all crushed medications at 11:32 a.m. LPN #3 was observed until 1:00 p.m., he never re-approached the Resident #10 who was sitting in the dining room, and never administered morning medications when the observation was stopped at 1:00 p.m. C. Record reviewAccording to the March 2023 CPO, the resident had the following medications to be administered in the morning:-Vitamin D 3 1,000 international units (IU)-Vitamin B 12 500 milligrams (mg)-Tylenol 650 mg for pain-Lasix 10 mg for edema-Sertraline 125 mg for depression-Oxycodone 5 mg for chronic painThe medication administration record (MAR) was marked with LPN's signature and number "5" code, meaning "hold/see progress note." The progress note by UM #2 on 3/23/23 at 8:49 p.m. read "Spoke earlier with nurse practitioner, requesting order to retime medication and to crush meds (medications) unless contraindicated. Nurse practitioner was okay with this. However, on further review, timing change was not necessary per documentation by the nurse. Informed on-call nurse practitioner of morning medication and noon medication. Okay to resume medications at their normal times. No further concerns noted at this time."-The note did not clarify if morning medications were given or not. II. Resident #9 A. Resident statusResident #9, age 70, was admitted on 5/26/22. According to the March 2023 computerized CPO, diagnoses included type one diabetes mellitus and vascular dementia. The 3/20/23 MDS assessment revealed the resident was cognitively impaired with a BIMS score of five out of 15. B. Medication administration observationsLPN #3 was continuously observed on 3/23/23 from 10:58 a.m. to 1:00 p.m.-At 11:59 a.m. LPN #3 entered Resident #9's room to check her blood sugar. The blood sugar was 366. LPN #3 exited the room, documented blood sugar and drew four units of humalog per sliding scale. -At 12:03 p.m. LPN #3 entered Resident #9's room and administered four units of insulin in the presence of UM #2. Resident #9 asked the nurse where her second dose of insulin was before lunch. LPN #3 said it was coming later. -At 12:20 p.m. LPN #3 exited the room and proceeded to administer medications to other residents. LPN #3 never entered Resident #9's room between 12:20 p.m. and 1:00 p.m. Resident #9 was served coffee with cream and cranberry juice at 12:05 p.m. and her lunch was delivered to her room at 12:30 p.m. C. Record reviewAccording to the March 2023 CPO, the resident had the following orders:-Humalog Solution 100 units/ml (Insulin Lispro), inject as per sliding scale before meals at 11:00 a.m.; and, -Humalog Solution 100 units/ml (Insulin Lispro), inject six units with meals at 12:00 a.m. The MAR administration times were reviewed with UM #2 at 1:15 p.m. The MAR timestamp indicated that LPN #3 signed four units of insulin (scheduled at 11:00 a.m.) and six units of insulin (scheduled at 12:00 p.m.) were both given to Resident #9 at 12:20 p.m. -This was contrary to observations above, as LPN #3 never entered Resident #9's room to administer six units of humalog between 12:20 and 1:00 p.m. He only administered four units of humalog per sliding scale at 12:20 p.m. The above findings were reported to the director of nursing (DON) on 3/23/22 at 1:20 p.m. III. Staff interviewsUM #2 was interviewed on 3/23/23 at 1:15 p.m. He said the MAR timestamp indicated that both doses of insulin were given to the Resident #9 at 12:20 p.m. He said all medications were administered an hour before and an hour after scheduled times. He said this rule applied to all medications without exclusions. He said if medication was given late or was not given on time, the nurse should call the doctor to notify about missed medication. He said based on MAR review for Resident #9 all medications were administered on time, including insulin. Regarding Resident #10, he said all morning medications were signed as given, and he said LPN #3 confirmed to him that all morning medications were administered. The DON was initially interviewed on 3/23/23 at 1:20 p.m. She said she would investigate reported findings. She said all medications were administered an hour before and an hour after scheduled times for all residents. She said she was not aware of any time sensitive medications that should be administered at a specific time. Primary care physician (PCP) #1 was interviewed on 3/27/23 at 10:51 a.m. She was a PCP for Resident #9. She said she did not receive any calls from the facility on 3/23/23 about missed or late insulin administration for Resident #9. She said insulin should be administered as scheduled and it was important to give insulin before the meals. She said late or missed insulin administration would result in high blood sugars. The pharmacy consultant was interviewed on 3/28/23 at 9:30 a.m. She said she reviewed medications on monthly bases and occasionally observed medication administrations. She said she did not identify any concerns with medication administration in the facility. She said she could not comment on whenever missed medications for Resident #10 and late/missed insulin administration for Resident #9 were significant medication errors. She said she would need to review the medical record and get back with her comments. She said she was not certain that insulin or any other medications should be given at a specific time. She said nurses always had a two hour window to administer all medications. -The pharmacy consultant did not return the call with further clarifications by the exit of the survey on 3/28/23. Nurse practitioner (NP) #1 was interviewed on 3/28/23 at 10:45 p.m. She said she was on call NP for Resident #10. She said she was off on 3/23/23 but she checked with other NP who was covering for her and she said covering NP received a call on 3/23/23 to clarify if Resident #10's medications could be crashed. She said there was no mention that morning medications were not given to Resident #10. She read a progress note by UM #2 on 3/23/23 and said she could not determine from the note if medications were given or not. She said some medications such as insulin, antibiotics and Parkinson's medications were time sensitive medications and should be given as scheduled (not an hour before or after scheduled time). She said the reasons for that were different for every medication. She said it was important to administer insulin on time as it was affecting an individual's blood sugar and was influenced by meal intake. She said insulin scheduled prior to meal should be given prior to meal. The DON was interviewed a second time on 3/28/23 at 12:20 p.m. She said on 3/23/23 after above observations were reported to her, she initiated facility wide training for all nurses on proper medication administrations. She said she contacted PCP #1 on 3/23/23 regarding insulin administration for Resident #9. She said her investigation did not show that medications were not given to Resident #9 and Resident #10. She said her investigation included an interview with LPN #3 who said that he administered morning medications to Resident #10 and both insulin doses to Resident #9 on time. She said since MAR was signed timely and LPN denied not administering medications she had no evidence of improper medication administration. She said she reported the above concerns to the medical director and facility wide training was initiated on 3/23/23 with random audits of medication administrations.

Plan of correction · submitted by the facility

How the corrective action will be accomplished for those issues identified by the alleged deficient practice?An investigation was initiated on 03/23/2023 related to alleged deficient practices of failure to provide medications to 2 of 12 residents reviewed. This investigation led to an audit of residents #9 and #10 medication and treatment records; these residents were identified during survey. Review of records and investigation indicates medication was given and no adverse effect was documented for resident #9 and #10. How will the facility identify other residents having the potential to be affected by the same alleged deficient practice?An audit of medication and treatment records for the first-floor memory care unit was completed on 03/23/2023. The audit was completed to ensure that no other residents were affected by alleged deficient practice. What measure will be put in place or systemic changes made to ensure that the deficient practice will not recur?Education provided to licensed and registered nurses on 03/23/2023 related to the importance of timely medication pass, signing of medications, and the required steps to take when these actions are not completed. How will the facility monitor its corrective actions to ensure the deficient practice is being corrected and will not recur?Nursing managers will audit a medication administration pass for the 7 rights of medication administration three times a week for one month, twice a week for one month, then weekly for one month. Results of these audits will be reported to the Administrator and the Process Improvement Committee monthly and as needed to ensure compliance and timely assistance of incontinent care. An emergency QAPI was held on 03/23/2023 as a result of this complaint survey. DOC: 04/26/2023

0880Infection Prevention & ControlS/S D▼

Findings

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of three units. Specifically, the facility failed to clean and sanitize the water pitcher that Resident #11 dropped on the floor. Findings include:I. ObservationsResident #11 was observed on 3/23/23 between 2:50 p.m and 4:15 p.m. He was strolling in a wheelchair in the hallway of the second floor unit. He was holding an empty water pitcher with a straw in it. -At 3:45 p.m. Resident #11 dropped his water pitcher on the floor, the lid and straw were in contact with the floor. The passing by certified nurse aide (CNA) picked up the pitcher and gave it back to the resident.-At 4:10 p.m. Resident #11's pitcher was observed on the floor. The resident strolled to the door with the sign "medication room" and kicked the door. Passing by unit manager (UM) #1 picked up an empty pitcher off the floor and gave it back to the resident. II. Staff interviewUM #1 was interviewed on 3/23/23 at 4:20 p.m. She said she did recall picking up a pitcher off the floor and giving it back to the Resident #11. She said Resident #11 wanted his soda drink and this was why he was kicking the door to the medication room (where soda was stored) and kept dropping his pitcher. She said she did not have time to refill his pitcher with a soda drink. She said she told him he should be patient. She said she should have washed the pitcher before giving it to the resident, but she forgot to do so. The director of nursing (DON) was interviewed on 3/28/23 at 12:15 p.m. She said nurses and CNAs should have cleaned the pitcher that was dropped on the floor prior to giving it back to the resident.

