COAL CREEK POST ACUTE & ASSISTED LIVING

A complaint survey, prompted by #CO36978, #CO36979 and #CO36981 was conducted on 8/26/24 to 8/27/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to promote and maintain resident dignity by providing care in a dignified, respectful and individualized manner for three (#1, #5 and #6) of three residents out of 12 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and Resident #6 were treated with dignity and respect when they asked for care assistance; and, -Ensure Resident #5, a resident with a diagnosis of Alzheimer's disease, was provided a dignified experience of receiving sufficient care to maintain good personal health and hygiene. Findings included:I. Facility policyThe Dignity policy, revised February 2021, was provided by the corporate nurse consultant (CNC) on 8/27/24 at 11:10 a.m. It read in pertinent part, "Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem."Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay."Individual needs and preferences of the resident are identified through the assessment process. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility."When assisting with care, residents are supported in exercising their rights. For example, residents are; groomed as they wish to be groomed (hairstyles, nails, facial hair)."The Resident Rights policy, revised December 2016, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, "Employees shall treat all residents with kindness, respect and dignity. The residents' rights include a dignified experience."The Activities of Daily Living (ADL), Supporting policy, dated 2001, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene."II. Resident #1A. Resident statusResident #1, age 74, was admitted on 7/29/24 and discharged on 7/29/24. According to the July 2024 computerized physician orders (CPO), diagnoses included diabetes and congestive heart failure. The minimum data set (MDS) assessment was not completed. The nursing admission assessment dated 7/29/24 documented Resident #1 was alert and oriented to person, place, time and situation and was calm and cooperative. The resident was motivated to participate in rehabilitation services and needed assistance with ADLs, including transferring, toileting, dressing and hygiene. The resident was incontinent of bladder and usually had daily bowel movements. B. Record reviewA review of Resident #1's electronic medical record (EMR) revealed the resident's baseline care plan had not yet been started and there was no CNA task record or Kardex (abbreviated plan of care for the CNA). -The CNC confirmed the facility did not have a Kardex for Resident #1. A social services note, dated 7/29/24 at 11:18 p.m., documented Resident #1 said he wanted to leave the facility due to the caregiver neglecting to provide timely assistance for him to use the bathroom. The facility investigation dated 7/29/24 documented that the resident asked his certified nurse aide (CNA) #2 for assistance to use the bathroom to have a bowel movement and CNA #2 told him to remain in bed, go to the bathroom in his brief and she would clean him up afterward. The resident insisted he be taken to the bathroom. CNA #2 finally took the resident to the bathroom. Staff interviews revealed Resident #1 waited so long for the staff to act that he thought he was not going to make it to the bathroom. The resident was unhappy with the way he was treated and told staff that he was leaving and going home. Resident #1 called the police, rolled himself outside of the facility and was taken to the hospital by ambulance transport. The facility's investigation concluded CNA #2 did not respond to Resident #1 in a dignified and respectful manner when she told him to go to the bathroom in his brief instead of providing him timely assistance to use the toilet as he asked. III. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on 7/26/24 and discharged on 8/11/24. According to the August 2024 CPO, diagnoses included Alzheimer's disease, overactive bladder and depression. The MDS assessment was not completed. The nursing admission summary dated 7/26/24 revealed the resident was alert and oriented to person only. The resident was incontinent of bowel and bladder and dependent on staff to complete ADLs and used a mechanical lift for transfers. B. Resident representative interviewResident #5's legal representative was interviewed on 8/26/24 at 10:33 a.m. The representative said she had talked to the facility during Resident #5's admission and several times afterward about the resident's care choices. The representative said Resident #5 spent a lot of time in bed but had requested that staff get her up before lunch so she could spend time with family when they visited. The representative said the resident also requested staff get her up so she could participate in Sunday church services, the one activity she enjoyed. She said there were several occasions when the family would visit and find Resident #5 with poor hygiene and wearing the same clothing as the day before. She said this was out of character for Resident #5. The resident's representative said she was in the facility to see the resident every day at different times of day and she found her mom in poor condition on several occasions making her fear for the resident's health. She said Resident #5 had a pressure injury when she admitted and it started worsening. She said if Resident #5 did not get proper hygiene and hydration assistance, her wounds would worsen. The resident's representative said Resident #5 had always had good hygiene and it was important to her. The representative said Resident #5 was in a total state of helplessness and was dependent on staff to provide good care for her overall wellbeing and happiness. She said staff did not take the time to change soiled linens, provide timely incontinence care or remove the resident's soiled clothing to be laundered. The representative said this left Resident #5 and her room with a foul odor. The resident's representative said it was disappointing to see the resident in a soiled state. The resident's representative said, on 8/4/24, she provided the facility a detailed letter of the family's observations and concerns with action items (interventions) that she and Resident #5 would like to have provided for the resident but she said things still were not corrected by the facility. The resident's representative said her concerns for the resident's well-being deepened when she learned that the nursing home administrator (NHA) had not been provided a copy of her grievance letter and was not informed of her request to meet with the leadership team to discuss the details of her grievance letter. The resident's representative said it was not long after she gave the facility the letter