32
Inspections
34
Deficiencies
2
Actual Harm or Above
24
Occurrences
July 8, 2026
Last Inspection
S/S D/E/F Potential for harmS/S G Actual harm
The most recent inspection of AVIVA AT FITZSIMONS on record is dated July 8, 2026. Across 32 published inspections, state surveyors cited 34 deficiencies, 2 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 (Medicare Only)
Administrator
Doiel, Lindsey Kristine
Owner
MSV FITZSIMONS, LLC
Phone
(303) 344-8282
Payor Source
Medicare, Private Pay
City
AURORA
ZIP
80045-7450
Inspections & Citations
32 inspections · 34 deficiencies7/8/2026Complaint Survey · ID 25CD92-H11 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO3026176, #CO3032348, #CO3066190, #CO3066676, #CO3069089 and Incident 3073095 was conducted on 7/6/26 to 7/8/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0580Notify of Changes (Injury/Decline/Room, etc.)▼
Findings
Based on record review and interviews, the facility failed to notify the resident’s provider when there was a significant change in the resident’s condition for one (#4) of four residents out of 12 sample residents. Specifically, the facility failed to notify the resident’s provider for Resident #4 when he had a change in blood pressure from his baseline. Findings include: I. Facility policy and procedure The Change in Resident Condition policy, revised 2/29/24, was received from the nursing home administrator (NHA) on 7/8/26 at 12:48 p.m. It documented in pertinent part, “A facility must immediately inform the resident; consult with the resident’s physician; and if known, notify the resident’s legal representative or an interested family member when there is a significant change in the resident’s physical, mental, or psychosocial status ( a deterioration in health, mental, or psychosocial status in either life – threatening conditions or clinical), a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) or a decision to transfer or discharge the resident from the facility.” II. Resident #4A. Resident status Resident #4, age 68, was admitted on 6/9/25. According to the July 2026 computerized physician orders (CPO), the diagnoses included metabolic encephalopathy (brain dysfunction caused by chemical imbalances or system illness), tracheostomy, quadriplegia (paralysis causing loss of function to parts of the body) and cognitive communication deficit. The 6/8/26 minimum data set (MDS) assessment revealed the resident had cognitive impairment with a short term and long term memory problem. He was dependent on staff with all activities of daily living. B. Observations Resident #4 was observed on 7/6/26 at 1:10 p.m. laying in bed with his feet elevated and head of bed up. He had tube feeding running through his gastrostomy tube. C. Record review A review of nursing progress notes from 5/19/26 included the following:A nursing progress note on 5/19/26 at 3:00 p.m. documented a series of events that occurred on 5/19/26. At 6:30 a.m. Resident #4’s blood pressure was 69/40 millimeters of mercury (mmHg) . The on-call provider was called and there was a new order to give 150 milliliters (ml) of free water, give scheduled Midodrine (medication to raise blood pressure) and recheck the blood pressure in one hour. The note documented the resident was not at baseline with regards to eye movement. The resident was usually able to track staff with his eyes and also blink yes and no. The note documented the resident was not currently normally responding. At 7:45 a.m. Resident #4’s blood pressure was 69/42 mmHg. At 9:00 a.m. the pulmonologist, physician assistant and the director of nursing (DON) made rounds and assessed the resident. -However, the pulmonologist and physician assistant reviewed the residents respiratory status and was not aware of the change in blood pressure (see interviews below). At 10:30 a.m. Resident #4’s blood pressure was 75/42 mmHg with no change in mentation. At 10:40 a.m. there was a new order to place a peripheral intravenous (IV) line and start normal saline at 100 ml/hour for a total of one liter. An IV was attempted to the right hand without success. At 10:55 a.m. an outside company to place IV lines was notified to place IV. At 11:15 a.m. scheduled Midodrine 20 milligrams (mg) was given. At 11:30 a.m. the assistant director of nursing (ADON) was notified of the regimen that was ordered. At 12:00 p.m. the IV nurse was present and placed a 22 gauge IV in the right forearm with ultrasound guidance. At 12:15 p.m. the IV fluids were started. At 12:30 p.m. Resident #4’s blood pressure was 81/42 mmHg. At 1:30 p.m. Resident #4’s blood pressure was 72/38 mmHg and the nurse notified Resident #4’s wife of the new orders. At 2:30 p.m., Resident #4’s blood pressure was 75/72 mmhg. At 2:40 p.m. Resident #4’s wife was presentand spoke with the physician assistant. At 2:45 p.m. there was a new order to send the patient out to the emergency room for evaluation. -The facility staff failed to notify Resident #4’s provider of the change in blood pressure at 7:45 a.m., which was two hours after the resident’s blood pressure continued to be below his baseline. A progress note by physician assistant on 5/19/26 at 1:00 p.m. documented a follow up for hypotension, anisocoria (unequal pupil sizes) and a concern for a stroke. The resident was seen and assessed laying in bed. Resident #4 was seen by the pulmonologist that morning who did not note any pulmonary concerns. The nurse reported hypotension, administeredMidodrine 20 mg, but the resident was persistently hypotensive at 80/48 mmHg. The patient was maxed out on Midodrine and remained severely hypotensive at 76/48 mmHg. On exam, the resident did not have reactive pupils, aniscoria, the left pupil was contracted and the right pupil was dilated. The resident did not track and was not responsive. He was a full code. The note documented they would push IV fluids and discuss the resident’s status with the wife who wanted the resident to remain a full code. The resident was sent to the emergency room for evaluation and treatment. D. Staff interviews Certified nursing aide (CNA) #1 was interviewed on 7/7/26 at 2:35 p.m. She said she was responsible for getting vital signs in the evening. She said she has a reference range for normal vital signs and if they are outside of the range, she reported the vital signs to the nurse right away. Registered nurse (RN) #1 was interviewed on 7/7/26 at 2:40 p.m. She said when a resident had a change in condition, she completed vital signs and completed an assessment. She said she would get in touch with a provider to communicate the abnormal findings, notify the resident’s representative and follow any new orders from the provider. She said a low blood pressure could lead to fainting, poor perfusion and unresponsiveness. She said a low blood pressure would be considered and change in condition and she would follow the facility’s procedure. Licensed practical nurse (LPN) #1 was interviewed on 7/7/26 at 2:45 p.m. She said if a resident has a systolic blood pressure in the 60 to 70’s, it meant the heart was not pumping adequately and the cells and organs in the body were not getting adequate oxygenation. She said she would immediately reach out to the provider for orders to address the low blood pressure. The physician assistant and the regional nurse consultant #1 were interviewed together on 7/6/26 at 5:24 p.m. The physician assistant said the morning of 5/19/26, she rounded with the pulmonology doctor starting at 9:00 a.m. She said the pulmonologist assessed Resident #4 and had no concerns regarding his pulmonary status. The physician assistant said nobody had mentioned any episode of hypotension to her. The physician assistant said she had access to the on call triage notes and she did not look at Resident #4’s notes from 5/18/26 or 5/19/26 before she got to the facility. She said she usually looked through these notes before rounding and she dropped the ball on this one. The physician assistant said she was notified of the hypotensive episodes shortly after 10:00 a.m. (two hours after the resident had a change in baseline blood pressure) and ordered IV fluids. The physician assistant said she assessed Resident #4 and was worried about a stroke so they decided to send him out to the emergency room for further evaluation.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH THE STATE OPERATIONS MANUAL.
1. Resident #4 was assessed on 5/19/26 by the pulmonologist at 9:00 a.m. and was found to be at baseline. Later in the morning, the physician assistant reassessed him after a change in condition and ordered a transfer to the emergency department for further evaluation and treatment. The resident’s responsible party was notified of the resident’s change in condition, new treatment orders, and transfer to the emergency department. The nurse involved received education on 7/8/26 by the DON (director of nursing)/designee regarding immediate provider notification for significant changes in condition, including persistent hypotension. 2. Residents with changes of condition have the potential to be affected by the alleged deficient practice. The DON/designee completed a whole house audit of residents with documented changes in condition during the previous 30 days. No concerns were identified. The provider and resident representative were notified when clinically indicated, and documentation was completed or clarified as appropriate. 3. Licensed nurses were educated starting on 7/8/26 by the DON/designee on the facility’s Change in Resident Condition policy. Education included the following: A significant change in condition requires immediate nursing assessment and timely provider consultation. The provider must be directly notified of pertinent findings. The nurse may not assume the provider is aware because the provider is present in the building, completing rounds, or has access to the electronic medical record. Persistent abnormal findings require repeat provider notification, even when the provider was notified of the initial finding. A nurse must notify the provider when the resident does not respond to the ordered intervention or when the resident’s condition continues to deteriorate. Licensed nurses were also educated to use the SBAR (Situation, Background, Assessment, Recommendation) when reporting changes in condition to the physician/extender. Education to be completed PRN (as needed). CNA (certified nurse aide) staff were reeducated starting on 7/8/26 by the SDC (staff development coordinator)/designee to immediately report abnormal vital signs, changes in responsiveness, changes in behavior, changes in breathing, and other deviations from baseline to the licensed nurse. Education to be completed PRN. The DON/designee will audit five residents with changes in condition weekly for one month, then monthly for two months to verify timely provider and resident representative notification. Any identified concerns will result in immediate corrective action, additional staff education, and progressive disciplinary action when appropriate. 4. The DON/designee will report findings from the audits to the QAPI (quality assurance performance improvement) Committee monthly for 90 days. The QAPI committee will identify any trends and take corrective action as needed.
7/8/2026Licensure Complaint Survey · ID 25CD93-H1No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A survey with #CO3026178 was completed from 7/6/26 to 7/8/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/19/2026Complaint Survey · ID 232881-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2788008, #CO2998257 and #CO2999037 was conducted on 5/18/26 to 5/19/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
5/19/2026Licensure Complaint Survey · ID 232883-H1No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A survey with #CO2788009 was completed on 5/18/26 to 5/19/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
8/26/2025Complaint Survey · ID 1D1AB3-H11 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2568031, #CO2582639, #CO2595054 and Incident #2599642 was completed on 8/25/25 to 8/26/25. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0689Free of Accident Hazards/Supervision/Devices▼
Findings
Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 10 sample residents remained free from accidents. Resident #1 was admitted to the facility on 8/1/25 with diagnoses of history of falling, a fracture of the left ilium (upper part of the pelvis), atrial fibrillation (AFIB), hypertension (high blood pressure) and dementia. Resident #1 had severe cognitive impairments and required maximum assistance from staff. On 8/13/25 at approximately 4:30 p.m. Resident #1 was seated at the nurses’ station where he sustained an unwitnessed fall. Resident #1 was assessed by a registered nurse (RN) and was assessed to have no injuries. After the fall, the staff assisted Resident #1 in his wheelchair back to the nurses’ station. Certified nurse aide (CNA) #2 assisted Resident #1 to his room. CNA #2 and another CNA assisted him into his recliner. At this time the resident’s representative walked into the room and observed Resident #1’s right foot was turned inward at a 90 degree angle. Resident #1 was additionally screaming out in pain. The hospice nurse arrived at the facility around 9:00 p.m. and called emergency services (EMS). Resident #1 was sent to the hospital where he was diagnosed with a closed displaced comminuted fracture of the shaft of the right femur, sequela (broken into three or more pieces) and a right femoral diaphyseal fracture (a break in the shaft of the right thigh bone often caused by high-energy trauma). The facility conducted an investigation on 8/14/25. Video footage revealed that CNA #2 propelled Resident #1 without foot pedals. While CNA #2 was propelling Resident #1, the resident’s right foot got stuck on the carpet under the wheelchair and CNA #2 continued to push him. Specifically, the facility failed to ensure CNA #2 propelled Resident #1 correctly in his wheelchair, which resulted in Resident #1 sustaining a fracture to his right femur. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 8/25/25 to 8/26/25, resulting in the deficiency being cited as past noncompliance with a correction date of 8/15/25. I. Incident on 8/13/25The facility investigation, dated 8/14/25, revealed Resident #1 sustained a fracture to his right thigh on 8/13/25. The investigation revealed while Resident #1 was being transported in his wheelchair by CNA #2, Resident #1 did not have the leg rests on his wheelchair. During video observation of the incident, video footage revealed while being assisted to his room in his wheelchair, the resident’s foot was caught twice on the carpet, causing leg fractures. The fractures were not caused by a fall. The hospital records revealed Resident #1 had a closed displaced comminuted fracture of the shaft of the right femur, sequela. The investigation documented that on 8/14/25 the nursing home administrator (NHA) reviewed the video footage from 8/13/25. The video footage revealed CNA #2 was escorting Resident #1 from the nurse’s cart back to his room. The video revealed CNA #2 was pushing Resident #1 in his wheelchair without the foot pedals in place. The video footage revealed that two different times, Resident #1’s right leg went under the wheelchair as CNA #2 pushed his wheelchair. Each time Resident #1’s leg went under the wheelchair, CNA #2 only momentarily backed the chair up to get his leg moved from where it was stuck on the carpet before the wheelchair was pushed again. Resident #1 grabbed his right thigh and his face was grimaced in pain. II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #1On 8/13/25 Resident #1 was sent to the hospital for an Xray based on a decision by the hospice nurse and Resident #1’s power of attorney (POA). On 8/14/25 Resident #1 had surgical intervention for his fractured right leg. On 814/25 CNA #2, who propelled Resident #1 in his wheelchair, was suspended and later terminated. CNA #2 had no contact with any residents after the shift of 8/13/25 through 8/14/25. B. Identification of other residentsAn audit was initiated by the therapy department on 8/14/25 and was completed by 8/15/25. The audit identified if any residents had missing foot pedals and no concerns were identified. C. Systemic changesAn education was initiated by the director of nursing (DON) on 8/15/25 with the facility’s CNAs regarding wheelchair mobility instructions. On 8/23/25 the same education was ongoing to other staff disciplines. The education was ongoing until (all) staff was trained. The DON/designee was to complete weekly observations of three residents who should have foot pedals available for use when in a wheelchair for 90 days. Identified concerns were to be addressed with staff. D. MonitoringThe DON/designee would report findings from the audits as well as any fractures related to mobility assistance to the quality assurance and performance improvement (QAPI) committee monthly for 90 days. The QAPI committee would identify any trends and take corrective action as needed. III. Facility policy and procedureThe Accidents and Incidents - Investigating and Reporting policy, revised 2017, was provided by the NHA on 8/26/25 at 12:53 p.m. via email. It revealed in pertinent part,“All accidents or incidents involving residents, employees, visitors, vendors occurring on our premises shall be investigated and reported to the administrator.“The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.“Incident/accident reports will be reviewed by the QAPI committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.”IV. Resident #1A. Resident statusResident #1, age greater than 65 ,was admitted on 8/1/25 and discharged to the hospital on 8/13/25. According to the August 2025 computerized physician orders (CPO), diagnoses included a history of falling, a fracture of the left ilium, AFIB, hypertension and dementia. The 8/5/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of two out of 15. He did not reject care from staff. He required maximum assistance with bathing, and transferring from his bed to a chair or wheelchair. He was dependent on staff for oral hygiene, toileting and dressing. The resident was receiving hospice care. B. Resident #1’s representative interviewResident #1’s representative was interviewed via the phone on 8/26/25 at 10:28 a.m. The representative said he visited the resident daily. He said when he came to the resident’s room on 8/13/25 around 6:00 p.m. to 6:30 p.m., Resident #1 was seated in his recliner. He said he could see Resident #1’s right leg was turned inward at a 90 degree angle. He said Resident #1 was screaming out in pain. The representative said he asked the CNA to get the nurse, which she did. The representative said the nurse called the hospice nurse to report Resident #1 had a fall around 4:30 p.m. and now he was in pain and yelling out. The representative said he asked the hospice nurse to call him when she was going to come to visit Resident #1. The representative said he left the facility and the hospice nurse called him around 8:30 p.m. and he returned to the facility. The representative said the hospice nurse gave him three choices for Resident #1, which included Resident #1 could stay in the facility and have his pain managed, he could be moved to the hospice company’s inpatient facility or Resident #1 could go to the hospital for an evaluation. The representative said he was the POA and he made the decision to send Resident #1 to the hospital by ambulance. The representative said while in the hospital, the hospital doctor recommended he either have Resident #1 transferred to the inpatient hospice facility or Resident #1 could have orthopedic surgery on his right leg. The representative said he wanted to give Resident #1 a chance to walk again so the representative selected the surgery for Resident #1. C. Record reviewThe 8/2/25 admission fall risk assessment revealed Resident #1 was a high fall risk. Resident #1 was wheelchair or bed bound, and had one to two falls in the last 90 days. Resident #1 was not able to walk unassisted. The fall risk care plan, dated 8/13/25, revealed Resident #1 was at risk for falls and he had confusion, dementia, impaired balance and limited mobility. He was unaware of safety needs. Pertinent interventions included providing substantial to maximal assistance by two staff members to move the resident between surfaces and providing assistance to activity functions. A risk management review, documented as a late entry progress note on 8/14/25, revealed on 8/13/25 Resident #1 fell and was transferred to the emergency room due to pain in his right leg, per the family request. The 8/14/25 hospital records revealed Resident #1 sustained a closed displaced comminuted fracture of the shaft of the right femur, sequela and a right femoral diaphyseal fracture. The note documented it was reported that the resident slipped out of a wheelchair yesterday (8/13/25) which led to the injury. -However, the facility investigation revealed the fracture occurred due to Resident #1 not being transported correctly in his wheelchair (see facility investigation above). V. Staff interviewsThe NHA, the DON and the corporate consultant (CC) were interviewed together on 8/25/25 at 12:56 p.m. The DON said on 8/13/25 at 8:30 p.m. she spoke to the nurse who assessed Resident #1 after the unwitnessed fall that Resident #1 had at 4:30 p.m. near the nurses’ station. The DON said the nurse told her Resident #1 was assessed, he did not have any injuries and he was assisted back into his wheelchair by two CNAs. The DON said Resident #1 then sat in his wheelchair next to the nurse for about an hour and then CNA #2 assisted Resident #1 back to his room to his recliner. The DON said after 6:00 p.m., the nurse was called to Resident #1’s room. The DON said the nurse saw that his right foot was turned inward and he was in pain. The DON said the nurse then called the hospice company’s phone line. The DON said the facility nurse thought the leg injury was from the resident’s 4:30 p.m. fall. The DON said the nurse was unaware of what was revealed on the video footage the following day (8/14/25). The NHA said the management thought the fall on 8/13/25 at 4:30 p.m. was the reason the resident was in pain. The NHA said the hospital notified her on 8/14/25 that Resident #1 had surgery. The NHA said the staff who worked that day were interviewed by her and the DON. The NHA said she suspended CNA #2 and two nurses pending the investigation outcome. The NHA said CNA #2 did not work with any residents after her shift. The NHA said upon the video footage being reviewed, it was determined that CNA #2 caught Resident #1’s leg under the wheelchair. The NHA said CNA #2 denied what was seen on the video. The NHA said even with telling CNA #2 that what happened to Resident #1 was caught on video, CNA #2 still denied the incident. The NHA said CNA #2 was terminated. The CC said it was determined that Resident #1 did not have his foot pedals on his wheelchair to support his feet and legs when he was transported in his wheelchair by CNA #2. The CC said an in-house audit was conducted to determine what residents needed foot pedals on their wheelchairs. The CC said immediate education began to all of the CNAs on 8/14/25 about wheelchairs that were required to utilize foot pedals being attached during transport. The CC said the education to the CNAs was completed on 8/15/25. The CC said the police department viewed the video footage. CNA #2 was interviewed on 8/25/25 at 4:00 p.m. via telephone. CNA #2 said after Resident #1 was assisted to his recliner, she noticed his right leg wasbent inward and he was in pain. CNA #2 said she informed the nurse. CNA #2 said she believed Resident #1 hurt his leg when he fell at the nurses station at 4:30 p.m. and not when she transported him to his room. The hospice nurse was interviewed on 8/26/25 at 2:30 p.m. via telephone. The hospice nurse said the facility nurse called the hospice company around 6:30 p.m. (on 8/13/25). She said it was determined by the facility nurse and the hospice company that Resident #1 had fallen around 4:30 p.m. The hospice nurse said she arrived at the facility shortly before 9:00 p.m. The hospice nurse said she did not know there was an urgent problem based on the information that was provided to her company from the facility. The hospice nurse said she put her hand on Resident #1’s right thigh and through his pants she could feel a bump. The hospice nurse said she called for an ambulance and when the ambulance drivers arrived, they cut off Resident #1’s pant leg from the bottom of the pants to above the knee. The hospice nurse said the bump above the knee, under the skin on Resident #1’s right thigh, appeared to be a bone. The hospice nurse said the emergency medical services team (EMS) took Resident #1 to the hospital. The NHA was interviewed again on 8/26/25 at 4:00 p.m. The NHA said she believed the facility had proper interventions in place to ensure the safety of all of the residents following the incident with Resident #1.
Plan of correction
The state did not require a plan of correction for this citation.
4/22/2025Complaint Survey · ID 6TG611No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO39693, #CO39694, #CO39724 and #CO39842 was conducted on 4/22/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: Federal Monitoring Survey Survey · ID BOYM22No 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.
Plan of correction
The state did not require a plan of correction for this citation.
3/10/2025Revisit: Recertification Survey · ID MQN322No 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.
Plan of correction
The state did not require a plan of correction for this citation.
3/4/2025Revisit: Complaint Survey · ID 1P0Y12No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit survey was completed on 3/4/25 for all previous deficiencies cited on 1/2/25. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
1/2/2025Complaint Survey · ID 1P0Y111 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A survey prompted by #CO38420, #CO38541, #CO38826 and Incident #38424 was conducted on 12/30/24 to 1/2/25. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0658Services Provided Meet Professional StandardsS/S D▼
Findings
Based on record review and interviews the facility failed to provide services for one (#3) of three residents out of seven sample residents according to professional standards of practice. Specifically, the facility failed to:-Ensure Resident #3 was consistently monitored when having a change in condition; -Follow the physician's orders; and, -Call the provider when Resident #3's blood pressure and heart rate dropped. Findings include:I. Facility policy and procedureThe Change in Resident Condition policy, dated 2/29/24, was provided by the regional clinical resource (RCR) on 12/30/24 at 2:59 p.m. It read in pertinent part, "A facility must immediately inform the resident; consult with the resident's provider; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychological status (deterioration in health in life threatening conditions)."Immediate notification to the provider would include but not limited to: a fall resulting in significant injury, critical lab values, respiratory arrest, acute changes in respiratory status, acute changes in cardiac status, significant change in wound status, significant changes to vital signs, sudden cognitive changes, or any life threatening episode."Document in the resident's medical record the date and time of change of condition, who (physician/family member/responsible party) was notified regarding the condition change, information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, care provided, document the time emergency personnel arrived and took over the care of the resident, if applicable and update the care plan as needed. The Verbal Orders policy, revised February 2014, was provided by the RCR on 12/30/24 at 2:59 p.m. It read in pertinent part, "Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols. "Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. A telephone order is a verbal order given over the telephone. The individual receiving the verbal order must write it on the physician's order sheet as a verbal order or a telephone order. "The individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed, record the ordering practitioner's last name and his or her credentials (MD, NP and PA) and record the date and time of the order. The Charting and Documentation policy, revised July 2017, was provided by the RCR on 1/2/24 at 11:36 a.m. It read in pertinent part: "All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care."The following information is to be documented in the resident medical record including objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the resident and progress toward or changes in the care plan goals and objectives."Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate."Documentation of procedures and treatments will include care-specific details including, the date and time the procedure/treatment was provided, the name and title of the individual(s) who provided the care, the assessment data and/or any unusual findings obtained during the procedure/treatment, how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated and the signature and title of the individual documenting."II. Resident #3A. Resident statusResident #3, age less than 65, was admitted on 1/17/23 and discharged to the hospital on 11/29/24. According to the November 2024 computerized physician orders (CPO), the diagnoses included acute and chronic respiratory failure with hypoxia (an absence of oxygen in the tissues to sustain bodily functions), dependence on oxygen, dependence on a ventilator (a machine that helps you breathe, encounter for attention to a tracheostomy, cerebral palsy, protein calorie malnutrition, chronic atrial fibrillation (irregular heart beat), type 2 diabetes, epilepsy (seizures) and bradycardia (slow heart rate). The 11/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status score (BIMS) of five out of 15. He was dependent on staff for all of his activities of daily living (ADLs). He received oxygen, suctioning, tracheostomy care and ventilator support. B. Record reviewOn 11/29/24 at 1:18 a.m., Resident #3's heart rate was 91 beats per minute (bpm) and his blood pressure was 106/52 millimeters of mercury (mmHg). At 1:39 a.m. the resident's heart rate was 36 bpm and his blood pressure was 131/44 mmHg. At 3:49 a.m. the resident's heart rate was 34 bpm and his blood pressure was 126/39 mmHg. -A review of Resident #3's electronic medical record (EMR) did not reveal any additional documentation indicating the resident's heart rate and blood pressure was taken every 30 minutes per the nurse practitioner's (NP) orders. A NP note, dated 11/29/24 at 12:50 a.m. revealed, the nurse reported that Resident #3 complained of dizziness to the respiratory therapist (RT) and was found to have a heart rate in the 30's. A new order was given for a STAT (immediate) EKG (electrocardiogram), a CBC (complete blood count) in the morning, check the resident's blood pressure and heart rate every 30 minutes until the heart rate was stable above 50 and call back for any changes in condition. -Review of the resident's vital signs from 11/29/24 after the NP was notified indicated the resident's blood pressure continued to drop. Review of the resident's EMR did not reveal documentation that the NP was notified after the resident's blood pressure continued to decrease. A nursing progress note, dated 11/29/24 at 6:52 a.m., documented the RT reported Resident #3's heart rate was in the 30s. The resident was assessed and no distress was noted. Manual palpation of the resident's pulse was 33 to 36 BPM. The resident had a history of cardiac arrhythmias (irregular heartbeat) and was on amiodarone (blood pressure medication). The note documented the nurse called the on-call NP who reviewed the resident's chart and gave orders for a STAT CBC and STAT EKG to be done today (11/29/24). Resident #3 remained stable. At 5:37 a.m., the nurse administered the morning medications. The resident was asleep and responsive to tactile stimuli. The nurse returned to the room around 6:10 a.m. to change the resident's tube feeding. The resident was unresponsive and diaphoretic (sweating heavily). The day nurse was present in the room with the night nurse. The resident's blood sugar was checked and his blood sugar was 248. The nurse called the on-call NP and informed her that resident condition had deteriorated. A new order was received to call 911. The RT went to the resident's room and initiated CPR (cardiopulmonary resuscitation). Emergency medical services were called and they arrived around 6:25 a.m. and took over CPR. The resident's mother was called and informed that CPR was being performed and she said to keep her informed.-Review of the resident's EMR did not reveal any further documentation indicating the licensed nursing staff monitored the resident per NP orders. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 1/2/25 at 10:52 a.m. LPN #1 said the nurses needed to follow the physician's orders as written to ensure care was provided as ordered. She said this ensured that the physician was in charge and the resident was getting care to promote their health. She said when the nurse received a telephone or verbal order they were supposed to read back the order to the provider to ensure they understood and wrote the order correctly. She said then the order was put into the medical record as a verbal order to show it was received over the phone and the provider did not write the order themself. LPN #2 was interviewed on 1/2/25 at 11:01 a.m. LPN #2 said it was important to follow the physician's orders to ensure the care was completed the way the physician wanted to get the best possible outcome. LPN #2 said when receiving an order over the phone, the nurse should repeat the order back to the provider to ensure they received the correct order. LPN #2 said the order was then put into the medical record as a verbal order to show it was received over the phone. The director of nursing (DON) was interviewed on 1/2/25 at 11:03 a.m. The DON said the nurse should always follow the physician's orders. She said the nurse should write down the verbal order and repeat it back to the provider for clarification. She said she had received a text message from the nurse, who was an agency nurse, on duty at the time of the incident and she said she was doing frequent vital sign checks. She said frequent checks did not have set parameters. She said when there was a change in Resident #3's blood pressure and heart rate, the NP should have been notified of his decline. The DON said there should have been documentation that the resident was monitored related to his change of condition.
Plan of correction · submitted by the facility
Provider’s legal statement
F658 PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Resident #3 no longer resides in the facility An audit of current residents on 1/1/15 was conducted to identify any orders that were written in a provider note to ensure that all orders were followed. Audits were conducted on a paper form. No issues identified with the audit. Residents with current change of condition have the potential to be affected by the alleged deficiency. The DON (director of nursing) provided education to the licensed nurses on the need to follow MD orders for frequency of monitoring and reporting any changes in condition to the medical provider. The licensed nurses were also educated on the need to document, in the progress notes, any ongoing monitoring and follow up with the medical providers. The education will be completed by 1/20/25. The DON or designee will review the acute notes made by the medical providers daily for 2 weeks and then weekly for 3 months to identify any new orders and that orders and follow up is in place as ordered and nurses are documenting the monitoring in the medical record. Any issues identified will be addressed immediately. The DON or designee will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
12/6/2024Revisit: Complaint, Recertification Survey · ID MQN312No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/6/24 for all previous deficiencies cited on 10/8/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
12/3/2024Federal Monitoring Survey Survey · ID BOYM211 deficiency▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A Comparative Federal Monitoring Survey was conducted on 12/3/24, following a State Agency Annual Survey on 10/31/24, in accordance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness). During this Comparative Federal Monitoring Survey, the facility was found to be in compliance with the Requirements for Participation in Medicare and Medicaid.
Findings · record 2 of 2
Two (2) story, Type II(111) construction. The building has complete coverage by an automatic sprinkler system. A Comparative Federal Monitoring Survey was conducted on 12/3/24, following a State Agency Annual Survey on 10/31/24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. The findings that follow demonstrate noncompliance with Title 42, Code of Federal Regulations, 483.90 (a) et seq. (Life Safety from Fire).
Plan of correction
The state did not require a plan of correction for this citation.
0927Gas Equipment - Transfilling CylindersS/S D▼
Findings
Based on observation and interview, the facility failed to separate the transfilling area from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction. The deficient practice affected 1 of 6 smoke compartments. The facility had a capacity for 100 beds with a census of 32 on the day of the survey. The findings include:Observation during the building inspection tour revealed first floor oxygen transfilling room was not separated from the rest of the facility by a fire barrier of 1 hour fire-resistive construction due to lack of a minimum 45 min fire rated door. An interview with the Maintenance Director revealed that facility was not aware of this requirement. The census of 32 was verified by the Administrator. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview.
Plan of correction
The state did not require a plan of correction for this citation.
9999Final ObservationsSurveyor note▼
Findings
The facility was found to be in compliance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness).
Plan of correction
The state did not require a plan of correction for this citation.
10/31/2024Recertification Survey · ID MQN3214 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). The facility is a two-story building Type II (000) construction without a basement. It is fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, which includes a wet fire sprinkler system. This survey was conducted on October 31, 2024, to ensure compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code (2012), Chapter 18 "New Health Care Occupancies", as well as the adopted portions of NFPA 99, Health Care Facilities Code (2012), and other referenced standards.
Plan of correction
The state did not require a plan of correction for this citation.
0223Doors with Self-Closing DevicesS/S F▼
Findings
STANDARD was not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain sprinkler-protected hazardous areas per Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following. The door to the Physical Therapy Gym serving as protection for hazardous areas that require a 1-hour separation from the main corridor. The self-closing device have been removed. Life Safety Code Section 19.3.2.1 requires that sprinkler-protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors installed to protect hazardous areas must be self-closing or automatic closing. During a facility tour, the Director of Maintenance acknowledged the hazardous area enclosures and door condition.
Plan of correction · submitted by the facility
K223 Self-closing doors were installed in the therapy gym on both doors of egress 10/28/24. All doors within the facility were checked by maintenance staff, any issues found were corrected. The maintenance staff was educated on the requirement of self-closers on specific doors in the building. The Maintenance Director will report the results of the inspections immediately to the NHA and monthly for 3 months to the QAPI committee or until substantial compliance is determined by the committee.
0291Emergency LightingS/S F▼
Findings
STANDARD was not met based on observation and staff interviews regarding the emergency lighting. The facility failed to maintain the battery-powered emergency lights per 7.9.3 and 19.2.9.1. This deficiency could affect all residents and staff throughout the facility during primary power loss. This was evidenced by the following:No documentation was available during the record review of the facility-required testing of the battery-powered emergency lighting system at 30-day intervals for not less than 30 seconds monthly or annually for not less than 1 ½ hours .2012 Life Safety Code 101-7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for at least 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The maintenance director acknowledges the need for emergency lighting testing during the facility tour.
Plan of correction · submitted by the facility
K291 Documentation for the emergency lighting equipment was redone to show locations of said equipment 10/30/24. The maintenance director has been educated on the proper documentation of the emergency lighting equipment; any issues found were corrected. The Maintenance Director will report the results of the inspections immediately to the NHA and monthly for 3 months to the QAPI committee or until substantial compliance is determined by the committee.
0353Sprinkler System - Maintenance and TestingS/S F▼
Findings
STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. The pendent sprinkler in 1 North Hall shows signs of foreign materials around the working parts of the head. NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and are installed, inspected, and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5The Director of Maintenance acknowledged the deficiency in the maintenance of the automatic sprinkler system during the facility's record review.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
K353 The fire sprinkler head located by the house keeping closet on the first-floor north was cleaned and cleared free of any debris on 10/28/24. Other fire sprinkler heads were checked to insure they function accordingly during an emergency. Any issues found were corrected. The Maintenance Director was educated on inspecting the fire sprinklers. The Maintenance Director will conduct monthly inspections on the fire sprinklers for 3 months to ensure ongoing compliance. The Maintenance Director will report the results of the inspections Immediately to the NHA and monthly for 3 months to the QAPI committee or until substantial compliance is determined by the committee.
0923Gas Equipment - Cylinder and Container StoragS/S F▼
Findings
STANDARD not met: Based on observation and staff interviews during the survey, it was determined that the facility needed to maintain the trans-filling of oxygen storage room ventilation per NFPA 99 - Health Care Facilities, 9.3.7.2 and NFPA 55 Compressed Gases and Cryogenic Fluids Code. This deficient practice could affect all residents and staff within the facility should a emergency occur. The following evidenced this:The oxygen trans-filling room is not mechanically ventilated correctly to maintain a negative pressure per NFPA 99 and NFPA 55. The exhaust is vented into the attic space rather than directly to the outside. 2012 NFPA 999.3.7.4 Transfilling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code. 9.3.7.5.3.1Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) off the floor and adjacent to the cylinder or containers. The Director of Maintenance acknowledged the ventilation issue during a facility tour.
Plan of correction · submitted by the facility
K923 Western mechanical extended the duct work in the oxygen room to terminate outside the building 11/6/24. Other oxygen rooms were inspected to be under code and in compliance. The Maintenance Director will report the results of the inspections immediately to the NHA and monthly for 3 months to the QAPI committee or until substantial compliance is determined by the committee.