Plan of correction · submitted by the facility

1. Corrective ActionThe facility will immediately implement an appropriate infection prevention and intervention plan consistent with the requirements of §483.80 for the affected resident(s)/neighborhood(s) identified in the deficiency. The infection preventionist (IP), director of nursing (DON), in conjunction with applicable interdisciplinary team (IDT) members, shall identify and implement a consistent system for ensuring resident drinkware is cleaned/sanitized after contact with the floor. The DON, staff development coordinator (SDC), IP or designee, in conjunction with applicable IDT members, will educate unit manager (UM) #1 on ensuring drinkware that contacts the floor is sanitized before resident use. 2. Identification of Others The IP and DON, in conjunction with the applicable interdisciplinary team (IDT) members will observe dining rooms and resident rooms to ensure staff replace utensils, drinkware, and nasal cannulas that are on the floor with clean items before resident use. 3. System ChangesOn or before 4/26/2023 the facility shall complete the following actions:(1) DON, IP and applicable IDT members will conduct root-cause analysis to identify and address the reasons for non-compliance related to failure to replace resident drinkware that was on the floor with a clean/sanitized cup/glass. Information about root cause analysis can be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceforRCA.pdf (2) The DON, SDC, IP or suitable designee will ensure all staff that work in dining rooms and resident rooms are educated to replace items like drinkware, utensils, and nasal cannulas that contact the floor with clean, sanitized items rather than permitting immediate reuse of the item retrieved from the floor.(3) The facility leadership will contact the Colorado Quality Improvement Organization (QIO), Telligen, to inquire about the assistance and services available from the QIO in improving infection prevention and control within the facility through quality assurance process improvement (QAPI) methods. 4. MonitoringWeekly for no less than 12 weeks, the DON, IP, SDC or a designee will conduct on-going monitoring to ensure, via observation, the approaches to correct deficient practice related to infection control and prevention are consistently implemented and effective. Such monitoring will include observation dining rooms and resident rooms to ensure staff replace utensils, drinkware, and nasal cannulas that are on the floor with clean items before resident use. Observations will be made across all shifts and neighborhoods/units. Observations of noncompliance with the above will result in ad hoc education for the involved staff. Such education will be documented on monitoring forms. After twelve weeks of monitoring, provided that such monitoring demonstrates expectations are consistently met, monitoring may be reduced to monthly. Monthly monitoring will continue for no less than three months. All monitoring will be reported to the quality assurance performance improvement (QAPI) committee as part of QAPI activities. Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director. 5. Correction Date4/26/2023 Adara Living - DPOC F880 - MYE711

1/25/2023Revisit: Licensure Complaint Survey · ID P3RI12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 1/25/23 for all previous deficiencies cited on 12/9/22. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

1/25/2023Revisit: Complaint, Focused Infection Control, Other-Fed Survey · ID Q1DU12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit of the COVID-19 Infection Control focused survey was completed on 1/25/23 for all previous deficiencies cited on 12/9/22. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

1/17/2023Focused Infection Control, Other-Fed Survey · ID HFOI111 deficiency▼

0884Reporting - National Health Safety NetworkS/S F▼

Findings

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.

Plan of correction

The state did not require a plan of correction for this citation.

1/9/2023Focused Infection Control, Other-Fed Survey · ID 13W6111 deficiency▼

0884Reporting - National Health Safety NetworkS/S F▼

Findings

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 01/02/2023 and 01/08/2023, 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.

Plan of correction

The state did not require a plan of correction for this citation.

1/3/2023Focused Infection Control, Other-Fed Survey · ID ZRBY111 deficiency▼

0884Reporting - National Health Safety NetworkS/S F▼

Findings

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 12/26/2022 and 01/01/2023, 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.

Plan of correction

The state did not require a plan of correction for this citation.

Reportable Occurrences

70 records

6/20/2026Brain Injury · ID 2602R989041Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/20/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a brain injury event. Staff reported client (A) became agitated and physically struck a staff member. Client (A) then grabbed a few items off the counter and turned to walk away, when they tripped and fell. Client (A) suffered a head laceration, hand bruise and scratch. Staff provided first aid until client (A) could be transferred to the hospital for further evaluation. Diagnostic test results revealed a brain bleed. During the course of the investigation, the healthcare entity conducted a post fall review, record review and interviews. Staff stated they attempted to calmly redirect when client (A) accidentally tripped over her own feet causing a fall. Once medically stable, client (A) returned at their baseline level of cognition and function. The interdisciplinary team reviewed client (A)'s medications for mood management. In addition, staff reassessed client (A)'s safety and preventative fall interventions. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/8/2026 · released to the public 7/15/2026.

4/19/2026Brain Injury · ID 2602R989030Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/19/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a brain injury event. Staff observed client (A) on the floor face down with facial injuries. Prior to being transported to the hospital, client (A) reported they were reaching for an item and fell out of the wheelchair. Client (A) was transferred to the hospital for further evaluation. Diagnostic test results revealed a brain bleed. During the course of the investigation, the healthcare entity conducted a post fall review, record review and interviews. Once medically treated and stable, client (A) returned and staff reassessed client (A)'s fall safety needs. Re-education was provided to client (A) regarding their safety plan. The facility's review of the fall event revealed the safety interventions were in place, and despite these measures, a fall occurred with injuries. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/11/2026 · released to the public 6/18/2026.

4/6/2026Physical Abuse · ID 2602R989029Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/9/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. While client (A) was in the hospital for a scheduled procedure, the facility learned that client (A) would not be returning. Client (A) alleged staff (1) threw them into the bed and had been rough when providing care. Client (A)'s family reported client (A) had bruises from the alleged interaction. Staff (1)'s identity could not be identified. During the course of the investigation, the healthcare entity conducted interviews and record reviews, reviewed staffing assignments and notified the police. Management could not verify if the client suffered any bruising. No staff reported having any difficulties with transferring or working with the client. No other clients reported having any concerns with staff mishandling. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/30/2026 · released to the public 7/7/2026.

1/12/2026Verbal Abuse · ID 2602R989005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/12/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Reportedly, client (A) stated someone threatened to kill them the previous night. Client (A) could not provide a consistent description of the alleged assailant. During the course of the investigation, the healthcare entity started safety checks, notified the police and conducted interviews. Staff reported client (A) had been exhibiting signs of agitation, experiencing delusions and was being assessed for end of life comfort care. No one could corroborate client (A)’s allegation of being threatened. Staff requested further medical review to help address a potential underlying cause for this mental change. Safety and support monitoring continued for client (A). The event could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/25/2026 · released to the public 4/1/2026.

12/31/2025Physical Abuse · ID 2602R989003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/31/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (B) became agitated with client (A) due to the volume of her voice. Client (B) yelled at client (A) to shut up and then proceeded to slap client (A) on the upper back. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. Management changed seating arrangements in the dining area, reviewed behavioral care plans and re-educated staff on the clients’ triggers and interventions. No visible injury was observed with client (A), and she could not participate in a follow up interview due to a severe cognitive impairment. Staff requested a medication review and client (B)’s medications were revised to help manage agitation and aggressive outbursts. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/10/2026 · released to the public 3/17/2026.

12/20/2025Sexual Abuse · ID 2502R989043Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/20/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a sexual abuse event. Client (A) alleged staff (1) touched her inappropriately and sexually assaulted her while providing care. During the course of the investigation, the healthcare entity suspended staff (1), conducted an assessment and interviews, notified the police and implemented a supportive and safety monitoring plan for the client. Through interviews with staff, staff (1) and client (A)’s roommate, client (A)’s allegation could not be corroborated. Management implemented female caregivers. Staff learned she was a former victim of sexual assault, and her plan of care was updated. Education was provided to staff on the client’s preferences and updated care plan. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/19/2026 · released to the public 2/28/2026.