that the family decided to remove Resident #5 from the facility's care. She said they moved Resident #5 out of the facility on 8/11/24, 16 days after she was admitted to the facility. C. Record reviewA care conference summary dated 8/2/24 revealed the resident and her legal representative were in attendance at the care conference, as were the facility's interdisciplinary team (IDT) members, including the director of nursing (DON) and the social services director (SSD). The summary documented the family planned for Resident #5 to remain in the long-term care setting and for the resident's husband to move to the facility's on-site assisted living community. The psychosocial mood care plan initiated on 8/2/24 revealed Resident #5 was at risk for decreased psychosocial well-being adjustment issues and emotional distress. The goal was for the resident to have no decline in mood or behavior that prevented her from functioning in her daily activities. Interventions included assessing the resident's preferences and choices with activities and encouraging involvement and encouraging friends and family support/visits. A nursing note dated 8/4/24 documented the resident's legal representative voiced concerns about the resident's care. The representative voiced concerns that, despite a request at a care conference, the resident was not up for church that morning (8/4/24) and she had the same shirt on from 8/2/24 (Friday). The representative was additionally concerned because the resident had not had a shower since her admission to the facility on 7/26/24 and soiled laundry was left on the shower floor. A care conference summary dated 8/8/24 revealed Resident #5, her legal representative and another family member were in attendance at the care conference, as were the facility's IDT members, including the DON, the SSD and the activities director (AD). The care conference summary documented the resident's representative and the other family member brought up concerns about the resident's personal and environmental hygiene. The representative said she had arrived at the facility to assist Resident #5 with the noon meal and found the resident in a darkened room and still in bed. The representative said she had asked the facility staff, upon the resident's admission to the facility, to make sure the resident was up and dressed by 11:00 a.m. so she could eat her meal while seated in her chair and not in bed. According to the care conference summary note, the representative's concerns included finding Resident #5 being left in heavily soiled undergarments and smelling strongly of urine. The sheets of the resident's bed were also stained and soiled with urine. The representative said the resident's bedding was covered with food crumbs from the resident being assisted to eat while in bed. Additionally, the representative was concerned because the resident had not been showered. The IDT's plan for the resident's care was to schedule management follow-up to make an observation of Resident #5 every morning at 9:00 a.m. to ensure the resident was provided assistance to meet her care needs. A comprehensive skin evaluation assessment dated 8/11/24 documented the resident was placed on a two-hour check and change schedule. -The care plan was not updated to reflect the two-hour check and change intervention. The facility investigation dated 8/14/24 documented that, after investigating the resident's legal representative's concerns, the facility substantiated that CNA #1 failed to provide the resident with a hygienic environment when they left soiled laundry in and around the resident's room. The facility separated from CNA #1 and did not schedule her for additional shifts. CNA #1 was interviewed on 8/14/24. CNA #1 said she checked on Resident #5 in the morning assisted her with breakfast and changed the resident. She did not prove the time that the care was completed. CNA #1 said she continued with rounds assisting her other residents and came back to Resident #5's room to find the family present. CNA #1 said the family was very upset by the condition of Resident #5 and by the presence of a soiled laundry being found on the floor of the resident's shower. -The facility's interview with CNA #1 did not provide answers and details about the exact nature of why the family was upset, the complaint the family voiced and the exact condition of how the resident was found. The investigation did not establish a timeline of events with CNA #1 and failed to provide any substantial evidence about CNA #1's knowledge of the resident's routine or careneeds. IV. Resident #6A. Resident statusResident #6, age less than 65, was admitted on 6/4/24 and discharged on 7/5/24. According to the July 2024 CPO, diagnoses included amputation between the left hip and knee, diabetes and pressure-induced deep tissue injury. The 6/10/24 MDS assessment documented the resident had intact cognition with a BIMS score of 15 out of 15. The resident was dependent on staff for toileting hygiene and bathing and substantial assistance with dressing. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. B. Record reviewThe facility investigation dated 7/10/24 documented Resident #6 filed a grievance on 7/3/24 that when she asked her assigned CNA (CNA #3) to assist her in changing her soiled brief, CNA #3 told her "You do not need me to change your diaper, you can do it your (expletive word) self." CNA#3 was removed from the care of Resident #6 and another CNA took over the resident's care and provided ADL assistance and emotional support. The investigation documented there were no witnesses to the exchange between CNA #3 and Resident #6 and the facility concluded it was a "He said, she said" situation. -However, the facility terminated CNA #3 when the investigation revealed there were four other times in the prior two weeks that CNA #3's conduct caused several other residents to request CNA #3 not to provide care for them. V. Interviews A frequent visitor (FV) to the facility was interviewed on 8/26/24 at 2:47 p.m. The FV said she had concerns about the way residents in the facility were treated. She said residents complained that they were not always treated respectfully and others had to wait a long time for care to be completed. The FV said residents had reported that staff did not address them directly and walked away from them in the middle of a conversation when they were asking for staff assistance. The FV said she brought resident-voiced concerns, as well as her observed concerns, to the leadership team and found that it took a long time for the facility to address resident grievances. The FV said the new NHA seemed to be taking things more seriously than the previous NHA and some things had improved. She said several of the problematic staff were