CENTER AT FORESIGHT LLC, THE

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

A revisit to the 1/12/23 survey was completed on 4/6/2023. The facility was in compliance with the regulations surveyed.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The building is three-story, Type II (111) construction, without a basement. The facility is divided into three smoke compartments on the first floor and two smoke compartments on floors two and three. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic sprinkler system. Emergency power is provided by a diesel driven generator. The facility is equipped with a piped medical gas system in the first level storage room. The facility is licensed for 54 beds, with the resident census on the day of survey at 47. A recertification survey was completed on February 7, 2023. The facility was reviewed and surveyed to the National Fire Protection Association (NFPA) Life Safety Code (2012) Chapter 18, New Health Care Occupancies; NFPA 99 Health Care Facilities Code (2012); and all referenced standards. This facility will meet these requirements upon completion of a plan of correction. All deficiencies were discussed with the Facility Administrator and the Maintenance Director during the exit conference. The following deficiencies are covered under the 1135 waiver:1) No documentation for semi-annual fire alarm battery load test. 2) No documentation for semi-annual kitchen hood inspection.

During the review of the facility records and observation, with the staff on February 7, 2023, the facility failed to maintain kitchen cooking appliances as required by NFPA 96. The following evidenced this:1) All moveable cooking appliances need floor cleats installed to ensure proper placement. 2) Stove in rehab does not have commercial hood installed. The Cooking Facilities deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. The maintenance director acknowledge the lack of cleaning and inspection of the system during survey.

Through a review of the records and discussion during the survey on February 7, 2023, it was determined the facility failed to inspect, test, and maintain the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.5) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). The following evidenced this:1)Annual fire alarm inspection report shows multiple deficiencies that need documentation for correction. Deficiencies include: L1D42 duct detector, FCPS A, FCPS B, FCPS C, and amplifier failed. The Fire Alarm System deficiency has the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. Maintenance director and administrator acknowledged the condition of testing the fire alarm system during the record review.

Based on record review, observation and staff interview during the course of the survey conducted on February 7, 2023, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 18.3.5.1, 9.7, 9.7.5, NFPA 25 and NFPA 13. The following evidenced this: 1)Annual fire sprinkler inspection report shows deficiencies that need documentation that correction has been made. Deficiency includes: Gauges need replaced/recalibrated. The fire sprinkler deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation and staff interview during the course of the survey conducted on February 7, 2023, it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 18.3.7.3 including 8.5. The following evidenced this: 1)Penetrations need sealed in 2nd floor O2 room. Maintenance director acknowledged the deficiency during a tour of the facility. The smoke barrier deficiency has the potential to affect all occupants, who might include staff and visitors in associated compartments; items were discussed during the survey and again during the exit conference.

Based on record review and staff interview during the survey on February 7, 2023, it was determined the facility failed to conduct fire drills in accordance with NFPA 101, 18.7.1. The following evidenced this: 1)No documentation for all fire drills. The fire drill deficiencies have the potential to affect all occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference. Life Safety Code, Section 18.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

A recertification survey with complaint #CO30523 was completed from 1/9/23 to 1/12/23. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/9/23 to 1/12/23. No deficiencies were cited.

