CENTER AT LINCOLN, LLC, THE

A complaint survey, prompted by #CO38895 was conducted on 1/13/25 to 1/15/25. No deficiencies were cited.

A revisit survey was completed on 1/14/25 for all previous deficiencies cited on 11/21/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/14/25 for all previous deficiencies cited on 11/21/24. The facility is in compliance with all regulations surveyed.

A re-certification survey was completed on December 11, 2024. The facility was reviewed and surveyed to the National Fire Protection Association (NFPA) Life Safety Code (2012) Chapter 19, Existing Health Care Occupancies. The building is three-story, Type II (111) construction, without a basement. The facility is divided into two smoke compartments on the first floor and five smoke compartments on floors two and three witch each compartment separated by one-hour rated construction. The first floor is arranged as a single fire alarm zone, floors two and three are arranged with fire alarm initiating devices zoned by each compartment. Audible / visual alarms activated in the zone of origin only. The remaining compartments notified via automatic voice notification. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. Emergency power is provided by a 150kw natural gas generator located on the roof. The facility equipped with piped medical gas system. Each of the deficiencies was discussed in the exit conference with the Administrator and Maintenance Director.

STANDARD not met as evidenced by: Based on observation and staff interviews of the emergency lighting, the facility needed to add emergency lighting at the transfer switches in accordance with NFPA 99 - 6.6.3.1.1, Life Safety 101- 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of losing primary power. There is no evidence of a necessary battery backup for emergency lighting at the generator transfer switch. 2012 NFPA 99 Section 6.6.3.1.1 The life safety and critical branches shall have an alternate source of power separate and independent from the normal source that will be effective for a minimum of 11?2 hours after lossof the normal source. The Maintenance Director acknowledge the lack of required battery back-up emergency lighting at the generator transfer switch during the tour of the facility.

STANDARD was not met based on observation and staff interviews during the survey. It was determined that the facility failed to maintain emergency power systems under Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 5.2.3. This deficient practice could affect all residents, staff, and visitors during power loss. A remote annunciator was not installed outside the generator room in a location that could be easily observed by staff at all times. NFPA 99-6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load.(b) When the battery charger is malfunctioning.(2) Individual visual signals plus a common audible signal to warn of an engine?generator alarm condition shall indicate the following:(a) Low lubricating oil pressure(b) Low water temperature (below that required in 6.4.1.1.11)(c) Excessive water temperature(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply(e) Overcrank (failed to start)(f) OverspeedThe remote annunciator deficiency was discussed with the Maintenance Director during the survey.

The facility did not meet the standard as it failed to maintain emergency power systems according to section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.7.1 Maintenance and Operational Testing. This failure could potentially impact all residents, staff, and visitors in the event of a power loss. At the time of the survey, no records were available to verify the monthly testing and recording of battery conductance testing in connection with the emergency power supply system (emergency generator). NFPA 110, Section 8.3.7. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. The emergency power supply system deficiency item was discussed with the Administrator and Maintenance Director during the survey.

A recertification survey with complaint #CO38211 was completed on 11/18/24 to 11/21/24. Twelve deficiencies were cited.

An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#226) of five residents reviewed for unnecessary medications out of 60 sample residents. Specifically, the facility failed to ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained for Resident #226 prior to the administration of a psychotropic medication. Findings include:I. Facility policy and procedureThe Psychotropic Medication Use policy and procedure, revised 2/8/21, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, "Psychotropic consent will be obtained from the resident and or family on admission or within 72 hours of admission."II. Resident #226A. Resident statusResident #226, age 74, was admitted on 11/14/24. According to the November 2024 computerized physician orders (CPO), diagnoses included adjustment disorder with mixed anxiety and depressed mood and depression. The 11/17/24 brief interview for mental status (BIMS) assessment revealed the resident was moderately cognitively impaired with a score of 10 out of 15. B. Record reviewThe antidepressant medication care plan, initiated 11/15/24, revealed Resident #226 received an antidepressant medication due to her depression and adjustment disorder diagnoses. Pertinent interventions included administering the medication as ordered and observing for side effects and effectiveness of the medication each shift. Review of Resident #226's November 2024 CPO revealed the following physician's order related to psychotropic medications:Venlafaxine (antidepressant) oral capsule extended release. Give 225 milligrams (mg) by mouth in the morning for depression, ordered 11/15/24. Review of Resident #226's electronic medical record (EMR) revealed a psychoactive medication therapy consent form for Venlafaxine dated 11/14/24. -However, the form was not signed by the resident and the staff member that obtained the consent until 11/18/24, four days after the resident's admission to the facility. Resident #226's November 2024 medication administration report (MAR) revealed the following Venlafaxine was marked as administered once a day from 11/15/24 through 11/20/24 andantidepressant monitoring was marked as completed each shift from 11/14/24 through 11/20/24. -However, the psychoactive medication therapy consent form was not signed by the resident until 11/18/24 (see above). III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 11/21/24 at 12:47 p.m. LPN #2 said the nurses at the facility were the ones who went over the medication consents with the residents along with the rest of their admission paperwork. LPN #2 said there had been times where agency staff had missed the consent forms and not had the resident sign them, or missed the medication orders and did not realize the resident needed a consent form. LPN #2 said the unit manager went through and checked to make sure the admissions packets were signed appropriately. LPN #1 was interviewed on 11/21/24 at 1:17 p.m. LPN #1 said the nurse that admitted the resident was responsible for ensuring all of the medication consents were signed. LPN #1 said there was sometimes a delay in getting the consents signed if the resident wanted a family member to read through it. LPN #1 said the nursing staff could not administer an antidepressant or other psychoactive medication until the resident had signed the respective consent form. LPN #1 said the unit manager followed up the next day after a resident was admitted to ensure all of the consent forms were signed appropriately on admission, and if they were not signed, the unit manager would follow up with the resident and try to answer any questions the resident might have. Registered nurse (RN) #2 was interviewed on 11/21/24 at 3:44 p.m. RN #2 said Resident #226 admitted to the facility with a physician's order for an antidepressant medication on 11/14/24. RN #2 said the facility had a consent form that the resident was supposed to sign prior to receiving the medication. RN #2 said sometimes the nurses missed the medication consent forms or the residents refused to sign them. RN #2 said she was not sure what happened in Resident #226's case, but thought that the agency nurse that admitted the resident may have missed the consent form for that medication. RN #2 said she, or one of the other unit managers, usually reviewed the admission paperwork to ensure all the paperwork was filled out correctly. The director of nursing (DON) was interviewed on 11/21/24 at 5:56 p.m. The DON said antidepressant medications had a consent form that the resident needed to sign immediately when they went through the admission packet with the admitting nurse, or have a family member come in to sign it. The DON said the resident was not supposed to receive psychotropic medication prior to signing the consent form. The DON said the hospital sent the facility a list of medications which the resident's practitioner then had to approve before it was ordered from the pharmacy. The DON said usually by the time the facility received the medication from the pharmacy, the consent form had been signed. The DON said RN #2 was the one that wrote the consent form so she guessed the form was dated incorrectly. The DON said she had not heard anything about Resident #226 not wanting to sign the medication consent form. The DON said consent forms were needed for any high risk medications to ensure the resident knew what they were taking, why they were taking it and what the side effects could be. D. Facility follow upA signed statement from Resident #226 was provided by the NHA on 11/22/24 at 11:29 a.m. (after the survey exit) The statement revealed Resident #226 signed all of her consent forms upon admission on 11/14/24, including her psychoactive medication therapy consent form for Venlafaxine. The statement was undated and also signed by a member of the staff.-However, the medication consent form in Resident #226's EMR during the survey was signed by Resident #226 and a staff member on 11/18/24, not 11/14/24 (see record review above).

Based on record review and interviews, the facility failed to honor resident choices for one (#53) of one resident out of 60 sample residents. Specifically, the facility failed to ensure Resident #53's preference to have her bed bath completed during the day shift was honored. Findings include:I. Resident #53A. Resident statusResident #53, age less than 65, was admitted on 10/4/24. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, bathing, and lower body dressing and was partially dependent on staff for all other activities of daily living (ADL). The assessment indicated that it was very important that she was able to choose between a tub bath, shower, bed bath or sponge bath. B. Resident interviewResident #53 was interviewed on 11/18/24 at 11:27 a.m. Resident #53 said bathing was scheduled based on the room the resident resided in. She said the certified nurse aide (CNA) would come to give her a bed bath at night. She said she had asked to be put on the day shift bathing schedule since she was admitted and the facility still had not accommodated her request. She said her hair had only been washed once since being admitted to the facility. Resident #53 was interviewed again on 11/20/24 at 8:56 a.m. Resident #53 said she was unable to sit in the shower chair comfortably, which was why she received bed baths. She said she had refused her bed bath because the CNA would come to give her a bed bath between 7:00 p.m. to 8:00 p.m. She said it was too late to receive a bed bath as she was starting to wind down for the evening. She said she requested to be moved to the day shift for her baths, but it still had not been done. Cross reference F684: The facility failed to prevent the development and worsening of Resident #53's abdominal wounds. C. Record reviewThe ADL care plan, revised 10/5/24, documented Resident #53 required assistance with ADLs due to her recent injury. It documented Resident #53 preferred to get up around 6:00 a.m. and preferred bed baths on her scheduled bath days. -The care plan did not address Resident #53's preference to receive bed baths during the day. The Kardex (a nursing tool that summarizes resident information regarding daily schedules and interventions) documented Resident #53 was scheduled to receive a bed bath on Wednesday and Saturday nights. Resident #53's preference sheet documented Resident #53 should receive a bed bath on Tuesdays, Thursday and Saturdays. -It did not document the resident preference of day or night. The shower documentation from 10/4/24 to 11/17/24 documented Resident #53 refused all of her bed baths except for one, on 11/3/24. It documented Resident #53 had requested to be changed from the night schedule to the day schedule and on days in which she did not receive dialysis on 10/12/24 and 11/16/24 II. Staff interviewsCNA #6 was interviewed on 11/21/24 at 9:59 a.m. CNA #6 said she never assumed a resident wanted a certain type of bath or shower and would ask them each time. She said she asked each resident when each resident preferred to have their bath or shower. She said if a resident refused, the resident had to sign a sheet of paper, but they would try and reschedule their bath or shower for another day and time. The director of nursing (DON) was interviewed on 11/21/24 at 5:38 p.m. The DON said the preferences sheet was completed upon admission and should identify when the resident preferred a shower or bath. She said showers were split between the day shift and the evening shift. She said if a resident communicated they wished to have their bathing day or time moved, then the residents preference should be honored. The DON said she was not made aware by the floor staff that Resident #53 had been refusing her bed baths because of the time of day they were being offered. She said she would change Resident #53 to the day shift immediately. The DON confirmed Resident #53's preference had been documented on 10/12/24 and 11/16/24.

Based on record review and interviews, the facility failed to prevent misappropriation of property for three (#228, #46 and #229) of three residents reviewed for personal property out of 60 sample residents. Specifically, the facility failed to prevent the loss of property for Resident #228, Resident #46 and Resident #229 during their time in the facility. Findings include:I. Facility policy and procedureThe Dignity policy and procedure, revised 8/15/22, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, "Residents' private space and property shall be respected at all times."Staff will not handle or move a resident's personal belongings (including radios and televisions) without the resident's permission."II. Resident #228A. Resident statusResident #228, age less than 65, was admitted on 7/18/24 and discharged home on 7/29/24. According to the November 2024 computerized physician orders (CPO), diagnoses included muscle weakness and hypotension (low blood pressure). The 7/23/24 brief interview for mental status (BIMS) assessment revealed the resident was cognitively intact with a score of 14 out of 15. B. Resident interviewResident #228 was interviewed on 11/21/24 at 6:29 p.m. via telephone. Resident #228 said her daughter had brought her some money to get her hair done while she was at the facility but she had not been able to get her hair done the day her daughter brought the money. Resident #228 said her sister visited her the next day and took her outside, but before they went outside, Resident #228 put her money into her bag inside her closet. Resident #228 said when she came back inside, the money was no longer in her bag. Resident #228 said an unidentified facility staff member was standing across the hallway from her room and when she told the staff member what happened, the staff member said she had not seen anything. Resident #228 said she spoke with the police but had not heard any updates about the investigation. Resident #228 said the facility never offered her a lockbox or a safe, and if they had, she would have given them all her belongings to secure. C. Record reviewThe facility's misappropriation investigation, dated 7/29/24, was provided by the NHA on 11/20/24 at 12:50 p.m. It documented Resident #228 stated she was missing $200. She said she had the money because she was scheduled to have her hair done yesterday (7/28/24) but the beautician was not able to get it done. She said her daughter came today (7/29/24) to pick up the $200 but when she went to get her money from her bag, she noticed her $200 was missing. The resident thought that the money went missing when she went outside with her sister at approximately 3:00 p.m. The police were notified and the resident was re-educated to lock her valuables in the business office manager's (BOM) safe or the director of nursing's (DON) office. The staff was educated about the incident. Based upon the interviews and review of documentation, the facility determined that Resident #228 did have the money and that the money was misplaced while the patient was staying at the facility. The facility would reimburse Resident #228 the full amount of $200. The staff were educated about the incident that occurred and the policy on locking items away for safety. A review of Resident #228's progress notes and electronic medical record (EMR) did not reveal any other information regarding the incident. A grievance for Resident #228, dated 7/25/24, was provided by the DON on 11/21/24 at 3:53 p.m. It revealed Resident #228 was crying because she wanted to have her hair done but the beautician at the facility told her it would be almost $200. Resident #228 was crying because she did not have enough money to pay for that. The resolution listed in the grievance was that the DON spoke with the beautician and determined she charged based on time and that it would take the beautician a long time to brush out Resident #228's hair. -However, both the interview with Resident #228 and the facility's investigation revealed the resident's family member brought her the money to have her hair done (see above). III. Resident #46A. Resident statusResident #46, age 83, was admitted on 10/21/24 and discharged home on 11/2/24. According to the November 2024 CPO, diagnoses included muscle weakness and right femoral fracture. The 10/24/24 BIMS assessment revealed the resident was cognitively intact with a score of 15 out of 15. B. Record reviewThe facility's misappropriation investigation, dated 10/31/24, was provided by the NHA on 11/20/24 at 12:50 p.m. It documented Resident #46 had a smart watch on the charger in her room on Friday 10/25/24. The resident noticed the next morning (10/26/24) that the watch was missing. Resident #46's daughter called the DON on 10/26/24 and reported the watch may have been missing but she wanted to verify before officially reporting. Resident #46's daughter called the DON again on Friday 11/1/24 and officially reported the watch missing. The watch was tracked electronically to a residential address. The police were notified. The facility staff and residents were interviewed immediately, without resolution. Education was completed for residents and staff to secure valuables in the BOM's safe or DON's office. The facility additionally educated the residents and staff to report any suspicious occurrences immediately. Based on interviews and review of documentation, the facility determined the watch could have been taken from the facility. The facility would reimburse the family the cost of the same make and model of the missing watch. A review of Resident #46's progress notes and EMR did not reveal any other information regarding the incident. IV. Resident #229A. Resident statusResident #229, age 71, was admitted on 8/26/24 and discharged home on 9/11/24. According to the November 2024 CPO, diagnoses included infection following a surgical procedure and disruption of an external surgical wound. The 8/28/24 BIMS assessment revealed the resident was cognitively intact with a score of 15 out of 15. B. Record reviewThe facility's misappropriation investigation, dated 9/9/24, was provided by the NHA on 11/20/24 at 12:50 p.m. It documented the alleged assailant was identified as certified nurse aide (CNA) #4. Resident #229 stated that she was missing $40. Resident #229 looked in her wallet and noticed the money was missing. Resident #229 thought the money went missing on 9/9/24 but was unsure. The DON and the NHA interviewed all of the residents residing on the same hallway that Resident #229 was residing on. The DON and the NHA interviewed the staff member identified by Resident #229. The police were notified and Resident #229 was re-educated on locking her valuables in the BOM's safe or the DON's office. The identified staff member was immediately suspended pending an investigation. The staff were educated about the incident. Resident #229 reported she last saw the money on 9/7/24. Resident #229 said she had the money in her wallet, had wrapped the wallet in a towel and placed the towel in a drawer in her bathroom. She said she noticed that the wallet had been unwrapped and that the money was missing on 9/9/24 and reported it to management on 9/10/24. Resident #229 was interviewed by the facility staff and reported that CNA #4 had asked her questions about the wallet. Resident #229 hid the wallet out of caution by wrapping it in a towel and placing it in a drawer in her bathroom. Resident #229 said she was 90% sure that CNA #4 had taken the money but was not 100% certain. CNA #4 was interviewed privately by the facility's administration staff. CNA #4 reported he was not aware that Resident #229 had money in her room. Based upon the interviews and review of documentation, the facility determined that Resident #229 did have the money and that the money was misplaced while she was staying at the facility. The facility would reimburse Resident #229 the full amount of $40. Re-education was provided to Resident #229 on how and where to keep valuable or personal items locked in the DON's office or the BOM's safe. Resident #229 was resistant to locking up her wallet. An interview with CNA #4, dated 9/10/24, was included with the investigation. It revealed CNA #4 was asked about the missing money from Resident #229's room. CNA #4 said he knew nothing about the money. CNA #4 then said he was upset and did not want to talk with the interviewer anymore. A review of Resident #228's progress notes and EMR did not reveal any other information regarding the incident. V. Staff interviewsThe NHA was interviewed on 11/20/24 at 1:37 p.m. The NHA said the facility did not have the police reports for the incidents but that he requested the reports from the local police department. CNA #2 was interviewed on 11/21/24 at 9:50 a.m. CNA #2 said he had not heard anything about any residents having their property misplaced. CNA #2 said he had not received any training about what to do when residents' property went missing, but that he would go tell the DON if he heard anything about missing property. CNA #3 was interviewed on 11/21/24 at 10:33 a.m. CNA #3 said she had heard about residents having property go missing on other hallways but did not know much about the situations. CNA #3 said she had received training on what to do about residents reporting missing property and that the facility staff had meetings about it once a month. Licensed practical nurse (LPN) #2 was interviewed on 11/21/24 at 12:47 p.m. LPN #2 said she had not personally received any training or education about what to do when residents reported missing property. The DON, the NHA, and the chief operating officer (COO) were interviewed together on 11/21/24 at 2:16 p.m. The DON said if a resident reported something missing, the facility staff filed a grievance, reviewed the grievance with the NHA and the DON and then filed a police report. The DON said the facility was trying to investigate CNA #4's role in the incidents, since CNA #4 had been involved in caring for both Resident #228 and Resident #229. The DON said they had suspended CNA #4 but he later quit. The DON said Resident #46's smart watch had been tracked to a residential address. The DON said the facility administrators had cross-referenced the residential address with their employees' home addresses but did not identify any potential suspects among the staff. The DON said the police also investigated the incident, including looking at the employees' families' home addresses and could not identify any connection to the facility staff. The NHA said the police department denied his request for Resident #229's police report as it was an ongoing investigation. The NHA said he had not heard back from the police department yet regarding the other two residents' investigations. The DON said the police had reached out with updates in the past regarding any ongoing investigations. The COO said the facility staff received training on missing property upon hire, annually, and if an incident occurred. The DON said an all-staff meeting on misappropriation of resident property was conducted on 11/4/24. The NHA said they had educated the staff on misappropriation and that the residents could secure their items in the BOM safe or the DON offices. The NHA said the CNAs and nurses should have been informing residents where they could secure their valuables and that the information on that subject was also in the residents' admissions agreement. The COO said the facility would be keeping in contact with the police department more regularly going forward. The NHA said if a resident declined to secure their valuables in the BOM safe or the DON office, the facility would encourage the resident's family to take their valuables home with them. The DON said she had discussed Resident #228's hair appointment with the resident and Resident #228 said she did not have enough money for the hair appointment and complained about how expensive it was. The DON said they filed a grievance with Resident #228 related to this prior to the incident in which Resident #228 reported having money go missing. The COO said Resident #228's daughter had visited the resident and that he thought the resident's daughter may have taken the money home. The COO said from a customer service standpoint, the facility generally just reimbursed any money residents report missing.-However, resident reports of missing property continued to occur at the facility and the facility had not implemented a process to effectively prevent misappropriation of resident property.

