CENTER AT CORDERA, LLC, THE

The initial comments are informational only and are a representative of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a three-story Type II (111) structure without a basement. The structure is protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. This survey, conducted Sep 20, 2024 inspected the facility for compliance with Chapter 19, "Existing Health Care Occupancies," of the 2012 edition of NFPA 101-Life Safety Code, the 2012 edition of NFPA 99, Health Care Facilities Code, and other publications as referenced. The facility will meet these requirements when the following deficiencies are corrected.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Fire Alarm Deficiency- Missed elevator detectors during the annual inspection - Need to update semi annual visual only language NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. 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 Administra at the exit conference.

A recertification survey was conducted from 8/26/24 to 8/29/24. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 8/26/24 to 8/29/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#30 and #5) of six residents reviewed for falls out of 28 sample residents. Resident #30, who was severely cognitively impaired and had a history of falls, was admitted to the facility on 7/19/24 after a fall at home which resulted in a left hip fracture requiring surgical repair. Upon the resident's admission, the facility initiated a fall care plan with generalized interventions that were implemented for all residents, including an intervention to ensure the resident's call light was within reach and a "Call, don't fall" sign was to be posted in the resident's room.-However, the facility failed to appropriately assess Resident #30's ability to use her call light and understand what the "Call, don't fall" sign was for due to her severe cognitive impairments. The facility did not implement person-centered fall interventions that were specific to Resident #30 and staff were not educated regarding the resident's increased need for supervision to prevent falls. On 7/26/24, Resident #30 sustained a fall from bed without injury. The immediate interventions were to remind the resident to use her call light, despite the fact the resident had severe cognitive impairments and frequent checks by staff for safety. On 8/1/24, Resident #30 sustained a second fall, this time in her bathroom. The resident complained of increased left hip pain and was transferred to the hospital where it was discovered the resident had refractured her left hip, requiring a second surgical repair. Due to the facility's failures to implement timely person-centered fall interventions and ensure staff were aware of the resident's increased need for supervision, Resident #30 sustained two falls within 13 days of being admitted to the facility, with the second fall resulting in a major injury. Additionally, for Resident #5, the facility failed to implement timely person-centered fall interventions and ensure staff were aware of the resident's increased risk for falls due to Parkinson's disease. Between 7/9/24, the date the resident admitted to the facility, and 8/15/24, Resident #5 sustained seven falls. Two of the falls occurred on 8/15/24 within one hour and 15 minutes of each other. Findings include:I. Facility policy and procedure The Fall Prevention policy, revised July 2023, was provided by the nursing home administrator (NHA) on 8/28/24 at 1:05 p.m. It read in pertinent part, "Falls in the skilled nursing setting represent one of the most potentially devastating occurrences that can negatively impact a resident's recovery. In facilities, falls directly cause tens of thousands of bone fractures, intracranial hemorrhages, re-hospitalizations, and deaths every year in the United States. It is because of these unfortunate events that the facility is implementing its comprehensive program to prevent falls and injury."Procedure: Any resident deemed to be high risk by nursing and/or therapy staff will have the following interventions at least considered:-Thorough physical and occupational therapy evaluation;-Low bed (or lower standard bed to its lowest position);-Routine toileting schedule throughout shift;-Line of sight as needed;-Nursing staff as needed;-Consult pharmacist to review medications as needed;-Encourage resident to participate in monitored activities; and,-Move the resident to a room closer to the nurse's station. "Dementia or altered mental status, not oriented:-Admit in a room closest to the nurses' station or observation room if available;-Routine toileting schedule throughout the shift;-Residents not to be left alone in the bathroom; and,-Round on residents throughout the shift. "Post fall procedure:-Determine what interventions need to be implemented to prevent further falls; and, -Complete orders and/or tasks for fall prevention."II. Resident #30A. Resident statusResident #30, age 88, was admitted on 7/19/24 and readmitted on 8/3/24. According to the August 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, other mechanical complication of internal fixation device of left femur, subsequent encounter, mild cognitive impairment, type 2 diabetes mellitus with hyperglycemia, muscle weakness, unspecified dementia and periprosthetic fracture (broken bone that occurs around an orthopedic implant) around internal prosthetic left hip joint. The 7/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. She required substantial/maximum assistance with toileting, bathing, and partial/moderate assistance with transfers. B. Resident observation and staff interviewResident #30 was observed on 8/26/24 at 12:40 p.m. in the nurses' station area. She was sitting in a wheelchair with her eyes closed. Registered nurse (RN) #1 said Resident #30 fell a few weeks ago (8/1/24) and refractured her left hip. She said on readmission, the resident was placed in the observation room close to the nurses' station for safety. RN #1 said the resident could not use the call light. She said the staff frequently brought Resident #30 to the nurses' station to keep an eye on her. She said Resident #30 had not made any physical progress since her readmission, had quit eating food and would be discharged to a hospice care facility. C. Record reviewResident #30's activities of daily living (ADL) care plan, initiated 7/19/24, revealed the resident had an actual/potential decline in her ability to perform her ADLs due to impaired mobility related to a left hip fracture with surgical repair. Interventions included encouraging the resident to do as much as possible for herself as able, placing the call light within reach and providing assistance as needed with grooming, bathing and personal hygiene and per the resident's preferences. The transfers/toileting care plan, initiated 7/19/24, revealed the resident required assistance with transfer/toileting related to impaired mobility secondary to weakness and debility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance.-The care plan did not indicate how often the resident should be checked on. The fall care plan, initiated 7/19/24, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility, a fall with a left hip fracture prior to admission, cognitive impairment and the resident's current drug regimen. Interventions included keeping the call light within reach, reinforcing the need to call for assistance and wearing proper non-slip footwear.-However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired. The high risk faller care plan, initiated 7/19/24, revealed the resident was at high risk for falls but was aware she might have a fall with major injury. Interventions included placing a "Call, don't fall" sign in the resident's room to remind the resident to call for assistance and having adequate lighting.-However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired. The actual fall care plan, initiated 7/26/24, revealed Resident #30 was at risk for further falls related to attempting to self transfer without calling for assistance, functional/clinical decline, impulsivity and poor safety awareness. Interventions included placing a "Call, don't fall" sign in the resident's room to remind the resident to call for assistance and rounding on the resident throughout the shift.-However, Resident #30 had severe cognitive impairments and herability to remember to use the call light or call for assistance was impaired.-The care plan did not indicate how often the resident should be rounded on during the shift.-None of the above care plans were updated with additional fall interventions upon Resident #30's readmission to the facility following her fall with major injury, hospitalization and surgical repair of her refractured left hip. 1. Fall #1A nurse progress note dated 7/26/24 documented the resident was found on the floor by certified nurse aide (CNA) at 6:30 a.m. When the nurse entered the resident's room, the resident was sitting on the floor near the bed. The resident was confused and said she tried to get up from the bed and slid on the floor but did not hit her head. The resident was assessed, able to move both hands and her right leg. She was not able to move her left leg due to her recent left hip repair. No injuries were noted. The resident was educated and reminded to use her call light for all transfers and needs. Frequent checks by staff for safety were implemented and the resident was assisted back to bed by two staff members with the use of a gait belt. The family and the physician were notified and an order for an x-ray was obtained as a precaution. A post fall evaluation dated 7/26/24 documented the probable cause of the fall was the resident did not use her call light and tried to get out of bed by herself. The resident was confused.-However, the intervention after the fall, despite the resident's cognitive impairments and confusion, was to remind the resident to use the call light. The interdisciplinary team's (IDT) review of the 7/26/24 fall documented the resident had no change in her level of consciousness or orientation status. The provider ordered bilateral hip x-rays after the fall, which her negative for any new fractures. The resident was verbally educated on call light use and verbalized verbalized understanding. Current fall interventions included a "Call, don't fall" sign. A new intervention for frequent checks was initiated and the resident would continue to work with therapy on balance and strength training. A physician's note dated 7/29/24 documented Resident #30's cognitive impairment was likely consistent with at least mild dementia. The resident did not have agitation but the resident was unable to provide much meaningful information and seemed to be repetitive. A social services note dated 7/30/24 documented Resident #30 was drowsy and unable to stay awake long enough to discuss the Notice of Medicare Non-coverage (NOMNC). The resident was only able to score a two out of 15 on BIMS assessment.-However, despite the resident's cognitive impairments and confusion, the facility continued to utilize reminding the resident to use the call light as a fall intervention. 2. Fall #2A nurse progress note dated 8/1/24 documented a RN was called to the resident's room for a reported fall. The resident was found on the floor in the bathroom, diagonally between the shower and the toilet. The resident was complaining to her post-surgical left hip. The RN assessed the resident and the surgical site was reasonably intact, however, there was suspicion the resident re-injured or refractured her left hip. The physician was notified and a physician's order was obtained to send the resident to the hospital for further assessment and treatment. The resident's family was notified. A post fall evaluation dated 8/1/24 documented the probable cause of fall was the resident's non-compliance with call light use, self-ambulating without assistance from staff and poor safety awareness. The IDT's review of the 8/1/24 fall documented the resident had no change in her level of consciousness or orientation status. Current fall interventions included a "Call, don't fall" sign. The resident was sent to the hospital due to concerns for re-injury to her left hip. Per the 8/1/24 hospital left hip x-ray (see hospital record below), worsening of the left hip fracture was noted. The resident was admitted to the hospital. The resident would be admitted into an observation room upon her readmission to the facility. A hospital progress note dated 8/1/24 documented the resident was a very pleasant female who sustained a ground level fall and was brought to the emergency department with a periprosthetic femur fracture. She had undergone cephalomedullary nailing of a left intertrochanteric femur fracture about two and half weeks prior. On 8/1/24 she was in a rehabilitation facility and sustained an unwitnessed fall. Upon presentation to the emergency department, she was noted to have a periprosthetic femur fracture around the short cephalomedullary nail that had been placed. The injury was discussed with the resident's legal representative regarding the diagnosis and treatment alternatives, including the risks of surgery. The resident's representative expressed understanding of the risks and desired to proceed with surgery. Resident #30 readmitted to the facility on 8/3/24 and was admitted into an observation room close to the nurses station (see interviews below). A social services note dated 8/14/24 documented the social worker spoke with the resident and family during a care conference. The discussion included information about hospice care and needs for next level care at home. The family was provided pamphlets about hospice services, Medicaid assistance and caregiving services. A nurse progress note dated 8/26/24 (during the survey) documented Resident #30 was discharged at 2:25 p.m. to another facility with hospice care services. D. Staff interviewThe director of rehabilitation (DOR) was interviewed on 8/29/24 at 10:45 a.m. The DOR said Resident #30 was initially admitted on the third floor, however, after two falls and the hospitalization, she was readmitted to the observation room close to the nurses station on the second floor on 8/3/24. He said he was not aware Resident #30 could not use a call light. III. Resident #5A. Resident statusResident #5, age 69, was admitted on 7/9/24. According to the August 2024 CPO, diagnoses included acute cystitis (inflammation of the bladder) with hematuria (blood in the urine), Parkinson's disease, insomnia, benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, type 2 diabetes mellitus, overactive bladder, unspecified mood disorder, history of transient ischemic attack (TIA) and cerebral infarction (stoke) and the presence of a neurostimulator (a device that uses electrical stimulation to treat neurological and psychiatric disorders). The 7/13/24 MDS assessment revealed the resident's cognition was intact with a BIMS score 14 out of 15. The resident did not have rejection of care and no behaviors were noted. The resident's range of motion of upper and lower extremity was impaired on both sides. He was dependent on staff with toileting and required substantial/maximal assistance with all transfers (bed/wheelchair/toilet). B. Resident and family interviewResident #5 and his wife were interviewed together on 8/26/24 at 2:30 p.m. Resident #5 said he was not aware how to use the call light for the first few days in the facility and he did not realize he was not strong enough to transfer himself from his bed to his wheelchair. Resident #5's family member said, with his Parkinson's diagnosis, Resident #5 was falling frequently at home when she was at work and the facility was aware of the resident's poor safety awareness upon his admission to the facility. She said Resident #5 had previously sustained traumatic brain injuries and he did not realize he needed assistance with transfers. C. Record reviewResident #5's ADL care plan, initiated 7/9/24, revealed the resident had actual/potential decline in his ability to perform his ADLs due to impaired mobility related to Parkinson's disease. Interventions included encouraging the resident to do as much as possible for himself as able, placing the call light within reach and providing assistance as needed with grooming, bathing and personal hygiene and per the resident's preferences. The bowel incontinence care plan, initiated 7/9/24, revealed the resident was incontinent of bowel due to impaired mobility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance.-The care plan did not indicate how often the resident should be checked on. The transfers/toileting care plan, initiated 7/9/24, revealed the resident required assistance with transfer/toileting related to weakness and debility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance.-The care plan did not indicate how often the resident should be checked on. The fall care plan, initiated 7/9/24, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility, Parkinson's disease, history of falls, neuropathy (a nerve disease or damage that can cause pain, numbness, or tingling in different parts of the body) and the resident's current drug regimen. Interventions included keeping the call light within reach, keeping commonly used items within reach, occupational therapy (OT) and physical therapy (PT) to evaluate and treat as needed. The actual fall care plan, initiated 7/25/24, revealed the resident had a fall at the facility and was at risk for further falls related to attempting to transfer without assistance, confusion, functional/clinical decline, impulsivity and poor safety awareness. Interventions initiated on 7/25/24 included placing a "Call, don't fall" sign in the resident's room to remind the resident to call for assistance, utilizing the "4 P's", including asking does the resident need to use the bathroom, does the resident need to be repositioned, are all commonly used belongings within reach of the resident, and is the resident having pain and notifying the nurse immediately if the answer to pain was yes. Interventions initiated 8/16/24 (after seven falls - see falls below) included the use of a fall mat, keeping the bed in a low position while the resident was in bed, keeping the call light within reach at all times, using a motion sensor, moving the resident closer to the nurses station, rounding on the resident throughout the shift and providing a soft touch call light.-The care plan did not indicate how often the resident should be rounded on throughout the shift.-Despite Resident #5's intact cognition BIMS score of 14 out of 15, the facility failed to appropriately assess Resident #5's ability to use his call light for assistance based on his history of traumatic brain injuries (see family interview above). The 7/9/24 Comprehensive Nursing Assessment revealed Resident #5's fall risk score was 40, which indicated he was a moderate risk for falls. 1. Fall #1A nurse progress note dated 7/24/24 at 3:50 a.m. documented a RN was called to Resident #5's room for a reported fall by the CNA. The resident was found lying on the floor parallel to his bed on his right side. The resident was alert with clear and discernible speech and no changes in mentation were noted. No injuries noted. The resident had little to no stated or observable pain. When asked what he was doing the resident said he fell out of bed but he did not know why he was trying to get out of bed. Staff was able to transfer the resident, once assessed, back to his bed. He was reassessed and no injuries were noted. Vital signs and neurological checks were started per protocol. The physician and family were notified. A post fall evaluation dated 7/24/24 documented the probable cause of the fall was the resident had very poor safety awareness with short term memory loss.-However, despite the resident's poor safety awareness and short term memory loss, the facility continued to utilize reminding the resident to use the call light and call for assistance as a fall intervention. The IDT's review of the 7/24/24 fall documented the resident had no change in his level of consciousness or orientation status. The resident obtained no injuries from the fall. Current fall interventions included a "Call don't fall" sign. New interventions initiated included the Fall Program and frequent rounding. The resident was verbally educated on the importance of call light use and the resident verbalized understanding. The resident would continue to work with therapy on balance and strength training.-Despite the resident's poor safety awareness and short term memory loss, the facility continued to utilize reminding the resident to use the call light and call for assistance as a fall intervention. 2. Fall #2A nurse progress note dated 7/28/24 documented Resident #5 had an unwitnessed fall at 12:00 a.m. after staff did rounds on him at 11:45 p.m. He was found by staff on the left side of his bed sitting on his legs and left foot with his knees bent. The resident had a superficial scratch on his left knee and his catheter had been pulled out of the securing device attached on his left leg. The resident reported he was trying to turn off his television (TV). The RN evaluated the resident and CNAs and the RN transferred the resident back to bed. Neurological checks were initiated.-A Post Fall Evaluation dated 7/28/24 failed to document the probable cause of the fall. The IDT's review of the 7/28/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. The facility planned to move the resident to an observation room once one was available. The resident would continue to work with therapy on strength training and balance. 3. Fall #3A nurse progress note dated 7/30/24 at 11:49 p.m. documented a RN was called to the resident's room with a suspected fall. The resident was found on the floor on his left side facing the bed, holding the bed tightly by the footboard handles, with a big grin on his face and saying he needed help. When asked, the resident stated he was needing help,and that's why he thought he might be on the floor. The resident was assessed, no injuries were noted and the resident was able to answer all inquiries per his baseline mentation. The resident returned to his bed and was reassessed with no injuries found, however, he needed to be changed which was what possibly perpetuated the fall. The physician and family were notified. Vital signs and neurological checks were restarted per protocol.-A post fall evaluation dated 7/30/24 failed to document the probable cause of the fall. The IDT's review of the 7/30/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. The facility planned to move the resident to an observation room once one was available. A medication review was completed on the resident by the physician and new orders were obtained to discontinue the resident's scheduled Ambien. The resident would continue to work with therapy on strength training and balance. 4. Fall #4A nurse progress note dated 8/6/24 at 6:24 a.m. documented the RN was called to the resident's room and no injuries were noted. The resident was assessed and returned to bed. Vital signs and neurological checks were started per protocol. The physician and family were notified.-A post fall evaluation dated 8/6/24 failed to document the probable cause of the fall. The IDT's review of the 8/6/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. A new intervention was implemented for a motion sensor at night. The resident would continue to work with therapy on strength training and balance.-However, staff was not aware the motion sensor needed to be turned on when the resident went to bed at night (see interviews below). 5. Fall #5A nurse progress noted dated 8/13/24 at 2:15 p.m. documented the nurse responded to Resident #5's fall and immediately placed a pillow underneath the resident's head for comfort. Neurological checks were within normal limits and the resident denied a headache, nausea or vomiting or vision changes. There was no immediate bruising or redness noted to any areas assessed. The resident's range of motion was intact as prior to the fall and there was no lengthening or shortening of his upper or lower extremities noted. The resident's speech was soft, but clear and understood. The resident was transferred to his wheelchair with the assistance of two staff members and a gait belt and tolerated it well. The resident was taken to the nurses' station/common area for one-to-one supervision.-The facility failed to document a Post Fall Evaluation or IDT review for the fall.-The progress note failed to document any new fall interventions put into place following the fall. 6. Fall #6A nurse progress note dated 8/15/24 at 9:20 p.m. documented a CNA notified the nurse about the resident lying on the floor lying on his back. He was alert and oriented to person and place. The resident stated he crawled from his bed, kneeled down to the floor and continued to crawl out to the door. He said he did not fall but wanted to get out of his room. The resident said he did not hit his head. His range of motion was within normal limits and he denied pain. The resident was able to follow all commands. He was assisted to sit in his chair and able to bear weight on both of his legs/feet. Neurological checks and monitoring were initiated.-The facility failed to document a post fall evaluation or IDT review for the fall.-The progress note failed to document any new fall interventions put into place following the fall. 7. Fall #7A nurse progress note dated 8/15/24 at 10:35 p.m. documented the resident's spouse was visiting and informed the nurse the resident was on the floor. The nurse found the resident crawling on his hands and knees in the doorway. There were no injuries noted. The fall was unwitnessed. The resident stated that he rolled onto his side and crawled onto the floor. The resident became a little upset when asked if he hit his head. He stated he did not hit his head. A RN assessed the resident and the resident was placed in his wheelchair after the assessment. The resident's spouse and the physician were notified. Neurological checks were initiated and the resident would continue to be monitored.-The progress note failed to document any new fall interventions put into place following the fall.-The facility failed to document a post fall evaluation for the fall. The IDT's review of the 8/15/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding the 4 P's, a motion sensor and the resident was in an observation room. The resident remained on the fall program and the resident's wife was often at the resident's bedside. Activities would continue to offer more one-to-one activities with the resident. A request was made for a soft touch call light and a fall mat was added for resident safety due to the resident's frequent falls. The resident would continue to work with therapy on strength training and balance. D. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 8/27/24 at 8:20 p.m. LPN #2 said he was not aware of any specific interventions for Resident #5 for falls prevention. He said the staff usually did rounds to check on all residents. He did not specify how frequent the rounds were. CNA #3 was interviewed on 8/27/24 at 8:24 p.m. CNA #3 said he was not aware Resident #5 was at risk for falls and had already had several falls while in the facility. He said he usually did rounds when he was not busy with residents' care, however, he said there was no specific time frame to do frequent rounds. He said he was not aware there was a motion sensor in the resident's room that needed to be turned on when the resident was in bed for the night. The DOR was interviewed on 8/29/24 at 10:13 a.m. The DOR said Resident #5 required moderate assistance with transfers and short distance walks with his front-wheeled walker. The DOR said falls were discussed in morning meetings. He said Resident #5 was moved to the observation room on the second floor by the nurses station from the third floor after a couple of falls. He said the resident's falls were related to his poor cognition. He said the resident was unable to maintain not any safety education. The DOR said therapy focused on transfer training and safety and routine with the resident, but he worried about injury prevention. He said the therapy staff was working on fall recovery techniques with the resident. LPN #1 was interviewed on 8/29/24 at 10:0 a.m. LPN #1 said he was not aware of any specific fall prevention approaches for Resident #5, except frequent checks and call light within reach. He said there was no set time frame for frequent checks, it could be once every hour. IV. Director of nursing (DON) interviewThe DON was interviewed on 8/29/23 at 10:45 a.m. The DON said when a resident was accepted for admission, the admission coordinator screened for fall risk and notified the floor nurse to initiate fall prevention interventions. The DON said the 4 P's were the facility's fall prevention program, and every resident was at risk for falling. The DON said the admissions coordinator needed clinical credentials and he was unaware of how the admissions coordinator determined a resident's fall risk. The DON said a baseline care plan was developed for every resident at admission. The DON said the care plan was updated when a resident had a fall or required additional interventions. The DON reviewed the baseline care plans for Resident #30 and Resident #5 and said the interventions were the same because all residents were at risk for falls. He said the facility did not need to identify levels of fall risk because every resident was a fall risk, and the 4 Ps were used to prevent falls. The DON said CNAs should be aware of every resident at risk for falling by reviewing Resident task lists. He said CNAs were prompted for each resident when a resident had a fall, the care plan was updated, and CNAs were notified when they reviewed their assigned task list.-However, staff interviews revealed staff were not aware of which residents were fall risks and what fall interventions were in place for specific residents (see interviews above).