10/8/2024Complaint, Recertification Survey · ID MQN3117 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A recertification survey with complaint #CO37564, #CO37601, #CO37663, #CO37736 and #CO37746 was completed on 10/2/24 to 10/8/24. Seven deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 10/2/24 to 10/8/24. 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 and interviews, the facility failed to ensure care for residents was provided timely and in a manner that maintained or enhanced the residents' dignity for two residents (#32 and #3) out of four residents reviewed for dignity of 26 sample residents. Specifically, the facility failed to provide Resident #32 and Resident #3 with a dignified existence by ensuring call lights were consistently answered in a timely manner. Findings include:I. Resident #32A. Resident statusResident #32, age less than 65, was admitted on 1/12/24. According to the October 2024 computerized physicians order (CPO), diagnoses included chronic respiratory failure and amyotrophic lateral sclerosis (a neurodegenerative disease that affects the nerve cells that control muscles). The 7/11/24 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 dependant on staff for all activities of daily living (ADL). B. Resident and resident representative interviewResident #32 and his representative were interviewed together on 10/3/24 at 4:15 p.m. Resident #32 said he had issues with wait times for call light responses at night when he needed help. Resident #32's representative said the resident's call lights were left on for 15 to 20 minutes at a time with no response. Resident #32's representative said the CNAs came into the resident's room and turned off his call light without providing him with assistance, so now they had no way of documenting how long Resident #32 had been waiting. Resident #32 said the issue was inhumane. C. Record reviewThe ADL care plan, dated 1/8/24, revealed Resident #32 had deficits in his ADL performance due increased weakness. Pertinent interventions included encouraging Resident #32 to use his call light to call for assistance. The fall care plan, dated 1/8/24, revealed Resident #32 was at risk for falls due to an inability to self-reposition. Pertinent interventions included ensuring Resident #32's call light was within reach and encouraging the resident to use it for assistance as needed as the resident needed prompt response to all requests for assistance. The myopathy care plan, dated 1/2/24, revealed Resident #32 had an alteration in his musculoskeletal status due to disease progression. Pertinent interventions included anticipating and meeting needs, ensuring Resident #32's call light was within reach and responding promptly to all requests for assistance. On 7/15/24 Resident #32's representative filed a grievance report which revealed neither the resident nor his representative had seen any improvements in call light times over 10 minutes. The resolution revealed staff education was provided on 7/16/24 regarding answering call lights timely, meeting the needs of residents, and waiting for a response before leaving the room. -However, Resident #32 was still experiencing long call wait times (see interview above). On 8/8/24 Resident #32's representative filed another grievance report that revealed on the date of the report the resident had waited 25 minutes for an respiratory therapist (RT). Resident #32 had asked a CNA twice for an RT but did not receive any response. The resolution, dated 8/13/24, revealed a training and inservice was conducted with the nursing staff which enforced answering call lights and following up on them as soon as possible. -However, Resident #32 was still experiencing long call wait times (see interview above). Call light records for Resident #32 from 9/3/24 to 10/4/24 were reviewed and revealed the following:-Activated on 9/3/24 at 9:46 p.m. for 33 minutes;-Activated on 9/4/24 at 5:56 a.m. for 24 minutes;-Activated on 9/5/24 at 4:24 a.m. for 24 minutes;-Activated on 9/5/24 at 8:47 p.m. for 42 minutes;-Activated on 9/7/24 at 7:07 p.m. for 21 minutes;-Activated on 9/7/24 at 7:51 p.m. for 21 minutes;-Activated on 9/10/24 at 4:48 a.m. for 25 minutes;-Activated on 9/10/24 at 9:37 p.m. for 21 minutes;-Activated on 9/11/24 at 5:23 a.m. for 24 minutes;-Activated on 9/12/24 at 7:28 p.m. for 24 minutes;-Activated on 9/12/24 at 8:48 p.m. for 29 minutes;-Activated on 9/12/24 at 9:46 p.m. for 25 minutes;-Activated on 9/13/24 at 5:53 a.m. for 33 minutes;-Activated on 9/15/24 at 4:53 a.m. for 38 minutes;-Activated on 9/16/24 at 5:15 a.m. for 35 minutes;-Activated on 9/18/24 at 3:17 a.m. for 23 minutes;-Activated on 9/19/24 at 3:48 a.m. for 23 minutes;-Activated on 9/22/24 at 6:09 p.m. for 29 minutes;-Activated on 9/23/24 at 3:57 a.m. for 27 minutes;-Activated on 9/24/24 at 5:49 a.m. for 26 minutes;-Activated on 9/25/24 at 3:53 a.m. for 21 minutes;-Activated on 9/26/24 at 3:21 a.m. for 30 minutes;-Activated on 9/26/24 at 4:47 a.m. for 42 minutes;-Activated on 9/26/24 at 11:19 p.m. for 24 minutes;-Activated on 9/27/24 at 4:32 a.m. for 41 minutes;-Activated on 9/30/24 at 4:53 a.m. for 50 minutes;-Activated on 10/1/24 at 1:25 a.m. for 30 minutes;-Activated on 10/1/24 at 3:39 a.m. for 27 minutes;-Activated on 10/1/24 at 11:20 p.m. for 25 minutes;-Activated on 10/2/24 at 4:42 a.m. for 22 minutes;-Activated on 10/2/24 at 7:14 a.m. for 20 minutes;-Activated on 10/2/24 at 8:49 p.m. for 32 minutes;-Activated on 10/3/24 at 12:14 a.m. for 21 minutes;-Activated on 10/3/24 at 2:15 a.m. for 22 minutes; and,-Activated on 10/3/24 at 4:30 a.m. for 43 minutes. II. Resident #3A. Resident StatusResident #3, age 83, was admitted on 7/21/22. According to the October 2024 CPO, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), hemiplegia (weakness in one side of the body) and hemiparesis (paralysis in one side of the body). The 7/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was dependant on staff for most ADLs. B. Resident interviewResident #3 was interviewed on 10/2/24 at 10:16 a.m. Resident #3 said the nursing staff had recently changed from 12 hour shifts to eight hour shifts and it seemed like they were not answering call lights as quickly since the change. Resident #3 said it took the nursing staff 15 to 20 minutes at a minimum before her call light was answered. Resident #3 said she sometimes had to put her call light on two or three times before someone responded. Resident #3 said some of the certified nurses aides (CNA) were quicker to respond to the call lights than others and call light response times were longer in the late afternoon. Resident #3 was interviewed a second time on 10/7/24 at 3:03 p.m. Resident #3 said she used her call light whenever she needed ice or water. Resident #3 said she tried not to use her call light excessively, as she realized the CNAs were busy. Resident #3 said since the change in scheduling she sometimes had to wait much longer for her call light to be answered. Resident #3 said waiting 15 to 20 minutes for a response may not have seemed like much, but since she was debilitated made her wonder if they were ever going to come and help her. C. Record reviewThe ADL care plan, revised 10/27/23, revealed Resident #3 had deficits in her ADL performance due hemiplegia and decline due to disease process. Pertinent interventions included encouraging Resident #3 to use her call light to call for assistance. The fall care plan, dated 7/26/22, revealed Resident #3 was at risk for falls due to lack of mobility. Pertinent interventions included ensuring Resident #3's call light was within reach and encouraging the resident to use it for assistance as needed as the resident needed prompt response to all requests for assistance. The oxygen therapy care plan, revised 1/28/23, revealed Resident #3 received oxygen therapy for her COPD. Pertinent interventions included having an agreed-on method for Resident #3 to call for assistance and having a staff member stay with her during episodes of respiratory distress. Call light records for Resident #3 from 9/3/24 to 10/4/24 were reviewed and revealed the following:-Activated on 9/12/24 at 8:18 p.m. for 41 minutes;-Activated on 9/14/24 at 7:32 p.m. for 21 minutes;-Activated on 9/19/24 at 6:50 p.m. for 60 minutes;-Activated on 9/24/24 at 8:03 p.m. for 42 minutes;-Activated on 9/28/24 at 8:17 p.m. for 61 minutes; and,-Activated on 9/30/24 at 8:35 p.m. for 31 minutes. III. Staff interviewsCNA #1 was interviewed on 10/7/24 at 3:29 p.m. CNA #1 said she answered the call lights as soon as she saw them. She said the CNAs had phones that beeped whenever the call lights were activated. CNA #1 said when she saw multiple call lights were activated, she went to whichever one she saw first. CNA #1 said the residents used the call lights when they needed to be changed, were ready for their shower, or needed to use the urinal. CNA #1 said Resident #32 used his call light whenever he needed a RT. CNA #1 said the facility's goal was to answer call lights within five to ten minutes of being activated. CNA #1 said the call lights were sometimes on for longer than that goal because the CNAs were already giving showers, helping the nurses change dressings, or helping reposition residents. CNA #1 said Resident #32 sometimes complained about the length of time his call light was activated, to which CNA #1 said she just apologized. CNA #1 said she knew of one instance where it took a longer time to answer Resident #32's call light in which she was helping transfer another resident. CNA #6 was interviewed on 10/8/24 at 9:33 a.m. CNA #6 said she usually had ten to eleven residents depending on the facility census that day. CNA #6 said the facility's call light system did not make a sound but instead they had telephones that rang when the lights were activated. CNA #6 said when there were multiple call lights going off, she checked the phone to see how many minutes the lights had been going off. CNA #6 said Resident #32 used his call light more so she tried to get to his room as fast as possible. CNA #6 said she tried to answer the call lights as quickly as possible but the facility's goal was five to six minutes. CNA #6 said certain residents called over and over for the same things. CNA #6 said longer call light times depended on how the facility was staffed, as when they had less staff things took more time. CNA #6 said most of the residents required the assistance of two staff members, so sometimes when the CNAs were showering residents everyone was occupied so call lights were activated for longer. CNA #6 said the facility also brought in a lot of agency staff which made things more difficult as the agency staff did not have the same routine or know the residents as well. CNA #6 said Resident #3 used her call light to ask for ice or an RT. CNA #6 said Resident #3 was alert and oriented and knew to use her call light whenever she needed help. Licensed practical nurse (LPN) #5 was interviewed on 10/8/24 at 9:44 a.m. LPN #5 said the goal for answering call lights was within five minutes. LPN #5 said they had a pager or phone system to let the nursing staff know when the call lights were activated. LPN #5 said the phone system cycled through with whether or not it was working. LPN #5 said she was not sure if the pagers were working or not, but the CNAs on shift that day had her nurse phone. LPN #5 said if the nurse phone started beeping that meant the call light had been activated for a while. LPN #5 said the pager system worked by having the CNAs receive the page first, then the nurses, then the unit manager. LPN #5 said since there was not presently a unit manager the system ended with the nurse on shift. She said the facility was trying to hire a unit manager. LPN #5 said the administration would call and ask why the call lights were still activated if they had been on for an extended period. LPN #5 said longer call light times could be caused by the RT needing help with a resident or if the CNAs were already in a room. LPN #5 said there were a lot of agency staff who did not answer call lights or keep up with call light response times. LPN #5 said LPN #3 was working on servicing the phones the week prior. LPN #5 said the CNAs knew to look up and down the hallway to check and see which call lights were going off. CNA #2 was interviewed on 10/8/24 at 9:49 a.m. CNA #2 said the unit used to have two phones for the CNAs but they were gone. CNA #2 said someone took them to get them fixed. LPN #3 was interviewed on 10/8/24 at 10:15 a.m. LPN #3 said he had taken over some of the unit manager responsibilities until the facility could hire one. LPN #3 said the call lights notified the nursing staff in a few ways. LPN #3 said once the call light was activated, it pushed alerts out to the notification system. LPN #3 said these notifications were sent out to pagers, which they had been struggling to keep functioning and cell phones. LPN #3 said ideally each CNA would have a pager. LPN #3 said he had gathered all the pagers the week prior to send them out for servicing. LPN #3 said there was a monitor in the administration office that showed how long the call lights had been activated and the managers got alerts once the call light had been activated over three minutes. LPN #3 said the goal for answering call lights was within three minutes. LPN #3 said call light times were typically longer in the hospital back-up unit because the CNAs had to work in pairs while providing care. LPN #3 said the facility had received grievances about call light times periodically. LPN #3 said the response for these grievances involved creating a plan of action that usually involved reeducating the staff before going back to the resident that submitted the grievance and ensuring they were satisfied with the outcome. LPN #3 said there had not been any issues brought to his attention regarding agency staff differing in call light response compared to the facility staff. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 10/8/24 at 11:56 a.m. The DON said the facility's call light system was electronic and notifications were sent to cell phones. The DON said the notifications immediately went to the CNAs, then were sent to the nurses after two to five minutes, then to the unit manager after ten minutes, and to the DON after 20 minutes of being activated. The DON said the administrative team had directed the nursing staff to go into the room once the call light was activated, but leave the call light on if the staff member could not meet the need of the resident and needed to retrieve another staff member such as an RT or nurse. The DON said this may skew the call light times. The DON said the nursing staff also forgot to turn off the call lights after addressing the resident's needs. The DON said call lights could be longer if the RT was having an emergency. The DON said she had called in during the night to see why call lights were not being answered timely. The DON said she encouraged residents to activate their call light again if they felt they had not had their needs addressed. The DON said she had also educated the staff on giving residents time to respond and communicate their needs. The DON said sometimes the staff asked rapid-fire questions and did not give Resident #32 the time he needed to respond. The DON said the facility had moved away from using pagers and transferred to cell phones. The NHA said she had received complaints about not having chargers for the cellphones. The NHA said she addressed this so there would be chargers that could not be unplugged and moved so they would not go missing. The DON said the facility had a lot of staff that were just floating around and not doing anything so they had to address those concerns.
Plan of correction · submitted by the facility
Provider’s legal statement
F550 PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Residents #32 and #3 are in stable condition. Residents who require assistance with ADLs have the potential to be affected by the alleged deficient practice. Call light times were reviewed using the computerized call system to identify call light times that exceed >20mins and residents with these call times were interviewed to identify if their needs were met. The IDT (interdisciplinary team) members will interview their assigned interviewable residents at least twice a week to identify any resident who feel their needs are not being met. Education to staff was provided beginning on 10/9/24 on the importance of answering call lights timely to meet the needs of the residents and the facility expectation that staff who carry pagers phones for the call light system report any issues with the phones. The IDT will Interview 10 residents per week for 3 months on call light response and observation of call lights within reach. Any concerns identified in the interviews will be addressed through the grievance process with the resident to ensure that any concerns with dignity are addressed. The DON (director of nursing) or designee will audit daily reports of the call light system for 1 month then weekly reports for 2 months to identify trends in call light response times. Any trend of increased call light response time will be addressed by the IDT. All monitoring will be completed on paper documentation. The DON or designee will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
Plan of correction · submitted by the facility
Provider’s legal statement
F550 PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Residents #32 and #3 are in stable condition. Residents who require assistance with ADLs have the potential to be affected by the alleged deficient practice. Call light times were reviewed using the computerized call system to identify call light times that exceed >20mins and residents with these call times were interviewed to identify if their needs were met. The IDT (interdisciplinary team) members will interview their assigned interviewable residents at least twice a week to identify any resident who feel their needs are not being met. Education to staff was provided beginning on 10/9/24 on the importance of answering call lights timely to meet the needs of the residents and the facility expectation that staff who carry pagers phones for the call light system report any issues with the phones. The IDT will Interview 10 residents per week for 3 months on call light response and observation of call lights within reach. Any concerns identified in the interviews will be addressed through the grievance process with the resident to ensure that any concerns with dignity are addressed. The DON (director of nursing) or designee will audit daily reports of the call light system for 1 month then weekly reports for 2 months to identify trends in call light response times. Any trend of increased call light response time will be addressed by the IDT. The DON or designee will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
0730Nurse Aide Peform Review-12 hr/yr In-ServiceS/S E▼
Findings
Based on record review and interviews, the facility failed to complete a performance review ofevery nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of five certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5 in order to determine potential training needs. Findings include:I. Facility policy and procedureThe In-Service Training, Nurse Aide policy and procedure, revised August 2022, was received from the infection preventionist (IP) on 10/7/24 at 1:02 p.m. It revealed in pertinent part,"All nurse aide personnel participate in regular in-service education. "The facility completes a performance review of nurse aides at least every 12 months. In-service training is based on the outcome of the annual performance reviews. "Supervised practical training means training in a setting in which instruction and oversight are provided by a person who has relevant education and/or experience specific to the subject of the training being provided. "Training curriculum includes learning objectives, performance standards and evaluation criteria. Nurse aides are evaluated based on individual performance when appropriate. Competency may also be demonstrated through a written exam or by consistently applying interventions necessary to meet the needs of the residents as identified in the facility assessment." II. Record reviewAnnual performance reviews were requested on 10/3/24 at 10:40 a.m. for CNA #2 (hired on 12/30/22), CNA #3 (hired on 6/6/23), CNA #4 (hired on 1/26/23) and CNA #5 (hired on 4/13/23). -The facility was unable to provide annual performance evaluations or regular in-service education based on the outcome of the reviews for CNA #2, CNA #3, CNA #4 or CNA #5. III. Staff interviewsThe nursing home administrator (NHA) was interviewed on 10/7/24 at 2:47 p.m. The NHA said annual performance evaluations had not been completed for CNAs. The NHA said the facility was implementing a process, going forward, where human resources would print out a list of CNAs/staff who required annual performance evaluations for each manager to complete. The NHA said each manager would then be responsible for getting them completed and she would review the evaluations prior to them being given to the staff for finalization.
Plan of correction · submitted by the facility
Provider’s legal statement
F730 - Performance Evals PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were named in the alleged deficient practice. An audit was conducted to identify any CNA (certified nurse aides) who has been an employee of the community for a year or more that has not had an annual performance evaluation. The employees identified in the audit were reviewed and a performance evaluation was completed The DON was educated on 10/9/24 on the need to complete annual performance evaluations that identify areas of needed education. The Human Resource Manager will track hire dates of CNAs and provide a list of CNAs who need to have a performance evaluation to the DON each month. The Human Resource Manager will complete a monthly audit based on hire date to ensure that evaluations due for the month are completed. Any issues with the audits will be addressed immediately. All monitoring will be completed on paper documentation. The HR manager will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
Plan of correction · submitted by the facility
Provider’s legal statement
F730 - Performance Evals PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were named in the alleged deficient practice. An audit was conducted to identify any CNA (certified nurse aides) who has been an employee of the community for a year or more that has not had an annual performance evaluation. The employees identified in the audit were reviewed and a performance evaluation was completed The DON was educated on 10/9/24 on the need to complete annual performance evaluations that identify areas of needed education. The Human Resource Manager will track hire dates of CNAs and provide a list of CNAs who need to have a performance evaluation to the DON each month. The Human Resource Manager will complete a monthly audit based on hire date to ensure that evaluations due for the month are completed. Any issues with the audits will be addressed immediately. The HR manager will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
0759Free of Medication Error Rts 5 Prcnt or MoreS/S D▼
Findings
Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.06%, or two errors out of 33 opportunities for error. Findings includeI. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication
2. The right dose
3. The right patient
4. The right route
5. The right time
6. The right documentation
7. The right indication."II. Facility policy and procedureThe Medication Administration policy and procedure, dated 2/29/24, was received from the infection preventionist (IP) on 10/7/24 at 1:02 p.m. It revealed in pertinent part, "Resident medications are administered in an accurate, safe, timely and sanitary manner. "Physician orders are administered in accordance with written orders of the attending physician or physician extender. If a dose is inconsistent with the resident's age and condition or medication order is inconsistent with the resident's current diagnosis or condition, contact the physician for clarification prior to the administration of the medication. Document the interaction with the physician in the nursing progress notes and elsewhere in the medical record, as appropriate. "Verify the medication label against the medication administered record (MAR) for accuracy of drug frequency, duration, strength and route. "Follow safe preparation practices as follows:"Be sure to check the bottle label against the physician's orders."Medication is to be given in compliance with the physician orders and or manufactures recommendations."III. Observations and interviewsOn 10/3/24 at 5:20 p.m. licensed practical nurse (LPN) #4 was administering medications to Resident #2. LPN #4 dispensed one tablet of Lactaid 9000 units. Resident #2's MAR indicated the resident had a physician's order for Lactaid oral tablet 3000 units via nasogastric tube (NGT) two times a day for abdominal bloating.-LPN #4 dispensed one tablet of Lactaid 9000 units. This was 6000 units more than the physician's order indicated the resident was to receive. When LPN #4 was asked to review the physician's order for Lactaid. After reviewing the order, she said she could cut the tablet in half. LPN #4 proceeded to cut the tablet in half with a pill cutter and placed a half tablet into the medication cup. -The half tablet of Lactaid 9000 units was still 1500 units more than the physician's order indicated the resident was to receive. LPN #4 was asked a second time to review Resident #2's Lactaid order. LPN #4 said she should have cut the tablet into three parts so it would equal the 3000 units of Lactaid indicated by the physician's order. LPN #4 removed the half tablet from the medication cup and disposed of the tablet. At 5:44 p.m. LPN #4 said she needed to check central supply to see if the facility carried the 3000 unit dose of Lactaid the physician ordered for Resident #2. LPN #4 checked the central supply medications and said the only Lactaid in stock was the 9000 units dose. She added Lactaid 3000 units to the order supply list in central supply.-LPN #4 did not administer Resident #2's Lactaid because she did not have the correct dose. LPN #4 said if a medication tablet did not have a score line (mark or indentation down the middle of a medication tablet that allows for accurate cutting of the medication) by the manufacturer it should not be cut. LPN #4 said she should not have attempted to administer the Lactaid tablet she cut with a pill cutter because it did not follow the dose the physician had ordered for Resident #2. LPN #4 said cutting a tablet in half that did not have a score line was not safe because staff could not ensure the medication concentration would equal the dose ordered. On 10/7/24 at 8:20 a.m. LPN #2 was administering medications to Resident #11. Resident #11's MAR revealed the resident had a physician's order for Flonase suspension 50 microgram/actuation (mcg/act) two inhalations in both nostrils every 12 hours for allergy, runny nose and sinusitis. LPN #2 said he was unable to find the medication so he reordered it from the pharmacy. LPN #2 said he documented the medication was on order with the pharmacy in the MAR.-LPN #2 did not administer the medication to Resident #11 as ordered because the medication was not available. IV. Additional staff interviewsLPN #3, who was also the unit manager, was interviewed on 10/7/24 at 10:18 a.m. LPN #3 said nurses were not supposed to cut medication tablets in half unless they contained a score line created in the medication by the manufacturer. LPN #3 said cutting a tablet without a score line in half could lead to the wrong dose of the medication being administered to a resident. She said cutting medications in half was the responsibility of the pharmacist. LPN #3 said if a medication was not available it should be ordered and the physician should be contacted to be notified of the missing dose. She said nurses should get an order from the physician to hold a medication until it was available or see if the physician wanted to change the medication to a different dose the facility may have on hand. The director of nursing (DON) was interviewed on 10/7/24 at 10:32 a.m. The DON said nurses were not to cut medication tablets in half unless the medication was scored. The DON said cutting an unscored tablet could lead to the resident getting too much or too little of a medication. The DON said if a medication was not available at the time of an ordered administration, the pharmacy should be contacted to reorder the medication. She said the physician should be contacted to inform them of the missing dose and get an order on how to proceed, whether it be to hold the medication until it was available or change the medication to a different dose on hand.
Plan of correction · submitted by the facility
Provider’s legal statement
F759 - Med Error rate PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Nurses #2 and #4 were educated on the 7 rights of medication administration and the process for medications that are not available. The Flonase was obtained from the pharmacy for resident #11 and the medical provider changed the dose of the Lactaid mediation for resident #2. Other residents have the potential to be affected by the alleged deficient practice. Education was provided on 10/9/24 to nurses on the 7 rights of medication administration and the procedure for medications that are not available and reporting any medication that is not available to the DON. The DON or designee will complete a medication administration observation with licensed nurses to ensure that nurses are following the 7 rights of administration. The DON will audit documentation weekly for medication that is not available, for 3 months to ensure that processes are followed for obtaining the medication. Any issues identified will be addressed immediately with further education. All monitoring will be completed on paper documentation. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
Plan of correction · submitted by the facility
Provider’s legal statement
F759 - Med Error rate PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Nurses #2 and #4 were educated on the 7 rights of medication administration and the process for medications that are not available. The Flonase was obtained from the pharmacy for resident #11 and the medical provider changed the dose of the Lactaid mediation for resident #2. Other residents have the potential to be affected by the alleged deficient practice. Education was provided on 10/9/24 to nurses on the 7 rights of medication administration and the procedure for medications that are not available and reporting any medication that is not available to the DON. The DON or designee will complete a medication administration observation with licensed nurses to ensure that nurses are following the 7 rights of administration. The DON will audit documentation weekly for medication that is not available, for 3 months to ensure that processes are followed for obtaining the medication. Any issues identified will be addressed immediately with further education. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
0812Food Procurement,Store/Prepare/Serve-SanitaryS/S E▼
Findings
Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination. Findings include:I. Failed to ensure ready-to-eat foods were handled in a sanitary mannerA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/8/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment."If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation."B. Facility policy and procedureThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary ConditionsPolicy, revised January 2024, was received from the nursing home administrator (NHA) on 10/7/24 at 2:30 p.m. It revealed in pertinent part, "Food is handled properly with frequent handwashing and proper sanitation guidelines per local, state and federal guidelines and codes."C. ObservationsDuring a continuous observation of the dinner meal service on 10/3/24, beginning at 4:40 p.m. and ending at 5:42 p.m. the following was observed:At 4:50 p.m. cook (CK) #1 was wearing a pair of gloves and handling meal tickets, plate warmers, a door handle and serving utensils. Using the same gloved hands, CK #1 sliced a chicken breast on the griddle and used his gloved hand to stabilize the chicken while he scooped it up with a spatula before setting it on a plate. CK #1 then took out a bag of bread, opened the plastic bag, and grabbed two slices of bread with the same gloved hands before setting them on the griddle. Using the same gloved hands, CK #1 grabbed a handful of french fries out of the fryer basket and set them on a plate. At 4:55 p.m. CK #2 began preparing a southwest salad. Using gloved hands, CK #2 opened the cold storage doors and took out a container of lettuce. Using the same gloved hands, CK #2 removed the lettuce lid and grabbed handfuls of lettuce to put into a bowl. CK #2 repeated this process with containers of chopped red onion and tortilla strips. At 5:00 p.m. CK #1 washed his hands and donned (put on) a new set of gloves. CK #1 handled several serving utensils before grabbing a handful of fries using his gloved hands and setting them on a plate. After this, CK #1 used a spatula to scoop up a cooked chicken breast and place it on a plate. CK #1 then used the same gloved hands to adjust the chicken breast on the plate before serving it. At 5:07 p.m. CK #2 was wearing a pair of gloves. CK #2 opened the cold storage doors and took out a container of egg salad. CK #2 set the egg salad container on the table and with the same gloved hands that had touched the lettuce she had previously set on a plate..At 5:10 p.m. CK #2 was preparing a to-go order salad. CK #2 took out a cardboard to-go container and using the same gloves retrieved the container of lettuce from the cold storage and took out handfuls of lettuce using the same gloved hands. At 5:25 p.m. CK #2 was handling meal tickets and serving utensils before returning to the to-go order salad. CK #2 sliced an avocado and used her same gloved hands to peel the skin off the avocado before placing the avocado slices into the to-go salad container. At 5:29 p.m. CK #1 was handling meal tickets and serving utensils on the service line with gloved hands. Using the same gloved hands, CK #1 picked up the plastic bread bag and used his gloved hand to push the slices of bread down before closing the bag and putting it away. D. Staff interviewThe dietary manager(DM) was interviewed on 10/7/24 at 12:19 p.m. The DM said the dietary staff typically did not handle much ready-to-eat food but that ready-to-eat food should be handled with gloves and clean utensils. The DM said gloves should be changed any time a staff member started a new task. The DM said gloves needed to be removed when handling meal tickets and new gloves donned afterward. The DM said one of the cooks was new to the role, so she was still trying to instill good hand hygiene habits in him.
Plan of correction · submitted by the facility
Provider’s legal statement
F812 - Kitchen Sanitation PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were identified in the alleged deficient practice All residents who are not NPO (nothing by mouth) have the potential to be affected by the alleged deficient practice On 10/8/24 the food and nutrition staff were educated on the process for safe handling of ready to eat food. The food and nutrition manager will conduct 5 staff observations of handling of ready to eat food per week for 3 months to ensure ongoing compliance. Any issues identified will be addressed immediately The food and nutrition manager will report the results of the observations to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
Plan of correction · submitted by the facility
Provider’s legal statement
F812 - Kitchen Sanitation PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were identified in the alleged deficient practice All residents who are not NPO (nothing by mouth) have the potential to be affected by the alleged deficient practice On 10/8/24 the food and nutrition staff were educated on the process for safe handling of ready to eat food. The food and nutrition manager will conduct 5 staff observations of handling of ready to eat food per week for 3 months to ensure ongoing compliance. Any issues identified will be addressed immediately. All monitoring will be completed on paper documentation. The food and nutrition manager will report the results of the observations to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
0813Personal Food PolicyS/S D▼
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 one of two units. Specifically the facility failed to ensure safe and appropriate storage of food items in personal resident refrigerators. Findings include:A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 10/8/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises or discarded"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."B. Facility policy and procedureThe Foods Brought by Family/Visitors policy, revised March 2022, was provided by the nursing home administrator (NHA) on 10/8/24 at 10:28 a.m. It revealed in pertinent part, "Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date."The nursing staff will discard perishable foods on or before the use by date."C. Resident interviewResident #3 was interviewed on 10/2/24 at 10:16 a.m. Resident #3 said her refrigerator had not been checked by a member of the dietary staff in months. Resident #3 was interviewed again on 10/7/24 at 9:58 a.m. Resident #3 said her daughter had come two days prior, defrosted her refrigerator and threw away all of the food items that had expired. -However, multiple items remained in the refrigerator that were expired. C. Observations and record reviewOn 10/2/24 at 10:16 a.m. the following items were found in Resident #3's refrigerator:-An open bag of croutons, with an expiration date of 12/14/23;-A bottle of Caesar salad dressing, with an expiration date of 6/21/23;-A bottle of barbeque sauce, with an expiration date of 1/24/24;-Another bottle of barbeque sauce, with an expiration date of 12/5/23;-A slice of zucchini bread wrapped in plastic wrap that had no date;-Two containers cocktail sauce, with an expiration date of 4/26/23;-A bag of sliced carrots, that had no date or label on it; and,-Two opened containers of chocolate pudding, with no date.-There were 10 to 15 small gnats or fruit flies that were dead at the inside of the refrigerator at the bottom. The paper on the side of the refrigerator was labeled October 2024 with columns for refrigerator and freezer temperatures. The temperatures for 10/1/24 and 10/2/24 had not been filled out. The following items were found in Resident #3's refrigerator 10/07/24 at 9:58 am:-The same open bag of croutons, with an expiration date of 12/14/23;-The same bottle of barbeque sauce, with an expiration date of 1/24/24; and,-An unlabeled and undated tupperware container of asparagus. The paper on the side of the refrigerator was labeled October 2024 with columns for fridge and freezer temperatures. The temperatures for 10/1/24 through 10/7/24 had not been filled out. D. Staff interviewThe dietary manager (DM) was interviewed on 10/7/24 at 12:19 p.m. The DM said the dietary staff had temperature logs for Resident #3's personal refrigerator. The DM said the dietary staff went through Resident #3's refrigerator to throw expired food items away and to ensure any food brought in by the resident's family was appropriately labeled and dated. The DM was interviewed again on 10/7/24 at 12:40 p.m. She said, while reviewing the contents of Resident #3's refrigerator, the refrigerator had a temperature log for October 2024 that no one had filled out. The DM said the expired croutons and the barbeque sauce needed to be thrown away. She asked Resident #3 if she could throw them away. The DM said there was a cook that was previously employed at the facility that was really consistent with checking through Resident #3's refrigerator. The DM said she had told the dietary staff members to ensure they were checking Resident #3's refrigerator and fill out the respective temperature log whenever they checked the unit refrigerators.
Plan of correction · submitted by the facility
Provider’s legal statement
F813 - Personal Food PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Expired items in Resident #3 fridge were removed on 10/7/24. A temp log was placed on the outside of the refrigerator. No other residents have personal refrigerators The kitchen and nursing staff who care for resident #3 were educated on 10/9/2024 the need to ensure that food that is stored in the refrigerator is dated and not past expiration dates. Education also includes checking the fridge temperature daily and recording the reading on the temp log and adjusting the temp control as needed to keep the temp in proper range for food safety. The food and nutrition staff will be responsible for recording the fridge temp and removing any expired food. The Food and Nutrition manager or designee will complete weekly audits of the fridge for 1 month and then monthly for 2 months to ensure ongoing compliance. Any issues identified will be addressed immediately. All monitoring will be completed on paper documentation. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
Plan of correction · submitted by the facility
Provider’s legal statement
F813 - Personal Food PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Expired items in Resident #3 fridge were removed on 10/7/24. A temp log was placed on the outside of the refrigerator. No other residents have personal refrigerators The kitchen and nursing staff who care for resident #3 were educated on 10/9/2024 the need to ensure that food that is stored in the refrigerator is dated and not past expiration dates. Education also includes checking the fridge temperature daily and recording the reading on the temp log and adjusting the temp control as needed to keep the temp in proper range for food safety. The food and nutrition staff will be responsible for recording the fridge temp and removing any expired food. The Food and Nutrition manager or designee will complete weekly audits of the fridge for 1 month and then monthly for 2 months to ensure ongoing compliance. Any issues identified will be addressed immediately. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
0851Payroll Based JournalS/S F▼
Findings
Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include:I. Record reviewThe PBJ staffing report for quarter three (4/1/24 to 6/30/24) showed the following triggered areas:-Excessive low weekend staffing; and,-One star rating. The trigger for low weekend staffing triggered the facility's one star rating.-However, review of the facility's April 2024 to June 2024 staff time cards revealed the facility did not have low weekend staffing. II. Staff interviewThe nursing home administrator (NHA) was interviewed on 10/7/24 at 2:45 p.m. The NHA said the facility used a third party processor to submit their PBJ report. She said the third party processor did not submit the report timely and it was rejected. The NHA said the one star rating and the low weekend staffing triggers occurred because the report was not submitted timely.
Plan of correction · submitted by the facility
Provider’s legal statement
F851 - PBJ PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were named. Staffing coordinator and payroll specialist were educated on 10/10/24 on prevention of missed punches and education was provided on the importance of verifying punch details. Punch details will be audited every payroll cycle to verify that staffing is sufficient. Punch details will be audited on every payroll cycle to resolve any discrepancies in licensed nurse hours. Proof will be printed of RN (registered nurse)/LPN (licensed practical nurse) 24hours/day utilizing the punch details. PBJ (payroll based journal) submission date will be discussed prior to future submissions to ensure that accurate data is reported. All monitoring will be completed on paper documentation. The NHA/Designee will report the results of the punch details audit to the QAPI meeting monthly for 3 months or until substantial compliance is determined by the committee.