no longer working in the facility. Resident #9 was interviewed on 8/26/24 at 3:41 p.m. Resident #9 said she had just filed a grievance concern earlier today (8/26/24) because of the disrespectful way one of the CNAs made her feel. Resident #9 said she never knew how she would be treated from day to day. She said there were good CNAs and then other CNAs were disrespectful and rough with care assistance. Resident #9 said some CNAs would drop off her meal tray and walk out quickly; never speaking to her to see if she needed anything. She said other CNAs would walk away mid-conversation and she did not get what she needed. Resident #9 said today (8/26/24), a CNA came in to take her to the bathroom and she hurriedly assisted her to the toilet. The CNA never apologized or said anything about it. The NHA was interviewed on 8/27/24 at 8:12 a.m. The NHA said he was new to the facility and started working as the NHA on 7/10/24. The NHA said, after becoming familiar with the facility's operating practices, he implemented several quality measures and improvement projects. He said a couple of areas of focus included developing an orientation binder for agency staff that they were to read before working in the facility. He said the binder would provide agency staff information on basic facility policy, expectations for resident care and following the resident care plan. The NHA said. initially, agency staff were not provided access to the resident's plan of care. He said the DON and assistant director of nursing (ADON) would be responsible for reviewing admission intake information and providing a report to staff on the day of admission to ensure appropriate care was provided for all residents. The NHA said he recognized the need for staff to be better educated on the importance of treating every resident with dignity and respect while meeting the resident-assessed care needs and preferences. The NHA said he was saddened when he learned about the care concerns brought forward by several residents and their families. He said poor quality of care should not be the resident experience. The NHA said it frustrated him that members of leadership had not brought the concerns of Resident #5's family members to him when they first voiced grievances because he believed the concerns could have been fixed and the resident could have been happy living in the facility. The NHA said he did not learn of the family's concerns until a few days before the resident was discharged. The NHA said once he started to investigate resident care concerns and grievances, he realized the leadership team needed to make some changes in the staff's approach to resident care and staff's understanding of the facility's expectations to ensure that all resident care needs were met in a dignified and respectful manner. The NHA said he called a mandatory all-staff meeting last night (8/26/24) and early this morning (8/27/24), which was the first of many training sessions where staff would be educated on the importance of customer service and resident care. The NHA said that staff who did not follow facility policies for resident care would be removed from employment. The DON, the unit manager (UM) and the CNC were interviewed on 8/27/24 at 10:56 a.m. The UM said every unit had a nurse-to-nurse report sheet that was updated each shift and the CNAs had access to the residents' Kardex. The UM said the floor nurse should have updated the CNA assigned to Resident #1 about his care needs, especially since the resident had been newly admitted. The DON said she expected the nursing staff to be compassionate, provide good customer service and treat the residents like family. The DON said the facility would be educating staff on the expectations of good customer service.

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 5/20/24 for all previous deficiencies cited on 2/29/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on March 19, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a two (2) story, Type V (111) wood frame construction with no basement. The facility was constructed in 2015. The LTC portion is located on the 1st floor only with the 2nd floor occupied as assisted living. The 1st floor is separated from the 2nd floor by a two-hour fire resistive separation. This facility contains delayed egress locking throughout the building at all exit doors. The facility is licensed for 70 beds and the census on the date of the survey was 49. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler system. The dry-pipe fire sprinkler system protects the front canopy and exterior overhangs. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Maintenance Director and the Facility Administrator during the exit conference

Based on observation and staff interview, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This was evidenced by the following: 1. Exit door near room 138 does not fully close due to a threshold issue. NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. This deficient practice could affect all residents, staff and visitors throughout the smoke compartment should this exit discharge be needed during an emergency. The exit deficiency was discussed during 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, Sections 19.7.1.6 and 4.7.4. This was evidenced by the following: 1. Fire drills were not conducted during varying times and conditions. Time of drills were too close to previous drills on all shifts. 2. No records or inadequate documentation of fire drills for all shifts in quarters 2, 3, and 4. NFPA 101 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12. This was evidenced by the following deficiency:1. Storage prohibited in main electrical room. NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical CodeNFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and skillful manner. This deficient practice could affect all occupants and staff throughout all smoke compartments if improper access/maintenance of main electrical equipment shutoffs. The deficiency was discussed during 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: 1. No records or documentation of generator battery monthly conductance testing. 2. No records for generator annual fuel sample. NFPA 110, 8.3.7.1 The required monthly testing and recording of electrolyte specific gravity or conductance results (Reserve Capacity, "RC") of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required. The emergency power supply system provides power for emergency lighting. Ref: 2012 NFPA 101 Section 21.2.9, 7.9.2.4, 4.6.12.1 / 2010 NFPA 110 Section 8.3.7.1NFPA 110, 8.3.1 A fuel quality test shall be performed at least annually using tests approved by ASTM standards. This was discussed during the record review and again during the exit conference.