Based on interviews and record review, the facility failed to develop an acute/baseline care plan for four (#380, #376, #382 and #225) of four residents reviewed for baseline care plans out of 60 sample residents. Specifically, the facility failed to ensure Resident #380, #376, #382 and #225 were provided a copy of their baseline care plan with 48 hours of admission to the facility. Findings include:I. Facility policy and procedureThe Baseline Care Plan policy and procedure, revised March 2020, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part, "It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan and manage resident care as evidenced by documentation from admission through discharge for each resident. "The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the patient's strengths, limitations, and goals. The care plan will be specific and appropriate to the individual needs for each resident. The interdisciplinary care plan will be developed through collaborative efforts of the IDT and other health care professionals. The care plan will be patient centered emphasizing the resident's and/or family's goals."The facility will develop, implement, and provide care in accordance with a comprehensive person-centered care plan for the resident consistent with regulatory requirements. The care plan is to include measurable objectives and timeframes to meet a resident's medical, nursing, psycho-social, and functional needs identified with completion of the comprehensive assessment. To the extent that is practical, the resident and/or family will be involved in the development of their care plan."The care plans will be modified when needed to meet the resident's current needs, problems, and goals. Any revision, additions, or deletion to the plan of care will be dated and initiated."II. Resident #380A. Resident statusResident #380, age 76, was admitted on 11/11/24. According to the November 2024 computerized physician orders (CPO), diagnoses included aftercare following joint replacement surgery and presence of bilateral artificial knee joint. The 11/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate assistance with activities of daily living (ADL). B. Resident interviewResident #380 was interviewed on 11/19/24 at 11:41 a.m. Resident #380 said she was not aware of her plan of care other than she had been receiving physical and occupational therapy. She said she had not been provided a written copy of her plan of care when she was admitted to the facility. She said she was frustrated that she did not know what was happening. C. Record reviewThe 11/14/24 care conference progress note documented an initial care conference meeting was held with the case manager, therapy, the resident and the resident's family. It documented the resident was oriented to the role of the case manager, how to contact the case manager, discussed discharge planning processes, services and guidelines. The progress note indicated a copy of the resident's medication list and care plan were provided to the resident.-However, a review of Resident #380's electronic medical record (EMR) on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the director of nursing as the facility's process (see DON interview below). III. Resident #376A. Resident statusResident #376, age 76, was admitted on 11/11/24. According to November 2024 CPO, diagnoses included encounters for other orthopedic aftercare, difficulty in walking, muscle weakness and right and left foot drop. The 11/13/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required maximum assistance with all ADLs. B. Resident interviewResident #376 was interviewed on 11/18/24 at 4:03 p.m. Resident #376 said she was visiting from another state when she ended up in the hospital for lumbar surgery. She said she had not received her care plan in writing since she was admitted to the facility. She said she had not received any communication from the case manager since she was admitted. C. Record reviewThe 11/14/24 care conference progress note documented an initial care conference meeting was held with the case manager, therapy, resident, and family. It documented the resident was oriented to the role of the case manager, how to contact the case manager, discussed discharge planning processes, services and guidelines. The progress note indicated a copy of the resident's medication list and care plan were provided to the resident.-However, a review of Resident #376's EMR on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the DON as the facility's process (see DON interview below). IV. Resident #382A. Resident statusResident #382, age greater than 65, was admitted on 11/3/24. According to the November 2024 CPO, diagnoses included fracture of left femur, history of falls, muscle weakness and gout. The 11/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required maximum assistance with all ADLs. B. Resident interviewResident #382 was interviewed on 11/18/24 at 4:52 p.m. Resident #382 said she had not been given a copy of her care plan since her admission to the facility. She said she had not received any communication regarding her discharge plan. C. Record review The 11/6/24 care conference progress note documented an initial care conference meeting was held with the case manager, therapy, resident, and family. It documented the resident was oriented to the role of the case manager, how to contact the case manager, discussed discharge planning processes, services and guidelines. The progress note indicated a copy of the resident's medication list and care plan were provided to the resident.-However, a review of Resident #382's EMR on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the DON as the facility's process (see DON interview below). V. Resident #225A. Resident statusResident #225, age 71, was admitted on 11/3/24. According to the November 2024 CPO, diagnoses included surgical aftercare and local infection of the skin and subcutaneous tissue. The 11/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. B. Record reviewA progress note dated 11/5/24 at 1:47 p.m. revealed the activities department completed an activities assessment of Resident #225. The activity care plan had been updated to reflect Resident #225's interests. A progress note dated 11/7/24 at 2:42 p.m. revealed a care conference had been completed with Resident #225, her family, the therapy team and Resident #225's case manager. The care conference notes revealed the team discussed discharge planning, processes, services and guidelines. The note documented a copy of Resident #225's medications and her care plan were provided to the resident. -However, a review of Resident #225's EMR on 11/21/24 did not reveal documentation of a signed Acknowledgement of Care Plan form to acknowledge the resident and/or responsible party were provided a copy of the baseline care plan, which was identified by the DON as the facility's process (see DON interview below). VI. Staff interviewsCase manager (CM) #2 and the DON were interviewed together on 11/21/24 at 3:46 p.m. CM #2 said she met with residents three to five days after their admission to the facility for an initial care conference. She said during the care conference, the resident's goals, preferences and initial discharge plan was determined with the resident and/or their family. CM #2 said she was not responsible for developing the discharge plan of care. She said the MDS nurse was responsible for developing the baseline care plan and providing each resident a copy within 48 hours of their admission to the facility. The DON was interviewed again on 11/21/24 at 3:57 p.m. The DON said all residents signed the Acknowledgement of Care Plan form upon receiving a copy of the baseline care plan. She said the form was then uploaded into the resident's EMR. The DON confirmed the facility did not have signed Acknowledgement of Care plan forms for Residents #380, #376, #382 and #225.

Based on observations, record review and interviews, the facility failed to develop and implement an effective discharge plan for nine (#376, #378, #380, #371, #388, #382, #10, #185 and #225) of 10 residents reviewed for discharge planning out of 60 sample residents. Specifically, for Residents #376, #378, #380, #371, #388, #382, #10, #185 and #225, the facility failed to:-Ensure residents and their representatives were involved in the development of the discharge plan; -Ensure the discharge plan of care was updated with the residents' discharge goals; and, -Ensure the discharge planning process was documented in the residents' electronic medical records (EMR). Findings include:I. Facility policy and procedureThe Admissions, Readmission, Transfers, and Discharge Process policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part, "It is the policy of this facility to permit each resident to remain in the facility, and not mandate a transfer out of the facility or discharge for the resident from the facility, except in limited circumstances."Once admitted, the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be provided at the facility or the mandated transfer out of the facility or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. "Staff involved in the move in, transfer and move out process will ensure that the focus is the resident and their family and their needs and concerns."II. Resident #376A. Resident statusResident #376, age 76, was admitted on 11/11/24. According to November 2024 computerized physician orders (CPO), diagnoses included encounters for other orthopedic aftercare, difficulty in walking, muscle weakness and right and left foot drop. The 11/13/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status (BIMS) score of 12 out of 15. She required maximum assistance with all activities of daily living (ADL). B. Resident interview and observationResident #376 was interviewed on 11/18/24 at 4:03 p.m. Resident #376 said she was visiting from another state when she ended up in the hospital for lumbar surgery. She said she had not received any communication regarding discharge planning. She said she felt she was forced to stay at the facility until the case manager deemed she was able to go home. She said she had not received any communication from the case manager since she was admitted to the facility. On 11/20/24 at 10:19 a.m., Resident #376 and certified occupational therapy assistant (COTA) #1 were in Resident #376's room. Resident #376 told COTA #1 that she was being discharged but she had not received any information. COTA #1 asked Resident #376 if she had received a Notice of Medicare Non-Coverage (NOMNC) and Resident #376 responded she had not received anything. COTA #1 told the resident she had not been told the resident was discharging and would go find out more information. Resident #376 refused therapy saying she was being discharged. C. Record reviewThe discharge care plan, initiated 11/11/24, documented Resident #376 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #376's specific discharge goal or include any revisions or updates. The 11/18/24 physician's progress noted documented the resident's discharge date was to be determined. The 11/20/24 daily skilled nursing progress note documented Resident #376 had a projected discharge date of the following week.-However, a review of the resident's EMR did not reveal documentation of an active discharge planning process. Resident #376 was discharged on 11/21/24. III. Resident #378 A. Resident statusResident #378, age 80, was admitted on 10/18/24. According to the November 2024 CPO, diagnoses included difficulty in walking, muscle weakness, infection and inflammatory reaction due to internal right knee prosthesis, sepsis due to methicillin resistant staphylococcus aureus (MRSA) and adjustment disorder with mixed anxiety and depressed mood. The 10/30/24 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status score of nine out of 15. She required substantial to maximum assistance with all (ADLs. B. Resident interview Resident #378 was interviewed on 11/18/24 at 3:48 p.m. Resident #378 said the facility had not discussed discharge plans with her. She said she had concerns about getting to out-patient physical therapy because she did not have any transportation. She said she had not been informed of any potential options for once she went home from the facility. She said she had not received any communication from the case manager since her initial care conference the first week she was admitted. C. Record review The discharge care plan, initiated 11/11/24, documented Resident #378 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #378's specific discharge goal or include any revisions or updates. -The daily nursing progress notes from 11/5/24 to 11/20/24 did not reveal documentation of any active discharge planning for Resident #378. -A review of the resident's EMR did not reveal documentation of an active discharge planning process. IV. Resident #380A. Resident statusResident #380, age 76, was admitted on 11/11/24. According to the November 2024 CPO, diagnoses included aftercare following joint replacement surgery and presence of artificial knee joint, bilateralThe 11/18/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance with ADLs. B. Resident interview Resident #380 was interviewed on 11/19/24 at 11:41 a.m. Resident #380 said she had not received any communication regarding her discharge plan or options for when she returned home. She said she felt like she was at the facility until they decided she could go home and she did not have any input. Resident #380 was interviewed again on 11/21/24 at 11:13 a.m. Resident #380 said a case manager came into her room and had her sign a document indicating she would be discharging on 11/22/24. She said prior to this meeting, she had not received any information or updates on her discharge status. C. Record review The discharge care plan, initiated 11/11/24, documented Resident #380 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #378's specific discharge goalor include any revisions or updates. The 11/18/24 physician progress note documented Resident #380's discharge date was to be determined. The 11/20/24 social services progress note documented a NOMNC was issued to the resident on 11/20/24 for a planned discharge of 11/23/24.-However, a review of the resident's EMR did not reveal documentation of an active discharge planning process since her admission. V. Resident #371A. Resident statusResident #371, age 77, was admitted on 11/3/24. According to the November 2024 CPO, diagnoses aftercare following joint replacement surgery, presence of left artificial knee, muscle weakness and post hemorrhagic anemia. The 11/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required moderate assistance with upper body activities and is dependent for walking/transfers that require lower body function. B. Resident and resident's representative interview Resident #371 and the resident's representative were interviewed together on 11/21/24 at 10:12 a.m. Resident #371 said her goal was to return home when she was ready. She said she had not received any communication since her admission regarding her discharge planning until two days prior, when the facility had her sign a document that indicated she was discharging. Resident #371's representative said they did not know if she was ready to return home, so he hired a private caregiver to assist with caring for the resident's ADLs. C. Record review The discharge care plan, initiated 11/3/24, documented Resident #371 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #371's specific discharge goal or include any revisions or updates. The 11/20/24 daily skilled nursing progress note documented there was no projected discharge date for Resident #371. However, the 11/20/24 social services progress note documented a NOMNC was issued to Resident #371 on 11/20/24 with the appeal rights explained.-Additionally, a review of the resident's EMR did not reveal documentation of an active discharge planning process. VI. Resident #388A. Resident statusResident #388, age 80, was admitted on 11/5/24. According to the November 2024 CPO, diagnoses included encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, morbid obesity, bilateral primary osteoarthritis and difficulty in walking. The 11/17/24 24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance with ADLs. B. Resident interview Resident #388 was interviewed on 11/19/24 at 9:12 a.m. Resident #388 said she had concerns regarding her discharge process. She said she was told when she was first admitted to the facility that she would be at the facility for two to three weeks. She said it had been two weeks since her admission and she had yet to receive any communication regarding her progress and discharge plan. Resident #388 said she was concerned about discharging home because she lived alone and her home was not set up for wheelchair access, as she was currently confined to a wheelchair. She said she did not have any assistance at home and had not been given any information or options for help when she did return home. C. Record review The discharge care plan, initiated 11/5/24, documented Resident #388 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #388's specific discharge goal or include any revisions or updates. -The nursing progress notes from 11/5/24 to 11/20/24 did not reveal documentation of discharge planning.-A review of the resident's EMR did not reveal documentation of an active discharge planning process. VII. Resident #382A. Resident statusResident #382, age greater than 65, was admitted on 11/3/24. According to the November 2024 CPO, diagnoses included fracture of left femur, history of falls, muscle weakness and gout. The 11/15/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required maximum assistance with all ADLs. B. Resident interview Resident #382 was interviewed on 11/18/24 at 4:52 p.m. Resident #382 said she had not received any communication about discharge planning since her admission to the facility. She said all she thought about was going home, but she did not know where she stood in that process. C. Record review The discharge care plan, initiated 11/3/24, documented Resident #382 wanted to be involved in her discharge planning. The interventions included communicating with the resident and/or family as needed related to the resident's progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and continuing to encourage the resident to make an effort toward achieving their goals. -Upon review, the care plan was not person-centered, had similar wording for every resident and did not document Resident #388's specific discharge goal or include any revisions or updates. -A review of the resident's EMR did not reveal documentation of an active discharge planning process. VIII. Staff interviewsCOTA #1 was interviewed on 11/20/24 at 1:29 p.m. COTA #1 said the therapy team was not aware of the discharge for Resident #376. She said the therapy department felt she had not progressed enough and was not ready to discharge from the facility. She said the ankle foot orthosis (AFO - medical device that supports the foot and ankle) had not been delivered yet and was needed in order for Resident #376 to discharge safely. She said they were working on re-routing the AFO to the resident's home instead of the facility. Case manager (CM) #2 was interviewed on 11/21/24 at 3:46 p.m. CM#2 said she met with each resident she was assigned within three to five days of their admission to the facility. She said the meeting was required at the facility and was called the admission care conference. She said during the meeting, she explained her role, the discharge planning process and discussed any equipment needs of the resident. She said discharge planning should begin on the first day of each resident's admission to the facility and should be documented. She said she was responsible for issuing a NOMNC letter when the resident was ready for discharge, according to the interdisciplinary team (IDT). CM #2 said she did not document any active discharge planning in the resident's EMR. She said she kept it on a log in a binder on her desk. She said each resident had notes regarding their progress with therapy, but did not contain any documentation where the resident and/or family were spoken with or apprised of each resident's progress and movement toward discharge. She said her notes contained updates from the therapy department. She acknowledged updates from the therapy department did not show active discharge planning. CM #2 confirmed Resident #380 was issued a NOMNC. She said she could not recall if she had met with the resident or done any active discharge planning prior to the NOMNC being issued. CM#2 said she had not met with Residents #376, #388 and #382 to discuss any discharge planning. CM #1 and the director of nursing (DON) were interviewed together on 11/21/24 at 4:05 p.m. CM #1 said discharge planning was only documented on a log she kept in her office and not in the residents' EMRs. She said she was not required to document anything in the residents' EMRs other than the NOMNCs being issued and care conference notes. CM#1 said she was not responsible for developing the discharge care plan and making revisions throughout the resident's stay at the facility. She confirmed she was responsible for discharge planning for assigned residents at the facility. She said she was not responsible for identifying barriers for a resident's discharge. CM#1 said she had not met with or discussed resident progress or discharge planning with Resident #378 and #371 since their initial care conferences. IX. Resident #10 A. Resident statusResident #10, age 80, was admitted on 10/25/24. According to the November 2024 CPO, diagnoses included fracture of the T9-T10 (thoracic) vertebra, bipolar disorder and Parkinson's disease. The 11/1/24 MDS assessment revealed that the resident was cognitively intact with a BIMS score of 14 out of 15. She required partial assistance with most of her activities of daily living (ADL) and was dependent on staff for bathing and lower body dressing. The assessment indicated the resident's overall goal was to be discharged back into the community or to go back home. B. Resident interviewResident #10 was interviewed on 11/18/24 at 10:50 a.m. Resident #10 said she had asked the facility staff several times if she could go home. She said the facility staff seemed more interested in completing physical therapy, however, she was admitted because of clostridioides difficile (C-diff - a bacteria that causes diarrhea). She said the case manager told her she would not be able to go home until she could dress herself, shower herself and go to the bathroom by herself. She said she lived at home with her spouse and son who had been assisting her with all of her ADLs for a long time. Resident #10 said she told the case manager she would not be able to do all those things by herself because she had Parkinson's disease. She said the case manager seemed kind of cold and she felt the case manager thought she was lazy. Resident #10 was interviewed a second time on 11/20/24 at 9:53 a.m. Resident #10 said the facility staff had not updated her on her discharge plan or how she was progressing toward her discharge goals. She said no one would give her a straight answer and she felt like a prisoner at the facility. She said the case manager seemed angry when she told her that she wanted to go home. She said she did not think the case manager fully understood that she would never be fully independent because of her Parkinson's disease. Resident #10 was interviewed a third time on 11/20/24 at 3:13 p.m. with a family member present. Resident #10 said the facility held a care conference the first week she was at the facility, but she could not remember what was discussed. She said she was under the impression she would be discharged once the C-diff was no longer an issue. Resident #10's family member said he had not been apprised of the progress that had been made toward the resident's discharge. He said he was given a folder of papers upon her admission to the facility, but no one ever explained the discharge process. The family member said he went and spoke to the case manager and she said she would let him know what was going on but he said she had never followed up with him. Resident #10's family member said the facility had not done any discharge planning that he was aware of and he felt like the facility was keeping Resident #10 at the facility for the insurance money. He said Resident #10 had not been able to do any ADLs on her own for the last twenty years due to her diagnosis of Parkinson's disease. Resident #10 said she felt intimidated by the case manager because she was the one who controlled when shegot to go home. C. Record reviewThe discharge care plan, revised 11/19/24 (during the survey process), documented Resident #10 wanted to be involved in her discharge planning. The interventions included communicating with the resident as needed related to progress, goals and plans, contacting the appropriate community agencies as needed when the resident was ready to discharge and encouraging the resident to make an effort toward achieving their goals. -Prior to the care plan being updated on 11/19/24, which was during the survey process, there were no new goals or interventions added to the care plan since 10/25/24, the date of the resident's admission. -The discharge care plan did not include Resident #10 lived at home with her spouse and son who provided assistance with her ADLs or any person-centered interventions or barriers to her discharge. The 10/28/24 discharge progress note documented Resident #10's plan for discharge was to increase her strength, mobility and ADL participation and return to her home with her spouse. The 10/29/24 discharge progress note documented the facility conducted a care conference. It documented the resident was welcomed to the facility and the discharge planning process was reviewed and a copy of her medications and care plan were given to the resident. It documented that case management would monitor for changes and needs and provide additional support throughout her stay. The review of the care plan summary revealed that the interdisciplinary team (IDT) met weekly to discuss and assess the progress of the resident's physical and medical status in determining the resident's date of discharge. -However, the resident's electronic medical record (EMR) did not reveal any documentation of the IDT meetings or the progress that the resident was making towards discharge. -The EMR failed to include any documentation that the resident and her family were involved in the discharge planning process or that a discharge planning process had occurred since Resident #10's admission to the facility. -The EMR did not reveal documentation that the resident's discharge goals had been identified and developed throughout her stay at the facility. D. Staff interviewsCM #1, the DON and the chief operations officer (COO) were interviewed together on 11/21/24 at 3:05 p.m. CM #1 said she kept all the discharge documentation on the residents she was assigned to in a binder that was kept in her office. She said the documentation contained updates from therapy on each resident's progress. She said each time she documented in the binder did not mean she had met with the resident and/or their family to discuss their discharge progress, just that she had written down what the therapy department had communicated. CM #1 said Resident #10 had not had a formal care conference since her admission to the facility. She said she had not documented any of her interactions with the resident or her family. The COO said that he did not think anyone would tell a resident they could not go home if they were unable to complete certain ADLs. The COO said, based on the assistance level Resident #10 and her family described, he did not see any difference between her prior level of function and her current level of function. CM#1 said she had not met with Resident #10 or her family to discuss her discharge planning. She said she would be meeting with them tomorrow (11/22/24) because therapy had set a discharge date that day (11/21/24) to issue the notice of medicare non-coverage (NOMNC). CM #1 said discharge planning should occur prior to the NOMNC being issued. X. Resident # 185A. Resident statusResident #185, age greater than 65, was admitted on 11/4/24. According to the November 2024 CPO, diagnoses included right knee prostheses complication (artificial knee), vascular access device (device to access the blood vessel), dysphagia (difficulty swallowing) and hypertension (high blood pressure). The 11/11/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required partial staff assistance with toileting, dressing and transfers. She was independent with eating. The resident was on antibiotics intravenous (IV) medications. The assessment revealed the resident wanted to be discharged to the communityB. Resident interviewResident #185 was interviewed on 11/18/24 at 11:36 a.m. Resident #185 said she was very concerned about her stay in the facility because she required at least six weeks of IV antibiotic treatment and no one had discussed with her what would happen if the insurance company did not allow her to stay in the facility that long. Resident #185 expressed financial concerns if her insurance did not cover her whole stay for the duration of her IV treatment. Resident #185 said her husband and son had been trying to communicate with the insurance company about her coverage and they had not been able to get any information on what could happen. Resident #185 said she was not able to care for IV lines and administer IV medication at home because it was a complicated system. Resident #185 said no one in the facility had discussed her discharge planning with her since her admission on 11/4/24 when they asked her what her plan was for discharge. She said her plan was to return home. C. Record review-Review of the 11/4/24 comprehensive care plan did not reveal a discharge planning care area focus for Resident #185. The care conference note dated 11/7/24 revealed the resident's discharge plan was to return home with her husband and son. The note indicated Resident #185 had 17 steps to go upstairs in her home. A social service note dated 11/7/24 revealed a care conference was held on 11/7/24. The note indicated the case manager discussed the resident and family discharge planning process, services and guidelines.-However, Resident #185 said she did not know what was occurring with her discharge plan (see resident interview above). D. Staff interviewCase manager (CM) #1 was interviewed on 11/21/24 at 3:04 p.m. CM #1 said she did not document discharge planning in the residents' electronic medical records (EMR). CM #1 said she only documented the initial care conference with residents and when a Notice of Medicare Non-Coverage (NOMNC) was given. CM #1 said Resident #185's plan was to discharge home with her husband and son but she needed to work therapy to ensure she could manage the 17 stairs within her home. CM #1 said she had not discussed any discharge planning, such as home health services, with Resident #185. CM #1 said she had not given Resident #185 any information about her discharge. XI. Resident #225A. Resident statusResident #225, age 71, was admitted on 11/3/24. According to the November 2024 CPO, diagnoses included surgical aftercare and local infection of the skin and subcutaneous tissue. The 11/5/24 brief interview for mental status (BIMS) assessment revealed the resident was cognitively intact with a score of 15 out of 15. B. Resident interviewResident #225 was interviewed on 11/20/24 at 2:37 p.m. Resident #225 said she had met the day prior (11/19/24) with her insurance representatives to discuss her discharge and she was going to discharge home from the facility on 11/24/24. Resident #225 said the facility staff had been coming in recently to talk to her about her upcoming discharge, and the occupational therapist had just been in to speak with her.-However, there was no documentation in Resident #225's EMR regarding updates to her discharge or changes in her discharge plan. C. Record reviewThe discharge care plan, initiated 11/2/24 and revised 11/3/24, revealed Resident #225 established appropriate goals for herself and wanted to be involved in her discharge planning. Pertinent interventions included communicating with the resident as needed related to progress, goals and plans, contacting appropriate community agencies as needed when the resident was ready to discharge and encouraging the resident to make an effort toward achieving their goals. A progress note dated 11/7/24 at 2:42 p.m. revealed a care conference had been completed with Resident #225, her family, the therapy team and Resident #225's case manager. The care conference notes revealed the team discussed discharge planning, processes, services and guidelines. The progress note documented a copy of Resident #225's medications and her care plan were provided to the resident. A progress note dated 11/21/24 at 4:32 p.m. revealed on 11/19/24 the case manager discussed with Resident #225 and her family that a discharge date had been set by her insurance company. The case manager confirmed with Resident #225 that she would be discharging home with her family member and that the nursing staff would educate the resident and her family on how to administer intravenous (IV) medications and management of the indwelling IV line. The case manager told Resident #225 that home health services had been set up for her and a new wound vacuum had been ordered for her.-However, the progress note note was not added to Resident #225's EMR after the interview with the case manager on 11/21/24, two days after the discharge discussion with Resident #225. (see interview below).-Review of the care plan and Resident #225's EMR did not reveal any further documentation related to discharge planning or discussion of the discharge plan with the resident. D. Staff interviewsThe DON and CM #2 were interviewed together on 11/21/24 at 1:42 p.m. CM #2 said Resident #225 was going to discharge on 11/24/24. CM #2 said the facility conducted caregiver training with Resident #225's spouse and the nursing staff did IV training for the resident. CM #2 said Resident #225 was discharging home with a wound vacuum and an IV line and was to receive home health services.-However, there was no documentation in Resident #225's EMR regarding the caregiver training for the resident's spouse or the IV training conducted by the nursing staff (see record review above). CM #2 said the facility staff had a care conference with Resident #225 on 11/7/24. CM #2 said she had talked with Resident #225 on 11/19/24 and 11/21/24. CM #2 said she had discussed with Resident #225 the wound vacuum the facility had ordered, the home health services the facility had arranged and the training the resident's husband would receive. CM #2 said she had documented these conversations in a binder. XII. Facility follow upOn 11/22/24 at 11:29 a.m., the NHA provided the logs for CM #1 and CM #2 for Resident #378, #376, #225, #388, #380, #10 and #382. -A review of the logs revealed therapy information on each resident's functional status but no discharge planning or coordination/communication with residents and or their representatives. -The information was not documented in the EMR.