Based on observations, record review and interviews, the facility failed to provide effective pain management in accordance with professional standards for one (#1) of one resident out of 27 sample residents. Resident #1 was admitted on 7/31/24 with a diagnosis of intracerebral hemorrhage (stroke), type 2 diabetes, muscle weakness and adult failure to thrive. According to the 7/31/24 nursing comprehensive admission assessment for skin, Resident #1 had no skin issues. He often refused repositioning and to get out of bed due to pain. On 8/12/24 he developed pressure ulcers on his buttocks and coccyx. Additional medication was not ordered for wound care and all he was receiving for pain was Tylenol four times per day and a Lidocaine patch. On 8/27/24 Resident #1 was observed to be in severe pain during wound care of his buttocks and coccyx wounds. The facility's failure to provide effective pain management contributed to the resident suffering prolonged pain from his wounds and other areas on his body. Findings include:I. Facility policy and procedureThe Pain Management policy and procedure, revised 2/8/21, was provided by the nursing home administrator (NHA) on 8/29/24 at 12:59 p.m. The policy read in pertinent part, "Frequently, patients arrive from the hospital with acute pain secondary to being transferred to the facility. Once a patient expresses the perception of pain or makes a request for pain medications, the patient will be provided with a dose of analgesic pain medication or non-pharmacological interventions will be initiated. It is the responsibility of the individual or staff member that heard the complaint to follow up and make sure that some intervention (pharmacological or otherwise) is initiated. Nurses must follow pain parameters and enter pain scales for pain medications."II. Resident #1A. Resident statusResident #1, age 79, was admitted on 7/31/24. According to the August 2024 computerized physician orders (CPO), diagnoses included intracerebral hemorrhage, type 2 diabetes, muscle weakness and adult failure to thrive. The 7/31/24 minimum data set (MDS) assessment revealed the resident had no brief interview for mental status (BIMS) completed due to the resident rarely/never being understood. The nursing comprehensive assessment for the neurological system, completed on 7/31/24, revealed Resident #1 was alert and oriented to himself. The resident required extensive assistance from two or more staff members for bed mobility, transfers, dressing, toileting and personal hygiene. He was always incontinent of bowel and had an indwelling catheter in place. The MDS assessment indicated the resident did not receive scheduled pain medications. He received as needed pain medication and non-pharmacological interventions for pain. The pain assessment indicated the resident did not have pain. The resident had no skin conditions upon admission and was at risk for developing pressure ulcers. B. Resident interview Resident #1 was interviewed on 8/27/24 at 8:30 a.m. Resident #1 said he had pressure sores that caused him to be in a lot of pain all the time. He said he always laid right on the sores, which caused more pain. He said the nurses put a pain patch on his back or neck and he got Tylenol for the pain but it did not relieve the pain. He said he would like to get out of bed but it was too painful. He said it was too painful to lift up his legs. Resident #1 was interviewed a second time on 8/28/24 at 10:25 a.m. Resident #1 said the CNAs did not offer to get him out of bed. He said he would like to get out of bed and into his wheelchair. He said the female CNAs that came in and helped him were not strong enough to get him out of bed. He said it took three or four of them to get his brief changed. He said they needed a couple strong men to come and get him out of bed and this had never been offered. He said his legs and back were almost always in pain when he was moved. C. Observations and staff interviewsDuring a continuousobservation on 8/27/24, beginning at 1:54 p.m. and ending at 2:40 p.m., registered nurse (RN) #2 gathered supplies to complete wound care for Resident #1's wounds. She walked into the room and two unidentified certified nurse aides (CNA) were in the room providing incontinence care. Resident #1 was yelling out and said it hurt when they rolled him to his side. The unidentified CNAs were telling the resident they had to roll him in order to clean up his bottom because he had a bowel movement. Resident #1 said they needed to get strong men to come in and roll him because the girls in there were not strong enough. Resident #1 was pushing against the CNAs trying to roll him. RN #2 explained to Resident #1 the procedure she needed to do. Resident #1 agreed and RN #2 removed two bandages from Resident #1's coccyx and right side of his bottom. He yelled out and said that hurt. RN #2 cleansed the wounds with a wound cleanser and applied medication to the wounds. Resident #1 was screaming in pain during the treatment and asked her multiple times to stop because it was so painful. RN #2 said she was almost done and they had to clean the wounds. She applied the new bandages to the wounds. RN #2 said Resident #1 was pre-medicated with Tylenol prior to the wound care. She said the resident had a stage 3 pressure ulcer to his gluteal fold and a stage 3 pressure ulcer to his right buttocks with maceration (skin around the wound is softened from moisture exposure) around the wounds. -RN #2 did not offer any pain interventions to Resident #1 during the wound care and did not stop wound care to give the resident a break when he was in pain. During a continuous observation on 8/28/24, beginning at 12:30 p.m. and ending at 1:30 p.m., the following was observed: CNA #5 was attempting to feed Resident #1 lunch. Resident #1 was refusing to eat. CNA #5 kept encouraging the resident to eat the chocolate ice cream while talking with him. He ate about ten bites. Resident #1 was talking about how much pain he was in. CNA #5 said she would tell the nurse about his pain after she fed him. During a continuous observation on 8/29/24, beginning at 12:15 p.m. and ending at 12:45 p.m. the following was observed: CNA #4 was assisting Resident #1 with his lunch. She sat him up in the bed and he yelled out to lay him back down. Resident #1 was yelling that it hurt when she sat him up. He told CNA #4 he did not want to eat because he was in so much pain. Resident #1 said if he was not in so much pain he would have liked to get up in his wheelchair. He said his back and bottom hurt. CNA #4 moved his left arm and he yelled out in pain. She said she was going to tell the nurse about his pain and come back to feed him later. D. Record reviewThe 8/28/24 comprehensive pain evaluation (completed during the survey) revealed Resident #1 had pain frequently in his knees, back and neck. The pain frequently interfered with therapy. Resident #1 exhibited calling out, moaning and groaning when he experienced pain. The pain affected Resident #1's mood and functioning in his daily life. The assessment indicated rest, relaxation, diversion, elevation of extremities and immobilization provided him with relief. Necessary treatments that caused him pain included therapy and wound dressing changes. The assessment documented it was unable to be determined if the current pain program was working. The August 2024 CPO revealed the resident had the following physician's orders for pain management: -Lidocaine patch 4%, apply to neck and back topically every morning and at bedtime for discomfort/pain, apply patch in morning and remove at hour of sleep, ordered on 8/13/24. -Tylenol oral tablet 325 milligrams (mg), give two tablets by mouth four times a day for pain, ordered on 8/13/24.-Evaluation of pain every shift and document, ordered 7/31/24. The care plan for acute/chronic pain, initiated on 7/31/24 and revised on 8/14/24, revealed the resident had chronic pain related to generalized chronic pain. Interventions for acute/chronic pain included acknowledging the presence of pain and discomfort, listening to the resident's concerns as needed, administering pain medications per physician's order and noting effectiveness, implementing non-pharmacological interventions when able, such as positioning/support, exercise/stretching, ice packs/moist hot pack application and relaxation, monitoring for pain every shift and as needed and notifying the physician as needed for any changes. According to the August 2024 (8/1/24 to 8/27/24) medication administration record (MAR), Resident #1 was offered repositioning and a calm environment for non-pharmacological pain interventions every four hours. -A review of Resident #1's electronic medical record (EMR) did not reveal the staff offered ice packs, moist hot packs, exercise/stretching or support to Resident #1 for non-pharmacological pain interventions.-A review of Resident #1's EMR did not reveal the staff were monitoring the effectiveness of Tylenol that was administered four times a day or the repositioning and calm environment. According to the turning and repositioning August 2024 CNA task log (8/1/24 to 8/26/24), Resident #1 was repositioned a total of 49 times. He was repositioned no more than two times a day. There were no refusals of repositioning documented on the log. III. Staff interviewsCNA #4 was interviewed on 8/29/24 at 12:15 p.m. CNA #4 said Resident #1 refused to eat and be repositioned frequently. She said he yelled out in pain and verbalized pain often. She said every time this happened, she told the nurse. She said the nurse told her that they would check on him when this happened but she did not know what they did to address the problems. She said it helped to explain the procedures to him before they did anything because he was scared anything they did would make him hurt. CNA #5 was interviewed on 8/28/24 at 10:30 a.m. CNA #5 said Resident #1 was incontinent of bowel and bladder and was checked and changed every two hours or as needed. She said he often yelled when they cleaned him and repositioned him. She said he got confused but was redirectable. She said the staff had to explain what they were going to do to him before doing it. She said he never got out of bed. She said she was not sure why, but he would get up every now and then with therapy. She said they offered to reposition him every two hours and charted it in the computer system. She said she assisted the nurses with his wound care. She said each time she did this, he would scream out in pain during the wound care. RN #2 was interviewed on 8/28/24 at 11:40 a.m. RN #2 said Resident #1 was repositioned and checked and changed every one to two hours. She said he had pressure ulcers on his bottom. She said he had pain when he was moved for wound care and repositioning. She said he received Tylenol scheduled and Lidocaine patches for his back and neck. RN #2 said he did not get out of bed and she was not sure why. She said there was no reason he was bedbound. CNA #6 was interviewed on 8/28/24 at 12:10 p.m. CNA #6 said the CNAs repositioned Resident #1 every two hours and assisted him at every meal. She said he often refused to eat and be repositioned. She said therapy got him out of bed sometimes but he refused to get out of bed when the CNAs offered. She said he did not want them to hurt themselves because he thought they were too small and weak to get him up safely. She said he was always in pain and he flinched in anticipation before she touched him to perform resident care. She said she made sure to explain what she would be doing before she touched him. RN #3 was interviewed on 8/29/24 at 12:00 p.m. RN #3 said Resident #1 had pain primarily with movement and when he was repositioned. He said the pain was mainly in his neck. He said he received scheduled Tylenol and Lidocaine patches for the pain. He said he documented Resident #1's pain level before administration of the Tylenol and every shift. He said non-pharmacological interventions to address pain included ice and heat packs but he never got these for the resident. RN #3 said therapy sometimes got the non-pharmacological pain interventions for the resident. He said the CNAs reported to him when the resident was having pain and he would go and check on the resident. He said he was not aware of Resident #1 refusing care due to pain. He said the Tylenol and patches helped the resident's pain. The director of nursing (DON) was interviewed on 8/29/24 at 10:00 a.m. The DON said Resident #1 was at risk for developing pressure ulcers at admission. He said on admission, Resident #1 was refusing care and could become aggressive with staff. He said Resident #1 was sleepy when he was admitted so the provider discontinued his pain medications. He said Resident #1 did experience pain in his neck and back. He said he got scheduled Tylenol and Lidocaine patches. He said he was not sure if the medications relieved the resident's pain.