A recertification survey with complaints #CO30459, #CO30960, #CO31774, #CO34692, #CO35061 was completed on 2/26/24-2/29/24. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/26/24 to 2/29/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity and respect for two (#12 and #133) of five residents reviewed for dignity and respect out of 18 sample residents. Specifically, the facility failed to:-Ensure Resident #12 was assisted during meal times in a dignified manner; and,-Ensure Resident #133 was treated with dignity and respect when she requested a cup of coffee. Findings include:I. Facility policyThe Dignity policy, revised February 2021, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, "Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. "Residents are treated with dignity and respect at all times. Individual needs and preferences of the resident are identified through the assessment process. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice."II. Resident #12Resident #12, age over 65, was admitted on 2/8/24. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs). The 2/14/24 minimum data set (MDS) revealed the resident was unable to complete the brief interview for mental status (BIMS). A staff assessment of the resident's cognitive status revealed the resident's cognitive skills for daily functioning were severely impaired. She required extensive assistance and was dependent on staff for all cares. A. ObservationsOn 2/26/24 at 9:03 a.m., Resident #12 was sitting in the dining room. Two plates with pureed food were in front of her on the tray, covered with plastic. At 9:10 a.m., certified nurse aide (CNA) #1 brought three plastic cups, one with apple juice, one with lemonade and one more with an unidentifiable liquid and placed them on the table in front of the resident. An Ensure (a nutritional supplement) was observed on the tray as well. At 9:16 a.m., CNA #1 opened the Ensure and poured it into a cup. She proceeded to mix part of Resident #12's pureed food into the Ensure. -CNA #1 did not call the resident by her name during the meal and she did not converse with the resident. At 9:35 a.m., CNA #1 got up to answer a call light. She returned to the resident at 9:38 a.m. and offered the resident a mixture of the Ensure and pureed food. At 9:41 a.m., CNA #1 left to find a nurse for another resident. At 9:42 a.m. she returned and offered Resident #12 the mixture of Ensure and pureed food. At 9:43 a.m., CNA #1 left to answer a call light. At 9:48 a.m. she returned and offered the resident the Ensure/pureed food mixture, apple juice, and lemonade. The resident refused. At 9:50 a.m., Resident #12's tray was taken away. At 12:27 p.m., lunch was delivered to Resident #12 in the dining room. Her lunch consisted of two plates of pureed food covered with plastic, applesauce, an Ensure supplement and chocolate cake in a cup. CNA #1 attempted to assist the resident with the meal but the resident appeared sleepy and was sitting with her eyes closed. At 12:36 p.m., CNA #1 offered a drink to the resident and the resident opened her eyes. CNA #1 mixed the Ensure supplement with the pureed dish in a cup and gave it to the resident. At 1:15 p.m. the resident was taken to her room. -CNA #1 did not interact with Resident #12 when she was assisting with meals. She did not call the resident by her name and did not talk to the resident when she got up in the middle of assisting the resident with her meal to go answer call lights. B. Resident representative interview Resident #12's representative was interviewed on 2/26/24 at 1:15 p.m. The resident's representative said the resident got very little social interaction from the staff. She said the resident was nonverbal and it was important for the staff to converse with her. However, she said she did not see staff talk with the resident while they were assisting her with her meals. C. Staff interviewThe director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 1:45 p.m. The DON and ADON said mixing Ensure and pureed food together was not the resident's preference. The DON and ADON said CNA #1 had not treated Resident #12 with dignity. The DON and ADON said staff was expected to treat all residents with respect and dignity and converse with every resident during resident care. III. Resident #133 A. Resident status Resident #133, over the age of 65, was admitted on 2/23/24. According to February 2024 CPO, diagnoses included hypoglycemia, chronic pain, protein calorie malnutrition, weakness, rheumatoid arthritis and cognitive communication deficit. The 2/23/24 MDS assessment had not been completed for the resident at the time of the survey. B. Resident observation On 2/26/24 at 9:44 a.m. Resident #133 was sitting on her bed. She was rearranging her items on the bedside table. -At 9:46 a.m., dietary aide (DA) #1 arrived in the resident's room to pick up a breakfast tray. Resident #133 asked DA #1 for a cup of warm coffee. DA #1 told the resident to ask her nurse and walked away from the resident's room without providing the cup of warm coffee. C. Resident interview Resident #133 was interviewed on 2/27/24 at approximately 10:14 a.m. Resident #122 said she did not receive the cup of warm coffee she asked for after finishing her breakfast the previous day (2/26/24). The resident said she asked the wrong staff member and she was disappointed that she could not get a cup of warm coffee when she needed it. D. Staff interviews DA #1 was interviewed on 2/27/24 at 10:22 a.m. DA #1 said she was informed she was not to provide any resident services including providing water and coffee for any of the residents in the facility. DA #1 said she informed the nursing staff about the resident's request for warm coffee, however, she did not recall who she talked to about the resident needing assistance with a cup of warm coffee. DA #1 said she did not know if the resident received the coffee. Licensed practical nurse (LPN) #3 was interviewed on 2/27/24 at 10:31 a.m. LPN #3 said she was not informed about the resident needing assistance with getting a cup of coffee. She said the dietary staff usually would notify the floor nurse about a resident's request and ask if they could assist. Unit manager (UM) #1 and the ADON were interviewed together on 2/28/24 at 10:15 a.m. The ADON and UM #1 both said they did not understand the reason DA #1 told Resident #133 to ask her nurse as the resident was recently admitted to the facility and did not know who the nurse was. The ADON said every staff member, regardless of position, had been trained to be able to assist residents. The ADON said she would ensure staff education was provided to prevent the incident from occurring again. UM #1 said DA #1 should have informed the nurse or the CNA about the resident's request for coffee.