Based on observations, record review and interviews the facility failed to ensure activities were designed to support residents physical, mental and psychosocial well-being were provided for two (#373 and #36) of two residents out of 60 sample residents. Specifically, the facility failed to identify and meet the socialization needs for Resident #373 and #36. Findings include:I. Facility policy and procedureThe Activities policy and procedure, revised February 2024, was received by the nursing home administrator (NHA) on 11/22/24 at 8:33 a.m. It read in pertinent part,"The resident has the right to choose activities and participate in activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility. The facility will ensure and implement an ongoing resident-centered activity program that incorporates the resident's hobbies and culture preferences, which is integral to maintaining and or improving a resident's physical, mental and psychosocial well-being and independence. The facility will support and create meaningful life by supporting his/her domain of wellness. "Activities Procedures: The resident will make choices about the activities they would like to participate in. The facility will promote one to one visits in the resident's room as needed. Activities will be provided seven days a week on days and evenings. The activity room will have self-directed activities 24 hours a day available to the resident."II. Resident #373A. Resident statusResident #373, age 75, was admitted on 10/22/24. According to the November 2024 computerized physician orders (CPO), diagnoses included spinal stenosis to the cervical region (when the spinal canal narrows putting pressure on the spinal cord and nerves) and muscle weakness. The 10/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. She required maximum assistance with activities of daily living (ADL)B. Resident and resident's representative interviews and observationsResident #373 was interviewed on 11/19/24 at 9:39 a.m. Resident #373 said she was lonely and just wanted someone to sit with her and watch The Price is Right (television show). She said she wanted someone to talk with and share her stories about her children and grandchildren. Resident #373 said she had asked facility staff to take her outside for a walk, but she was always told they were too busy. She said she wanted to get some fresh air. On 11/19/24 at 2:00 p.m. the facility had a scheduled group activity of painting. -Resident #373 was not invited to attend the group activity. During a continuous observation on 11/20/24, beginning at 8:50 a.m. and ending at 11:30 a.m., Resident #373 activated her call light five times for non-care related reasons from 8:50 a.m. to 9:56 a.m. At 11:00 a.m. the facility held a group activity of Monopoly.-Resident #373 was not invited to attend the group activity. At 1:30 p.m. Resident #373's representative was observed wheeling the resident out of her room and down the hallway. Resident #373's representative was interviewed on 11/20/24 at 1:57 p.m. The representative said he had just taken Resident #373 for a walk outside. He said Resident #373 was happy to go outside and have someone to talk to and tell her stories to. On 11/20/24 from 1:30 p.m. to 3:00 p.m. the facility had a group activity of pet visits. -Resident #373 was not invited to participate. C. Record reviewThe activities care plan, initiated 10/24/24, documented Resident #373 expressed interest in participating in group activities and enjoyed watching television. It indicated the resident required one-to-one activities to be coordinated by the activities director (AD). The interventions included activity calendar to be available for resident's review, encourage participation in expressed individual and/or group activities of interest, AD will remind, encourage/assist and/or transport resident to activities of interest as needed, AD will encourage maximum participation according to functional capacity, and provide supplies as needed such as books, newspapers, magazines, batteries, craft supplies, word games, etc ... A review of the November 2024 treatment administration record (TAR) revealed Resident #373 should have activities available as requested for both day and night shifts. The TAR documented Resident #373 was only offered activities on 11/4/24 at 4:09 p.m. and 11/13/24 at 3:48 p.m. III. Resident #36A. Resident statusResident #36, age greater than 65, was admitted on 10/14/24. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of the left femur (broken bone of the upper leg), kidney failure, major depressive disorder (disorder affecting how someone feels) and hypertension (high blood pressure). The 10/21/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She was dependent on staff for toileting, dressing and transfers. She required moderate assistance for eating and personal hygiene. B. ObservationsOn 11/18/24 at 4:22 p.m. Resident #36 was observed to be calling out to anyone who walked by her room.-Staff did not enter the resident's room to see what she needed or offer to provide her with any activities of interest. On 11/19/24 at 10:00 a.m. Resident #36 was observed to be calling out from her room saying "help me."-Staff did not enter the resident's room to see what she needed or offer to provide her with any activities of interest. On 11/19/24 at 3:34 p.m. Resident #36 said good morning to an unidentified certified nurse aide (CNA) who was sitting at the nurses station. Resident #36 called out three times before the CNA went to her room. The unidentified CNA remained in the resident's room for 30 seconds then returned to the nurses station.-The CNA did not offer to provide the resident with any activities of interest. On 11/20/24 at 11:40 a.m. Resident #36 was awake in her bed looking out the door towards the nurses station. The television was not on and no books were observed in her room. C. Record reviewThe activity care plan, initiated 10/14/24, revealed Resident #36 enjoyed watching television, reading (historical fiction) and spending time with her family. An activities progress notes dated 10/16/24 revealed an initial activities assessment was completed for Resident #36. The progress note documented Resident #36 would be involved in leisure activities as desired and the activity care plan had been developed to reflect these interests. Staff would monitor for any problems or concerns that might inhibit Resident #36's participation in leisure activities. Furthermore, staff would support the leisure needs of Resident #36 by offering reminders, encouragement, assistance and supplies as needed. A late entry activities progress note dated 11/1/24 revealed Resident #36 was offered a monthly activities calendar. The calendar identified times and locations of future activities. Resident #36 was told to contact activities at the activities extension number for any additional supplies or if she had an interest in any group activities.-However, according to Resident #36's 10/21/24 MDS assessment (see resident status above), the resident was severely cognitively impaired and therefore would not have been able to call the activities extension number for activities supplies. An activities progress note dated 11/4/24 documented Resident #36 refused the daily chronicle which had an educational short read and an engaging puzzle. -However the comprehensive care plan identified Resident #36 liked to read but the daily chronicle was not a topic she enjoyed (see record review above). There was no other documentation to indicate Resident #36 had been provided with individual activities of interest or been invited to group activities. The activities log identified several days where one-to-one visits occurred for Resident #336.-However, the one-to-one visits were with the resident's family members and not members of the facility's activities staff (see interviews below). IV. Staff interviewsCNA #5 was interviewed on 11/20/24 at 3:16 p.m.. CNA #5 said Resident #373 was lonely and wanted someone to sit and talk with her. She said most of the time, Resident #373 wanted the CNAs to sit on her bed and watch television with her. The AD and the NHA were interviewed together on 11/21/24 at 5:03 p.m. The AD said she did not actually conduct the one-to-one activities for each resident, but instead relied on each residents' family and friends. She said she did not take residents outside during this time of the year because of the cold weather. The AD said she provided a monthly calendar of activities to all residents on admission and monthly. The AD said she relied on floor staff to encourage residents to attend activities the day before the activity and to help her identify any residents who may need help to attend activities. The AD said, because the facility had a large census, it was difficult for her to meet with all residents prior to the activity but she had her CNA license which helped her transport residents to the activities. The AD said each resident's participation in group activities was based on their physical and cognitive abilities. She said the nursing staff should notify her of any residents asked to attend activities. She said the activities staff did not personally invite residents to group activities. She said there was not usually a high turnout for regular group activities. The AD said each resident's activity preferences were established upon admission and she did not re-evaluate those preferences throughout their stay at the facility. She said she was the only one that provided activities to all residents in the facility and it was a lot for one person to handle. The AD said she had not been informed that Resident #373 was lonely or wanted to attend activities. She confirmed she had documented the resident wanted to attend group activities and required one-to-one visits during Resident #373's admission activity assessment. She said she had not personally provided Resident #373 with any one-to-one activities but relied on the resident's family for that. The AD said Resident #36 had a cognitive impairment and made communication difficult for the resident. The AD said Resident #36 had a strong family involvement and the one-to-one visits documented on the resident's activities log were when the resident's family visited with her. The AD said she did not conduct one-to-one activities visits with Resident #36. The AD said she had not checked in with Resident #36 about needing any books or other leisure activities supplies. The AD said she did not think she needed to make any changes to the activity program at the facility. The NHA said Resident #36 enjoyed visits from family members. He said Resident #36 seemed to like familiar faces over strangers. The NHA said the housekeeping staff would remove books from residents' rooms when they were cleaning and return them to the library. He said that might be the reason no books were observed in Resident #36's room (see observations above). The NHA said the activities department needed to change their approach with residents in order to build rapport with residents to ensure their needs were being met. The NHA said, going forward, the activity staff would check in with the residents more often and determine if their preferences had changed throughout their stay at the facility. He said he would put a system in place to ensure residents were being invited to group activities every day. The director of nursing (DON) was interviewed on 11/21/24 at 5:47 p.m. The DON said she did not have any involvement in activities other than directing residents to seek out the activities staff for something to do or to review the calendar with a resident. The DON said the AD, along with all other staff, were responsible for inviting residents to group activities 30 minutes prior to the start of the activity. The DON said the AD should be completing one-to-one visits with residents and should be inviting residents to all planned/scheduled activities.

Based on record review, observations, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#53) one resident out of 60 sample residents. Resident #53 was admitted to the facility for rehabilitation services on 10/4/24 with a diagnosis of fracture of the left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/5/24 admission skin assessment indicated the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. The assessment did not indicate that the resident had any abdominal wounds. On 10/24/24 the resident was noted to have two facility acquired moisture associated skin disorder (MASD) wounds to her abdominal folds. The facility failed to provide the resident with showers per her preferences. Due to the facility's failures, observations revealed the resident had developed three MASD wounds to her abdomen. Through observations, the facility failed to follow infection control practices when providing wound care and failed to document the third MASD wound. Additionally, the facility also failed to communicate the worsening of the abdominal wounds to the primary care physician and ensure a timely referral to a wound physician. Findings include:I. Resident #53A. Resident statusResident #53, age less than 65, was admitted on 10/4/24. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of left femur, end stage renal disease, type two diabetes, and morbid obesity. The 10/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, bathing, and lower body dressing and was partially dependent for all other activities of daily living (ADL). The assessment indicated that the resident did not have any skin conditions. B. Resident interviewResident #53 was interviewed on 11/18/24 at 11:24 a.m. Resident #53 said she had wounds underneath her abdominal fold that she had developed when she was admitted to the facility. She said the abdominal wounds were very painful. She said the pain was what caused her to ask the staff to look under her abdominal fold. She said she did not understand how the wounds developed so quickly and when she asked the nurse they said that they did not know either. Resident #53 was interviewed again on 11/20/24 at 8:06 a.m. She said the facility gave her bed baths instead of showers because she was unable to sit in the shower chair comfortably. She said she preferred to receive a bed bath in the morning, however she often refused her bed bath because the certified nurse aide (CNA) would come between 7:00 p.m. and 8:00 p.m., which she had told them repeatedly was too late. She said she had requested to be moved to the day shift for her bed baths to ensure she received it during the day, but her request had still not been honored. Resident #53 said when the facility the staff did give her a bed bath, they did not lift up her abdominal fold and clean underneath. She said she had full feeling in her abdominal fold and underneath it, and she would have felt if they had cleaned underneath it. Cross reference F561: The facility failed to ensure Resident #53's preference to have her bed bath done during the day shift was honored. C. ObservationsOn 11/21/24 at 8:40 a.m. the certified wound nurse (CWN) and the director of nursing (DON) were observed providing Resident #53's wound care and dressing change. The CWN cleared off the resident's bedside table and wiped it down with a disinfectant wipe, applied a barrier pad and placed her bag of resident wound care supplies on top. The DON entered the room as well and put a clean chucks pad (disposable absorbent pad) under the resident's abdominal fold but below the wounds. Three dressings were observed on the resident, one on the right, one in the middle and one on the left. All of the dressings had the date 11/20/24 with a nurse's signature. Both the DON and the CWN completed hand hygiene and put on clean gloves. The CWN removed all three dressings, the right and left sides had moderate serosanguineous drainage (a thin watery fluid), the middle had a small amount of bloody drainage. The wound on the right was the largest of the three wounds. It was noted to have a ring of redness around it and the center had 20% eschar and 10% yellow slough the remaining tissue was red and it had no odors. The middle wound was the size of a nickel and had red tissue throughout and did not have an odor. The wound on the left was noted to be about the size of a quarter and had 80% slough and 20% red tissue and did not have an odor. The CWN changed her gloves to set up her supplies for the wound care. She set up a stack of gauze, a continuous spray can of saline solution and a lidocaine spray. She started on the left wound by taking one gauze she sprayed it with saline and wiped the wound, folded it over and wiped again three times with the same gauze, the wound was noted to have bloody drainage. The CWN then threw the gauze away and with her dirty glove touched the saline bottle and then re-sprayed all three wounds with lidocaine per the resident's request due to pain, with contaminated gloves. Using the same gloved hands the CWN then took another piece of gauze and sprayed it with the saline solution and moving from the left wound to the middle wound she wiped twice with the same piece of gauze. The CWN then moved to the wound on the right and wiped the wound three times with the same piece of gauze. She then collected a second piece of gauze moistened it with saline and wiped eight times over the wounds with the same piece of gauze, she then took another piece of gauze moistened it with saline solution and proceeded to wipe six more times over the wound areas. She took a third piece of gauze and dabbed the area three times due to bloody drainage. She threw away the gauze and changed her gloves and performed hand hygiene. The CWN conducted a wound culture to the right wound. She took the culture tubing out of the sterilized package. She swabbed the right wound. She then inserted the sample into the test tube. The CWN then changed her gloves, performed hand hygiene. She started on the left side of the wound, using gauze and saline to wipe, applied skin prep to the peri-wound and cut calcium alginate (highly absorbent dressing) sheet to size and applied it. She applied Medihoney (antimicrobial gel) and covered the wound with a border foam dressing. The CWN moved to the middle wound and used a saline-soaked gauze to wipe the wound four times, using the same gauze to apply the skin prep to the peri-wound. She cut another piece of calcium alginate and Medihoney and applied both to the resident's wound and covered it with the foam dressing. Using the same gloved hands, the CWN moved to the right wound, using saline soaked gauze, she wiped the wound four times with noted serosanguinous drainage coming out of the wound as she applied skin prep. She measured the right wound at this time 3.5 centimeter (cm) length by 9 cm width by 0.1 cm depth and said the wound was larger than last week. She took calcium alginate and Medihoney and applied it to the wound and covered it with a foam dressing. Cross-reference F880: the facility failed to follow proper infection control practices for wound care. D. Record reviewThe potential for skin breakdown care plan, revised on 10/5/24, documented Resident #53 had a surgical incision on her left hip, brace to the left knee, double right chest port, folded abdomen and a hard abdomen. The interventions included applying antifungal powder beneath the pannus (abdominal fold) every shift, completing a Braden scale every week per protocol, providing prophylactic skin treatments as ordered, performing skin assessments as needed, wound nurse to evaluate and treat and the wound physician to evaluate and provide treatment as needed. -The comprehensive care plan did not include Resident #53's actual skin breakdown of three abdominal wounds. The 10/4/24 hospital discharge summary documented Resident #53's skin was warm, dry, intact and had no rashes. The 10/5/24 admission skin assessment documented Resident #53 had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. -It did not document Resident #53 had abdominal wounds upon admission. The 10/10/24 and 10/17/24 skin assessments documented the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. -It did not indicate Resident #53 had sustained any abdominal wounds. The 10/24/24 skin assessment documented the previously identified skin concerns and additionally a wound to the abdomen. It did not include any information regarding the wound to the abdomen. The 10/24/24 wound progress note documented the floor nurse requested the wound nurse to come and assess the abdominal wounds. The note indicated that there were two moisture-associated skin damage (MASD) wounds underneath the pannus. The right wound measured 2.5 cm in length by 4 cm in width by 0.5 cm depth with 50% granulation tissue (new connective tissue) and 50% slough (dead tissue) with little signs or symptoms of drainage. The wound was debrided with no complications. The left wound measured 1 cm length by 1.5 cm width by 0.2 cm depth with 70% granulation tissue and 30% slough with little signs or symptoms of drainage. The wound dressing order read: cleanse with wound cleaner, apply skin prep to peri-wound (skin surrounding a wound), apply collagen to the wound bed, cover with a foam border dressing every other day or as needed, replace the Interdry sheets (fabric to absorb moisture) beneath the abdomen every three days or as needed and monitor placement of the Interdry sheets every shift. The 10/31/24 wound note documented that the size of both wounds had not changed, however the right wound now had 20% gran and an increase of 80% slough with little signs or symptoms of drainage. The left wound was unchanged with 70% granulation tissue and 30% slough with little signs or symptoms of drainage. The wound dressing order was changed and read as: cleanse with wound cleaner, apply skin prep to the peri-wound, apply medihoney and then collagen to the wound beds, cover the wound with a foam border dressing everyday and as needed, replace the Interdry sheets beneath abdomen every three days or as needed and monitor placement of the Interdry sheets every shift. The 11/13/24 provider note documented that the nurse practitioner (NP) saw Resident #53 to follow up on her abdominal wound and her lab work. It documented the NP saw the wounds via picture. It documented that the wound team was following the MASD open wounds. The 11/14/24 wound progress note documented there were no changes to both wounds. -The wound progress notes did not reveal accurate documentation of the wounds in describing the eschar (scab-like dead tissue covering the wounds) observed to the right wound and that Resident #53 had three abdominal wounds (see observations above of wound care during the survey process), not only two wounds. Review of the record revealed that the resident's primary care physician or her nurse practitioner did not physically see the abdominal wounds except for via photograph which was noted on 11/13/24 (see NP interview below). II. Staff interviewsThe CWN was interviewed on 11/21/24 at 9:11 a.m. The CWN said Resident #53 had abdominal wounds upon admission and were caused from moisture. -However, according to the facility admission skin assessment, Resident #53's she had a surgical incision on her left hip and scattered bruises on her upper extremities upon admission to the facility. The CWN said the wound physician had not been referred to see Resident #53's wounds, but she had referred the resident that week, during the survey process, since the wounds had gotten worse and were not healing. She said she observed Resident #53's wounds weekly. The CWN said she was notified from the floor nurse yesterday (11/20/24), that Resident #53's wound had deteriorated. She said she contacted the wound physician and received an order to culture one of the wounds. The CWN said her cleaning technique with the gauze was to move from clean to dirty and then discard the gauze. She said she had not realized she had used the same gauze up to eight times to wipe the wound. She said she should have changed the gauze in between each wipe to decrease the risk of infection. She said she should have changed her gloves in between each wound site to decrease the risk of infection. Primary care physician (PCP) #1 was interviewed on 11/21/24 at 11:55 a.m. PCP #1 said she was the PCP for Resident #53. PCP #1 said Resident #53's skin was clear from any wounds upon admission, except for the surgical incision. She said she observed the wounds on 10/25/24, but had not observed the wounds since because the wound nurse was following and she expected the wound nurse to provide her with updates. She said the NP was following the wounds more closely for this resident. She said she had not been informed Resident #53's wound had deteriorated to include eschar and slough. She said she would assume the wound physician ordered a wound culture because there was concern about a potential infection of the wound. She said she would have expected the CWN to have referred Resident #53's wounds to the wound physician sooner, who was an expert in that area. NP #1 was interviewed on 11/21/24 at 12:21 p.m. NP #1 said she was the NP for Resident #53. She said she had not directly observed Resident #53's abdominal wounds. She said she hated to take off the bandage to look at the wound because of Resident #53's pain and creating more work for the floor nurse. She said she had asked the CWN for pictures of the wounds. She said she was not informed Resident #53's wounds had deteriorated to include eschar and slough, just that they had increased in size. NP #1 said an increase in measurements did not necessarily mean the wounds were deteriorating. She said if she had been provided more information and informed of the eschar and slough, she would have acted differently, to ensure the wound physician was involved sooner. NP #1 said the presence of eschar and yellow slough meant the wound was deteriorating. She said that using the same gauze to wipe the wound multiple times could spread bacteria as well as not changing gloves, which had potential to lead to an infection. She also said that by not debriding the wound before getting a culture of the wound could potentially cause inaccurate test results. NP #1 said she was unaware the wound physician was not already following and involved in the wound care for Resident #53's abdominal wounds. The CWN was interviewed again on 11/21/24 at 4:32 p.m. The CWN said she was not concerned about Resident #53's abdominal wounds until yesterday (11/20/24), when the floor nurse informed her the wound had gotten worse. She said by the time she had been notified of the worsening of the wounds, the wound physician had already left for the day. The CWN said it was up to her discretion as to when a wound required the wound physician's expertise. She said the wound physician would see Resident #53's abdominal wounds next week.

