Haven of Sierra Vista, LLC

Based on observations, the facility failed to repair the patient sleeping room corridor doors. Failing to protect patient sleeping rooms from heat or smoke will cause harm to patients and/or staff.

Based on personnel file review, staff interviews, job description, and facility policy and procedures, the facility failed to ensure one staff (#63) received training in cardiopulmonary resuscitation (CPR). The deficient practice could result in a delayed response to provide CPR by a trained and licensed staff. Findings include: A review of the personnel file for the licensed practical nurse (LPN/staff #63) revealed that she was hired on July 7, 2023 as a LPN. Further review of the file did not reveal a CPR certificate of completion. Review of the employee time card revealed that staff #63 worked 458.42 hours from July 7, 2023 through December 6, 2023. Review of the facility staff list revealed that staff #63 was a licensed pratical nurse. During an interview conducted on December 6, 2023 at 8:21 a.m. with human resources (staff #201), she stated that CPR training/licensing is required by all nurses and certified nursing assistants and must be completed by the 7th day of employment. She also stated that (LPN/staff #63) has worked in the facility providing care for the residents. She stated that staff #63 is scheduled to attend CPR training today. An interview was conducted on December 6, 2023 at 11:17 a.m. with the Director of Nursing (DON/staff #100), who stated that the nurses are required to be CPR certified. She stated that there is a risk if the nurse working is not CPR certified because the nurse may not be able to provide CPR accurately. The facility policy "Staff Development Pogram" states that licensed and certified staff are required to maintain licensure and certifications according to their respective positions, in compliance with any state and federal requirements, rules and regulations. In accordance with the requirements of \'a7483.24, registered nurses, licensed practical nurses and certified medical assistants must maintain CPR certification.

Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#2). Findings include: Resident #2 was initially admitted to the facility on April 25, 2019 and was re-admitted on January 26, 2022 with diagnoses that included acute stress reaction, and suicidal ideations. A cognition care plan revised on November 7, 2019 revealed that the resident has impaired cognitive function or impaired thought process. Interventions indicated to use residents name and identify yourself at each interaction. Review of a medication care plan revised on November 4, 2019 revealed that the resident is on psychotropic medications related to schizoaffective disorder. Interventions included administer medications as ordered, monitor/record occurrence of target behavior symptoms, monitor/record/report to physician side effects and adverse reaction to medication, and psychiatric/psychological consult as ordered. A medication care plan initiated on September 23, 2020 indicated that the resident is on antidepressant medication related to depression. Interventions included to monitor/document/report to physician as needed ongoing signs/symptoms of depression that is unaltered by medication, give antidepressant medications as ordered by physician, and refer for psychiatric/psychological consult as ordered. Review of the resident's face sheet revealed the following new diagnoses and date of onset: major depressive disorder dated July 11, 2021, anxiety disorder dated September 26, 2020, and schizoaffective disorder dated August 21, 2021. A medication care plan revised on September 28, 2020 revealed that the resident is on anti-anxiety medication related to anxiety disorder. Interventions included to give anti-anxiety medications as ordered, monitor/record occurrence of target behavior symptoms, and psychiatric/psychological consult as ordered. Review of the PASRR Level I Screening Tool dated March 9, 2021 revealed the form was not adequately filled out. Section B. Mental Illness was left blank. The symptoms portion under the area interpersonal with the question has the individual exhibited interpersonal symptoms or behaviors was left unanswered. Additionally, the concentration/task related symptoms portion was left answered. The portion pertaining to History of Psychiatric Treatment was also left blank. The area titled "Psychotropic Medications" was also left blank. A communication care plan revised April 25, 2022 revealed that the resident has impaired hearing. Interventions included to be conscious of the resident's position when in groups, activities, and dining room to promote proper communication with others. It also recommended to use communication techniques which enhance interaction and to allow adequate time to respond. A care plan revised on April 25, 2