12/18/2025Physical Abuse · ID 2502R989042Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/18/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Staff observed two small lacerations that were bleeding on the back of client (A)’s head. Client (A) told staff some mean man hit him and hurt him in the bathroom. During the course of the investigation, the healthcare entity conducted an assessment and interviews, attempted to identify the alleged assailant, notified the police and implemented a safety monitoring plan. A nurse provided first aid treatment to client (A) and pain medications due to complaint of pain. No alleged assailant could be identified. Staff indicated the client might have lost his balance and fell into some object. Care plan revisions occurred to help support client (A), which also included staff education on the new interventions. The findings of how client (A) suffered the lacerations were inconclusive, and an abuse event could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/19/2026 · released to the public 2/26/2026.

12/10/2025Verbal Abuse · ID 2502R989040Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Client (A) alleged client (B) raised a shoehorn at him in a gesture like a hitting motion. The two clients started arguing after that when staff intervened to separate the clients. Initially client (A) reported being fearful. During the course of the investigation, the healthcare entity conducted assessments and interviews, reviewed care plans, notified the police and implemented a monitoring plan for client safety. After further conversations, staff noted client (A) was the aggressor, which triggered client (B). Client (A) indicated he overreacted in the situation and voiced needing to work on his patience. Education was provided to both clients to seek staff help with any frustrations and/or needs. Both clients chose to remain roommates. A medication review occurred with client (B) related to increase aggression. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/19/2026 · released to the public 2/26/2026.

11/9/2025Verbal Abuse · ID 2502R989036Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/9/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Client (A) allegedly threw a cup as a threatening gesture at Client (B) during a verbal altercation. During the course of the investigation, the healthcare entity separated and assessed the clients, notified police, and conducted interviews. No visible injuries were reported. After exhibiting signs of fear and expressing the desire to not return to the room, Client (B) was moved to another room. Client (B) received one-on-one supervision and was discharged from the facility a few days later. Client (A) remains on 15 minute staff checks to reduce the risk of recurrence due to diminished cognitive functioning. The event was substantiated. This is the second report of a client to client altercation involving Client (A). Please refer to case ID# 2502R989022 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/8/2025 · released to the public 12/15/2025.

10/29/2025Physical Abuse · ID 2502R989035Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, staff observed two clients yelling and grabbing at one another resulting in a scratch to client (A)’s chest. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. Both clients had a cognitive impairment and could not state what triggered the incident. Staff requested a medication and behavioral review for the clients to help identify any triggers for agitation. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 1/8/2026 · released to the public 1/15/2026.

10/13/2025Physical Abuse · ID 2502R989031Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, female client (A) approached male client (B) in the dining room and asked a question. In response, client (B) hit client (A)’s head causing pain. Staff reported client (A) exhibited signs of being fearful. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. No visible injury was observed with client (A). Client (B) could not indicate what triggered his aggression, but staff reported it appeared he thought client (A) might have wanted his food. Staff continued monitoring the dining area to help redirect clients. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 1/7/2026 · released to the public 1/14/2026.

10/7/2025Verbal Abuse · ID 2602R989006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/28/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Client (A) alleged staff (1) yelled at him and refused to administer a medication when requested. The alleged incident occurred back in October 2025, and no further details were known. During the course of the investigation, the healthcare entity suspended staff (1), conducted an assessment, record review and interviews. Management notified the police and implemented a supportive and safety monitoring plan for the client. With client (A)’s cognitive impairment, they did not recall making the allegation. Record review revealed no entries related to medication issues. No other clients or staff reported having any concerns about staff (1) or their medication. Staff (1) returned to work, and as a precautionary measure, management implemented a monitoring plan. Client (A)’s allegation could not be corroborated, and the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/10/2026 · released to the public 4/17/2026.

10/1/2025Verbal Abuse · ID 2502R989030Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Reportedly, male client (A) screamed at female client (B) and threated to harm her if she went to his spot in the dining room. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, notified the police and implemented a monitoring plan for peer safety. Client (B) had a moderate cognitive impairment and indicated she was not sure what he said to her but knew he spoke in a loud voice. Staff requested a medical and medication for client (A) due to his aggression. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/16/2025 · released to the public 12/23/2025.

8/21/2025Neglect · ID 2502R989027Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/22/25, the healthcare entity investigated a reportable event of neglect. Client (B) experienced a change in her cognitive status and presented with symptoms of slurred speech, difficulty following commands, vital sign changes and increased lethargy. She was transferred to the hospital for an evaluation and treatment. While in the hospital, client (B) questioned if she received the right medications at the facility. Client (B) indicated nurse (1) handed her a cup of medications labeled with a different client’s name, but nurse (1) said they were her (client B) medications and administered them to client (B). During the course of the investigation, the healthcare entity conducted interviews and record reviews. Management suspended agency nurse (1) and notified their staffing agency. Through interviews and record review, the facility concluded nurse (1) did not follow physician orders or medication policies with medication administration, which led to client (B) receiving the wrong medications. The event was substantiated. Nurse (1) was not allowed to return. Facility wide education was provided to nursing staff regarding medication error prevention. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 10/8/25, Event ID 1D8E61-H1.

Publication

Sent to facility 12/29/2025 · released to the public 1/5/2026.

8/1/2025Verbal Abuse · ID 2502R989026Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Reportedly, when client (A) was experiencing a behavioral episode, client (B) alleged client (A) threatened to kill her. Client (B) reported being fearful. During the course of the investigation, the healthcare entity separated the clients, provided emotional support to client (B), notified the police and implemented direct monitoring with client (A). The event was substantiated. A medical and mental health review occurred with client (A), which led to medication changes. Client (A) was moved to a new room and staff revised her behavioral and safety plan. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/23/2025 · released to the public 9/30/2025.

7/30/2025Physical Abuse · ID 2502R989025Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/31/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical and sexual abuse event. Client (B) alleged someone has been rubbing her lower legs at night and then said the touch progressed to the person grabbing her breasts. No assailant was identified. During the course of the investigation, the healthcare entity conducted assessments and interviews, notified the police, and started safety monitoring. Through staff interviews and client (B)’s roommate, client (B)’s allegation could not be corroborated. After a medical and behavioral assessment, client (B) was treated for a urinary tract infection and a behavioral change. Staff implemented care in pairs. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/23/2025 · released to the public 9/30/2025.

6/11/2025Sexual Abuse · ID 2502R989024Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a sexual abuse event. Client (B) alleged a male person touched her inappropriately. During the course of the investigation, the healthcare entity started frequent monitoring with client (B), attempted to identify the alleged assailant, notified the police and conducted interviews. With client (B)’s cognitive impairment, she could not provide additional details. An assailant could not be identified based on the description. No one could corroborate client (B)’s allegation, so an abuse event could not be substantiated. Client (B)’s plan of care was reviewed to help support and monitor her needs. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/11/2025 · released to the public 9/18/2025.

5/20/2025Sexual Abuse · ID 2502R989023Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/20/25, the healthcare entity investigated a reportable event of sexual abuse involving a male and female client. This was the second incident involving male client (A) touching another client inappropriately, refer to event ID # 2502R989021 for further details. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 6/23/25, Event ID 9UXN11. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/19/2025 · released to the public 8/26/2025.

5/11/2025Physical Abuse · ID 2502R989022Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event involving two clients. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, implemented a safety monitoring plan, revised individual care plans, and notified the police. One client was moved to a new room, and her medications were adjusted to help manage aggression. Although there was no visible injury, the assailant intentionally struck her peer. Staff support and monitoring continued per their individual plans. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/12/2025 · released to the public 8/19/2025.

5/2/2025Sexual Abuse · ID 2502R989021Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/2/25, the healthcare entity investigated a reportable event of sexual abuse. Reportedly, staff witnessed male client (A) touching female client (B) inappropriately. Staff separated the clients, notified the police and implemented a safety plan to help monitor, redirect and support client (A)’s changing needs. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 6/23/25, Event ID 9UXN11. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/11/2025 · released to the public 8/18/2025.