Based on observations, record review and interviews, the facility failed to ensure one (#174) of one resident reviewed for pressure ulcers out of 60 sample residents received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure Resident #174's physician ordered heel protection boots were consistently implemented as an intervention to prevent potential pressure wounds. Findings include:I. Professional referenceAccording to the International Wound Journal's Summary of Best Evidence For Prevention and Control Of Pressure Ulcers on Support Surfaces (3/9/23), retrieved on 12/2/24 from https://pmc.ncbi.nlm.nih.gov/articles/PMC10332999/#:~:text=Therefore%2C%20this%20study%20included%20heel,in%20a%20%E2%80%9Cfloating%E2%80%9D%20position.&text=This%20means%20keeping%20the%20heel,risk%20assessment%20in%20the%20future, "A pressure ulcer is a localized injury caused by continuous pressure on the skin and/or subcutaneous soft tissues, usually located at a bony prominence, or involving a medical device or other instrument. Pressure redistribution is important in pressure ulcer prevention and control strategies."The ideal way to prevent heel pressure ulcers is to ensure that the heel does not touch the bed to avoid all pressure, that is, to keep the heel in a 'floating' position. For patients with established pressure ulcers and those who are bedridden, heel support devices are recommended, but there are many different types, such as heel suspension boots."II. Facility policy and procedure The Pressure Ulcer policy and procedure, reviewed on 3/14/24, was received from the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part "The facility will provide the necessary requirements to ensure that a resident receives the treatment and care in accordance with professional standards of practice."Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin."The physician will assist with identifying factors contributing to or predisposing residents to skin breakdown."III. Resident #174A. Resident statusResident #174, age greater than 65, was admitted on 11/13/24. According to the November 2024 computerized physician orders (CPO), diagnoses included cerebral hemorrhage (brain bleed) affecting the right side, dysphagia (difficulty swallowing), aphasia (difficulty speaking), hypertension (high blood pressure) and pre-diabetes (abnormal glucose). The 11/20/24 minimum data set (MDS) assessment revealed the resident had short and long term memory issues. She required maximal assistance from staff for transfers, toileting, personal hygiene and dressing. The resident required minimal staff assistance with bed mobility and eating. B. ObservationsOn 11/18/24 at 10:50 a.m. Resident #174 was sleeping in bed. A right foot heel protection boot was hanging off the bed and not on the resident's foot in order to protect the heel. Resident #174's right heel was resting directly on the mattress. On 11/20/24 at 10:42 a.m. Resident #174 was in her wheelchair visiting with her family. She was not wearing her heel protection boots while in the wheelchair. Resident #174's feet were resting directly on the foot pedals of the wheelchair. On 11/20/24 at 11:34 a.m. Resident #174 was transferred back into bed. Her heel protection boots were not put on when she was transferred back into bed. On 11/20/24 at 11:48 Resident #174's was laying in bed with her feet resting directly on the mattress. The resident's heel protection boots were lying on the desk in the room. On 11/20/24 at 3:02 p.m. Resident #174 was laying in bed with three visitors in her room. Resident #174 did not have her heel protection boots on and the boots were still lying on the desk in the room. On 11/20/24 at 3:26 p.m. Resident #174 was sleeping in her bed with her feet resting directly on the bed. The resident's heel protection boots were lying on the desk in her room. On 11/20/24 at 4:04 p.m. registered nurse (RN) #1 entered Resident #174's room and observed that the resident's heel protection boots were not on the resident's feet but were instead lying on the desk approximately five feet from the resident. RN #1 completed a skin check of Resident #174's bilateral feet and applied the heel protection boots to both feet. RN #1 said one of the boots was broken because it was missing a strap which would help ensure the boot remained on the resident's foot. On 11/21/24 at 10:22 a.m. Resident #174 was laying in bed. The resident's heel protection boots were on her bed but were not on the resident's feet. Resident #174's feet were resting directly on the mattress. C. Resident family member interviewResident #174's family member was interviewed on 11/19/24 at 10:08 a.m. The family member said Resident #174 could not move her right hand or her right leg due to her medical condition. The family member said the resident had been wearing heel protection boots to both feet since her hospital stay but the family member was not sure why the resident needed them. The family member said no one in the facility had informed the family when the resident should or should not be wearing the heel protection boots. D. Record reviewThe 11/13/24 admission Braden Scale assessment (a tool used to calculate the risk of pressure injuries) revealed Resident #174 was at high risk for skin breakdown. The resident's high risk factors contributing to skin breakdown included limited sensory response, bedfast (confined to bed), completely immobile and required maximum assistance in moving. Review of Resident #174's November 2024 CPO revealed the following physician's order:Turn and reposition throughout shift, as tolerated. Offload bilateral heels while in bed, as tolerated. Foam boots to be worn at all times as tolerated. May remove during ambulation, ordered 11/14/24. The 11/13/24 comprehensive care plan revealed Resident #174 had potential for skin breakdown related to pressure points, immobility and incontinence. Resident #174 was admitted with redness under bilateral breasts and bruises on her abdomen from medication injections. Her heels and coccyx were intact. Resident #174 had heel protection boots on bilateral feet. The goal was for Resident #174's skin to remain intact. Interventions included conducting a Braden Scale assessment every week per protocol, encouraging the resident to turn and reposition throughout the shift, offloading bilateral heels while in bed every shift for skin integrity, providing pressure reduction devices as needed for mattress and wheelchair, prophylactic skin treatments as ordered and skin assessments as needed. IV. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 11/20/24 at 3:15 p.m. CNA #1 said, on admission, a resident's care plan would document any special care the resident may need so staff was aware of their needs. CNA #1 said if a resident required heel protection boots, the therapy department would assess the resident and order the correct size or style of heel protection boots needed. CNA #1 said Resident #174 did not wear any heel protection boots and her heels could be floated off the bed with pillows. -However, Resident #174 had a physician's order for heel protection boots to be worn on her bilateral feet at all times, except when she was ambulating (see record review above). CNA #1 said Resident #174 required assistance with transfers and bed mobility because she was weak on the right side of her body due to her medical condition. RN #1 was interviewed on 11/20/24 at 4:04 p.m. RN #1 said the nursing staff was to conduct an assessment on residents to determine their risk of skin breakdown and interventions would be implemented based on the outcome of the assessment. RN #1 said pressure areas were considered to be any bony areas that had direct contact with a surface, such as a mattress. RN #1 said Resident #174 had a physician's order for heel protection boots to her bilateral feet. RN #1 said Resident #174 had right-sided weakness and limited mobility to her right side, which increased her risk of skin breakdown. RN #1 said heel protection boots were important to prevent skin breakdown for Resident #174. RN #1 said Resident #174 should have been wearing her heel protection boots per the physician's order. The director of nursing (DON) was interviewed on 11/21/24 at 5:37 p.m. The DON said heel protection boots were implemented to prevent skin breakdown on a resident who was at an increased risk of skin breakdown. The DON said the admitting nurse was to complete a Braden Scale assessment to determine the risk a resident had for the development of pressure injuries. The DON said it was up to the nurses to check to ensure that Resident #174's heel protection boots were on every shift if there was a physician's order for them. The DON said if a resident had a physician's order for heel protection boots, it was important for the intervention to be used to help prevent skin breakdown. The DON said the nurses would be educated on the importance of ensuring heel protection boots were in place when ordered to help prevent skin breakdown.

Based on observations, record review and interviews, the facility failed to ensure one (#382) of one resident reviewed for pain out of 60 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to ensure Resident #382, who experienced an acute episode of pain, was provided pain relief and had an effective pain management program to address her continuous pain. Findings include:I. Facility policy and procedureThe Analgesia policy and procedure, revised August 2022, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It read in pertinent part, "Pain management procedure: based on the assessment, the facility, in collaboration with the attending physician, or medical director, and the resident initiated interventions to prevent or manage the resident's pain, beginning at admission. These interventions may be integrated into components of the comprehensive care plan, but at minimum will be evaluated at admission and every shift thereafter. Once a patient expresses the perception of pain or makes a request for pain medication, the patient will be provided with a dose of analgesic pain medication or non-pharmacological intervention will be initiated."The facility will address/treat the underlying causes of the pain, to the extent possible. "Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both."It is the responsibility of the staff member to address the complaint of pain and make sure some intervention (pharmacological or otherwise) is initiated."In the event the resident does not have an order for pain medications, contact the physician immediately to obtain an order for analgesia. In the interim, attempt non-pharmacological modalities for pain control such as repositioning, touch therapy, biofeedback, distraction (television, conversation)."II. Resident #382 A. Resident statusResident #382, age greater than 65, was admitted on 11/3/24. According to the November 2024 computerized physician orders (CPO), the diagnoses included left femur fracture status post closed reduction, muscle weakness, history of falls, heart disease and peripheral vascular disease (chronic condition that occurred when blood vessels outside of the brain and heart narrow or become blocked). The 11/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required moderate to maximum assistance with all activities of daily living (ADLs). The MDS assessment indicated the resident received scheduled pain medications and as needed opioids. The resident did not receive as needed pain medications or non-pharmacological interventions for pain on three days of the five days during the assessment period. Of these three days the resident reported a pain level of 5 or greater on a pain scale of 1 to 10, with an identified acceptable pain level of 5 out of 10 on the pain scale. B. Resident interview and observationsResident #382 was interviewed on 11/19/24 at 10:37 a.m. Resident #382 was sitting up in her bed, grimacing and appeared in distress. Resident #382 said she was in a lot of pain and needed pain medication. She said she had told a facility staff member she was in extreme pain, but had been waiting for two hours. She said no one ever returned to address her pain. Licensed practical nurse (LPN) #3 was immediately informed of the resident's verbal and non-verbal expressions of pain. LPN #3 entered Resident #382's room, however, did not administer the resident any pain medication (see record review and interviews below). Resident #382 was interviewed on 11/19/24 at 1:20 p.m. Resident #382 was sitting up in her bed, eating fast food and visiting with a familymember. Resident #382 said her pain was okay for now but would like her pain medications to be given on time so her pain does not get out of control. She said the nurse took her catheter out the night before, it was very painful, and was not given pain medication prior to the procedure. Resident #382 was interviewed on 11/21/24 at 6:34 p.m. with the director of nursing (DON) and infection preventionist (IP) present. Resident #382 said she was very hesitant to talk as she did not want to get LPN #3 in trouble. The resident was reassured by all that this was not the case, but wanted to ensure that her needs were addressed. Resident #382 said she was always in pain and that some position changes made her feel better. She said her pain was not being managed effectively. She said she was only being given acetaminophen (Tylenol) prior to physical and occupational therapy. She said the Tylenol was not enough to address her pain and felt it did not work. She said it was difficult to participate in physical and occupational therapy to the best of her ability because she was in pain. She said her pain was throughout her right leg. She said the pain was throbbing all the time. Resident #382 said the tramadol was sometimes effective but not all the time. The DON said they would plan to meet with the physician in the morning to make adjustments to address her pain. C. Record reviewThe opioid use care plan, initiated on 11/4/24, documented Resident #382 was on opioid pain medication therapy. The goal was to be free of any discomfort or adverse side effects from the pain medication. The interventions included administering analgesic medication as ordered by the physician and observing for side effects and effectiveness. The pain management care plan, initiated on 11/4/24, documented Resident #382 expressed pain related to pressure points, decreased mobility related to a fall, a left intertrochanteric hip fracture status post closed reduction and gout. It indicated the resident's pain was alleviated/relieved by rest, repositioning and medication. The interventions included anticipating the resident's need for pain relief by monitoring her pain level at every shift and as needed, notifying the physician of any changes in condition as needed, administering pain medication per physician orders and note the effectiveness, administering Biofreeze Gel 4% during therapy services observing, giving pain medications as needed for breakthrough pain per physician orders and note the effectiveness, acknowledging the resident's presence of pain and discomfort, listening to the patient's concerns as needed, and implementing non-pharmacological interventions when able such as: positioning/support, assistive devices/braces, exercise/stretching, ice packs/moist hot pack application, relaxation. etc. The November 2024 (11/4/24 to 11/21/24) medication administration record (MAR) revealed Resident #382 reported her pain greater than her acceptable level of pain rating of a 5 out of 10 on the pain scale, a total of 10 times since her admission on 11/3/24. A level 9 out of 10 pain on the pain scale was the highest pain level reported. Record review of the November 2024 (11/4/24 to 11/20/24) treatment administration record (TAR) and medication administration MAR confirmed that on 11/19/24, Resident #382 expressed pain and requested pain medication, however the facility failed to administer a dose of analgesic pain medication from the hours of 10:37 a.m. when it was verbally requested by Resident #382 until the scheduled acetaminophen dose was administered at 2:00 p.m.-A review of the narcotic log on 11/21/24 at 10:02 a.m. and MAR with registered nurse (RN) #3 confirmed the findings. The 11/7/24 pain assessment revealed that Resident #382 responded "almost constantly" when asked the question: "Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain". Resident # 382 also rated her highest pain level at a 9 out of 10 over the previous five days. The 11/14/24 pain assessment revealed no change in response to the same question and rated her pain level an 8 out of 10 over the past five days. The November 2024 CPOs documented the following:-Oxycodone 5 milligrams (mg) four times per day as needed for pain, ordered on 11/12/24 and discontinued on 11/17/24. -Tramadol 50 mg three times per day as needed for pain, ordered on 11/3/24 and discontinued on 11/4/24.-Tramadol 50 mg three times per day (every 8 hours) as needed for pain, ordered on 11/5/24. -Lidocaine Patch 4% (percent) apply two patches to the affected area topically in the morning for discomfort/pain, remove at hour of sleep, ordered on 11/4/24. -Oxycodone 5 mg every four hours as needed for pain level 1-10 for 14 days, order to be held for dates of 11/4/24 to 11/12/24 and was discontinued on 11/15/24. -Voltaren External Gel 1% apply topically in the morning for discomfort/pain, ordered on 11/3/24. -Acetaminophen 1000 mg given three times per day for pain, not to exceed 3 grams daily, ordered on 11/3/24. The 11/19/24 daily skilled nursing progress note identified Resident #382 had a new area of pain to the left great toe and right ankle, with increased edema, and rated her pain level as a 4 out of 10 on the pain scale with her maximum acceptable rating of 5. LPN #3 documented she administered scheduled Tylenol and Gabapentin, as the resident had reported this was effective for pain. It indicated that Resident #382 declined repositioning or elevating her bilateral lower extremities as a form of non pharmacological intervention, and tubi grips were applied to bilateral lower extremities. -However, Gabapentin was not a physician's order documented in the CPO or MAR and according to a review of the narcotic log with RN #3 confirmed Gabapentin was not administered to Resident #382.-The progress note failed to identify any person centered non-pharmacological or medication interventions that were attempted or how Resident #382's pain was addressed when LPN #3 was informed the resident was in acute pain on 11/19/24 at 10:37 a.m. III. Staff interviewsRN #3 was interviewed on 11/21/24 at 10:02 a.m. RN #3 said acetaminophen was administered as scheduled on 11/19/24 at 8:00 a.m., 2:00 p.m. and 10:00 p.m., and Tramadol was administered once at 9:00 a.m. RN #3 said that no other pain medications were administered to Resident #382 on 11/19/24 after 10:37 a.m., when LPN #3 was informed the resident was in acute pain. RN #3 confirmed the resident did not have an order to receive Gabapentin for pain. LPN #3 and the DON were interviewed together on 11/21/24 at 2:30 p.m. LPN #3 said the Gabapentin that was documented on the daily nursing note on 11/19/24 was an error. She said she did not administer Gabapentin to Resident #382. LPN #3 said she administered acetaminophen as ordered at 8:00 a.m. and 2:00 p.m. LPN #3 said she recalled the events from 11/19/24. She said she used non-pharmacological interventions with Resident #382 by repositioning, asked the resident if she needed to go to the restroom and that she folded and placed tubi grips in the drawer while she was in the resident's room. She said she remembered exactly what she did because the resident was eating fast food brought in by the resident's daughter.-However, according to observations made during the survey process, the resident's family member did not bring Resident #382 fast food until later that afternoon, three hours after LPN #3 was informed of the resident's acute pain.-Additionally, record review showed LPN #3 had documented in the daily nursing note on 11/19/24 at 4:00 p.m. that the resident had a 4 out of 10 pain level, the resident declined repositioning or elevating to her bilateral lower extremities and that she had applied the tubi grips to the resident's bilateral lower extremities. The DON was interviewed on 11/21/24 at 3:56 p.m. The DON said if a resident's pain regimen was not effective, the facility should review the medications and call the physician. She said it was the facility's goal to always keep residents comfortable and free of pain. She said acute pain should be addressed immediately either by providing non-pharamacological interventions or medication to alleviate the resident's pain. She said any acute pain should be documented in the resident's medical record at the time the resident expressed pain and interventions provided. She said all documentation should be accurate and should pertain to the resident.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure foods were appealing and palatable in temperature and seasoning. Findings include:I. Facility policy and procedureThe Food Palatability policy and procedure, revised 8/22/22, was provided by the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, "Food and drink each resident receives and the facility provides foods prepared by methods that conserve nutritive value, flavor, and appearance. In addition, the food is palatable, attractive, and served at a safe and appetizing temperature."The dietary staff prepares foods according to the menu and recipes available in the dietary department."Foods are sampled daily by designated staff to ensure the taste and quality of the foods remain at a high level."Use of seasonings and proper cooking methods are followed to ensure the food is appealing and palatable."II. Resident interviewsResident #221 was interviewed on 11/18/24 at 9:30 a.m. Resident #221 said some of the food at the facility tasted okay. Resident #221 said she had received a thick slice of turkey for dinner that she could not even cut into, much less chew. Resident #224 was interviewed on 11/18/24 at 10:05 a.m. Resident #224 said the food at the facility was served cold and that he had yet to be served a hot meal. Resident #226 was interviewed on 11/18/24 at 10:13 a.m. Resident #226 said the food at the facility was not good. Resident #226 said the food at the facility was tasteless and that they served the same things over and over again. Resident #234 was interviewed on 11/18/24 at 10:19 a.m. Resident #234 said breakfast at the facility was always served cold. Resident #225 was interviewed on 11/18/24 at 11:14 a.m. Resident #225 said the food at the facility was bland. Resident #231 was interviewed on 11/18/24 at 11:21 a.m. Resident #231 said the food could be a bit warmer when served. Resident #53 was interviewed on 11/18/24 at 11:33 a.m. Resident #53 said the food served by the facility was not great. Resident #53 said the meat was very overcooked and the mixed vegetables seemed like they were microwaved too long. Resident #233 was interviewed on 11/18/24 at 1:42 p.m. Resident #233 said the food at the facility could be better and that it was served cold. Resident #232 was interviewed on 11/18/24 at 1:51 p.m. Resident #232 said the food at the facility was for the most part always cold and barely edible. Resident #232 said by the time the meals were served they were already cold. Resident #190 was interviewed on 11/18/24 at 2:04 p.m. Resident #190 said the food at the facility was cold and "yucky." Resident #190 said it was especially cold if your room was at the last place on the delivery list. Resident #322 was interviewed on 11/18/24 at 2:20 p.m. Resident #322 said the food was awful when she first got to the facility. Resident #322 said her husband had to heat up her lunch in the microwave sometimes because the food arrived cold. Resident #322 said her coffee was rarely served hot and that the food was tepid in temperature. Resident #52 was interviewed on 11/18/24 at 3:25 p.m. Resident #52 said most of the meals at the facility were bland. Resident #52 said the meals at the facility were unseasoned. Resident #324 was interviewed on 11/18/24 at 3:44 p.m. Resident #324 said the food at the facility was served at room temperature. Resident #378 was interviewed on 11/18/24 at 3:48 p.m. Resident #378 said the food at the facility did not look good and that they had to have the staff reheat it a few times because it was served cold. Resident #126 was interviewed on 11/18/24 at 4:08 p.m. Resident #126 said he was not impressed with the food at the facility and that it did not taste "right". Resident #388 was interviewed on 11/19/24 at 9:18 a.m. Resident #388 said their dinner a few days prior was a pork chop that was very thin and so overcooked and tough they could not eat it. Resident #388 said the pork chop hurt to chew. Resident #388 said they were supposed to be eating a lot of protein, and when they received protein that was inedible they were not able to have enough intake to help their wounds heal or help with their constipation issues. Resident #382 was interviewed on 11/19/24 at 10:27 a.m. Resident #125 said the quality of the meals at the facility had declined since his last stay. Resident #125 said the meals he received were barely warm. Resident #33 was interviewed on 11/19/24 at 10:30 a.m. Resident #33 said the food at the facility was not great and was served at room temperature. Resident #379 and their family member were interviewed on 11/19/24 at 1:42 p.m. Resident #379 ' s family member said the meals Resident #379 was served looked terrible and turned the resident ' s stomach. Resident #379 said she ordered over-easy eggs for breakfast but received overcooked and cold eggs. Resident #221 was interviewed a second time on 11/20/24. Resident #221 said her breakfast that morning was okay. Resident #221 said her eggs were so rubbery she could barely eat them. Resident #221 said eating the eggs was comparable to eating a rubber bouncy ball. III. Resident council minutesResident council minutes, dated 11/11/24 at 2:00 p.m., revealed an unidentified resident reported the food at the facility lacked seasoning and that the portions of the desserts were too small.-However, there was no documentation that indicated these concerns were addressed by the facility staff. Resident council minutes, dated 10/7/24 at 2:00 p.m,. revealed an unidentified resident said the texture of the food at the facility was not good and that the food lacked flavor and seasoning. -However, there was no documentation that indicated these concerns were addressed by the facility staff. Resident council minutes, dated 9/9/24 at 2:00 p.m., revealed an unidentified resident said the food was sometimes served cold.-However, there was no documentation that indicated these concerns were addressed by the facility staff. Resident council minutes, dated 7/8/24 at 2:00 p.m., revealed an unidentified resident said the meal temperatures were sometimes cold. -Notes in the margins of the 7/8/24 resident council meetings revealed the facility staff recommended that the residents could have their food reheated. IV. Test tray observationsA test tray for a regular texture diet was evaluated by six surveyors immediately after the last round of room trays were delivered at 12:37 p.m. The test tray consisting of beef fajitas served on a corn tortilla, fajita vegetables, refried beans, and cilantro lime rice:-The rice was overcooked. The rice had no flavor or seasoning and was gluey to chew.-The refried beans were dry in texture. -The beef was dry. The beef l had no seasoning or flavor.-The fajita vegetables were bland.-The tortilla was hard and gluey in texture. V. Staff interviewsThe executive chef (EC) was interviewed on 11/20/24 at 11:45 a.m. The EC said she was looking into getting different plate warmers, as the food was served hot on her line but was cold by the time it was served to the residents. The EC said some of the residents had complained about food temperature, especially with breakfast. The EC said she individually delivered meals for residents that complained about food temperature so the food had a chance of being served hot. The EC was interviewed a second time on 11/20/24 at 3:53 p.m. The EC said she only ever received complaints about the temperatures of the eggs served for breakfast. The EC said some of the residents had complained about the palatability of the food served at the facility because they wanted salt in their food and that they could not use salt in the food at the facility. The EC said the dietary staff did not really follow specific recipes but would look up recipes on their phones or find a recipe if their food provider had one. The EC said the plate warmers used at the facility were able to hold temperatures but that the EC was looking for better solutions. The EC said there were a few complaints about breakfast temperatures but said it was for no more than five residents. The EC said the food delivery carts were new and closed so there was less air-flow that could cool the food down. Certified nurse aide (CNA) #2 was interviewed on 11/21/24 at 12:23 p.m. CNA #2 said the dietary aides and a few other facility staff members usually came to help him pass out meal trays. CNA #2 said it only took a few seconds to get all of the meal trays on his hallway passed out when other staff members came to help, and even when it was only him passing out trays it still only took a few minutes. CNA #2 said some of the residents thought the food was very bland and would ask him to get them seasoning packets.