Plan of correction · submitted by the facility
Provider’s legal statement
F851 - PBJ PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were named. Staffing coordinator and payroll specialist were educated on 10/10/24 on prevention of missed punches and education was provided on the importance of verifying punch details. Punch details will be audited every payroll cycle to verify that staffing is sufficient. Punch details will be audited on every payroll cycle to resolve any discrepancies in licensed nurse hours. Proof will be printed of RN (registered nurse)/LPN (licensed practical nurse) 24hours/day utilizing the punch details. PBJ (payroll based journal) submission date will be discussed prior to future submissions to ensure that accurate data is reported. The NHA/Designee will report the results of the punch details audit to the QAPI meeting monthly for 3 months or until substantial compliance is determined by the committee.
0880Infection Prevention & ControlS/S E▼
Findings
Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents' rooms and high frequency touched areas (call lights, door handles and handrails);-Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents' rooms;-Ensure housekeeping staff performed appropriate hand hygiene and changed gloves after cleaning residents' toilets; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when administering medications through a feeding tube for a resident who was on Enhanced Barrier Precautions (EBP). Findings include:I. Housekeeping failuresA. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 10/9/24 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part,"High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment."The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 10/9/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/preent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part,"High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs."Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."B. Facility policy and procedureThe Cleaning and Disinfecting Resident Rooms policy and procedure, revised August 2013, was provided by the director of nursing (DON) on 10/7/24 at 3:20 p.m. It read in pertinent part, "The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident rooms."Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products. Floor mopping solution will be replaced every three resident rooms, or changed no less often than at 60 minute intervals. "Resident room cleaning:-Gather supplies as needed;-Prepare disinfectant according to manufacturer's recommendations;-Discard disinfectant/detergent solutions that become soiled or clouded with dirt and grime and prepare fresh solution;-Change mop solution water at least every three (3) rooms, or as necessary;-Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters; and,-Clean personal use items (lights, phones, call bells, bed rails) with disinfectant solution at least twice weekly."C. ObservationsDuring a continuous observation on 10/7/24, beginning at 8:22 a.m. and ending at 8:44 a.m., housekeeper (HSK) #1 was observed cleaning room #229 and room #231. HSK #1 removed a purple rag, a green rag, the toilet brush and a bottle of disinfectant from the cart. She entered room #229 and wiped the surfaces of the dresser and the bedside table with the purple rag. -HSK #1 did not use a disinfectant while cleaning the room or disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 entered the bathroom and sprayed the disinfectant on the counter and sink. She immediately wiped the surface off. HSK #1 sprayed the toilet rim and bowl with the disinfectant. She used the toilet brush to clean the inside of the toilet bowl and used the green rag to wipe the rim of the toilet.-HSK #1 failed to allow the disinfectant to remain on surfaces for the appropriate disinfectant dwell time.-HSK #1 failed to disinfect any other parts of the toilet, the bathroom grab bars, the shower, the light switch or the door knobs. HSK #1 placed the soiled rags and the disinfectant bottle in the cart. Without removing her gloves or performing hand hygiene, she removed two mop pads from a bucket on her cleaning cart and the mop handle. She dropped one of the mop pads on the floor by the door and one in the bathroom and proceeded to mop the resident's room and bathroom. -HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water.-HSK #1 did not change her gloves or perform hand hygiene after cleaning the toilet before removing the mop pads from the bucket of plain water. After finishing the mopping in room #229, HSK #1 proceeded to room #231. HSK #1 removed two green rags, the toilet brush and a bottle of disinfectant from the cart. She wiped the dresser and bedside table with the dry cloth. -HSK #1 did not use a disinfectant while cleaning the room or disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 entered the bathroom and sprayed the disinfectant on the counter and sink. She immediately wiped the surface off. HSK #1 sprayed the toilet rim and bowl with the disinfectant. She used the toilet brush to clean the inside of the toilet bowl and used the second green rag to wipe the toilet seat, the top of the tank, the tank, behind the seat, the rim and then the base of the toilet.-HSK #1 failed to allow the disinfectant to remain on surfaces for the appropriate disinfectant dwell time.-HSK #1 failed to disinfect the toilet from top to bottom, the grab bars, the shower, the light switch or the door knobs. HSK #1 placed the soiled rags and the disinfectant bottle in the cart. Without removing her gloves or performing hand hygiene, she removed two mop pads from the bucket on her cleaning cart and the mop handle. She dropped one of the mop pads on the floor by the door and one in the bathroom. and proceeded to mop the resident's room and bathroom.-HSK #1 did not change her gloves or perform hand hygiene after cleaning the toilet before removing the mop pads from the bucket of plain water. D. Staff interviews HSK #1 was interviewed on 10/7/24 at 8:45 a.m. HSK #1 said she did not clean the bed because the resident never left the bed. She said she should have sprayed the rag with the disinfectant and immediately wiped it off. HSK #1 said she did not know what high touch surfaces were. She said she usually wore the same gloves through the entire cleaning process and did not know if a cleaner or disinfectant needed to be in the mop water. The housekeeping and laundry manager (HLM) was interviewed on 10/7/24 at 9:38 a.m. The HLM said HSK #1 should have cleaned the residents' rooms from clean to dirty and all surfaces, as well as high touch areas, should have been disinfected. The HLM said the disinfectant had a dwell time of one minute and should not be wiped off immediately. The HLM said surfaces should remain wet for a full minute before wiping in order to kill the pathogens that may be present. The HLM said HSK #1 should not have mopped the floor with plain water. The HLM said a disinfectant should have been mixed with the water in the mop bucket. The HLM said housekeepers should always change gloves and perform hand hygiene after cleaning the toilet. The HLM said based on the observation of HSK #1, hand hygiene was not adhered to, cleaning methods were not followed per the facility's procedures and the surface disinfectant times were not followed. The HLM said she would immediately educate the housekeepers on the proper techniques for room cleaning. The DON was interviewed on 10/7/24 at 10:39 a.m. The DON said every room should be cleaned and disinfected daily and the housekeepers should follow the manufacturer's recommended dwell time for the products to disinfect properly. The DON said gloves should be changed and hand hygiene performed after cleaning the bathroom. The DON said all high touch surfaces need to be cleaned daily, especially with the medically complex residents that resided at the facility. The DON said the residents' rooms should be cleaned from clean to dirty and top to bottom. The infection preventionist (IP) was interviewed on 10/7/24 at 12:45 p.m. The IP said the residents' rooms should be cleaned and disinfected daily, gloves should be changed after each task and a disinfectant needed to be used on all surfaces, including the floor. The IP said the toilet should be cleaned from clean to dirty and the disinfectant dwell times followed for infection control purposes. The IP said she would immediately re-educate the housekeeping staff on the facility's cleaning procedures, hand hygiene and the disinfectant dwell time. II. Failure to ensure staff wore appropriate PPE when administering medications through a feeding tube for a resident on EBPA. Facility policy and procedureThe Enhanced Barrier Precautions (EBP) policy and procedure, dated 1/6/23, was received from the IP on 10/7/24 at 1:02 p.m. It read in pertinent part, "EBP are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents."EBP employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing high-contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray."Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, and tracheostomy/ventilator)and complicated wound care (any skin opening requiring a dressing)."EBP remains in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk as they can still serve as a source of transmission even after the infection has resolved."Staff are trained prior to caring for residents on EBP."Signs are posted on the door or wall outside the residents' rooms indicating the type of precautions and PPE required."PPE is available outside of the residents' rooms."The gown and gloves used for each resident during high-contact resident care activities should be removed and discarded after each resident care encounter. Hand hygiene should be performed, and new gown and gloves should be donned before caring for a different resident."B. Observations and staff interviewOn 10/7/24 at 8:40 a.m. licensed practical nurse (LPN) #1 was administering medications to Resident #27. Resident #27 had a physician's order for medications to be administered via G-tube (gastrostomy tube - a tube inserted through the belly directly into the stomach). LPN #1 prepared all medications as ordered. LPN #1 went to Resident #27's room, knocked on the door and announced herself. There was a sign outside Resident #27's door that indicated the resident was on EBP. LPN #1 entered the resident's room, placed medications on the bed side table, performed hand hygiene with an alcohol based hand rub and applied clean gloves. LPN #1 collected water and a large syringe to administer the medications via the resident's G-tube. LPN #1 administered the medications as ordered. During administration of the medications, the G-tube was connected to a large syringe, bubbles were seen in the syringe and gurgling noises were heard as LPN #1 administered the medications. LPN #1 washed her hands with soap and water prior to exiting Resident #27's room. -LPN #1 failed to apply PPE, including a gown, mask, and face shield prior to the administration of Resident #27's medications via the G-tube. LPN #1 was interviewed immediately upon exiting Resident #27's room at 8:59 a.m. LPN #1 said she did not have to wear all of the PPE for medication administration via G-tube. She said the PPE was only required for Resident #27 when his wound care was being provided. C. Additional staff interviewsLPN #3, who was also the unit manager, was interviewed on 10/7/24 at 10:18 a.m. LPN #3 said PPE, such as gowns, masks and gloves were required to be worn when administering medications via a G-tube to a resident on EBP. LPN #3 said the PPE was needed due to the increased risk of splashing from a G-tube. LPN #3 said the PPE was to be worn to help prevent the spread of infection. The DON was interviewed on 10/7/24 at 10:32 a.m. The DON said if medications were being administered to a resident on EBP via a G-tube, PPE, such as a gown, gloves and mask should be worn to prevent infection. The DON said the G-tube was an opening in the body which increased the risk of infection. The IP was interviewed on 10/7/24 at 12:50 p.m. The IP said PPE should be worn during medication administration via G-tube for a resident on EBP. The IP said a mask, gown and gloves were to be worn to help prevent the spread of infection. The IP said staff would be re-educated on EBP procedures.
Plan of correction · submitted by the facility
Provider’s legal statement
F880 - Infection Control PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were named in the alleged deficient practice All residents have the potential to be affected by the alleged deficient practice Housekeeping staff were educated on 10/7/24 on the need to follow dwell times for disinfection, proper order for cleaning all high touch surfaces, hand hygiene. The nursing staff were reeducated on 10/9/2024 on using EBP (enhanced barrier precautions), including gown and gloves, when administering medications through a feed tube. The housekeeping supervisor will conduct 3 observations of housekeeping staff per week for 1 month and then 3 per month for 2 months to ensure ongoing compliance. The DON or designee will conduct 3 observations of nursing staff providing care per week for 1 month and then 3 per month for 2 months to ensure ongoing compliance. Any issues identified will be addressed with the staff members immediately. The DON and Housekeeping will report the results of the observations to the QAPI meeting monthly for 3 months or until substantial compliance is determined by the committee.
Plan of correction · submitted by the facility
Provider’s legal statement
F880 - Infection Control PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
No residents were named in the alleged deficient practice All residents have the potential to be affected by the alleged deficient practice Housekeeping staff were educated on 10/7/24 on the need to follow dwell times for disinfection, proper order for cleaning all high touch surfaces, hand hygiene. The nursing staff were reeducated on 10/9/2024 on using EBP (enhanced barrier precautions), including gown and gloves, when administering medications through a feed tube. The housekeeping supervisor will conduct 3 observations of housekeeping staff per week for 1 month and then 3 per month for 2 months to ensure ongoing compliance. The DON or designee will conduct 3 observations, including dwell times, order of cleaning, proper PPE use, and cleaning of high touch areas, of nursing staff providing care per week for 1 month and then 3 per month for 2 months to ensure ongoing compliance. Any issues identified will be addressed with the staff members immediately. All monitoring will be completed on paper documentation. The DON and Housekeeping will report the results of the observations to the QAPI meeting monthly for 3 months or until substantial compliance is determined by the committee.
6/11/2024Complaint Survey · ID JG2N11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO36305 and #CO36321 was conducted from 6/10/24 to 6/11/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/20/2024Complaint Survey · ID 1FI411No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO35012, #CO35013 and #CO35014 was conducted on 2/20/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/18/2023Revisit: Licensure Complaint Survey · ID X8FO12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 12/18/23 for all previous deficiencies cited on 10/11/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
12/18/2023Revisit: Complaint Survey · ID LUS512No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit survey was completed on 12/18/23 for all previous deficiencies cited on 10/11/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
12/13/2023Revisit: Recertification Survey · ID BULE22No 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.
Plan of correction
The state did not require a plan of correction for this citation.
10/11/2023Complaint Survey · ID LUS5111 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO33712, #CO33714, #CO33716 and #CO33815 was conducted on 10/4/23 to 10/11/23. One deficiency was 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 record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#240, #242, #245 and #246) of five residents out of 11 sample residents. Specifically, the facility failed to ensure Resident #240, Resident #242, Resident #245 and Resident #246 experienced a dignified living experience by answering the residents' call lights in a timely manner. Resident #240 and Resident #242, who required assistance with toileting, expressed embarrassment, frustration and anger due to long call times and not being provided timely assistance which resulted in them experiencing episodes of urinary incontinence. Findings include:I. Facility policy and proceduresThe Accommodation of Needs policy, revised March 2021, was provided by the clinical mentor (CM) on 10/18/23 at 11:11 a.m. It read in pertinent part, "Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being." -The policy did not specifically address resident call lights. II. Resident #240A. Resident statusResident #240, age greater than 65, was admitted on 9/26/23. According to the October 2023 computerized physician orders (CPO), diagnoses included unsteadiness on feet, need for assistance with personal care and history of falling. The 9/30/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required one-person extensive assistance for bed mobility and personal hygiene. He required one-person limited assistance for dressing and toilet use. Transfers occurred only once or twice during the seven day MDS look back period and required the assistance of one person. B. Resident interviewResident #240 was interviewed on 10/5/23 at 1:15 p.m. Resident #240 said he sometimes had to wait a long time for his call light to be answered. He said he occasionally was incontinent of urine when staff did not come to assist him to the bathroom in time. He said he understood that the staff was very busy, however, he said it was frustrating and extremely embarrassing when he did not make it to the bathroom in time. He said it was embarrassing because he was a grown man and should not be wetting himself. He said he was not supposed to take himself to the bathroom, however, he said he sometimes tried to do it himself so that he would not have a urinary accident. He said he had not spoken to anyone about his concerns with the long call wait times. C. Record reviewReview of Resident #240's fall care plan, initiated 9/26/23, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #240's call light log report from 9/26/23 to 10/5/23 revealed the following:-9/27/23 at 7:28 a.m: the call light was on for 17 minutes;-9/27/23 at 12:21 p.m: the call light was on for 21 minutes;-9/29/23 at 3:43 p.m: the call light was on for 15 minutes;-9/29/23 at 6:06 p.m: the call light was on for 17 minutes;-9/29/23 at 7:13 p.m: the call light was on for 34 minutes; and,-9/29/23 at 8:04 p.m: the call light was on for 37 minutes. III. Resident #242A. Resident statusResident #242, age greater than 65, was admitted on 8/24/23. According to the October 2023 CPO, diagnoses included history of falling, difficulty with walking, muscle weakness and need for assistance with personal care. The 8/28/23 MDS assessment revealed that the resident was cognitively intact with a BIMS score of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers and toilet use. She required one-person limited assistance for dressing. She required supervision for personal hygiene. B. Resident interviewResident #242 was interviewed on 10/5/23 at 1:02 p.m. Resident #242 said it sometimes took staff a long time to answer her call light. She said she had occasionally had to wait longer than 15 to 20 minutes for staff to answer her light. She said she had experienced a couple incidents of urinary incontinence when staff did not answer her call light in a timely manner. She said she was on a diuretic medication which made it difficult sometimes to hold her urine until staff was able to assist her if it took a long time for them to answer her light. She said it was frustrating and made her embarrassed and angry when she was incontinent of urine because she had to wait too long to use the bathroom. She said she was embarrassed because she was an adult and should be able to urinate in the toilet instead of her pants. She said she had not spoken to anyone regarding her frustrations with the long call wait times. She said she knew the staff worked hard and she did not want to get anyone in trouble. C. Record reviewReview of Resident #242's fall care plan, initiated 8/24/23, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #242's call light log report from 8/24/23 to 10/5/23 revealed the following:-8/26/23 at 8:55 a.m: the call light was on for 17 minutes;-8/29/23 at 7:43 p.m: the call light was on for 15 minutes;-8/30/23 at 7:59 a.m: the call light was on for 15 minutes;-9/2/23 at 10:25 a.m: the call light was on for 16 minutes;-9/7/23 at 1:14 p.m: the call light was on for 15 minutes;-9/8/23 at 7:04 a.m: the call light was on for 23 minutes;-9/8/23 at 2:52 p.m: the call light was on for 17 minutes;-9/8/23 at 8:25 p.m: the call light was on for 18 minutes;-9/11/23 at 4:56 a.m: the call light was on for 18 minutes;-9/16/23 at 10:31 p.m: the call light was on for 17 minutes;-9/17/23 at 9:15 a.m: the call light was on for 15 minutes;-9/19/23 at 11:40 a.m: the call light was on for 25 minutes;-9/20/23 at 2:05 p.m: the call light was on for 17 minutes;-9/24/23 at 7:23 p.m: the call light was on for 22 minutes; and,-9/28/23 at 4:10 p.m: the call light was on for 30 minutes. IV. Resident #245A. Resident statusResident #245, age greater than 65, was admitted on 9/14/23 and discharged to the community on 9/20/23. According to the September 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness and reduced mobility. The 9/19/23 MDS assessment revealed that the resident was cognitively intact with a BIMS score of 15 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person extensive assistance for dressing and personal hygiene. She required one-person limited assistance for toilet use. B. Record reviewReview of Resident #245's fall care plan, initiated 9/14/23, revealed the resident was at risk for falls, however, there were no pertinent interventions listed on the care plan. Review of Resident #245's call light log report from 9/14/23 to 9/21/23 revealed the following:-9/14/23 at 3:27 p.m: the call light was on for 17 minutes;-9/14/23 at 4:22 p.m: the call light was on for 33 minutes;-9/14/23 at 6:49 p.m: the call light was on for 19 minutes;-9/14/23 at 11:05 p.m: the call light was on for 37 minutes;-9/15/23 at 5:44 a.m: the call light was on for 25 minutes;-9/15/23 at 12:08 p.m: the call light was on for 36 minutes;-9/15/23 at 3:06 p.m: the call light was on for 18 minutes;-9/15/23 at 5:11 p.m: the call light was on for one hour and three minutes;-9/16/23 at 10:13 a.m: the call light was on for 23 minutes;-9/16/23 at 6:46 p.m: the call light was on for 16 minutes;-9/16/23 at 10:51 p.m: the call light was on for 29 minutes;-9/17/23 at 8:03 a.m: the call light was on for 17 minutes;-9/17/23 at 11:17 a.m: the call light was on for 17 minutes;-9/17/23 at 11:44 a.m: the call light was on for 30 minutes;-9/17/23 at 2:25 p.m: the call light was on for 32 minutes;-9/17/23 at 5:02 p.m: the call light was on for 20 minutes;-9/17/23 at 8:59 p.m: the call light was on for 30 minutes;-9/18/23 at 7:17 a.m: the call light was on for 15 minutes;-9/18/23 at 12:41 p.m: the call light was on for 16 minutes;-9/18/23 at 6:35 p.m: the call light was on for 22 minutes;-9/19/23 at 1:31 a.m: the call light was on for 32 minutes;-9/19/23 at 3:07 a.m: the call light was on for 16 minutes;-9/19/23 at 6:15 a.m: the call light was on for 19 minutes;-9/19/23 at 10:54 a.m: the call light was on for 18 minutes;-9/20/23 at 4:38 a.m: the call light was on for 17 minutes;-9/20/23 at 5:54 a.m:the call light was on for 35 minutes; and,-9/20/23 at 6:37 a.m: the call light was on for 38 minutes. V. Resident #246A. Resident statusResident #246, age greater than 65, was admitted on 8/29/23 and discharged to the community on 9/21/23. According to the September 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness and reduced mobility. The 8/31/23 MDS assessment revealed that the resident had moderate cognitive impairment with a BIMS score of eight out of 15. She required two-person limited assistance for bed mobility. Transfers occurred only once or twice during the seven day MDS look back period and required the assistance of two people. Toilet use and personal hygiene occurred only once or twice during the seven day MDS look back period and required the assistance of one person. Dressing did not occur during the seven day MDS look back period. B. Record reviewReview of Resident #246's fall care plan, initiated 9/11/23, revealed the resident was at risk for falls due to impaired balance and required staff assistance for stability. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #246's call light log report from 8/29/23 to 9/21/23 revealed the following:-8/29/23 at 6:14 p.m: the call light was on for 16 minutes;-8/30/23 at 9:34 a.m: the call light was on for 16 minutes;-9/1/23 at 12:05 p.m: the call light was on for 17 minutes;-9/3/23 at 5:39 p.m: the call light was on for 28 minutes;-9/4/23 at 10:05 a.m: the call light was on for 18 minutes;-9/7/23 at 1:33 p.m: the call light was on for 19 minutes;-9/9/23 at 6:34 p.m: the call light was on for 16 minutes;-9/10/23 at 3:30 p.m: the call light was on for 18 minutes;-9/10/23 at 7:43 p.m: the call light was on for 23 minutes;-9/12/23 at 7:26 a.m: the call light was on for 15 minutes;-9/13/23 at 8:20 a.m: the call light was on for 19 minutes;-9/14/23 at 8:55 a.m: the call light was on for 19 minutes;-9/15/23 at 9:10 a.m: the call light was on for 16 minutes;-9/15/23 at 2:00 p.m: the call light was on for 18 minutes;-9/15/23 at 7:19 p.m: the call light was on for 32 minutes;-9/16/23 at 10:43 a.m: the call light was on for 25 minutes;-9/16/23 at 6:43 p.m: the call light was on for 20 minutes;-9/17/23 at 9:28 a.m: the call light was on for 45 minutes; and,-9/20/23 at 11:39 a.m: the call light was on for 29 minutes. VI. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/11/23 at 9:55 a.m. RN #1 said certified nurse aides (CNA) answered call lights. He said CNAs had a pager that let them know a resident's call light was on. He said nurses did not have a pager. He said nurses' cell phones were programmed to get a text message on their phone if the call light had not been answered by the CNAs after five minutes. He said call lights should be answered as soon as possible. He said a reasonable expectation to answer a call light was in five to six minutes. RN #2 was interviewed on 10/11/23 at 10:10 a.m. RN #2 said resident call lights should be answered as soon as possible. He said staff should attempt to answer resident call lights within two to three minutes. RN #2 said CNAs had a pager that alerted them to a resident's call light. He said nurses had a pager and a cell phone. He said the pager and the cell phones were set up to receive an alert that a resident's call light was on if it had not been answered after five minutes. CNA #1 was interviewed on 10/11/23 at 10:15 a.m: CNA #1 said CNAs carried pagers that alerted them a resident's call light was on. She said a call light should be answered in less than five minutes if possible. She said if a resident's call light could not be answered quickly, the CNA should let the nurse know so the nurse could assist with getting the resident's call light answered timely. CNA #2 was interviewed on 10/11/23 at 10:25 a.m. CNA #2 said CNAs wore a pager which alerted them when a call light was turned on. She said call lights needed to be answered as soon as possible. She said call lights should be answered in under 15 minutes. The director of nursing (DON) was interviewed on 10/11/23 at 11:15 a.m. The DON said call lights should be answered as soon as possible and all attempts should be made to answer the call lights in less than 10 minutes. She said CNAs and nurses wore pagers which alerted them a resident's call light was on. She said CNA pagers alerted them at the time a resident's call light was turned on and kept alerting them every minute afterward until the call light was answered. The DON said nurses wore a pager which alerted them a resident's call light was on after the call light had been on for three minutes without being answered. She said the nurses received repeat alerts every two minutes after the initial alert until the call light was answered. The DON said the nurses' cell phones were programmed to receive text message alerts that a resident's call light was on. She said the nurses received a text message about the call light when it had been on for six minutes, 10 minutes and 15 minutes. The DON said unit managers did not have pagers, however, she said they received text message alerts on their cell phones if a call light had gone unanswered for 10 minutes. She said they received another alert if a call light had been on for 15 minutes. The DON said she and the assistant director of nursing (ADON) received text message alerts on their cell phones if a call light had gone unanswered for 15 minutes. She said the alert system program for the cell phones did not have the capability to send alerts past 15 minutes. The DON said everyone who received an alert was expected to go and investigate why the resident's call light had not been answered and assist residents with their needs. She said sometimes staff forgot to turn off a resident's call light when it was answered and that was why some of the call light response times were so long. She said with the way the facility's call light alert system was set up a resident's call light should never be unanswered for more than 20 minutes at the most. The DON said she conducted random call light audits, however she said she did not have documentation of the audits. She said she would pull up call lights on the call light log by unit and see if there was a concern for long call wait times on a specific unit. She said if she found an issue she would check in with the staff on that unit to make sure the pagers were all functioning and not turned to the silent mode. The DON said she conducted random visits on night shift and asked unit managers to follow up to ensure the pagers on their units were functioning properly and that batteries were available on a daily basis. VII. Facility follow upOn 10/11/23 at 12:00 p.m. the DON provided an email which was sent by her to the NHA and unit managers on 9/14/23 at 2:51 a.m. The email informed the recipients that she had conducted a night shift visit and discovered two pagers that were in disrepair on the 2 North unit. She instructed the unit managers to conduct an audit of all of the pagers on their units on the morning of 9/14/23 and bring any concerns with pagers to the morning meeting. There were no other concerns found with the pagers in the facility.-There was no other documentation provided by the facility regarding call light audits or other random night shift visits.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident #240, #242, #245 and #246 no longer reside in the facility. 2. Residents who require assistance with ADLs have the potential to be affected by the alleged deficient practice. Call light times were reviewed using the computerized call system to identify call light times that exceed >20mins and residents with these call times were interviewed to identify if their needs were met. 3. The call light notification system was updated on 10/12/23 to increase the alerts to staff when a call light is activated. The IDT members will interview their assigned interviewable residents at least twice a week to identify any resident who feel their needs are not being met. Education to staff was provided beginning on 10/12/23 on the importance of answering call lights timely to meet the needs of the residents and the facility expectation that staff who carry pagers for the call light system report any issues with the pagers. The IDT will Interview 10 residents per week for 3 months on call light response and observation of call light within reach. Any concerns identified in the interviews will be addressed through the greivance process with the resident to ensure that any concerns with dignity are addressed. The DON or designee will audit daily reports of the call light system for 1 month then weekly reports for 2 months to identify trends in call light response times. Any trend of increased call light response time will be addressed by the IDT. 4. The DON or designee will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
10/11/2023Licensure Complaint Survey · ID OVMJ11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A health survey with complaint #CO33333 was completed 10/4/23 to 10/11/23. No response necessary.
Plan of correction
The state did not require a plan of correction for this citation.
10/11/2023Licensure Complaint Survey · ID X8FO111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A survey prompted by complaint #CO34027 was completed 10/4/23 to 10/11/23. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1515Resident Rights - Statement of Rights▼
Findings
Based on record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#240, #242, #245 and #246) of five residents out of 11 sample residents. Specifically, the facility failed to ensure Resident #240, Resident #242, Resident #245 and Resident #246 experienced a dignified living experience by answering the residents' call lights in a timely manner. Resident #240 and Resident #242, who required assistance with toileting, expressed embarrassment, frustration and anger due to long call times and not being provided timely assistance which resulted in them experiencing episodes of urinary incontinence. Findings include:I. Facility policy and proceduresThe Accommodation of Needs policy, revised March 2021, was provided by the clinical mentor (CM) on 10/18/23 at 11:11 a.m. It read in pertinent part, "Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being."-The policy did not specifically address resident call lights. II. Resident #240A. Resident statusResident #240, age greater than 65, was admitted on 9/26/23. According to the October 2023 computerized physician orders (CPO), diagnoses included unsteadiness on feet, need for assistance with personal care and history of falling. The 9/30/23 facility assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required one-person extensive assistance for bed mobility and personal hygiene. He required one-person limited assistance for dressing and toilet use. Transfers occurred only once or twice during the seven day facility assessment look back period and required the assistance of one person. B. Resident interviewResident #240 was interviewed on 10/5/23 at 1:15 p.m. Resident #240 said he sometimes had to wait a long time for his call light to be answered. He said he occasionally was incontinent of urine when staff did not come to assist him to the bathroom in time. He said he understood that the staff was very busy, however, he said it was frustrating and extremely embarrassing when he did not make it to the bathroom in time. He said it was embarrassing because he was a grown man and should not be wetting himself. He said he was not supposed to take himself to the bathroom, however, he said he sometimes tried to do it himself so that he would not have a urinary accident. He said he had not spoken to anyone about his concerns with the long call wait times. C. Record reviewReview of Resident #240's fall care plan, initiated 9/26/23, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #240's call light log report from 9/26/23 to 10/5/23 revealed the following:-9/27/23 at 7:28 a.m: the call light was on for 17 minutes;-9/27/23 at 12:21 p.m: the call light was on for 21 minutes;-9/29/23 at 3:43 p.m: the call light was on for 15 minutes;-9/29/23 at 6:06 p.m: the call light was on for 17 minutes;-9/29/23 at 7:13 p.m: the call light was on for 34 minutes; and,-9/29/23 at 8:04 p.m: the call light was on for 37 minutes. III. Resident #242A. Resident statusResident #242, age greater than 65, was admitted on 8/24/23. According to the October 2023 CPO, diagnoses included history of falling, difficulty with walking, muscle weakness and need for assistance with personal care. The 8/28/23 facility assessment revealed that the resident was cognitively intact with a BIMS score of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers and toilet use. She required one-person limited assistance for dressing. She required supervision for personal hygiene. B. ResidentinterviewResident #242 was interviewed on 10/5/23 at 1:02 p.m. Resident #242 said it sometimes took staff a long time to answer her call light. She said she had occasionally had to wait longer than 15 to 20 minutes for staff to answer her light. She said she had experienced a couple incidents of urinary incontinence when staff did not answer her call light in a timely manner. She said she was on a diuretic medication which made it difficult sometimes to hold her urine until staff was able to assist her if it took a long time for them to answer her light. She said it was frustrating and made her embarrassed and angry when she was incontinent of urine because she had to wait too long to use the bathroom. She said she was embarrassed because she was an adult and should be able to urinate in the toilet instead of her pants. She said she had not spoken to anyone regarding her frustrations with the long call wait times. She said she knew the staff worked hard and she did not want to get anyone in trouble. C. Record reviewReview of Resident #242's fall care plan, initiated 8/24/23, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #242's call light log report from 8/24/23 to 10/5/23 revealed the following:-8/26/23 at 8:55 a.m: the call light was on for 17 minutes;-8/29/23 at 7:43 p.m: the call light was on for 15 minutes;-8/30/23 at 7:59 a.m: the call light was on for 15 minutes;-9/2/23 at 10:25 a.m: the call light was on for 16 minutes;-9/7/23 at 1:14 p.m: the call light was on for 15 minutes;-9/8/23 at 7:04 a.m: the call light was on for 23 minutes;-9/8/23 at 2:52 p.m: the call light was on for 17 minutes;-9/8/23 at 8:25 p.m: the call light was on for 18 minutes;-9/11/23 at 4:56 a.m: the call light was on for 18 minutes;-9/16/23 at 10:31 p.m: the call light was on for 17 minutes;-9/17/23 at 9:15 a.m: the call light was on for 15 minutes;-9/19/23 at 11:40 a.m: the call light was on for 25 minutes;-9/20/23 at 2:05 p.m: the call light was on for 17 minutes;-9/24/23 at 7:23 p.m: the call light was on for 22 minutes; and,-9/28/23 at 4:10 p.m: the call light was on for 30 minutes. IV. Resident #245A. Resident statusResident #245, age greater than 65, was admitted on 9/14/23 and discharged to the community on 9/20/23. According to the September 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness and reduced mobility. The 9/19/23 facility assessment revealed that the resident was cognitively intact with a BIMS score of 15 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person extensive assistance for dressing and personal hygiene. She required one-person limited assistance for toilet use. B. Record reviewReview of Resident #245's fall care plan, initiated 9/14/23, revealed the resident was at risk for falls, however, there were no pertinent interventions listed on the care plan. Review of Resident #245's call light log report from 9/14/23 to 9/21/23 revealed the following:-9/14/23 at 3:27 p.m: the call light was on for 17 minutes;-9/14/23 at 4:22 p.m: the call light was on for 33 minutes;-9/14/23 at 6:49 p.m: the call light was on for 19 minutes;-9/14/23 at 11:05 p.m: the call light was on for 37 minutes;-9/15/23 at 5:44 a.m: the call light was on for 25 minutes;-9/15/23 at 12:08 p.m: the call light was on for 36 minutes;-9/15/23 at 3:06 p.m: the call light was on for 18 minutes;-9/15/23 at 5:11 p.m: the call light was on for one hour and three minutes;-9/16/23 at 10:13 a.m: the call light was on for 23 minutes;-9/16/23 at 6:46 p.m: the call light was on for 16 minutes;-9/16/23 at 10:51 p.m: the call light was on for 29 minutes;-9/17/23 at 8:03 a.m: the call light was on for 17 minutes;-9/17/23 at 11:17 a.m: the call light was on for 17 minutes;-9/17/23 at 11:44 a.m: the call light was on for 30 minutes;-9/17/23 at 2:25 p.m: the call light was on for 32 minutes;-9/17/23 at 5:02 p.m: the call light was on for 20 minutes;-9/17/23 at 8:59 p.m: the call light was on for 30 minutes;-9/18/23 at 7:17 a.m: the call light was on for 15 minutes;-9/18/23 at 12:41 p.m: the call light was on for 16 minutes;-9/18/23 at 6:35 p.m: the call light was on for 22 minutes;-9/19/23 at 1:31 a.m: the call light was on for 32 minutes;-9/19/23 at 3:07 a.m: the call light was on for 16 minutes;-9/19/23 at 6:15 a.m: the call light was on for 19 minutes;-9/19/23 at 10:54 a.m: the call light was on for 18 minutes;-9/20/23 at 4:38 a.m: the call light was on for 17 minutes;-9/20/23 at 5:54 a.m:the call light was on for 35 minutes; and,-9/20/23 at 6:37 a.m: the call light was on for 38 minutes. V. Resident #246A. Resident statusResident #246, age greater than 65, was admitted on 8/29/23 and discharged to the community on 9/21/23. According to the September 2023 CPO, diagnoses included need for assistance with personal care, muscle weakness and reduced mobility. The 8/31/23 facility assessment revealed that the resident had moderate cognitive impairment with a BIMS score of eight out of 15. She required two-person limited assistance for bed mobility. Transfers occurred only once or twice during the seven day facility assessment look back period and required the assistance of two people. Toilet use and personal hygiene occurred only once or twice during the seven day facility assessment look back period and required the assistance of one person. Dressing did not occur during the seven day facility assessment look back period. B. Record reviewReview of Resident #246's fall care plan, initiated 9/11/23, revealed the resident was at risk for falls due to impaired balance and required staff assistance for stability. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and providing a prompt response to all requests for assistance. Review of Resident #246's call light log report from 8/29/23 to 9/21/23 revealed the following:-8/29/23 at 6:14 p.m: the call light was on for 16 minutes;-8/30/23 at 9:34 a.m: the call light was on for 16 minutes;-9/1/23 at 12:05 p.m: the call light was on for 17 minutes;-9/3/23 at 5:39 p.m: the call light was on for 28 minutes;-9/4/23 at 10:05 a.m: the call light was on for 18 minutes;-9/7/23 at 1:33 p.m: the call light was on for 19 minutes;-9/9/23 at 6:34 p.m: the call light was on for 16 minutes;-9/10/23 at 3:30 p.m: the call light was on for 18 minutes;-9/10/23 at 7:43 p.m: the call light was on for 23 minutes;-9/12/23 at 7:26 a.m: the call light was on for 15 minutes;-9/13/23 at 8:20 a.m: the call light was on for 19 minutes;-9/14/23 at 8:55 a.m: the call light was on for 19 minutes;-9/15/23 at 9:10 a.m: the call light was on for 16 minutes;-9/15/23 at 2:00 p.m: the call light was on for 18 minutes;-9/15/23 at 7:19 p.m: the call light was on for 32 minutes;-9/16/23 at 10:43 a.m: the call light was on for 25 minutes;-9/16/23 at 6:43 p.m: the call light was on for 20 minutes;-9/17/23 at 9:28 a.m: the call light was on for 45 minutes; and,-9/20/23 at 11:39 a.m: the call light was on for 29 minutes. VI. Staff interviewsRegistered nurse (RN) #1 was interviewed on 10/11/23 at 9:55 a.m. RN #1 said certified nurse aides (CNA) answered call lights. He said CNAs had a pager that let them know a resident's call light was on. He said nurses did not have a pager. He said nurses' cell phones were programmed to get a text message on their phone if the call light had not been answered by the CNAs after five minutes. He said call lights should be answered as soon as possible. He said a reasonable expectation to answer a call light was in five to six minutes. RN #2 was interviewed on 10/11/23 at10:10 a.m. RN #2 said resident call lights should be answered as soon as possible. He said staff should attempt to answer resident call lights within two to three minutes. RN #2 said CNAs had a pager that alerted them to a resident's call light. He said nurses had a pager and a cell phone. He said the pager and the cell phones were set up to receive an alert that a resident's call light was on if it had not been answered after five minutes. CNA #1 was interviewed on 10/11/23 at 10:15 a.m: CNA #1 said CNAs carried pagers that alerted them a resident's call light was on. She said a call light should be answered in less than five minutes if possible. She said if a resident's call light could not be answered quickly, the CNA should let the nurse know so the nurse could assist with getting the resident's call light answered timely. CNA #2 was interviewed on 10/11/23 at 10:25 a.m. CNA #2 said CNAs wore a pager which alerted them when a call light was turned on. She said call lights needed to be answered as soon as possible. She said call lights should be answered in under 15 minutes. The director of nursing (DON) was interviewed on 10/11/23 at 11:15 a.m. The DON said call lights should be answered as soon as possible and all attempts should be made to answer the call lights in less than 10 minutes. She said CNAs and nurses wore pagers which alerted them a resident's call light was on. She said CNA pagers alerted them at the time a resident's call light was turned on and kept alerting them every minute afterward until the call light was answered. The DON said nurses wore a pager which alerted them a resident's call light was on after the call light had been on for three minutes without being answered. She said the nurses received repeat alerts every two minutes after the initial alert until the call light was answered. The DON said the nurses' cell phones were programmed to receive text message alerts that a resident's call light was on. She said the nurses received a text message about the call light when it had been on for six minutes, 10 minutes and 15 minutes. The DON said unit managers did not have pagers, however, she said they received text message alerts on their cell phones if a call light had gone unanswered for 10 minutes. She said they received another alert if a call light had been on for 15 minutes. The DON said she and the assistant director of nursing (ADON) received text message alerts on their cell phones if a call light had gone unanswered for 15 minutes. She said the alert system program for the cell phones did not have the capability to send alerts past 15 minutes. The DON said everyone who received an alert was expected to go and investigate why the resident's call light had not been answered and assist residents with their needs. She said sometimes staff forgot to turn off a resident's call light when it was answered and that was why some of the call light response times were so long. She said with the way the facility's call light alert system was set up a resident's call light should never be unanswered for more than 20 minutes at the most. The DON said she conducted random call light audits, however she said she did not have documentation of the audits. She said she would pull up call lights on the call light log by unit and see if there was a concern for long call wait times on a specific unit. She said if she found an issue she would check in with the staff on that unit to make sure the pagers were all functioning and not turned to the silent mode. The DON said she conducted random visits on night shift and asked unit managers to follow up to ensure the pagers on their units were functioning properly and that batteries were available on a daily basis. VII. Facility follow upOn 10/11/23 at 12:00 p.m. the DON provided an email which was sent by her to the NHA and unit managers on 9/14/23 at 2:51 a.m. The email informed the recipients that she had conducted a night shift visit and discovered two pagers that were in disrepair on the 2 North unit. She instructed the unit managers to conduct an audit of all of the pagers on their units on the morning of 9/14/23 and bring any concerns with pagers to the morning meeting. There were no other concerns found with the pagers in the facility.-There was no other documentation provided by the facility regarding call light audits or other random night shift visits.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident #240, #242, #245 and #246 no longer reside in the facility. 2. Residents who require assistance with ADLs have the potential to be affected by the alleged deficient practice. Call light times were reviewed using the computerized call system to identify call light times that exceed >20mins and residents with these call times were interviewed to identify if their needs were met. 3. The call light notification system was updated on 10/12/23 to increase the alerts to staff when a call light is activated. The IDT members will interview their assigned interviewable residents at least twice a week to identify any resident who feel their needs are not being met. Education to staff was provided beginning on 10/12/23 on the importance of answering call lights timely to meet the needs of the residents and the facility expectation that staff who carry pagers for the call light system report any issues with the pagers. The IDT will Interview 10 residents per week for 3 months on call light response and observation of call light within reach. Any concerns identified in the interviews will be addressed through the grievance process with the resident to ensure that any concerns with dignity are addressed. The DON or designee will audit daily reports of the call light system for 1 month then weekly reports for 2 months to identify trends in call light response times. Any trend of increased call light response time will be addressed by the IDT. 4. The DON or designee will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
10/9/2023Revisit: Complaint, Recertification Survey · ID BULE12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 10/4/23 to 10/9/23 for all previous deficiencies cited on 7/31/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
10/9/2023Revisit: Licensure Complaint Survey · ID WYPS12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 10/4/23 to 10/9/23 for all previous deficiencies cited on 7/31/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
8/24/2023Recertification Survey · ID BULE212 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). The facility is a two (2) story, Type II (000) construction, with no basement. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system that consists of a wet fire sprinkler system. This survey was conducted August 24, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 18, New Health Care Occupancies; The adopted portions of NFPA 99, Health Care Facilities Code (2012); and referenced standards.