4/18/2025Physical Abuse · ID 2502R989019Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/19/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (B) alleged someone hit her on the arm causing pain. Through additional interviews, management reported her story kept changing about the event, and she could not identify an alleged assailant. During the course of the investigation, the healthcare entity conducted an assessment and interviews, notified the police, and started safety monitoring. No visible injury was observed. No assailant could be identified. Staff reported client (B) was exhibiting signs of increased confusion, exit seeking and agitation, so she was sent to the hospital for further evaluation. As client (B)’s allegation could not be corroborated, the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/10/2025 · released to the public 7/17/2025.

4/17/2025Physical Abuse · ID 2502R989018Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/17/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) grabbed client (B)’s wrist with both hands in an attempt to stop them from grabbing food off her plate and hitting the table with a fork. Client (B) suffered a bruise to her wrist where she was grabbed. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews and notified the police. The seating arrangements were modified in the dining room. Staff was unsure of what triggered client (B)’s actions but safety monitoring was also started. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/10/2025 · released to the public 7/17/2025.

3/29/2025Physical Abuse · ID 2502R989017Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 3/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) entered client (B)’s room with the intention of harming client (B). Client (B) ended up falling. During the course of the investigation, the healthcare entity kept the clients separated, conducted an assessment and interviews, and implemented safety monitoring. Staff requested a medication review for client (A) due to his aggression. In addition, staff was asked to be mindful of the environment and redirect client (A) to a new area if he was exhibiting signs of being overstimulated. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/28/2025 · released to the public 6/4/2025.

3/26/2025Physical Abuse · ID 2502R989016Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/26/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Client (B) alleged staff (1) had been rough when providing care and felt like she had been “beaten” up. Client (B) indicated she told staff (1) to stop because she was hurting her, but staff (1) did not stop. During the course of the investigation, the healthcare entity suspended staff (1), notified the police, and conducted an assessment and interviews. No visible injuries were observed. Through interviews with staff and client (B)’s roommate, client (B)’s allegation could not be corroborated, and the event was not substantiated. However, due to client (B) comments and staff (1)’s employment history regarding rights and delivery of care concerns, management decided to terminate staff (1)’s employment. A unit manager met with client (B) to help understand her care preferences and re-educated staff accordingly. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/29/2025 · released to the public 8/5/2025.

3/19/2025Verbal Abuse · ID 2502R989014Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/19/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a verbal abuse event. Reportedly, client (A) exited his room with a butter knife in hand and started to approach client (B) in a threatening manner. Staff quickly intervened to redirect. Client (B) indicated he was fearful. During the course of the investigation, the healthcare entity separated the clients, conducted a search for any other sharp objects in client (A)’s room, notified the police, and implemented a safety monitoring plan. Client (A) reported he heard client (B) talking about him, so he got upset at client (B). Staff was instructed to provide plastic silverware to client (A). A medication review occurred with client (A) to help address his aggression along with referring him for a mental health evaluation. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/23/2025 · released to the public 8/5/2025.

2/9/2025Sexual Abuse · ID 2502R989013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 2/9/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a sexual abuse event. Reportedly, the police showed up to investigate an allegation of sexual assault made by client (B). Client (B) alleged she and her roommate had been sexually assaulted by two unknown males. She requested to be sent to the hospital. During the course of the investigation, the healthcare entity secured transport to send client (B) to the hospital, implemented a safety monitoring plan for current clients during the investigation and conducted interviews. A forensic examination revealed no results of sexual assault. The roommate denied any allegation of sexual assault. There were no findings to support client (B)’s allegation. There was a report of increased confusion related to an acute medical change. Client (B) did not return per her request. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/22/2025 · released to the public 6/2/2025.

2/4/2025Physical Abuse · ID 2502R989011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 2/4/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported an event of potential harm with a physical abuse allegation. Reportedly, client (B)’s friend had been supplying non-prescribed and potential for harm medications for client (B) to ingest. Client (B) had a moderate cognitive impairment. During the course of the investigation, the healthcare entity conducted a search for any further medications, and contacted the visitor, family and medical provider. Medical tests were ordered to help evaluate for any adverse outcomes to the client (B). Education was provided to the client regarding taking only prescribed medications. With any future visits with the friend, they would be supervised and were instructed they could not provide medications to the client. Client (B) admitted to self-medicating to help manage his cognitive status. The facility concluded staff had been unaware of the allegation and no one had witnessed any medication drop offs or client (B) ingesting medications. There were no reported adverse findings, and the event could not be substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/9/2025 · released to the public 4/16/2025.

2/4/2025Sexual Abuse · ID 2502R989012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 2/24/25, the healthcare entity investigated a reportable event of physical abuse. Reportedly, a medical provider witnessed male client (A) touching female client (B)’s breasts inappropriately. During the course of the investigation, the healthcare entity separated the clients, conducted interviews, and provided education on personal boundaries. Safety checks were started. Client (A) had a history of sexually inappropriate behaviors typically directed towards staff. Client (B) reported she did not provide consent, and the touch made her uncomfortable. Client (A) admitted to touching client (B) without consent. Client (A) was moved to a different unit and safety monitoring continued. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 3/17/25, Event ID#UKIY11.

Publication

Sent to facility 4/9/2025 · released to the public 4/16/2025.

2/2/2025Physical Abuse · ID 2502R989010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 2/3/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Client (B) alleged agency staff #1 slammed a cup into his hand causing it to hurt. Also, he reported staff #1 responses were unprofessional. During the course of the investigation, the healthcare entity suspended staff #1 and conducted an assessment and interviews. No visible injury was observed, and the pain had resolved. Staff #1 did not return, and the facility reported them to the board of nursing. No other clients or staff could corroborate client (B)'s report, but due to client (B)’s statement about the interaction, the event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/4/2025 · released to the public 4/11/2025.

1/28/2025Physical Abuse · ID 2502R989009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/28/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) approached client (B) and hit him on the head with a metal water bottle. Client (B) reported it hurt where he was struck. Per staff witness, the act was unprovoked. During the course of the investigation, the healthcare entity separated the clients, conducted an assessment and interviews, and started 1:1 monitoring with client (A). Initially, client (A) claimed client (B) struck first, which staff could not corroborate that statement. A medication review was requested for client (A). Client (B) was moved to a new unit, and staff continued monitoring client (A) to help redirect him when needed. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/16/2025 · released to the public 6/23/2025.

1/20/2025Physical Abuse · ID 2502R989007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/20/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) physically assaulted client (B) while saying he was going to help client (B) get to “Jesus.” Client (B) suffered a nasal injury and complained of head pain. Client (B) also indicated he was fearful of client (A). During the course of the investigation, the healthcare entity separated the clients, provided first aid treatment, and started safety checks. Client (B) was sent to the hospital for further evaluation and returned without any newly reported injuries. Client (A) was placed on a mental health hold and sent for a mental health evaluation. Through interviews, the facility determined client (A) was angry with client (B) and his act of violence was unprovoked. The event was substantiated. When client (A) returned, he would be placed in a different unit and staff would reassess his behavioral and safety plan. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/2/2025 · released to the public 6/9/2025.

1/9/2025Physical Abuse · ID 2502R989005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/9/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, staff witnessed client (A) push client (B). One staff member was able to intervene and helped lower client (B) to the floor. The act was unprovoked, which resulted in an injury to client (B)'s finger. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, and started safety monitoring. The facility concluded client (A) was reacting to an active hallucination and paranoia that others were out to get him. Staff requested a medication review for client (A) due to these mental health changes and aggression. Safety monitoring remained in place. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/28/2025 · released to the public 6/4/2025.

1/6/2025Physical Abuse · ID 2502R989004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/6/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, as the two clients passed one another in their wheelchairs, the wheelchairs accidentally bumped together. Client (A) responded by slapping client (B) on the face causing redness. During the course of the investigation, the healthcare entity separated the clients, conducted assessments and interviews, and started safety checks. Client (A) reported getting pissed at client (B), so he slapped him. With client (A)’s diagnoses, management was unsure if the slap was a result of impaired impulse control versus intentional. However, client (A) reported he got pissed and slapped the other client causing redness. The event was substantiated. Staff reviewed and revised client (A)’s behavioral care plan and requested a medication review. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/31/2025 · released to the public 6/7/2025.