Based on observations, record review, and interviews, the facility failed to ensure residents who entered the facility with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (#12) of five residents reviewed for range of motion out of 18 sample residents. Specifically, the facility failed to ensure Resident #12 was assessed for a restorative program for her contracted right hand. Findings include:I. Facility policyThe Prevention of Decline in Range of Motion policy, revised March 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy stated in pertinent part, "The facility in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care." II. Resident status Resident #12, age over 65, was admitted on 2/8/24. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs). The 2/14/24 minimum data set (MDS) revealed this resident had severe cognitive impairment with a brief interview for mental status was unable to be completed. It was documented that cognitive skills for daily functioning were severely impaired. There were no behaviors or refusals of care documented. She required extensive assistance and was dependent on staff for all cares. The assessment coded the resident as not having an upper extremity impairment. -However, according to observations and interviews (see below) she did have an upper extremity impairment. The assessment did not code the resident as having therapy or restorative services. III. ObservationsResident #12 was observed on 2/26/24 at 9:03 a.m. She was sitting in a geri chair in the dining room holding a towel roll in her right hand. Resident #12 was observed again on 2/26/24 at 1:00 p.m. Staff were changing her brief and put a stuffed animal in her right hand once she was back up in the geri chair. -Although Resident #12 had items in her right hand during the observations, there was no formal restorative program in place for her contracture (see interviews and record review below). IV. Resident's representative interviewResident #12's representative was interviewed on 2/26/24 at 1:00 p.m. She said she had requested restorative therapy upon admission. She said she had not witnessed the resident receiving therapy. She said the nursing staff sometimes put towel rolls in her contracted hand. V. Record review-The comprehensive care plan, initiated on 2/9/24 and revised on 2/14/24, did not mention the resident's contracture. There were no listed interventions in place. VI. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/27/24 at 4:00 p.m. She said Resident #12 had a contracture to her right hand and she was unable to move it on her own. She said the nursing staff put a towel in her right hand to prevent the contracture from worsening. She said there was currently no formal restorative therapy program. The director of rehabilitation (DOR) was interviewed on 2/28/24 at 12:03 p.m. She said there was currently no restorative program in place for long term care residents. She said the facility started accepting long term care residents about two months ago. She said contracture care was important because it helped maintain the ability to care for oneself. She said contractures could be very painful and appropriate care could help to alleviate the pain. She said every resident should be assessed for contractures and providing flexion, extension and splints to contracted areas in part of the treatment. The director of nursing (DON), assistant director of nursing (ADON) and NHA were interviewed on 2/29/24 at 1:45 p.m. Theysaid the facility currently did not have a restorative therapy program in place and they should have a program in place. They were aware of Resident 12's contracture and failed to provide her with appropriate treatment.

Based on observations, record review and interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#137 and #191) of five residents reviewed for supplemental oxygen use out of 18 sample residents. Specifically, the facility failed to obtain a physician's order for the administration of oxygen for Resident #137 and Resident #191. Findings include: I. Facility policy The Oxygen Administration policy, revised October 2010, was provided on 2/27/24 by the nursing home administrator (NHA). It read in pertinent part, "The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure and review the physician orders or the facility protocol for oxygen administration." II. Resident #137 A. Resident status Resident #137, over age 65, was admitted on 2/17/24. According to the February 2024 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease, systolic congestive heart failure, and hypertension. According to the 2/21/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required limited assistance with bed mobility, grooming, and toileting, and one-person assistance with transfers. The resident's assessment was not coded for the use of oxygen therapy. B. Resident observations and interview On 2/26/24 at 9:27 a.m., Resident #137 was sitting on her bed with a nasal cannula receiving oxygen through her nostrils. The resident's oxygen concentrator was set to 3 liters of oxygen per minute (LPM). Resident #137 said she did not normally require the use of oxygen, however, she said her oxygen saturation level (level of oxygen in the blood) dropped from 90 percent (%) to 81% that morning (2/26/24). She said the nurse put her on oxygen to get her oxygen saturation levels back up above 90%.On 2/26/24 at 2:15 p.m., Resident #137 was sleeping in her bed. She continued to have an oxygen nasal cannula in her nostrils and she was receiving oxygen at 3 LPM. C. Record review -The comprehensive care plan, initiated on 2/19/24, did not identify that the resident required the use of oxygen.-There were no interventions included for oxygen therapy. The care plan did not include signs and symptoms to monitor for the use of oxygen. -The February 2024 CPO did not include a physician's order to administer oxygen. -Nursing progress notes written on 2/17/24 and 2/27/24 documented the resident did not require oxygen. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/27/24 at 3:20 p.m. LPN #2 said Resident #137 was not receiving oxygen therapy until the day before (2/26/24)when the resident's oxygen saturation levels dropped below 90%. She said Resident #137 received continuous oxygen at 3 LPM throughout the rest of the day. LPN #2 said she notified the resident's physician about the incident but forgot to request an order for the continued use of oxygen for the resident. Certified nurse aide (CNA) #2 was interviewed on 2/28/24 at 10:30 a.m. CNA #2 said Resident #137 did not normally use oxygen. The CNA said she did not know the reason the resident was on continuous oxygen. She said she had never seen the resident on oxygen since the resident was admitted to the facility. The assistant director of nursing (ADON) was interviewed on 2/29/24 at 2:00 p.m. The ADON said there should be a physician's order for the use of oxygen for every resident who required oxygen therapy. The ADON said she did not know why LPN #2 did not obtain a physician's order for Resident #137's oxygen after she had identified the resident needed oxygen. The ADON said too much oxygenation could slow breathing and heart rate to dangerous levels which could result in death. The ADON said the facility was revising the oxygen administration protocol including providing education to the nursing staff regarding obtaining physician's orders when a resident needed oxygen. III. Resident #191A. Resident statusResident #191, age 70, was admitted on 2/24/24. According to the February 2024 CPO, diagnoses included aftercare following right hip joint replacement surgery, nausea and tachycardia (heart rate of more than 100 beats per minute at rest). The 2/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance of one to two staff members with transferring, toileting and walking. B. Resident