Life Care Center of Yuma

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#27) was not neglected and her basic needs were being met. Findings include: Resident #27 was admitted to the facility on April 28, 2021 and re-admitted on June 15, 2024 with diagnoses that included Alzheimer's disease, depression, and osteoporosis. The care-plan initiated May 4, 2021 and a revision date of September 4, 2024 revealed that the resident was at risk for injury from a fall related to weakness, pain, and a history of a fall with a lumber spine fracture. The resident has poor safety awareness. With noted interventions of assist with activities of daily living (ADL's) as needed, call-light within reach, complete fall risk assessment, move resident to common areas for more eyes on supervision, and anticipate and meet the resident's needs. The functional goal care-plan initiated April 27, 2022 with a revision date of September 4, 2024 revealed that the resident has limited physical mobility related to Alzheimer's disease, dementia, osteoporosis, osteoarthritis, and weakness. Interventions included that staff will assist with ADL's 1-2 assist as needed with a date initiation of March 4, 2024 and a revision date of September 4, 2024. Review of a shower sheet for resident #27 dated June 29, 2024 revealed that the resident was bathed and had no new skin issues, It was observed that the shower sheet consists of a list of residents names and if the residents were bathed. Nail clipping and hair washing was not documented on the shower sheet for any of the residents. Review of weekly skin assessment dated July 3, 2024 revealed a scab to the left shin. A progress note dated July 8, 2024 revealed a skin tear to the right thumb from bumping the bed table. A new order for foam dressing to right thumb area every three days and as needed until healed. Review of the weekly skin assessment dated July 10, 2024 included a scab to the left shin. The minimum data set (MDS) dated July 17, 2024 included a staff assessment for mental status score of 2 indicating the resident had a severe cognitive impairment. It also included that the resident had skin problems related to skin tear(s). Review of the functional abilities and goals assessment revealed that the resident was dependent on the assistance of helpers for showering, personal hygiene, rolling left to right, and transfers. Review of the weekly skin assessment dated July 17, 2024 included a scab to the left shin. Review of a shower sheet dated July 20, 2024 revealed that the resident did not receive a shower and did not refuse. It was observed that the shower sheet consists of a list of residents names and if the residents were bathed. Nail clipping, hair washing and condition of skin was not documented on the shower sheet for any of the residents. Review of progress note dated July 22, 2024 revealed that the resident was found sitting on the floor leaning against her bed. She

Based on record review and staff interview, the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency if the specific needs of both the patient and staff are not identified as part of the EP plan. Findings include: Based on record review and staff interview on July 2, 2024 revealed the facility failed to obtain a community-based risk assessment and use it to develop a facility-based risk assessment prior to developing the facility's emergency plan Facility management confirmed during the exit conference that the facility did not obtain a community-based risk assessment and use it to create the facility's Emergency Plan.

Based on record review and staff interview the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may cause disruption of services to patients/clients during an emergency which could lead to harm. Findings include: Based on record review and staff interview on July 2, 2024, revealed the facility was unable to locate any documentation addressing the needs of the patient population within the current written plan. Additionally the facility did not have the required delegation of authority. Management confirmed during the exit conference that the facility was unable to locate any documentation addressing the needs of the patient population or delegation of authority within the current written plan.

Based record review and staff interview the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. and created policies that were not risk-based. The facility also failed to have policies for the required CMS hazards Failure to develop emergency plans based on a facility-based risk assessment may cause harm to the patients and staff during an emergency. Findings include: Based record review and staff interview on July 2, 2024, revealed the policies provided, were not based on a current risk assessment. CFR 494.62 requires both facility and community hazard assessments but is used to develop the policy and procedures. The assessment provided listed items that do not occur in Arizona and the policies don't match the identified hazards. Most of the policies provide were instruction on how to develop the policy not the instructions on what action the facility would take during the event. Management confirmed during the document review that the facility did not have a copy of the facility-based risk assessment to provide proof it was used to create the policies and procedures

Based on interview and record review, the facility failed to develop a written emergency communications plan that contains how the facility coordinates resident care within the facility, across the healthcare providers and with state and local public health departments, and emergency management systems. Failure to develop an emergency communications plan cause harm to the residents during an emergency as needed information may not be able to be transmitted or received. Findings include: Based on interview and record review on July 2, 2024, revealed the facility was not able to provide a written emergency communications plan. Management during document review that the facility did not a written communications plan as part of their Emergency Preparedness program.