Based on observations, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on one of five hallways. Specifically, the facility failed to: -Ensure the housekeeping staff completed proper hand hygiene when cleaning resident rooms and followed the appropriate guidelines for disinfectant solution; and,-Ensure the nursing staff followed enhanced barrier precautions (EBP) appropriately during resident care. Findings include:I. Failure to ensure housekeeping completed proper hand hygiene and followed appropriate disinfectant guidelines when cleaning resident roomsA. Professional referenceThe Center for Disease Control (CDC) (February 2024) Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 9/4/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, "Recommendations to clean your hands include immediately before touching a patient, before performing an aseptic technique, before moving from work on a soiled body site to a clean body site, after touching a patient or patient's surroundings, after contact with body fluids and immediately after glove removal."The 730 hp disinfectant cleaner manufacturer label was retrieved on 9/5/24 from https://picol.cahnrs.wsu.edu/Download/LabelByLegacyPath?legacyPath=/~picol/pdf/WA/66222.pdf It read in pertinent part, "For use as a daily one-step cleaner/disinfectant: dilute at two ounces of product per gallon of water, pre-clean heavily soiled surfaces, apply use solution by coarse trigger sprayer to hard surfaces, spray six to eight inches from surface making sure to wet surfaces thoroughly, all surfaces must remain wet for ten minutes, wipe surfaces and let air dry."B. Facility policy and procedure The Hand Hygiene policy and procedure, revised 1/7/24, was received from the nursing home administrator (NHA) on 8/29/24 at 12:59 p.m. It documented in pertinent part, "Use soap and water when hands become dirty or soiled. Use an alcohol-based hand sanitizer that contains at least 60% alcohol. Put enough sanitizer on your hands to cover all surfaces, rub your hands together until they feel dry."C. Observations During a continuous observation on 8/27/24, beginning at 10:00 a.m. and ending at 11:08 a.m., the following was observed:Housekeeper (HSKP) #1 was observed cleaning resident room #308. She finished mopping the room and removed her dirty gloves. Without performing hand hygiene, she donned (put on) clean gloves. HSKP #1 moved to room #306. She started cleaning the bathroom by spraying 730 hp disinfectant solution on the sink. She immediately wiped the sink with a towel. She sprayed the grab bars in the bathroom with the disinfectant and immediately wiped them down with a towel. She repeated this process with the toilet. She mopped the bathroom. She removed the dirty gloves, and without performing hand hygiene, she donned clean gloves. She moved to the bedroom and sprayed the bedside table with 730 hp disinfectant solution. She immediately wiped down the surface with a towel. She repeated this process with the window sill and the desk. She mopped and swept the floor.-HSKP #1 did not follow the correct dwell time for the 730 hp disinfectant solution.-HSKP #1 did not perform hand hygiene in between glove changes. HSKP #1 moved to room #305. She sprayed the door handles with 730 hp disinfectant solution and immediately wiped them down with a towel. She repeated this process with the sink in the bathroom, the toilet and the commode. She mopped the bathroom and removed the dirty gloves. Without performing hand hygiene, she donned clean gloves. She sprayed the bedside table with 730 hp disinfectant solution and immediately wiped it down with a new rag. She repeated this process with the window sill and desk. She mopped the room. She removed the dirty gloves. Without performing hand hygiene, she began to wipe down the window sill in the hallway. -HSKP #1 did not follow the correct dwell time for the 730 hp disinfectant solution. -HSKP #1 did not perform hand hygiene in between glove changes. D. Staff interviews The housekeeping director (HSKD) was interviewed on 8/28/24 at 4:06 p.m. The HSKD said the dwell time for the 730 hp disinfectant solution was one minute for cleaning their standard rooms with no transmission based precautions. He said hand hygiene should be completed after removing dirty gloves and prior to donning clean gloves. -However, the 730 hp disinfectant solution manufacturer label indicated the dwell time was 10 minutes. The director of nursing (DON) was interviewed on 8/29/24 at 10:00 a.m. The DON said hand hygiene should be performed after removing dirty gloves. He said hand hygiene should be performed prior to donning clean gloves. II. Failure to ensure nursing staff followed enhanced barrier precautions (EBP) appropriately during resident caresA. Facility policy and procedure The Enhanced Barrier Precautions policy and procedure, issued 3/27/24, was received from the NHA on 8/29/24 at 12:59 p.m. It documented in pertinent part, "Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the number of multidrug resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP are required for patients with wounds and/or indwelling medical devices. High-contact care activities included dressing, bathing, transferring, working with patients in the therapy gym, providing hygiene, changing linens, changing briefs or assisting with toileting, device care and wound care."B. Observations During a continuous observation, beginning on 8/27/24 at 10:00 a.m. and ending at 11:08 a.m, the following was observed:An unidentified certified nursing assistant (CNA) entered into room #309 after an unidentified transportation staff member assisted the resident to his room after the resident returned from a doctor's appointment. He had an indwelling foley catheter device and was on EBP. There was a sign posted outside the room and a cart that contained gowns and gloves outside his door. The unidentified CNA donned clean gloves and walked into the room. She transferred the resident from his wheelchair to his bed using a gait belt. The unidentified CNA moved the catheter drainage bag from the wheelchair and hooked it onto the bottom of his bed. She walked out of his room and removed the dirty gloves. She washed her hands. -The CNA did not put a gown on to provide resident care to a resident on EBP. During an observation on 8/28/24 at 3:17 p.m., the following was observed:The resident in room #309 initiated his call light . The staffing coordinator (SC) walked into the room. She grabbed gloves on her way into the room. There was a sign on the door that indicated the resident was on EBP. There was a cart stocked with gowns and gloves outside his room. She asked how she could help him and he asked to get out of bed. She put a gait belt on him and assisted him out of bed and into a wheelchair. She moved his catheter drainage bag from the bed to his wheelchair. She removed her gloves and washed her hands. -The SC did not wear a gown when she assisted the resident with transferring and when handling a resident who had a foley catheter that was on EBP. C. Staff interviewsThe DON was interviewed on 8/29/24 at 10:00 a.m. The DON said EBP should be followed when providing resident care for those with medical devices or chronic wounds. He said high contact activity included when the staff members were in direct contact with the resident. He said some of these activities included toileting residents, changing linens, dressing residents, transferring residents and providing wound care. He said staff should put a gown and gloves on prior to providing these care activities with residents on EBP.