observations and interviewOn 2/26/24 at 9:41 a.m., Resident #191 was in her room. An oxygen concentrator was continuously providing her with 2.5 LPM of oxygen through a nasal cannula in her nostrils. Resident #191 said she was admitted to the facility on 2/24/24 from the hospital for physical and occupational therapy after having elective hip surgery. She said the hospital attempted to discontinue the use of supplemental oxygen twice and were unsuccessful so she was admitted to the facility with oxygen. She said prior to having surgery she was not using an oxygen concentrator at home and she was unsure why there was a continued need for it at the facility or how long she was expected to use it. On 2/27/24 at 1:37 p.m., Resident #191 was in her room. She continued to have a nasal cannula in her nostrils and the oxygen concentrator was providing her with 2.5 LPM of oxygen. On 2/28/24 at 9:30 a.m., Resident #191 was again in her room with the oxygen concentrator continuously providing her 2.5 LPM of oxygen through the nasal cannula. C. Record reviewThe 2/24/24 facility admission note revealed Resident #191 admitted from the hospital on three LPM of oxygen through a nasal cannula following right hip replacement surgery.-Review of Resident #191's February 2024 CPO revealed there was not a physician's order for the administration of oxygen. The 2/26/24 physician's progress note revealed Resident #191 had a new need for oxygen use after surgery related to acute respiratory failure and the resident's respiratory status was to be monitored and the oxygen weaned as tolerated. The progress note further indicated Resident #191's oxygen use was decreased to 2 LPM from 3 LPM. -However, the facility failed to have an order for the use of oxygen to include monitoring and weaning as tolerated.-Additionally, Resident #191's comprehensive care plan did not include a care plan focus for the use of oxygen. On 2/28/24, during the survey, the following physician's order was entered, in pertinent part, into Resident #191's electronic medical record (EMR): Oxygen at 2 liters (L) a minute via (through) nasal cannula due to post surgical hypoxia (low levels of oxygen in your body tissues). Attempt oxygen titration as able, respiratory therapist to evaluate and treat one time only for hypoxia.-However, the resident's care plan was still not updated to include the use of oxygen. D. Staff InterviewsRegistered nurse (RN) #1 was interviewed on 2/28/24 at 9:58 a.m. RN #1 said Resident #191 was using 2.5 LPM of oxygen and she knew this because she had just taken her vital signs. She said supplemental oxygen was considered a medication and required a physician's order. RN #1 was unable to find an order for the use of oxygen in the EMR for Resident #191. Unit manager (UM) #1 was interviewed on 2/28/24 at 10:08 a.m. UM #1 said oxygen was considered a medication and should have a physician's order for use. She was unable to find an order for the use of oxygen listed in the EMR for the resident, nor was she able to identify a diagnosis it was being used for. UM #1 was able to locate an admitting report sheet from 2/24/24 indicating the use of 3 LPM of oxygen for Resident #191. She did not know why the resident was using 2.5 LPM instead of 3 LPM or if she could be weaned off the oxygen. UM #1 said the facility had a respiratory therapist on staff who could workwith the physician regarding the appropriateness of oxygen use for Resident #191. The ADON was interviewed on 2/29/24 at 2:29 p.m. The ADON said it was concerning Resident #191 was using oxygen without a physician's order or a diagnosis. She said there was not an order for the respiratory therapist to evaluate and treat the resident for oxygen use and a care plan had not been initiated for the resident's use of oxygen. She said oxygen use was considered a medication and should have a physician's order for use and a care plan in place if a resident was receiving oxygen. The ADON said the facility needed a better system in place to ensure physician orders were obtained for the use of oxygen and that a care plan was initiated for the use of oxygen. She said the facility started an audit on 2/28/24 to ensure other residents who were receiving oxygen had physician orders and a care plan for the use of oxygen in place.

Based on observation, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for two of two medication storage rooms. Specifically, the facility failed to:-Ensure medication storage refrigerators were within acceptable parameters for proper medication storage;-Ensure medication storage refrigerator temperatures were monitored and documented consistently; -Ensure a Schedule IV controlled medication was properly stored in a locked, permanently affixed compartment in the medication storage refrigerator; and, -Ensure expired medications were properly disposed of. Findings include:I. Facility policyThe Storage of Medications policy, revised November 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, "Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the proper pharmacy or destroyed. Schedule II-V controlled medication are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications."The Storage of Medications Requiring Refrigeration policy, revised November 2022, was received from the NHA on 2/29/24 at 1:03 p.m. The policy read in pertinent part, "It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. 'Refrigerated' refers to temperature maintained between 36-46 degrees Fahrenheit (F)."Temperatures should be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of the person performing the check clearly written." II. Observations On 2/29/24 at 10:00 a.m., the west hallway medication storage room was observed with licensed practical nurse (LPN) #4. The medication storage refrigerator contained vaccines and insulin.-The medication storage refrigerator thermometer read 48 degrees F, which was above the acceptable parameters for safe refrigerated medication storage of 36 degrees to 46 degrees F. On 2/29/24 at 10:15 a.m., the east hallway medication storage room was observed with registered nurse (RN) #1. The medication storage refrigerator contained a lockbox of emergency medications. The medications in the box included Humulin 70/30 insulin, a Lantus Solostar insulin pen, Humulin N insulin, Humulin R insulin, two lorazepam (a Schedule IV controlled medication used to treat anxiety) injectable syringes and a lorazepam multi-dose vial.-The emergency medication box was not locked and had a label on it which indicated the medication kit expired in January 2024.-The lorazepam, a Schedule IV controlled substance, was not stored in a locked, permanently affixed compartment in the medication storage refrigerator.-The medication storage refrigerator thermometer read 30 degrees F, which was below the acceptable parameters for safe refrigerated medication storage of 36 degrees to 46 degrees F.-The temperature logs for the medication storage refrigerator revealed several missing dates of documentation for the months of December 2023, January 2024 and February 2024. III. Staff interviews Registered nurse (RN) #1 was interviewed on 2/29/24 at 10:20 a.m. RN #2 said controlled medications were supposed to be kept under two locked systems. She said the consulting pharmacy was responsible for collecting expired medications and disposing of them properly. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 2/29/24 at 10:43 a.m. She said controlled medications should be stored under a double lock system. She said the refrigerator temperatures were inappropriate for storing medications safely. She said if controlled medications were stored in the medication storage refrigerator they must be in a place permanently affixed to the refrigerator. She said the facility's pharmacy was responsible for tracking and disposing of expired medications.