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for one (#8) out of 27 sample residents. Specifically, the facility failed to: -Promptly and thoroughly investigate a grievance and provide resident follow-up for resolution regarding potential mistreatment by a staff member; and, -Have a system in place to promptly identify and seek grievance resolution, when a resident reported missing items. Findings include:I. Facility Policy The Grievance policy, revised 2/8/21, was provided by the minimum data set coordinator (MDSC) on 1/12/23. According to the policy, residents had the right to voice complaints and/or grievances regarding respect, care, treatment or any other matters related to quality of care or quality of life. Grievances could be communicated to a staff member either verbally or in writing. The facility would make every effort to promptly investigate and resolve any grievances. The policy procedure read in pertinent part: "If the complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. The completed form must be provided to the executive director (nursing home administrator) or designee immediately. The grievance will be given to the appropriate department manager for follow-up and resolution. All grievances will be reviewed in morning meetings with the IDT (interdisciplinary team) members. Department managers are responsible for resolution of all complaints within his/her department. Department managers will note the disposition of the grievance in writing to the executive director or designee as soon as possible, but no later than 72 hours of the receipt. It is the responsibility of the department manager in coordination with the executive director, when appropriate, to develop a process/plan for resolution of the grievance and notify the complainant about the plan for resolution. All actions taken on the grievance included meetings with the patient, telephone calls, action plans, revision of care plans, ect. must be documented on the grievance form."The Quality of Life - Dignity policy, undated, was provided by the facility on 1/12/23. According to the policy, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy identified residents shall be treated with dignity and respect at all times. The policy indicated that "treating with dignity" meant the resident would be assisted in maintaining enhancing his or her self-esteem and self-worth. II. Resident #8 statusResident #8, age 77, was admitted on 10/12/22. According to the January 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus, Alzheimer's disease late onset, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, depression, and anxiety disorder. The 10/15/22 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment identified the resident did not have inattention or disorganized thinking. According to the MDS assessment, the resident required extensive one person physical assistance for transferring, locomotion on the unit, and toileting. Resident #8 required limited one person physical assistance for dressing, bed mobility and personal hygiene. The MDS assessment identified the resident had corrective lenses. III. Failed to promptly and thoroughly investigate a grievance and resident follow up for resolution regarding mistreatment by a staff member. A. Resident interviewResident #8 was interviewed on 1/10/23 at 8:41 a.m. She said she had not been treated with respect and dignity by one certified nurse aide (CNA). She said she did not know the name of the CNA but she was usually "rude, pushy, and gruff" with her. She said the CNA had also touched her after wiping her nose with hands and then touched the resident without performing hand hygiene. The resident said the CNA refused to wash her hands after the resident asked her too and said she would perform hand hygiene when she left the room. Resident #8 said she had reported her concerns to her nurse. B. Staff interviewsRegistered nurse (RN) #1 was interviewed on 1/12/23 at 1:06 p.m. She identified herself as a routine nurse for Resident #8. The RN said Resident #8 was very pleasant and did not usually complain. She said Resident #8 reported to her that CNA #2 was mean to her. The RN #1 clarified and said the resident reported the CNA was mean to her in a verbal tone and was not patient with her. RN #1 said she had seen CNA #2 impatient with other residents. The RN said she reported the concern to the infection preventionist registered nurse (IPRN) and then the CNA lead. RN #1 said she interviewed CNA #2 and identified that the CNA had personal concerns she was dealing with. The RN said she reminded CNA #2 to leave her personal issues at home. The CNA lead was interviewed on 1/12/23 at 1:16 p.m. The CNA lead said she talked to Resident #8 almost every day and she had not expressed her concerns to her regarding any staff members. The CNA lead said she was recently on vacation but when she returned on 1/5/23, she was informed Resident #8 did not want to have CNA #2 as her CNA. The CNA lead said Resident #8 felt the CNA did not want to help her and was impatient with her. She said she thought the concern occurred on the previous weekend shift (1/1/23) because the CNA worked weekends but was not sure exactly when. The CNA lead said she reported the concern to the NHA on 1/5/23. She said a grievance form was not generated. The CNA lead said the CNA was moved off the hall of Resident #8 and she completed an education with CNA #2. The assistant director of nursing (ADON) was interviewed on 1/12/23 at 10:02 a.m. She said she was not aware of any grievances or investigations regarding Resident #8 but would look. The social services director (SS) was interviewed on 1/12/23 at 10:07 a.m. She said she was not aware of any concern or grievances regarding Resident #8. The MDS coordinator (MDSC) who was identified as the former director of nursing (DON), the new DON, the assistant director of nursing (ADON) and the corporate clinical consultant (CCC) was interviewed on 1/12/23 at 6:26 p.m. The MDSC said