Based on clinical record review, facility documentation, staff interviews, and policies and procedures, the facility failed to ensure one resident (#166) was free from resident to resident abuse, which resulted in physical harm as evidenced by a 5 x 4 cm bruise on the resident's right wrist. The deficient practice could result in other residents being abused. Findings include: -Regarding Resident #166 Resident #166 (alleged victim) was admitted to the facility on July 12, 2019 with diagnoses that included chronic kidney disease, anxiety disorder, major depressive disorder, and schizoaffective disorder. A neurological care plan initiated on July 13, 2019 indicated that the resident has an alteration in neurological status related to dementia. Goals included: resident will be able to communicate daily needs, and will maintain optimal status and quality of life within limitations imposed by neurological deficits. Interventions included give medications as ordered, monitor/document for side effects and effectiveness, evaluate and treat as ordered. Review of a care plan initiated on July 25, 2019 revealed that the resident demonstrated physical behaviors related to his impaired cognition. The goal was resident will not harm self or others. Interventions included to analyze key times, place, circumstances, triggers, and what deescalates behavior and document. Review of a quarterly Minimum Data Set (MDS) assessment dated October 7, 2021 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS assessment indicated that at the resident was negative for psychosis, behavioral symptoms, rejection of care, and wandering. A nursing note dated November 4, 2021 revealed that the resident presented to the nursing office and showed a nurse a bruise to his right wrist. The nursing note stated that the resident reported that his roommate punched him causing the bruise which measured 5 x4 cm. The note documented that resident #166 stated that he was going to his room when his roommate grabbed then punched him. A follow-up nursing note dated November 4, 2021 indicated that resident #166 demonstrated exit seeking behavior after the incident. The note also noted that the resident wanted to talk to someone and kicked the exit door. The note documented that this occurred twice within a 30-minute period. A Health Status note dated November 4, 2021 indicated that during conversation with the resident regarding the incident, the resident stated that the man who hit him was standing next to him. Review of a progress note dated November 5, 2021 revealed that the incident which left a bruise on the resident's wrist was reported to Adult Protective Services (APS), non-emergency police, and the ombudsman. The note also stated that the residents were separated into different rooms. A weekly skin assessment dated November 5, 2021 indicated that resident #166 had a new skin condition. It was described as ri

Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#2). The deficient practice could result in specialized services not being identified and provided to residents. Findings include: Resident #2 was initially admitted to the facility on April 25, 2019 and was re-admitted on January 26, 2022 with diagnoses that included acute stress reaction, and suicidal ideations. A cognition care plan revised on November 7, 2019 revealed that the resident has impaired cognitive function or impaired thought process. Interventions indicated to use residents name and identify yourself at each interaction. Review of a medication care plan revised on November 4, 2019 revealed that the resident is on psychotropic medications related to schizoaffective disorder. Interventions included administer medications as ordered, monitor/record occurrence of target behavior symptoms, monitor/record/report to physician side effects and adverse reaction to medication, and psychiatric/psychological consult as ordered. A medication care plan initiated on September 23, 2020 indicated that the resident is on antidepressant medication related to depression. Interventions included to monitor/document/report to physician as needed ongoing signs/symptoms of depression that is unaltered by medication, give antidepressant medications as ordered by physician, and refer for psychiatric/psychological consult as ordered. Review of the resident's face sheet revealed the following new diagnoses and date of onset: major depressive disorder dated July 11, 2021, anxiety disorder dated September 26, 2020, and schizoaffective disorder dated August 21, 2021. A medication care plan revised on September 28, 2020 revealed that the resident is on anti-anxiety medication related to anxiety disorder. Interventions included to give anti-anxiety medications as ordered, monitor/record occurrence of target behavior symptoms, and psychiatric/psychological consult as ordered. Review of the PASRR Level I Screening Tool dated March 9, 2021 revealed the form was not adequately filled out. Section B. Mental Illness was left blank. The symptoms portion under the area interpersonal with the question has the individual exhibited interpersonal symptoms or behaviors was left unanswered. Additionally, the concentration/task related symptoms portion was left answered. The portion pertaining to History of Psychiatric Treatment was also left blank. The area titled "Psychotropic Medications" was also left blank. A communication care plan revised April 25, 2022 revealed that the resident has impaired hearing. Interventions included to be conscious of the resident's position when in groups, activities, and dining room to promote proper communication with others. It also recommended to use communication te