1/3/2025Physical Abuse · ID 2502R989003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/3/25, the healthcare entity investigated a reportable event of physical abuse. Reportedly, there was a physical incident between two clients, which resulted in client (A) pushing client (B). Client (B) fell down. Staff observed finger indentations and scratches on client (A)’s arm. Staff separated the clients, conducted assessments and interviews and provided first aid treatment. Safety monitoring was implemented. Both clients had a cognitive impairment, and the initial version of what started the incident between the two clients changed. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 1/16/25, Event ID DBHI11. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/28/2025 · released to the public 6/4/2025.

1/2/2025Sexual Abuse · ID 2502R989008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/28/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a sexual abuse event. Reportedly, a detective arrived to visit with client (B) as a police report of an alleged sexual assault was filed. Allegedly, a staff member (agency staff 1) touched her breasts in a sexual manner. Client (B) was unable to provide additional details about a date or time. She indicated she had not reported the event to management due to her embarrassment. During the course of the investigation, the healthcare entity suspended staff (1), conducted interviews and provided emotional support to client (B). No other clients or staff reported having any concerns about staff (1) violating any personal boundaries. Management reported staff (1) did not respond to interview requests, and there were no witnesses to the alleged interaction. The facility concluded the findings were inconclusive, so the event was not substantiated. Staff (1)’s work contract was ended. Supportive counseling was offered to client (B). In addition, her care plan was updated to reflect female care providers only and for staff to provide care in pairs. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/16/2025 · released to the public 6/23/2025.

12/20/2024Physical Abuse · ID 2402R989046Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/20/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, staff heard screaming and found female client (B) on the floor with male client (A) standing over them. Client (B) was attempting to kick client (A) unsuccessfully while client (A) had his hand near and around her neck per witness report. During the course of the investigation, the healthcare entity kept the clients separated, conducted an assessment, and started safety checks. No visible injury was observed to client (B), and staff reported she was not exhibiting signs of pain. Client (B) had a cognitive impairment and could not participate in a follow up interview about what happened in the room. A stop sign was placed across client (A)’s door to deter others from entering the room along with other safety modifications being put in place. Client (A) indicated he got upset with her presence and she has entered his room before. He admitted to his actions and told staff he should have “decked” her out. Safety monitoring continued to decrease client (B)’s wandering habits. The facility concluded client (A) reacted in a physically aggressive manner to client (B)’s presence, but without a visible injury, the facility determined the allegation of abuse was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/1/2025 · released to the public 4/8/2025.

12/17/2024Brain Injury · ID 2402R989045Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 12/17/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury event. Reportedly, staff found the client on the floor with injuries and a medical change of condition. During the course of the investigation, the healthcare entity provided first aid treatment and obtained transport to the hospital for further evaluation. Diagnostic test results showed several facial fractures, a brain bleed and urinary infection. The client was admitted for care. The facility concluded the client suffered an accidental fall when she got up by herself. If she returned, staff would reassess her care and safety needs. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/1/2025 · released to the public 4/8/2025.

10/29/2024Physical Abuse · ID 2402R989040Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/29/24, the healthcare entity investigated a reportable event of physical abuse. Client (B) alleged client (A) slapped her arm, and she felt he intended to hurt her. Reportedly, client (A) wandered into her room causing a negative interaction. Direct staff monitoring was started with client (A) until a medication change occurred. A stop sign was placed across client (B)’s doorway to deter others from wandering inside and safety monitoring continued. As no visible injury was observed, the facility concluded an abuse allegation was not substantiated. In addition, this occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 1/16/25, Event ID DBHI11. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/8/2025 · released to the public 5/15/2025.

10/4/2024Physical Abuse · ID 2402R989038Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/4/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. During the course of the investigation, the healthcare entity reported client (A) hit client (B) on the forehead causing pain. Client (B) yelled out for staff, as she felt fearful. Staff kept the clients separated, conducted an assessment, and started frequent safety checks. No visible injury was observed with client (B). No treatment was required for pain. The facility concluded client (A) got mad with client (B)’s presence and struck out. Modifications were made for client (A) to address her behaviors. With client’s report of pain and fear, the event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/18/2025 · released to the public 3/25/2025.

9/23/2024Physical Abuse · ID 2402R989037Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 9/23/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, two clients became upset with one another and engaged in a physical altercation resulting in a skin abrasion to client (B)’s eyebrow. During the course of the investigation, the healthcare entity separated the clients, provided first aid treatment and started safety checks. Staff noted client (B) was upset after the incident and provided emotional support. Management concluded both clients became triggered by their perception of events in the dining area, which led to the physical incident. Safety monitoring remained in place to keep a low stimulation area for dining. As the clients engaged in reckless responses resulting in a bodily injury, the event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/8/2025 · released to the public 5/15/2025.

9/8/2024Brain Injury · ID 2402R989035Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/9/24, the healthcare entity investigated a reportable event. The entity acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a potential brain injury event involving client (A) post-fall. During the course of the investigation, the healthcare entity provided first aid treatment and initiated neurological monitoring. The client was transferred to the hospital for further evaluation. Diagnostic imaging showed acute changes to a surgical site but no acute brain bleed and she returned to the entity. Fall safety measures were reviewed and additional interventions were implemented. The client’s physical and mental status then declined, which required transport back to the hospital for further imaging and assessments. The event was not substantiated that the client experienced a brain bleed related to the fall out of bed. The entity reported the change in the client’s surgical site and neurological change was determined not to be related to the fall. Once medically stable, the client returned and was referred to therapy services. Staff continued monitoring the client per her revised safety plan of care. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/8/2025 · released to the public 2/15/2025.

8/21/2024Physical Abuse · ID 2402R989030Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 8/21/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. During the course of the investigation, the healthcare entity reported staff heard screaming and observed client (A) exiting client (B)’s room. Client (A) said she hit client (B) causing moderate facial pain. Staff kept the clients separated, conducted an assessment, and continued safety monitoring. A unit move occurred for client (B) and medication adjustments were made for client (A) due to her aggression. The facility concluded client (A) was experiencing an active delusion that led to her aggression towards client (B). However, with client (A)’s dementia, the facility determined her ability to form intent was questionable, so the facility did not substantiate the event. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/4/2025 · released to the public 3/11/2025.

8/6/2024Physical Abuse · ID 2402R989028Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 8/6/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event involving two clients. During the course of the investigation, the healthcare entity reported staff witnessed client (A) push client (B), which caused her to lose her balance against the wall. Client (B) complained of a sore shoulder. Staff redirected client (A) due to exit seeking behaviors. A nurse assessed client (B) and staff implemented safety checks. No visible injury was observed. Pain medication was provided to help with pain management. The facility determined client (A) pushed client (B) in an aggressive manner, as client (B) was in his way. However, the facility concluded from their investigation that client (A) did not act intentionally to cause harm as his only desire was to leave the facility. Safety monitoring remained in place. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/24/2025 · released to the public 3/31/2025.

8/2/2024Physical Abuse · ID 2402R989027Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 8/2/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event involving two clients. During the course of the investigation, the healthcare entity reported two clients started arguing, which led to alleged physical acts of aggression. Staff kept the clients separated, conducted an assessment and started safety monitoring. Client (B) reported feeling unsafe. However, no visible injury was observed, and she had no current complaint of pain. Client (A) had wandered into client (B)’s room, but denied hitting client (B) as alleged. No staff witnessed what happened in the room but did hear them arguing. Safety monitoring continued with both clients. Environmental changes were made to help deter wandering habits. As there was no visible injury and due to conflicting statements about what happened inside the room, the facility concluded the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/13/2025 · released to the public 3/20/2025.

7/12/2024Physical Abuse · ID 2402R989024Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 7/13/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event involving client (A). During the course of the investigation, the healthcare entity reported client (A)’s private caregiver alleged staff #1 had been rough when providing care to the client (A) causing her to experience pain and bruising. Management removed staff #1 from providing care and nursing conducted an assessment. For safety, care in pairs was implemented. Documentation showed the bruise was present upon admission and not related to this allegation. No other clients reported concerns with staff #1. The facility concluded staff #1’s actions were not intentional or reckless. Management identified the client (A) would benefit from two-person assist related to her size and behavioral history. Staff received education on the updated care plan, and staff #1 returned to work. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/3/2025 · released to the public 3/10/2025.