Plan of correction
The state did not require a plan of correction for this citation.
0372Subdivision of Building Spaces - Smoke BarrieS/S F▼
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:Penetrations found in fire barriers above ceiling on first/second floor in the corridorNFPA 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 maintenance director and administrator at the exit conference.
Plan of correction · submitted by the facility
Plan of Correction NFPA 101 Deficiency 0372 Smoke Barriers Open penetration was observed in the smoke compartment located at the following locations; Above the smoke compartment door on the first and second floor North and South. Items were found and corrected on 9/8/2023The Maintenance Director created an audit to check the affected areas for penetration for 90-days to prevent this deficiency and provide safety for all occupants of the facility including residents, staff, and visitors. This inspection audit for penetrations is going to be reviewed every month with NHA and (QUAPI) Quality Assurance and Performance Improvement.
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 19.7.1.6No report available for 1st shift fire drill for the 4th quarter 2022NFPA 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
Plan of CorrectionNFPA 101 Deficiency 0712 Fire DrillThe Life Safety Officer reviewed the paperwork and he noticed that there was no report available for the 4th quarter 2022. The Maintenance Director is going to be responsible to conduct fire drills each quarter to prevent this deficiency and provide all staff inservice reviewing with them what to do in case of a fire in the facility and provide safety for all occupants of the facility including resident, staff and visitors. The Fire Drills Audit is going to be reviewed every quarter with NHA and (QAPI ) Quality Assurance and Performance Improvement.
7/31/2023Complaint, Recertification Survey · ID BULE119 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A recertification survey with #CO32934, #CO32942, #CO32943, #CO32944, #CO32945, #CO32947, #CO32948, #CO32976, #CO32986 and #CO32993 was conducted from 7/24/23 to 7/31/23. Nine deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 7/24/23 to 7/31/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0585GrievancesS/S E▼
Findings
Based on interviews and record review, the facility failed to provide prompt acceptable resolution to resident/resident representative grievances that were important to the residents. Specifically, the facility failed to resolve grievances for long call wait times in a manner that was satisfactory to the residents in the facility. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, reviewed 10/10/19, was provided by the nursing home administrator (NHA) on 5/12/22 at 4:48 p.m. It read, in pertinent part, "to ensure residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form."A resident, family member, staff member or visitor may file a grievance at any time with an appropriate staff member or supervisor. There is no set time frame or minimum amount of time in which it must be filed except for those required under the Elder Justice Law."Upon receipt of a Grievance and Complaint Report or Complaint Concern form, the social services director or designee will begin an exploration into the allegations/concerns. The appropriate department director will be notified of the nature of the complaint and that follow up is necessary. The investigation and report will include, as each may apply: the date and time the incident took place; the circumstances surrounding the incident; where the incident took place; the names of any witnesses and their account of the incident; the resident's account of the incident; the employee's account of the incident; accounts of any other individuals involved; and recommendations for corrective action if not already remedied."The Grievance and Complaint Investigation Report must be filed with the administrator within five working days of the receipt of the grievance of complaint form."II. Resident interviews Resident #41 was interviewed on 7/25/23 at 1:45 p.m. Resident #41 said she waited several hours for staff to answer her call light. Resident #41 said she used the call light and no staff came. She said it sometimes made her upset and anxious and the staff did not care. Resident #68 was interviewed on 7/25/23 at 1:45 p.m. Resident #68 said he waited 45 minutes for staff to answer his call light when he used it to request pain medication. Resident #1 was interviewed on 7/25/23 at 3:05 p.m. Resident #1 said it could take staff 20 to 30 minutes or more to answer the call light. Sometimes the certified nursing aids (CNA) came into the room after the 20 to 30 minute wait and did nothing for her; turned off the call light; left the room and then did not come back for another 20-30 minutes. Resident #1 said she did not like it because there were several times they turned off the light and left when she felt uncomfortable and needed personal care. Resident #233 was interviewed on 7/27/23 at 4:20 p.m. Resident #233 said she waited in pain for about 45 minutes for staff to come when she needed the bedpan on 7/15/23. Resident #233 said there were sometimes after she used her call light that she waited for longer than 20 minutes after activating the call light when she needed to use the bedpan. Resident #233 said sometimes when staff did not answer the call light it made her scared, worried and anxious about having an accident. III. Record reviewA. Grievance logThe grievance log from 6/6/23 to 7/17/23 revealed there were 13 grievances for call lights. B. Call light alert and response times reportA request was made for call light response time for residents who reported long call light wait times during the survey; and for observations during the survey where call light's where staff failed to respond to the resident's call light effectively. The call light response logs (incident details report) revealed the following:-Resident #4's call light log for 7/24/23 at 8:37 a.m. revealed the call light was not answered for 30 minutes.-Resident #233's call light log for 7/15/23 at 5:10 a.m. revealed the call light was not answered for 44 minutes and not answered for 24 minutes during the same morning at 6:09 a.m.-Resident #34's call light log for on 7/26/23 at 9:22 p.m. revealed the call light was not answered for 18 minutes.-Resident #22's call light log for 7/17/23 between 8:35 a.m. and 4:47 p.m. revealed the call light was not answered timely five times during that day. The call light activated at 8:35 a.m., was not answered for 48 minutes; the call light activated at 10:11 a.m, was not answered for 45 minutes; the call light activated at 1:46 p.m., was not answered for 26 minutes; the call light activated at 2:17 p.m., was not answered for 55 minutes; and the call light activated at 4:47 p.m., was not answered for 45 minutes. IV. Staff interviewsCNA #1 was interviewed on 7/25/23 at 4:08 p.m. CNA #1 said the CNAs were supposed to answer the call lights within three minutes, but sometimes she was busy with other residents and could not answer right away. CNA #1 said she when a call light was activated she would check on the resident and turn off their call. If the resident needed to be changed or toileted, she would help them immediately. If she could not help the resident immediately then she would let the nurse know. CNA #2 was interviewed on 7/25/23 at 4:08 p.m. CNA # 2 said she tried to answer the call lights within three minutes, but answering call lights in that time was sometimes difficult when there were a lot of call lights on at the same time. CNA #2 said when that happened she would finish up with the resident she was working with and then answer the next call light as soon as possible. CNA # 2 said if she could not get to the residents she would tell the nurse. CNA #3 was interviewed on 7/27/23 at 11:56 a.m. CNA #3 said she tried to answer the call light as soon as possible. If she was in the middle of helping a resident she would finish with them before answering the call light. She said if a resident could wait she would go in and turn off the call light and return after finishing with another resident. CNA #3 said if a resident needed personal care or the bathroom she would find another staff member to help right away. Licensed practical nurse (LPN) #2 was interviewed on 7/27/23 at 4:13 p.m. LPN #2 said the resident call light system used pagers which the CNAs had. LPN #2 said the CNAs should answer the call lights within a reasonable time frame, which was considered to be within seven minutes. LPN #2 said there were times when the CNA would be in with a resident and was unable to answer the call lights timely. LPN #2 said when that happened another CNA would help them. LPN #2 said it would depend on a resident's need, if it was something simple then the CNA could help them quickly. LPN #2 said if it was a more significant need, such as personal care was needed for a resident who required a two-person lift, the CNA might turn off the call light and then leave to get help from another staff member. LPN #2 said there were times when the CNA would forget to turn off the call light when they went to get another staff, which would show an increase in the call light response time. The director of nursing (DON) was interviewed on 7/31/23 at 3:56 p.m. The DON said the call light system used pagers and an escalation system. The CNAs, the unit nurses and nurse managers carried pagers. The assistant director of nursing (ADON) and the DON got the call light alerts on their cell phones. The DON said when a call light was used the CNAs get an alert on their pagers letting them know which room and resident needed attention. The CNAs needed to respond to the call light within three minutes if they did not the unit nurse received an alert page after the three minute mark. If the call light was not answered by six minutes, the nurse manager would then receive an alert pager message; and the ADON would receive an alert after 10 minutes. Then after 15 minutes DON received a notification message a resident's call light was still unanswered. The DON said when she received the notification on her phone she would call the unit/facility to determine what happened. The DON said she reviewed the call light report weekly and would determine why there were long call light times and provide education for staff who were involved in the long call light times. The DON said a CNA was to answer the call light within a reasonable time of 10 minutes or less. The DON said for a CNA to answer a call light timely would depend upon several factors such as time of day; if there was an emergency; if someone had a change in condition; if a resident needed a two person assist; or if the CNAs were busy helping another resident. The DON said another reason for the long call light times could be due to the CNA forgetting to turn off the call light before helping the resident, not turning off the call light off prior to leaving the room to finish up with another resident or getting help from another CNA.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident #1 and #41 call light times are being monitored and are on daily (Monday through Friday) interviews to ensure that their needs are being met. Residents #68 and #233 no longer reside at the facility 2. Other residents who reside in the facility are interviewed five times per week using an Ambassador Round questionnaire to identify any concerns. Identified concerns are addressed through the grievance process. 3. The facility staff were educated beginning on 8/3/23 on the grievance process, including assisting residents with filing a grievance if the resident is unable to complete one independently, timely follow up to resolve the grievance with the resident and tracking and trending of grievances to monitor for need for systemic changes to current practice. The Social Service Director will review all grievances for follow up, resolution with the resident and enter the information into the grievance log daily (Monday-Friday) to ensure ongoing monitoring. Any concerns identified will be addressed immediately. 4. The SSD will report the results of the tracking and trending to the QAPI for review monthly for 3 months or until substantial compliance is determined by the committee.
0679Activities Meet Interest/Needs Each ResidentS/S E▼
Findings
Based on observations, record review and interviews, the facility failed to ensure meaningful activities designed to support residents physical, mental, and psychosocial well-being were provided for three (#1, #4 and #41) of six residents out of 52 sample residents. Specifically, the facility failed to:-Offer the resident population a consistent and regular scheduled activities program that included both facility-sponsored group and individual activities and independent 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;-To provide residents #1, #4 and #41 meaningful activities; and,-To offer residents #1, #4 and #41 regularly scheduled activities of choice. Findings include:I. Facility policy and procedureThe Activity Documentation policy and procedure, revised on 6/20/23, was provided by the director of nursing (DON) on 7/31/23 at 4:00 p.m. It revealed, in pertinent part, "The community will offer at least three group activities per week, one of which must be offered in the evening (after dinner) that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies and culture of the participants and community. Activities include community sponsored group and assistance in individualized/independent activities."Activities will create opportunities for participants to have a meaningful life by supporting their domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning)."Activities will be designed to meet participants' best ability to function, incorporating their strengths and abilities."The activity department will provide 1:1 (one-to-one) recreation and social visits if the individual was unable to participate in independent leisure, or, upon participant request."II. Activities programmingA. Resident interviews Resident #34 was interviewed on 7/24/23 at 9:05 a.m. She stated activities were none existent. She said that staff provided assistance to select television programs. She said that staff had not offered a selection of activities and that she had participated once with an activity but it was not meaningful because it was not interesting to her. She said she had not been invited to participate in other activities. Resident #57 was interviewed on 7/26/23 at 11:42 a.m. Resident #57 said he had been at the facility for about six weeks, since mid June 2023. Resident #57 said he had not met any other residents for his first three weeks at the facility. Resident #57 said the first time he met other residents was when he attended a group therapy session. He then began to eat meals with the other residents. Resident #57 said he suggested to staff they have group activities such as an ice cream social, bingo or games in order for residents to meet each other and socialize. Resident #57 said he was not offered one-to-one or group activities since he had arrived. Resident #57's room did not have an activities calendar posted. Resident #23 was interviewed on 7/27/23 at 9:52 a.m. Resident #23 was unable to speak answers aloud but was able to answer some questions with gestures. Resident #23 shook his head no when asked if he was offered or participated in activities. When Resident #23 was asked how long it had been since he was offered or participated in activities and he held up three fingers indicating he had not been offered activities opportunities in the three months since he arrived in the facility. Resident #23 shook his head yes that he would participate in activities if they were offered. Resident #23's room did not have an activities calendar posted. B. Record reviewThe combined July 2023 therapeutic and activity calendar documented the following activities opportunities: -On 7/5/23 activities offered Bingo at 5:45 p.m.;-On 7/11/23 activities offered a viewing of a docu-series show at 5:45 p.m.;-On 7/18/23 activities offered evening devotional at 5:45 p.m.;-On 7/25/23 activities offered a social with card games at 5:45 p.m..-All other offerings listed on the calendar were therapy-oriented groups activities provided by the therapy department. C. The activities director (AD) interview The AD was interviewed on 7/27/23 11:06 a.m. The AD said the activities staff were offering only one group activity a week in the evenings from 5:00 p.m. to 7:00 p.m., due to lack of staff. There were no group activities being offered during the day time hours. The AD was the only staff member in the activities department but when the department was fully staffed there were three to five staff and they were able to provide regular activities programming when they were fully staffed. When fully staffed there would be two group activities every day and one-to-one activities programming would be provided to all residents assessed to need that level of programming on a regular schedule. The one to one activities would be completed by the AD and one other activity staff while the others would provide group programming and offer resident supplies for independent activities. The AD said she was currently the only staff providing one-to-one activities to residents. The AD said over the last couple of months the activity calendar was merged with the therapeutic group exercise calendar since the activities department was only able to provide one group activity weekly. The therapeutic group exercise programming was a part of the therapy department services; the therapy department provided physical therapy and occupational therapy for residents who received skilled nursing services. The group therapy sessions listed on the combined activities therapy calendar was open to all residents if they wanted to attend. The AD said when the activity department was fully staffed a separate calendar would be posted to include two recreational and social group activities per day. A paper copy of the calendar would be posted in each of the residents ' rooms so the resident would be aware of what activity was offered by the AD. At present, they did not post an activity calendar in the residents ' rooms. The AD described independent leisure activities as any activity residents were observed participating in independently such as reading, watching television, talking or visiting with someone. III. Resident #4 A. Resident statusResident #4, age 68, was admitted on 7/20/22 and readmitted on 10/20/22. According to the July 2023 computerized physician orders (CPO), the diagnoses included ventilator dependence, reduced mobility, dementia, bipolar II disorder and anxiety disorder. The 5/1/23 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. She required extensive assistance of two people for most activities of daily living (ADLs). The assessment documented the resident's speech was unclear, but the resident was able to make concrete requests and to respond adequately to simple direct communication. The 8/7/22 MDS initial assessment indicated it was very important for Resident #4 to listen to music, have animals/pets around, to participate in her favorite activities and religious services. It was somewhat important for Resident #4 to have books, newspapers and magazines to read and to go outside to get fresh air in good weather. B. Resident observations and interview-On 7/26/23 at 2:34 p.m., Resident #4 was in bed resting, she appeared to be sleeping. -From 3:33 p.m. to 3:39 p.m., two staff provided personal care and repositioning. There was no additional stimulation or interactions between the staff and the resident and the resident was not offered or encouraged to participate in any type of recreational activity. -At 5:02 p.m. Resident #4 was in bed sleeping. Resident #4 did not have any external stimulation or social interactions. -On 7/27/23 at 9:54 a.m., 11:14 a.m. and 1:49 p.m. Resident #4 was observed in her room sleeping with no external stimulation or social interactions.-At 2:48 p.m. staff provided personal care and repositioning. There was no additional stimulation or interactions with others. Resident #4 was interviewed on 7/27/23 at 2:54 p.m. Resident #4 was awake, looking out her window and moving around in bed. Resident #4's television was not on and she did not have any additional stimulation or items for independent activities. Resident #4 was unable to speak aloud but was able to respond to questions by mouthing simple words and by use of gestures. Resident #4 mouthed yes to wanting to participate in activities including listening to music, visiting with animals and observing or working with art. When asked if she wanted to get out of her room to participate in activities she nodded her head yes. She then pointed to the window and smiled, she nodded her head when asked if she enjoyed looking out of the window. Resident #4's room did not have an activities calendar posted. C. Resident representative interviewThe resident's representative was interviewed on 7/27/23 at 2:10 p.m. The representative said Resident #4 loved music, animals and art. The resident representative said she did not think Resident #4 did any activities right now. She said she would like it if Resident #4 could participate in activities that interested her. She would especially like it if Resident #4 were to be able to get out of her room to participate in activity programming. The resident representative said Resident #4 would not refuse those activities if they were offered to her either for a one-to-one or group activity. D. Record reviewActivities care plan initiated on 8/5/22 revealed Resident #4's interests were reading books, listening to music (rock n ' roll, country, Conway Twitty, and blues), being around animals, watching movies, westerns, or sports on the television (TV). Resident #4 was a Broncos football fan and enjoyed getting fresh air and having her blinds and windows open. Resident #4 was Christian and practiced by listening to gospel music. The care focus goal initiated on 8/5/22 revealed Resident #4 would participate in independent leisure activities of choice approximately three to five times per week by watching shows of interest on TV, reading or listening to music of interest. Goal initiated on 2/10/23 revealed Resident #4 would accept therapeutic one-to-one visits approximately three to five times per week which included activities of interest such as listening to music, being spoken to or reading books by nodding her head and making eye contact. Activities participation documentation revealed Resident #4 participated in a one-to-one activity in the month of July 2023 on 7/17/23; and participated 15 times in independent leisure activities from 7/3/23 to 7/28/23.-Independent leisure activities were described by the activities director (AD) as any activity residents were observed participating in independently such as reading, watching tv, talking or visiting with someone (see above).-There was no other documentation in record of Resident #4 participating in one-to-one or group activities of choice. IV. Resident #41 A. Resident statusResident #41, age 88, was admitted on 5/21/23 and readmitted on 7/17/23. According to the July 2023 CPO, the diagnoses included aphasia (difficulty with language), dysphagia (difficulty with swallowing), cervical disc disorder, and muscle wasting and atrophy. The 5/23/23 MDS assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She required extensive assistance of two people for most ADLs. The assessment documented it was very important for Resident #41 to keep up with the news, do her favorite activities, go outside and get fresh air and participate in religious services or practices. It was somewhat important for Resident #41 to have books, newspapers and magazines to read, listen to music and to do things with groups of people. A. Resident interview and observations Resident #41 was interviewed on 7/25/23 at 9:42 a.m. Resident #41 was sitting up in bed and said she had not been offered activities in the two months since she had been at the facility. Resident #41 said she would like to go to activities if they had them. Resident #41 was interviewed again on 7/25/23 at 4:32 p.m. Resident #41 was in her room sitting up in bed, she said she was happy she attended the resident group meeting and felt much better now that she met other residents she could talk to. She said she had not met any other residents prior to the meeting because she never got out of her room to meet residents. Resident #41 said she had not been offered an invitation to activities and was unaware of activities opportunities. The resident said she did not have an activities calendar posted. Resident #41 was interviewed again on 7/26/23 at 2:03 p.m. Resident #41 said things had been going pretty well, but she still had not been offered an opportunity to participate in activities. B. Record reviewThere was no documentation in the resident record showing that Resident #41 had been offered or had participated in activities since during her time in the facility. V. Resident #1 A. Resident status Resident #1, age 82, was admitted on 7/21/22. According to the July 2023 computerized CPO the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominance (stroke with left side weakness), chronic obstructive pulmonary diseases (lung disease), multiple sclerosis, post polio syndrome, tracheostomy, ventilator dependence, depression and weakness. The 4/19/23 MDS assessment documented the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required two person assistance to extensive assistance with most ADLs. The resident's activity prefrence were not assessed. B. Resident interview Resident #1 was interviewed on 7/24/23 at 1:45 p.m. Resident #1 said she used to play Bingo. The activities staff would bring a computer tablet to her bed so she could play with the other residents from her bed. She said it stopped when one of the activities staff members stopped working at the facility and they no longer brought her the tablet so she could participate. The resident said she loved to play Bingo and missed participating. Resident #1 said she missed letter writing with a family member. An activities staff member used to pick up her outgoing mail every day at 11:00 a.m. since she was unable to leave her room to get the written letter in the mail. The activities staff did so to help the resident participate in a letter writing exchange with a special family member. The resident said this letter writing exchange was a great sense of enjoyment and was very important to her. The activities staff's participation in this social activity was necessary to ensure that her letters got out in the day's mail and arrived to its recipient in a timely fashion so the recipient could respond timely and she could receive letters back in exchange. She looked forward to the recipient's response to her letters. The resident said the staff member who picked up her mail stopped working at the facility three weeks ago and no staff came to pick up her mail in their absence. The resident filed a grievance and they started to pick up her mail; but then that stopped five days later and had not resumed. Resident #1 said she felt terrible because there were times she would work to find staff to take her mail to the receptionist only to find out the letter was not picked up by the postman. Resident #1 said sending and receiving mail was the most important thing to her. She had a family member who was only able to visit once a month so they wrote to each other every day. The resident and her family member set up a system of letter writing so they could expect a letter from one another most every day, but without activity staff's assistance that was not happening. The resident said to most people mail may not be that important but for her, it was important because she was in her bed 24 hours a day, 7 days a week and the correct correspondences made her feel connected. C. Record review The 7/25/23 comprehensive care plan focus for activities program revealed Resident #1 loved to write letters everyday, visit family and playing games like Bingo with groups of people. Interventions included sending mail daily and providing Resident #1 with assistance setting up a tablet in the resident's room to use for virtual group activities of interest. The resident's activity record revealed she had three total one-on-one visits in the past 30 days. One for each of the following activities: social, music and drawing in the past 30 days. -The activity record did not document any resident participation for playing Bingo in the virtual group setting nor did the activities record document that mail assistance was provided to the resident as care planned. D. Staff interviewThe corporate nurse consultant (CNC) was interviewed on 7/31/23 at 3:57 p.m.. The CNC looked in the resident's record and confirmed that there was no record of mail being sent out and no record of the resident attending Bingo. VI. Other staff interviewsCertified nurse aide (CNA) #3 was interviewed on 7/27/23 at 11:56 a.m. CNA #3 said group activities such as bingo and movies were held upstairs in the activity room. The residents were offered one-on-one activities in their rooms. CNA #3 said there used to be more activity staff but right now there was only one staff available. CNA #1 was interviewed on 7/31/23 1:10 p.m. CNA #1 said she had not seen residents participating in any activities in the last two months. CNA #1 said two months ago residents would offer group activities such as bingo, movies, arts and crafts and also one-to-one activities in their rooms. CNA #1 said she was not sure why there had not been any activities recently. CNA #4 was interviewed on 7/31/23 at 2:37 p.m. CNA #4 said she had been working at the facility for two months and had worked on both long term care and rehabilitation floors. CNA #4 said had not seen one-to-one or group activities being offered to residents since she had started working. The nursing home administrator (NHA) was interviewed on 7/31/23 at 2:23 p.m. The NHA said there was currently one activity staff and he said the activity department was fully staffed. The NHA said there were two staff in the activity department a month ago. The NHA said group activities were located on the calendar but was unsure as to how many group activities were held daily. The NHA said the therapeutic group activities were counted as activities and all residents were offered therapy. The NHA said for social activities the residents were encouraged to self-initiate and could join other residents in the dining hall during meals. The NHA said one-to-one activities were offered to residents up to six times a week depending on what was refused or accepted by the resident. The resident's preferences were included in the resident's file. The NHA said they instituted an ambassador program where each department head was assigned residents to visit each morning. Every resident was visited daily and had the option to share any concerns they had during the visit. The concerns were documented in a spreadsheet and all concerns were addressed at the morning meeting.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
Residents #1, #4 and #41 are being offered independent leisure materials approx. 1-2x a week. Resident #1 is being offered assistance with her mail each day the mail runs. Resident #1 prefers independent activities; Resident #1 will be offered staff assistance for activities. Resident’s #4 & #41 are offered 1-3 group activities per week. Residents #1, #4, and #41 are offered 2-3 1:1/social visits per week, based on their assessed preferences. SSA transitioned into AD role on 8.16.23. Residents residing at the community are offered independent leisure at least 1x per week and are notified of where independent leisure materials are in the community, so they or a staff member can grab for them if they are unable to leave their room. Residents residing at the community will be offered group activities 1-3x per week, based on their activity assessment noted preferences. The AD or designee will complete independent leisure rounds to observe and assist Residents with initiating independent leisure PRN. During independent leisure rounds, Residents are offered mail assistance. At the beginning of each month residents will be offered and oriented to the new month's Activity calendar. All Residents unable to participate in group activities and are unable to self-initiate independent activities will be offered therapeutic 1:1 visits approximately 2-3x per week by a staff member. AD was provided additional education on 8.16.23 on rounding and documenting independent leisure rounds. AD was provided additional education on social/therapeutic 1:1 visit program, documentation and facilitation of program on 8.21.23 to begin visits with Residents #1, #4 and #41. September calendar was created and reviewed by corporate CTRS to ensure at least 3 activity-based programs are offered weekly, in addition to therapy programs; AD is aware of this expectation moving forward. AD provided educationto care team on 08.24.23 with support from NHA and DON to include breakout of 1:1 caseload, leisure visits and documentation of visits moving forward. AD will audit 6 participants on the social/1:1 visit program for 2 weeks, 5 days a week, to ensure that residents on the program are receiving approx. 2-3 visits per wk. After maintaining 2 weeks of compliance, AD will audit 6 residents on the social/1:1 visit program weekly for at least 90 days, or until maintaining compliance. AD will audit 6 Residents independent leisure participation on a weekly basis to ensure Residents are offered independent leisure approx. 3-5x per week. AD will audit 6 Residents group participation to ensure that residents that are able to participate in group activities are offered approx. 1-3 group activities per week. AD or designee will report the results of the audits to the QAPI for review monthly for 3 months or until substantial compliance is determined by the committee.