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 and two of two nourishment refrigerators. Specifically, the facility failed to:-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen; and, -Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators. 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 11/25/24 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 Use of Gloves/Hairnets/Covering of Food policy and procedure, revised 10/12/22, was received from the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It revealed in pertinent part, "Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited."Gloved hands are considered a food contact surface that can get contaminated or soiled. 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."C. ObservationsDuring a continuous observation of the lunch meal service on 11/20/24, beginning at 10:30 a.m. and ending at 12:37 p.m. the following was observed:At 11:07 a.m. cook (CK) #1 retrieved a plastic bag containing heads of lettuce. With his bare hands, CK #1 reached into the plastic bag and grabbed the lettuce and put it onto the cutting board. CK #1 washed his hands, then using his bare hands held the lettuce as he cut it. CK #1 then used his bare hands to move the lettuce to a steam table bin.-The lettuce was placed into a steam table bin on the line and was added to the carnitas without any further washing or modification. At 11:09 a.m. dietary aide (DA) #1 was wearing a pair of gloves. With her gloved hands, DA #1 handled a plastic bag of bread and the buttons on a toaster. Using the same gloved hands, DA #1 pulled two pieces of bread out of the toaster. DA #1 grabbed the handle and opened the lid for the cold storage preparation area and retrieved several condiment packets. DA #1 squeezed the contents out of the condiment packets and used the same gloved hands to stabilize the pieces of toast while applying the condiments. With the same gloved hands, DA #1 retrieved the plastic bread bag and took out two more pieces of bread and put them in the toaster. With the same gloved hands DA #1 grabbed pieces of lettuce and put them on the toasted bread with the condiments applied. DA #1 repeated this process with several slices of tomato while wearing the same gloves. DA #1 then pressed buttons on the toaster with her gloved hand. DA #1 then used her gloved hands to sort through a plate of bacon, select several pieces, then put them on top of the lettuce and tomato. With the same gloved hands, DA #1 grabbed the pieces of bread out of the toaster and put them on top of the sandwiches. At 11:22 a.m. CK #1 was wearing a pair of gloves. Using his gloved hands, CK #1 retrieved a plastic bag of tortillas, opened it, and placed several tortillas onto the grill. Using the same gloved hand, CK #1 held the stack of tortillas as he took them off the grill and placed them into a steam table bin. At 11:34 a.m. CK #2 used his bare hand to grab a handful of lettuce and place it onto a plate containing pork carnitas. The executive chef (EC) told CK #2 to use tongs when performing that task.-However, the plate was still served. At 11:36 a.m. CK #1 used tongs to place two tortillas onto a plate. CK #1 then used his bare hands to separate the tortillas, then used his bare hand to stabilize the tortillas as he scooped beef into them. At 11:40 a.m. CK #1 was handling tongs and serving utensils with his bare hands. Using his same bare hands, CK #1 reached into a container of parsley, grabbed a pinch of the herb, and sprinkled it onto a plate containing mashed potatoes. CK #1 then used his bare hand to stabilize two tortillas on the same plate as he ladled pork into them.-CK #1 used his bare hands to sprinkle herbs onto several plates prepared during the lunch service. At 11:51 a.m. CK #2 donned (put on) a pair of gloves. Using his gloved hands, CK #2 used tongs and serving utensils. CK #2 used the same gloved hands to grab lettuce and shredded cheese and put them onto a plate containing carnitas. CK #2 then used the same gloved hands to adjust two halves of a grilled cheese sandwich on a plate prior to setting it into the window to be served. At 12:01 p.m. a pea sized amount of mashed potatoes landed on the bare forearm of CK #1. Using his bare hands, CK #1 grabbed the piece of mashed potatoes and flung it back into the steam table bin of mashed potatoes. At 12:08 p.m. CK #2 donned a pair of gloves and retrieved a plastic bag of bread. Using his gloved hands, CK #2 opened the bag of bread, grabbed two pieces of bread and put them onto a cutting board. CK #2 grabbed a knife that was previously used to cut fish, retrieved a towel from a sanitizer bucket, and wiped the knife off. Using the same gloved hands, CK #2 opened several packets of peanut butter and held the pieces of bread to stabilize them as he spread peanut butter onto the bread with the knife. Using the same gloved hands, CK #2 pressed the two pieces of bread together. At 12:11 p.m. CK #1 used his bare hands to handle serving utensils. Using the same bare hands, CK #1 reached into the container of shredded cheese and sprinkled it onto the pork carnitas. At 12:16 p.m. the EC was wearing a pair of gloves and handling serving utensils and the lid to a pot. Using the same gloves, the EC grabbed two pieces of toast out of the toaster and set them onto a plate. At 12:18 p.m. CK #2 was wearing gloves and handling serving utensils and tongs. Using the same gloved hands, CK #2 grabbed a handful of shredded lettuce and placed it onto pork carnitas. CK #2 used the same gloved hands to repeat this process with shredded cheese. At 12:19 p.m. CK #1 was handling serving utensils and tongs with his bare hands. Using his bare hands, CK #1 grabbed a stack of five plates and laid them out along the food service line. CK #1 then placed the entirety of his bare hand onto the top of one of the five plates prior to putting food onto the plate and serving it. At 12:21 p.m. CK #2 took the same knife that was used to cut cooked fish and spread peanut butter onto bread and wiped the knife with the same rag that was used to wipe the knife prior. CK #2 then used the knife to cut a veggie burger into bite-sized pieces.-The towel had been left on the counter between uses and had not been replaced in the sanitizer bin. D. Staff interviewsThe EC was interviewed on 11/20/24 at 11:45 a.m. The EC said the dietary staff were not allowed to use gloves during food service. The EC said she told her dietary staff not to use gloves. The EC said she told CK #2 to wear gloves if that was what felt more comfortable for him but that CK #2 needed to change his gloves whenever he left the food service line. The EC was interviewed a second time on 11/20/24 at 3:53 p.m. The EC said ready to eat foods should be handled with clean glovesand only after hands had been washed. The EC said gloves should only be used for one task before being changed. The EC said whenever the dietary staff left the line they needed to remove their old gloves and perform hand hygiene before donning new gloves. II. Failed to store food items correctly in the refrigeratorsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 11/25/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (F)) or less for a maximum of seven days. The day of preparation shall be counted as day one."The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety."B. Facility policy and procedureThe Kitchen Sanitation policy and procedure, revised 9/4/23, was received from the NHA on 11/22/24 at 8:38 a.m. It revealed in pertinent part, "The staff shall maintain the sanitation of the kitchen through compliance with an established cleaning schedule. "Cleaning and sanitation tasks for the kitchen will be defined. Frequency of cleaning for each task will be defined."C. ObservationsOn 11/18/24 at 8:50 a.m. an initial tour of the kitchen revealed the following in the refrigerator by the food service line:-A pitcher of tea, unlabeled and undated;-A pitcher of fruit punch, dated 10/22/24;-A cup of juice, dated 11/3/24; and,-A boat shaped reusable container with meat in it, unlabeled and undated. At 4:48 p.m. observations of the nourishment refrigerator on the 200 unit revealed the following:-An open carton of milk with a name written on it, with an expiration date of 11/12/24;-A carton of yogurt, with an expiration date of 10/30/24;-A container with an apple-based dessert with a room number written on it but no date; and,-A container of noodles with a room number and resident name but no date. At 4:52 p.m. observations of the nourishment refrigerator on the 300 unit revealed the following:-A milk carton, with an expiration date of 11/4/24;-A milk carton, with an expiration date of 10/28/24;-A protein shake, with an expiration date of 11/17/24;-A protein shake, with an expiration date of 2/24/24;-A protein shake, with expiration date of 11/17/24;-Two yogurt containers, with an expiration date of 10/18/24;-A bowl of an unidentified food substance, dated 10/22/24;-A container of food from a fast food restaurant , unlabeled and undated;-A cup of juice, unlabeled and undated;-A cup of milk, unlabeled and undated;-A container of ranch, dated 10/21/24;-A container of red liquid, dated 10/22/24;-A bottle of lemon juice, with an expiration date of 10/2/24; and,-A packet of sour cream, with an expiration date of 10/16/24.-The freezer had a foul odor. On 11/19/24 at 10:25 a.m., the nourishment refrigerator on the 300 unit was reviewed again. The same contents listed above remained in the refrigerator. During the observation period, an unidentified resident and unidentified staff member were walking by. The resident said it smelled like something died in the freezer. The staff member then replied to the resident and said they needed to clean it out more. D. Staff interviewThe EC was interviewed on 11/18/24 at 9:05 a.m. The EC said the pitcher of tea was hers from that morning. The EC said the boat shaped container was the staff's personal food from yesterday. The EC said the staff brought in food every Sunday to share among the staff. The EC said she told her staff to make sure they took their personal food containers home with them but they had forgotten it. The EC said the pitchers of juice were good for seven days once prepared, sothe 10/22/24 and 11/3/24 containers needed to be thrown out. The EC was interviewed a second time on 11/20/24 at 3:53 p.m. The EC said the nourishment refrigerators were cleaned out twice a week on both units by the dietary staff. The EC said the process for cleaning out the refrigerators was to throw away any food without a name or date on it. The EC said the third floor refrigerator was last cleaned out the Tuesday (11/12/24) prior to observations taking place, and the second floor refrigerator was cleaned out that Wednesday (11/13/24) prior to observations taking place. The EC said food items prepared by the facility needed to be thrown out three days after the date written on them.

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 staff wore the appropriate personal protective equipment (PPE) in COVID-19 positive resident rooms;-Ensure proper infection control practices were followed for wound care;-Identify an effective process to ensure staff were aware of which residents required enhanced barrier precautions (EBP); and,-Ensure staff wore the appropriate PPE for residents on EBP.Findings include:I. Failure to ensure staff wore the appropriate personal protective equipment (PPE) in COVID-19 positive resident roomsA. Professional referenceAccording to the Center for Disease Prevention and Control (CDC) Infection control Guidance: SARS-CoV-2, (9/23/22) retrieved on 11/26/24 from https://www.cdc.gov/covid/hcp/infection-control/,"Healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face)."Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy."B. ObservationsOn 11/18/24 at 8:54 a.m. an unidentified housekeeper entered Resident #32's room. Resident #32 was on isolation precautions for COVID-19. The unidentified housekeeper was wearing a surgical mask. -The unidentified housekeeper did not put on a N95 mask, gown, gloves, or protective eyewear prior to entering Resident #32's room. On 11/20/24 at 2:52 p.m. a bin containing PPE was sitting outside the doorway to Resident #32's room. There were three signs on the resident's door. The first sign identified the room as requiring droplet precautions and instructed everyone entering the room to sanitize their hands and wear masks and face shields. The second sign said EBP and instructed everyone to sanitize their hands when entering the room and providers and staff must also wear a gown, gloves, mask and face shield when providing care. The third sign was a stop sign which instructed people to check with the nurse before entering the room. On 11/20/24 at 4:50 p.m. an unidentified certified nurse aide (CNA) put on a N95 mask, gown and gloves and delivered Resident #32's dinner tray. -The unidentified CNA did not perform hand hygiene or put on protective eyewear prior to entering the resident's room. On 11/20/24 at 5:57 p.m. a visitor was walking down the hallway and stopped at Resident #32's room. The visitor turned and spoke with registered nurse (RN) #4. RN #4 informed the visitor that Resident #32 was still on isolation precautions until the next day (11/21/24). The visitor proceeded to enter Resident #32's room without applying PPE.-RN #4 failed to educate the visitor on the appropriate PPE and precautions that should be taken when entering Resident #32's COVID-19 positive room. C. Staff interviewsHousekeeper (HSK) #1 was interviewed on 11/19/24 at 11:18 a.m.. HSK #1 said housekeepers were to wear PPE, including gloves, gown, mask when cleaning a COVID-19 positive room or any room with isolation precautions. HSK #1 said it was important to wear PPE to protect the residents and to protect herself/staff. The infection preventionist (IP) was interviewed on 11/21/24 at 3:39 p.m.. The IP said COVID-19 was considered to be droplet transmission. The IP said droplet transmission meant the virus had to be inhaled to be transmitted to someone else and it could not be picked up off a surface. The IP said housekeepers were to wear PPE when cleaning rooms when residents were on droplet or contact isolation precautions in order to prevent the spread of an infection. II. Failure to ensure proper infection control procedures were following during wound careA. ObservationsOn 11/21/24 at 8:40 a.m. the CWN and the DON were observed providing Resident #53's wound care and dressing change. The CWN cleared off the resident's bedside table, wiped it down with a disinfectant wipe, applied a barrier pad and placed her bag of resident wound care supplies on top. The DON placed a clean chucks pad (disposable absorbent pad) under the resident's abdominal fold but below the wounds. Three dressings were observed on the resident, one on the right, one in the middle and one on the left. All of the dressings had the date 11/20/24 with a nurse's signature. Both the DON and the CWN completed hand hygiene and put on clean gloves. The CWN removed all three dressings. The right and left wounds had moderate serosanguineous drainage (a thin watery fluid), the middle wound had a small amount of bloody drainage. The wound on the right was the largest of the three wounds. It was noted to have a ring of redness around it and the center had 20% eschar and 10% yellow slough (dead tissue). The remaining tissue was red and it had no odors. The middle wound was the size of a nickel and had red tissue throughout and did not have an odor. The wound on the left was noted to be about the size of a quarter and had 80% slough and 20% red tissue and did not have an odor. The CWN changed her gloves to set up her supplies for the wound care. She set up a stack of gauze, a spray can of saline solution and a lidocaine (used for pain control) spray. She started with the left wound by taking one gauze, sprayed it with saline and wiped the wound. She folded over the gauze and wiped the wound bed again three times with the same piece of gauze. The wound was observed with bloody drainage. The CWN threw the gauze away, and with her dirty glove, touched the saline bottle and then re-sprayed all three wounds with lidocaine per the resident's request due to pain. -The CWN did not change gauze pads after each wipe of the wound.-The CWN did not change her gloves or perform hand hygiene after cleaning the left wound, which had bloody drainage, and before picking up the saline and lidocaine spray bottles. Using the same dirty gloves, the CWN took another piece of gauze, sprayed it with the saline solution and moved to the middle wound. She wiped the wound bed twice with the same piece of gauze. The CWN moved to the wound on the right and wiped the wound bed three times with the same piece of gauze. She collected a second piece of gauze, moistened it with saline and wiped eight times over the wound. She disposed of that piece of gauze, took another piece of gauze, moistened it with saline solution and proceeded to wipe six more times over the wound bed. She disposed of the piece of gauze, grabbed another and dabbed the area three times due to bloody drainage. She threw away the gauze, changed her gloves and performed hand hygiene. The CWN used the same dirty gloves throughout the entire process.-The CWN did not change her gloves and perform hand hygiene after cleaning the left wound and before proceeding to clean the middle wound.-The CWN did not change gauze pads after each wipe of the wound.-The CWN did not change her gloves or perform hand hygiene after cleaning middle wound, which had bloody drainage, and before picking up the saline and lidocaine spray bottles. The CWN then conducted a wound culture to the right wound based on the wound physician's recommendation. She took only the culture tubing out of the sterilized package. She swabbed the right wound. She did not perform debridement of the wound prior to the wound culture. She inserted the sample into the test tube, closed it and used a resident label, placing it directly over the test tube so the sample could be identified. The CWN changed her gloves and performed hand hygiene. She started on the left wound, using gauze and saline to wipe the wound bed, applied skin prep to the peri-wound and cut calcium alginate (highly absorbent dressing) sheet to size and applied it. She applied medihoney (type of antimicrobial gel) and covered the wound with a border foam dressing. Using the same gloves, the CWN moved to the middle wound and used a saline-soaked gauze to wipe the wound four times. using the same gauze to apply the skin prep to the peri-wound. She cut another piece of calcium alginate and medihoney and applied both to the resident's wound and covered it with the foam dressing. Using the same gloves, the CWN moved to the right wound, using saline soaked gauze, she wiped the wound four times with noted serosanguinous drainage coming out of the wound as she applied skin prep. She measured the right wound which was 3.5 cm (centimeters) length by 9 cm width by 0.1 cm depth and said the wound was larger than last week. She took calcium alginate and medihoney and applied it to the wound and covered it with a foam dressing.-The CWN did not change her gloves or perform hand hygiene in between performing the treatment for each wound. All supplies were cleaned up, trash was removed, PPE was doffed and hand hygiene was performed by all parties prior to leaving the room. B. Staff interviewsThe CWN was interviewed on 11/21/24 at 9:11 a.m. The CWN said her cleaning technique with the gauze was to move from clean to dirty and then discard the gauze. She said she did not realize she had used the same gauze up to eight times to wipe the wound bed. She said the gauze should be changed in between each wipe to decrease the risk of infection. She said gloves should be changed in between each wound. She said she should have changed her gloves in between each wound site to decrease the risk of infection. NP #1 was interviewed on 11/21/24 at 12:21 p.m. NP #1 said the presence of slough in a wound could mean a wound had a potential infection. She said using the same gauze to wipe the wound multiple times could spread bacteria throughout the wound. She said not changing gloves in between cleaning each wound had the potential to spread a possible infection to the other wounds. The IP was interviewed on 11/21/24 at 3:39 p.m. The IP said each piece of gauze used to clean wounds should only be used for one wipe over the wound to prevent the spread of infection. The IP said the CWN should have changed her gloves between each wound site to prevent the spread of infection from one site to another. III. Failure to identify an effective process to ensure staff were aware of which residents required EBP and ensure staff wore appropriate PPE for residents on EBPA. Professional referenceThe Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 11/25/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, "Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities."Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization."Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions 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, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing."B. Facility policy and procedureThe Enhanced Barrier Precautions policy and procedure, dated 3/27/24, was received from the nursing home administrator (NHA) on 11/22/24 at 8:38 a.m. It read in pertinent part, "Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. Per the CDC, EBP are recommended (when contact precautions do not otherwise apply) during high-contact care activities with residents who are at higher risk of acquiring or spreading an MDRO. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. "EBP are indicated for residents with infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO."Residents with MDROs, wounds, or indwelling medical devices will be placed on proper precautions when at the facility. Residents will be put on EBP when contact precautions do not otherwise apply. EBP involves staff utilizing gown and gloves during specified high-contact activities with the resident. Residents are not restricted to their room and can participate in group activities. EBP are intended to be in place for the duration of a resident's stay in the facility or until a resolution of wound or discontinuation of the indwelling medical device that placed them at higher risk. "EBP are required for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO during high contact activities, including wounds that are chronic with drainage, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. "High contact care activities: EBP include use of gown and gloves during the high contact patient care activities, including dressing, bathing/showering, transferring, when working with patients in the therapy gym that need mobility assistance and/or transfers that require a longer duration, providing hygiene, changing linens, changing briefs or assisting toileting and with device care or use of a central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care."C. Resident #2251. ObservationsOn 11/19/24 at 9:57 a.m. RN #2 entered Resident #225's room. Resident #225 was receiving antibiotics via a peripherally inserted central catheter (PICC) line. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). RN #2 donned gloves after entering the room, flushed Resident #225's PICC line with normal saline, disconnected the PICC line, wiped the connection points on the PICC line and removed her gloves.-RN #2 did not don a protective gown prior to performing care of Resident #225's PICC line..-On 11/19/24 at 2:06 p.m. an EBP sign was observed on Resident #225's door and a bin containing PPE had been placed outside the resident's room. 2.. Resident interviewResident #225 was interviewed on 11/19/24 at 9:55 a.m. Resident #225 said the nurses at the facility wore gloves to connect and disconnect her PICC line. Resident #225 said the nurses at the facility did not wear gowns when they handled her PICC line. D. Resident #2311. ObservationsOn 11/19/24 at 10:08 a.m. RN #2 entered Resident #231's room. Resident #231 had a PICC line and a wound vacuum (a treatment device that uses suction to help wounds heal). -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). RN #2 performed hand hygiene and donned gloves after entering the room, flushed Resident #231's PICC line with normal saline, disconnected the PICC line, wiped the connection points on the PICC line and removed her gloves. RN #2 offered to hold Resident #231's wound vacuum as the resident readjusted in bed.-RN #2 did not don a protective gown prior to performing care of Resident #231's PICC line or while holding the wound vacuum.-On 11/19/24 at 2:06 p.m. an EBP sign was observed on Resident #231's door and a bin containing PPE had been placed outside the resident's room. E. Resident #401. Resident observation and interviewOn 11/20/24 at 8:52 a.m. Resident #40 said he had a port (a small, disk-shaped device that's surgically implanted under the skin to provide access to a vein for medical treatments and blood draws) on his chest and a fistula (a surgically created connection between an artery and a vein that allows for hemodialysis treatments) in his left arm. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). On 11/21/24 at 1:26 p.m. an unidentified nurse said Resident #40 should have a sign on his door and a bin containing PPE outside his door so staff was aware PPE was required when working with the resident. The nurse went to obtain the items. 2. Staff interviewLicensed practical nurse (LPN) #1 was interviewed on 11/21/24 at 1:17 p.m. LPN #1 said EBP was used for any residents that had any indwelling device in their body and were used when doing any care related to that indwelling device. LPN #1 said residents were identified for EBP on admission or if a new indwelling device was implemented. LPN #1 said since Resident #40 had a dialysis port and should be on EBP. LPN #1 said if Resident #40 should have EBP put in place immediately. F. Resident #2241. Resident observations and interviewOn 11/18/24 at 10:05 a.m. a PICC line was observed in Resident #224's arm. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews).-At 12:04 p.m. an unidentified member of the activities staff went into Resident #224's room without performing hand hygiene. At 2:42 p.m. Resident #224 said the nursing staff administered medications through his PICC line in the evenings. Resident #224 said he could not recall whether the nursing staff wore gowns while caring for his PICC line. On 11/19/24 at 8:41 a.m. an EBP sign was observed on Resident #224's door and a bin containing PPE had been placed outside the resident's room. At 10:05 a.m. two unidentified members of the therapy staff were preparing to enter Resident #224's room. The therapy staff members were overheard discussing whether or not they needed to don gowns before entering the room. The therapy staff members said that since Resident #224 did not have COVID-19, they only needed to wear gloves while working with the resident.-The therapy staff members proceeded to enter the resident's room without putting on gowns. G. Resident #2221. ObservationsOn 11/19/24 at 3:00 p.m. there were no signs on the Resident #222's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). Resident #222's electronic medical record (EMR) identified the resident had bilateral extremity wounds. On 11/21/24 at 1:11 p.m. LPN #2 posted an EBP sign on Resident #222's door and a bin containing PPE inside or outside of the resident's room. 2. Staff interviewsCNA #2 was interviewed on 11/21/24 at 9:50 a.m. CNA #2 said EBP were for residents with PICC lines or other indwelling devices. CNA #2 said the nursing staff needed to wear PPE for more high contact care, including a gown, gloves, and a mask. CNA #2 saidthe different signs on the residents' doors told the nursing staff what PPE they needed to wear for that specific resident.-However, EBP required a gown and gloves, but not a mask (see professional reference above). CNA #2 was interviewed again on 11/21/24 at 12:23 p.m. CNA #2 said he did not have to wear any gown, gloves, or other PPE when working with Resident #222 because the resident did not have any catheters or indwelling lines.-However, Resident #222 had bilateral lower extremity wounds which required the implementation of EBP (see professional reference above and facility follow up below). LPN #2 was interviewed on 11/21/24 at 12:47 p.m. LPN #2 said EBP were for residents with devices such as PICC lines, foley catheters and wound vacuums. LPN #2 said EBP was implemented so that when the nursing staff worked with the resident, it protected the nursing staff, the resident indicated and other residents from the spread of infection. LPN #2 said EBP meant staff needed to don a gown, gloves, and a mask. LPN #2 said EBP were identified when the resident arrived from the hospital when the nurses doing the admission identified the resident had an indwelling medical device. LPN #2 said EBP were only used for residents with wound vacuums and were not used for residents with more general open wounds. LPN #2 said staff did not need to use EBP for residents with open wounds.-However, EBP required a gown and gloves, but not a mask (see professional reference above).-Additionally, according to the CDC, EBP should be implemented for all residents with wounds or indwelling devices, regardless of their MDRO status (see professional reference above). LPN #2 there were were no signs or materials for EBP for Resident #222 because the resident did not have any indwelling lines or catheters, but she said the resident might be put on EBP by the wound nurse if he had some sort of infection in his wounds. LPN #2 said the nursing staff had not been using EBP during Resident #222's care because there were no signs or PPE outside his door to indicate EBP was required for the resident. LPN #2 said she thought he may have had an EBP sign up on his door at one time but she was not sure where it went. H. Resident #2261. ObservationsOn 11/18/24 at 10:13 a.m. there were no signs on Resident #226's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). Resident #226's EMR identified the resident had venous stasis wounds (open sores that develop on the lower legs or ankles due to poor blood circulation) on both lower extremities. 2. Staff interviewsRN #2 was interviewed on 11/21/24 at 3:44 p.m. RN #2 said the IP had been putting residents on EBP if they had open and draining wounds, PICC lines or other indwelling lines. RN #2 said staff members only needed to wear PPE when working with the specific area that the resident needed EBP for. She said if staff was providing foley catheter care or working with a resident's PICC line, the staff should put on PPE. RN #2 said residents on EBP should have a sign on their door and a bin with PPE outside of their room. RN #2 said Resident #226 had wounds on both legs, however, she was not aware if the resident required EBP. RN #2 said she needed to clarify with the IP to see what constituted a wound that required EBP.-However, Resident #226 had venous stasis wounds on both legs which required the implementation of EBP (see professional reference above and facility follow up below). I. Resident #531. ObservationsOn 11/21/24 at 8:40 a.m. the CWN and the DON were observed providing Resident #53's wound care and dressing change. -There were no signs on the resident's door or a bin containing PPE inside or outside of the resident's room, which was identified as the facility's process for EBP (see staff interviews). On 11/21/24 at 11:40 a.m. an EBP sign was observed on Resident #53's door and a bin containing PPE had been placed outside the resident's room. 2. Staff interviewsLPN #4 was interviewed on 11/21/24 at 11:48 a.m. LPN #4 said Resident #53 was on EBP because she had a dialysis port and an open wound. She said an EBP sign had been on the door and a PPE bin had been outside the resident's room previously, but she did not know who removed them or when. She said she replaced the EBP sign and put a bin outside the resident's room after the wound care was performed (on 11/21/24). J. Additional staff interviewsCNA #3 was interviewed on 11/21/24 at 10:33 a.m. CNA #3 said the different signs on the residents' doors meant different things. CNA #3 said the EBP signs meant the resident had an intravenous (IV) line. CNA #3 said for EBP, the nursing staff needed to wear PPE, including a mask, gown, and gloves.-However, EBP required a gown and gloves, but not a mask (see professional reference above). The IP was interviewed on 11/21/24 at 3:39 p.m. The IP said the facility used signs on resident doors to indicate which residents were to be on EBP precautions and placed bins containing PPE outside the residents' doors. She said floor staff were not great at putting EBP in place. The IP said when she reviewed residents or became aware of an infection/illness, usually at morning meetings, which required isolation precautions ,she would complete an audit to ensure a bin with PPE supplies and a precaution sign on the resident's door was in place. The IP said she also ensured the residents met the criteria for EBP or any other infection precautions needed. The IP said it was the floor staff's responsibility to ensure the PPE carts outside of a residents room were stocked with all of the needed PPE. The IP said EBP were put into place when a resident had a MDRO infection and had devices such as ports, urinary catheters or chronic non-healing wounds and wounds showing signs of infection. The IP said when EBP were required, all caregivers/staff providing care needed to sanitize hands, apply gloves, gown and a mask. -However, according to the CDC, EBP should be implemented for all residents with wounds or indwelling devices, regardless of their MDRO status (see professional reference above). The director of nursing (DON) was interviewed on 11/21/24 at 5:56 p.m. The DON said that EBP was used for PICC lines, draining wounds, chronic wounds, foley catheters, and dialysis ports. The DON said EBP was used by the nursing staff when handling the resident and providing high-contact care. The DON said they used the PPE bins and EBP signs as indicators and thought the housekeeping staff may have been moving the PPE bins away from resident rooms. The DON said EBP was used to protect the residents and the nursing staff from infection. The DON said staff providing care to residents with those devices should be wearing PPE, including gloves, gown and a mask.-However, EBP required a gown and gloves, but not a mask (see professional reference above). The DON said a sign for EBP should have been placed on the doors and a PPE cart should have been placed outside the rooms for Residents #225, #231, #40, #224, #222, #226 and #53. K. Facility follow upThe NHA provided CDC guidelines on EBP via email on 11/22/24 at 11:29 a.m. (after the survey). The guidelines revealed in pertinent part, "In the guidance, wound care is included as a high-contact resident care activity and is generally defined as the care of any skin opening requiring a dressing. However, the intent of EBP is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds and not those with only shorter-lasting wounds. "Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers and chronic venous stasis ulcers."-However, observations and interviews revealed the facility had not implemented EBP for residents with wounds (see above).