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that adequate documentation for one resident's (#40) nutritional intake was completed. The deficient practice could result in nutritional deficiencies not being monitored. Findings include: Resident #40 was admitted to the facility on August 13, 2021 and readmitted on October 10, 2023 with diagnoses that included unspecified protein-calorie malnutrition, iron deficiency, chronic obstructive pulmonary disease, and acute kidney failure. Review of the care plan dated October 10, 2023 revealed that the resident is at risk for nutritional and hydration problems as evidenced by a low mini nutritional assessment (MNA) score of 6: malnourished. Interventions included fortified cereal, Med Pass nutritional shake two times daily, and to encourage intake. A mini nutritional assessment (MNA) dated October 11, 2023 revealed the resident's height was 68 inches and weight was 142 lbs and had a moderate decrease in food intake and lost more than 6.6 pounds over the last three months. The minimum data set (MDS) dated October 14, 2023 included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The order summary revealed an order dated October 10, 2023 for a regular diet, regular texture, thin liquids consistency and fortified cereal. A progress note by the dietician dated November 12, 2023 revealed that the resident's weight was 133.5 lbs on November 3, 2023 and he had a 5.6% weight loss over the last 30 days. The resident is on a regular diet with 67% intake times one week, variable intake of fortified cereal, and an appetite stimulant is in place. The resident's weight is trending down despite interventions and will add Med Pass nutritional shake twice a day to maximize nutrition. Review of task for cereal intake revealed that there was no documentation on November 2, and 6, 2023 and documented as not applicable on November 10, 11, 12, 17, 18, 19, 23, 24, 25, 26, and December 1, 2, and 3, 2023. An interview was conducted on December 7, 2023 at 12:52 p.m. with a certified nursing assistant (CNA/staff #36), who stated that the percentage of food intake for every meal is documented for all the residents. She stated that if a resident refuses to eat, she documents the refusal on the task sheet and reports it to the nurse. She knows that the resident eats fortified cereal with a protein shake for breakfast and if it is a standing order, he should received the cereal every morning. She stated that if there is no documentation regarding the percentage of cereal eaten, it may mean that the cereal was not sent to the resident. During an interview conducted on December 7, 2023 at 1:14 p.m. with a registered nurse (RN/staff #81), she referred to the cereal order and stated that it was part of the dietary order, but was not sure how often the resident was supposed to receive it. She went to check with the Direc

Based on observations, clinical record review, interviews, and policy review, the facility failed to ensure one resident (#23) received the necessary services to maintain good bathing and grooming hygiene. This deficient practice could result in bathing and grooming needs not being met. Findings include: Resident #23 was admitted on October 10, 2023 with diagnosis including Parkinson's Disease, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, arthritis, major depressive disorder, muscle weakness and need for assistance with personal care. A review of the MDS (minimum data set) dated November 07, 2023 revealed a BIMS (brief interview of mental status) of 5 and further noting that for personal hygiene the resident requires one-person physical assistance. A review of the care plan for resident #23 revealed that the resident is at risk for functional selfcare deficits and that facility staff is to communicate the resident and or family regarding the resident's needs. A observation was conducted on December 07, 2023 at 1:54 P.M. Resident #23 was observed to be seated in the communal area of the unit watching television. The resident was not clean shaven and was observed to exhibit facial hair. A telephone interview with the representative, Individual #203, of resident #23. She stated that the resident likes to be shaved but had not been. Individual #203 stated that the resident's presonal razor had been brought to the facility and it was requested that staff shave the resident; however, based on the representatives statement and per observation, the resident had not been shaven. An interview was conducted on December 7, 2023 at 2:02 P.M. with resident #23. The resident stated that he did not like facial hair and would like to have a shave. The CNA (certified nursing assistant), staff #31, had walked into the room and stated that the resident had not been shaven for 3 to 4 days, because she can't find his personal razor. She stated that facility razors were available but they tend to cause 'nicks' and that is why she had not shaved the resident. When asked about an electric razor, staff #31stated that the facility does have one but she would have to track it down; however, neither a bladed or electric razor had been utilized to shave the resident. She stated that the last time the resident had received a shower was on December 06, 2023. She further stated that anytime a resident wants to be shaved that he should be shaved. An interview was conducted with 2 additional CNA's, staff #94 and staff #202, on December 07, 2023 at 2:06 P.M. CNA #202 stated that residents generally bring their own razors, but if not, a facility razor would be utilized and CNA #94 if a resident prefers to be shaven, staff would shave the resident on a daily basis. An interview was conducted on December 07, 2023 at 2:27 P.M. with LPN (licensed practical nurse) staff #3. Staff #3 stated that personal hygiene tasks such as shaving are generally completed twic