0684Quality of CareS/S G▼
Findings
Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (#52) of three residents reviewed out of 52 sample residents. Resident #52 was admitted to the facility after being hospitalized for worsening congestive heart failure. The resident had a history of chronic congestive heart failure and resistance to oral antibiotics. During the hospital stay just prior to the resident's admission the resident was treated for severe edema/ water retention as evidenced by a rapid significant weight gain and swelling in both lower extremities and muscle weakness and fatigue. The hospital treated the resident with intravenous (IV) diuretics and the resident's cardiac condition stabilized enough to discharge the resident. The resident however was not stable enough to undergo a needed surgery to repair a leak in the mitral valve of the heart and the resident was sent to the facility for cardiac monitoring and therapy to strengthen muscle and functional condition. The hospital sent a discharge summary and discharge orders to the hospital for the facility to monitor the resident's cardiac function. Orders included medication, a cardiac low sodium diet, and monitoring for edema with daily weights taken at the same time each day, a fluid restriction, and assessing the status of edema throughout the resident's body. The facility did not order and provide a cardiac low sodium diet and did not concisely monitor the resident fluid intake, assess the resident weights daily and at the same time of day, or provide daily assessment of the status of the resident edematous symptoms. Additionally, when the resident started to experience a worsening of cardiac symptoms classically associated with congestive heart failure the facility did not consult with the resident's long time cardiologist for treatment recommendations, or ensure that the resident's primary care physician examined the resident timely when the resident's symptoms worsened. As a result of the facility failures to develop a baseline care plan and initiate orders to follow hospital discharge orders, the resident's cardiac condition worsened. The resident gained 12.6 pounds while in the care of the facility and complained of feeling weaker and more fatigued. The edema in the resident's legs worsened causing the skin on the lower legs to open and weep fluid. In addition to edema in the lower legs, the hospital 7/17/23 assessment revealed the resident had pitting edema in the groin and presacral edema (edema in the area between the rectum and lowest part of the spine). The resident required hospitalization and parenteral diuresis (IV diuretic medication to aid the body in removing significant water retention). Findings include: I. Facility policy The Care Plans-Baseline policy revised March 2022, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: "A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.-The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders ..." II. Resident #52 A. Resident status Resident #52, age 69, was admitted to the facility on 6/30/23 and was discharged to the hospital on 7/19/23. According to the July 2023 computerized physician's orders, diagnoses included biventricular heart failure (a condition affecting both sides of the heart that occurs when the heart muscles cannot not pump enough blood to meet the body's need for blood and oxygen, where blood and fluid collects in the lungs and legs over time); nonthematic mitral (valve) insufficiency (occurs when the mitral valve does not close properly, allowing blood to flow backwards into the heart and as a result, the heart cannot pump efficiently, causing symptoms like fatigue and shortness of breath); presence of an automatic cardiac defibrillator (an internal device capable of restoring normal heartbeat); chronic stage 3 kidney disease; and chronic peripheral venous insufficiency (the body's inability to move blood through the veins of the legs or arms). The admission minimum data set assessment (MDS) assessment dated 7/5/23 documented the resident had intact cognition with a brief interview for mental status score of 15 out of 15. The resident needed staff supervision to complete activities of daily living (ADLs).-The resident received daily diuretics. B. Resident representative interview The resident was not available for an interview. Two resident representatives were interviewed on 7/31/23 at 10:06 a.m. The resident's daughter said Resident #52 had a history of cardiac complications and had been seeing a cardiologist for outpatient care for some time. The cardiologist determined the resident was a candidate for a clip procedure to stop leaking in the mitral value of the heart and repair a malfunctioning heart valve; the resident was scheduled to have the procedure at the end of June 2023. However, the resident started to experience general weakness, fatigue, weight gain, and low blood pressure and the procedure was postponed. Resident #52 went to the hospital for assessment, and was admitted for worsening heart failure and severe edema. The resident was treated with intravenous (IV) diuretic medication with a goal of removing the buildup of fluid. Once the fluid buildup was removed and the resident was determined to be stable, the resident was released from the hospital. It was determined Resident #52 needed time to strengthen his cardiac function and ensure the edema did not return before proceeding with the clip procedure. It was ultimately decided the resident would be admitted to a skilled nursing facility for medical monitoring until he was strong enough to undergo surgery to repair his mitral valve. The resident representative said that within two days of being in the facility Resident #52 began regaining the water weight (edematous fluid) he had lost while in the hospital. By day three, Resident #52 had gained 4.36 pounds and was retaining fluid in his lower legs. Resident #52 was complaining of weakness and general malaise. The resident representative said she talked to the resident's physician on 7/8/23; the physician said he would increase Resident #52's diuretic medication to better manage the resident's edema. The following day the nursing staff still did not have an order to increase the diuretic dosage. The physician did not increase Resident#52's diuretic medication until seven days after telling the resident representative he was placing an order to increase the medication (7/15/23). The resident representative said she spoke to the resident's physician and nursing staff several times relaying Resident #52's complaints of increased weakness, tiredness and increased edema; but felt the physician and nursing staff were not responsive to Resident's #52 and his declining health. The facility was supposed to weigh the resident at the same time, every morning after going to the bathroom. If he gained more than three pounds in a day, they should have notified the cardiologist; that did not happen despite Resident #52 asking staff to comply with that order. The resident representative said Resident #52 continued to complain that he was not feeling well and that his legs were swelling with fluid, which interfered with his ability to walk and participate in physical therapy; by 7/18/23 the resident weight was 284 pounds and Resident #52 asked to be sent to the hospital. The facility failed to respond timely to Resident #52's declining health. Resident #52's wife said the resident was determined to get better and was focused on being compliant with the treatment orders and recommendations of his cardiologist as well as the recommendations received at discharge from the hospital. Once at the hospital Resident #52 was started on IV diuretics. C. Record review Hospital treatment records dated 6/30/23 documented in pertinent part: Resident #52 was admitted to the (hospital name) on 6/17/23 and discharged on 6/30/23. "Primary diagnosis included acute and chronic HFrEF (heart failure with reduced ejection fraction - a condition that occurs when the heart's lower left chamber (left ventricle) doesn't pump blood out to the body as well as it should.) Recommended cardiology follow up for reevaluations within two weeks. "Resident #52 was ultimately discharged to (facility name) in a medically stable improved condition with instruction to follow-up with his cardiologist, neurologist, and PCP (primary care physician) in the upcoming weeks. Admission weight was 279 pounds and discharge weight was 268 pounds. "Diet orders: two (2) gram sodium (very low salt) and Limit fluids to two (2) liters (L);Activity orders: activity as toleratedHeart failure orders: (Refer to "Your Guide to Managing Heart Failure" for detailed information)-Fluid Guidelines (all liquids including food, i.e., soup, ice cream): 2000 milliliters ml/ cubic centimeters (cc) 18 cups or 167 ounces per day;-Weigh self-daily at the same time of day. Call if weight gain of three (3) pounds (lbs) in one day or five (5) lbs weight gain over a week.-Call your physician if you have increased cough, shortness of breath, increased leg swelling, or chest tightness or pain.-Diet: Eat a low salt diet. Avoid excess salt. Your sodium intake should be less than 2000 milligrams (mg) per day." The facility Nursing Admission Data collection and Baseline document, dated 6/30/23, read in pertinent part: "Admission 6/30/23 at 3:15 p.m. Vital signs; pulse 80 beats per minute and regular; respirations 16; blood pressure 156/65; oxygen saturation 97 percent on oxygen therapy; admission weight was 270.6 pounds at 7:20 p.m. No edema present. Pain level was zero. Cardiovascular condition: heart sounds regular; radial (wrists) and pedal (ankle) pulses detected as normal; (no other conditions documented)." -There was no documentation to identify dietary or hydration needs/restrictions and there was no documentation to identify cardiac conditions for heart failure monitoring or monitor for edema and water weight gain. -The comprehensive care plan initiated 6/30/23 failed to document the resident's cardiac needs and treatment for heart failure and monitoring for dietary and hydration restriction and monitor for edema and water weight gain. -The care plan did document a care focus for nutrition problems or potential for nutritional problems related to declining health status secondary to heart failure exacerbation and a relevant medical history of arterial fibrillations, initiated 7/4/23. The goal was for the resident not to be malnourished. Interventions included monitor weights as ordered, initiated; provide diet as ordered; and registered dietitian to evaluate and make diet change recommendations. The July 2023 CPO revealed the following orders:-Diet order: regular diet, start date 6/30/23;-Obtain admission weight and height, start date 6/30/23;-Obtain daily weight, in the morning for congestive heart failure, start 7/1/23; and,-Skilled nursing documenting daily every shift. The hospital discharge orders were not included. Weight log: The weight log revealed inconsistent weight assessments. The resident's weights were not assessed daily; were not assessed in the morning at the same time of day and not assessed by the same scale. The resident weight was only assessed one time before breakfast and sometimes the staff assessed the resident's weight with a chair scale and sometimes with a standing scale. The resident admission weight was recorded as 270.6 lbs., on day 18 the resident's weight was recorded at 283.2. Resident #52 gained a total of 12.6 lbs. in the 18 days since admission. Medical records revealed the resident entered with edema and by day 16 had 3-4 millimeter (mm) pitting edema with delayed rebound of skin when pressed inward (see below). On 6/30/23 at 7:21 p.m., the resident's weight was 270.6 lbs., on day of admission;On 7/1/23, the resident's weight was not assessed;On 7/2/23 at 4:21 p.m., the resident's weight was 273.0 lbs., an increase of three lbs. in two days;On 7/3/23 at 4:36 p.m., the resident's weight was 274.6 lbs., an increase of 1.6 lbs. or 4.6 lbs. in three days;On 7/4/23 at 3:45 p.m., the resident's weight was 271.0 lbs., a decrease of 3.6 lbs. in one day;On 7/5/23 at 11:37 a.m., the resident's weight was 273.4 lbs., an increase of 2.4 lbs. in one day;On 7/6/23, the resident's weight was not assessed;On 7/7/23 at 12:53 p.m., the resident's weight was 273.0 lbs., a decrease of 0.4 lbs. in one day;On 7/8/23 at 14:05 p.m., the resident's weight was 273.2 lbs., an increase of 0.3 lbs. in one day;On 7/9/23 at 11:55 p.m., the resident's weight was 279.5 lbs., an increase of 6.3 lbs. in one day;On 7/10/23, the resident's weight was not assessed;On 7/11/23 at 12:24 p.m., the resident's weight was 274.4 lbs., a decrease of 5.1 lbs.;On 7/12/23 and 7/13/23, the resident's weight was not assessed;On 7/14/23 at 9:30 a.m., the resident weight was 279.6 lbs., an increase of 5.2 lbs. in an undetermined number of days;On 7/15/23 at 11:17 a.m., the resident's weight was 278.8 lbs., a decrease of 0.8 lbs.;On 7/16/23 at 12:06 p.m., the resident's weight was 278.8 lbs., no change;On 7/17/23, the resident's weight was not assessed;On 7/18/23 at 8:09 a.m., the resident's weight was 283.2 lbs., an increase of 4.4 lbs., in one day. The resident's medical record contained two fluid intake records, neither documenting that the resident was on a fluid restriction. One record documented fluid intake and the other documented fluid intake with meals. There was no documentation of a daily total fluid intake and it was unclear if the documents were a duplication of the resident fluid intake or if each fluid intake record was a separate account of the amount of fluid the resident drank. The resident's medical record and progress note from 6/30/23 to 7/18/23 documented, in pertinent part, the following information: -The physician's admission history and physical exam dated 7/1/23 documented the resident was examined by the facility physician. The note revealed Resident #52 was admitted after a "complicated hospital course...was ultimately discharged to (facility name) in medically stable condition. (Resident #52's) main concern was getting enough physical therapy (PT) and occupational therapy (OT) so he could manage at home. He denied chest pain and felt he was breathing at baseline. We reviewed his care plan and medications. He understood a low sodium diet was key to reducing his edema in preparation for possible MVR (mitral valve repair).-Physical Exam: He is not in acute distress. Appearance: Normal appearance. He is not ill appearing. Swelling present. Normal range of motion. Right lower leg: Edema present. Left lower leg: Edema present." Nursing progress note dated 7/4/23 at 12:09 p.m. read: "Residents blood pressure this morning was 98/51. Blood pressure was rechecked and it was 84/57. Paged physician team and an on-call physician called back and gave verbal orders to discontinue the losartan (medication to lower blood pressure) and to give metoprolol medication (to lower blood pressure) in the mid-afternoon. The physician sent a message for the resident regular facility physician to re-evaluate the resident tomorrow. The on-call physician wants the resident's blood pressure to be checked while sitting, and also encourage fluids." Nursing progress note dated 7/4/23 at 12:09 p.m. read the on-call physician said, "The resident should be on a cardiac low salt diet."-However, there was no further documentation about the resident's dietary needs for a cardiac low sodium diet. The resident's diet was never changed from a regular diet to a cardiac low sodium diet. -The resident's physician did not provide a follow up visit until three days later, at that point the resident was experiencing additional cardiac symptoms including redevelopment of pitting edema and complaints of weakness. Physician visit note dated 7/7/23 revealed the resident was seen for a follow up visit. The note revealed the resident's blood pressure had been improved after medication change, "No specific complaints at this time. He is not in acute distress; is not toxic-appearing. Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Comments: 2+ (2 mm with delayed rebounds) BLE (bilateral/both lower extremities/legs) edema to just above knees; patient says this has been stable lately (neither worse nor better since admission to SNF) spent additional talking with the patient's family." -Up to this date the resident's medical record failed to document the status of Resident #52's edema. -Per the resident's weight log, the resident had an increase of 6.3 lbs. from 7/8/23 to 7/9/23, there was no documentation whether the resident primary care physician or cardiologist had been notified of the resident's weight gain until two days later and the physician did not examine the resident until five days later (see below). The physician visit note dated 7/7/23 failed to document if the physician assessed the resident's weight gain and if any additional medical treatment was necessary. Daily skilled nursing notes dated 7/10/23 at 6:53 p.m. documented in pertinent part that the resident continued to have impaired balance and weakness. "Skin Integrity: weeping to the right lower extremity, edema to the left and right lower extremities." Nursing progress note dated 7/11/23 revealed Resident #52 had edema to both lower extremities and a couple of blisters, with weeping. The physician gave verbal orders to wrap the resident's legs in kerlix (a bandage rolls that provide wicking action, aeration and absorbency) and apply tubi grips (a tubular bandage that provides consistent and even compression). Daily skilled nursing notes dated 7/11/23 at 7:05 p.m. documented in pertinent part the resident's "Skin Integrity: weeping to right lower extremity, edema to left and right lowerextremities." -There was no documentation in the daily skilled nursing notes for the section about edema or in any nursing note to document the status of the resident's edema on 7/13/23. Daily skilled nursing notes dated 7/14/23 at 12:14 a.m. documented in pertinent part: the resident had no edema. -However, nursing and physician notes before and after this date documented the resident had signs and symptoms of edema. Physician's visit note dated 7/14/23 documented the resident was seen for a follow up visit for daily weights, monitoring of blood pressure and wound care ... The note revealed the resident was seen at the heart failure clinic on 7/5/23. Recommendations from the last visit were to monitor edema and weights.-During this follow up visit 7/14/23 (Resident #52) "told me he felt his legs were more swollen. He has developed clean venous stasis ulcers and is followed by the wound team. Physical exam record review weights reviewed. Medication changes: - Increase Torsemide (Demadex) (medication to help treat fluid retention (edema) and swelling that is caused by congestive heart failure) 20 mg, oral tab; take three tablets by mouth, daily, for chronic congestive heart failure." Skilled nursing note dated 7/16/23 at 5:12 p.m. documented in pertinent part: "Edema is present: in bilateral lower extremity. Edema leaves a slight indentation of 3-4 millimeters (mm), 15 second or less rebound, none noted. Bilateral lower legs red and using Kerlix. Dressing changed as pre-treatment orders." Nursing progress note dated 7/18/23 at 8:10 a.m. documented "Resident voiced some concerns on how he is feeling. Resident feels shaky, and like he is retaining more fluid, he feels bad." Transfer form dated 7/18/23 at 11:10 a.m. documented the resident was sent to the hospital for further evaluation due to water weight gain of five lbs. in two days. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 7/25/23 at 10:30 a.m. LPN #2 had no knowledge of Resident #52. LPN #2 said the nurse should fully assess the resident experiencing a change of condition and document the assessment in the resident progress notes. The nurse should contact the resident's physician and document the contact and any orders. The admitting nurse was responsible for reviewing hospital orders and entering the orders into the resident record. LPN #3 was interviewed on 7/25/23 at 11:02 a.m. LPN #3 said the skilled nursing assessment was completed. Each shift the nurse should document the resident's status on the form completing a response for each section on the form. If the resident had a change in condition after the skill nursing note was completed the nurse should make an additional entry in the resident record. If there was a change in the resident's condition, the nurse should contact the resident's physician for treatment orders and document that contact. The resident's representative should also be notified. The registered dietitian (RD) and the RD consultant (RDC) were interviewed on 7/27/23 at 2:20 p.m. The RD said she assessed Resident #52 and talked to the resident about his dietary needs. They discussed the importance of getting good nutrition and a low sodium; however, the RD believed it was important to put the resident on a regular diet due to poor intake and risk of malnutrition. The RD's focus for Resident #52 was to make sure he ate enough food. The resident had a good understanding of low sodium food choices and said he understood he limited his fluid intake. The CNC was interviewed on 7/27/23 at 11:30 a.m. The CNC said the Nursing Admission Data collection and Baseline document was the resident baseline care plan. The document triggered a care focus with interventions for any assessed area where the nurse found concern. If no concern was identified the document would not trigger the need for interventions. The CNC, director of nursing (DON), nursing home administrator (NHA) and corporate consultant (CC) were interviewed on 7/31/23 at 3:55 p.m. The DON said the admitting nurse would transcribe all medication and treatment orders from the resident's hospital discharge records into the resident record. The resident's physician got a copy of the discharge documents and was responsible for reviewing the resident medication administration record and treatment administration record for accuracy and signing off on the orders. The resident's primary care physician would make the decision whether or not to follow the hospital discharge orders. The nursing staff should document the resident's health status in the daily skilled nursing note and any additional changes of condition in the resident record.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident #52 no longer resides in the facility. 2. Other residents who have the diagnosis of congestive heart failure on admission have the potential to be affected by the alleged deficient practice. These residents will be reviewed by the DON and unit managers to ensure that weight monitoring, diet orders and edema checks are in place as ordered by the physician. 3. The nursing staff were educated by the DON beginning on 8/3/23 on the need to follow physician orders and document an assessment of clinical findings in the medical record and to report any unusual findings to the physician for further follow up. The DON or designee will audit 5 post-acute residents per week for 3 months with CHF for weight monitoring weekly (or per MD order), that edema checks are documented , and that MD was notified of any changes. Any issues identified will be addressed immediately. 4. The DON or designee will report the results of the audits to the QAPI for review monthly for 3 months or until substantial compliance is determined by the committee.
0697Pain ManagementS/S D▼
Findings
Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one (#52) out of 52 sample residents. Specifically, the facility failed to administer scheduled pain medication, for neuropathy pain, at the correct dosage as ordered by the resident's physician, to Resident #52. Findings include: I. Professional referenceAccording to Saunders Nursing Drug Handbook 2020, Kizior, R. J. and Hodgson, K.J., St. Louis Missouri 2020, revealed the following pharmaceutical information, page (pp). 963-965 read in part: Pregabalin. Use: Management of neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia. Administration: discontinue gradually over at least one week. II. Facility policy The Administering Medications policy revised April 2109, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: "Medications are administered in a safe and timely manner, and as prescribed."The Pharmacy Services Overview policy revised April 2109, was provided by the corporate nurse CNC on 7/31/23 at 2:35 p.m. The policy read in pertinent part: "The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements.-Pharmacy services are available to residents 24 hours a day, seven days a week.-Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.-Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration."III. Resident #52 A. resident status Resident #52, age 69, was admitted to the facility on 6/30/23 and was discharged to the hospital on 7/19/23. According to the computerized physician's orders, diagnoses included heart failure, diabetes mellitus with diabetic neuropathy and chronic stage 3 kidney disease. The admission minimum data set assessment (MDS) dated 7/5/23 documented the resident had intact cognition with a brief interview for mental status score of 15 out of 15. The resident needed staff supervision to complete activities of daily living (ADL).-The resident had frequent pain and received scheduled and as needed pain medications to manage the pain. The resident rated his worst pain as an 8 on a pain scale of 1 to 10. B. Resident representative interview The resident was not available for an interview. The resident's representative was interviewed on 7/31/23 at 10:06 a.m.. The resident representative said there was a pharmacy error and Resident #52 did not get the correct dosage of pregabalin (Lyrica) for neuropathy and Resident #52 complained of increased pain. The resident was prescribed pregabalin 150 milligrams (mg) twice a day, upon admission to the facility he was receiving the correct dose of medication but the facility ran out of medication and the nursing staff gave him 100 mg capsules instead until the pharmacy delivered the correct dose of medication a couple of days later. C. Record review The July 2023 CPO documented the following orders:- Lyrica (pregabalin) oral capsule 150 mg, give 1 capsule by mouth two times a day for pain; start date 6/30/23.-Lyrica (pregabalin) oral capsule 100 mg, give 100 mg by mouth one time only for neuropathic pain for one day; order date 7/12/23.--Lyrica (pregabalin) oral capsule 100 mg, give 100 mg by mouth one time only for neuropathic pain for one day; order date 7/13/23. Review of the July 2023 medication administration records (MAR) revealed: Lyrica (pregabalin) was not administered on 7/12/23, 7/13/23 for the morning and evening dose and 7/14/23 for the morning dose. The resident received a one time dose of Lyrica 100 mg at 7/12/23 at 11:00 p.m. and 7/13/23 at 2:13 p.m. Physician admission summary dated 7/1/23 read in pertinent part: "Other orders: Pregabalin (Lyrica) 150 mg oral capsule; take one capsule by mouth two times a day for neuropathy."Medication administration note dated 7/12/23 at 11:46 a.m. read: "Lyrica 150 mg (was unavailable). Waiting for the pharmacy to deliver." Medication administration note dated 7/12/23 at 10:00 p.m. read: "Lyrica oral capsule 150 mg, give one capsule by mouth two times a day for pain. (Medication) unavailable. On-call physician notified." Skilled nursing note dated 7/13/23 at 5:12 a.m. read in pertinent part: "Lyrica 150 mg was unavailable. On call physician notified. Obtained an order to give 100 mg by mouth tonight and in the morning. Prescription to be sent to the pharmacy. Lyrica 100 mg provided from emergency medication stock. IV. Staff interview Licensed practical nurse LPN #3 was interviewed on 7/25/23 at 11:02 a.m. LPN #3 said the nurse was to administer medication as ordered. The nurse should check the resident's MAR for the order, correct medication, dosage and time; if the medication was unavailable, the nurse should notify the physician that the medication is unavailable and document the communication and any additional orders. The nurse should also contact the pharmacy to reorder the mediation. Medication should be ordered at least three to seven days prior to the medication running out. Some medication could be obtained from the emergency medication storage with pharmacy approval. The CNC, director of nursing (DON), nursing home administrator (NHA) and corporate consultation (CC) were interviewed on 7/31/23 at 3:55 p.m. The DON said medication should be reordered prior to the medication running out. If medications were unavailable, the nurse should check the emergency medication supply to see if the medication is available in the kit; then contact the pharmacy for an approval code to provide them medication and a prescription refill. When the medication is unavailable, the nurse should contact the prescribing physician for additional orders.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL 1. Resident #52 no longer resides in the facility. 2. Other residents who require controlled substances for pain have the potential to be affected by the alleged deficient practice. 3. The nursing staff were educated by the DON beginning on 8/3/23 on the need to reorder controlled medications from the pharmacy at a minimum of 3 days prior to the supply being depleted and if a medication is not available the nurse is to notify the MD and follow any new orders or precautions the MD recommends. The DON or designee will review 10 controlled substance medication cards weekly for 3months to ensure that medications are being reordered timely. Any issues identified will be addressed immediately. 4. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
0760Residents are Free of Significant Med ErrorsS/S E▼
Findings
Based on record review and interview, the facility failed to ensure one (#124) of three residents out of 52 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #124:-Received the medication selpercatinib, a prescribed kinase inhibitors medication (a medication that blocks the action of an abnormal protein that signals cancer cells to multiply) according to manufacturer's directions when give with a protein pump inhibitor (PPI) medication (a class of medications that blocks gastric acid secretions by dissolving chemical bonds within food molecules); and,-Received the medication selpercatinib timely within permeates of also giving the medication before meals and doses 12 hours apart per manufacturer's directions. I. Professional reference According to the manufacture Eil Lilly and Company Prescribers Information highlights, revised September 2022, retrieved from https://uspl.lilly.com/retevmo/retevmo.html#pi on 7/27/23 "Retevmo- selpercatinib capsule is indicated for the treatment of adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) with a rearranged during transfection (RET) gene fusion, as detected by an FDA-approved test. "Retevmo may be taken with or without food unless co-administered with a proton pump inhibitor (PPI) "Dosage modifications for concomitant (given with) use of acid-reducing agentsAvoid concomitant use of a PPI, a histamine-2 (H2) receptor antagonist (a medication used to treat gastric intestinal ulcers and for some conditions, in which the stomach produces too much acid), or a locally-acting antacid with Retevmo. "If concomitant use cannot be avoided:-Take Retevmo with food when co-administered with a PPI.-Take Retevmo 2 (two) hours before or 10 hours after administration of an H2 receptor antagonist-Take Retevmo 2 (two) hours before or (two) hours after administration of a locally-acting antacid. "Concomitant use of RETEVMO with acid-reducing agents decreases selpercatinib plasma concentrations, which may reduce RETEVMO anti-tumor activity. "Patient counseling information:-Advise patients that they will require regular blood pressure monitoring and to contact their healthcare provider if they experience symptoms of increased blood pressure or elevated readings;-Advise patients that RETEVMO may increase the risk for bleeding and to contact their healthcare provider if they experience any signs or symptoms of bleeding;-Advise patients to contact their healthcare provider promptly to report any signs and symptoms of tumor lysis syndrome (TLS-caused by massive tumor cells lysis with the release of large amounts of potassium, phosphate and nucleic acid into the the circulatory system) symptom include: nausea, vomiting, diarrhea, muscle cramps or twitches, weakness, numbness or tingling, fatigue, and decreased urination.-Advise patients and caregivers to inform their healthcare provider of all concomitant medications, including prescription medicines, over-the-counter drugs, vitamins, and herbal products." According to Potter, P.A. and Perry, A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 599 - 609. "Nurses play an important role in patient safety, especially in the area of medication administration. The safe administration of medications is also an important topic for current nursing researchers. As a nurse you need to know how to calculate medication doses accurately and understand the different roles that members of the health care team play in prescribing and administering medications. "The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. -Preventing medication errors is essential.-Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. "Professional standards such as scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors follow the seven rights of medication administration consistently every time you administer medication. -The right medication; the right dose; the right patient; the right route; the right time; the right documentation; and right indication." II. Facility policy The Administering Medications policy revised April 2109, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: "Medications are administered in a safe and timely manner, and as prescribed. "Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:a. enhancing optimal therapeutic effect of the medication;b. preventing potential medication or food interactions; andc. honoring resident choices and preferences, consistent with his or her care plan. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders)." The Medication Regimen Reviews policy revised May 2109, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: "The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication.-Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated.-The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.-The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example:a. medications ordered in excessive doses or without clinical indication;b. medication regimens that appear inconsistent with the resident's stated preferences;c. duplicative therapies or omissions of ordered medications;d. inadequate monitoring for adverse consequences;e. potentially significant drug-drug or drug-food interactions;f. potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences;g. incorrect medications, administration times or dosage forms; orh. other medication errors, including those related to documentation.-Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity.-An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical servicesstandards of practice; is not supported by medical evidence; and/or impedes or interferes with achievingthe intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences.-If the identified irregularity represents a risk to a person's life, health, or safety, the consultant pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally, and documents the notification.-If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator.-The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it." III. Resident #124 A. Resident status Resident #124, under the age of 65, admitted on 5/2/23 and discharged on 7/4/23. According to the July 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm (cancer) of the bronchus/lungs, malignant neoplasm of the brain, respiratory failure, epilepsy and gastroesophageal reflux disease (GERD). The 6/22/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for a mental status score of 14 out of 15. The resident needed limited assistance from staff for mobility and completion of activities of daily living (ADL). B. Record review 1. Physician's orders and medication administration record (MAR) The June and July 2023 CPO and MARs documented the following orders: Selpercatinib (Retevmo) oral capsule 80 mg, give two capsules by mouth every 12 hours, for cancer. Give at 8:00 a.m. and 8:00 p.m. Pantoprazole sodium (protonix -a PPI) oral tablet delayed release 40 mg, give one tablet by mouth one time a day for GERD. Give at 7:00 a.m. -The CPO and MAR gave the same instruction; failing to give specific instructions for giving the two medications concomitant per manufacturer's directions (see professional reference above). -Review of the June and July 2023 CPO and MAR revealed the resident's medication was given late consistently for four of 13 morning doses and five of 14 evening doses (see below). The pantoprazole sodium (PPI medication) was only scheduled for one hour before the selpercatinib medication as directed by the pharmaceutical manufacturer and in most cases the PPI medication was given at the same time as the selpercatinib medication (see below). The MAR administration time revealed both the selpercatinib and the pantoprazole sodium (PPI medication) were given incorrectly and in direct contradiction to selpercatinib manufacturer's instructions. On 6/20/23Selpercatinib was given at 8:53 p.m., this was almost one hour late. On 6/21/23Pantoprazole sodium was given at 8:27 a.m., this was almost one hour and 39 minutes late. Selpercatinib was given at 8:27 a.m. Selpercatinib was given at 8:40 p.m. On 6/22/23Pantoprazole sodium was given at 8:20 a.m., this was over one hour late. Selpercatinib was given at 8:20 a.m. Selpercatinib was given at 1:42 p.m. (this was over six hours early from being 12 hours after the previous dose. On 6/23/23Pantoprazole sodium was given at 8:10 a.m., this was over an hour late. Selpercatinib was given at 5:36 p.m., this was over nine hours and 30 minutes late. Selpercatinib was given at 7:55 p.m., this was less than three hours after the previous dose was administered. On 6/24/23Pantoprazole sodium was given at 9:10 a.m., this was over two hours late. Selpercatinib was given at 10:07 a.m., this was over two hours late. Selpercatinib was given at 10:20 p.m., this was over two hours late and within the orders to administer doses 12 hours apart, which throws off the 12 hours between administration times. On 6/25/23Pantoprazole sodium was given at 9:02 a.m., this was over two hours late. Selpercatinib was given at 9:05 a.m., this was over an hour late. Selpercatinib was given at 10:23 p.m., this was over two hours late. On 6/26/23Pantoprazole sodium was given at 8:49 a.m., this was one hour and 49 minutes late. Selpercatinib was given at 8:49 a.m. Selpercatinib was given at 8:14 p.m. On 6/27/23Pantoprazole sodium was given at 7:15 a.m. Selpercatinib was given at 7:14 a.m. Selpercatinib was given at 7:13 p.m. On 6/28/23Pantoprazole sodium was given at 7:11 a.m. Selpercatinib was given at 711 a.m. Selpercatinib was given at 8:38 p.m. On 6/29/23Pantoprazole sodium was given at 11:17 a.m., this was over four hours late. Selpercatinib was given at 11:26 a.m., this was over four hours late. Selpercatinib was given at 10:29 p.m., this was over two hours late. On 6/30/23Pantoprazole sodium was given at 8:48 a.m., this one hour and 48 minutes late. Selpercatinib was given at 8:47 a.m. Selpercatinib was given at 8:41 p.m. On 7/1/23Pantoprazole sodium was given at 9:02 a.m., this was over two hours late. Selpercatinib was given at 8:59 a.m. Selpercatinib was given at 8:12 p.m. On 7/2/23Pantoprazole sodium was given at 8:06 a.m., this was over an hour late. Selpercatinib was given at 8:07 a.m. Selpercatinib was given at 9:59 p.m., this was three hours late. On 7/3/23Pantoprazole sodium was given at 8:58 a.m., this was two hours late. Selpercatinib was given at 8:58 a.m., this was almost one hour late. Selpercatinib was given at 8:05 p.m. 2. Nursing notes Orders note dated 5/2/23 read in pertinent part: "The order you have enteredSelpercatinib oral capsule 80 mg, has triggered the following drug protocol alerts/warning(s):Drug to drug interaction. Interaction: Severity: Severe. Interaction: Pharmacologic effects and plasma concentrations of selpercatinib may be decreased by proton pump inhibitors (Pantoprazole sodium oral tablet delayed release 40 mg." -This alert appeared again on the progress notes on 5/9/23, 6/20/23 and 6/21/23 when the resident readmitted to the facility. There was no documentation in the residents records that any facility staff took action to address the drug interaction alert note. Physician's note dated 5/5/23 read in pertinent part: "Resident with a diagnosis of lung cancer metastasis to the brain; started chemo pill again on 4/28/23 after a one-month hiatus. Was referred to SNF (skilled nursing facility) for physical and occupational therapy (PT/OT) to increase strength, mobility, and ADL independence related to her decreased ability to care for herself at home and reduced activity tolerance over the last several weeks. There is a potential drug interaction with another medication, selpercatinib oral capsule. Continue selpercatinib 160 mg twice a day. Continue pantoprazole 40 mg daily." -The physician's note did not document if the physician looked into the details of the drug interaction or took consideration for the manufacturer's warnings when taking selpercatinib with a PPI medication to take action to make sure the administration orders outlined precautions to lessen the potential drug interactions and outcomes. 3. Comprehensive care plan The resident's comprehensive care plan initiated 6/23/23 did not contain a care for the resident's cancer treatment or for GERD. IV. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 7/25/23 at 11:02 a.m. LPN #3 said medications should be administered to a resident as close to the prescribed administration time as possible, but no earlier or later than one hour before or after the scheduled administration time. The pharmacy conducts an initial review of resident medications and monthly thereafter to identify any irregularities and alert the facility to recommendations for findings. The nurse was responsible to administer the medication correctly as ordered. The pharmacist consultant (PC) was interviewed on 7/27/23 at 4:05 p.m. The PC said according to manufacturer's recommendations selpercatinib had a warning related to an adverse interaction. While manufactures recommendations selpercatinib should be given twice a day with each administration being12 hours apart, it was more importantly that when given with a PPI, the selpercatinib should be given two hours before the PPI or 10 hours after the administration of the PPI mediation. When the manufacturer's recommendations were not followed, the effectiveness of selpercatinib as a cancer treatment was reduced by 70 percent. The CNC, director of nursing (DON), nursing home administrator (NHA) and corporate consultation (CC) were interviewed on 7/31/23 at 3:55 p.m. The DON said she was not familiar with any administration warnings for the resident's selpercatinib medication. The DON said she talked with the resident and the resident's representative specifically about how she was taking the selpercatinib medication and based on the resident selpercatinib to be administered at 8:00 a.m. and 8:00 p.m. so she would received it 12 hours apart. The DON was not aware there were manufacturer's warning instructions when the resident was also taking a PPI. The CNC said the administering nurse should be aware of medication administration standards and if they were unfamiliar with a medication the nurse should look up the medication for administration instructions.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident #124 no longer resides in the facility 2. Other residents have the potential to be affected by the alleged deficient practice. An audit of severe interactions will be conducted and any identified will be discussed with physician for follow-up. 3. The nursing staff were educated by the DON beginning on 8/3/23 on reviewing medication warnings in the medical record and notifying the MD of any significant interactions. The consultant pharmacist was notified to alert the DON and physician of any new potential medication interactions. The DON or designee will auditall new admissions for 5 days, then 5 new admissions per week for 3 months to identify any significant medication interactions and notify the MD or Pharmacist for recommendations. Any issues identified will be addressed immediately 4. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
0761Label/Store Drugs and BiologicalsS/S D▼
Findings