A licensure survey was completed on 8/26/24 to 8/29/24. Two deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide effective pain management in accordance with professional standards for one (#1) of one resident out of 27 sample residents. Resident #1 was admitted on 7/31/24 with a diagnosis of intracerebral hemorrhage (stroke), type 2 diabetes, muscle weakness and adult failure to thrive. According to the 7/31/24 nursing comprehensive admission assessment for skin, Resident #1 had no skin issues. He often refused repositioning and to get out of bed due to pain. On 8/12/24 he developed pressure ulcers on his buttocks and coccyx. Additional medication was not ordered for wound care and all he was receiving for pain was Tylenol four times per day and a Lidocaine patch. On 8/27/24 Resident #1 was observed to be in severe pain during wound care of his buttocks and coccyx wounds. The facility's failure to provide effective pain management contributed to the resident suffering prolonged pain from his wounds and other areas on his body. Findings include:I. Facility policy and procedureThe Pain Management policy and procedure, revised 2/8/21, was provided by the nursing home administrator (NHA) on 8/29/24 at 12:59 p.m. The policy read in pertinent part, "Frequently, patients arrive from the hospital with acute pain secondary to being transferred to the facility. Once a patient expresses the perception of pain or makes a request for pain medications, the patient will be provided with a dose of analgesic pain medication or non-pharmacological interventions will be initiated. It is the responsibility of the individual or staff member that heard the complaint to follow up and make sure that some intervention (pharmacological or otherwise) is initiated. Nurses must follow pain parameters and enter pain scales for pain medications."II. Resident #1A. Resident statusResident #1, age 79, was admitted on 7/31/24. According to the August 2024 computerized physician orders (CPO), diagnoses included intracerebral hemorrhage, type 2 diabetes, muscle weakness and adult failure to thrive. The nursing comprehensive assessment for the neurological system, completed on 7/31/24, revealed Resident #1 was alert and oriented to himself. The resident required extensive assistance from two or more staff members for bed mobility, transfers, dressing, toileting and personal hygiene. He was always incontinent of bowel and had an indwelling catheter in place. The 7/31/24 facility assessment indicated the resident did not receive scheduled pain medications. He received as needed pain medication and non-pharmacological interventions for pain. The pain assessment indicated the resident did not have pain. The resident had no skin conditions upon admission and was at risk for developing pressure ulcers. B. Resident interview Resident #1 was interviewed on 8/27/24 at 8:30 a.m. Resident #1 said he had pressure sores that caused him to be in a lot of pain all the time. He said he always laid right on the sores, which caused more pain. He said the nurses put a pain patch on his back or neck and he got Tylenol for the pain but it did not relieve the pain. He said he would like to get out of bed but it was too painful. He said it was too painful to lift up his legs. Resident #1 was interviewed a second time on 8/28/24 at 10:25 a.m. Resident #1 said the CNAs did not offer to get him out of bed. He said he would like to get out of bed and into his wheelchair. He said the female CNAs that came in and helped him were not strong enough to get him out of bed. He said it took three or four of them to get his brief changed. He said they needed a couple strong men to come and get him out of bed and this had never been offered. He said his legs and back were almost always in pain when he was moved. C. Observations and staff interviewsDuring a continuous observation on 8/27/24, beginning at 1:54 p.m. and ending at 2:40 p.m., registered nurse (RN) #2 gathered supplies to complete wound care for Resident #1's wounds. She walked into the room and two unidentified certified nurse aides (CNA) were in the room providing incontinence care. Resident #1 was yelling out and said it hurt when they rolled him to his side. The unidentified CNAs were telling the resident they had to roll him in order to clean up his bottom because he had a bowel movement. Resident #1 said they needed to get strong men to come in and roll him because the girls in there were not strong enough. Resident #1 was pushing against the CNAs trying to roll him. RN #2 explained to Resident #1 the procedure she needed to do. Resident #1 agreed and RN #2 removed two bandages from Resident #1's coccyx and right side of his bottom. He yelled out and said that hurt. RN #2 cleansed the wounds with a wound cleanser and applied medication to the wounds. Resident #1 was screaming in pain during the treatment and asked her multiple times to stop because it was so painful. RN #2 said she was almost done and they had to clean the wounds. She applied the new bandages to the wounds. RN #2 said Resident #1 was pre-medicated with Tylenol prior to the wound care. She said the resident had a stage 3 pressure ulcer to his gluteal fold and a stage 3 pressure ulcer to his right buttocks with maceration (skin around the wound is softened from moisture exposure) around the wounds. -RN #2 did not offer any pain interventions to Resident #1 during the wound care and did not stop wound care to give the resident a break when he was in pain. During a continuous observation on 8/28/24, beginning at 12:30 p.m. and ending at 1:30 p.m., the following was observed: CNA #5 was attempting to feed Resident #1 lunch. Resident #1 was refusing to eat. CNA #5 kept encouraging the resident to eat the chocolate ice cream while talking with him. He ate about ten bites. Resident #1 was talking about how much pain he was in. CNA #5 said she would tell the nurse about his pain after she fed him. During a continuous observation on 8/29/24, beginning at 12:15 p.m. and ending at 12:45 p.m. the following was observed: CNA #4 was assisting Resident #1 with his lunch. She sat him up in the bed and he yelled out to lay him back down. Resident #1 was yelling that it hurt when she sat him up. He told CNA #4 he did not want to eat because he was in so much pain. Resident #1 said if he was not in so much pain he would have liked to get up in his wheelchair. He said his back and bottom hurt. CNA #4 moved his left arm and he yelled out in pain. She said she was going to tell the nurse about his pain and come back to feed him later. D. Record reviewThe 8/28/24 comprehensive pain evaluation (completed during the survey) revealed Resident #1 had pain frequently in his knees, back and neck. The pain frequently interfered with therapy. Resident #1 exhibited calling out, moaning and groaning when he experienced pain. The pain affected Resident #1's mood and functioning in his daily life. The assessment indicated rest, relaxation, diversion, elevation of extremities and immobilization provided him with relief. Necessary treatments that caused him pain included therapy and wound dressing changes. The assessment documented it was unable to be determined if the current pain program was working. The August 2024 CPO revealed the resident had the following physician's orders for pain management: -Lidocaine patch 4%, apply to neck and back topically every morning and at bedtime for discomfort/pain, apply patch in morning and remove at hour of sleep, ordered on 8/13/24. -Tylenol oral tablet 325 milligrams (mg), give two tablets by mouth four times a day for pain, ordered on 8/13/24.-Evaluation of pain every shift and document, ordered 7/31/24. The care plan for acute/chronic pain, initiated on 7/31/24 and revised on 8/14/24, revealed the resident had chronic pain related to generalized chronic pain. Interventions for acute/chronic pain included acknowledging the presence of pain and discomfort, listening to the resident's concerns as needed, administering pain medications per physician's order and noting effectiveness, implementing non-pharmacological interventions when able, such as positioning/support, exercise/stretching, ice packs/moist hot pack application and relaxation, monitoring for pain every shift and as needed and notifying the physician as needed for any changes. According to the August 2024 (8/1/24 to 8/27/24) medication administration record (MAR), Resident #1 was offered repositioning and a calm environment for non-pharmacological pain interventions every four hours. -A review of Resident #1's electronic medical record (EMR) did not reveal the staff offered ice packs, moist hot packs, exercise/stretching or support to Resident #1 for non-pharmacological pain interventions.-A review of Resident #1's EMR did not reveal the staff were monitoring the effectiveness of Tylenol that was administered four times a day or the repositioning and calm environment. According to the turning and repositioning August 2024 CNA task log (8/1/24 to 8/26/24), Resident #1 was repositioned a total of 49 times. He was repositioned no more than two times a day. There were no refusals of repositioning documented on the log. III. Staff interviewsCNA #4 was interviewed on 8/29/24 at 12:15 p.m. CNA #4 said Resident #1 refused to eat and be repositioned frequently. She said he yelled out in pain and verbalized pain often. She said every time this happened, she told the nurse. She said the nurse told her that they would check on him when this happened but she did not know what they did to address the problems. She said it helped to explain the procedures to him before they did anything because he was scared anything they did would make him hurt. CNA #5 was interviewed on 8/28/24 at 10:30 a.m. CNA #5 said Resident #1 was incontinent of bowel and bladder and was checked and changed every two hours or as needed. She said he often yelled when they cleaned him and repositioned him. She said he got confused but was redirectable. She said the staff had to explain what they were going to do to him before doing it. She said he never got out of bed. She said she was not sure why, but he would get up every now and then with therapy. She said they offered to reposition him every two hours and charted it in the computer system. She said she assisted the nurses with his wound care. She said each time she did this, he would scream out in pain during the wound care. RN #2 was interviewed on 8/28/24 at 11:40 a.m. RN #2 said Resident #1 was repositioned and checked and changed every one to two hours. She said he had pressure ulcers on his bottom. She said he had pain when he was moved for wound care and repositioning. She said he received Tylenol scheduled and Lidocaine patches for his back and neck. RN #2 said he did not get out of bed and she was not sure why. She said there was no reason he was bedbound. CNA #6 was interviewed on 8/28/24 at 12:10 p.m. CNA #6 said the CNAs repositioned Resident #1 every two hours and assisted him at every meal. She said he often refused to eat and be repositioned. She said therapy got him out of bed sometimes but he refused to get out of bed when the CNAs offered. She said he did not want them to hurt themselves because he thought they were too small and weak to get him up safely. She said he was always in pain and he flinched in anticipation before she touched him to perform resident care. She said she made sure to explain what she would be doing before she touched him. RN #3 was interviewed on 8/29/24 at 12:00 p.m. RN #3 said Resident #1 had pain primarily with movement and when he was repositioned. He said the pain was mainly in his neck. He said he received scheduled Tylenol and Lidocaine patches for the pain. He said he documented Resident #1's pain level before administration of the Tylenol and every shift. He said non-pharmacological interventions to address pain included ice and heat packs but he never got these for the resident. RN #3 said therapy sometimes gotthe non-pharmacological pain interventions for the resident. He said the CNAs reported to him when the resident was having pain and he would go and check on the resident. He said he was not aware of Resident #1 refusing care due to pain. He said the Tylenol and patches helped the resident's pain. The director of nursing (DON) was interviewed on 8/29/24 at 10:00 a.m. The DON said Resident #1 was at risk for developing pressure ulcers at admission. He said on admission, Resident #1 was refusing care and could become aggressive with staff. He said Resident #1 was sleepy when he was admitted so the provider discontinued his pain medications. He said Resident #1 did experience pain in his neck and back. He said he got scheduled Tylenol and Lidocaine patches. He said he was not sure if the medications relieved the resident's pain.