A licensure survey was completed on 11/18/24 to 11/21/24. One deficiency was cited.

Based on record review, observations, and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#53) one out of 59 sample residents. Resident #53 was admitted to the facility for rehabilitation services on 10/4/24 with a diagnosis of fracture of the left femur, end stage renal disease, type two diabetes and morbid obesity. The 10/5/24 admission skin assessment indicated the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. The assessment did not indicate that the resident had any abdominal wounds. On 10/24/24 the resident was noted to have two facility acquired moisture associated skin disorder (MASD) wounds to her abdominal folds. The facility failed to provide the resident with showers per her preferences. Due to the facility's failures, observations revealed the resident had developed three MASD wounds to her abdomen. Through observations, the facility failed to follow infection control practices when providing wound care and failed to document the third MASD wound. Additionally, the facility also failed to communicate the worsening of the abdominal wounds to the primary care physician and ensure a timely referral to a wound physician. Findings include:I. Resident #53A. Resident statusResident #53, age less than 65, was admitted on 10/4/24. According to the November 2024 computerized physician orders (CPO), diagnoses included fracture of left femur, end stage renal disease, type two diabetes, and morbid obesity. The 10/10/24 facility assessment revealed the resident was cognitively intact. She was dependent on staff for toileting, bathing, and lower body dressing and was partially dependent for all other activities of daily living (ADL). The assessment indicated that the resident did not have any skin conditions. B. Resident interviewResident #53 was interviewed on 11/18/24 at 11:24 a.m. Resident #53 said she had wounds underneath her abdominal fold that she had developed when she was admitted to the facility. She said the abdominal wounds were very painful. She said the pain was what caused her to ask the staff to look under her abdominal fold. She said she did not understand how the wounds developed so quickly and when she asked the nurse they said that they did not know either. Resident #53 was interviewed again on 11/20/24 at 8:06 a.m. She said the facility gave her bed baths instead of showers because she was unable to sit in the shower chair comfortably. She said she preferred to receive a bed bath in the morning, however she often refused her bed bath because the certified nurse aide (CNA) would come between 7:00 p.m. and 8:00 p.m., which she had told them repeatedly was too late. She said she had requested to be moved to the day shift for her bed baths to ensure she received it during the day, but her request had still not been honored. Resident #53 said when the facility the staff did give her a bed bath, they did not lift up her abdominal fold and clean underneath. She said she had full feeling in her abdominal fold and underneath it, and she would have felt if they had cleaned underneath it. C. ObservationsOn 11/21/24 at 8:40 a.m. the certified wound nurse (CWN) and the director of nursing (DON) were observed providing Resident #53's wound care and dressing change. The CWN cleared off the resident's bedside table and wiped it down with a disinfectant wipe, applied a barrier pad and placed her bag of resident wound care supplies on top. The DON entered the room as well and put a clean chucks pad (disposable absorbent pad) under the resident's abdominal fold but below the wounds. Three dressings were observed on the resident, one on the right, one in the middle and one on the left. All of the dressings had the date 11/20/24 with a nurse's signature. Both the DON and the CWN completed hand hygiene and put on clean gloves. The CWN removed all three dressings,the right and left sides had moderate serosanguineous drainage (a thin watery fluid), the middle had a small amount of bloody drainage. The wound on the right was the largest of the three wounds. It was noted to have a ring of redness around it and the center had 20% eschar and 10% yellow slough the remaining tissue was red and it had no odors. The middle wound was the size of a nickel and had red tissue throughout and did not have an odor. The wound on the left was noted to be about the size of a quarter and had 80% slough and 20% red tissue and did not have an odor. The CWN changed her gloves to set up her supplies for the wound care. She set up a stack of gauze, a continuous spray can of saline solution and a lidocaine spray. She started on the left wound by taking one gauze she sprayed it with saline and wiped the wound, folded it over and wiped again three times with the same gauze, the wound was noted to have bloody drainage. The CWN then threw the gauze away and with her dirty glove touched the saline bottle and then re-sprayed all three wounds with lidocaine per the resident's request due to pain, with contaminated gloves. Using the same gloved hands the CWN then took another piece of gauze and sprayed it with the saline solution and moving from the left wound to the middle wound she wiped twice with the same piece of gauze. The CWN then moved to the wound on the right and wiped the wound three times with the same piece of gauze. She then collected a second piece of gauze moistened it with saline and wiped eight times over the wounds with the same piece of gauze, she then took another piece of gauze moistened it with saline solution and proceeded to wipe six more times over the wound areas. She took a third piece of gauze and dabbed the area three times due to bloody drainage. She threw away the gauze and changed her gloves and performed hand hygiene. The CWN conducted a wound culture to the right wound. She took the culture tubing out of the sterilized package. She swabbed the right wound. She then inserted the sample into the test tube. The CWN then changed her gloves, performed hand hygiene. She started on the left side of the wound, using gauze and saline to wipe, applied skin prep to the peri-wound and cut calcium alginate (highly absorbent dressing) sheet to size and applied it. She applied Medihoney (antimicrobial gel) and covered the wound with a border foam dressing. The CWN moved to the middle wound and used a saline-soaked gauze to wipe the wound four times, using the same gauze to apply the skin prep to the peri-wound. She cut another piece of calcium alginate and Medihoney and applied both to the resident's wound and covered it with the foam dressing. Using the same gloved hands, the CWN moved to the right wound, using saline soaked gauze, she wiped the wound four times with noted serosanguinous drainage coming out of the wound as she applied skin prep. She measured the right wound at this time 3.5 centimeter (cm) length by 9 cm width by 0.1 cm depth and said the wound was larger than last week. She took calcium alienate and Medihoney and applied it to the wound and covered it with a foam dressing. D. Record reviewThe potential for skin breakdown care plan, revised on 10/5/24, documented Resident #53 had a surgical incision on her left hip, brace to the left knee, double right chest port, folded abdomen and a hard abdomen. The interventions included applying antifungal powder beneath the pannus (abdominal fold) every shift, completing a Braden scale every week per protocol, providing prophylactic skin treatments as ordered, performing skin assessments as needed, wound nurse to evaluate and treat and the wound physician to evaluate and provide treatment as needed. -The comprehensive care plan did not include Resident #53's actual skin breakdown of three abdominal wounds. The 10/4/24 hospital discharge summary documented Resident #53's skin was warm, dry, intact and had no rashes. The 10/5/24 admission skin assessment documented Resident #53 had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. -It did not document Resident #53 had abdominal wounds upon admission. The 10/10/24 and 10/17/24 skin assessments documented the resident had a surgical incision on her left hip, multiple scattered bruises to both upper extremities and a chest port for dialysis. -It did not indicate Resident #53 had sustained any abdominal wounds. The 10/24/24 skin assessment documented the previously identified skin concerns and additionally a wound to the abdomen. It did not include any information regarding the wound to the abdomen. The 10/24/24 wound progress note documented the floor nurse requested the wound nurse to come and assess the abdominal wounds. The note indicated that there were two moisture-associated skin damage (MASD) wounds underneath the pannus. The right wound measured 2.5 cm in length by 4 cm in width by 0.5 cm depth with 50% granulation tissue (new connective tissue) and 50% slough (dead tissue) with little signs or symptoms of drainage. The wound was debrided with no complications. The left wound measured 1 cm length by 1.5 cm width by 0.2 cm depth with 70% granulation tissue and 30% slough with little signs or symptoms of drainage. The wound dressing order read: cleanse with wound cleaner, apply skin prep to peri-wound (skin surrounding a wound), apply collagen to the wound bed, cover with a foam border dressing every other day or as needed, replace the Interdry sheets (fabric to absorb moisture) beneath the abdomen every three days or as needed and monitor placement of the Interdry sheets every shift. The 10/31/24 wound note documented that the size of both wounds had not changed, however the right wound now had 20% gran and an increase of 80% slough with little signs or symptoms of drainage. The left wound was unchanged with 70% granulation tissue and 30% slough with little signs or symptoms of drainage. The wound dressing order was changed and read as: cleanse with wound cleaner, apply skin prep to the peri-wound, apply medihoney and then collagen to the wound beds, cover the wound with a foam border dressing everyday and as needed, replace the Interdry sheets beneath abdomen every three days or as needed and monitor placement of the Interdry sheets every shift. The 11/13/24 provider note documented that the nurse practitioner (NP) saw Resident #53 to follow up on her abdominal wound and her lab work. It documented the NP saw the wounds via picture. It documented that the wound team was following the MASD open wounds. The 11/14/24 wound progress note documented there were no changes to both wounds. -The wound progress notes did not reveal accurate documentation of the wounds in describing the eschar (scab-like dead tissue covering the wounds) observed to the right wound and that Resident #53 had three abdominal wounds (see observations above of wound care during the survey process), not only two wounds. Review of the record revealed that the resident's primary care physician or her nurse practitioner did not physically see the abdominal wounds except for via photograph which was noted on 11/13/24 (see NP interview below). II. Staff interviewsThe CWN was interviewed on 11/21/24 at 9:11 a.m. The CWN said Resident #53 had abdominal wounds upon admission and were caused from moisture. -However, according to the facility admission skin assessment, Resident #53's she had a surgical incision on her left hip and scattered bruises on her upper extremities upon admission to the facility. The CWN said the wound physician had not been referred to see Resident #53's wounds, but she had referred the resident that week, during the survey process, since the wounds had gotten worse and were not healing. She said she observed Resident #53's wounds weekly. The CWN said she was notified from the floor nurse yesterday (11/20/24), that Resident #53's wound had deteriorated. Shesaid she contacted the wound physician and received an order to culture one of the wounds. The CWN said her cleaning technique with the gauze was to move from clean to dirty and then discard the gauze. She said she had not realized she had used the same gauze up to eight times to wipe the wound. She said she should have changed the gauze in between each wipe to decrease the risk of infection. She said she should have changed her gloves in between each wound site to decrease the risk of infection. Primary care physician (PCP) #1 was interviewed on 11/21/24 at 11:55 a.m. PCP #1 said she was the PCP for Resident #53. PCP #1 said Resident #53's skin was clear from any wounds upon admission, except for the surgical incision. She said she observed the wounds on 10/25/24, but had not observed the wounds since because the wound nurse was following and she expected the wound nurse to provide her with updates. She said the NP was following the wounds more closely for this resident. She said she had not been informed Resident #53's wound had deteriorated to include eschar and slough. She said she would assume the wound physician ordered a wound culture because there was concern about a potential infection of the wound. She said she would have expected the CWN to have referred Resident #53's wounds to the wound physician sooner, who was an expert in that area. NP #1 was interviewed on 11/21/24 at 12:21 p.m. NP #1 said she was the NP for Resident #53. She said she had not directly observed Resident #53's abdominal wounds. She said she hated to take off the bandage to look at the wound because of Resident #53's pain and creating more work for the floor nurse. She said she had asked the CWN for pictures of the wounds. She said she was not informed Resident #53's wounds had deteriorated to include eschar and slough, just that they had increased in size. NP #1 said an increase in measurements did not necessarily mean the wounds were deteriorating. She said if she had been provided more information and informed of the eschar and slough, she would have acted differently, to ensure the wound physician was involved sooner. NP #1 said the presence of eschar and yellow slough meant the wound was deteriorating. She said that using the same gauze to wipe the wound multiple times could spread bacteria as well as not changing gloves, which had potential to lead to an infection. She also said that by not debriding the wound before getting a culture of the wound could potentially cause inaccurate test results. NP #1 said she was unaware the wound physician was not already following and involved in the wound care for Resident #53's abdominal wounds. The CWN was interviewed again on 11/21/24 at 4:32 p.m. The CWN said she was not concerned about Resident #53's abdominal wounds until yesterday (11/20/24), when the floor nurse informed her the wound had gotten worse. She said by the time she had been notified of the worsening of the wounds, the wound physician had already left for the day. The CWN said it was up to her discretion as to when a wound required the wound physician's expertise. She said the wound physician would see Resident #53's abdominal wounds next week.

A revisit survey was completed on 11/5/24 for all previous deficiencies cited on 10/8/24. The facility is in compliance with all regulations surveyed.

A survey prompted by #CO37545 was conducted on 10/8/24. One deficiency was cited.

Based on record review and interviews, the facility failed to provide pharmaceutical services to meet the needs of one (#1) of three residents out of three sample residents. Specifically, the facility failed to ensure two inhaler medications for Resident #1 were ordered and delivered to the facility as ordered by the physician. Findings include:I. Facility policy and proceduresThe Medication Ordering From Pharmacy policy, reviewed 4/2/24, was provided via email on 10/9/24 at 1:21 p.m. by the director of nursing (DON). It revealed in pertinent part,"The purpose of this policy is to assure that patients receive their medication delivery when admitted to the facility in a timely manner."Standard Process:All medications will be faxed to the pharmacy once the medications have been verified with the provider when a patient admits to the facility or when a new RX (prescription) is received and patient(s) need a medication refill."If medications are on the delivery manifest but were not delivered the provider pharmacy should be contacted for a correction and nurse management should be notified."II. Resident #1A. Resident statusResident #1, age 85, was admitted on 7/7/24 and discharged on 7/9/24. According to the July 2024 computerized physician orders (CPO), diagnosis included COVID-19, sepsis, acute respiratory failure with hypoxia (low levels of oxygen in the body tissues), anemia, unspecified atrial fibrillation (AFIB), hypertension (high blood pressure) and depression. The minimum data set (MDS) admission assessment was not completed because the resident discharged before it could be completed. The 7/9/24 admissions functional ability assessment revealed the resident required maximum assistance with oral hygiene. The resident was dependent on staff for toileting, sitting to lying down, sitting to stand, and chair to bed transfers. The resident required staff supervision or touch assistance with eating. B. Record reviewResident #1 was admitted to the hospital on 6/27/24 with a diagnosis of COVID-19 pneumonia and was admitted to the facility 11 days later, on 7/7/24. The comprehensive care plan, initiated 7/8/24, revealed Resident #1 was at respiratory risk related to respiratory conditions and/or deficiencies/abnormalities in pulmonary function, acute respiratory failure with hypoxia, deconditioning with hospital stay/acute medical condition, metabolic encephalopathy, COVID-19, sepsis, pleural effusion and elevated white blood count. The goal was that respiratory risks related to pulmonary conditions/function would be minimized with interventions over the next 90 days. Interventions included administering medications per physician orders. Review of Resident #1's July 2024 CPO revealed the following physician's orders:Fluticasone-Salmeterol Inhalation Aerosol PowderBreath (steroid medication inhaler) Activated 113-14 MCG (micrograms)/ACT (activation) (one) puff inhale(d) orally two times a day, ordered 7/7/24. Spiriva HandiHaler Inhalation (medication used to treat shortness of breath) Capsule 18 MCG (micrograms) (Tiotropium Bromide Monohydrate) one puff inhale(d) orally at bedtime, ordered 7/7/24. Review of the July 2024 medication administration treatment record (MAR) revealed the following:The Fluticasone-Salmeterol Inhalation Aerosol PowderBreath was not administered on the evening of 7/7/24, the morning of 7/8/24 or the evening of 7/8/24 (for a total of three doses). The Spiriva HandiHaler Inhalation Capsule 18 MCG was not administered on the evening of 7/7/24 or 7/8/24 (for a total of two doses). The nursing progress note on 7/7/24 at 8:48 p.m. documented the Fluticasone-Salmeterol inhalation aerosol powder and the Spiriva Handihaler inhaler were not available. The pharmacist progress note on 7/8/24 at 10:27 a.m. documented an admission review of medications was completed and there were no clinically significant medication issues identified. The nursing progress note on 7/8/24 documented the Fluticasone-Salmeterol inhalation aerosol powder and the Spiriva Handihaler inhaler were not available. III. Staff interviewsThe DON was interviewed on 10/8/24 at 2:00 p.m. The DON said the pharmacy decided, on 7/7/24 at 2:30 p.m., that the medication list in the medical record system was Resident #1's medication current list, however, she said that was incorrect. The DON said the facility always ensured the physician, as well as two nurses, read and signed off on a medication order before the order went to the pharmacy to be filled. The DON said the facility sent the correct medication list to the pharmacy on 7/7/24 at 3:40 p.m. The DON said she spoke with the pharmacy today (10/8/24) and the pharmacy representative told her the medication list which had been sent to the pharmacy on 7/7/24 at 3:40 p.m. was deleted and put into the computer trash bin with the assumption that what was read by the pharmacy on 7/7/24 at 2:30 p.m. was the correct medication list for Resident #1. The DON said the pharmacy never did get the order correctly done for Resident #1's stay in the facility from 7/7/24 through 7/9/24. She said today (10/8/24) the pharmacy representative told her the pharmacy would do a plan of correction with the pharmacy employees so this type of situation would never occur again. The DON said the pharmacy threw away the facility's correct medication list for Resident #1. She said the particular medications in this situation were not carried in their emergency medication kit to be retrieved. She said with all Resident #1 had been through with her health, the inhalers would have benefited the resident. The DON said she was not informed of the medication situation for Resident #1 by the nursing staff. Registered nurse (RN) #1 was interviewed on 10/8/24 at 3:17 p.m. RN #1 said she called the pharmacy on 7/8/24 to request them to send over the missing medications. RN #1 said she assumed the pharmacy would comply with her request. RN #1 said she did not document the conversation with the pharmacy and she did not report the situation to the DON. The DON was interviewed again on 10/8/24 at 3:35 p.m. The DON said the facility had started a training (during the survey) for all of the facility nursing staff about how to ensure pharmacy orders were to be followed through on if a medication was not delivered. The DON said the training contained information to let the DON know when the pharmacy did not comply with the physician's medication orders. The DON said the training reminded the nursing staff to document in the residents' medical records when a call to the pharmacy took place to correct a pharmacy order. IV. Facility follow-upOn 10/9/24 at 9:04 a.m. (after the survey) the DON provided an email written by the pharmacy representative on 10/8/24 at 4:27 p.m. The email read in pertinent part, "Admission orders faxed on 7/7/2024 for Resident #1 for Spiriva and Fluticasone were misinterpreted by pharmacy staff as duplicate orders. Facility did not report missing these or any medications. The incident has been reviewed and pharmacy staff has been counseled. We have updated our process to include a review of duplicate orders to prevent further incident(s)."