Based on documentation, staff and resident interviews, and the facility policy and process, the facility failed to ensure one resident (#40) had access to activities. The deficient practice could impact the psychosocial well-being of residents. Findings include: Resident #40 was admitted to the facility on October 10, 2023 with diagnoses that included a displaced intertrochanteric fracture of the left femur, chronic obstructive pulmonary disease, dependence on oxygen, major depressive disorder and an anxiety disorder. The activities care plan dated October 10, 2023 stated that the resident enjoys being in his room watching TV and looking outside his window getting sunlight and included one intervention to offer a variety of activity types and locations. Note: resident #40 shares a room and his roommate's bed is located on the side of the room where the window is located. The minimum data set (MDS) dated October 14, 2023 included a brief interview for mental status score of 14 indicating the resident was cognitively intact. Review of the clinical record did not reveal any documentation of activities that the resident attended or refused to attend. During the initial interview conducted on December 4, 2023 at 1:07 p.m. with resident #40, he stated that he is not invited to activities and doesn't know what activities are being offered. An activity calendar was observed hanging on wall directly across from the resident's bed and was dated November 2023. An interview was conducted on December 7, 2023 at 2:07 p.m. with the Activities Manager (#staff 61), who stated that the purpose of activities is to get the residents out of their rooms, to distract them. She makes an activities calendar each month for the residents, so they know what activities are being offered. She stated that she goes to the residents' rooms and invites them to activities and she memorizes which residents are not participating. She stated that resident #40 usually doesn't want to attend activities because he is not interested. She stated that the prior Activities Manager trained her, which included tracking and documenting resident participation, but she has not done this. An interview was conducted on December 7, 2023 at 2:27 p.m. with the Executive Director (ED/staff #11), who stated that he supervises the Activities Manager (staff #61) and he has never required her to track resident participation in activities. He stated that there is a large activities calendar posted in the hallway, so residents know what activities are scheduled. During a second interview conducted on December 7, 2023 at 2:47 p.m. with resident #40, he stated that he can't get out of bed by himself, so he would need assistance to attend an activity. He also stated that he can read, but he can't see the activities calendar hanging on the wall across the room. The facility's policy "Activity Programs" dated January 2011 states that the activity programs are designed to encourage maximum individual participatio

Based on clinical documentation, staff interviews, and the facility policy and process, the facility failed to complete baseline vital assessments upon one resident's (#116) admission. The deficient practice result in a change of condition not being recognized. Findings include: Resident #116 was admitted to the facility on May 26, 2023 with diagnoses that included displaced intertrochanteric fracture of the left femur, hypothyroidism, and depression. The admission evaluation dated May 26, 2023 at 3:25 p.m. did not include vitals. An admission summary progress note dated May 26, 2023 at 7:38 p.m. revealed that the resident arrived at the facility around 1:30 p.m. The resident was admitted for a displaced intertrochanteric fracture of the left femur, subsequent encounter for a closed fracture with routine healing. The resident's weight was 158 pounds. Review of the weights and vitals summary revealed that the resident's blood pressure was 129/68 and temperature was 97.6 F. at 4:00 p.m. A health status progress note dated May 26, 2023 at 5:37 p.m. revealed that the resident felt warm and her temperature was 99.5 F. The resident was offered Tylenol and declined stating that it gives her diarrhea. The resident was checked again at 8:58 p.m. and stated that she was having chest pain and that she had called her husband and told him to call 911. The ambulance arrived at 9:05 p.m. to transport the resident to the hospital as per the resident's request. Saturation of peripheral oxygen (SPO2) was 95%. Staff attempted other vitals, but the emergency staff arrived and took vitals. The discharge/transfer assessment dated May 26, 2023 at 9:23 p.m. did not include vital signs. An interview was conducted on December 6, 2023 at 10:14 a.m. with the reporting source (#200), he stated that the resident had surgery and was treated for infection at the hospital. He stated that the resident called him and said that she was hot and sweaty, warm to the touch, and having heart palpitations. He was concerned because staff did not take the resident's vitals when she was admitted and her temperature baseline was below average. He called 911 and had the resident transported to the hospital. An interview was conducted on December 6, 2023 at 11:17 a.m. with the Director of Nursing (DON/staff #100), she stated that when a resident is admitted, the staff establish a baseline, which includes: mentation, vitals, skin check, heart and lung sounds, and pedal pulses and the results are documented in the initial evaluation or could be found in a progress note. It is her expectation that the vitals are done within the first hour of the resident being admitted. She referred to the admission evaluation and acknowledged that the vitals were not included. Then, she referred to the clinical record and stated that the resident was admitted at 1:30 p.m., blood pressure was taken at 4:00 p.m., and temperature was taken at 4:00 p.m. She stated that if the vitals were not taken when the resident