Based on observations, record review and interviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#30 and #5) of six residents reviewed for falls out of 28 sample residents. Resident #30, who was severely cognitively impaired and had a history of falls, was admitted to the facility on 7/19/24 after a fall at home which resulted in a left hip fracture requiring surgical repair. Upon the resident's admission, the facility initiated a fall care plan with generalized interventions that were implemented for all residents, including an intervention to ensure the resident's call light was within reach and a "Call, don't fall" sign was to be posted in the resident's room.-However, the facility failed to appropriately assess Resident #30's ability to use her call light and understand what the "Call, don't fall" sign was for due to her severe cognitive impairments. The facility did not implement person-centered fall interventions that were specific to Resident #30 and staff were not educated regarding the resident's increased need for supervision to prevent falls. On 7/26/24, Resident #30 sustained a fall from bed without injury. The immediate interventions were to remind the resident to use her call light, despite the fact the resident had severe cognitive impairments and frequent checks by staff for safety. On 8/1/24, Resident #30 sustained a second fall, this time in her bathroom. The resident complained of increased left hip pain and was transferred to the hospital where it was discovered the resident had refractured her left hip, requiring a second surgical repair. Due to the facility's failures to implement timely person-centered fall interventions and ensure staff were aware of the resident's increased need for supervision, Resident #30 sustained two falls within 13 days of being admitted to the facility, with the second fall resulting in a major injury. Additionally, for Resident #5, the facility failed to implement timely person-centered fall interventions and ensure staff were aware of the resident's increased risk for falls due to Parkinson's disease. Between 7/9/24, the date the resident admitted to the facility, and 8/15/24, Resident #5 sustained seven falls. Two of the falls occurred on 8/15/24 within one hour and 15 minutes of each other. Findings include:I. Facility policy and procedure The Fall Prevention policy, revised July 2023, was provided by the nursing home administrator (NHA) on 8/28/24 at 1:05 p.m. It read in pertinent part, "Falls in the skilled nursing setting represent one of the most potentially devastating occurrences that can negatively impact a resident's recovery. In facilities, falls directly cause tens of thousands of bone fractures, intracranial hemorrhages, re-hospitalizations, and deaths every year in the United States. It is because of these unfortunate events that the facility is implementing its comprehensive program to prevent falls and injury."Procedure: Any resident deemed to be high risk by nursing and/or therapy staff will have the following interventions at least considered:-Thorough physical and occupational therapy evaluation;-Low bed (or lower standard bed to its lowest position);-Routine toileting schedule throughout shift;-Line of sight as needed;-Nursing staff as needed;-Consult pharmacist to review medications as needed;-Encourage resident to participate in monitored activities; and,-Move the resident to a room closer to the nurse's station. "Dementia or altered mental status, not oriented:-Admit in a room closest to the nurses' station or observation room if available;-Routine toileting schedule throughout the shift;-Residents not to be left alone in the bathroom; and,-Round on residents throughout the shift. "Post fall procedure:-Determine what interventions need to be implemented to prevent further falls; and, -Complete orders and/or tasks for fall prevention."II. Resident #30A. Resident statusResident #30, age 88, was admitted on 7/19/24 and readmitted on 8/3/24. According to the August 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, other mechanical complication of internal fixation device of left femur, subsequent encounter, mild cognitive impairment, type 2 diabetes mellitus with hyperglycemia, muscle weakness, unspecified dementia and periprosthetic fracture (broken bone that occurs around an orthopedic implant) around internal prosthetic left hip joint. The 7/25/24 facility assessment revealed the resident had severe cognitive impairment. She required substantial/maximum assistance with toileting, bathing, and partial/moderate assistance with transfers. B. Resident observation and staff interviewResident #30 was observed on 8/26/24 at 12:40 p.m. in the nurses' station area. She was sitting in a wheelchair with her eyes closed. Registered nurse (RN) #1 said Resident #30 fell a few weeks ago (8/1/24) and refractured her left hip. She said on readmission, the resident was placed in the observation room close to the nurses' station for safety. RN #1 said the resident could not use the call light. She said the staff frequently brought Resident #30 to the nurses' station to keep an eye on her. She said Resident #30 had not made any physical progress since her readmission, had quit eating food and would be discharged to a hospice care facility. C. Record reviewResident #30's activities of daily living (ADL) care plan, initiated 7/19/24, revealed the resident had an actual/potential decline in her ability to perform her ADLs due to impaired mobility related to a left hip fracture with surgical repair. Interventions included encouraging the resident to do as much as possible for herself as able, placing the call light within reach and providing assistance as needed with grooming, bathing and personal hygiene and per the resident's preferences. The transfers/toileting care plan, initiated 7/19/24, revealed the resident required assistance with transfer/toileting related to impaired mobility secondary to weakness and debility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance.-The care plan did not indicate how often the resident should be checked on. The fall care plan, initiated 7/19/24, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility, a fall with a left hip fracture prior to admission, cognitive impairment and the resident's current drug regimen. Interventions included keeping the call light within reach, reinforcing the need to call for assistance and wearing proper non-slip footwear.-However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired. The high risk faller care plan, initiated 7/19/24, revealed the resident was at high risk for falls but was aware she might have a fall with major injury. Interventions included placing a "Call, don't fall" sign in the resident's room to remind the resident to call for assistance and having adequate lighting.-However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired. The actual fall care plan, initiated 7/26/24, revealed Resident #30 was at risk for further falls related to attempting to self transfer without calling for assistance, functional/clinical decline, impulsivity and poor safety awareness. Interventions included placing a "Call, don't fall" sign in the resident's room to remind the resident to call for assistance and rounding on the resident throughout the shift.-However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired.-The care plan did not indicate how often the resident should be rounded on during the shift.-None of the above care plans were updated with additional fall interventions upon Resident #30's readmission to the facility following her fall with major injury, hospitalization and surgical repair of her refractured left hip. 1. Fall #1A nurse progress note dated 7/26/24 documented the resident was found on the floor by certified nurse aide (CNA) at 6:30 a.m. When the nurse entered the resident's room, the resident was sitting on the floor near the bed. The resident was confused and said she tried to get up from the bed and slid on the floor but did not hit her head. The resident was assessed, able to move both hands and her right leg. She was not able to move her left leg due to her recent left hip repair. No injuries were noted. The resident was educated and reminded to use her call light for all transfers and needs. Frequent checks by staff for safety were implemented and the resident was assisted back to bed by two staff members with the use of a gait belt. The family and the physician were notified and an order for an x-ray was obtained as a precaution. A post fall evaluation dated 7/26/24 documented the probable cause of the fall was the resident did not use her call light and tried to get out of bed by herself. The resident was confused.-However, the intervention after the fall, despite the resident's cognitive impairments and confusion, was to remind the resident to use the call light. The interdisciplinary team's (IDT) review of the 7/26/24 fall documented the resident had no change in her level of consciousness or orientation status. The provider ordered bilateral hip x-rays after the fall, which her negative for any new fractures. The resident was verbally educated on call light use and verbalized verbalized understanding. Current fall interventions included a "Call, don't fall" sign. A new intervention for frequent checks was initiated and the resident would continue to work with therapy on balance and strength training. A physician's note dated 7/29/24 documented Resident #30's cognitive impairment was likely consistent with at least mild dementia. The resident did not have agitation but the resident was unable to provide much meaningful information and seemed to be repetitive. A social services note dated 7/30/24 documented Resident #30 was drowsy and unable to stay awake long enough to discuss the Notice of Medicare Non-coverage (NOMNC). The resident was only able to score a two out of 15 on BIMS assessment.-However, despite the resident's cognitive impairments and confusion, the facility continued to utilize reminding the resident to use the call light as a fall intervention. 2. Fall #2A nurse progress note dated 8/1/24 documented a RN was called to the resident's room for a reported fall. The resident was found on the floor in the bathroom, diagonally between the shower and the toilet. The resident was complaining to her post-surgical left hip. The RN assessed the resident and the surgical site was reasonably intact, however, there was suspicion the resident re-injured or refractured her left hip. The physician was notified and a physician's order was obtained to send the resident to the hospital for further assessment and treatment. The resident's family was notified. A post fall evaluation dated 8/1/24 documented the probable cause of fall was the resident's non-compliance with call light use, self-ambulating without assistance from staff and poor safety awareness. The IDT's review of the 8/1/24 fall documented the resident had no change in her level of consciousness or orientation status. Current fall interventions included a "Call, don't fall" sign. The resident was sent to the hospital due to concerns for re-injury to her left hip. Per the 8/1/24 hospital left hip x-ray (see hospital record below), worsening of the left hip fracture was noted. The resident was admitted to the hospital. The resident would be admitted into an observation room upon her readmission to the facility. A hospital progress note dated 8/1/24 documented the resident was a very pleasant female who sustained a ground level fall and was brought to the emergency department with a periprosthetic femur fracture. She had undergone cephalomedullary nailing of a left intertrochanteric femur fracture about two and half weeks prior. On 8/1/24 she was in a rehabilitation facility and sustained an unwitnessed fall. Upon presentation to the emergency department, she was noted to have a periprosthetic femur fracture around the short cephalomedullary nail that had been placed. The injury was discussed with the resident's legal representative regarding the diagnosis and treatment alternatives, including the risks of surgery. The resident's representative expressed understanding of the risks and desired to proceed with surgery. Resident #30 readmitted to the facility on 8/3/24 and was admitted into an observation room close to the nurses station (see interviews below). A social services note dated 8/14/24 documented the social worker spoke with the resident and family during a care conference. The discussion included information about hospice care and needs for next level care at home. The family was provided pamphlets about hospice services, Medicaid assistance and caregiving services. A nurse progress note dated 8/26/24 (during the survey) documented Resident #30 was discharged at 2:25 p.m. to another facility with hospice care services. D. Staff interviewThe director of rehabilitation (DOR) was interviewed on 8/29/24 at 10:45 a.m. The DOR said Resident #30 was initially admitted on the third floor, however, after two falls and the hospitalization, she was readmitted to the observation room close to the nurses station on the second floor on 8/3/24. He said he was not aware Resident #30 could not use a call light. III. Resident #5A. Resident statusResident #5, age 69, was admitted on 7/9/24. According to the August 2024 CPO, diagnoses included acute cystitis (inflammation of the bladder) with hematuria (blood in the urine), Parkinson's disease, insomnia, benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, type 2 diabetes mellitus, overactive bladder, unspecified mood disorder, history of transient ischemic attack (TIA) and cerebral infarction (stoke) and the presence of a neurostimulator (a device that uses electrical stimulation to treat neurological and psychiatric disorders). The 7/13/24 facility assessment revealed the resident's cognition was intact. The resident did not have rejection of care and no behaviors were noted. The resident's range of motion of upper and lower extremity was impaired on both sides. He was dependent on staff with toileting and required substantial/maximal assistance with all transfers (bed/wheelchair/toilet). B. Resident and family interviewResident #5 and his wife were interviewed together on 8/26/24 at 2:30 p.m. Resident #5 said he was not aware how to use the call light for the first few days in the facility and he did not realize he was not strong enough to transfer himself from his bed to his wheelchair. Resident #5's family member said, with his Parkinson's diagnosis, Resident #5 was falling frequently at home when she was at work and the facility was aware of the resident's poor safety awareness upon his admission to the facility. She said Resident #5 had previously sustained traumatic brain injuries and he did not realize he needed assistance with transfers. C. Record reviewResident #5's ADL care plan, initiated 7/9/24, revealed the resident had actual/potential decline in his ability to perform his ADLs due to impaired mobility related to Parkinson's disease. Interventions included encouraging the resident to do as much as possible for himself as able, placing the call light within reach and providing assistance as needed with grooming, bathing and personal hygiene and per the resident's preferences. The bowel incontinence care plan, initiated 7/9/24, revealed the resident was incontinent of bowel due to impaired mobility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance.-The care plan did not indicate how often the resident should be checked on. The transfers/toileting care plan, initiated 7/9/24, revealed the resident required assistance with transfer/toileting related to weakness and debility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance.-The care plan did not indicate how often the resident should be checked on. The fall care plan, initiated 7/9/24, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility, Parkinson's disease, history of falls, neuropathy (a nerve disease or damage that can cause pain, numbness, or tingling in different parts of the body) and the resident's current drug regimen. Interventions included keeping the call light within reach, keeping commonly used items within reach, occupational therapy (OT) and physical therapy (PT) to evaluate and treat as needed. The actual fall care plan, initiated 7/25/24, revealed the resident had a fall at the facility and was at risk for further falls related to attempting to transfer without assistance, confusion, functional/clinical decline, impulsivity and poor safety awareness. Interventions initiated on 7/25/24 included placing a "Call, don't fall" sign in the resident's room to remind the resident to call for assistance, utilizing the "4 P's", including asking does the resident need to use the bathroom, does the resident need to be repositioned, are all commonly used belongings within reach of the resident, and is the resident having pain and notifying the nurse immediately if the answer to pain was yes. Interventions initiated 8/16/24 (after seven falls - see falls below) included the use of a fall mat, keeping the bed in a low position while the resident was in bed, keeping the call light within reach at all times, using a motion sensor, moving the resident closer to the nurses station, rounding on the resident throughout the shift and providing a soft touch call light.-The care plan did not indicate how often the resident should be rounded on throughout the shift.-Despite Resident #5's intact cognition BIMS score of 14 out of 15, the facility failed to appropriately assess Resident #5's ability to use his call light for assistance based on his history of traumatic brain injuries (see family interview above). The 7/9/24 Comprehensive Nursing Assessment revealed Resident #5's fall risk score was 40, which indicated he was a moderate risk for falls. 1. Fall #1A nurse progress note dated 7/24/24 at 3:50 a.m. documented a RN was called to Resident #5's room for a reported fall by the CNA. The resident was found lying on the floor parallel to his bed on his right side. The resident was alert with clear and discernible speech and no changes in mentation were noted. No injuries noted. The resident had little to no stated or observable pain. When asked what he was doing the resident said he fell out of bed but he did not know why he was trying to get out of bed. Staff was able to transfer the resident, once assessed, back to his bed. He was reassessed and no injuries were noted. Vital signs and neurological checks were started per protocol. The physician and family were notified. A post fall evaluation dated 7/24/24 documented the probable cause of the fall was the resident had very poor safety awareness with short term memory loss.-However, despite the resident's poor safety awareness and short term memory loss, the facility continued to utilize reminding the resident to use the call light and call for assistance as a fall intervention. The IDT's review of the 7/24/24 fall documented the resident had no change in his level of consciousness or orientation status. The resident obtained no injuries from the fall. Current fall interventions included a "Call don't fall" sign. New interventions initiated included the Fall Program and frequent rounding. The resident was verbally educated on the importance of call light use and the resident verbalized understanding. The resident would continue to work with therapy on balance and strength training.-Despite the resident's poor safety awareness and short term memory loss, the facility continued to utilize reminding the resident to use the call light and call for assistance as a fall intervention. 2. Fall #2A nurse progress note dated 7/28/24 documented Resident #5 had an unwitnessed fall at 12:00 a.m. after staff did rounds on him at 11:45 p.m. He was found by staff on the left side of his bed sitting on his legs and left foot with his knees bent. The resident had a superficial scratch on his left knee and his catheter had been pulled out of the securing device attached on his left leg. The resident reported he was trying to turn off his television (TV). The RN evaluated the resident and CNAs and the RN transferred the resident back to bed. Neurological checks were initiated.-A Post Fall Evaluation dated 7/28/24 failed to document the probable cause of the fall. The IDT's review of the 7/28/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. The facility planned to move the resident to an observation room once one was available. The resident would continue to work with therapy on strength training and balance. 3. Fall #3A nurse progress note dated 7/30/24 at 11:49 p.m. documented a RN was called to the resident's room with a suspected fall. The resident was found on the floor on his left side facing the bed, holding the bed tightly by the footboard handles, with a big grin on his face and saying he needed help. When asked, the resident stated he was needing help,and that's why he thought he might be on the floor. The resident was assessed, no injuries were noted and the resident was able to answer all inquiries per his baseline mentation. The resident returned to his bed and was reassessed with no injuries found, however, he needed to be changed which was what possibly perpetuated the fall. The physician and family were notified. Vital signs and neurological checks were restarted per protocol.-A post fall evaluation dated 7/30/24 failed to document the probable cause of the fall. The IDT's review of the 7/30/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. The facility planned to move the resident to an observation room once one was available. A medication review was completed on the resident by the physician and new orders were obtained to discontinue the resident's scheduled Ambien. The resident would continue to work with therapy on strength training and balance. 4. Fall #4A nurse progress note dated 8/6/24 at 6:24 a.m. documented the RN was called to the resident's room and no injuries were noted. The resident was assessed and returned to bed. Vital signs and neurological checks were started per protocol. The physician and family were notified.-A post fall evaluation dated 8/6/24 failed to document the probable cause of the fall. The IDT's review of the 8/6/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. A new intervention was implemented for a motion sensor at night. The resident would continue to work with therapy on strength training and balance.-However, staff was not aware the motion sensor needed to be turned on when the resident went to bed at night (see interviews below). 5. Fall #5A nurse progress noted dated 8/13/24 at 2:15 p.m. documented the nurse responded to Resident #5's fall and immediately placed a pillow underneath the resident's head for comfort. Neurological checks were within normal limits and the resident denied a headache, nausea or vomiting or vision changes. There was no immediate bruising or redness noted to any areas assessed. The resident's range of motion was intact as prior to the fall and there was no lengthening or shortening of his upper or lower extremities noted. The resident's speech was soft, but clear and understood. The resident was transferred to his wheelchair with the assistance of two staff members and a gait belt and tolerated it well. The resident was taken to the nurses' station/common area for one-to-one supervision.-The facility failed to document a Post Fall Evaluation or IDT review for the fall.-The progress note failed to document any new fall interventions put into place following the fall. 6. Fall #6A nurse progress note dated 8/15/24 at 9:20 p.m. documented a CNA notified the nurse about the resident lying on the floor lying on his back. He was alert and oriented to person and place. The resident stated he crawled from his bed, kneeled down to the floor and continued to crawl out to the door. He said he did not fall but wanted to get out of his room. The resident said he did not hit his head. His range of motion was within normal limits and he denied pain. The resident was able to follow all commands. He was assisted to sit in his chair and able to bear weight on both of his legs/feet. Neurological checks and monitoring were initiated.-The facility failed to document a post fall evaluation or IDT review for the fall.-The progress note failed to document any new fall interventions put into place following the fall. 7. Fall #7A nurse progress note dated 8/15/24 at 10:35 p.m. documented the resident's spouse was visiting and informed the nurse the resident was on the floor. The nurse found the resident crawling on his hands and knees in the doorway. There were no injuries noted. The fall was unwitnessed. The resident stated that he rolled onto his side and crawled onto the floor. The resident became a little upset when asked if he hit his head. He stated he did not hit his head. A RN assessed the resident and the resident was placed in his wheelchair after the assessment. The resident's spouse and the physician were notified. Neurological checks were initiated and the resident would continue to be monitored.-The progress note failed to document any new fall interventions put into place following the fall.-The facility failed to document a post fall evaluation for the fall. The IDT's review of the 8/15/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a "Call don't fall sign, frequent rounding the 4 P's, a motion sensor and the resident was in an observation room. The resident remained on the fall program and the resident's wife was often at the resident's bedside. Activities would continue to offer more one-to-one activities with the resident. A request was made for a soft touch call light and a fall mat was added for resident safety due to the resident's frequent falls. The resident would continue to work with therapy on strength training and balance. D. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 8/27/24 at 8:20 p.m. LPN #2 said he was not aware of any specific interventions for Resident #5 for falls prevention. He said the staff usually did rounds to check on all residents. He did not specify how frequent the rounds were. CNA #3 was interviewed on 8/27/24 at 8:24 p.m. CNA #3 said he was not aware Resident #5 was at risk for falls and had already had several falls while in the facility. He said he usually did rounds when he was not busy with residents' care, however, he said there was no specific time frame to do frequent rounds. He said he was not aware there was a motion sensor in the resident's room that needed to be turned on when the resident was in bed for the night. The DOR was interviewed on 8/29/24 at 10:13 a.m. The DOR said Resident #5 required moderate assistance with transfers and short distance walks with his front-wheeled walker. The DOR said falls were discussed in morning meetings. He said Resident #5 was moved to the observation room on the second floor by the nurses station from the third floor after a couple of falls. He said the resident's falls were related to his poor cognition. He said the resident was unable to maintain not any safety education. The DOR said therapy focused on transfer training and safety and routine with the resident, but he worried about injury prevention. He said the therapy staff was working on fall recovery techniques with the resident. LPN #1 was interviewed on 8/29/24 at 10:0 a.m. LPN #1 said he was not aware of any specific fall prevention approaches for Resident #5, except frequent checks and call light within reach. He said there was no set time frame for frequent checks, it could be once every hour. IV. Director of nursing (DON) interviewThe DON was interviewed on 8/29/23 at 10:45 a.m. The DON said when a resident was accepted for admission, the admission coordinator screened for fall risk and notified the floor nurse to initiate fall prevention interventions. The DON said the 4 P's were the facility's fall prevention program, and every resident was at risk for falling. The DON said the admissions coordinator needed clinical credentials and he was unaware of how the admissions coordinator determined a resident's fall risk. The DON said a baseline care plan was developed for every resident at admission. The DON said the care plan was updated when a resident had a fall or required additional interventions. The DON reviewed the baseline care plans for Resident #30 and Resident #5 and said the interventions were the same because all residents were at risk for falls. He said the facility did not need to identify levels of fall risk because every resident was a fall risk, and the 4 Ps were used to prevent falls. The DON said CNAs should be aware of every resident at risk for falling by reviewing Resident task lists. He said CNAs were prompted for each resident when a resident had a fall, the care plan was updated, and CNAs were notified when they reviewed their assigned task list.-However, staff interviews revealed staff were not aware of which residents were fall risks and what fall interventions were in place for specific residents (see interviews above).