A complaint survey, prompted by #CO36081, #CO36095, #CO36096 and Incident #35705 was conducted on 5/22/24. No deficiencies were cited.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/04/2024 and 03/10/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/04/2023 and 12/10/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

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

A complaint survey, prompted by #CO33989 was completed on 10/25/23. No deficiencies were cited.

A complaint survey prompted by #CO33480 was conducted on 9/11/23. No deficiencies were cited.

A revisit survey was completed on 8/21/23 for all previous deficiencies cited on 6/6/23. The facility is in compliance with all regulations surveyed.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/17/2023 and 07/23/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A re-certification survey was completed on June 27,2023. The facility was reviewed and surveyed to the National Fire Protection Association (NFPA) Life Safety Code (2012) Chapter 19, Existing Health Care Occupancies. The building is three-story, Type II (111) construction, without a basement. The facility is divided into two smoke compartments on the first floor and five smoke compartments on floors two and three witch each compartment separated by one-hour rated construction. The first floor is arranged as a single fire alarm zone, floors two and three are arranged with fire alarm initiating devices zoned by each compartment. Audible / visual alarms activated in the zone of origin only. The remaining compartments notified via automatic voice notification. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. Emergency power is provided by a 150kw natural gas generator located on the roof. The facility equipped with piped medical gas system. The facility will meet these requirements when the following deficiencies are corrected. Each of the deficiencies was discussed in the exit conference with the Administrator and Maintenance Director.

Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code Sections 19.7.9.3.1.1. 90 minute inspection report not available for exit lighting at time of inspectionNFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. (3) An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 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. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. Kitchen appliances on casters need chalks installedKitchen suppression no detailed report 18 July 2022No december report available at time of inspectionNeed to replace Class K extinguisher DamagedNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Through documentation review, it was determined that the facility did not to meet the Fire Alarm testing and maintenance requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:Fire shutters need to be repaired to operation condition stairwellElevator shaft detectors not testedSmoke detector sensitivity report not available at time of inspectionNeed to identify yellow pull stationLife Safety Code Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101Need to clear noted deficiency - Missing control valve signs on jockey pump Semi-annual inspection overdue for system7 gauges noted as needing replacement Incomplete sprinkler report on file No back flow report available at time of inspectionDry head in sprinkler head and freezer need to be replacedStairwell D riser yellow tagged NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.12This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on 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. Penetrations in stairwell A & DNFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire Drills Missed 1st Shift 4th quarter NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

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

A recertification survey with complaints #CO30210 and #CO32350 was conducted from 5/31/23 to 6/6/23. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/31/23 to 6/6/23. One deficiency was cited.

Based on record review and interview, the facility failed to conduct two exercises annually to test the facility's emergency plan and maintain documentation of the facility's response to all drills, tabletop exercises, and emergency events and then revise the facility's emergency plan, as needed. Specifically, the facility failed to conduct and fully assess the facility's emergency preparedness program (EPP) plan through two full-scale exercises; individual facility based functional exercises; a mock disaster drill; a tabletop exercise; or community based disaster event or workshop in the last year (12-month cycle). Findings include: I. Facility policy The Emergency Management Plan - Emergency Preparedness Program (EPP). Section A: Policies and Planning, last reviewed 1/10/23, was provided by the nursing home administrator (NHA) on 5/32/23 at 10:30 a.m. The EPP read in pertinent part: "Annual testing: The facility will conduct annual testing of the Emergency Preparedness Program through exercisesas follows:-The facility will conduct two separate exercises on an annual basis. One of these exerciseswill be a community based full scale exercise (when available) and the second may be a tabletop of similar exercise.-Each calendar year, the facility will participate in a community based full scale exercise.-When a community based full scale exercise is not available. the facility will conduct anindividual facility based disaster on an annual basis and document its actions and invitationstowards having community partners and stakeholders involved. "The facility response to each exercise will be documented to capture lessons learned,opportunities for plan and procedure improvements, and to evaluate staff knowledge and response. "The facility will document all drills, tabletops exercises and emergency events utilizing theAfter-Action Report (AAR). Any plan revisions needed as a result of a drill of exercise will becaptured in the Improvement Plan of the APR. The Executive Director/Administrator or Designee along with the QA/QAPI (quality assurance/quality assurance performance improvement) Committee will be responsible for reviewing, tracking and assigning improvement tasks." II. Record review The plan revealed the facility participated in a tornado drill when experiencing a high winds event on 5/10/23. The facility presented a scenario based on actual risk to have staff prepare for the possibility that the facility might have had to enact the EPP if the high winds caused the facility to experience a real life natural disaster. -However, the facility did not document the steps taken by staff to test the facility's EPP; the staff or resident response to the testing drill; or the outcome of the EPP test with any recommendations to update the existing EPP with potential procedural updates or improvements. The facility enacted a real event natural disaster for blizzard reaction through the EPP with a snow storm with blizzard like conditions that occurred in March 2022.-However, the facility failed to document the detail of the event with staff and resident response to the event; or the outcome of the EPP test with any recommendations to update the existing EPP with potential procedural updates or improvements. III. Staff interviews The NHA was interviewed on 6/5/23 at 3:50 p.m. The NHA said he was new to the facility and had started to train staff in the detail of the facility's EPP, but had not yet conducted an event to test the facility's EPP. The NHA said the prior administration had left records of events set up to test the EPP; however, there was no documentation to show that the facility had made efforts to assess the outcomes of the test drills or actual natural disasters the facility conducted.

Based on record review observations and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents. Specifically, the facility failed to:-Follow up and document Resident #33's grievance reported to a staff member; and, -Ensure residents were aware how to file a grievance and place grievance forms in prominent locations throughout the facility. Findings include: I. Facility policyThe Grievance policy, last revised on 2/8/21, was provided by the director of nursing (DON) on 6/6/23 at 5:30 p.m. it read in pertinent, "Grievances can be communicated to a staff member either verbally or in writing. All patients will be informed of the location of the facility's grievance forms should they wish to write a formal complaint. Any patient who wishes to do so may express his/her grievances in writing or verbally to any staff member; however, they are strongly encouraged to express the complaint (s) directly to Social Services, Executive Director, or the Manager on Duty. If the complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. "The completed form must be provided to the Executive Director or Designee immediately. It is the responsibility of the Department Managers in coordination with the Executive Director, when appropriate, to develop a process/plan for resolution of the grievance and notify the complainant about the plan for resolution. If the complainant or aggrieved party is dissatisfied with the finding and/or remedies, the Executive Director will make reasonable attempts to resolve the grievance. The Ombudsman will be notified if the grievance is not resolved per patient/family representative request." II. Resident #33A. Resident statusResident #33, 83 years old, admitted on 5/21/23, according to the June 2023 computerized physician orders (CPO) diagnosis included abdominal surgical infection, benign prostatic hyperplasia (BPH a blockage of urine flow), type two diabetes (insulin insufficiency) and dementia (impaired memory). The 5/25/23 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status score of 10 out of 15. He required one person physical assistance with transfers, bed mobility, dressing, toileting and personal hygiene. B. Resident interviewResident #33 was interviewed on 5/31/23 at 11:55 a.m. he said he had a nurse or certified nurse aide (CNA) come in one night and tell me "what are you doing? Who told you you could do this.'' Resident #33 said he was in the bathroom and had to go and could not wait for staff. He said he felt reprimanded and he soiled himself and staff did not offer assistance. He was unable to recall the specific night it occurred but believed it was around 5/24/23 around 1:00 to 2:00 a.m. in the morning. Resident #33 said the staff member's tone of voice was harsh and made him mad. He said he asked the staff member "why are you doing this to me? He said he did not need an attitude, what he needed was assistance to use the restroom inorder to pass stool related to my surgery and here the staff are yelling at me when using the restroom." Resident #33 was interviewed a second time on 5/31/23 at 4:37 p.m. He said the staff member said what were you doing without staff here to escort you to the restroom. He identified the staff member but was unsure if it was a nurse or CNA. Resident #33 said he had not seen the staff member since that night. He said he was startled with the situation and felt the staff member was bold to talk to him the way she did. Resident #33 said his call light had to have been on,why else would the staff member come into the room and find him in the bathroom. Resident #33 said he was left soiled and had to clean himself up, which was not easy due to his current medical condition. Resident #33 said he reported to the occupational therapist (OT) the next morning that the CNA was rude to him. Resident #33 said no staff had followed up with him since reporting to the OT. C. Record reviewThe 5/22/23 care plan revealed Resident #33 required assistance with activities of daily living (ADLs) due to self care deficits and decreased functional mobility secondary to recent hospitalization for surgical interventions. Interventions were: call light within reach, encouraged to do as much for self as able and praise for effects with self care. Resident #33 needs assistance with transferring, toileting related to weakness from colostomy closure with infection at surgical site. Interventions check patient frequently and offer toileting as needed. D. Grievance form A grievance form was requested on 5/31/23, per the NHA interview (see below) there was not a grievance form for Resident #33. The NHA was interviewed on 5/31/23 at 5:11 p.m. He said he had not heard about Resident #33 having complaints about staff. He said he would start an investigation. The NHA completed a grievance form on 5/31/23 for Resident #33 (after being identified during the survey). The grievance form identified Resident #33 was self ambulating in room late at night, he had used his call light but could not wait much longer. While he was urinating a CNA came behind him and startled him saying "who said you could do that?" She was intent on conveying to him going to the bathroom independently was wrong. The resident was told staff would be educated and he was satisfied with the outcome. E. Staff interviewsThe OT was interviewed on 6/1/23 at 12:21 p.m. She said during a morning visit with resident #33 he advised her of a situation he had that night. She said Resident #33 said "I'm ok, I had a problem last night. Someone was rude to me and my feelings got hurt." She said she offered to lodge a formal complaint for the resident and the resident said "no it will be ok." She said the resident appeared to be his baseline other than staff who were curt with him. The OT was unable to recall a specific date the resident reported this to her. The OT acknowledged that she did not document the situation nor report it to administration. She said in the future she would report a resident grievance to her supervisor even if she was unsure about the situation. The DON was interviewed on 6/6/23 at 4:28 p.m. She said Resident #33 was not independent with ambulation and required assistance to restroom. The DON said all staff were to treat residents with respect and dignity. The grievance follow up was completed on 5/31/23 by the NHA and DON after extensive discussion with Resident #33. He did not indicate fear or harm during the 30 minute interview. III. Grievance process and forms A. ObservationsOn 6/5/23 at 1:10 p.m. the second floor had no grievance forms located anywhere on the unit or on the counter of the nurses' station. At 1:20 p.m. the third floor one of the nurses' station had grievance forms located on the counter and the other nurses station there were no grievance forms found. At 2:43 p.m. CNA #4 had an admission packet on the counter. The admission packet did not have a grievance form in it. B. Resident group interviewsThe resident group interview was conducted on 6/5/23 at 11:00 a.m. with three residents (#62, #330 and #335) identifed by the facility and assessment as interviewable. All the residents said they did not know how to file a complaint or where the grievance forms were kept. C. Staff interviewsCNA #3 was interviewed on 6/5/23 at 2:38 p.m. CNA #3 said she did not know where the grievance forms were and said to speak with the registered nurse (RN). Licensed practical nurse (LPN #3) was interviewed on 6/5/23 at 2:40 p.m. LPN #3 said the grievance forms were kept behind the nurses' station in a black bin hung on the wall. LPN #3 then pointed to the black bin on the wall. She said residents did not have access to the grievance forms and the forms were not convenient for residents to get at any time. CNA #4 was interviewed on 6/5/23 at 2:43 p.m. CNA #4 said the grievance forms are kept behind the nurses' station. She said that if someone was upset about something she offered them a grievance form and assured them it was ok to file a grievance. RN #4 was interviewed on 6/5/23 at 2:53 p.m. RN #4 said the grievance forms were located on the counter at the nurses' station counter. RN #4 could not find any grievance forms on the counter, so she went behind the desk and started looking through a drawer and could not find a grievance form. The physical therapist (PT) was interviewed on 6/5/23 at 2:56 p.m. She said the grievance forms were located on the counter at the nurses' station. The PT could not find the grievance form, so she went to the other nurses' station on the other side and took a form from their counter and brought it back, made copies and placed them on the nurses' station counter. The case manager (CM) was interviewed on 6/6/23 at 2:20 p.m. He said the grievance process was a group effort and everyone had a hand in resolving the grievances at the facility. He said he would send an email to the DON and the nursing home administrator (NHA) to let them know they have grievances since they handled the resident grievances. The CM said he did not know how long the grievance process took to resolve the complaint. He said he was not sure if residents knew how to fill out a grievance and had to talk with the NHA about the process. The CM spoke with the NHA and he was informed during the resident's admission process the nurses verbally went over the grievance process with each resident. The CM said the grievance forms were not part of the admission packet and said it would be beneficial to include them in the packet. The CM said residents should have a hard copy of the grievance form instead of being informed by nursing staff verbally.

Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for three residents (#226, #232 and #236). Specifically, the facility had a medication error rate of 7.89 percent, which was three errors out of 38 opportunities for error. Findings includeI. Professional reference and manufacturer recommendationsAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607, retrieved on 6/12/23, "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."According to the Humalog (Lispro) package insert, retrieved 6/12/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf "Instructions for use: priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin."According to the Humalin N kwikpen (NPH) instructions for use, retrieved on 6/12/23 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf "priming your pen; prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If not primed before each injection, you may get too much or too little insulin. To prime the pen, turn the dose knob to two units, hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. You should see insulin at the tip of the needle."II. Facility policyThe Medications Administration policy and procedure, revised on 2/8/21, received from the director of nursing (DON) on 6/5/23 at 11:29 a.m. revealed in pertinent part, "medications are to be administered as prescribed by the attending physician."The Insulin Pen Injection policy and procedures, revised on 6/14/22, received from the DON on 6/5/23 at 12:24 p.m. revealed in pertinent part, "the insulin pen is an injection device that delivers insulin. Prime the insulin pen. Priming means removing air bubbles from the needle and ensures the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear."III. Observations On 6/5/23 at 8:20 a.m. registered nurse (RN) #1 was observed administering medication to Resident #236. The medication ordered was Insulin NPH (neutral protamine Hagedorn type of intermediate use insulin)100 units/milliliter (used to manage diabetes) give10 units subcutaneously two times a day for diabetes mellitus. The nurse collected an insulin NPH pen, she rolled the pen between her hands to mix insulin within the pen and dialed the pen to 10 units. RN #1 administered the insulin to the resident. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 8:37 a.m. RN #1 was observed administering insulin to Resident #232. The medication ordered was insulin lispro (humalog) 100 units/milliliter per sliding scale 71-149= 0 (no intervention);150-200=2 units give Subcutaneous; 201-250=4 units give subcutaneous;251-300=6 units give subcutaneous;301-350=8 units give subcutaneous; 351-400=10 units give subcutaneous. If greater than 400, call a physician. RN #1 collected Lispro insulin from the medication cart, reviewed the resident's blood sugar reading 155 and reviewed lispro insulin order. RN #1 said Resident #232 required two units based on order. RN #1 dialed the pen to two units and administered insulin into the resident's right arm. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 9:26 a.m. RN #2 was observed passing medication to Resident #226. The medication order was Insulin NPH subcutaneous Suspension 100 UNIT/ML; give five units two times a day. RN #1 reviewed Resident #226 blood sugar reading 196 and indicated the resident would receive five units of NPH insulin. RN #2 entered the residents room and administered the insulin.-RN #2 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). IV. Staff interviewsRN #1 was interviewed on 6/5/23 at 9:16 a.m. She said in order to administer insulin via a pen the nurse must first verify the order, if an insulin was cloudy in nature it must be rolled between their hands to ensure insulin was mixed well. Then the nurse dialed the pen to the physician's order and administered the insulin. RN #1 said she only primed an insulin pen on initial access to remove air if any air was seen in the pen. RN #1 said she would not prime a pen for each injection. RN #2 was interviewed on 6/5/23 at 9:52 a.m. She said the process of administering insulin via a pen was to dial the pen to the ordered dose and administer medication. RN #2 said insulin pens would not prime as they were pressurized and it made it hard. RN #2 then demonstrated by dialing the insulin pen to two units, pressed the injection button and nothing was observed coming out of the pen. There was no needle attached to the pen during RN #2 demonstrations. RN #2 said she was unaware of the need to prime an insulin pen for each administration. The director of nursing (DON) was interviewed on 6/5/23 at 10:26 a.m. She said nursing staff were to administer insulin by reviewing the order, collecting the medication, alcohol swabs and needle. The insulin pen then could be dialed to the ordered units of insulin and then administer the insulin. The DON said after observations of the insulin pen not being primed (see above), the insulin pen needed to be primed with two units of insulin prior to each injection to remove the air in the needle. The DON said if a needle was not primed it could deliver too much or too little insulin to the resident, which could cause issues with regulating the resident's blood glucose levels.

Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for three residents (#226 #232 and #236) of four reviewed for medication administration out of 44 sample residents. Specifically, the facility failed to ensure insulin pens were primed prior to medication administration for Residents #226, #232 and #236. Cross-reference F759 failure to ensure the medication error rate was less than five percent. Findings include:I. Professional referenceAccording to the Humalog (Lispro) package insert, retrieved 6/12/23 from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf "Instructions for use: priming ensures the pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin."According to the Humalin N kwikpen (NPH) instructions for use, retrieved on 6/12/23 from: https://pi.lilly.com/us/HUMULIN-N-KWIKPEN-IFU.pdf "priming your pen; prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If not primed before each injection, you may get too much or too little insulin. To prime the pen, turn the dose knob to two units, hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. You should see insulin at the tip of the needle."II. Facility policyThe Medications Administration policy and procedure, revised on 2/8/21, received from the director of nursing (DON) on 6/5/23 at 11:29 a.m. revealed in pertinent part, "medications are to be administered as prescribed by the attending physician."The insulin pen injection policy and procedures, revised on 6/14/22, received from the DON on 6/5/23 at 12:24 p.m. revealed in pertinent part, "the insulin pen is an injection device that delivers insulin. Prime the insulin pen: priming means removing air bubbles from the needle and ensures the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. III. ObservationsOn 6/5/23 at 8:20 a.m. registered nurse (RN) #1 was observed administering medication to Resident #236. The medication ordered was Insulin NPH (neutral protamine Hagedorn type of intermediate use insulin)100 units/milliliter (used to manage diabetes) give10 units subcutaneously two times a day for diabetes mellitus. The nurse collected an insulin NPH pen, she rolled the pen between her hands to mix insulin within the pen and dialed the pen to 10 units. RN #1 administered the insulin to the resident. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 8:37 a.m. RN #1 was observed administering insulin to Resident #232. The medication ordered was insulin lispro (humalog) 100 units/milliliter per sliding scale 71-149= 0 (no intervention);150-200=2 units give Subcutaneous; 201-250=4 units give subcutaneous;251-300=6 units give subcutaneous;301-350=8 units give subcutaneous; 351-400=10 units give subcutaneous. If greater than 400, call a physician. RN #1 collected Lispro insulin from the medication cart, reviewed the resident's blood sugar reading 155 and reviewed lispro insulin order. RN #1 said Resident #232 required two units based on order. RN #1 dialed the pen to two units and administered insulin into the resident's right arm. -RN #1 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). At 9:26 a.m. RN #2 was observed passing medication to Resident #226. The medication order wasInsulin NPH subcutaneous Suspension 100 UNIT/ML; give five units two times a day. RN #1 reviewed Resident #226 blood sugar reading 196 and indicated the resident would receive five units of NPH insulin. RN #2 entered the residents room and administered the insulin.-RN #2 failed to prime the insulin pen prior to administration of insulin per manufacturer's directions (see manufacturer's directions above). IV. Staff interviewsRN #1 was interviewed on 6/5/23 at 9:16 a.m. She said in order to administer insulin via a pen the nurse must first verify the order, if an insulin was cloudy in nature it must be rolled between their hands to ensure insulin was mixed well. Then the nurse dialed the pen to the physician's order and administered the insulin. RN #1 said she only primed an insulin pen on initial access to remove air if any air was seen in the pen. RN #1 said she would not prime a pen for each injection. RN #1 said it was important residents got the correct dose of insulin to help regulate their glucose levels. RN #2 was interviewed on 6/5/23 at 9:52 a.m. She said the process of administering insulin via a pen was to dial the pen to the ordered dose and administer medication. RN #2 said insulin pens would not prime as they were pressurized and it made it hard. RN #2 then demonstrated by dialing the insulin pen to two units, pressed the injection button and nothing was observed coming out of the pen. There was no needle attached to the pen during RN #2's demonstrations. RN #2 said she was unaware of the need to prime an insulin pen for each administration. She said insulin was used to regulate blood glucose levels and residents need to get the correct dose ordered in order to maintain healthy blood glucose levels. The DON was interviewed on 6/5/23 at 10:26 a.m. She said nursing staff were to administer insulin by reviewing the order, collecting the medication, alcohol swabs and needle. The insulin pen then could be dialed to the ordered units of insulin and then administer the insulin. The DON said after observations of the insulin pen not being primed (see above), the insulin pen needed to be primed with two units of insulin prior to each injection to remove the air in the needle. The DON said if a needle was not primed it could deliver too much or too little insulin to the resident, which could cause issues with regulating the resident's blood glucose levels. The DON acknowledged not priming a pen prior to administration was a medication error due to incorrect dose of insulin being administered.