4/23/2024Missing Person · ID 2402R989017Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 4/23/24 resident (A) was not found in their room for medication administration. Resident (A) resided in the memory care unit and was identified to be an at risk adult. After a search was conducted resident was not found on the premises or surrounding area. The doors were checked and were secured. It was identified resident (A)’s window was tampered with and the screen was pushed out onto the ground. Resident (A) was found by the police around 1:15 a.m. and returned to the facility without any injuries. The facility’s investigation concluded resident (A) was agitated early and was able to exit the facility through his window. To help prevent a recurrence, his window was fixed and all residents' windows were re-secured with a new mechanism. Resident (A) was also provided with a one-to-one staff member. Resident (A)’s care plan was updated to reflect he had the capacity to be handy based on his employment history and his ability to use objects to exit the facility. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/26/2024 · released to the public 12/3/2024.

4/16/2024Physical Abuse · ID 2402R989014Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 4/16/24, resident (A) reported that when s/he was put to bed by staff #1 and staff #2, they were rough and moved them back and forth in a fast manner. Reportedly, resident (A) felt this was abusive. The facility notified the police. Resident (A) did not remember the exact date and time this occurred and s/he reported feeling unsafe “last night.” The record review showed that resident (A) then reported after staff #3 spoke to staff #1 and #2; they were nice and moved slowly next time they took care of her. Resident (A) reported the staff members may just have needed education on how to care for them. Resident (A) was assessed by a registered nurse (RN) and an open area was observed to their left hip and a scab to the left knee. The resident was provided treatment. The facility’s investigation did not determine if the wounds were directly related to the allegation or were pre existing. The record review showed resident (A) declined to use a Hoyer (mechanical) lift for transfers and repositioning based on their care plan. Both staff #1 and #2 said resident (A) was difficult to move in the bed due to the resident’s claims of increased pain at night, refusal of the Hoyer lift and the resident curled up when being repositioned making care difficult. The facility was unable to substantiate the allegation of physical abuse based on their findings and determined the staff members were meeting the resident’s need for care to the best of their ability. Resident (A)’s medications were reviewed and adjusted for pain relief and mood. The facility reported resident (A) will receive care in pairs. Both staff members were provided education regarding the resident’s specific care needs. All staff were educated regarding the resident’s care needs. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/27/2024 · released to the public 12/4/2024.

4/16/2024Neglect · ID 2402R989015Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/16/24, resident (A) reported staff #1 did not provide incontinence care to her or her roommate (resident B) when requested. Resident (A) reported they had not been changed in 3 hours and that they intentionally waited for someone else to help. Resident (A) said s/he did not trust staff #1 to take care of their toileting needs. This allegedly placed both residents at potential risk for harm. Staff #1 was immediately removed from returning to the facility pending the outcome of the investigation. Both residents were assessed and no injuries or behavioral changes were observed. The record review showed resident (A) was dependent on staff for toileting. Resident (B)’s toileting status was unknown; however the record review showed resident (B) had called on their call light for help due to having diarrhea. Staff #1 said they did provide toileting and incontinence care to both residents when they asked for it. Resident (B) said they told staff #1 s/he had to go to the bathroom and staff #1 told them they did not have to go and left the room. Resident (B) said s/he had an accident in their adult brief in bed and staff #1 responded to their call for assistance an hour later. The facility was unable to substantiate the allegation of neglect based on inconclusive evidence. The facility reported that staff will provide care in pairs to ensure residents needs are being met. Staff #1, an agency employee, was not allowed to return to the facility. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/27/2024 · released to the public 12/4/2024.

4/14/2024Physical Abuse · ID 2402R989013Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 4/14/24 resident (A) stated resident (B) entered her room and as she was trying to exit and she was slapped in the face by resident (B). No visible injury was seen however resident (A) stated her forehead was hurting but went away. Staff notified the police. Resident (B) has cognitive impairment with memory loss. Resident (B) could not recall the incident. Staff member (1) saw resident (A) pushing resident (B) out of her room, and resident (A) stating she was hit by resident (B). The facility investigation concluded there were no witnesses and the allegation of abuse was not substantiated. To help prevent a recurrence, resident (A) has a stop sign velcroed to her doorway to help stop other residents from entering into their room. Resident (B) had frequent checks implemented and will be redirected when wandering. Resident (B)’s plan of care was updated to help with her being in others' space and their belongings. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 12/4/2024 · released to the public 12/11/2024.

4/13/2024Physical Abuse · ID 2402R989012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/13/24 staff responded to a call light and found resident (B) on the floor leaning on the bed of resident (A). Reportedly, resident (B) was angry at resident (A) due to their television being on and they went over to get them to turn it off. Both residents then began a physical altercation with resident (B) allegedly provoking the incident. Both residents were observed to have injuries from the altercation. Staff separated both residents and removed resident (B) to another area of the facility and implemented 15 minute checks. Resident (A) was assessed and provided first aid for their injuries. S/he said they acted in self-defense. The facility substantiated physical abuse based on their findings. Both residents' care plans were updated and psychosocial support was offered. To help prevent a recurrence both residents were provided education to reach out to staff before things get out of hand. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/27/2025 · released to the public 2/3/2025.

4/3/2024Physical Abuse · ID 2402R989011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/3/24, as two residents passed one another in the hallway, resident (A) abruptly stopped and looked at resident (B). Resident (A) then lifted an object from his lap and hit resident (B), which struck her on the right side of her head. Staff intervened to separate the residents. Resident (B) had a cognitive impairment and was unable to participate in a follow up interview about the incident. No visible injuries were observed. Staff reported the act was unprovoked. As witnessed, the facility substantiated the report of resident (A) striking resident (B) after becoming triggered for an unknown reason. Resident (A)’s care plan was updated to reflect potential triggers of agitation for staff awareness. Education to staff was conducted immediately about safety devices needing to be stored unless using a resident was utilizing it properly. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/20/2025 · released to the public 1/27/2025.

4/1/2024Physical Abuse · ID 2402R989010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/1/24, a bruise of unknown origin was found on a resident’s hand. When alerting the resident’s power of attorney, they alleged staff mishandled the resident resulting in bruising. There was an allegation of staff abuse for the resident, who was dependent on staff assistance with mobility and care needs. The resident denied the allegation of being mishandled. Staff reported they have witnessed the resident reach out more often, strike the wall or other objects as a potential source of the bruise. The facility investigation concluded the allegation of mishandling could not be substantiated as a source of the bruise. Management implemented care in pairs. Interventions were put in place to help improve skin integrity and decrease the risk of future bruising. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/9/2025 · released to the public 1/16/2025.

3/27/2024Physical Abuse · ID 2402R989008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/27/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported an alleged physical abuse event involving client (A). During the course of the investigation, the healthcare entity reported client (A) alleged staff had been abusing her and hurting her when providing care. She reported staff do not listen to client requests and her staff preferences are not being honored. Cares in pairs were implemented as well as education to her change in condition including increased pain and preference against male caregivers. Hospice notified and completed visit to evaluate pain and unmet need. During a follow up interview, client (A) denied abuse but said at times, care interventions were painful or “jerky.” The care plan was revised to address her needs. Staff received education on the best approach when working with client (A). The facility did not substantiate the event. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/11/2025 · released to the public 2/18/2025.

2/20/2024Physical Abuse · ID 2402R989006Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 2/9/2025 · released to the public 2/16/2025.