Based on observations and interviews, the facility failed to ensure biologicals were labeled and stored in accordance with accepted professional standards for one of four medication storage rooms. Specifically, the facility failed to discard expired vaccines from the medication storage room. Findings include:I. Facility policyThe Storage of Medications policy, dated November 2020, was received on 7/31/23 at 2:35 p.m. from the corporate nurse consultant (CNC). The policy read in pertinent part:"The nursing staff is responsible for maintaining medication storage and preparation areas. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed."II. Observations Medication room two-south unitOn 7/26/23 at 3:03 p.m., the medication room was observed with registered nurse (RN) #1 and the unit manager (UM). After the observation, RN #1 and the UM verified the medication room had the expired biological items including:Sanofi Pasteur fluzone influenza (flu vaccine), 10 pre-filled syringes that expired 4/30/23, 97 days prior to the observation. III. InterviewsRN #1 and the UM were interviewed together immediately after the observation on 7/26/23 at 3:09 p.m. The UM said the expired vaccines should have been removed from the supply room. The UM said the policy for vaccine storage was to discard or return expired vaccines to the pharmacy. RN#1 disposed of the expired vials immediately. The assistant director of nursing (ADON) was interviewed on 6/27/23 at 2:15 p.m. The ADON said the expired vaccines should be removed from storage immediately to prevent expired items being administered.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL 1. No residents were named in the alleged deficient practice. The expired vaccine was removed from the four refrigerators at the time of the survey 2. The other mediation refrigerators in the facility were audited and no other expired vaccines were identified. 3. The nursing staff were educated by the DON beginning on 8/3/23 on the policy of removing all expires medications or vaccines from service areas. The DON or designee will conduct weekly rounds of medication rooms and refrigerators for 3 months to ensure ongoing compliance. Any issues identified will be addressed immediately 4. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
0842Resident Records - Identifiable InformationS/S F▼
Findings
Based on record review and interviews, the facility failed to keep confidential resident-identifiable personal information and medical treatments for 27 of 27 residents; and to ensure medical records were complete and accurately documented medical status and response to nursing/medical care and treatment in keeping with accepted standards of practice for a sample of two of four residents reviewed. Specifically, the facility failed to:-Keep confidential information specifically protected health information (PHI) out of view of other residents and visitors for 27 of 27 residents on the unit; and, -Ensure Resident #47's medical record contained accurate and complete documentation regarding the resident's restorative management plan; restorative services provided; and the resident's response to services. Findings included:I. Confidentiality of PHIA. Facility policyThe Confidentiality of Information and Personal Privacy policy, dated October 2017, was requested and received from the corporate nurse consultant (CNC) on 7/27/23 at 9:45 a.m. The policy documented in pertinent part:"The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records;"The facility will strive to protect the resident's privacy regarding medical treatment and personal care;"Access to resident personal and medical records will be limited to authorized staff and business associates."B. ObservationsThe facility respiratory therapy department hung a white board on the wall in the common area on the two-south hallway. The white board contained PHI information which was clearly visible to any person (visitors or other resident) entering the unit. The white board contained the following PHI:-Resident first and last name;-Resident code status (do not resuscitate/full code);-Resident room number;-Resident ventilator settings;-Resident oxygen settings;-Resident respiratory therapy treatments and treatment schedule;-Resident ventilator settings; and ,-Resident tracheostomy details (size and type) and treatment schedule. Respiratory therapist (RT) #3 was observed updating the white board on 7/25/23 and 7/26/23 with resident PHI as listed above. C. Staff interviewsThe unit manager (UM) was interviewed on 7/26/23 at 9:35 a.m. The UM said the white board was used by the respiratory therapy department to share pertinent medical information about the residents to whom they provided services. The UM said the board contained resident specific PHI that applied to end of life decisions (code status) and life support care provided. The UM said resident specific healthcare information should be protected from the public such as visitors and other resident family members. RT #1 was interviewed on 7/26/23 at 11:18 a.m. RT #1 said the white board was helpful to quickly identify which residents had ventilators, the settings and treatments they received and was referenced during shift reports and as needed during her shift. The RT said the resident information was also available to reference in the resident's electronic health record. The CNC was interviewed on 7/27/23 at 9:45 a.m. The CNC said a board in public view should not include PHI. The CNC said she would review confidentiality of PHI with facility staff. The respiratory therapy manager (RTM) was interviewed on 7/31/23 at 3:01 p.m. The RTM said the white board had been relocated to an office behind the nurses desk to prevent any confusion regarding what information was considered private and protected. II. Accurate medical record A. Facility policyThe Charting and Documentation policy, revised July 2017, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy documented in pertinent part:"All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.""The following information is to be documentedin the resident medical record: Objective observations; Medications administered; Treatments or services performed; Changes in the resident's condition; Events, incidents or accidents involving the resident; and Progress toward or changes in the care plan goals and objectives." B. Resident status Resident #47 was admitted on 12/21/22 and readmitted 3/22/23. According to the July 2023 computerized physician order (CPO), the diagnoses included acute and chronic respiratory failure, diabetes, tracheostomy, hemiplegia (paralysis) and dysphagia (difficulty swallowing) due to non traumatic intracranial hemorrhage (stroke), weakness and reduced mobility. The 6/23/23 minimum data sheet (MDS) assessment documented that the resident was rarely understood and a brief interview for mental status score (BIMS) was not completed. She required two person assistance with bed mobility, transfer, toileting, bathing, dressing, personal hygiene and total dependence on eating. The assessment document that the resident was not receiving physical therapy, occupational therapy or restorative nursing services at the time of the assessment. C. Record review The 7/3/23 care plan revealed that the resident had limited physical mobility. One intervention was to provide gentle range of motion as tolerated with daily care. There was a physical therapy and occupational referral; this was not care planned, or documented as being provided to the resident anywhere in the resident record. The 1/12/23 occupational therapy discharge summary revealed that the nursing staff were trained on how to provide the resident's recommended restorative nursing program as well as what safety precautions were needed, in order to promote mobility, safety and reduce the risk of further medical complications to the resident. The 3/24/23 physical therapy progress note revealed that the resident would benefit from a restorative program for maintaining and improving bilateral lower extremities flexibility by passive range of motion and repositioning to decrease risk of skin breakdown. -There was no documentation in the resident medical record to explain how the resident restorative services benefited the resident, the frequency of services provided and the resident's response to services provided. D. Staff nterviewsThe director of rehabilitation (PTD) was interviewed on 7/27/23 at 1:32 p.m. The PTD said the resident was evaluated a couple times for mobility needs and recommendations for ongoing restorative services were made. At the last evaluation in March 2023, the resident was totally dependent on staff for care. The rehabilitation therapist recommended the resident be placed on a restorative nursing program (RNP) to maintain flexibility and reduce skin breakdown. The RNP included passive range of motion (ROM) and positioning. The restorative nursing staff would be responsible for documenting services. The director of nursing (DON) and unit manager (UM) were interviewed on 7/27/23 at 1:56 p.m. The DON said she and the UM needed to do some research to see if there was any documentation of services. The DON was interviewed on 7/27/23 at 2:55 p.m. The DON said that there was no documentation that passive ROM was being provided by the restorative staff. The DON said that passive ROM was included with routine care that certified nurse aide (CNA) performed. The DON said that going forward there would be a separation from routine provision of care and provision of restorative nursing program services so that the restorative nursing care was clearly defined and documented accurately in the resident's record. The corporate nurse consultant (CNC) was interviewed on 7/31/23 at 11:23 a.m. The CNC provided an updated care plan that reflected interventions that clearly defined the resident restorative nursing program services for type and frequency of ROM services. The intervention was initiated on 7/27/23. The DON was interviewed on 7/31/23 at 5 p.m. The DON said that there was no documentation of the resident restorative nursing program in the resident's record to explain how often services were provided or how the resident was responding to the service.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. The white board on the 2 north unit was relocated to a secure location during the survey. Resident #47’s care plan was updated to include a specific ROM program to allow for documentation of the program. 2. Common areas were audited to ensure that PHI was protected. No other issues were noted. Other residents who require ROM programs will be reviewed by therapy and/or nursing to ensure that programs are in place and being documented. 3. The nursing staff were educated by the DON beginning on 8/3/23 on the need to implement ROM programs in the EMR and document the intervention and document the resident's response. The DON or designee will complete weekly rounds of corridors for 3 months to ensure that PHI is protected. The DON or designee will review new restorative residents for the week to ensure that programs are set up and documented and 5 residents per week for 3 months to ensure ongoing compliance. Any issues identified will be addressed immediately. 4. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee
0908Essential Equipment, Safe Operating ConditionS/S F▼
Findings
Based on observations and interviews, the facility failed to maintain emergency patient care equipment in safe operating condition. Specifically, the facility failed to perform daily quality readiness checks on the emergency response cart and to ensure expired items were removed and replaced. Findings include: I. Facility policyThe facility policy for maintaining patient care equipment was requested on 7/27/23 and a copy of the Crash Cart (a cart containing medicine and equipment for use in emergency resuscitations) Checklist, undated, was received from the corporate nurse consultant (CNC) on 7/27/23 at 11:30 a.m. The checklist documented, "the crash cart should be checked daily and contain the following items: -suction machine,-record keeping paperwork,-vitals machine,-nonrebreather mask,-nasal cannula high flow,-nebulizer mask,-14 French (FR) suction cath kits,-yankauer suctioning wand,-spare suction canister with short and long tubing,-ventilation (AMBU) bag (a device to provide respiratory support to an individual in distress) with mask,-oxygen regulator,-oxygen tank wrench, and an-extension cord." II. ObservationsOn 7/26/23 at 3:15 p.m. the two-south emergency response cart was observed with the unit manager (UM)). Observations revealed the cart contained several expired and missing items (see crash cart checklist above). Expired items included: -Wolf Medical Supply, 10 cubic centimeters (cc) prefilled normal saline syringes, expired 9/4/21, 673 days prior to the observation;-Two 100 militer (ml) medline sterile water solutions, expired, 6/19/21, 777 days prior to the observation; -Three B Braun Introcan safety IV (intravenous) start catheters needles, 22 gauge (needle width) by one inch, expired 7/1/23, 25 days prior to the observation; and,-Two McKesson IV start catheter needles, expired 9/11/21, 693 days prior to the observation.-The UM was unable to locate a wrench to open the oxygen canister on the emergency response cart and had to look for one. A spare wrench was located on the nurses desk. -In the event of a true emergency the oxygen wrench would not have been easily accessible to staff responding to an emergency without having to leave the emergency area to locate the wrench if oxygen was needed. -The crash cart did not include a checklist for equipment readiness or documentation of when the cart was last checked for completeness of supply and expression date of the supplies. III. InterviewsThe UM was interviewed on 7/26/23 at 3:15 p.m. The UM said the expired items (see observations above) could no longer be used and needed to be replaced. The UM removed the expired items and said they would be replaced. The UM said he did not know if the facility had a checklist or policy and was unaware of when the emergency equipment cart was last checked. The UM and the assistance director of nursing (ADON) were interviewed together on 7/26/23 at 3:27 p.m. The ADON said the emergency response carts were checked daily as part of a risk management review. The ADON said the daily checks did not include a checklist and the UM on each unit was responsible to monitor the equipment for readiness. The UM said he was unaware of the equipment checklist. IV. Facility follow-upOn 7/27/23 the emergency equipment cart for two-north and two-south were observed with the UM. The equipment carts included a designated binder with an equipment readiness checklist and the equipment carts were properly stocked.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. The expired items on the emergency carts were removed and oxygen keys were replaced during the survey 2. Other emergency carts were inspected during the survey to ensure that there were no expired items and oxygen wrenches were available. 3. The nursing staff were educated by the DON beginning on 8/3/23 on the need to check the emergency carts daily and replace any missing or expired equipment. A check list was provided to the DON and Unit Mangers to place on each cart as a reference for the nurses. The DON will complete weekly rounds of the emergency carts for 3 months to ensure ongoing compliance. Any issues identified will be addressed immediately. 4. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
0921Safe/Functional/Sanitary/Comfortable EnvironS/S E▼
Findings
Based on observations and staff interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public in one of three units. Specifically, the facility failed to:-Control foul odors throughout the two-south unit; -To properly dispose of trash soiled with feces and urine;-To maintain cleanliness in the dirty utility room; and, -To keep electrical cords out of walkways, in resident rooms in order to prevent trip hazards. Findings include:I. Facility policyThe facility policy for environment maintenance was requested on 7/31/23 and was not received before survey exit on 7/31/23. II. ObservationsFoul odors were detected in the hallway near trash collection bags and outside resident's rooms on the two-north unit on:7/24/23 at 9:15 a.m., 11:30 a.m., and 12:45 p.m.; 7/26/23 at 11:30 a.m., 1:15, p.m. and 4:15 p.m.;7/27/23 at 1:25 p.m., and 3:55 p.m.; and,7/31/23 at 10:35 a.m., and 3:00 p.m. On 7/25/23 at 11:37 a.m., the dirty utility room was observed in the presence of the respiratory therapy manager (RTM). The trash collection bins were approximately one half full and there were two clear plastic trash bags full of trash soiled with bodily fluid discarded on the counter of the hand washing sink, in the utility room. The trash bags contained trash generated as a result of providing incontinence care to residents. The trash was smeared feces which was visible through the plastic. There was a 12 inch x 12 inch circle size, moist, brown and mucous spot on the floor in the walkway. III. Staff interviewsOn 7/25/23, a family member of the resident in room 215, said when he visited the resident, the foul odors were always present in the hallway where the trash disposal bags were frequently left in the hallway outside the resident's room and the odor could be smelled in the resident's room. Certified nurse aide (CNA) #6 was interviewed on 7/25/23 at 11:40 a.m. CNA #6 said she was unsure why the trash bags were on the counter top and she placed the bags into the trash collection container. The CNA said sometimes the trash collection bags in the hallways were filled to capacity and piled up in the dirty utility room before the end of shift, staff removed trash from the facility for disposal, as time allowed. The CNA said the floors in the soiled utility room were monitored and cleaned by the housekeeping staff. On 7/26/23 trash collected by the housekeeping department was observed sitting outside the dirty utility room in the hallway adjacent to the two-north nurses desk, next to the emergency equipment cart and vital signs machine. The unit manager (UM) and the assistant nursing home administrator (ANHA) were interviewed on 7/26/23 at 9:12 a.m. They said they were unaware the housekeeping department left the collected trash in the hallway next to the dirty utility room. The UM and ANHA said the housekeeper should have placed the collected trash into the trash collection bags or removed the trash from the facility for disposal. II. Electrical cords and trip hazards A. Facility policyThe Safety Precautions, Electrical policy, revised 2011, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 3:44 p.m. The policy read in pertinent part: "Report any and all unsafe electrical hazards to your supervisor immediately."-However, the policy did not document any methods of how and where electrical cords should be plugged in to prevent electrical cords from creating a trip hazard. B. ObservationOn 7/26/23 and 7/27/23 observations of resident rooms on the second floor unit were conducted. The resident's on the second unit were highly vulnerable individuals requiring the use of complex electrically powered medical equipment for life support. Each resident had several pieces of equipment that required electrical power to remain operational (ventilators, oxygen concentrators, suction machines, nebulizers, tube feeding pumps, pressure relieving mattresses and electrically controlled beds) and their rooms contained other non medical items (televisions, radios, fans) that required electricity to operate. There were not enough electrical outlets for all of the equipment and the electrical outlets were not placed strategically to keep electrical cords out of walkways so that staff and visitors did not trip; trip on a cord and pull it out of the outlet; or trip and fall onto the resident's bed. Some rooms used medical grade surge protectors to extend power cord so they reach outlets and several power cord laid in walkways; cords were not secured in place or affixed to walls to reduce potential trip hazards. The resident's on the unit were dependent on staff for all care and positioning needs, requiring equipment including ventilator and or use of oxygen treatment. Observations revealed there were several rooms where electrical cords laid unsecured in walkways where staff and visitors had to walk in order to provide resident care and have conversations with the resident in the room. Of 27 rooms observed on the second floor units there were 13 rooms were an electrical cord (for medical equipment) laid in the walkway causing a trip hazard for staff and visitors leaving the vulnerable resident at risk for injury due to staff getting injured and not being able to continue needed care; equipment being unplugged improperly; due to being improperly pulled out after a staff tripped over it; and/or a person falling on the resident after tripping over the cord.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Lids for soiled linen and garbage were obtained for the 2 North unit to decrease the potential for odors. The dirty utility room on 2 North unit was cleaned and dirty items were discarded. The electrical cords were placed in a manner to prevent trip hazards. These items were corrected during the survey. 2. The other units were audited during the survey and any similar issues found were corrected. 3. The nursing and therapy staff were educated by the DON beginning on 8/3/23 on the need to keep lids on garbage cans, dispose of soiled trash in a bag and placed in the proper receptacle with a lid, and to ensure that all electrical cords are kept neat and do not cause a trip hazard. The DON or designee will complete weekly rounds of soiled utility rooms, and 5 random rooms for 3 months to ensure that odors and safety from trip hazards are in compliance. Any issues identified will be addressed immediately. 4. The DON or designee will report the results of the audits to the QAPI monthly for 3 months or until compliance is determined by the committee.
7/31/2023Licensure Complaint Survey · ID WYPS111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A survey prompted by complaint #CO33289 was completed 7/24/23 to 7/31/23. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0701Resident Care - Overall Care of the Residents▼
Findings
Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (#52) of three residents reviewed out of 52 sample residents. Resident #52 was admitted to the facility after being hospitalized for worsening congestive heart failure. The resident had a history of chronic congestive heart failure and resistance to oral antibiotics. During the hospital stay just prior to the resident's admission the resident was treated for severe edema/ water retention as evidenced by a rapid significant weight gain and swelling in both lower extremities and muscle weakness and fatigue. The hospital treated the resident with intravenous (IV) diuretics and the resident's cardiac condition stabilized enough to discharge the resident. The resident however was not stable enough to undergo a needed surgery to repair a leak in the mitral valve of the heart and the resident was sent to the facility for cardiac monitoring and therapy to strengthen muscle and functional condition. The hospital sent a discharge summary and discharge orders to the hospital for the facility to monitor the resident's cardiac function. Orders included medication, a cardiac low sodium diet, and monitoring for edema with daily weights taken at the same time each day, a fluid restriction, and assessing the status of edema throughout the resident's body. The facility did not order and provide a cardiac low sodium diet and did not concisely monitor the resident fluid intake, assess the resident weights daily and at the same time of day, or provide daily assessment of the status of the resident edematous symptoms. Additionally, when the resident started to experience a worsening of cardiac symptoms classically associated with congestive heart failure the facility did not consult with the resident's long time cardiologist for treatment recommendations, or ensure that the resident's primary care physician examined the resident timely when the resident's symptoms worsened. As a result of the facility failures to develop a baseline care plan and initiate orders to follow hospital discharge orders, the resident's cardiac condition worsened. The resident gained 12.6 pounds while in the care of the facility and complained of feeling weaker and more fatigued. The edema in the resident's legs worsened causing the skin on the lower legs to open and weep fluid. In addition to edema in the lower legs, the hospital 7/17/23 assessment revealed the resident had pitting edema in the groin and presacral edema (edema in the area between the rectum and lowest part of the spine). The resident required hospitalization and parenteral diuresis (IV diuretic medication to aid the body in removing significant water retention). Findings include: I. Facility policy The Care Plans-Baseline policy revised March 2022, was provided by the corporate nurse consultant (CNC) on 7/31/23 at 2:35 p.m. The policy read in pertinent part: "A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.-The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders ..." II. Resident #52 A. Resident status Resident #52, age 69, was admitted to the facility on 6/30/23 and was discharged to the hospital on 7/19/23. According to the July 2023 computerized physician's orders, diagnoses included biventricular heart failure (a condition affecting both sides of the heart that occurs when the heart muscles cannot not pump enough blood to meet the body's need for blood and oxygen, where blood and fluid collects in the lungs and legs over time); nonthematic mitral (valve) insufficiency (occurs when the mitral valve does not close properly, allowing blood to flow backwards into the heart and as a result, the heart cannot pump efficiently, causing symptoms like fatigue and shortness of breath); presence of an automatic cardiac defibrillator (an internal device capable of restoring normal heartbeat); chronic stage 3 kidney disease; and chronic peripheral venous insufficiency (the body's inability to move blood through the veins of the legs or arms). The admission facility assessment dated 7/5/23 documented the resident had intact cognition with a brief interview for mental status score of 15 out of 15. The resident needed staff supervision to complete activities of daily living (ADLs).-The resident received daily diuretics. B. Resident representative interview The resident was not available for an interview. Two resident representatives were interviewed on 7/31/23 at 10:06 a.m. The resident's daughter said Resident #52 had a history of cardiac complications and had been seeing a cardiologist for outpatient care for some time. The cardiologist determined the resident was a candidate for a clip procedure to stop leaking in the mitral value of the heart and repair a malfunctioning heart valve; the resident was scheduled to have the procedure at the end of June 2023. However, the resident started to experience general weakness, fatigue, weight gain, and low blood pressure and the procedure was postponed. Resident #52 went to the hospital for assessment, and was admitted for worsening heart failure and severe edema. The resident was treated with intravenous (IV) diuretic medication with a goal of removing the buildup of fluid. Once the fluid buildup was removed and the resident was determined to be stable, the resident was released from the hospital. It was determined Resident #52 needed time to strengthen his cardiac function and ensure the edema did not return before proceeding with the clip procedure. It was ultimately decided the resident would be admitted to a skilled nursing facility for medical monitoring until he was strong enough to undergo surgery to repair his mitral valve. The resident representative said that within two days of being in the facility Resident #52 began regaining the water weight (edematous fluid) he had lost while in the hospital. By day three, Resident #52 had gained 4.36 pounds and was retaining fluid in his lower legs. Resident #52 was complaining of weakness and general malaise. The resident representative said she talked to the resident's physician on 7/8/23; the physician said he would increase Resident #52's diuretic medication to better manage the resident's edema. The following day the nursing staff still did not have an order to increase the diuretic dosage. The physician did not increase Resident#52's diuretic medication until seven days after telling the resident representative he was placing an order to increase the medication (7/15/23). The resident representative said she spoke to the resident's physician and nursing staff several times relaying Resident #52's complaints of increased weakness, tiredness and increased edema; but felt the physician and nursing staff were not responsive to Resident's #52 and his declining health. The facility was supposed to weigh the resident at the same time, every morning after going to the bathroom. If he gained more than three pounds in a day, they should have notified the cardiologist; that did not happen despite Resident #52 asking staff to comply with that order. The resident representative said Resident #52 continued to complain that he was not feeling well and that his legs were swelling with fluid, which interfered with his ability to walk and participatein physical therapy; by 7/18/23 the resident weight was 284 pounds and Resident #52 asked to be sent to the hospital. The facility failed to respond timely to Resident #52's declining health. Resident #52's wife said the resident was determined to get better and was focused on being compliant with the treatment orders and recommendations of his cardiologist as well as the recommendations received at discharge from the hospital. Once at the hospital Resident #52 was started on IV diuretics. C. Record review Hospital treatment records dated 6/30/23 documented in pertinent part: Resident #52 was admitted to the (hospital name) on 6/17/23 and discharged on 6/30/23. "Primary diagnosis included acute and chronic HFrEF (heart failure with reduced ejection fraction - a condition that occurs when the heart's lower left chamber (left ventricle) doesn't pump blood out to the body as well as it should.) Recommended cardiology follow up for reevaluations within two weeks. "Resident #52 was ultimately discharged to (facility name) in a medically stable improved condition with instruction to follow-up with his cardiologist, neurologist, and PCP (primary care physician) in the upcoming weeks. Admission weight was 279 pounds and discharge weight was 268 pounds. "Diet orders: two (2) gram sodium (very low salt) and Limit fluids to two (2) liters (L);Activity orders: activity as toleratedHeart failure orders: (Refer to "Your Guide to Managing Heart Failure" for detailed information)-Fluid Guidelines (all liquids including food, i.e., soup, ice cream): 2000 milliliters ml/ cubic centimeters (cc) 18 cups or 167 ounces per day;-Weigh self-daily at the same time of day. Call if weight gain of three (3) pounds (lbs) in one day or five (5) lbs weight gain over a week.-Call your physician if you have increased cough, shortness of breath, increased leg swelling, or chest tightness or pain.-Diet: Eat a low salt diet. Avoid excess salt. Your sodium intake should be less than 2000 milligrams (mg) per day." The facility Nursing Admission Data collection and Baseline document, dated 6/30/23, read in pertinent part: "Admission 6/30/23 at 3:15 p.m. Vital signs; pulse 80 beats per minute and regular; respirations 16; blood pressure 156/65; oxygen saturation 97 percent on oxygen therapy; admission weight was 270.6 pounds at 7:20 p.m. No edema present. Pain level was zero. Cardiovascular condition: heart sounds regular; radial (wrists) and pedal (ankle) pulses detected as normal; (no other conditions documented)." -There was no documentation to identify dietary or hydration needs/restrictions and there was no documentation to identify cardiac conditions for heart failure monitoring or monitor for edema and water weight gain. -The comprehensive care plan initiated 6/30/23 failed to document the resident's cardiac needs and treatment for heart failure and monitoring for dietary and hydration restriction and monitor for edema and water weight gain. -The care plan did document a care focus for nutrition problems or potential for nutritional problems related to declining health status secondary to heart failure exacerbation and a relevant medical history of arterial fibrillations, initiated 7/4/23. The goal was for the resident not to be malnourished. Interventions included monitor weights as ordered, initiated; provide diet as ordered; and registered dietitian to evaluate and make diet change recommendations. The July 2023 CPO revealed the following orders:-Diet order: regular diet, start date 6/30/23;-Obtain admission weight and height, start date 6/30/23;-Obtain daily weight, in the morning for congestive heart failure, start 7/1/23; and,-Skilled nursing documenting daily every shift. The hospital discharge orders were not included. Weight log: The weight log revealed inconsistent weight assessments. The resident's weights were not assessed daily; were not assessed in the morning at the same time of day and not assessed by the same scale. The resident weight was only assessed one time before breakfast and sometimes the staff assessed the resident's weight with a chair scale and sometimes with a standing scale. The resident admission weight was recorded as 270.6 lbs., on day 18 the resident's weight was recorded at 283.2. Resident #52 gained a total of 12.6 lbs. in the 18 days since admission. Medical records revealed the resident entered with edema and by day 16 had 3-4 millimeter (mm) pitting edema with delayed rebound of skin when pressed inward (see below). On 6/30/23 at 7:21 p.m., the resident's weight was 270.6 lbs., on day of admission;On 7/1/23, the resident's weight was not assessed;On 7/2/23 at 4:21 p.m., the resident's weight was 273.0 lbs., an increase of three lbs. in two days;On 7/3/23 at 4:36 p.m., the resident's weight was 274.6 lbs., an increase of 1.6 lbs. or 4.6 lbs. in three days;On 7/4/23 at 3:45 p.m., the resident's weight was 271.0 lbs., a decrease of 3.6 lbs. in one day;On 7/5/23 at 11:37 a.m., the resident's weight was 273.4 lbs., an increase of 2.4 lbs. in one day;On 7/6/23, the resident's weight was not assessed;On 7/7/23 at 12:53 p.m., the resident's weight was 273.0 lbs., a decrease of 0.4 lbs. in one day;On 7/8/23 at 14:05 p.m., the resident's weight was 273.2 lbs., an increase of 0.3 lbs. in one day;On 7/9/23 at 11:55 p.m., the resident's weight was 279.5 lbs., an increase of 6.3 lbs. in one day;On 7/10/23, the resident's weight was not assessed;On 7/11/23 at 12:24 p.m., the resident's weight was 274.4 lbs., a decrease of 5.1 lbs.;On 7/12/23 and 7/13/23, the resident's weight was not assessed;On 7/14/23 at 9:30 a.m., the resident weight was 279.6 lbs., an increase of 5.2 lbs. in an undetermined number of days;On 7/15/23 at 11:17 a.m., the resident's weight was 278.8 lbs., a decrease of 0.8 lbs.;On 7/16/23 at 12:06 p.m., the resident's weight was 278.8 lbs., no change;On 7/17/23, the resident's weight was not assessed;On 7/18/23 at 8:09 a.m., the resident's weight was 283.2 lbs., an increase of 4.4 lbs., in one day. The resident's medical record contained two fluid intake records, neither documenting that the resident was on a fluid restriction. One record documented fluid intake and the other documented fluid intake with meals. There was no documentation of a daily total fluid intake and it was unclear if the documents were a duplication of the resident fluid intake or if each fluid intake record was a separate account of the amount of fluid the resident drank. The resident's medical record and progress note from 6/30/23 to 7/18/23 documented, in pertinent part, the following information: -The physician's admission history and physical exam dated 7/1/23 documented the resident was examined by the facility physician. The note revealed Resident #52 was admitted after a "complicated hospital course...was ultimately discharged to (facility name) in medically stable condition. (Resident #52's) main concern was getting enough physical therapy (PT) and occupational therapy (OT) so he could manage at home. He denied chest pain and felt he was breathing at baseline. We reviewed his care plan and medications. He understood a low sodium diet was key to reducing his edema in preparation for possible MVR (mitral valve repair).-Physical Exam: He is not in acute distress. Appearance: Normal appearance. He is not ill appearing. Swelling present. Normal range of motion. Right lower leg: Edema present. Left lower leg: Edema present." Nursing progress note dated 7/4/23 at 12:09 p.m. read: "Residents blood pressure this morning was 98/51. Blood pressure was rechecked and it was 84/57. Paged physician team and an on-call physician called back and gave verbal orders to discontinue the losartan (medication to lower blood pressure) and to give metoprolol medication (to lower blood pressure) in the mid-afternoon. The physician sent a message for the resident regular facility physician to re-evaluate the resident tomorrow. The on-call physician wants the resident's blood pressure to be checked while sitting, and also encourage fluids." Nursing progress note dated 7/4/23 at 12:09 p.m. read the on-call physician said, "The resident should be on a cardiac low salt diet."-However, there was no further documentation about the resident's dietary needs for a cardiac low sodium diet. The resident's diet was never changed from a regular diet to a cardiac low sodium diet. -The resident's physician did not provide a follow up visit until three days later, at that point the resident was experiencing additional cardiac symptoms including redevelopment of pitting edema and complaints of weakness. Physician visit note dated 7/7/23 revealed the resident was seen for a follow up visit. The note revealed the resident's blood pressure had been improved after medication change, "No specific complaints at this time. He is not in acute distress; is not toxic-appearing. Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Comments: 2+ (2 mm with delayed rebounds) BLE (bilateral/both lower extremities/legs) edema to just above knees; patient says this has been stable lately (neither worse nor better since admission to SNF) spent additional talking with the patient's family." -Up to this date the resident's medical record failed to document the status of Resident #52's edema. -Per the resident's weight log, the resident had an increase of 6.3 lbs. from 7/8/23 to 7/9/23, there was no documentation whether the resident primary care physician or cardiologist had been notified of the resident's weight gain until two days later and the physician did not examine the resident until five days later (see below). The physician visit note dated 7/7/23 failed to document if the physician assessed the resident's weight gain and if any additional medical treatment was necessary. Daily skilled nursing notes dated 7/10/23 at 6:53 p.m. documented in pertinent part that the resident continued to have impaired balance and weakness. "Skin Integrity: weeping to the right lower extremity, edema to the left and right lower extremities." Nursing progress note dated 7/11/23 revealed Resident #52 had edema to both lower extremities and a couple of blisters, with weeping. The physician gave verbal orders to wrap the resident's legs in kerlix (a bandage rolls that provide wicking action, aeration and absorbency) and apply tubi grips (a tubular bandage that provides consistent and even compression). Daily skilled nursing notes dated 7/11/23 at 7:05 p.m. documented in pertinent part the resident's "Skin Integrity: weeping to right lower extremity, edema to left and right lowerextremities." -There was no documentation in the daily skilled nursing notes for the section about edema or in any nursing note to document the status of the resident's edema on 7/13/23. Daily skilled nursing notes dated 7/14/23 at 12:14 a.m. documented in pertinent part: the resident had no edema. -However, nursing and physician notes before and after this date documented the resident had signs and symptoms of edema. Physician's visit note dated 7/14/23 documented the resident was seen for a follow up visit for daily weights, monitoring of blood pressure and wound care ... The note revealed the resident was seen at the heart failure clinic on 7/5/23. Recommendations from the last visit were to monitor edema and weights.-During this follow up visit 7/14/23 (Resident #52) "told me he felt his legs were more swollen. He has developed clean venous stasis ulcers and is followed by the wound team. Physical exam record review weights reviewed. Medication changes: - Increase Torsemide (Demadex) (medication to help treat fluid retention (edema) and swelling that is caused by congestive heart failure) 20 mg, oral tab; take three tablets by mouth, daily, for chronic congestive heart failure." Skilled nursing notedated 7/16/23 at 5:12 p.m. documented in pertinent part: "Edema is present: in bilateral lower extremity. Edema leaves a slight indentation of 3-4 millimeters (mm), 15 second or less rebound, none noted. Bilateral lower legs red and using Kerlix. Dressing changed as pre-treatment orders." Nursing progress note dated 7/18/23 at 8:10 a.m. documented "Resident voiced some concerns on how he is feeling. Resident feels shaky, and like he is retaining more fluid, he feels bad." Transfer form dated 7/18/23 at 11:10 a.m. documented the resident was sent to the hospital for further evaluation due to water weight gain of five lbs. in two days. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 7/25/23 at 10:30 a.m. LPN #2 had no knowledge of Resident #52. LPN #2 said the nurse should fully assess the resident experiencing a change of condition and document the assessment in the resident progress notes. The nurse should contact the resident's physician and document the contact and any orders. The admitting nurse was responsible for reviewing hospital orders and entering the orders into the resident record. LPN #3 was interviewed on 7/25/23 at 11:02 a.m. LPN #3 said the skilled nursing assessment was completed. Each shift the nurse should document the resident's status on the form completing a response for each section on the form. If the resident had a change in condition after the skill nursing note was completed the nurse should make an additional entry in the resident record. If there was a change in the resident's condition, the nurse should contact the resident's physician for treatment orders and document that contact. The resident's representative should also be notified. The registered dietitian (RD) and the RD consultant (RDC) were interviewed on 7/27/23 at 2:20 p.m. The RD said she assessed Resident #52 and talked to the resident about his dietary needs. They discussed the importance of getting good nutrition and a low sodium; however, the RD believed it was important to put the resident on a regular diet due to poor intake and risk of malnutrition. The RD's focus for Resident #52 was to make sure he ate enough food. The resident had a good understanding of low sodium food choices and said he understood he limited his fluid intake. The CNC was interviewed on 7/27/23 at 11:30 a.m. The CNC said the Nursing Admission Data collection and Baseline document was the resident baseline care plan. The document triggered a care focus with interventions for any assessed area where the nurse found concern. If no concern was identified the document would not trigger the need for interventions. The CNC, director of nursing (DON), nursing home administrator (NHA) and corporate consultant (CC) were interviewed on 7/31/23 at 3:55 p.m. The DON said the admitting nurse would transcribe all medication and treatment orders from the resident's hospital discharge records into the resident record. The resident's physician got a copy of the discharge documents and was responsible for reviewing the resident medication administration record and treatment administration record for accuracy and signing off on the orders. The resident's primary care physician would make the decision whether or not to follow the hospital discharge orders. The nursing staff should document the resident's health status in the daily skilled nursing note and any additional changes of condition in the resident record.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL 1. Resident #52 no longer resides in the facility. 2. Other residents who have the diagnosis of congestive heart failure on admission have the potential to be affected by the alleged deficient practice. These residents will be reviewed by the DON and unit managers to ensure that weight monitoring, diet orders and edema checks are in place as ordered by the physician. 3. The nursing staff were educated by the DON beginning on 8/3/23 on the need to follow physician orders and document an assessment of clinical findings in the medical record and to report any unusual findings to the physician for further follow up. The DON or designee will audit 5 post-acute residents per week for 3 months with CHF for weight monitoring weekly (or per MD order), that edema checks are documented , and that MD was notified of any changes. Any issues identified will be addressed immediately. 4. The DON or designee will report the results of the audits to the QAPI for review monthly for 3 months or until substantial compliance is determined by the committee.