A survey for Incident #CO35571 was conducted 5/13/24 to 5/14/24. No deficiencies were cited.

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

A revisit survey was completed on 7/13/23 for all previous deficiencies cited on 4/25/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 7/13/23 for all previous deficiencies cited on 4/25/23. The facility is in compliance with all regulations surveyed

The initial comments are informational only and are a representative of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a three-story Type II (111) structure without a basement. The structure is protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. This survey, conducted May 09, 2023 inspected the facility for compliance with Chapter 19, "Existing Health Care Occupancies," of the 2012 edition of NFPA 101-Life Safety Code, the 2012 edition of NFPA 99, Health Care Facilities Code, and other publications as referenced. The facility will meet these requirements when the following deficiencies are corrected.

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. 12 Months of emergency light inspection reports not available at time of inspection12 Months of exit light inspection reports not available 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 installedNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101Fire Line Backflow preventer failed during inspectionNFPA 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 survey, it was determined that the facility failed to maintain corridor doors in accordance with Life Safety Code Section and NFPA 80. This was evidenced by the following:Fire and Smoke door inspection report not available at the time of inspectionNFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.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.

It was determined during record review that the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. Records were not available at the time of the survey to document the inspection and test operation of the fire dampers installed in the facility. NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary. 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 19.7.1.612 months of fire drills not available to review at time of inspectionNFPA 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.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: Inspection Weekly - 12 month report history not available at time of inspectionSpecific Gravity or Battery Conductance - 12 month report history not available at time of inspectionMonthly load test 20 days to 40 days - 12 month report history not available at time of inspectionAnnual Fuel Test Report - not available at time of inspection Transfer Switch: Monthly test with generator 20 days to 40 days - 12-month report history not available at time of inspection8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

A recertification survey with complaints #CO31710 and #CO31726 was completed from 4/19/23 to 4/25/23. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/19/23 to 4/25/23. Three deficiencies were cited.

Based on record review and interview, the facility failed to develop and maintain an emergency preparedness training and testing program. Specifically, the facility failed to have an emergency preparedness training and testing program for current and new staff. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the maintenance supervisor (MS) and nursing home administrator (NHA) on 4/25/23 at 9:45 a.m. Review of the EPP revealed the facility did not have an emergency preparedness training and testing program for current and new staff. II. Staff interview The EPP was reviewed with the MS and NHA on 4/25/23 at 9:45 a.m. The NHA said the facility did not have a current training or testing program for staff and new hires included in the EPP. She said it was important to have an EPP training and testing program to ensure the staff were up to date on the most current information available to provide the best care possible to the residents who resided in the facility.

Based on record review and interview, the facility failed to develop a training and testing program based on the emergency plan. Specifically, the facility failed to provide emergency preparedness training at least annually and maintain documentation of the training. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and maintenance supervisor (MS) on 4/25/23 at 9:45 a.m. Review of the EPP revealed the facility failed to provide emergency preparedness training at least annually and maintain documentation of the training. II. Staff interview The EPP was reviewed with the NHA and MS on 4/25/23 at 9:45 a.m. The NHA said the facility failed to provide emergency preparedness training at least annually and maintain documentation of the training. The NHA said it was important to update the EPP annually and as needed to keep up with the requirements.

Based on record review and interview, the facility failed to have a plan for how it will keep emergency power systems operational during the emergency unless it evacuates. Specifically, the facility failed to devise a plan to provide a backup power system in the event of a major power outage. Findings include: I. Facility plan The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) and maintenance supervisor (MS) on 4/25/23 at 9:45 a.m. Review of the EPP revealed at minimum the facility did not have a plan to provide alternative backup power for the facility in the event of a major power outage to protect residents' health and safety included in the EPP. II. Staff interview The maintenance supervisor (MS) was interviewed on 4/25/23 at 9:45 a.m. He did not have an onsite fuel source to power emergency generators to keep emergency power systems operational during the emergency unless it evacuated.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 17 of 44 resident rooms in four hallways. Specifically, the facility failed to ensure walls, and ventilation fans were cleaned and properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 4/24/23 at 3:30 p.m. revealed: Room #230: The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. Room #239: The wall next to the resident's restroom had peeling and chipped sheetrock approximately four feet high by two inches wide. The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. Room #238: The wall next to the resident's restroom had chipped and peeling sheetrock approximately four two feet high by two inches wide. The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. Room #237: The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. Room #240: The wall next to the resident's restroom had chipped and peeling sheetrock approximately three feet high by two inches wide. The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. The certified nurse station on the second floor had chipped and damaged sheetrock approximately five inches wide by four inches wide. Room #212: There was a metal bracket approximately four inches by three inches wide from the missing coat rack. Room #311: The wall next to the resident's restroom had a large chipped and peeling sheetrock approximately four feet high by five inches wide. The wall next to Room #303 had chipped and damaged sheet rock approximately five inches wide by four inches wide with the metal corner visible. Room #315: The counter next to the resident's bed had a section of missing laminate approximately five inches long by two inches wide. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 4/25/23 at 9:35 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said the facility utilized a computer system to identify environmental issues. The MS said he did not have any repair requisition requests for the above-mentioned items. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner. The MS said the facility had a flood about two months ago and it caused some issues with the heating ventilation air conditioner system. He said the dirty exhaust fans were a result of the filters not being changed. He said the dirty exhaust fans did not allow the functionality of the exhaust fans and could be a fire hazard. He said the filters would be changed immediately and the vents cleaned.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for one (#9) of two residents reviewed out of 28 sample residents. Specifically, the facility failed to ensure Resident #9's bilateral heels were offloaded while in bed. Findings include: I. Professional reference The National Pressure Injury Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers accessed on 4/27/23 from https://npiap.com/ read, "steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time."II. Facility policy and procedure The Pressure Ulcer policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 4/25/23 at 12:25 p.m. It read in pertinent part: "The (name) will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards." III. Resident #9 A. Resident status Resident #9, age 90, was admitted on 3/9/23. According to the April 2023 computerized physician orders (CPO), diagnoses included congestive heart failure, acute respiratory failure, acute kidney failure and assistance with personal care. According to the 3/13/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The MDS assessment coded the resident was at risk for pressure ulcers. The MDS assessment coded the resident as not having any behaviors or refusal of care. B. Observations and interview On 4/19/23 at 10:21 a.m. the resident was lying in bed sleeping. The resident did not have her feet off loaded. On 4/20/23 at 9:14 a.m. the resident was lying in bed sleeping. The resident did not have her feet off loaded. -At 10:33 a.m. the resident was lying in bed eating her ice cream. The resident did not have her feet off loaded. Resident #9 said, "They never put anything under my feet or have I been asked to have a pillow under my feet." -At 11:02 a.m. an unidentified certified nurse aide (CNA) asked the resident if she needed anything. The resident was not offered to be repositioned or offloaded. On 4/24/23 at 2:54 p.m. licensed practical nurse (LPN) #2 observed the resident did not have her feet off loaded. LPN #1 placed the pillow under her ankles to offload her heels from the mattress. During this care, the resident was cooperative and friendly with LPN #2. LPN #2 said according to the tasks and the care plan Resident #9 feet should be offloaded while the resident was in bed. She said a negative outcome would be the resident's heels would develop redness, cause skin breakdown and become a pressure ulcer. C. Record review The care plan, initiated 3/9/23 and revised 3/18/23, identified the resident had actual/potential skin breakdown or surgical wound(s) related to: fragile skin moisture associated skin damage (MASD) sacral wound left heel red. Intervention included Braden scale every week per protocol, and skin assessment as ordered and as needed. Pressure relieving mattress per facility protocol and as ordered. Off load heels as tolerated in bed. The April 2023 CPO showed an order for the resident to monitor bilateral heels every shift for signs and symptoms of skin breakdown, notify medical doctor (MD) and wound care specialist of complications. Start date 3/9/23. The Braden scale completed on 4/17/23 showed the resident was at mild risk for pressure ulcers with a score of 17. III. Interviews The director of nurses (DON) was interviewed on 4/25/23 at 9:05 a.m. The DON said the reside