Based on observations, record review and interviews, the facility failed to ensure residents received and the facility provided food that accommodated resident preferences for one (#12) of three residents reviewed for food preferences out of 18 sample residents. Specifically, the facility failed to ensure Resident #4 was provided with a vegetarian diet per her preference. Findings include:I. Facility policyThe Resident Food Preferences policy, revised July 2017, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modification to diet will only be ordered with the resident's or representative's consent. Nursing staff will document the resident's food and eating preferences in the care plan."II. Resident statusResident #12, age over 65, was admitted on 2/8/24. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs). The 2/14/24 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). The staff assessment for mental status revealed the resident's cognitive skills for daily functioning were severely impaired. She required extensive assistance and was dependent on staff for all cares. III. ObservationsOn 2/26/24 at 9:03 a.m., Resident #12 was sitting in her wheelchair at a table in the dining room. There were two plates of pureed food on a tray in front of her. The plates were covered with plastic. The resident's meal ticket documented the resident was on a puree diet and thickened liquids.-The puree food on the plates was not labeled to indicate what each food item was.-The resident's meal ticket did not document what food the resident received for breakfast.-The meal ticket did not indicate Resident #12 was to receive a vegetarian diet. On 2/26/24 at 12:27 p.m., Resident #12 was sitting in the dining room for lunch. There were two plates with pureed food covered with plastic on the table in front of the resident.-The puree food on the plates was not labeled to indicate what each food item was.-The resident's meal ticket did not document what food the resident received for lunch.-The meal ticket did not indicate Resident #12 was to receive a vegetarian diet. On 2/29/24 at 12:45 p.m., Resident #12 was sitting in the dining room when her lunch was delivered. The food in the dishes delivered to the resident were labeled as beef pot pie, beans and bread. -The resident's meal ticket indicated she was to receive a vegetarian diet, however, the resident was served beef pot pie for lunch.-The resident's meal ticket did not document what food the resident received for lunch. IV. Resident's representative interviewResident #12's representative was interviewed on 2/26/24 at 1:00 p.m. She said she the resident had been assessed for dietary preferences. The representative said she told the facility's registered dietitian (RD) that the resident preferred a vegetarian diet. She said the facility frequently served the resident food which was inconsistent with a vegetarian diet. V. Record review Review of Resident #12's nutrition care plan, revised 2/14/24, revealed she was at a nutritional risk related to hospice. Interventions included providing a diet per physician order, dietary supplements as ordered, monitoring skin for signs of breakdown and for the registered dietitian (RD) to reassess as indicated. -There was no intervention for the resident's food preferences documented on the care plan. -The care plan did not document the resident was vegetarian. VI. Staff interviews The dietary manager (DM) was interviewed on 2/28/24 at 4:30 p.m. The DM said Resident #12t probably received the main dish listed on the menu every day for lunch. He said the resident was not verbal and her meals were communicated by her representative. The DM said he did not know who had contacted the representative for the resident's preferences or where resident's preferences were documented. He said he was not sure what the resident's diet preferences were. The DM said if the resident preferred a vegetarian diet, she should probably receive the main dish option without the meat. He was not sure if Resident #12 was offered a protein substitute as an alternative to the meat portion of the menu. The DM said he did not have a vegetarian menu and it was improvised for every meal. Licensed practical nurse (LPN) # 4 was interviewed on 2/29/24 at 12:50 p.m. LPN #4 looked at Resident #12's meal ticket and said she was not sure what resident received for lunch because her food items were not listed on the meal ticket. After looking at the resident's food tray which was labeled, LPN #4 said the resident was served pureed beef pot pie, pureed beans and pureed bread. LPN #4 said she was not aware the resident was vegetarian. The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 1:45 p.m. The DON and ADON said staff should follow residents' preferences for their diet. The DON and ADON said Resident #12 should be receiving a vegetarian diet if that was her preference and the vegetarian diet preference should be included on the care plan.

Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (#3, and #9) of five residents out of 18 sample residents. Specifically, the facility failed to ensure transmission-based precautions were implemented for Resident #3 and #9. Findings include:I. Facility policyThe Transmission-Based (Isolation) Precautions policy, undated, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy stated in pertinent part, "It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Contact precautions refers to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident of the resident's environment. "When implementing transmission-based precautions, the facility will consider the following: the identification of resident risk factors that increase the likelihood of transmission, the provision of a private room, cohorting residents with the same pathogen, and sharing a room with a roommate with limited risk factors. "Residents on transmission-based precautions should remain in their rooms except for medically necessary care. "Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. "Contact precautions are recommended for multi-resistant organisms, infection or colonization."II. Resident #3A. Resident statusResident #3, under the age of 65, was admitted on 12/08/23. According to the February 2024 computerized physician orders (CPO), diagnoses included infection following a procedure and a deep surgical incision site and methicillin-resistant staphylococcus aureus (MRSA) infection (highly contagious infection on the skin). The 2/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required partial/moderate assistance for activities of daily living (ADL) which included dressing, toilet transferring and standing. B. ObservationsOn 2/26/24 at 10:30 a.m., Resident #3 was sitting in her wheelchair in the hallway outside her room. Licensed practical nurse (LPN) #1 was preparing the resident's intravenous (IV) antibiotic infusion and hooked it up to her central line (a tube utilized for the administration of fluids or medications which is surgically placed in the neck, groin, chest or arm and can remain in place longer than a standard IV) in the hallway. Resident #3 remained in the hallway for the entire IV administration of her antibiotic.-LPN #1 wore gloves to administer the IV medication, however, she did not put on a gown. On 2/27/24 at 1:45 p.m., Resident #3 was in her room. LPN #1 gathered supplies for Resident #3's IV antibiotic infusion and entered the resident's room. She set up the IV antibiotic and attached it to the resident's central line.-LPN #1 failed to put on a gown or gloves when she set up Resident #3's IV antibiotic infusion.. -There was no isolation cart with personal protective equipment (PPE) in it outside of Resident #3's room. -There was no sign on Resident #3's door which informed staff the resident was on transmission-based precautions or what type of PPE should be worn when working with the resident. III. Resident #9A. Resident statusResident #9, age 78, was admitted on 12/21/23. According to the February 2024 CPO, diagnoses included fracture of the neck and pressure injuries to the chin and back of the head. The 11/28/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for most ADLs. B. Record reviewThe wound care note by the wound care physician, dated 12/20/23, revealed the resident's wound on her chin had a MRSA infection. C. Observations Wound care observations for Resident #9 were completed on 2/29/24 at 9:30 a.m. The wound care was completed by wound care nurse (WCN) #1.-WCN #1 did not put on a gown before performing wound care for Resident #9, despite the resident having a MRSA infection in the wound on her chin, which required contact precautions, including the use of a protective gown. WCN #1 entered the room, placed an Ipad (tablet computer) on the resident's table, donned gloves and prepared supplies for the wound. He approached the resident, removed the dressing on the right side of her chin and disposed of the dressing in the trash. The dressing was saturated with yellow drainage. WCN #1 soaked a gauze pad in a wound cleanser solution and used the gauze pad to clean the wound. After cleaning the wound, he picked up the Ipad from the table, logged in, and took a picture of the resident's wound. -WCN #1 did not change his gloves or perform hand hygiene before picking up the Ipad. WCN #1 returned the Ipad to the table and proceeded to apply a clean dressing to the wound. -WCN #1 did not remove his gloves or perform hand hygiene prior to applying the clean dressing to the wound. After applying the clean dressing to the wound, WCN #1 removed his gloves. He applied clean gloves and started the wound care for the second wound on the back of the resident's head. -WCN #1 did not perform hand hygiene prior to starting wound care on the resident's second wound. WCN #1 removed the soiled dressing, which was saturated with yellow drainage, from Resident #9's wound on the back of her head. WCN #1 proceeded to pick up his Ipad and took a picture of the wound.-WCN #1 did not change his gloves or perform hand hygiene before picking up the Ipad. WCN #1 returned the Ipad to the table and proceeded to apply a clean dressing to the resident's head wound.-WCN #1 did not remove his gloves or perform hand hygiene prior to applying the clean dressing to the wound. IV. Staff interviewsLPN #2 was interviewed on 2/28/24 at 8:47 a.m. She said she was not aware of any resident on transmission-based precautions. She said she was not aware of any resident with an active MRSA infection. She said residents with MRSA were placed on contact precautions, which included a gown and gloves. LPN #2 said residents on contact precautions should have an isolation cart outside their room and a sign on the door to stop anyone who entered the room to see the nurse before entering. The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 11:07 a.m. The ADON said she was serving as the facility's infection preventionist. She said any resident with an active MRSA infection or a history of the infection were placed on contact precautions. This included wearing a gown, gloves, mask, and goggles or a face shield if splashing was a risk. She said residents on contact precautions should have an isolation cart outside their room with PPE in it. She said there should also be a stop sign on the resident's door stopping anyone from entering without checking with the nurse on duty. She said the facility had an adequate supply of PPE. The ADON said she was unaware of Resident #3's MRSA infection. The ADON said it was inappropriate to set up and run an antibiotic in the hallway for a resident on transmission-based precautions. She said this was because of the potential to spread the infection to other staff members and residents.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/10/2023 and 07/16/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/19/2023 and 06/25/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/12/2023 and 06/18/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/10/2023 and 04/16/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.