in morning meetings the interdisciplinary team reviewed resident grievances. The grievance resolution would then be signed off by the nursing home administrator (NHA). The ADON and the MDSC said they did not review grievances or any heard information related to Resident #8 reporting a CNA was rude or mean. The ADON said she believed Resident #8 had a preference not to work with a CNA as reported by the CNA lead. She said she did not know which CNA. The ADON said she would have to follow up with the CNA lead. She said the CNA lead was in charge of CNA concern follow ups. The MDSC said she remembered the resident had an interaction with a staff member. The MDSC said she did not remember more regarding the concern discussed. She said when a resident reports a staff member being mean to them, the facility should make sure the person being accused was removed from the environment and immediately interview the resident. She said nursing management would then check with other staff on the same shift, family, and other residents about it. She said concerns should be reported right away. She said education would need to be completed with staff members. The ADON said education was completed with CNA #2 but she was not sure when. The MDSC said they were not made aware of the resident's concern until after the fact. The ADON said they were made aware when it was later reported to the CNA lead. The MDSC and ADON said the CNA had not worked with the resident since her concerns were reported. The ADON said the facility haddone multiple training of abuse in the past and did a CNA skills training in October 2022. She said abuse education was conducted across the board with nursing shortly after management became aware of the resident's reports. The MDSC said the last education was specific about if they see something, report it right away. The MDSC said staff education was the first starting point in prevention. The education should include self identification of tone of voice, reminder to leave attitudes at the door, and present happy demeanor. She said the facility needed to continue coaching, continued follow up, working with our nurses, and coaching CNAs by example such as tone of voice and modeling appropriate behavior to others. The CCC identified the facility could benefit from outside education resources related to resident rights, dignity/respect, appropriate communication/interactions with residents. The CCC suggested potential available community education resources that could be obtained for additional staff training. The MDSC said the facility needed to improve their investigation process, including root cause analysis, when resident concerns are identified. The DON said they would immediately start reviewing their grievance processes and staff training. They said they would have something in process within next week, an ongoing thing, refreshing, and continuous and would probably start tomorrow (1/13/23). They said their actions would be in addition to already occurring patient advocate room rounds which were done daily by managers. The MDSC said she was not sure if there was follow up with Resident #8 after she reported her concerns with CNA #2. The MDSC said she would have to pull the room rounds. C. Record reviewThe records did not identify a grievance was generated and the resident was followed up with to ensure her concern was resolved. The records did identify and investigation was conducted, identifying resident concerns, facility response and action, including interviews with the resident, staff, or other residents who have worked with CNA #2 to identify if they had additional concerns related to CNA #2 inappropriate treatment/behaviors. The review of Resident #8's progress notes did not identify her dignity, grievance was not documented or readdressed/followed up with her. A 1/5/23 abuse and mistreatment education was provided by the ADON via email on 1/13/23. The education was labeled "Take 5" and instructed staff the read the following information:"The (facility) has a zero tolerance for any abuse or mistreatment of our patients. we take pride and treating our patients with respect, dignity, kindness and compassion if you see or hear mistreatment remember your training brief reminder below:-Intervene if you witness the mistreatment ( make sure patient is safe)-Report immediately to your supervisor and administrator we comply with strict reporting to authorities as mandated by the state.-Always ask for help or ask questions when needed-When in doubt ask-You're supervisor, social services, d o n, and administrator always available- if not in-house they're available by phone-Remember our patients are here because they need our care, compassion and understanding. Making the patients feel safe and comfortable is our top priority."The 1/6/23 CNA #2 on the spot training related to patient complaints/concerns was provided by the facility on 1/12/22. The training identified the CNA lead conducted the education. The plan of correction/education read: "Need to watch your tone of voice with patient. Perception is everything. The tone of your voice can come across as being rude and or aggressive. Also need to slow down while providing care so patients do not feel rushed, or feel that you're being impatient with them." -However, the facility did not follow up with the resident on her grievance with CNA #2 she reported. IV. Failed to timely follow up on Resident #8 concern of a missing pair of glassesA. Resident interviewResident #8 was interviewed on 1/10/23 at 8:41 a.m. She said she was not happy that she was still missing her glasses. She said she told "everyone." The resident said they told her they would tell everyone else. She said not having her glasses, she was having a difficult time reading the menu, and reading the communication board located on the wall across from her bed. She said because she could not read the communication board, she did not know which staff members she would be working with that day or