Based on observations, interviews, and record review, the facility failed to implement interventions to reduce hazards and risks for falls for two (#198 and #197) residents out of five residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to ensure Resident #197 and #198 were provided the interventions available to prevent repeated falls and staff were aware of person-centered interventions. Findings include: I. Facility policy and procedureThe Fall Prevention Program policy, revised August 2022, was provided by the nursing home administrator (NHA) on 4/24/23 at 4:06 p.m. It read in pertinent part,"Any patient deemed to be high risk will have the following interventions implemented or at least considered: -Low bed (or lower our standard bed to its lowest position)-Bedside floor pads on both sides of bed.""For post falls:-Determine what interventions need to be implemented to prevent further falls. Intervention will be reviewed by Interdisciplinary Team for appropriate interventions and care plan will be updated. -Initiate orders and/or tasks for fall prevention and for skin injuries if indicated." II. Resident #198A. Resident statusResident #198, age 75, was admitted on 4/5/23. According to the April 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease and major depressive disorder. The 4/17/23 minimum data set (MDS) assessment revealed a brief interview of mental status (BIMS) was not conducted with the resident indicated by he was rarely to never understood or understands. A staff interview showed the resident had severe cognitive impairments. The resident required extensive assistance with bed mobility, transfers, walking, toileting, dressing and personal hygiene. Falls were not coded. B. Observations and interviewResident #198 was observed on 4/19/23 at 9:00 a.m laying in his bed in room. The bed was not in the lowest position and no fall mat present. There was no yellow fall star on the resident's door (as indicated for resident with fall risk, see interviews below). Resident #198 was observed at 9:39 a.m. sitting on the edge of his bed in room. The bed was not in the lowest position and no fall mat present. There was no yellow fall star on the resident's door. Certified nurse aide (CNA) #4 was interviewed on 4/19/23 at 12:45 p.m. She stated Resident #198's bed was in the lowest position. She then checked on the resident's bed and discovered it was not in the low position. Resident #198 was observed on 4/20/23 at 3:00 p.m. laying in bed in his room. The bed was not in the lowest position and the resident was not wearing non-grip socks. There was no yellow fall star on the resident's door. Resident #198 was observed on 4/24/23 at 9:03 a.m. laying in his bed in room. He was agitated and moving his legs. There was no fall mat present and no yellow fall star on the resident's door. Resident #198 was observed at 12:00 p.m. laying in bed in his room. He was agitated and moving his legs. There was no fall mat present and the bed was not in the lowest position. C. Record reviewThe comprehensive care plan, revised on 4/14/23, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility. History of falls and limited mobility. Interventions were to ensure call light is within reach, use of handrails, environment free of clutter, commonly used articles within reach, physical/occupational therapy to evaluate and treat, frequent rounds on resident, and ensure resident wears proper non-slip footwear. Post fall evaluations dated 4/14/23 revealed the resident had an unwitnessed fall in the hallway and was found on the floor. The resident was unable to explain the fall and it was determined the fall was due to wandering, poor safety awareness, and refusals for assistance. Recommended to initiate the 4 P's (asking if the resident needs to use the restroom, needed repositioning, had common items inreach or asking if the resident is in pain). Post fall evaluations dated 4/20/23 revealed the resident had an unwitnessed fall in his room kneeling on the floor. The resident was unable to explain the fall, and it was determined the fall was due to confusion and poor safety awareness. Recommended to use non-skid socks, check for need for toileting, place bed in lowest position, and add fall mats. The April 2023 facility tasks (a care directive for CNAs revealed the fall interventions were as follows: -Ask the 4 P's started on 4/21/23.-Gripper socks in place started on 4/20/23.-Bed in lowest position started on 4/6/23.-Yellow falling star on resident's door started on 4/24/23.-Leave resident's door open unless providing care started on 4/6/23.-Round on resident frequently started on 4/7/23. -Fall mats while in bed started on 4/21/23. III. Resident #197A. Resident statusResident #197, age 93, was admitted on 4/7/23 and passed away 4/19/23. According to the April 2023 CPO, diagnoses included pulmonary embolism, diabetes, and chronic kidney disease. The 4/11/23 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The resident required extensive assistance with bed mobility and toileting. The resident required limited assistance with dressing, personal hygiene, walking, and transfers. Falls were not coded. B. ObservationsResident #197 was observed on 4/19/23 at 9:00 a.m laying in his bed in room. The bed was not in the lowest position. There was no yellow fall star on the resident's door. Resident #197 was observed at 1:15 p.m. being assisted to his room by the activities director (AD) and he stated to the AD that he did not feel well and wanted to lie down. CNA #4 stopped the resident, and advised the AD the resident's wife was not present to watch him in his room so he needed to be taken to sit at the nurses station. At 1:24 p.m. a nurse was observed taking the resident to his room and assisted him to lie down. The resident's bed was not in the lowest position. At 1:28 p.m. the resident began calling for help. CNA #4 came to the resident's room at 1:38 p.m., got him out of his bed and took him back to the nurses station. C. Record reviewThe comprehensive care plan initiated on 4/7/23, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility. History of falls and limited mobility. Interventions were to ensure call light is within reach, use of handrails, environment free of clutter, commonly used articles within reach, physical/occupational therapy to evaluate and treat, frequent rounds on resident, use yellow fall star on door, ensure resident wears proper non-slip footwear, and wife stays at night. Post fall evaluations dated 4/12/23 revealed the resident had an unwitnessed fall in his room while his wife was sleeping in the room. The resident was trying to transfer himself. Recommended to redirect and conduct frequent rounding. Post fall evaluations dated 4/19/23 revealed the resident had an unwitnessed fall in his room and was found on the floor. The resident was attempting to get out of his wheelchair without assistance. Recommended for wife to sit in room with the resident daily to prevent falling. The April 2023 facility tasks revealed the fall interventions were as follows:-Ask the 4 P's started on 4/12/23.-Gripper socks in place started on 4/12/23.-Bed in lowest position started on 4/12/23.-Yellow falling star on resident's door started on 4/12/23.-Leave resident's door open unless providing care started on 4/13/23.-Round on resident frequently started on 4/7/23. III. Staff interviewsCNA #4 was interviewed on 4/24/23 at 9:03 a.m. She said fall interventions for Resident #198 were to redirect him, keep his bed in the lowest position, frequent checks and ensure he had a yellow fall indicator star on his door. During interview, she checked on the fall star for Resident #198 and discovered there was not one on his door. CNA #4 stated fall interventions for Resident #197 consisted of frequent checks, making sure his door remained open and putting him at the nurses station. The fall precautions would be found in the tasks. The director of nursing (DON) was interviewed on 4/24/23 at 2:28 p.m. She stated the 4 P's were the facility's fall program. The staff were to check the resident to determine if they needed to use the restroom, needed to be repositioned, had commonly used items in reach and were not in pain. She acknowledged sitting Resident #197 at the nurses station was not a fall intervention. She said she had staff available that could have provided him one-on-one supervision in his room until his wife arrived. The DON said the wife should not be responsible for ensuring the resident did not fall. The staff should be doing frequent checks even when the wife was visiting. She said the CNAs were responsible for putting magnetic yellow fall stars on the resident's door to indicate they are a high fall risk. The DON stated the facility did not use fall mats because they were considered a restraint but did not explain how the mats were a restraint. The DON said fall interventions for Resident #198 were the 4 P's. She said she helped with entering the tasks for the CNAs but was not aware that staff had put fall mats as an intervention. She was not aware that his bed was not in the lowest position and he did not have a yellow star on his door but the CNAs were signing off that those things were in place. The DON said that she did chart audits but missed the fall mats as interventions.

Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure:-Appropriate hand hygiene by food service staff; -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; and,Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. "Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by;2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device." B. Observations Observation of the meal service was conducted on 4/24/23 at 10:45 a.m. Dietary aide (DA) #1 was observed setting up for the afternoon lunch meal. DA #1 walked over to the oven and opened the door with her gloved hand and retrieved a large metal container of lasagna. She walked over to the serving table and placed the lasagna on the counter. She proceeded to remove the clear saran wrap from the metal container. She rolled the clear wrap into her hand and proceeded to throw it in the trash can touching the side of the trash can with her hand. She wiped her hand on the side of her apron. DA #1 repeated this process for all of the food items for the afternoon menu. DA #1 reached down under the heating table and grabbed several serving scoops and proceeded to place them into the metal food containers on the heating table. She then would grab the metal lids and place them on the food items covering them until the service began. DA #1 then proceeded to take the temperature of the food. She took a thermometer and took the temperature of the lasagna. She proceeded to grab a thermometer and several sanitizing wipes. She took the temperature of the food and then wiped the thermometer with the alcohol wipe. She then grabbed a pen from her pocket and documented the temperature of the food. This was repeated for all of the food items on the serving line. She then grabbed the used alcohol wipes and again threw them into the trash can. DA #1 then reached into the sanitizing bucket and grabbed a rag and wiped the counter on the serving line. She replaced the rag into the sanitizing bucket and wiped her hands on the side of her pants. She then proceeded to start serving the meals. DA #1 was preparing a hamburger for a special order. She reached in the bag with her gloved hand and retrieved a hamburger bun. She reached under the counter and grabbed a frying pan. She placed it on the stove and placed the buns into the pan. She buttered the hamburger buns holding them in her gloved hand and placed them into the pan. She then walked over to the heating oven and retrieved a hamburger patty from a plate. She removed the clear wrap from the plate and rolled it into her hand and placed it into the trash can. She again reached under the counter and retrieved another pan placing it on the stove. She placed the hamburger patties into the pan and turned the stove burners on. She returned to the serving line and proceeded to serve other residents ' meals. The hamburger patties were cooked and she grabbed the hamburger buns and placed them on a plate. She then opened the sandwich area lid and retrieved a slice of cheese, slice of onion and other condiments out of the sandwich area. She grabbed a slice of cheese with her gloves and placed it on the bun. She then grabbed several slices of onion with her gloved hand and placed them on the bun. She then placed the cooked hamburger patty on the bun and then grabbed the other slice of bun and placed it on top of the hamburger. She then placed the hamburger on the cutting board and proceeded to cut it holding it with her gloved hand and then she plated it and placed it on the counter. DA #1 then returned to serving the rest of the residents ' meals. DA #1 did not perform hand hygiene during this process. The dietary manager (DM) was observed in and out of the walk-in cooler getting the side deserts, salad and other items for lunch. The DM was observed going in and out of the walk-in cooler and into his office during this process. He went into the storage room and retrieved some Styrofoam meal containers. He walked into the walk-in cooler and retrieved a bag of lettuce. He opened the bag of lettuce with his gloved hand and proceeded to grab several handfuls of lettuce and place them into the Styrofoam container. He wiped his gloved hand on the side of his pants. He wrapped the lettuce and placed it back into the walk-in cooler opening the door with his gloved hand. He returned with a tomato. He cut the tomatoes on the cutting board and placed the pieces into the salad. He then walked over to the sandwich area and grabbed several handfuls of shredded cheese with his gloved hand and placed them on the salad on the Styrofoam container and closed it and placed it on a metal rack. He then walked into the walk-in cooler and grabbed the handle with his gloved hand. He returned with a bag of red grapes and proceeded to wash them in the sink. He grabbed a handful of grapes and placed them into a dessert dish. He wiped his hands on the side of his pants. He replaced the grapes back into the walk-in cooler. The DM then assisted the DA #1 with serving the afternoon meals. The DM did not perform hand hygiene during this process. DA #3 was observed placing the residents ' drinks on the meal trays and then placing them into the warming carts. DA #3 was observed several times walking out of the kitchen to the dining room and then returning to the kitchen area. DA #3 was observed opening the residents ' drinks and adding thickener to the drinks. She removed the lid with her hand and squirted two pumps of thickener into the cup. She then reached over and retrieved a spoon and proceeded to stir the thickener into the drinks and then replace the lids. She was observed wiping her hands on the side of her apron after getting the thickener on her hand. DA #3 was observed doing this repeatedly during the serving process. DA #3 did not perform hand hygiene during this process. C. Staff interview The DM was interviewed on 4/24/23 1:58 p.m. He said all kitchen staff needed to wash their hands when their hands become contaminated. He said all staff must wash their hands before handling or serving food. He said staff should never touch ready to eat foods with their bare hands. He said they should use serving tongs even if they have gloves on. Staff should wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash their hands between tasks to avoid cross contamination. II. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36 "Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated forhot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds." B. Observations and staff interview On 4/24/23 at 10:45 a.m., DA #1 was observed preparing minced moist mechanical soft meals of grilled chicken and meat lasagna that was being held for lunch service. DA #1 proceeded to the warming oven and retrieved a small metal container of chicken. She placed the grilled chicken into the blender and proceeded to mince the chicken. She grabbed the small metal container with broth and poured it into the blender until she reached the correct consistency of the minced moist grilled chicken. She grabbed a small metal container and sprayed it with cooking oil. She poured the minced moist grill chicken into the metal container and placed it on the counter. She proceeded to start wrapping aluminum foil on the container. The surveyor requested for the cook to take temperatures of the puree food. The cook stated the temperature of the grilled chicken was 118 degrees F. She then wrapped the metal container and placed it into the warming oven. She proceeded to complete the same process for the lasagna. She then placed seven large pieces of lasagna into the blender and proceeded to mince the lasagna. After getting it to the correct consistency she grabbed another metal pan and poured the minced moist lasagna into the pan. She placed it on the counter and took the temperature, which was 120 degrees F. She wrapped it with aluminum foil and placed it into the oven. -At 11:00 a.m., the DA #1 was asked if she checked the temperature of the minced moist foods after pureeing them. The cook said, "No, I do not, but I would take the temperatures before serving them and they should be at 150 degrees F." -At 11:20 a.m., DA #1 took the temperatures of the grilled chicken and the lasagna. The temperature of the grilled chicken was 128 degrees F and the lasagna was at 130 degrees F. -At 11:39 a.m., the DA #1 again took the temperature of all items listed above. The grilled chicken was at 145 degrees F and the lasagna was at 150 degrees F. -At 11:45 a.m. the DA #1 again took the temperature of all items listed above. The grilled chicken was at 160 degrees F and the lasagna was at 163 degrees F. C. Additional interview The DM was interviewed on 4/23/15/23 at 1:58 p.m. He said he was aware that the temperatures of the modified food dropped at times. He said "It's my expectation that the food was ok as long as it reached 165 degrees F before serving." He said dietary staff would be educated immediately to ensure the modified consistency of food reached proper temperatures and time frames. III. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and "Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized." B. Observation The initial kitchen tour conducted on 4/19/23 at 8:30 a.m. revealed four large cutting boards. There were green, red, white and brown cutting boards as well as a large white cutting board at the sandwich prep area; all cutting boards were heavily scored and stained. On 4/20/23 at 8:32 a.m., the DM was cutting toast on the green cutting board. On 4/24/23 at 10:40 a.m. during kitchen observations DM was observed cutting vegetables on the red cutting board. C. Staff Interview The DM was interviewed on 4/24/23 1:58 p.m. The DM was told of the observations of the cutting boards in the kitchen. He acknowledged the cutting boards were visibly stained and showed wear. He said he had purchased his cutting board from another supplier but he did not think they were made of good quality material. He said he would replace them immediately. He said the deep scratches could be a potential for bacteria to grow.