12/16/2023Physical Abuse · ID 2302R989046Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 12/16/23, a visitor notified staff (1) that a Resident entered a room that was under construction. The CNA entered the room and per witness account, they used the wheelchair handles to assist the Resident out of the potentially unsafe environment. During this time, the resident showed signs of agitation with physical aggression and made verbal threats of harm towards the CNA. The resident then entered his room and the CNA left the area to get cleaned up and to allow resident time to de-escalate. Later, the Resident came out of their room with scratches to their face alleging the CNA had abused him. AGENCY/FACILITY ACTION: The facility conducted an internal investigation and notified the police, physician, family and ombudsman. The CNA was immediately suspended pending the investigation. The Resident was placed on 15 minute checks to ensure safety from harm and the room under construction was cleared of potential hazards. The resident was assessed and found to have had scratches to his right cheek. Blood and skin were observed underneath the Residents fingernails. The injury was cleansed and treated with first aid. The Resident stated he went into the closed room and the CNA told them they could not be in there. The resident reported the CNA started hauling them out by pulling on the wheelchair and then on their neck. The resident's account of the event did not match the witness or staff member's statements. Other residents were interviewed with no concerns noted. A chart review showed the Resident had a recent gradual dose reduction of his psychotropic medication which had been deemed a failure due to increased delusions. The facility concluded the allegation of Physical Abuse was unsubstantiated based on interview and superficial wounds that seemed to be self-inflicted. The facility reported the resident had a history of making unsubstantiated claims of abuse allegations against staff. Interventions put into place to help prevent a recurrence included staff education regarding securing rooms under construction. The staff member who left the room unsecured was counseled. Management implemented an auditing tool for staff compliance with securing rooms. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the facility. This public summary is based on information provided by the facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. The occurrence report was submitted within the required timeframe. The facility complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department. Prior to the next onsite investigation of the facility, this occurrence will be reviewed by the State Agency.

11/15/2023Physical Abuse · ID 2402R989002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE:On 1/4/24, resident (A) reported to his psychologist an incident of physical abuse that allegedly occurred on 11/15/23. He reported being fearful. Reportedly, staff #1 placed their hands on resident (A) and pulled him out of his room and then called the police to have them threaten him. Resident (A) said there was a witness to this incident. AGENCY/FACILITY ACTION:The facility conducted an internal investigation and notified the police, physician, family/guardian and ombudsman. Staff #1 was suspended pending the outcome of the investigation. Resident (A) was interviewed and he reiterated that staff #1 had laid hands on him trying to pull him out of bed and get him to move across the hall. He said this action made him fearful. Staff #1 was interviewed and they denied putting hands on resident (A). They said at the time of the alleged event the resident was refusing to have his room deep cleaned and there was a concern of a potential bug infestation. Staff #1 said they were concerned this could possibly affect other residents. Staff #1 said they did call the police for support and to see what other options were available to convince resident (A) to allow deep cleaning of his room to occur. They said they did not tell the police to threaten patient (A). The record review showed additional residents were interviewed as well as staff to confirm their knowledge of abuse reporting. Staff present on the date of the alleged event were interviewed including staff #2 that allegedly witnessed the interaction between resident (A) and staff #1. No staff confirmed seeing, hearing or witnessing any abuse by staff #1 towards resident (A). The facility reported resident (A) had reported similar allegations against staff in the past and these events were unsubstantiated. The facility was unable to substantiate the allegation of abuse based on their findings. Staff #1 was allowed to return to work duty. Resident (A) will continue to receive psychological services for support. Staff will provide care in pairs and staff were re-educated about this to reinforce the importance of this approach. Additionally, resident (A) met with an outside visitor assigned to advocate for the residents regarding a temporary room move. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency.

11/14/2023Neglect · ID 2302R989042Reported on time: Yes▼

Occurrence summary

Summary of Findings: On 11/14/23, during a community outing, resident (A) ended up rolling down a ramp while in her wheelchair, which resulted in a fall out of the wheelchair. Reportedly, staff (1) left the resident (A) unsupervised while attending to another resident matter. Resident (A) had a moderate cognitive impairment. She was transferred to the hospital for an evaluation and diagnostic results showed a possible rib fracture, elbow abrasion/bruising and chest abrasion. Treatment was provided and she returned to the facility. Resident and staff reports indicated staff (1) ensured the resident’s wheelchair brakes were locked, secured her in a safe place at the top of the ramp, and she was directed to please wait until they returned to assist. Within an estimated timeframe of five minutes and staff (1)’s absence, resident (A) unlocked her brakes and rolled over to throw a cup away, which resulted in her rolling down the ramp. In addition, there was a miscommunication between staff so at the time, only one staff member was present to assist several residents at one time. Staff involved received a disciplinary action for their parts in failure to prevent this accident from happening. Education was provided to staff regarding the expectation to maintain direct supervision of all residents and ensuring effective communication between staff occurred. Systemic changes were made to activity programs and resident safety to help prevent a recurrence. Department Findings: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency.

Publication

Sent to facility 10/9/2024 · released to the public 10/16/2024.

10/26/2023Verbal Abuse · ID 2302R989040Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/26/23, Resident A in her 70’s was attempting to use the phone when she accidently pulled the cord from the phone. Staff #1, an agency staff member, raised her voice and told Resident A she was required to pay $80 for breaking the phone. Resident A was tearful, worried and anxious following the incident. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian and physician. Resident A was removed from the area and Staff #1 was suspended pending the outcome of the investigation. Resident A stated she did not understand Staff #1’s reaction when the cord came out of the phone. Resident A stated that during the altercation, Staff #1 was yelling: it scared her and made her uncomfortable. Resident A stated she was not sure why she owed her money. Staff #1 confirmed s/he had told Resident A s/he owed money for the phone, but denied raising their voice and said s/he was joking with the resident. Staff #2 who witnessed the altercation, stated Staff #1 had raised their voice and was yelling at Resident A in a tone of voice that was not jovial. From the investigation, the facility substantiated the allegation of Staff #1 had verbally abused Resident A. To help prevent a recurrence, the facility will assist Resident A with phone calls as needed. Staff #1 was removed from the schedule and placed on the do not return list. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 12/28/2023 · released to the public 1/4/2024.

10/12/2023Verbal Abuse · ID 2302R989039Reported on time: Yes▼

Occurrence summary

Summary of Findings: On 10/12/23, staff (1) alleged staff (2) raised their voice at resident (B) while pointing a finger in their face stating, “go ahead and hit me and I’ll call the police.” Staff (1) reported resident (B) made no attempt to hit staff (2). Management suspended staff (2) and notified the police. Resident (B) exhibited signs of distress following the interaction and reported being confused as to why staff (2) treated him poorly and threatened him. He reported feeling unsafe when staff (2) worked. Staff (2) denied threatening the resident and said they were pointing to the television area to redirect him. From the facility investigation, management concluded the allegation of verbal abuse was substantiated. Staff (2)’s employment was terminated. Resident (B)’s care plan was updated to reflect potential triggers of Post-traumatic stress disorder. Department Findings: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 8/5/2024 · released to the public 8/12/2024.

10/10/2023Sexual Abuse · ID 2302R989037Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/1/23, staff observed two residents together in a common area where male resident (A)’s private parts were exposed to female resident (B), who was sitting in front of him. At the time, the staff did not witness any physical contact but resident (A) was allegedly encouraging resident (B) to touch his private parts. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, and families/guardians. Staff intervened to separate the residents and started 15-minute safety checks. Resident (B) had a severe cognitive impairment with a reported history of thinking male residents are her husband. She did not recall the incident but indicated the other resident was a good guy. Staff reported she was not exhibiting signs of distress. Initially, resident (A) denied exposing himself but then admitted to his actions. From the facility’s investigation, an allegation of sexual abuse could be neither substantiated nor unsubstantiated. Resident (B) was moved to a different unit. Management provided education to resident (A) regarding sexual boundaries, privacy options, and asked him to sign a behavioral contract, which was signed. Staff monitoring continued per their individual plans of care. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 7/8/2024 · released to the public 7/8/2024.

10/1/2023Physical Abuse · ID 2302R989036Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/1/23, a resident reported to the nurse she was experiencing vaginal pain and alleged a staff member intentionally “pinched or poked” her down there. The resident did not have a cognitive impairment and reported having difficulties urinating due to the pain. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian and physician. The staff member was removed from the work schedule during the investigation. A nurse assessed the resident and no bruising or redness was observed. The pain resolved and she was able to urinate. Management requested staff provide care in pairs. With follow up interviews, the facility reported the resident’s statement changed about how the staff member might have caused her pain. The staff member said they were adjusting the resident’s incontinent brief when she yelled out that she had been pinched and it hurt. The staff member denied an allegation of intentionally hurting the resident but noted the resident had been upset. Other residents, whom received care from the staff member, voiced no concerns about their care. From the findings, the facility could not substantiate the resident’s allegation of the staff member intentionally hurting the resident. It was possible the staff member inadvertently scratched the area when adjusting the brief. A therapy referral was requested to help the resident with hygiene needs. Staff continued to provide care in pairs and planned to encourage the resident to perform self-care as much as possible. The staff member returned to work. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 7/8/2024 · released to the public 7/8/2024.