when therapy was scheduled that day. Resident #8 was interviewed again on 1/12/23 at 10:15 a.m. She knew her daughter did not have her glasses because she was the first one checked with. She said staff looked in her room for the glasses but that was all she knew about the follow up. B. Record reviewThe vision care plan, initiated on 10/14/22 identified the resident had impaired vision. The care plan read the resident's needs would be met and not affected by her vision impairment. The care plan directed staff to assist her with glasses as needed. Records did not identify Resident #8 reported she was missing her glasses or what steps the facility took to find her glasses, and seek resolution. C. Staff interviewCNA #1 was interviewed on 1/11/23 at 9:54 a.m. She said she was the resident's bath aide and also provided care. She said she knew Resident #8 had been missing her glasses for the past couple of weeks. She said she believed the glasses had been around since her last hospital appointment (12/23/22). She said the resident's nurse and her daughter were aware the glasses were missing. The SS was interviewed on 1/11/23 at 1:36 p.m. She said there was not a tracking process that she was aware of for missing items. She said if a resident reported a missing item, then nursing or the CNA lead would look for the item and check with the family. The SS said she was not usually involved in the process and not sure of the procedure. She said known missing items would be reported in the morning meeting. The ADON was interviewed on 1/12/23 at 9:53 a.m. She said if a resident was missing an item, the DON and the ADON and possibly the CNA lead. The ADON said the family would be contacted. She said if appropriate, laundry would be notified. She said they would also sometimes check with admissions to determine if the resident admitted with the identified missing item. The ADON said the IDT would also talk about the missing item in the morning meeting. She said there was no paper trail for missing items and follow-up, just verbal communication. She said she was not aware Resident #8 were missing glasses prior to 1/12/23. The SS was interviewed again on 1/12/23 at 10:05 a.m. She said she was not aware Resident #8 was missing her glasses. She said the CNA nor the resident's family reported the missing item to her. The CNA lead was interviewed on 1/12/23 at 10:09 a.m. She said if a concern of a missing item was reported to her, the concern would be flagged till the item was replaced or closed/resolved. She said it would be good to generate a grievance form for tracking. The CNA lead said she was not aware of Resident #8 missing glasses. She said she knew the resident had an outpatient patient hospital appointment she went to with her daughter in December 2022. She said she would follow up with her daughter. RN #1 was interviewed on 1/12/23 at 12:58 p.m. She said the resident and daughter reported to her that she was missing her glasses. She said she thought she heard that the glasses were missing since Christmas. The RN said she checked if the facility had a lost and found, but they did not have one. She said she asked the kitchen if they found any glasses that were left on the tray after meals. She said she had not heard back but assumed they did not find them. She said she found out today (1/12/23) that she should have filled out a grievance form for missing items. She said she brought the resident reading glasses but did not know the resident was still having difficulty seeing without her original glasses. The CNA lead was interviewed on 1/12/23 at 1:22 p.m. She said she followed up with missing glasses and identified they had been missing since 12/25/22 and not lost when she went out to her (12/23/22) appointment. She said the glasses were not reported to her or a grievance was completed. She said she educated staff today (1/12/23) to start using the grievance form to identify when a resident reports a concern with missing items. She said the facility used to use the grievance forms to report and track missing resident items but for the last couple of years, the process went away. She said up till 1/12/23, the facility just relied on verbal communication as their missing item process. She said the grievance form would provide a paper trail for notification, actions taken, and attempts for resolution. She said she would be the designated person to follow up and track missing items identified on the grievance forms. The CNA lead said having a set system in place would help address the missing items concern right away, increasing the probability of finding the item. The MDSC, the new DON, the ADON and the CCC was interviewed on 1/12/23 at 6:26 p.m. The MDSC said the facility had reached out to the resident's family but had not heard back. She said the CNA lead was reimplementing the grievances for missing items and would use the grievance forms as a tracking tool. The MDSC said it was within their policy to replace missing items if needed and the facility had replaced items in the past. D. Facility follow-upThe Quality Education Performance Improvement attendance sheet, dated 1/12/23, was provided by the CNA lead on 1/12/23 4:04 p.m. According to the Performance Improvement attendance sheet, staff were educated on 1/12/23 regarding the new missing item process. The education read: "If something is reported to you as missing, you need to check the patient's room for the item. If the item is not found, you are to write it up on the orange grievance forms located at the nurses station on both floors and give it to (CNA lead) as soon as possible." A grievance form, on behalf of Resident #8 was dated 1/12/23 and provided on 1/12/23 at 4:04 p.m. The grievance form read the resident was missing glasses. The grievance form identified missing glasses were reported to RN #1 on 1/5/23. The RN looked through the resident's room and called the front desk to check lost and found. The RN brought the resident a pair of reading glasses on 1/12/23.