Based on observation, record review and interviews the facility failed to maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for two (#198 and #104) of two residents reviewed for hospice care services out of five residents reviewed for hospicare care out of 28 sample residents. Specifically, the facility failed to:-Demonstrate documentation of a collaboration of care between the facility and the hospice provider for Resident #198; and,-Ensure medication orders from the hospice provider were received and administered for Resident #104. Findings include:I. Resident #198A. Resident statusResident #198, age 75, was admitted on 4/5/23. According to the April 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease and major depressive disorder. The 4/17/23 minimum data set (MDS) assessment revealed a brief interview of mental status (BIMS) was not conducted with the resident indicated by he was rarely to never understood or understands. A staff interview showed the resident had severe cognitive impairment. Hospice care was not coded. B. Record reviewThe April 2023 CPO revealed the resident admitted with an order for hospice services dated 4/6/23. The resident's comprehensive care plan was reviewed and the plan for hospice was initiated on 4/6/23, with the goal to have effective pain control. Pertinent care plan interventions initiated 4/6/23 included:-Acknowledge presence of pain and discomfort.-Administer pain medication per physician order. -Implement non-pharmacological interventions as possible.-Monitor for pain every shift. -Notify the physician as needed for any changes.-Refer to hospice if required. -The care plan did not delineate the care provided by the hospice provider and did not indicate the frequency of their visits. -A review of the resident's progress notes dated 4/5/23 to 4/23/23 revealed the progress notes failed to show regular hospice visits or document the services hospice provided to Resident #198 when they visited him.-A review of scanned documents failed to reveal hospice visit notes. C. Staff interviewsLicensed practical nurse (LPN) #2was interviewed on 4/24/23 at 9:19 a.m. She stated there was a hospice communication binder at the nurses station for Resident #198. She was unable to locate the binder. After ten minutes of looking for the binder, LPN #3 returned and stated she was unable to locate the binder and there was no hospice communication binder for Resident #198. The hospice nurse gave the LPN verbal visit reports only. The director of nursing (DON) was interviewed on 4/24/23 at 9:27 a.m. She said Resident #198's hospice provider did not provide the facility with a communication binder to leave visit notes or orders. The hospice provider gave the hospice visit notes to the resident's nurse and they gave the notes to the DON. The DON would put the hospice visit notes in the mailbox for the medical record clerk to scan into the resident's electronic medical record. On 4/24/23 at 11:47 a.m., an email was sent to the nursing home administrator (NHA) requesting the hospice visit notes for Resident #198. Daily hospice visit notes were received from NHA at 3:18 p.m. for dates 4/5/23 to 4/23/23. The NHA was interviewed on 4/24/23 at 3:50 p.m. She stated she was uncertain where the hospice visit notes that she had provided had been located. She believed the notes had been in a pile of documents to scan in the medical records office. She was unable to explain why the delay in uploading Resident #198's hospice visit notes had gone back to 4/5/23, his date of admission. The DON was interviewed on 4/24/23 at 4:00 p.m. She stated she had requested the hospice visit notes from the medical records clerk who informed her there were no outstanding hospice notes to scan into Resident#198's chart. The facility's admissions coordinator had reached out to the hospice provider and requested faxed visit notes. The DON stated she had been told by the hospice provider they did not provide communication binders for resident's in rehabilitation facilities on respite (short stay) care. The hospice nurse would give a verbal report to the facility nurse after the patient visit. According to the DON, she said the hospice provider was to use a communication binder or provide documented visit notes to the facility so the facility could include those notes into the resident's medical record. The admissions coordinator (ADM) was interviewed on 4/25/23 at 8:50 a.m. She stated she had reached out to Resident #198's hospice provider on 4/24/23 to request visit notes for 4/5/23 to 4/23/23. She said she did that to assist the facility but that was not a normal practice for receiving hospice notes. The hospice clinical director (HCD) was interviewed on 4/25/23 at 8:53 a.m. She said the hospice nurse should be having conversations with the resident's nurse and providing orders when they visit the resident. Their normal practice for long term or short stay residents was to prepare a communication binder for the facility. The decision to have a communication binder or not to was a facility driven decision and based on the facility's preference. The facility for Resident #198 had declined a binder stating they did not have a place for a binder. The hospice provider did not normally provide their internal visit notes taken on the tablets to the facility. The HCD acknowledged that with the absence of a binder and lack of documentation following a visit could provide a lack in the collaboration of care for the resident. She was unaware when the hospice nurses, CNAs, chaplains and social workers visited Resident#198. She said when hospice staff visited they gave a report to the resident's nurse and a progress note was not being made in his resident's electronic medical record. II. Resident # 104A. Resident statusResident #104, age 89, was admitted on 4/17/23 and discharged on 4/22/23. According to the April 2023 computerized physicians orders (CPO), diagnoses included lung cancer, Parkinson's disease, and shingles. The minimum data set (MDS) assessment had not been completed for the short respite stay. The resident recieved hospice services during the stay. B. Record reviewThe care plan, initiated 4/19/23, identified the resident was on strict transmission based precautions due to shingles. The intervention was transmission based precautions and to have all care and services be limited to the resident's room. The April 2023 CPO did not identify Acyclovir. The 4/17/23 Hospice nurse visit note included, "Were all medications reviewed for effectiveness, side effects, interactions, duplicative action, and needed lab monitoring? Yes, medication changes required."Indicate medications changed: Acyclovir 800 milligrams (mg) five times a day for seven days."C. InterviewsLicensed practical nurse (LPN) #4 was interviewed on 4/24/23 at 9:05 a.m. She said when the facility received a physician order either verbal or written, the orders were entered into the electronic record and sent to the pharmacy for a fill. She said the pharmacy delivered medications a couple times a day. She said the facility had a "pyxis" machine (a machine with various medications monitored by the pharmacy) they could utilize if necessary. At 2:31 p.m. she and the staff could review the hospice notes if the hospice providers left a note. She said she had not observed hospice notes for Resident #104. The director of nursing (DON) was interviewed on 4/24/23 at 3:42 p.m. She said any orders were verified by her and the floor nurses. The floor nurses could enter orders into the resident's electronic records and send the order to the pharmacy. She said if a verbal order was given to the floor nurse, they were trained to input the orders into the resident's electronic record. She said she checked the fax daily for new orders. She said she was not aware of the Acyclovir order for shingles for Resident #104. On 4/25/23 at 9:26 a.m. the DON said she interviewed the floor staff and none of the nurses she spoke to knew of an order for Acyclovir. She said the hospice provider had not notified the facility of the order. She said a new medication ordered by hospice would be provided by hospice and the facility had no record of receiving the medication. She said the facility needed to improve a process to communicate more effectively with the hospice provider. The hospice clinical director (HCD) was interviewed on 4/26/23 at 9:45 a.m. She said the nurse she interviewed reported to her that a hospice staff had given the facility floor nurse at the time a verbal order for the Acyclovir. She said she could not locate a faxed order to the facility. She said a nurse at the facility had signed for a delivery of the Acyclovir. She said the medication was sent home with Resident #104 upon discharge from the facility. She said she had contacted the hospice medical director and was told there was not a negative outcome for not starting the medication while in the facility, and the hospice provider would be starting the medication since the resident had returned home. The DON was interviewed on 4/26/23 at 10:17 a.m. She said normally orders from hospice providers were received by fax, or if verbal there would be a form. She said medications ordered by the hospice provider were provided by them. She said none of the interviewed staff verified the arrival of the medication. She said the facility would be revising communication with the hospice providers to try to avoid the identified situation from occurring again.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on hoses in two maintenance closets, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 4/24/23 at 3:30 p.m. revealed: The hoses on the second and third floor maintenance closets did not have a backflow prevention valve on them. The hose on the third floor was long enough to sit on the bottom of the drain pan. The hose on the second floor was approximately 25 feet long and coiled and was sitting at the bottom of the sink pan. There was visible standing water at the base of both of the sink pans. II. Staff Interview The housekeeping supervisor (HKS) was interviewed on 4/25/23 at 9:40 a.m. He said the hoses in the maintenance closet should have had a backflow prevention valve on them. He said he would install them immediately.

A licensure survey was completed on 4/19/23 to 4/25/23. One deficiency was cited.

Based on record review and interviews the facility failed to ensure compliance with the Colorado Adult Protective Services Data System (CAPS) check requirement for staff. Specifically, the facility failed to have CAPS requests completed prior to hiring for four of five staff reviewed. Findings include: This deficiency was cited previously during a state licensure survey 1/20/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. I. Professional reference The Colorado Adult Protective Services Caps Check Unit, Statute and Rule Requirements 4/24/23, retrieved from https://ccu.colorado.gov/statute-and-rule-requirements revealed in pertinent part: "Employers who are required to request a CAPS Check prior to hiring an employee, including a contractor, who will be providing direct care to at-risk adults include the following agency types. "Agencies licensed by the Colorado Department of Public Health and Environment under Title 25 and listed below are required to request CAPS Checks: "Any licensed health facility (Section 25-1.5-103, C.R.S.), including those wholly owned and operated by any governmental unit. "More specifically, these agencies include nursing homes." II. Record review The nursing home administrator (NHA) provided requested employee records on 4/24/23 at 3:39 p.m. Review of the employee files revealed:-Certified nurse aide (CNA) #1 was hired on 4/18/23, and the CAPS request was submitted 4/19/23.-CNA #2 was hired 4/13/23, and the CAPS request was submitted 4/17/23.-CNA #3 was hired 4/4/23, and the CAPS request was submitted 4/5/23.-Licensed practical nurse (LPN) #1 was hired 3/28/23, and the CAPS was submitted 3/29/23. III. Interview The human resources director (HR) was interviewed on 4/24/23 at 2:41 p.m. She said included in the onboarding hiring process was a background check. She said she was new to her position and was new to the CAPS process. The NHA was interviewed on 4/24/23 at 3:30 p.m. She said CAPS requests were submitted prior to hiring because the process could take time. She said the staff were hired with the understanding if the CAPS comes back negatively they would terminate. On 4/25/23 at 9:31 a.m. she said the CAPS had been requested after the date of hire for the identified staff. She said she provided education to HR and going forward the CAPS would be completed prior to hire. She said it was important to submit the request prior to hire and follow the guidelines set by CAPS to ensure the safety of the residents.

A focused infection control survey with complaints #CO30535, #CO30553, #CO30576 and #CO30591 was conducted on 1/17/23 to 1/19/23. No deficiencies were cited.

An Emergency Preparedness focused infection control survey was conducted 1/17/23 to 1/19/23. No deficiencies were cited.