Based on personnel file review, staff interviews, and job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in a lack of appropriate activity programs for residents. Findings include: A review of the personnel file for the activity manager (staff #61) revealed that she was hired on March 16, 2023 as an activity manager. Further review of the file did not reveal any experience in a social, recreational, or a therapeutic activities program. The personnel file also revealed no evidence of completion of a course and certification of therapeutic activities. Review of the facility staff list revealed that staff #61 was the Activities Manager. During an interview was conducted on December 6, 2023 at 9:19 a.m. with the Executive Director (ED/staff #11), he stated that the Activities Manager (staff #61) has not completed an certification course and has no prior experience in an activities role. An interview was conducted on December 7, 2023 at 2:07 p.m. with the Activities Manager (#staff 61), who stated that was her first job in activities and does not have any prior experience. Review of the facility job description for activity manager revealed the minimum requirements for the position were a background check, fingerprint clearance card, Tuberculosis clearance, an employee health screening post hire, and must be able to speak and understand English. Further review revealed that staff #61 signed and dated the job description on March 16, 2023.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure a sanitary kitchen with regards to peeling paint over the tray line counter. The deficient practice could increase the risk of foodborne illness. Findings include: An observation was conducted of the kitchen on December 6, 2023 at 12:13 p.m. During this observation, peeling ceiling paint was noticed above the tray line counter. A follow-up observation was conducted on December 6, 2023 at 3:00 p.m. It was observed that the cracked and peeling ceiling paint spanned the length of the 3 vents on top of the tray line counter. An interview with the Nutrition Services Manager (staff #55) was conducted on December 6, 2023 at 2:55 p.m. Staff #55 stated that there are plans for a kitchen renovation. He said that the facility knows about the cracked/peeling ceiling paint in the kitchen but no action has been taken. He stated that the facility has assessed but nothing has been done. Staff #55 stated that it does bother him and that the crack/peeling ceiling paint is around the 3 vents. He said that potentially particles can get in the food they are preparing. Staff #55 noted that over 6-months ago, he placed a work order about the ceiling but it still has not been fixed. An interview was conducted with the Executive Director (ED/staff #11) inside the kitchen on December 6, 2023 at 3:02 p.m. Staff #11 admitted that all the times he has been at the kitchen he has never looked up. Now looking at it, he admitted that it is a concern that there is cracked/peeling ceiling paint over the tray line. Staff #11 stated that it has probably been months that the ceiling has cracked/peeling paint. He indicated that renovations for the kitchen is supposed to start next week. Staff #11 agreed that having cracked/peeling ceiling paint over the tray line is an issue. Review of the TELS work order log with the timeframe of May 1, 2023 through December 5, 2023 did not reveal a work order request regarding the peeling ceiling paint in the kitchen. On December 7, 2023 at 9:16 a.m., the ED (staff #11) and the Nutrition Services Manager (staff #55) showed the surveyor that the kitchen ceiling was fixed. Review of the facility policy titled "Sanitation" revised October 2008 indicated that the food service area shall be maintained in a clean and sanitary manner. The facility policy titled "Maintenance Service" revised December 2009 indicated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Furthermore, the policy stated that the functions include maintaining the building in good repair and free from hazards. The policy noted that the Maintenance Director is responsible for maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee collected data and monitored it's performance regarding adverse events for performance improvement. Findings include: An interview was conducted on December 7, 2023 at 3:21 P.M. with the administrator, staff #11, and the director of nursing, staff #25. Staff #11 stated that the QAA comittee meets at least quarterly and that data for performance improvement is obtained from a variety of sources to include audits, staff and resident feedback. Some of the topics for PIP's (performance improvement plans) had included the facility census, pressure ulcers, weight loss, falls, psychotropic medications, call-light response and showers. Staff #11 stated that the data for each PIP is reviewed the following month during the QAPI (quality assurance and performance improvement program) meeting. Staff #11 stated that staff #25 utilizes audit forms and that data is kept in a specific binder. Status updates are then shared forward with staff and residents as applicable. She stated that two of the PIP's tracked included call-light response, which were stated to be ongoing and showers, which were stated as a completed PIP; however, when asked about the data tracking, the facility was unable to provide evidence of data tracking for either PIP. The administrator stated that both analysis of data and graphing of the data would be an expectation for any PIP. He stated that the risk of not tracking and appropriately documenting the data could include that the problem would not actually get fixed. A review of the Quality Assurance and Performance Improvement Meeting policy with a copyright date of 2016 revealed that the purpose of QAPI is to establish data-driven, facility-wide processes that improve the quality of care; however, for 2 of the performance measures, there was no evidence of data trend tracking for the identified PIP's.