Based on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchens during meal services. Specifically, the facility failed to:-Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; and,-Ensure beverages were served at the appropriate temperature. Findings include:I. Professional standardsThe Centers for Disease Control and Prevention (CDC), reviewed 8/5/22, retrieved on 1/17/23 from: https://www.cdc.gov/foodsafety/keep-food-safe.html, under "Four Steps to Food Safety" read bacteria could multiply rapidly if left at room temperature or in the "Danger Zone" between 40°F and 140°F.II. Facility policyThe Handwashing for Dietary Staff policy, revised 2/8/21, was provided by the dietary manager (DM) on 1/13/23 via email. The policy indicated staff should wash their hands as frequently as needed throughout the day using proper hand washing procedures. According to the policy, staff should wash their hands and exposed portions of the arms immediately before engaging in food preparation and as often as necessary to remove soil or contamination in efforts to prevent cross contamination. The policy hand hygiene should also occur when changing tasks during food preparation and other activities that could contaminate staff's hands. III. Observations A continuous observation of the lunch meal preparation and service was completed on 1/11/23 between 11:17 a.m. to 12:29 p.m. A. Cross-contamination During plating of the 1/11/23 lunch, the cook placed a plate of ready-to-eat food on the steamline shelf. Dietary aide (DA) #1 placed an empty tray on the back side of the steam table and set a covered dessert, paper napkin rolled silverware, and a pre-poured beverage on the tray with his bare hands. The DA then collected the plate off the shelf, covered it, and placed it on the prepared meal tray. DA #2 then placed a hot beverage (if ordered) on the tray and placed the completed meal tray inside a covered mobile unit for room delivery. Between 11:20 p.m. and 12:23 p.m. DA #1 placed his hands inside his pants pockets while he waited for the cook to place the plated meal on the shelf. The DA would then remove his hands from his pockets, place the plate of the tray, passing it to DA #2, and prepared the next tray. DA #1 did not perform hand hygiene after the removal of his hands in his pockets, and touching the outside surfaces of the paper napkin, plate holder, dessert bowl or beverage glass. Throughout the observation, DA #1 frequently retrieved the covered beverage glass of a cart by placing his hand over the top of the glass with his fingers, touching the drinking surface of glass, his fingers exceeding the surface of the thin covered lip of the glass. -At 11:57 a.m. DA #2 placed his right forearm across the prepared tray, resting the bare portion of his arm on the rolled napkin as he waited for the plated meals. DA #2 was not observed to wash his forearm prior to placing it across the tray. -At 12:04 p.m. DA #1 collected a plate from the shelf, touching the overhanging lettuce with his thumb before he placed a cover over the plate and set it on the tray. -At 12:09 p.m. DA #1 left the tray line and entered the dry storage room. The DA did not perform hand hygiene before returning to the tray line. -At 12:14 p.m. DA #2 touched the outside of his surgical mask and then proceeded to pour hot beverages in cups and place completed trays in the mobile unit. DA #2 did not perform hand hygiene after touching his mask.-Throughout the observation, DA #1 and DA #2 did not perform hand hygiene while preparing trays for resident delivery. B. Above temperature milk for resident consumption. On 1/11/23 between 11:20 a.m. and 12:23 p.m., pre-poured beverages in covered glasses were observed sitting out on a cart behind the steamline in the kitchen. The pre-poured beverages included several glasses of milk. On the bottom shelf on the cart was half of a gallon of milk. The pre poured glasses of milk and the milk container were not stored/held on ice or with another other system designed to keep the milk cold prior resident delivery. During observations, the dietary aides would retrieve an ordered an glass of milk from the cart, place the milk on a meal tray next to the covered hot food, and then place the tray with the milk in the covered mobile unit designed to keep meals warm. The mobile units would then be sent to the hallways for resident room delivery. -At 12:23 p.m. a test tray with a glass of pre-pour milk was placed in the mobile unit and sent to the second floor west hall. -At 12:27 p.m. the test tray arrived on the unit, along with resident meals, some of which included milk.-At 12:29 p.m. the test tray was removed from the mobile unit.-At 12:32 p.m. the temperature of the pre-pour glass of milk on the tray was collected. The temperature of the milk was 52.7 degrees Fahrenheit (F). IV. Staff interviewThe infection preventionist registered nurse (IPRN) and the corporate clinical consultant (CCC) was interviewed on 1/11/23 at 2:42 p.m. The IPRN said her infection control involvement with dietary, primarily consisted of Monday through Friday "glance around" to check if infection control practices were conducted as she placed her lunch order. The IPRN said she had also conducted a recent dietary audit and identified areas for dietary follow up. The DM was interviewed on 1/12/23 at 3:38 p.m. The DM said the dietary staff have had past in-services on appropriate infection control practices when handling food. She said infection control was an ongoing process. The above observations were reviewed with the DM. She said hands in the pocket, mask touching, and appropriate handling of resident drinking glasses/cups were all identified in the past and reviewed with the staff, due to the risk for cross-contamination. The DM said 52.7 F was not an acceptable temperature of milk to be served to the residents. The DM said the high temperature of milk could create a food borne illness. She said the milk should have been on ice to maintain an acceptable temperature. She said she would work on a different way to serve cold beverages. V. Facility follow-upThe DM provided facility follow up to ensure infection control practice improvement according to a 1/13/23 provided email with an attached education checklist (Skills Check-Off Hand Washing form.) According to the email, the dietary department would be reviewing the below handwashing skill checklist on 1/16/23 through 1/21/23. In addition, and according to the provided email, the dietary department immediately corrected the beverage holding temperatures for meal delivery, starting with the evening meal service on 1/12/23. The beverages were placed in tubs containing ice to make sure they were within appropriate serving temperatures. The 1/13/22 DM provided Skills Check-Off Hand Washing form, identified the staff were instructed on how to wash their hands properly with a competency review.