9/17/2023Physical Abuse · ID 2302R989034Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 9/17/23, a resident, in her 80s, reports she was sleeping in her room when an agency nurse entered her room and started shaking her. The resident reported experiencing pain as a result. The resident said she told the nurse to stop causing her unnecessary pain and alleged the nurse started shaking her again. She thought the nurse shook her again to show her it did not hurt. She also alleged the agency nurse verbally abused her by calling her prejudice. She asked the nurse to leave and refused her medications. The resident had no cognitive impairments. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and physician. Management blocked the agency nurse from picking up additional shifts. A facility nurse assessed the resident and found no visible injuries. She had no current complaint of pain. During a follow up interview with the agency nurse, they reported touching the resident’s arm to wake her up for medications. The nurse noted the resident got upset and started screaming at them to stop pulling on her. They denied making any derogatory comments. The nurse denied the resident’s allegations and reported leaving the room to request help from facility staff. The resident eventually took her medications from another staff member. No other residents reported any concerns about this nurse. From the findings, the facility could not substantiate the resident’s allegations due to conflicting statements. Management requested staff to provide care in pairs and to speak her name if they needed to wake her up. The agency nurse did not return. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/27/2023 · released to the public 12/4/2023.

7/30/2023Physical Abuse · ID 2302R989027Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 7/30/23, nurse (1) was administering medications to resident (A), who was seated in his wheelchair. Another resident (B) was close by in his wheelchair. Resident (A) asked resident (B) if he could move in a polite manner. Resident (B) moved closer to resident (A) and struck him in his face. Resident (A) sustained a laceration to his left eyebrow. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families, and physician. Both residents were immediately separated from each other. Resident (A) was provided treatment for his cut. Resident (B) refused to give a statement about his actions. The facility investigation concluded resident (B) purposefully struck resident (A) out of anger, and the act was unprovoked. Staff started 15-minute safety checks on resident (B) to help keep other residents safe. Staff requested a medication review for resident (B) due to his aggression. In addition, management discussed the need to seek an alternate placement for resident (B) that was a more appropriate setting. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 6/10/2024 · released to the public 6/17/2024.

7/16/2023Neglect · ID 2302R989020Reported on time: No▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 07/16/23 a female resident, in her 80s, was noted to have slight discoloration to the bridge of her nose. She had no reported injury or fall. On 07/18/23 the resident's daughter expressed concern and though that "someone was not telling everything". FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and family/guardian. The resident was not able to say how the injury occurred due to her cognitive status. The resident was assessed and had discoloration to the bridge of her nose and left eye. The resident was on hospice care and had very thin, fragile skin. Staff were interviewed. It was determined that a staff member turned the resident for a check/change while the resident had her glasses on and the discoloration aligned with the glasses. The discoloration came on very slowly. No abuse or neglect was substantiated. Staff were educated to remove the resident's glasses prior to care. A mat that aligns the wall next to the resident's bed was placed for extra padding. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/13/2023 · released to the public 11/20/2023.

7/9/2023Physical Abuse · ID 2302R989018Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 7/9/23, there was a report of resident (A), in his 70s, striking two other female residents. Resident (B) complained of pain. Staff intervened and separated the residents. As resident (A) remained agitated and aggressive, a decision was made to send him out to the hospital for an evaluation. He told staff he got upset because he wanted to get out of the unit. The incident occurred in the memory care unit. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. A nurse assessed the other two female residents and no visible injuries were observed. Resident (B) had no current complaint of pain. Staff reported they were providing 15-minute safety checks when he struck both victims within seconds. The act was unprovoked. The facility substantiated the allegation of resident (A) striking others when he was agitated. Resident (A) did not return, and he was discharged home with family. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/16/2023 · released to the public 11/23/2023.

6/22/2023Missing Person · ID 2302R989017Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/22/23 around 3:45 a.m., staff discovered a resident, in his 70s, missing from the facility. He was newly admitted to the facility less than 24 hours and had a diagnosis of dementia. Staff last saw him around 2 a.m. during a bed check. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and physician. Staff started an internal search of the facility and grounds. When he could not be found on campus, staff expanded the search area, and he was located one block away at 5:20 a.m. Staff observed minor scratches to his right elbow and face. First aid treatment was provided, and he was transferred to the hospital for an evaluation. Lab results showed the resident had a urinary tract infection, which appeared to be contributing to his confusion. Antibiotics were started, and he returned. After discussing a safety plan, a wanderguard alarm bracelet was placed that would trigger an alarm if he attempted to exit the building again without staff awareness. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 9/25/2023 · released to the public 10/2/2023.

4/23/2023Physical Abuse · ID 2302R989011Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 4/23/23, there was a report of resident (A), in her 80s, entering resident (B)’s room without permission. Resident (A) allegedly started going through resident (B)’s personal belongings and attempted to empty a basket of items. Resident (B), in her 70s, yelled at resident (A) to stop. In response, resident (A) allegedly pulled resident (B)’s hair and bit her on the arm, which left a red mark. There were no staff witnesses. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. Staff separated the residents and started direct monitoring of resident (A). A nurse assessed resident (B) and observed a red mark on her arm. First aid treatment was provided. Resident (A) had a cognitive impairment and was unable to participate in a follow up interview. She was ambulatory and had a history of claiming other resident personal items as her own. From the findings, the facility concluded that resident (A) was not aware of her actions, but the two residents reacted to the situation. Management issued a 30-day discharge notice to resident (A) as staff are recommending an alternate placement. A care conference occurred for resident (A) and her case manager to discuss the discharge plan. While she remained in the facility, direct staff monitoring remained in place. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/15/2023 · released to the public 11/22/2023.

3/20/2023Physical Abuse · ID 2302R989007Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 3/20/23, there was a report of resident (A), in her 80s, striking resident (B) across the eye, after resident (B), in her 70s, backed her chair into resident (A). Resident (B) had accidentally run into resident (A)’s wheelchair which caused resident (A) to say, “ouch.” Staff intervened and separated the residents. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, and physician. A nurse assessed both residents and found no visible injuries. Additional monitoring was started. Both residents had a severe cognitive impairment and were unable to participate in a follow up interview. From the findings, the facility concluded resident (A) reacted by striking out when resident (B) accidentally backed her wheelchair into resident (A). There was no visible injury. A decision was made to move resident (A) to a new unit. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 9/29/2023 · released to the public 10/6/2023.

2/13/2023Physical Abuse · ID 2302R989004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 2/13/23, there was a report of resident (B), in his 70s, entering resident (A)’s room and they started exchanging words. Resident (B) then pushed past resident (A), in her 80s, to exit the room. She fell into the closet door as he pushed her, and then she hit him across the face causing a scratch to his face. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, and physician. Staff separated the residents and provided additional monitoring. First aid treatment was provided to resident (B). Both residents have dementia and resided in the memory care unit. The facility concluded both residents reacted to one another’s actions, which resulted in resident (B) suffering a superficial facial scratch. Following the event, a medication review occurred for both residents. Staff continued monitoring them per their individualized plans of care. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 9/1/2023 · released to the public 9/8/2023.

1/22/2023Physical Abuse · ID 2302R989002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/23/23, a resident, in her 80s, reported that while a staff member took her blood pressure, her arm was squeezed too hard causing discoloration of her skin. At the time, the resident did not report this as intentional. Three days later, the resident alleged the staff member knew it was hurting her arm and continued with the blood pressure check anyways. She then said the staff member pulled her arm during the check. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and physician. Management removed the agency staff member from the work schedule. A nurse assessed the resident and observed the discoloration on her forearm. The discoloration was directly where the automatic blood pressure cuff was used. No other residents reported having any concerns about the staff member or rough handling. The facility reported the resident was on blood thinners that increased her risk of bruising. Staff said there have been no previous issues with using the cuff when taking her blood pressure. From the facility findings, the facility concluded the allegation of physical abuse could neither be substantiated or unsubstantiated. There were no findings of intent or reckless handling. A decision was made to stop the agency’s staff members work contract. Staff was educated not to use the automatic blood pressure cuff with this resident. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 8/15/2023 · released to the public 8/22/2023.