Based on observations and interviews the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards on two of two units reviewed of four units. Specifically the facility failed to:-Ensure prescribed medications were labeled correctly; -Remove expired medications from the cart; and, -Ensure topical medications were not stored with oral medications. I. Professional standardsAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 608, "Medication error often occurs because a patient gets a medication intended for another patient. Therefore, an important step in safe medication administration is being sure that you give the right medication to the right patient."II. Facility policyThe Storage of Medications policy and procedure, revised on 2/8/21, received from the director of nursing (DON) on 6/5/23 at 11:29 a.m. revealed in pertinent part, "the medication and biological were stored properly, following manufactures or provider pharmacy recommendations, to maintain integrity and to support safe effective drug administration. Provider pharmacy dispensed medications in containers that meet state and federal labeling requirements. Internally administered medications were stored separately from medications used externally such as lotions, creams, and ointments."III. Observations and staff interviewsReview of the second floor D wing cart on 6/1/23 at 3:39 p.m. revealed three cefazolin two grams in 100 milliliters solution intravenous (IV) bags that expired on 5/29/23. Registered nurse (RN) #3 removed the three IV bags from the cart and took them to the medication storage room and placed them into the return to pharmacy bin. RN #3 said the medications should have been removed from the cart by the 30th to ensure expired medications were not given to the resident. RN #3 said she thought the night shift went through the medication carts to remove expired medications and keep the carts clean but unsure how often this occurred. Review of the third floor D wing cart on 6/1/23 at 3:49 p.m. revealed a tube of miconazole nitrate 1% antifungal cream stored next to oral medications. Licensed practical nurse (LPN) #1 said the antifungal cream should not have been stored next to oral medications. He said topical creams could leak and contaminate medications. A bottle of latanoprost ophthalmic solution 0.005% (eye drop used for glaucoma) with an open date of 4/30/23 was in the medication cart. The prescription label identified the medication belonged to a resident however the name was blacked out with a permanent marker. The blacked out name was still visible. Another resident name was handwritten in permanent marker on the prescription label over the other resident's name. LPN #1 said the medication had been relabeled with another resident name. He said medication should not be relabeled for another resident. LPN #1 placed the miconazole nitrate %1 cream into another section of the cart that stored topicals only. LPN #1 then took the latanoprost eye drops to the DON. The DON was interviewed on 6/1/23 at 3:59 p.m. The DON said the prescription label had been relabeled when LPN #1 showed her the latanoprost. She said prescriptions were resident specific and should not be relabeled to be administered to another resident. The DON said topical medications were to be stored in separate sections in the medication cart from oral medications. Topical medications have the potential to leak and contaminate other medications or cause a chemical reaction. The DON said expired medications should be removed immediately by the nurse who finds them or by a night shift nurse who reviews the medication cart nightly. Expired medications or discontinued medications were to be disposed of in the medication room for pharmacy to destroy.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures for all residents. Specifically, the facility failed to ensure resident food was palatable in taste and temperature. Findings include: I. Resident interviews Resident #2 was interviewed on 5/31/23 at 10:26 a.m. Resident #2 said the facility meals were sometimes cold when served, making the meal unappealing. Resident #33 was interviewed on 5/31/23 11:34 a.m. Resident #33 said the facility food was bland; and there was not much variation in the menu. He was served mash potatoes and gravy almost daily. Resident #33 would have liked to have seed potatoes in a different form; "there needs to be more variety." Resident #33 said he made certain menu choices and did not get what he ordered; especially when it came to asking for a banana; food often arrived cold when it should have been hot. Resident #33 said he asked for sausages the other day and when the sausage arrived it was cold like it just came out of the refrigerator. Resident #33 said the food was often dry. He ordered the tuna casserole a couple of days prior and it was dry and inedible. Resident #33 said he usually liked tuna noodle casserole. Resident #16 was interviewed on 5/31/23 at 2:35 p.m. Resident #16 said the facility food was terrible and had no taste to it. Resident #48 was interviewed on 5/31/23 at 3:09 p.m. Resident #48 said the facility food was average but bland. Resident #33 was interviewed again on 5/31/23 at 4:37 p.m. Resident #33 said he was unable to eat lunch because the marinated chicken had a lot of little bones in it, making it difficult for him to separate the bone from the chicken meat. Resident #33 said he was afraid of choking on the little bones. Resident #49 was interviewed on 6/1/23 at 10:59 a.m. Resident #49 said all of the facility's meat, chicken and pork were always served dry; there room for improvement with the meals served. A group interview was conducted with three alert and oriented residents selected to participate by the facility on 6/5/23 at 11:00 a.m. The residents (#62, #330 and #335) said that the facility food was terrible, had no taste and was bland. One resident said that the pork was always overcooked and dry; and the meat was tough. The residents said they had not made a formal complaint about their food concerns or the quality of the facility food and did not know what the grievance process was (cross-reference to F585 failure to ensure an accessible grievance process). II. Observations A test tray was made on 6/5/23 at 12:15 p.m. The test tray was plated at the end of meal service and placed in an insulated cart and transported to the resident floor for delivery. The test tray consisted of a regular diet meal with baked seasoned chicken, mashed potatoes and gravy, mixed vegetables and a roll. The test tray for a regular diet was evaluated by five surveyors:-The baked chicken was heavily seasoned and had a dry internal texture. The seasoning on top of the chicken made the texture of the chicken drier due to the dryness of the seasoning flakes;-The mashed potatoes had a powdery texture and were dry in parts that were not covered by gravy. Both the mashed potatoes and gravy lacked flavor and were bland and left an unappealing flavor after tasting;-The vegetable mix was crisp but had no flavor of the vegetable. The provided seasoning packet was applied; the seasoning was heavy with black pepper and did not enhance the taste of the vegetables. III. Staff interviews The dietary manager (DM) was interviewed on 6/6/23 at 3:36 p.m. The DM said she was unaware of the resident's food complaints since the residents were mostly in the facility for short term rehabilitation; they did not have a resident food committed to discuss menus and food concerns. The facility did try to identify resident preferences on admission and had adjusted menus when a number of admitted residents expressed certain food choices. The facility did provide seasoning packets with meals but only had one variety of seasoning to offer in addition to salt and pepper. The DM said the cook had a hard time keeping the baked chicken moist due to its serving size and probably should keep a cover on the chicken pan until serving time to preserve the moisture in the meat.

Based on observations, record review, and staff interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of one kitchens. Specifically, the facility failed to:-Ensure a clean and sanitary kitchen within the dry storage room; around the grill and fryer; within smaller refrigerator units; and surfaces of the kitchen; and,-Ensure open food items were properly labeled with open dates and sealed for storage to prevent contamination. Findings include: I. Professional standards According to The Colorado Department of Public Health and Environment (CDPHE), Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 6/12/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view"Persons who are more likely than other people in the general population to experience foodborne disease because they are older adults; and they obtain food at a facility that provides services such as nursing homes. "Food Storage. Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; "Preventing Food and Ingredient Contamination: food shall be protected from cross contamination by: storing the food in packages, covered containers, or wrappings; "Food packaged in a food establishment, shall be labeled as specified in law, including Labeling, marking devices, and containers. Label information shall include:The common name of the food , or absent a common name, an adequately descriptive identity statement; The name of the food source for each major food allergen contained in the food unless the food source is already part of the common or usual name of the respective ingredient. "Cleaning, Frequency and Restrictions. Physical facilities shall be cleaned as often as necessary to keep them clean. "Soiled receptacles and waste handling units for refuse, recyclables, and returnable shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents." II. Facility policy and procedure The Food Storage policy, last reviewed 2/8/21, was provided by the director of nursing (DON) on 6/6/23 at 5:15 p.m. It read in pertinent part: "Food items within the building are to be stored to ensure they are optimal for safe consumption by patients and staff. Storing foods properly helps to prevent foodborne illness and maintains the food's peak qualities such as flavor, texture, color and aroma." An untitled, undated document with the facility's logo was provided by the DON on 6/6/23 at 5:15 p.m., it read in pertinent part: "Keep all kitchen equipment and utensils used to produce food products clean and in a good condition. Protect food from dirt, vermin, unnecessary handling, droplet contamination, overhead leakage, or other environmental sources of contamination." III. Observations On 5/31/23 at 9:08 a.m., the main kitchen was observed, the following conditions were present:-Two large trash cans did not have lids on them;-The floor in the dry storage room was heavily soiled at the side walls where the floor met the wall to include a heavy layer of blackened debris and dust all along the long wall where food was stored.-The was behind the food storage shelves were solid with dried drips of red, brown, tan and blackened substances;-Condiment containers were soiled with blackened smudges and dried drips of tan, debris;-There were four dented cans stored on food shelves with un-dented cans with no indication to not use the dented cans;-There was a large open bag of bread crumbs that was fully open to air and not resealed or dated after opening;-Two packages of pasta that had been opened were not sealed for storage;-The walk-in refrigerator shelved several unlabeled, undated and some uncovered prepared leftover food items. Some foods appeared to be easily identifiable (corn, cauliflower and broccoli) and other items were not so easily identifiable (two containers of differing type of a thick brown gelatinous substance, red sauce with of unidentified brown chuck mixed in);-There were four open packages of sliced cheese not dated or resealed after opening;-In the main kitchen, the ice machine outer vent was heavily soiled with gray dust and the door and top surface was soiled with a film of fine dust;-The stand alone refrigerator was soiled with dust and the inner door had dried brown drips on it;-The trashcan placed in between two meal prep tables and the steam table prep area had a layer of dust and debris on the push lid and around the edges were it met the prep tables met the tables;-Exposed pipes behind the grill were soiled with dust and blackened debris; -The top of the back wall of the grill was heavily soiled with a thick layer of a dark black substance; and,-The metal splatter guard surfaces on either side of the deep fat fryer were heavily soiled with a thick layer of dark amber grease. During observations of the walk-in refrigerator, the dietary manager (DM) said the unlabeled food items should have been tossed out. During the observation of the main kitchen, the DM said the kitchen trash cans had lids and needed to be placed on the trash cans for sanitation. On 6/5/23 at 10:50 a.m. the main kitchen was observed the conditions in the main kitchen and dry storage room continued as observed on 5/31/23 (see above). IV. Staff interviews The DM was interviewed on 6/6/23 at 11:22 a.m., during a tour of the kitchen. The DM said since returning to work in the facility, she had done a lot of work to get the kitchen cleaned particularly with the floor; it had to be bleached to get rid of the past buildup of soiling and restore it. The DM said some areas like in the dry storage were missed due to having to move the food storage shelving and really be able to remove the surface dirt. The DM said there was still some work to complete. The DM said the kitchen was cleaned routinely after each meal service and at the end of the day; then given a deeper clean once a week. The DM said the splattered oil on the metal splash guard walls on each side of the fryer were very hard to keep clean. During the interview, the DM assigned specific kitchen staff to clean on specific areas identified during the kitchen tour. The DM said any opened unused food item should be thoroughly sealed for storage and removed the bread crumbs due to the product being exposed for an extended period of time. The DM said she would in-service kitchen staff and address all identified areas to ensure proper food storage and kitchen sanitation.

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 for six out of six rooms. Specifically, the facility failed to:-Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles, phone and hand rails);-Ensure surface disinfectant times were followed; and, -Ensure staff followed personal protective equipment (PPE) precautions for a resident diagnosed with COVID-19 when providing care and when cleaning the resident room. 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. 2021 Jul;113:104-114 was retrieved on 6/6/23 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 stay, 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 (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 6/9/23 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:-bedrails-IV (intravenous) poles-sink handles-bedside tables-counters-edges of privacy curtains-patient monitoring equipment (keyboards, control panels)-call bells-door knobs"Proceed From Cleaner To DirtierProceed 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.-Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."B. Facility policy and procedureThe Housekeeping Services policy and procedure, issued on 11/1/17, was provided by the director of maintenance (DOM) on 6/5/23 at 4:07 p.m. It read in pertinent part, "We prevent our patients, visitors and staff from infections everyday. Our team can control the spread of infection by daily disinfection and following all hand hygiene protocols. Disinfecting kills germs. Allowing adequate time for a disinfectant to sit on a surface assures 100% disinfection. This is known as the 'kill time'. We currently use a 1:10 bleach solution that has a 3 minute kill time and 730 hydrogen peroxide disinfectant cleaner that has a kill time of 10 minutes. Only use approved cleaners as they are kept track of with up to date MSDS (material safe data sheets) sheets and safety binders. Daily routine needs to include high touch areas which can include: door, knobs, light switch, sharps table and tray, call light, and phone, call box and pull cord, commode seat, rim and flusher. All patient rooms to include the bathroom and shower should be cleaned daily and some may need to be cleaned more often."C. Manufacturer recommendations The disinfectants in the facility were identified as:730 HP Disinfectant CleanerThe product label was reviewed which read in pertinent part, "For Use as a Daily One-Step Cleaner/Disinfectant: Pre-clean heavily soiled surfaces. Apply Use Solution by coarse trigger sprayer to hard, non-porous surfaces. Spray 6-8 inches from the surface, making sure to wet surfaces thoroughly. All surfaces must remain wet for ten minutes. Wipe surfaces and let air dry."D. Observations On 6/5/23 housekeeper (HSKP) #1 was continuously observed cleaning in room #243 from 10:42 a.m. to 11:04 a.m. HSKP #1 wiped the surfaces in the room with a soaked 730 HP disinfectant cloth for nine seconds per surface. The surface was no longer wet within 45 seconds from when the disinfectant was applied and she did not apply the disinfectant correctly by spraying it on the surface. The resident's towel fell on the ground twice prior to the floor being mopped and was not replaced. HSKP #1 folded the towel and hung it back on the bathroom rail for the resident to use. The shower was not cleaned or disinfected. No high frequency touch areas were disinfected (see above policy and procedure). HSKP #2 was continuously observed cleaning in room #220 from 11:21 a.m. to 11:41 a.m. HSKP #2 wiped the surfaces in the room with the soaked 730 HP disinfectant cloth for a few seconds per surface. She did not apply the disinfectant correctly by spraying it on the surface and did not clean the entire surface of the bedside table and desk. The surface was no longer wet within 45 seconds from when the disinfectant was applied. High frequency touch areas were wiped but not disinfected (hand rail, room call light, light switches, closet handles, bed controller and television remote). For the areas HSKP #2 did use the disinfectant to clean, the surface disinfectant time was not followed per manufacturer recommendations. E. Staff interviewsHSKP #1 was interviewed on 6/5/23 at 11:07 a.m. HSKP #1 said she did not know the surface disinfectant time of the housekeeping disinfectant products and she did not clean all high frequency touch areas in the residents' room. HSKP #1 said she ran out of chemicals monthly and therefore she would dilute chemicals with water and clean the residents' rooms if the facility ran out of disinfectant. HSKP #2 was interviewed on 6/5/23 at 11:46 a.m. HSKP #2 said she did not know the surface disinfectant time of the housekeeping disinfectant products. The director of maintenance (DOM) was interviewed on 6/5/23 at 3:53 p.m. The DOM said chemicals should never be diluted because they would no longer be effective. The DOM said if the surface disinfectant time(how long the surface must remain wet) was not adhered to; the disinfectant then would not be effective. The DOM said the facility should use Virex and "ready to use" bleach (not to be diluted) and not use 730 HP. The DOM said she needed to provide training to all housekeeping staff and she needed to revise the current training and onboarding program to cover surface disinfectant times, cleaning supply access and locations, room cleaning procedures and high frequency touch areas. The infection preventionist (IP) was interviewed on 6/6/23 at 3:07 p.m. The IP said she was involved with the housekeeping department, it was her job to make sure housekeeping adhered to infection control guidelines. Surface disinfectant times should be adhered to, adherence to the surface disinfectant time would ensure surfaces were properly disinfected and all pathogens were destroyed. High frequency touch areas should be disinfected and chemicals should never be diluted. Diluted chemicals would be ineffective. D. Additional informationThe facility provided two different versions of the housekeeping policy. The version provided by the DOM was issued on 11/1/17. No revision and or review dates have been listed since 2017(6 years ago). The chemicals used in the policy were in contrast with the DOM's chemical list (see above). The DOM said she trained housekeeping staff according to the policy provided dated 11/1/17. The nursing home administrator (NHA) was interviewed on 6/6/23 at 1:43 p.m. The NHA said the policies and procedures of the facility needed to be revised as some were outdated; once the policies were revised all staff would receive education on the revised policies and procedures. Policies and procedures should be reviewed and updated as needed and or at least annually. The NHA acknowledged there were discrepancies between the housekeeping policy provided by the DOM and the current last revised policy that he provided. The NHA said the facility should be following the current last revised policy. The NHA said the facility's housekeeping practice should align with the policy established. The NHA provided an updated housekeeping policy last revised on 8/17/22. II. COVID-19 PPE precautions A. Observations and record review Certified nurse aide (CNA)# 5 was observed on 6/31/23 at 3:47 p.m., entering and exiting room 331 (a room under COVID-19 isolation precautions) while wearing a surgical mask and no other PPE. CNA #5 did not use hand sanitizer after leaving the room and walked down the hallway wearing the same mask that was worn in the isolation room. The COVID-19 positive resident was moved to room #325. On 6/1/23 at 2:07 p.m. an unknown female staff member was observed with a medication cart delivering supplies. The unknown staff member walked into the COVID-19 positive room and was about two feet inside the room talking to the resident. They remained inside of the room for a couple of minutes. The unknown staff member came out of the room without sanitizing her hands. She looked through the cart and continued the task. There was a PPE cart and folder with diagnosis and PPE instructions. The instructions said all staff including housekeeping staff need to wear full PPE which include the following: N95 mask, goggles, gown and gloves. Staff should put PPE on before entering the room and take it off before leaving the room. At 2:12 p.m., room #331 had been occupied by a resident that had COVID-19. Room #331 was empty and had previously worn PPE in a trash bag located on the ground. At 2:23 p.m. HSKP #3 was observed while cleaning room #331. HSKP #3 did not wear any PPE except gloves, while cleaning a room previously occupied by a resident that was diagnosed with COVID-19. B. Staff nterviewsThe DON was interviewed on 6/1/23 at 3:20 p.m. She said when a resident contracted COVID-19, administration puts the resident on isolation and all staff who entered the resident's room should adhere to full precautions; which include N95 mask, goggles or face shield, a gown and gloves. The staff should perform hand hygiene after exiting the room. She said staff should dispose of all PPE before exiting the isolation room and dispose of the mask they wore in the isolation room and get a new mask. She said she did not know the expectation of PPE for housekeeping when cleaning a room after a resident diagnosed with COVID-19 left but they should deep clean the room. She said staff should not wear surgical masks in a COVID-19 resident rooms and should not continue to wear masks after exiting the room. She said staff should not be in the isolation room without proper PPE and when they exit they should perform hand hygiene. She said she would follow up with education for all staff on proper protocol when working with a resident that is diagnosed with COVID-19. The DON was interviewed again on 6/5/23 at 2:01 p.m. She said she talked CNA #5 said she wore a N95 mask over her surgical mask and wore PPE in the isolation room. She said the unidentified staff was on the threshold and not inside the room. She educated the staff on proper PPE while working with COVID-19 positive residents. The housekeeping supervisor (HSKS) was interviewed on 6/5/23 at 4:00 p.m. She said housekeepers should wear full PPE when cleaning a room that had occupied a positive COVID-19 resident. She said the housekeeper did not know room #331 had been occupied with a COVID-19 positive resident. She said nursing staff notified housekeeping staff when there was a COVID-19 positive resident. She said HSKP #3 was not aware the room had been occupied by a resident that had COVID-19. The DON was interviewed again 6/5/23 at 4:45 p.m. She said staff knew residents have COVID-19 because they have carts in front of their rooms with a folder telling staff directions on how to proceed. She said housekeeping staff would know the COVID-19 positive residents by the carts in front of the door. She said if a resident moved rooms housekeeping staff should know since the cart and folder was previously there.

Based on record review and interview, the facility failed to implement an effective training program for staff. Specifically, the facility failed to: -Ensure two certified nurse aides (CNA) out of five CNAs reviewed completed the required annual abuse identification, prevention and reporting training; and, -Ensure three CNAs out of five CNAs reviewed completed the required annual dementia care training. Findings include:I. Facility policy and procedureThe Facility Assessment policy, revised 12/13/2020, was provided by the nursing home administrator (NHA) on 6/6/23 at 1:15 p.m. It documented in the pertinent part,"All staff members complete (computer program) training modules during orientation and prior to beginning on the job training. Additionally, staff complete the training modules annually. "These modules included recognizing and reporting abuse and understanding Alzheimer's and dementia."II. Record reviewThe facility provided employee training records on 6/6/23 for five randomly selected CNAs. -CNA #6 and CNA #7 did not have annual abuse identification, prevention and reporting training completed in the last year. -CNA#1, CNA #6 and CNA #7 did not have annual dementia care training completed in the last year. III. Staff interviewThe director of nursing (DON) was interviewed on 6/6/23 at 12:43 p.m. The DON said training for abuse, dementia and resident rights was done through computer based training and human resources keep track of this training. The DON said staff got emails that they need to do training. The DON said HR notifies her when staff was behind in training and the DON would remind staff to do the training. The DON said she had not received an email about training in six months. The NHA was interviewed on 6/6/23 at 12:59 p.m. The NHA said he had been there for a couple of months and the NHA and HR identified training as being deficient. The NHA said he knew that CNAs were not up to date on training. The NHA said human resources (HR) recognized the training was behind and HR had started a few months ago. The NHA said HR had it on their list to fix.

A complaint survey, prompted by #CO31535 and #CO31655 was conducted on 4/12/23 and 4/13/23. No deficiencies were cited.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/13/2023 and 03/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.