6/5/2023Revisit: Licensure Complaint Survey · ID 7KCP12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 6/5/23 for all previous deficiencies cited on 4/6/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
6/5/2023Revisit: Complaint Survey · ID 9SVI12No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit survey was completed on 6/5/23 for all previous deficiencies cited on 4/6/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
6/5/2023Complaint Survey · ID RVTG11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO32362 was conducted on 6/5/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
4/6/2023Licensure Complaint Survey · ID 7KCP111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A survey prompted by complaint #CO31777 was completed 4/3/23 to 4/6/23. 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, observations and interviews, the facility failed to ensure three (#6, #2 and #9) of three residents received adequate supervision to prevent accidents out of 16 sample residents reviewed. Specifically, the facility failed to ensure Resident #6, who had a history of falls and was assessed to be a high fall risk upon admission, received the care and services indicated in her comprehensive plan of care. The facility failed to ensure Resident #6's call light was answered timely, which was an intervention on her care plan, to prevent the resident from getting up without assistance. On 1/30/23, Resident #6 reported she pushed her call light and waited for 30 minutes to be assisted to the bathroom. Resident #6 said she got up from the bed, using her walker, because she could "not wait any longer" and did not want to soil herself. Upon returning from the bathroom, she became dizzy and fell to the ground, hitting her head and the right side of her body. Upon further studies conducted at the hospital, the resident had sustained a right proximal humeral (shoulder) fracture. Additionally, the facility failed to ensure an assessment by the registered nurse (RN) was completed following a fall for Resident #2 and Resident #9. Findings include:I. Facility policy and procedureThe Fall Management policy and procedure, dated November 2019, was provided by the nursing home administrator on 4/6/23 at 1:30 p.m. It revealed in pertinent part, "The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury."A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs."Research has shown that structured fall reduction programs can substantially reduce the rate of falls and related injuries in nursing facilities, however, falls may likely occur. Identifying risk factors, followed by timely and appropriate interventions, is the key to a successful program."Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Please note interventions are to be re-evaluated when a resident falls."II. Failure to ensure Resident #6 received the care and services documented on the comprehensive plan of careA. Resident #6 statusResident #6, age 87, was admitted on 1/19/23, readmitted on 2/1/23 and discharged home on 3/14/23. According to the March 2023 computerized physician orders (CPO), the diagnoses included fracture of the upper end of the left humerus, history of falling, need for assistance with personal care; and paroxysmal atrial fibrillation. The 2/7/23 facility assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 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. It indicated the resident had a fall in the last two to six months with a fracture. It indicated the resident was continent of bowel and bladder. B. Resident interviews Resident #6 was interviewed on 4/5/23 at 1:34 p.m. She said she had been discharged from the facility during the previous month and was living at home with her husband. She said while she had resided at the facility, she had multiple issues with call lights not being answered timely. She said she would activate her call light and it would take the staff from 30 minutes to over an hour to respond on multiple occasions. She said on one occasion she had to lay in urine and a bowel movement for 45 minutes. She said she had notified the management of the facility of her call light response time concerns, but did not feel they had resolved the concern, as it continued to happen. She said on 1/30/23, she had activated her call light because she needed to use the bathroom. She said she was able to walk with a walker, but needed assistance because she would get dizzy. She said she looked at the clock when she pushed her call light. She said after about 30 minutes, she got up, used the walker and walked to the bathroom because she could "not wait any longer and I did not want to soil myself." She said she got dizzy on her way back from the bathroom and fell to the ground. She said she was sent to the hospital where she learned she had broken her right arm. C. Resident #6's reported concerns of call light response times The 2/10/23 compliments/complaints/concerns report documented that the resident had reported a concern regarding the call light response times. She had reported that she had been left by a certified nurse aide (CNA) on the bed pan for over an hour. The facility documented a call light report was reviewed with the resident averaging 10 minute call light wait times with the longest wait time of 20 minutes. It indicated the resident was provided re-education on how to press the call light and an investigation was started regarding the allegation of being on the bed pan for over an hour. -The grievance did not include the "report" that the social worker reviewed that documented the resident's call light wait times and was unable to print out a report to be reviewed during the survey process (see staff interviews) to corroborate that the resident had not waited for an extended period of time. D. Record review The activities of daily living (ADL) care plan, initiated on 1/21/23 and revised on 3/15/23, documented the resident had a self-care performance deficit related to decreased mobility. It indicated the resident required assistance with ambulation and toileting. The interventions included, in pertinent part, encouraging the resident to use the call bell for assistance. The fall risk care plan, initiated on 1/21/23 and revised on 3/15/23, documented the resident was at a high risk for falls. The interventions included, in pertinent part, anticipating and meeting the resident's needs, ensuring the resident's call light is within reach, encouraging the resident to use the call light when she needed assistance and providing prompt response times to her call light. The 1/19/23 fall risk evaluation documented the resident had sustained one to two falls in the past 90 days and was considered a high fall risk. The January 2023 ADL documentation revealed the resident had been provided toileting no toileting assistance on 1/19/23-1/22/23, twice on 1/23/23, no toileting assistance on 1/24/23, three times on 1/25/23, no toileting assistance on 1/26/23, one time on 1/27/23 and 1/28/23, twice on 1/29/23 and 1/30/23. 1. Fall incident on 1/30/23 The 1/30/23 interdisciplinary team (IDT) risk management review progress note documented the resident sustained an unwitnessed fall, which required emergency transportation to the hospital. It indicated the root cause was dizziness, weakness, a history of falls and ambulating without assistance. The interventions included encouraging the resident to utilize the call light for assistance with ambulation. The 1/30/23 physician progress notes documented Resident #6 was sent to the emergency room due to a fall with a sustained right upper extremity injury. The 1/30/23 incident report documented the nurse was notified that Resident #6 had sustained a fall. Upon arriving in the room, the nurse observed the resident lying on the floor, on her back by her dresser, being evaluated by the director of nursing (DON). It indicated the resident was unable to move due to "excruciating" pain to the right arm. Resident #6 said she was coming back from the bathroom, got dizzy and fell to the floor, hitting her head and right side of her body. It indicated the resident used her walker to ambulate in her room. Upon assessment, the resident had a lump to the right side of the resident's forehead and swelling to the right shoulder. Emergency services were contacted and transported the resident to the emergency room for further testing and evaluation. The 2/1/23 physician progress note documented on 1/30/23, while the resident attempted to get out of the chair and transfer herself, she fell and suffered a right proximal humeral fracture. She was placed in a sling and returned to the facility after it was determined the break was non-operable. According to the interventions documented in Resident #6's comprehensive plan of care, the facility was to encourage the resident to use her call light and provide prompt assistance, however, according to the grievance filed by the resident and the resident's interview, the facility failed to ensure her call light was answered promptly, which according to the resident, was the reason she got up out of bed unassisted to walk to the bathroom, because she could not wait any longer. E. Additional resident interviews and resident council minutesResident #16, who the facility identified as cognitively intact, was interviewed on 4/6/23 at 9:14 a.m. She said up until two weeks prior when the facility put a new system in place, it would take between 30 to 40 minutes for the call lights to be answered. She said it was very frustrating and she would not use her call light because she did not feel there was a point. Resident #13, who the facility identified as cognitively intact, was interviewed on 4/6/23 at 9:46 a.m. She said she had to wait for 30 minutes for the facility staff to answer her call light. She said because of the call light response time, she started only pressing the call light when she needed something really bad. She said the facility had gotten pagers about two weeks prior and that had been helping with the call light response time. Resident #14, who the facility identified as cognitively intact, was interviewed on 4/6/23 at 10:04 a.m. He said he chose not to use his call light very often because the facility staff did not answer it timely and he felt they would get mad at him for asking for help. He said he would hold his urine until a staff member would come to check on him instead of using the call light. He said it took 30 to 40 minutes for the facility staff to answer the call light. The February, March and April 2023 resident council meeting minutes documented the resident's reported call light response times of greater than 15 minutes. -It indicated in March 2023, a new call light system was installed at the facility. When a call light was activated, at different time intervals the call light would page the nurse, the unit manager and the director of nursing. F. Staff interviews The NHA was interviewed on 4/5/23 at 1:00 p.m. He said he was unable to pull call light reports from a couple of months ago. He said he could only print off reports of call lights for that week. He said he was unable to provide any documentation of the call light report that was reviewed by the social worker for Resident #6's grievance regarding timely call light responses. The social services director (SSD) was interviewed on 4/5/23 at 3:57 p.m. She said she had investigated Resident #6's grievances for call light response times. She said she had reviewed the call light report but had not included it with the documentation of the grievance. She said she only remembered that the longest call light wait time was 20 minutes. She said that the facility was unable to pull the report of the call light times for Resident #6 during her stay at the facility. The DON was interviewed on 4/6/23 at 1:17 p.m. She said she was aware the facility had a lot of resident concerns regarding call light response times. She said one of the issues with the older call light system was the audible portion of the call light activation was not working and with the way the nursing station was built, the nurses and CNAs were unable to see down the hallway to determine if a call light had been activated. She said during the last week of March 2023, the facility had installed a new call light system. She said the system now sent an alert to the CNA's pager when a call light was activated and then after so many minutes of it not being answered, the nurse would be alerted, then the unit manager and then the DON. She said she pushed for a system that would have an escalation process in it so she would be able to tell if the resident's concerns of long call light wait times were being addressed. She said the facility had concerns of call light wait times while Resident #6 resided in the facility. She said she was in the facility on 1/30/23, when Resident #6 fell in her room. She said she did not remember seeing the call light activated. She said she sat on the ground with her until emergency services arrived. She said she was not aware the reason the resident had gotten up out of bed by herself was because she had activated her call light for 30 minutes and was unable to wait any longer and did not want to soil herself. She said Resident #6 did not have a history of being impulsive and she was aware the resident had concerns with her call light response times. She said the call light should be answered in less than 10 minutes. III. Failure to ensure a registered nurse (RN) assessment was completed following a fallA. Resident #2 1. Resident statusResident #2, age 85, was admitted on 11/29/22 and discharged to the hospital on 12/6/22. According to the December 2022 CPO, the diagnoses included end stage renal disease. The 12/5/22 facility assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required a one-person physical assistance with bed mobility, dressing, toileting and personal hygiene. She required two-person assistance with transferring. 2. Record reviewThe fall risk assessment dated 11/29/22 revealed Resident #2 was a high risk for falls, the resident had periods of confusion and had one to two falls within the past 90 days. The fall risk care plan, initiated on 11/30/2022, revealed the resident was at risk for falls. The interventions included ensuring the resident's call light was within reach and encouraging the resident to use the call light assistance and providing prompt responses to all requests for assistance. The 12/6/22 incident progress note, written by LPN #1, documented Resident #2 was heard yelling for help and was found lying supine (lying face up) with her bilateral feet near the wall and head and upper torso underneath the bed. It indicated the resident was responsive to verbal stimuli and complained of pain to her tailbone. It indicated the resident was assessed by the writer (LPN #1) and she had notified the physician, the resident's medical durable power of attorney (MDPOA), and the DON. -A review of Resident #2's medical record did not reveal documentation that the resident had been assessed by an RN following the fall on 12/6/22.-The facility was unable to provide additional documentation to show that an RN assessment was completed during the survey process. B. Resident #9 1. Resident statusResident #9, age 74, was admitted on 3/15/23 and re-admitted on 3/27/23. According to the April 2023 CPOs, diagnoses included unspecified dementia without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, muscle weakness and epilepsy. The 3/29/23 facility assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score of three out of 15. He required extensive assistance of two people for all activities of daily living. 2. Record reviewThe fall risk care plan, initiated on 3/29/23 and revised on 4/1/23, documented the resident was a high fall risk. The interventions included placing the call light within the resident's reach, educating the resident on how to use the call light, providing a prompt response when the call light was activated and educating the resident, family, and caregivers about safety reminders and what to do if a fall occurred. The 3/30/23 nursing progress note documented that Resident #9 had sustained a witnessed fall. It indicated the resident slid out of bed and onto the ground, which was witnessed by the CNA who was answering the resident's call light. It indicated the resident did not sustain any injuries from the fall. The nursing progress note was documented by an LPN. A review of the resident's medical record did not reveal documentation that Resident #9 had been assessed by an RN following the fall and prior to being moved from the ground. C. Staff interviewsLPN #2 was interviewed on 4/6/23 at 12:19 p.m. She said if a resident sustained a fall, an RN would need to assess the resident before the resident was moved from the ground. She said it was not within the LPN's scope of practice to conduct an assessment. The DON was interviewed on 4/6/23 at 1:17 p.m. She said an assessment of the resident should be completed by an RN following a fall. She said it was not within an LPN's scope of practice to perform an assessment. She said the RN's assessment should be documented in the progress notes of the resident's medical record.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident’s #2, #6 and #9 no longer reside at the facility 2. Residents who currently reside in the facility have the potential to be affected by the alleged deficient practice. 3. The facility installed an upgrade the the facility call light system to enable increased oversight of call light response as stated in the deficiency list. Beginning on 4/7/23 nursing staff were educated on the importance of responding timely to resident call lights and the requirement to have an RN assess residents at the time of a fall and the need to implement a new intervention for fall prevention following a fall. The DON or designee will review all falls for 2 weeks and then 5 falls per week for 3 months to ensure that there is evidence of an RN assessment and new interventions to reduce falls. The NHA or designee will review call light response times weekly for 3 months to identify any trends in slow response times to resident’s call lights. Any issues identified with the audits will have follow up as needed 4. The DON and NHA will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee
4/6/2023Complaint Survey · ID 9SVI114 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO29346, #CO29459, #CO30560, #CO31490, #CO31510, #CO31513 and #CO31514 was conducted on 4/3/23-4/6/23. Four deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0573Right to Access/Purchase Copies of RecordsS/S E▼
Findings
Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for three (#5, #4 and #2) of four out of 16 sample residents. Specifically, the facility failed to ensure records were provided timely upon request for Resident #5, Resident #4 and Resident #2 from a government adult protection agency. Findings include:I. Facility policy and procedureThe Release of Information, revised November 2009, was provided by the nursing home administrator (NHA) on 4/6/23 at 1:38 p.m. It revealed, in pertinent part, "Access to the resident's medical records will be limited to the staff and consultants providing services to the resident. (Note: Representatives of state and federal regulatory agencies have access to resident information without the resident's consent)."Closed or thinned medical records are maintained in the medical records department and are available only to authorized personnel. Authorized personnel include, but are not necessarily limited to: nursing personnel; physicians; consultants; support services; administration; government agencies; and/or resident/representative."A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request."A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services."The facility may recommend that the resident or representative review the active chart in the presence of a knowledgeable staff person who can discuss the information and answer questions capably."II. Failure to provide medical records as requested by a government agencyA. InterviewsThe supervisor with the government adult protection agency was interviewed on 4/5/23 at 11:58 a.m. He said his staff had entered the facility on three occasions to conduct an investigation and each time when they had requested medical records they were either not provided at all or not provided timely. He said three different members of his staff had the same experience when requesting medical records. He said obtaining the medical records was important in the agency's goal to protect vulnerable adults. He said a request was sent to the NHA on 11/8/22 for Resident #5's medical records. He said they had still not received the requested documents. He said a request was sent via email to the director of nursing (DON) on 11/18/22 for Resident #4's medical records. He said the facility did not respond to the request and they had still not received the records. He said a request was sent to the NHA on 12/20/22 for Resident #2's medical records. He said they did not receive the requested records until 12/28/22. B. Record reviewThe 11/8/22 records request was sent via email from the government adult protection agency to the NHA for the following records for Resident #5: all hospital, clinic, nursing and treatment facility admissions; treatment and physical therapy records; test results; ER (emergency room), outpatient and inpatient records; and pharmacy and prescription information; neuro-psychiatric exam or similar assessment to determine cognition, mental status, competency, or capacity; and current list of diagnosis and medication.-The response from the NHA documented he had received the request for records for Resident #5. The 11/29/22 email communication from the adult protection agency to the NHA indicated they had not received the records or any other communication for their request for Resident #5's records on 11/8/22. The 11/18/22 records request was sent via email from the government adult protection agency to the DON for the following records for Resident #4: all hospital, clinic, nursing and treatment facility admissions; treatment and physical therapy records; test results; ER (emergency room), outpatient and inpatient records; and pharmacy and prescription information; neuro-psychiatric exam or similar assessment to determine cognition, mental status, competency, or capacity; and current list of diagnosis and medication.-The facility was unable to provide documentation to indicate they had responded to the government adult protection agency's request for records. The request was not documented on the facility's request for records log.-According to the government adult protection agency, they never received a response or the records that were requested (see interview above). The 12/20/22 records request was sent via email from the government adult protection agency to the NHA for the following records for Resident #2: all hospital, clinic, nursing and treatment facility admissions; treatment and physical therapy records; test results; ER (emergency room), outpatient and inpatient records; and pharmacy and prescription information; neuro-psychiatric exam or similar assessment to determine cognition, mental status, competency, or capacity; and current list of diagnosis and medication.-According to the facility's request for records log, the request was documented as received and records sent on 12/28/22. However, the email record clearly indicated the request was sent to the facility on 12/20/22. III. Staff interviewsThe health information manager (HIM) was interviewed on 4/6/23 at 12:42 p.m. She said when a request for records was submitted, she would indicate the request on the log and then provide the records according to the request within 24 to 48 hours of the request being made. She said emailed records were sent secured within 24 hours of the request. She said she was aware of the requests made by the government adult protection agency. She said she was only aware of the requests as indicated on the log. She said she had received the requests for Resident #5 and Resident #4 from the NHA.She said she was not aware a request had been made for records regarding Resident #2. The NHA was interviewed on 4/6/23 at 1:15 p.m. He said he was aware of the requests for medical records from the government adult protection agency. He confirmed the records had not been provided timely or at all for Resident #5 and Resident #2.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Residents’ #2, #4 and #5 no longer reside at the facility and all information was submitted as stated in the 2567. 2. Any other records requested by adult protective services has been submitted. 3. The facility staff responsible for sending records were educated on the requirement of timely submission of information by the clinical consultant RN. The NHA will forward all requests for medical records from APS to the Health Information Manager when it is received. The Health Information manager will be responsible to submit the information in a timely manner. The Health information manager will keep a log of all record requests that includes the date of the request and the date of submittal of records. The NHA will review the log weekly to ensure that all information is submitted timely. Any issues identified will be addressed. 4. The HIM will provide a copy of the log for review by the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee
0686Treatment/Svcs to Prevent/Heal Pressure UlcerS/S D▼
Findings
Based on record review, observations and interviews, the facility failed to ensure two (#7 and #5) of four out of 16 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to:-Ensure timely incontinence and reposition was provided to Resident #7, who had a pressure injury; -Ensure a treatment was in place for a pressure injury to the coccyx for Resident #7;-Ensure treatments were provided as ordered by the physician for Resident #7; and,-Assess, notify the physician and obtain treatment order for newly identified skin concern for Resident #5. Cross reference F880: failure to ensure wound care was provided within accepted infection control standards of practice. Findings include:I. Professional referenceThe National Pressure Ulcer Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 4/18/23 read in pertinent part:"Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. "Stage 1 Pressure Injury:Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. "Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). "Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. "Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. "Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed."The National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (2/17/2017), accessed on 4/18/23. It read in pertinent part, "Steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time."The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing:-Positioning that places pressure on the pressure injury should be avoided.-The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented.- The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications.-Signs of deterioration in the wound should be addressed immediately.-The assessment should include: location, category/stage, size, tissue type, color, periwound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order."II. Facility policy and procedureThe Pressure Injury Management policy and procedure, reviewed October 2019, was provided by the nursing home administrator (NHA) on 4/6/23 at 1:30 p.m. It revealed in pertinent part, "The purpose of this policy is to establish protocols for the care of residents who have been admitted to the facility with a pressure injury or who have developed a pressure injury while residing in the facility."If a resident admits to the facility with a pressure injury or is assessed to have a pressure injury: the charge nurse will be responsible to assess the pressure injury to include site/location of the pressure injury, staging of the pressure injury, size in cm (centimeters) (length x width), appearance of the wound bed, depth, undermining, draining/exudates to include the type/amount, color of the wound bed, and surrounding skin color and any pain related to the pressure injury."The charge nurse or designee will be responsible to initiate the evaluation in the resident medical record. The charge nurse or designee will be responsible to notify the physician and the responsible party regarding the development of the pressure injury. A treatment order will be initiated."The charge nurse or designee will be responsible to complete an initial narrative note in the resident's medical record to describe the resident's identified risk factors and a description of how the pressure injury most probably occurred if known."A care plan will be initiated to identify actual skin breakdown to include identified risk factors and individualized interventions to aid in wound healing."Residents will be offered position changes at least every two hours unless otherwise specified per their plan of care."Any resident who has a pressure injury - nursing will be responsible to complete daily documentation on the monitoring of the wound in the progress note section of the medical record."III. Failure to provide repositioning and incontinence timelyA. Resident statusResident #7, age less than 65, was admitted on 1/6/23. According to the March 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (low blood oxygen), long-term use of anticoagulants, contracture of the right elbow, contracture of the left elbow and tracheostomy (an opening in the windpipe). The 4/3/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He was dependent upon staff for all activities of daily living. It indicated the resident did not have any unhealed pressure injuries. B. ObservationsOn 4/4/23, during a continuous observation starting at 8:55 a.m. and ended at 1:30 p.m. Resident #7 was observed lying on his back, in bed, sleeping. At 9:04 a.m. an unidentified certified nurse aide (CNA) entered the resident's room to check on the resident. She did not provide care and exited the room at 9:15 a.m. The resident remained in the same position. At 9:21 a.m. three unidentified staff members entered the resident's room. Upon exiting, one CNA was observed exiting the room with a bag of soiled incontinence supplies. The resident's bed was lowered and the resident remained positioned on his back, with the head of the bed positioned at a 30-degree angle. -The resident was supposed to be repositioned on his left and right side, not in the supine position (see record review). At 1:30 p.m. facility staff had not re-entered Resident #7's room, in over four hours, to provide incontinence care or repositioning. On 4/5/23, during a continuous observation starting at 8:57 a.m. and ended at 12:00 p.m., Resident #7 was observed lying on his back, in bed, sleeping. At 9:43 a.m. two unidentified staff members entered the resident's room and provided incontinence care. The resident was observed still lying on his back in the supine position. At 11:26 a.m. two unidentified CNAs were observed entering the resident's room and closing the door. At 11:29 a.m. an unidentified nurse entered the resident's room At 11:45 a.m. CNA #1 and CNA #2 said they had repositioned Resident #7 when they provided incontinence care. They said they had cleaned the resident's face, mouth, and performed oral care, however the resident was observed still lying on his back, in the supine position. C. Record review The April 2023 CPO documented the following:-Reposition on the left and right side only to offload pressure of the coccyx, every shift for wound care - ordered 3/10/23. The ADL care plan, initiated and revised on 12/10/22, documented the resident had a self-care performance deficit due to an anoxic (lack of oxygen) brain injury. It indicated the resident was dependent upon staff for bed mobility, personal hygiene, toileting and transfers. The communication care plan, initiated on 12/10/22 and revised on 2/8/23, documented the resident had a communication problem due to an anoxic brain injury and was unable to make his needs known. It indicated the facility staff would anticipate his needs. The bowel and bladder incontinence care plan, initiated and revised on 12/10/22, documented the resident was incontinent of bowel due to an anoxic brain injury. The interventions included checking the resident for incontinence often, assisting with toileting as needed and providing peri care after each incontinence episode. The risk for pressure injuries care plan, initiated on 12/10/22 and revised on 3/13/23, documented the resident had potential for pressure injury development related to immobility and bowel and bladder incontinence. It indicated the resident had actual skin breakdown of moisture associated skin disease (MASD) to the right buttocks. The resident was dependent upon the facility staff for turning and repositioning. The interventions included, in pertinent part, administering treatments as ordered and providing education as to the causes of skin breakdown and frequent repositioning. The resident went to the hospital from 3/27/23 to 4/3/23 due to a clogged G-tube. The 4/3/23 hospital wound physician notes documented to reposition Resident #7 on the right and the left side only. It indicated not to position the resident in the supine position. The hospital physician noted if a hand cannot be placed underneath the resident's coccyx, then the resident was not turned enough. IV. Failure to provide treatments as ordered by the physician and ensure treatments were in place for an existing woundA. Wound observations On 4/6/23 at 9:20 a.m., during a wound observation with the assistant director of nursing (ADON), Resident #7 was repositioned by two unidentified CNAs flat on his back with his feet offloaded onto a rectangular cushion. Neither heel had a dressing in place. A dressing was observed to the left elbow, however no dressing was observed to the right elbow and foam was present underneath the tracheostomy ties on the left side of the resident's neck. There was no dressing on the right elbow, the left elbow had a foam dressing. Foam was positioned under the tracheostomy ties on the left side of the resident's neck. When the CNAs rolled Resident #7 to his left side, the dressing to the right ischium was not intact. It had migrated down his leg and was completely saturated in serosanguinous (blood, serum) fluid. The dressing was not dated. The disposable pad under the resident also had a large amount of serosanguinous (approximately five to six inches in diameter) drainage. The entire buttock on each side were deep red/purple in areas and macerated with peeling skin caked with a white powdery substance. The left buttock, midway down toward where the buttocks meet, had a superficial round open area approximately one centimeter (cm) in the center of the MASD (moisture associated skin disease). The sacral coccyx area had an opening toward the right buttock. It was liner and covered in yellow slough. The ADON said that he and the wound physician did not see the area that morning when he had evaluated Resident #7's wounds. He said the facility did not have a treatment in place for the open area. The open area was very visible when the resident was rolled over. The ADON said he would contact the physician for a treatment to the open area to the sacral coccyx. The ADON said he thought the wound to the right ischium was a stage 3 but he could not remember. The ischium was observed and had two wounds, close to each other in proximity. There was a large wound over the ischium area with a smaller wound above it. The wound bed was red and shiny with the skin around the edges of the wound peeling and rolling. The ADON measured the wound to the left of the coccyx. It measured 0.5 cm (w) x 1.8 cm (l) x 0.4 cm (d). It was covered in a layer of yellow slough which did not come off when the ADON cleansed the area with gauze and normal saline. The ADON sent the CNA to get barrier cream. He said he would apply the barrier cream to the MASD on the buttocks. He said he did not know what the treatment orders were for the buttocks. The ADON did not leave the room to check the orders to ensure he was following the physician ordered treatment. The ADON dressed the wound to the right ischium, however he did not use medi honey, which was the physician ordered treatment. The ADON put barrier cream over the MASD on the buttocks, even though there was still a dry and crusty substance on them. He placed barrier cream over the coccyx area and the open area on the left buttock because he said he had no other orders. He said he was going to cover the coccyx wound with Tegaderm. He then placed it on top of the coccyx wound which was covered in barrier cream. The ADON said the elbows should both have a foam dressing for protection. He said he was not sure why the right elbow did not have a dressing in place. He said the left elbow was healed. He removed the left elbow dressing and revealed a quarter size deep reddened area. The ADON pushed on it and said the area did not blanch. He said he saw the area that morning, however just before he had said the left elbow was healed. The resident's right and left heel were observed. The ADON confirmed there was no dressing in place and the resident did not have any open areas. He said a foam dressing should have been in place for protection. He said he did not know why the dressing was not in place. The resident's left index finger was observed with a pulse oximeter tube taped to it. The respiratory therapist (RT) said that was not one of the facility's pulse oximeter wires. She said it must be from when the resident was recently in the hospital. The taped wire was removed with difficulty and the pad of the resident's fingertip was deep red and blanchable. The resident's G-tube had a drain sponge (gauze) on it, not taped down, with no visible ointment or cream applied. The area around the tube was raw, red and shiny and about one cm circumference with approximately 0.5 cm pink tissue. The ADON said he thought there should be a treatment for the area but did not know what it was. B. Record reviewThe risk for pressure injuries care plan, initiated on 12/10/22 and revised on 3/13/23, documented the resident had potential for pressure injury development related to immobility and bowel and bladder incontinence. It indicated the resident had actual skin breakdown of moisture associated skin disease (MASD) to the right buttocks, MASD to the right distal buttocks and an abrasion to the neck from the trach tie. The resident was dependent upon the facility staff for turning and repositioning. The interventions included, in pertinent part, administering treatments as ordered, monitoring for the effectiveness of the treatments, providing education as to the causes of skin breakdown, frequent repositioning, informing the family of any new skin breakdown, monitoring the resident's non-verbal cues of pain prior to and during treatments, monitoring and reporting any changes to the resident's skin status, utilizing barrier cream as indicated and following incontinent episodes and conducting weekly skin checks by the licensed nurse.-The comprehensive care plan did not include the actual skin breakdown of the resident's coccyx or ischium. The 3/28/23 hospital wound physician progress note documented Resident #7 was admitted to the hospital due to a clogged/leaking G-tube. The wound physician was consulted for an unstageable pressure injury to the perineum, blanchable erythema (superficial reddening of the skin) and scar tissue to the left elbow and blanchable erythema to the bilateral ankles and dorsal feet. It indicated the perineum had soft eschar covering the wound with it beginning to open to the right side of the wound with nongranular and granular tissue noted. The left elbow, bilateral ankles and dorsal feet had well defined areas and the wound physician placed bordered foam to the heels for preventative measures. The 4/3/23 nursing data collection documented the resident was readmitted to the facility from the hospital due to a clogged G-Tube. It indicated the resident returned with open areas to the coccyx, redness to the bilateral buttocks, bilateral elbows and heels. The April 2023 CPO documented the following physician ordered treatments:-Wound care: peri g-j-tube (GJT): Clean with normal saline (NS) moistened gauze, pat dry and apply skin prep to peri wound. Cover with Mepilex Ag one time per day for wound care - ordered 4/4/23;-Bilateral elbows and heels: Cleanse with NS, pat dry and cover with bordered foam dressing, one time a day for wound care - ordered 4/4/23;-Bilateral buttock: Cleanse with peri wipes or foam cleanser (avoid rubbing, only remove soiled cream for skin). Apply lidocaine/nystatin/zinc oxide cream. Alternate with clear-aid after each incontinence episode, three times a day for wound care - ordered 4/4/23;-Coccyx: Cleanse with NS, apply skin prep to the peri wound, apply Dakins moistened gauze to the open area and cover with ABD Medipore tape, two times per day for wound care - ordered 4/4/23. The 4/3/23 Braden scale for predicting pressure sore risk documented the resident was unresponsive, had very moist skin, was bedfast (confined to a bed) and completely immobile. It revealed the resident scored a 10 out of 18, which indicated the resident was at a high risk for developing pressure injuries. V. Staff interviewsCNA #3 interviewed on 4/6/23 at 12:30 p.m. She said that Resident #7 required the assistance of two staff members with repositioning. She said Resident #7 was incontinent of bowel and bladder. She said Resident #7 had pressure injuries and should be repositioned from side to side and sometimes on his back. The director of nursing (DON) and the ADON were interviewed on 4/6/23 at 11:24 a.m. The DON said that residents who were dependent upon staff, should be repositioned every two hours. She said facility staff should check in with dependent residents to determine if they required incontinence care every two to three hours. She confirmed Resident #7 had pressure injuries and was at high risk of skin breakdown. She acknowledged repositioning and timely incontinence care was a tool that assisted in the healing and prevention of the worsening or continued skin breakdown for Resident #7. She said repositioning only occurred if the resident had actually changed positions. The ADON confirmed when the wound observations were conducted, the treatment to the ischium was floating. He said he had forgotten to date when he had conducted wound rounds with the wound physician that morning. He said, according to the wound physician notes, he had identified it as a stage three pressure injury. He said he contacted the wound physician who confirmed he did not see the open area to the coccyx. He said he obtained a treatment order and the wound physician said he would come to the facility to evaluate the wound. He said the wound physician had clustered the wound to the right ischium as a stage 2. The DON said when the wound physician performed weekly wound rounds, he did not perform a head to toe skin assessment. She said the wound physician assessed and treated the wounds he was aware of. She said the nurse should have caught the new open area to the coccyx on the daily skin checks, the CNA during incontinence care and upon the resident's readmission to the facility. The ADON said the resident had barrier cream on the surrounding area and that was why he missed it. He said prior to the resident being recently admitted to the hospital, the resident's coccyx had been healed. The ADON confirmed the resident did not have dressings in place on both heels. He said the resident did not have any open areas but the dressings were preventative. The DON said the admission nurse should have identified the pulse oximeter tubing upon the resident's admission to the facility. She said the nurse must have thought it was from the facility, however it was not. She said it had been removed, the physician was notified and a treatment was put in place. VI. Assess, notify the physician and obtain treatment order for newly identified skin concernA. Resident statusResident #5, age 79, was admitted on 10/5/22 and discharged on 10/30/23 to home. According to the October 2022 CPO, the diagnosis included stage three chronic kidney disease and hypertension. The 10/5/22 nursing data collection documented the resident was cognitively intact and required assistance of one person with transfers, dressing, toileting and personal hygiene. It indicated the resident did not have any skin concerns. B. Record reviewThe activities of daily living (ADL) care plan, initiated on 10/7/23, documented the resident had a self-care performance deficit related to weakness. The interventions included encouraging the resident to participate to the fullest extent possible with each interaction, encouraging the resident to use the call bell for assistance and an evaluation by physical and occupational therapy.-A review of the resident's comprehensive care plan did not indicate the resident was at risk for developing pressure injuries. The 10/5/22 nursing data collection documented the resident had redness to the right buttocks. -However, the CPO did not reveal a treatment in place for the reddened right buttocks. The 10/16/22 nursing progress note documented the resident had developed redness to the buttocks. The nurse provided the resident with Calazinc cream for her buttocks.-It did not indicate the nurse had completed an assessment of the area or notified the physician and obtained a treatment order. The 10/18/22 nursing progress note documented that a skin assessment was completed for the resident by the assistant director of nursing (ADON). During the assessment, the resident's daughter informed the ADON that the resident had a fluid filled blister to the right buttocks. It indicated that the blister was healing and the peri area appeared pink and dry.-It did not indicate the ADON had notified the physician or obtained a treatment order for the blister. The 10/19/22 discharge summary documented the resident was discharged with home health physical and occupational therapy. It did not document that a nurse was ordered for wound care. The 10/20/22 social services progress note documented the resident discharged home with physical and occupational home health therapy.-It did not indicate a nurse was provided for wound care. C. Staff interviewsThe DON and ADON were interviewed on 4/5/23 at 4:56 p.m. She said the ADON was the nurse that documented Resident #5 had a blister to the buttocks. She said he noted that the surrounding tissue was healthy and dry. The ADON said he had performed the skin assessment for the nurse that was assigned to Resident #5. He said he expected that the nurse would have contacted the physician and obtained a treatment order. He said he was unable to find documentation that the physician had been notified or a treatment had been put into place. He said the facility did not order a home health nurse for wound care. He said that had been an oversight. The DON said when a new skin concern was identified, the physician should be notified immediately and a treatment put into place. She said the nurse should continue to follow up until the area was resolved. She said the area should be assessed to include measurements. She said that assessment should be documented in the resident's medical record. The DON confirmed Resident #5's medical record did not reveal documentation that the blister had been assessed to include measurements, the physician was notified or a treatment was put into place.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident #5 no longer resides at the facility. Resident #7’s treatment orders have been reviewed and updated to ensure that all wounds that require a treatment have a physician order. Resident #7’s care plan and Kardex have been updated to ensure that staff have access to review the interventions to promote wound healing and prevent further skin breakdown, including incontinent and repositioning care. 2. Other residents /with pressure injuries were reviewed to ensure orders are present for wounds that require treatment and the care plan and Kardex include preventative and healing measures. 3. Beginning on 4/7/23 the nursing staff were provided education by the nursing leadership team on the importance of notifying the physician with any new wounds, having physician order for wounds that require treatment, providing preventative measures to assist with wound healing and prevention that is based on the individual resident need. The DON or designee will review all new admissions/admission for presence of pressure injury for 1 month then 2 admits per week for 2 months to ensure that orders are in place for each wound and sites of wounds are consistent and The DON or designee will conduct rounds of 2 residents with pressure injuries daily at random times for 2 weeks and then weekly for 3 months to monitor for residents being repositioned and being provided incontinent care. Any issues identified will be addressed, 4. The DON will provide the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee
0689Free of Accident Hazards/Supervision/DevicesS/S G▼
Findings
Based on record review, observations and interviews, the facility failed to ensure three (#6, #2 and #9) of three residents received adequate supervision to prevent accidents out of 16 sample residents reviewed. Specifically, the facility failed to ensure Resident #6, who had a history of falls and was assessed to be a high fall risk upon admission, received the care and services indicated in her comprehensive plan of care. The facility failed to ensure Resident #6's call light was answered timely, which was an intervention on her care plan, to prevent the resident from getting up without assistance. On 1/30/23, Resident #6 reported she pushed her call light and waited for 30 minutes to be assisted to the bathroom. Resident #6 said she got up from the bed, using her walker, because she could "not wait any longer" and did not want to soil herself. Upon returning from the bathroom, she became dizzy and fell to the ground, hitting her head and the right side of her body. Upon further studies conducted at the hospital, the resident had sustained a right proximal humeral (shoulder) fracture. Additionally, the facility failed to ensure an assessment by the registered nurse (RN) was completed following a fall for Resident #2 and Resident #9. Findings include:I. Facility policy and procedureThe Fall Management policy and procedure, dated November 2019, was provided by the nursing home administrator on 4/6/23 at 1:30 p.m. It revealed in pertinent part, "The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury."A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs."Research has shown that structured fall reduction programs can substantially reduce the rate of falls and related injuries in nursing facilities, however, falls may likely occur. Identifying risk factors, followed by timely and appropriate interventions, is the key to a successful program."Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Please note interventions are to be re-evaluated when a resident falls."II. Failure to ensure Resident #6 received the care and services documented on the comprehensive plan of careA. Resident #6 statusResident #6, age 87, was admitted on 1/19/23, readmitted on 2/1/23 and discharged home on 3/14/23. According to the March 2023 computerized physician orders (CPO), the diagnoses included fracture of the upper end of the left humerus, history of falling, need for assistance with personal care; and paroxysmal atrial fibrillation. The 2/7/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 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. It indicated the resident had a fall in the last two to six months with a fracture. It indicated the resident was continent of bowel and bladder. B. Resident interviews Resident #6 was interviewed on 4/5/23 at 1:34 p.m. She said she had been discharged from the facility during the previous month and was living at home with her husband. She said while she had resided at the facility, she had multiple issues with call lights not being answered timely. She said she would activate her call light and it would take the staff from 30 minutes to over an hour to respond on multiple occasions. She said on one occasion she had to lay in urine and a bowel movement for 45 minutes. She said she had notified the management of the facility of her call light response time concerns, but did not feel they had resolved the concern, as it continued to happen. She said on 1/30/23, she had activated her call light because she needed to use the bathroom. She said she was able to walk with a walker, but needed assistance because she would get dizzy. She said she looked at the clock when she pushed her call light. She said after about 30 minutes, she got up, used the walker and walked to the bathroom because she could "not wait any longer and I did not want to soil myself." She said she got dizzy on her way back from the bathroom and fell to the ground. She said she was sent to the hospital where she learned she had broken her right arm. C. Resident #6's reported concerns of call light response times The 2/10/23 compliments/complaints/concerns report documented that the resident had reported a concern regarding the call light response times. She had reported that she had been left by a certified nurse aide (CNA) on the bed pan for over an hour. The facility documented a call light report was reviewed with the resident averaging 10 minute call light wait times with the longest wait time of 20 minutes. It indicated the resident was provided re-education on how to press the call light and an investigation was started regarding the allegation of being on the bed pan for over an hour. -The grievance did not include the "report" that the social worker reviewed that documented the resident's call light wait times and was unable to print out a report to be reviewed during the survey process (see staff interviews) to corroborate that the resident had not waited for an extended period of time. D. Record review The activities of daily living (ADL) care plan, initiated on 1/21/23 and revised on 3/15/23, documented the resident had a self-care performance deficit related to decreased mobility. It indicated the resident required assistance with ambulation and toileting. The interventions included, in pertinent part, encouraging the resident to use the call bell for assistance. The fall risk care plan, initiated on 1/21/23 and revised on 3/15/23, documented the resident was at a high risk for falls. The interventions included, in pertinent part, anticipating and meeting the resident's needs, ensuring the resident's call light is within reach, encouraging the resident to use the call light when she needed assistance and providing prompt response times to her call light. The 1/19/23 fall risk evaluation documented the resident had sustained one to two falls in the past 90 days and was considered a high fall risk. The January 2023 ADL documentation revealed the resident had been provided toileting no toileting assistance on 1/19/23-1/22/23, twice on 1/23/23, no toileting assistance on 1/24/23, three times on 1/25/23, no toileting assistance on 1/26/23, one time on 1/27/23 and 1/28/23, twice on 1/29/23 and 1/30/23. 1. Fall incident on 1/30/23 The 1/30/23 interdisciplinary team (IDT) risk management review progress note documented the resident sustained an unwitnessed fall, which required emergency transportation to the hospital. It indicated the root cause was dizziness, weakness, a history of falls and ambulating without assistance. The interventions included encouraging the resident to utilize the call light for assistance with ambulation. The 1/30/23 physician progress notes documented Resident #6 was sent to the emergency room due to a fall with a sustained right upper extremity injury. The 1/30/23 incident report documented the nurse was notified that Resident #6 had sustained a fall. Upon arriving in the room, the nurse observed the resident lying on the floor, on her back by her dresser, being evaluated by the director of nursing (DON). It indicated the resident was unable to move due to "excruciating" pain to the right arm. Resident #6 said she was coming back from the bathroom, got dizzy and fell to the floor, hitting her head and right side of her body. It indicated the resident used her walker to ambulate in her room. Upon assessment, the resident had a lump to the right side of the resident's forehead and swelling to the right shoulder. Emergency services were contacted and transported the resident to the emergency room for further testing and evaluation. The 2/1/23 physician progress note documented on 1/30/23, while the resident attempted to get out of the chair and transfer herself, she fell and suffered a right proximal humeral fracture. She was placed in a sling and returned to the facility after it was determined the break was non-operable. According to the interventions documented in Resident #6's comprehensive plan of care, the facility was to encourage the resident to use her call light and provide prompt assistance, however, according to the grievance filed by the resident and the resident's interview, the facility failed to ensure her call light was answered promptly, which according to the resident, was the reason she got up out of bed unassisted to walk to the bathroom, because she could not wait any longer. E. Additional resident interviews and resident council minutesResident #16, who the facility identified as cognitively intact, was interviewed on 4/6/23 at 9:14 a.m. She said up until two weeks prior when the facility put a new system in place, it would take between 30 to 40 minutes for the call lights to be answered. She said it was very frustrating and she would not use her call light because she did not feel there was a point. Resident #13, who the facility identified as cognitively intact, was interviewed on 4/6/23 at 9:46 a.m. She said she had to wait for 30 minutes for the facility staff to answer her call light. She said because of the call light response time, she started only pressing the call light when she needed something really bad. She said the facility had gotten pagers about two weeks prior and that had been helping with the call light response time. Resident #14, who the facility identified as cognitively intact, was interviewed on 4/6/23 at 10:04 a.m. He said he chose not to use his call light very often because the facility staff did not answer it timely and he felt they would get mad at him for asking for help. He said he would hold his urine until a staff member would come to check on him instead of using the call light. He said it took 30 to 40 minutes for the facility staff to answer the call light. The February, March and April 2023 resident council meeting minutes documented the resident's reported call light response times of greater than 15 minutes. -It indicated in March 2023, a new call light system was installed at the facility. When a call light was activated, at different time intervals the call light would page the nurse, the unit manager and the director of nursing. F. Staff interviews The NHA was interviewed on 4/5/23 at 1:00 p.m. He said he was unable to pull call light reports from a couple of months ago. He said he could only print off reports of call lights for that week. He said he was unable to provide any documentation of the call light report that was reviewed by the social worker for Resident #6's grievance regarding timely call light responses. The social services director (SSD) was interviewed on 4/5/23 at 3:57 p.m. She said she had investigated Resident #6's grievances for call light response times. She said she had reviewed the call light report but had not included it with the documentation of the grievance. She said she only remembered that the longest call light wait time was 20 minutes. She said that the facility was unable to pull the report of the call light times for Resident #6 during her stay at the facility. The DON was interviewed on 4/6/23 at 1:17 p.m. She said she was aware the facility had a lot of resident concerns regarding call light response times. She said one of the issues with the older call light system was the audible portion of the call light activation was not working and with the way the nursing station was built, the nurses and CNAs were unable to see down the hallway to determine if a call light had been activated. She said during the last week of March 2023, the facility had installed a new call light system. She said the system now sent an alert to the CNA's pager when a call light was activated and then after so many minutes of it not being answered, the nurse would be alerted, then the unit manager and then the DON. She said she pushed for a system that would have an escalation process in it so she would be able to tell if the resident's concerns of long call light wait times were being addressed. She said the facility had concerns of call light wait times while Resident #6 resided in the facility. She said she was in the facility on 1/30/23, when Resident #6 fell in her room. She said she did not remember seeing the call light activated. She said she sat on the ground with her until emergency services arrived. She said she was not aware the reason the resident had gotten up out of bed by herself was because she had activated her call light for 30 minutes and was unable to wait any longer and did not want to soil herself. She said Resident #6 did not have a history of being impulsive and she was aware the resident had concerns with her call light response times. She said the call light should be answered in less than 10 minutes. III. Failure to ensure a registered nurse (RN) assessment was completed following a fallA. Resident #2 1. Resident statusResident #2, age 85, was admitted on 11/29/22 and discharged to the hospital on 12/6/22. According to the December 2022 CPO, the diagnoses included end stage renal disease. The 12/5/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required a one-person physical assistance with bed mobility, dressing, toileting and personal hygiene. She required two-person assistance with transferring. 2. Record reviewThe fall risk assessment dated 11/29/22 revealed Resident #2 was a high risk for falls, the resident had periods of confusion and had one to two falls within the past 90 days. The fall risk care plan, initiated on 11/30/2022, revealed the resident was at risk for falls. The interventions included ensuring the resident's call light was within reach and encouraging the resident to use the call light assistance and providing prompt responses to all requests for assistance. The 12/6/22 incident progress note, written by LPN #1, documented Resident #2 was heard yelling for help and was found lying supine (lying face up) with her bilateral feet near the wall and head and upper torso underneath the bed. It indicated the resident was responsive to verbal stimuli and complained of pain to her tailbone. It indicated the resident was assessed by the writer (LPN #1) and she had notified the physician, the resident's medical durable power of attorney (MDPOA), and the DON. -A review of Resident #2's medical record did not reveal documentation that the resident had been assessed by an RN following the fall on 12/6/22.-The facility was unable to provide additional documentation to show that an RN assessment was completed during the survey process. B. Resident #9 1. Resident statusResident #9, age 74, was admitted on 3/15/23 and re-admitted on 3/27/23. According to the April 2023 CPOs, diagnoses included unspecified dementia without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, muscle weakness and epilepsy. The 3/29/23 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score of three out of 15. He required extensive assistance of two people for all activities of daily living. 2. Record reviewThe fall risk care plan, initiated on 3/29/23 and revised on 4/1/23, documented the resident was a high fall risk. The interventions included placing the call light within the resident's reach, educating the resident on how to use the call light, providing a prompt response when the call light was activated and educating the resident, family, and caregivers about safety reminders and what to do if a fall occurred. The 3/30/23 nursing progress note documented that Resident #9 had sustained a witnessed fall. It indicated the resident slid out of bed and onto the ground, which was witnessed by the CNA who was answering the resident's call light. It indicated the resident did not sustain any injuries from the fall. The nursing progress note was documented by an LPN. A review of the resident's medical record did not reveal documentation that Resident #9 had been assessed by an RN following the fall and prior to being moved from the ground. C. Staff interviewsLPN #2 was interviewed on 4/6/23 at 12:19 p.m. She said if a resident sustained a fall, an RN would need to assess the resident before the resident was moved from the ground. She said it was not within the LPN's scope of practice to conduct an assessment. The DON was interviewed on 4/6/23 at 1:17 p.m. She said an assessment of the resident should be completed by an RN following a fall. She said it was not within an LPN's scope of practice to perform an assessment. She said the RN's assessment should be documented in the progress notes of the resident's medical record.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident’s #2, #6 and #9 no longer reside at the facility 2. Residents who currently reside in the facility have the potential to be affected by the alleged deficient practice. 3. The facility installed an upgrade to the facility call light system to enable increased oversight of call light response as stated in the deficiency list. Beginning on 4/7/23 nursing staff were educated on the importance of responding timely to resident call lights and the requirement to have an RN assess residents at the time of a fall and the need to implement a new intervention for fall prevention following a fall. The DON or designee will review all falls for 2 weeks and then 5 falls per week for 3 months to ensure that there is evidence of an RN assessment and new interventions to reduce falls. The NHA or designee will review call light response times weekly for 3 months to identify any trends in slow response times to resident’s call lights. Any issues identified with the audits will have follow up as needed 4. The DON and NHA will report the results of the audits to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee
0880Infection Prevention & ControlS/S D▼
Findings
Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure wound care was provided within accepted infection control standards for Resident #7. Cross-reference F686: failure to ensure timely incontinence care and repositioning was provided, a treatment was in place for a pressure injury, treatments were provided as ordered by the physician, and a newly identified skin concern was assessed and the physician was notified with a treatment obtained. Findings include: I. Resident #7 statusResident #7, age less than 65, was admitted on 1/6/23. According to the March 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (low blood oxygen), long-term use of anticoagulants, contracture of the right elbow, contracture of the left elbow and tracheostomy (an opening in the windpipe). The 4/3/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He was dependent upon staff for all activities of daily living. It indicated the resident did not have any unhealed pressure injuries. A. Observations On 4/6/23 at 9:20 a.m., during a wound observation with the assistant director of nursing (ADON), Resident #7 was repositioned by two unidentified CNAs flat on his back with his feet offloaded onto a rectangular cushion. The ADON brought a bedside table over to the bed and wiped the table one time with a wipe. The tabletop dried in less than one minute. He brought a drape over to the table and waited a full minute before he laid it on the table. He said he wanted to make sure they waited the full two minutes for the surface disinfectant time of the wipe, however the table had been dry for over a minute. He laid the drape on the table and began laying out the wound care supplies. During the wound observation, the ADON used alcohol based hand rub (ABHR), donned clean gloves and cleaned the large wound to the resident's right ischium. The disposable pad underneath Resident #7 was observed with a large amount of drainage. The ADON did not place a new disposable pad prior to cleaning the wound. He cleaned the outside edges and then worked toward the center of the wound. Instead of cleaning the wound from the center and moving to the outside, the ADON used gauze soaked with normal saline to clean the wound from the outside and then moved inside. He obtained a new gauze soaked in saline and cleaned the wound to the coccyx sacral area with the same technique. As the ADON measured the wound, his gloved hands rubbed on the dirty drainage covered area of the disposable pad. The ADON dressed the wound to the right ischium. As he was placing the foam gauze and sealing the edges, his gloved hands were again touching the drainage on the pad underneath the resident. He moved to the bedside table, with the same gloved hands, and began cutting a Tegaderm (dressing) adhesive to place over the top of the dressing to ensure it was secured. As he was placing the Tegaderm over the top of the dressing, his gloved hands touched the drainage on the disposable pad, underneath the resident. B. Record review The April 2023 CPO documented the following physician ordered treatments: -Wound care: peri g-j-tube (GJT): Clean with normal saline (NS) moistened gauze, pat dry and apply skin prep to peri wound. Cover with Mepilex Ag one time per day for wound care - ordered 4/4/23;-Bilateral elbows and heels: Cleanse with NS, pat dry and cover with bordered foam dressing, one time a day for wound care - ordered 4/4/23;-Bilateral buttock: Cleanse with peri wipes or foam cleanser (avoid rubbing, only remove soiled cream for skin). Apply lidocaine/nystatin/zinc oxide cream. Alternate with clear-aid after each incontinence episode, three times a day for wound care - ordered 4/4/23;-Coccyx: Cleanse with NS, apply skin prep to the peri wound, apply Dakins moistened gauze to the open area and cover with ABD Medipore tape, two times per day for wound care - ordered 4/4/23. II. Staff interviews The ADON and director of nursing (DON) were interviewed on 4/6/23 at 11:24 a.m. The ADON said he used a sani-wipe to clean the bedside table prior to placing the drape and supplies. He said the wipes required a two minute surface disinfectant time. He said the area should be wiped down and let sit for two minutes prior to placing supplies. The DON acknowledged the surface should remain wet for the entire two minute surface disinfectant time. The ADON acknowledged there was a significant amount of drainage on the disposable pad underneath Resident #7 during the wound dressing change. He said he should have disposed of the pad and placed a new one prior to cleaning and dressing the wound. The DON said there should always be a clean field underneath when cleaning and dressing a wound. The ADON said he should have changed his gloves when they touched the drainage underneath the resident. The DON said each wound should be cleansed starting from the inside with one swipe. She said a new gauze should be obtained for each swipe and the wound should be cleansed starting from the inside to the outside edges. The ADON acknowledged he started from the outside and worked on the cleansing of the wound. He acknowledged that he used the same piece of gauze for multiple swipes.
Plan of correction · submitted by the facility
Provider’s legal statement
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF FEDERAL AND STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH FEDERAL REQUIREMENTS OF PARTICIPATION, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY'S ALLEGATION OF COMPLIANCE IN ACCORDANCE WITH SECTION 42 C.F.R. §488.18 AND SECTION 7317A OF THE STATE OPERATIONS MANUAL.
1. Resident #7 has no current infection to wounds. 2. Nurses who provide wound care were reeducated on standards of infection control during the wound care procedure. 3. Nurses who provide wound completed education on 4/7/23 on standards of practice for Infection Control that includes practices to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The rounding wound physician will assess pressure injuries for signs and symptoms of infection in wounds to ensure that proper infection control practices are effective. The DON or designee will observe 2 residents with pressure injuries or 2 nurses per week for 3months. Any issues identified will be addressed 4. The DON or designee will report wound infections and the results of the observations to the QAPI committee monthly for 3 months or until substantial compliance is determined by the committee.
Reportable Occurrences
24 records5/8/2026Physical Abuse · ID 2602S294006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/8/26, 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. Reportedly, two clients engaged in a physical altercation, which involved one client being poked with a Reacher device and the other client being struck on the face. During the course of the investigation, the healthcare entity kept the clients separated, conducted assessments and interviews, and notified the police. No visible injuries were observed with either client. The police educated the clients to stay away from one another and the potential consequences if they engaged in another physical altercation. The facility was not able to determine what action triggered the physical response due to conflicting stories from each client. However, physical contact occurred without a result of injury. Staff continued to support and monitor the individuals per their plan of care. 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 7/17/2026 · released to the public 7/24/2026.
4/10/2026Misappropriation of Property · ID 2602S294005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/10/26, 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 misappropriation of property event. Due to client (A)'s financial representative failure to take action to help rectify client (A)'s financial situation and non-payment for client (A)'s care, there were concerns of financial exploitation and fund mismanagement. With non-payment, client (A) was at risk of being discharged. During the course of the investigation, the healthcare entity reported they made multiple attempts to educate and communicate with client (A)'s family regarding the financial situation for client (A). Management notified the police and Adult Protective Services. In addition, management reached out to discuss the matter with another family member to help with the situation. Staff continued providing services and care for the client until all investigations were complete. At a facility level, the event was substantiated. An outside and external investigation was ongoing. 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.
3/20/2026Neglect · ID 2602S294004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/24/26, 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 neglect event. Client (A)'s family filed a grievance form indicating they found at-risk and dependent client (A) soaked in urine on 3/21/26. Allegedly staff had not changed the client in a timely manner. In addition, the family stated that when they brought the issue to staff's attention, staff asked them if they wanted to change the client versus addressing the situation. During the course of the investigation, the healthcare entity checked on the client's needs and provided incontinence care. Staff conducted skin assessments and interviews. Management talked to staff regarding the expectations to ensure care needs are consistently met and that care roles are clearly defined. No skin integrity issues were identified with client (A). Records showed care had been provided per the client's plan of care. No staff recalled asking the family to provide care, but at times, staff said the family assisted voluntarily. Staff indicated the client was wet, but nothing more than normal. From the findings, it appeared the family's arrival time occurred between staff's schedule of care. Supervisory staff conducted rounds and routine audits to monitor staff compliance. 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 6/24/2026 · released to the public 7/1/2026.
2/24/2026Neglect · ID 2602S294003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/24/26, 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 neglect event. After client (A)'s hospitalization to address a medical issue, the family alleged staff neglect with client (A)'s care contributed to the reason for hospitalization. During the course of the investigation, the healthcare entity checked on current clients to ensure their medical and care needs were being addressed. Management conducted interviews and record reviews. The facility indicated client (A)'s medical crisis event is a known and potential complication. Per the medical provider's review, staff actions did not contribute to client (A)'s medical condition and follow up actions were deemed appropriate. No other clients or families reported concerns with staff care or treatment. The event was/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 6/1/2026 · released to the public 6/8/2026.
1/4/2026Physical Abuse · ID 2602S294002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/5/26, 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. When conducting an assessment, two nurses reported concerns about client (A) having a dislocated shoulder and a hospice nurse observed new bruises on his neck resembling finger marks. The hospice nurse alleged abuse by a family member. During the course of the investigation, the healthcare entity conducted further assessments, interviews, and record review. Staff notified the police. Upon further review of client (A)’s neck, no fingermark bruises were observed. Redness was observed to the area, which was attributed to a sling rubbing his neck. X-ray results showed no dislocation. Client (A) denied being a victim of abuse by a family member. No facility staff reported witnessing any mishandling incidents. Care support remained in place for client (A) through hospice services and facility staff. Staff received re-education on being mindful of sling placement with transfers. 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 3/10/2026 · released to the public 3/17/2026.
12/31/2025Neglect · ID 2502S294024Reported 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 neglect event. After client (A) was transferred to the hospital for an evaluation of their respiratory status, the police showed up at the facility to investigate concerns with poor skin management and an acute infection. Hospital staff reported they discovered old, outdated bandages on person, an infection of a skin site and acute wounds on client (A), who was dependent on staff to help meet his needs. During the course of the investigation, the healthcare entity conducted interviews and record reviews. Immediate education was provided to staff regarding wound identification, wound care, and wound dressing management. All current clients were assessed to ensure no additional concerns were identified. The facility indicated existing wounds, except for the findings of an old dressing being in place (11/18), were documented and managed by the nurses and a wound care physician. In regard to the alleged infection at one of the sites, the facility indicated treatments had been completed per physician orders and no acute infection developed despite the allegation. When client (A) returned, staff reassessed all wounds, reviewed his care plan needs and ensured physician orders were in place. The facility identified staff deviated from facility protocols and did not follow physician orders for all wounds. Education was provided to staff on the expectations with wound care, conducting proper dressing procedures, and performing thorough skin assessments. Management implemented an audit plan to monitor staff compliance. 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 3/27/2026 · released to the public 4/3/2026.
12/9/2025Misappropriation of Property · ID 2502S294022Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/9/25, 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 a misappropriation of property event. Client (A) reported a gold chain was missing and thought it had been stolen. During the course of the investigation, the healthcare entity conducted searches and re-educated client (A) to ensure he secured his items. The facility was unable to determine what happened to the chain as it was either lost, misplaced or taken. No perpetrator was identified. As the findings were inconclusive, 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 2/9/2026 · released to the public 2/16/2026.
12/4/2025Physical Abuse · ID 2502S294020Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/4/25, 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 help prevent a future recurrence. The healthcare entity reported a physical abuse event. Client (A) called 911 requesting transport to the hospital. While in the hospital, client (A) alleged facility staff caused her pain and physically held her down in bed. Client (A) reported she was fearful to say anything at the facility. During the course of the investigation, the healthcare entity conducted interviews and record reviews. Client (A)’s allegation could not be corroborated. Per client (A)’s wishes, she did not return. 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 2/4/2026 · released to the public 2/11/2026.
9/15/2025Verbal Abuse · ID 2502S294019Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/16/25, 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 and physical abuse event. Client (A) alleged staff (1) provided personal care in a rough manner due to being frustrated with them. Also, client (A) said staff (1) raised their voice when responding to her and appeared angered and irritated. Client (A) reported she was frightened and fearful of staff (1). 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. No visible injuries were observed with client (A), but she continued to report being fearful of staff (1) and fear of retaliation. Staff (1) denied any wrongdoing and wanted to know who reported them. Management decided to terminate staff (1)’s employment and reported them to their oversight licensing board. 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.
9/3/2025Misappropriation of Property · ID 2502S294018Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/3/25, 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 help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. One client reported several items were missing from his belongings and thought they had been stolen. During the course of the investigation, the healthcare entity conducted a search and interviews. The client was unable to provide any additional information or timeline about when the items went missing. Family could not confirm if the items were even brought into the building, and the items were not listed on the inventory sheet. No pattern of theft was reported by the facility. 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 1/8/2026 · released to the public 1/15/2026.
8/13/2025Neglect · ID 2502S294017Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/14/25, the healthcare entity investigated a reportable event of neglect. At-risk and dependent client (B) was diagnosed with a femur fracture that required surgical intervention. Reportedly, staff did not properly support his lower extremities while transporting him in the wheelchair. The leg got caught and bent two different times resulting in acute pain and suspected fracture. 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 8/26/25, Event ID 1D1AB3-H1. 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 10/3/2025 · released to the public 10/10/2025.
8/13/2025Neglect · ID 2502S294016Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/13/25, 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 neglect event. A family member reported concerns about management of client (B)’s skin and the development of two new injuries. During the course of the investigation, the healthcare entity conducted an assessment, record review and interviews. Staff indicated the client had been seen by two different medical providers regarding the skin issue and treatments were completed. Due to client (B)’s medical co-morbidities and history of poor nail care, the skin around his toes became compromised. Antibiotics were prescribed. The facility concluded that through removal of ingrown toenails, non-pressure skin integrity issues developed. There were no findings of neglect as care was offered and provided. 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 10/3/2025 · released to the public 10/10/2025.
4/14/2025Neglect · ID 2502S294011Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/14/25, the healthcare entity investigated a reportable event of neglect involving at-risk client (B). After client (B)’s hospitalization and diagnosis of dehydration, a family member alleged facility staff had been neglectful with meeting client (B)’s needs. Client (B) was completely dependent on staff to meet her care needs. Per the facility, the family member did not provide specific details about the concerns. During the course of the investigation, the healthcare entity conducted a medical record review and staff interviews. The facility indicated a medical provider reviewed the record and found no concerns of neglect. Staff were following physician orders, monitoring the client’s status and appropriately communicating with the physician and family about any changes. One week earlier during a care conference, the facility indicated the family did not express any concerns. No other issues of neglect were identified with any clients. The client did not return. 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. 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 4/22/25, Event ID 6TG611.
Publication
Sent to facility 7/10/2025 · released to the public 7/17/2025.
3/5/2025Sexual Abuse · ID 2502S294009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/5/25, 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 staff (1) engaged in a sexually inappropriate act on him. Client (B) requested not to work with staff (1) anymore. During the course of the investigation, the healthcare entity suspended staff (1), notified the police, provided emotional support to client (B) and conducted interviews. Through review of the event and re-enactment of the interaction, the facility was unable to determine if the act was considered sexual or accidental contact and misperception of the interaction. No other clients or staff reported any issues about staff (1). Staff (1) tendered his resignation effectively immediately. 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 7/23/2025 · released to the public 7/30/2025.
2/21/2025Misappropriation of Property · ID 2502S294008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 2/21/25, 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 misappropriation of property event. Client (B) alleged a $500 winning scratch lottery ticket went missing from his room. During the course of the investigation, the healthcare entity conducted a search and interviews. No other clients reported having any concerns with their personal items. No staff had awareness of the winning ticket, and management was unable to verify if it truly existed as claimed. Client (B) discharged from the facility on the same day he reported it missing. Clients were reminded to safeguard their valuables and to alert staff about any inventory changes. Staff was educated to be vigilant on marking items and ensure items were safeguarded. The facility concluded 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 5/28/2025 · released to the public 6/4/2025.
2/9/2025Brain Injury · ID 2502S294007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 2/7/25, 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 brain injury event. Staff noted a mental change of condition three days after client (B) fell. Reportedly, diagnostic test results showed an acute brain bleed. During the course of the investigation, the healthcare entity secured transportation to the hospital for a medical evaluation and conducted interviews and a chart review. Client (B) was admitted to the hospital. With the unwitnessed fall, the client reported he did not hit his head. Post a medical review, the facility indicated the brain bleed could not be attributed to the fall but related to his current medical condition. The fall was determined to be accidental, as he got up without calling for staff assistance. Fall safety measures would be implemented upon his return. 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 5/28/2025 · released to the public 6/4/2025.
2/2/2025Misappropriation of Property · ID 2502S294006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 2/2/25, 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 misappropriation of property event. Client (B) reported money was missing from his wallet. During the course of the investigation, the healthcare entity conducted a search, reviewed his inventory list and encouraged him to use the lock box to secure his valuables. The money was not located. The facility was unable to determine what happened to money. Management reimbursed the client for the missing money and requested that he should not receive large sums of money. Staff was educated on resident rights and to encourage clients to safeguard their valuables. Due to inconclusive findings and without an identified alleged assailant, a deliberate misappropriation 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 4/4/2025 · released to the public 4/11/2025.
1/18/2025Physical Abuse · ID 2502S294003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 1/22/25, the healthcare entity investigated a reportable event of potential neglect and/or abuse. Staff discovered an area of skin irritation outside of the client’s feeding tube site, and the initial assessment indicated the compromised area could be from a chemical burn. Staff indicated, “the top layer of the skin was scraped off.” Reportedly, staff were not providing proper feeding tube care. During the course of the investigation, the healthcare entity conducted assessments and interviews, provided treatment and reassessed the client’s tube feeding requirements. With medical provider assessments, the investigation determined the cause of the burn was related to gastric contents excreting from the gastric tube site itself, but there was no connection to support any findings of abuse or staff negligence. Management reviewed potential items that staff could use to decrease risks of a tube being dislodged. 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. 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 4/22/25, Event ID 6TG611.
Publication
Sent to facility 6/2/2025 · released to the public 6/9/2025.
1/17/2025Diverted Drugs · ID 2502S294005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 1/27/25, 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 diverted drug event. Reportedly, staff (2) discovered a medication variance by agency staff (1)’s documentation with client (B)’s pain medications. There was a suspicion of a drug diversion by staff (1). During the course of the investigation, the healthcare entity suspended staff (1), assessed client (B) and provided the required pain medications. Management conducted a medication audit and checked clients to help identify any pain management issues. There were no reported adverse outcomes to clients. The audit revealed other medication variances made by staff (1). The facility concluded staff (1) diverted medications from client (B) for personal use. Staff (1)’s work contract was terminated, and management notified the oversight licensing board. 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.
1/12/2025Physical Abuse · ID 2502S294002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 1/13/25, 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 abuse event. Reportedly, a staff member (staff 1) inappropriately grabbed client (B) in the “crotch” area to check if her incontinent brief was wet. Client (B) reported being startled and uncomfortable. During the course of the investigation, the healthcare entity suspended staff (1), and conducted an assessment and interviews. Client (B) requested staff (1) no longer work with her anymore. The facility concluded staff (1) provided inappropriate care when rushing with care. Management terminated staff (1)’s employment. Re-education was provided to other staff on appropriate manners when checking and providing care with 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 5/28/2025 · released to the public 6/4/2025.
10/29/2024Physical Abuse · ID 2402S294006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 10/29/24, the healthcare entity investigated a reportable event of physical abuse. Client (B)’s family made an allegation of physical abuse as the cause of a new bruise discovered around the client’s eye. During the course of the investigation, the healthcare entity requested a medical provider assessment and conducted interviews. Several medical providers concluded the hematoma, and related bruising was related to a medical event and not abuse. No changes were made to the client’s plan of care. 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. 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 1/2/25, Event ID 1POY11.
Publication
Sent to facility 5/8/2025 · released to the public 5/15/2025.
10/20/2024Brain Injury · ID 2402S294004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS: On 10/22/24, 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. Two days after a fall on 10/20/24, staff noted a change in client (B)'s baseline level of mentation. During the course of the investigation, the healthcare entity secured transport to the hospital where diagnostic test results showed a new brain bleed. She was admitted for medical monitoring. 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 5/6/2025 · released to the public 5/13/2025.
1/8/2024Neglect · ID 2402S294001Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/8/24, after a resident had been transferred to the hospital for a medical evaluation, hospital staff alleged mold was found in the external section of the gastric feeding tube. The resident’s tube was replaced at the hospital. The hospital did not test the tubing for mold or any other pathogens, so the findings were inconclusive. Record review indicated nursing staff was providing the necessary care to the tube per physician orders. Nurses reported the tube was flushed and clear prior to her transport to the hospital. Management checked all other feeding tubes, and with any issues identified, physicians were notified. The allegation of staff neglect and presence of mold could not be substantiated. As a precautionary measure, staff received education on ensuring that all ports of the Lopez valve are flushed and secured properly to decrease any back flow into the tube or valve.
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. In addition to this off-site occurrence review, 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 2/20/24.
Publication
Sent to facility 12/26/2024 · released to the public 1/2/2025.
10/24/2023Brain Injury · ID 2302S294001Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:
On 10/24/23, staff found a resident on the floor. With the assessment, the resident’s blood pressure was elevated and his oxygen saturation levels were low. Oxygen was applied to help raise the oxygen level. As he took two blood thinners and was at risk for bleeding, he was transferred to the hospital for an evaluation. CT scan results showed intracranial bleeding, which was a change from a scan completed a few days earlier. However, facility staff was unsure if the bleeding was new or a latent result of his medical episode prior to his initial admission to the facility.
FACILITY / AGENCY ACTION:
The facility conducted an internal investigation and notified the family/guardian, ombudsman, and physician. Upon admission to the facility, the resident had been instructed to call for staff assistance. He was identified as being a fall risk. With this fall event, the resident did not call for staff assistance and suffered a fall. Once he was medically stable, he returned. Staff re-educated the resident to request assistance before getting up by self and staff implemented frequent monitoring. The facility was unsure if the brain bleed occurred with this fall or the previous fall prior to his admission to the facility.
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 7/17/2024 · released to the public 7/24/2024.