Based on personnel file reviews, staff interviews, and the facility policy and procedures, the facility failed to provide evidence that 3 out of 10 staff (#98, #26, and #27) were provided resident rights training. The deficient practice could result in residents not being afforded their rights. Findings include: Review of the personnel file for staff #98, a physical therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #98 had received training on resident rights. -Review of the personnel file for staff #26, a occupational therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #26 had received training on resident rights. -Review of the personnel file for staff #27, a speech therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #26 had received training on resident rights. An interview was conducted on December 6, 203 at 9:19 a.m. with the human resources (staff #201) all staff are required to complete training on resident rights. An interview was conducted on December 6, 2023 at 3:27 p.m. with a certified occupational therapy assistant (COTA)/Area Manager (staff #111. She stated that she doesn't have a sign-in sheet to show that staff (#98, #26, and #27) attended resident rights training. The facility policy "Staff Development Program" states all personnel must participate in initial orientation and regularly scheduled in-service training classes. DHS Mandatory topics include resident's rights.

Based on personnel file review, staff interviews, and the facility policy and procedures, the facility failed to provide evidence that 1 out of 10 staff (#98) was provided dementia training. The deficient practice could result in residents with dementia not receiving the care needed. Findings include: Review of the personnel file for staff #98, a physical therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #98 had received dementia training. An interview was conducted on December 6, 203 at 9:19 a.m. with the human resources (staff #201) all staff are required to complete dementia training. An interview was conducted on December 6, 2023 at 3:27 p.m. with a certified occupational therapy assistant (COTA)/Area Manager (staff #111. She stated that she doesn't have a sign-in sheet to show that staff (#98) attended dementia training. The facility policy "Staff Development Program" states all personnel must participate in initial orientation and regularly scheduled in-service training classes. Topics did not include dementia training.

Based on clinical record review, facility documentation, staff interviews, and policies and procedures, the facility failed to ensure one resident (#166) was free from resident to resident abuse, which resulted in physical harm as evidenced by a 5 x 4 cm bruise on the resident's right wrist. Findings include: -Regarding Resident #166 Resident #166 (alleged victim) was admitted to the facility on July 12, 2019 with diagnoses that included chronic kidney disease, anxiety disorder, major depressive disorder, and schizoaffective disorder. A neurological care plan initiated on July 13, 2019 indicated that the resident has an alteration in neurological status related to dementia. Goals included: resident will be able to communicate daily needs, and will maintain optimal status and quality of life within limitations imposed by neurological deficits. Interventions included give medications as ordered, monitor/document for side effects and effectiveness, evaluate and treat as ordered. Review of a care plan initiated on July 25, 2019 revealed that the resident demonstrated physical behaviors related to his impaired cognition. The goal was resident will not harm self or others. Interventions included to analyze key times, place, circumstances, triggers, and what deescalates behavior and document. Review of a quarterly Minimum Data Set (MDS) assessment dated October 7, 2021 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS assessment indicated that at the resident was negative for psychosis, behavioral symptoms, rejection of care, and wandering. A nursing note dated November 4, 2021 revealed that the resident presented to the nursing office and showed a nurse a bruise to his right wrist. The nursing note stated that the resident reported that his roommate punched him causing the bruise which measured 5 x4 cm. The note documented that resident #166 stated that he was going to his room when his roommate grabbed then punched him. A follow-up nursing note dated November 4, 2021 indicated that resident #166 demonstrated exit seeking behavior after the incident. The note also noted that the resident wanted to talk to someone and kicked the exit door. The note documented that this occurred twice within a 30-minute period. A Health Status note dated November 4, 2021 indicated that during conversation with the resident regarding the incident, the resident stated that the man who hit him was standing next to him. Review of a progress note dated November 5, 2021 revealed that the incident which left a bruise on the resident's wrist was reported to Adult Protective Services (APS), non-emergency police, and the ombudsman. The note also stated that the residents were separated into different rooms. A weekly skin assessment dated November 5, 2021 indicated that resident #166 had a new skin condition. It was described as right wrist bruise. Further review of the resident's clinical notes rev

Based on observations, staff interviews, and policy reviews, the facility failed to ensure a sanitary kitchen with regards to peeling paint over the tray line counter. Findings include: An observation was conducted of the kitchen on December 6, 2023 at 12:13 p.m. During this observation, peeling ceiling paint was noticed above the tray line counter. A follow-up observation was conducted on December 6, 2023 at 3:00 p.m. It was observed that the cracked and peeling ceiling paint spanned the length of the 3 vents on top of the tray line counter. An interview with the Nutrition Services Manager (staff #55) was conducted on December 6, 2023 at 2:55 p.m. Staff #55 stated that there are plans for a kitchen renovation. He said that the facility knows about the cracked/peeling ceiling paint in the kitchen but no action has been taken. He stated that the facility has assessed but nothing has been done. Staff #55 stated that it does bother him and that the crack/peeling ceiling paint is around the 3 vents. He said that potentially particles can get in the food they are preparing. Staff #55 noted that over 6-months ago, he placed a work order about the ceiling but it still has not been fixed. An interview was conducted with the Executive Director (ED/staff #11) inside the kitchen on December 6, 2023 at 3:02 p.m. Staff #11 admitted that all the times he has been at the kitchen he has never looked up. Now looking at it, he admitted that it is a concern that there is cracked/peeling ceiling paint over the tray line. Staff #11 stated that it has probably been months that the ceiling has cracked/peeling paint. He indicated that renovations for the kitchen is supposed to start next week. Staff #11 agreed that having cracked/peeling ceiling paint over the tray line is an issue. Review of the TELS work order log with the timeframe of May 1, 2023 through December 5, 2023 did not reveal a work order request regarding the peeling ceiling paint in the kitchen. On December 7, 2023 at 9:16 a.m., the ED (staff #11) and the Nutrition Services Manager (staff #55) showed the surveyor that the kitchen ceiling was fixed. Review of the facility policy titled "Sanitation" revised October 2008 indicated that the food service area shall be maintained in a clean and sanitary manner. The facility policy titled "Maintenance Service" revised December 2009 indicated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Furthermore, the policy stated that the functions include maintaining the building in good repair and free from hazards. The policy noted that the Maintenance Director is responsible for maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. The facility policy (2018) pertaining to general sanitation of the kitchen stated that food and nutrition services staff will maintain the sanitation of th

Based on document review and interview, the facility failed to maintain, review and update the Emergency Preparedness (EP) Plan annually. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency and failure to ensure the EP plan was reviewed annually poses a potential risk that all required revisions to the plan will not be recognized and revised as needed. Findings include; Based on document review and interview on December 13, 2023, revealed in the kitchen near a hand washing sink was a wall mounted copy of the EP. Reviewing the EP the date inside the book was August 31, 2012. During the exit conference on December 13, 2023, the above finding was again acknowledged by the management team.

Based on observation the facility failed to maintain a special locking exit door located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only." Findings include: Observations made while on tour on December 12, 2023, revealed the 400 Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 30+ lbf to set the alarm in motion and 43 lbf to open the door to exit. During the exit conference on December 12, 2023, the above findings were again acknowledged by the management team.

Based on observations while on tour, the facility failed to having sprinkler heads in the maintenance office. Failure to have a sprinkler system throughout the facility could bring harm to patients and/or staff during an emergency. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." Findings include: Observations made while on tour on December 13, 2023, revealed in the maintaince office two (2) sprinkler heads were not extended through the drop ceiling. During the exit conference on December 13, 2023, the above findings were again acknowledged by the management staff.

Based on document review and interview, the facility failed to provide documentation for two quarterly inspections and failed to provide documentation for weekly gauge inspections for the facility dry sprinkler system. Failing to inspect test and maintain the sprinkler system quarterly could cause the system to be inoperable due to lack of maintenance during a fire and could cause harm to the patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems. 5.2.4 Gauges. 5.2.4.2 Gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained. Findings include: Based on document review and interview on December 12, 2023, revealed the following; 1) the facility failed to provide documentation for weekly gauge inspection for the dry system 2) the facility failed to provide documentation for two (2) quarters of inspections for the dry system During the exit conference conducted on December 12, 2023, the above findings were again acknowledged by the management team.