Based on record review and staff interview the facility is a part of an Integrated healthcare system and could not demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated Emergency Preparedness program. Additionally, the facility was unable to provide documentation of a facility-based risk assessment, utilizing an all hazard approach. Failure to have an integrated EP program may lead to confusion and disorganization during an emergency. Confusion and disorganization may lead to patient harm. Findings include: Based on record review and staff interview on July 2, 2024, revealed the facility's EP program was unable to provide documentation that each separately certified facility within the system actively participated in the development of the unified and integrated Emergency Preparedness program. Facility management confirmed during the exit conference that the facility was not involved in the development of the provided emergency plan.

Based on record review and staff interview the facility failed to have a primary and alternate means of communication during an emergency. Failure to have a primary and alternate means of communication during an emergency could lead to harm to both patients and staff, if all involved in the emergency situation do not know how to communicate needs to others in the community (c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every year. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. Findings include: Based on record review and staff interview on July 2, 2024 revealed the facility's Emergency Plan documentation specifically the section related to requirements to identify a primary and alternate means of communicating with provider type staff or Federal, State, Tribal, Regional, and Local emergency management agencies during an emergency was requested. The Emergency Plan did not identify a primary and alternate means of communicating between the facility staff or Federal, State, tribal, regional, and local emergency management agencies during an emergency. Management confirmed during and interview the facility EP did not identify a primary and alternate means of communicating between staff or Federal, State, tribal, regional, and local emergency management agencies during an emergency.

Based on record review and interview the facility did not have documentation in the emergency preparedness communication plan that complies with Federal, State and local laws that included a method for sharing information. Failure to have a means to share private information to assist in patient care could result in miss information being provided to other providers providing care for the facility's patients. Findings include: Based on record review and interview on July 2, 2024 of the facility's Emergency Plan did not include policies and procedures, in the communication plan for the following: 1) Sharing information and medical documentation for patients under the facility's care, as necessary, with other health care providers to maintain the continuity of care. 2) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510. 3) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510. Facility Management confirmed during the exit conference that the facility did not identify a method for sharing information and medical documentation for patients under the facilities care as necessary and develop policy and procedures that address the means the facility will use to release patient information to include the general condition and location of patients.

Based on record review and staff interview the facility failed to develop a means for sharing information on occupancy/needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed. Findings include: Based on record review and staff interview on July 2, 2024, revealed the facility's Emergency Plan documentation related to requirements for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center did not include a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center. Facility management confirmed during the exit interview that the EP plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Based on interview and record review the facility failed to develop and implement emergency preparedness policies and procedures for providing information from the emergency plan with the residents and their families or representatives. Failure to develop policy and procedures for providing information from the emergency plan to the residents and their families or representatives may result in higher levels of anxiety and confusion during an emergency. Finding include: Based on interview and record review on July 2, 2024, revealed the facility Emergency Plan did not include policies or procedures for providing information from the emergency plan with the residents and their families or representatives. Facility management confirmed during the exit conference on November July 2, 2024, the plan did not include policies or procedures for providing information from the emergency plan with the residents and their families or representatives.

Based on record review and staff interview the facility failed to develop a facility based emergency planning, training and testing program. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency if staff are not aware of what is required by them to do, during an emergency situation. Finding include: Based on record review and staff interview on July 2, 2024, revealed the documentation related specifically to the facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan. Facility management confirmed during the document review that the EP plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan.

Based record review and staff interview the facility failed to participate in required emergency drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency. Findings include: Based record review and staff interview on July 2, 2024, revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based or based exercise or table top drills for the last two cycles. The documents which were provided did not include a required after action report. Facility management confirmed during the exit interview that the facility was not able to locate proof of participation in a full-scale exercise that was community-based or a facility based exercise in the last year.

Based on observation the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " 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." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress there from, or visibility thereof. Observations on July 02, 2024, revealed the facility failed to maintain a clear path to the exits, with items such as tables and equipment in the 500 hallway and other corridors throughout the building. Management confirmed during the tour that the above-listed exit pathways were restricted.

Based observations made while o tour, the facility failed to provide battery-operated emergency lighting to all EPS equipment locations. Failing to install, test, and document the battery backup emergency lighting units in case of an emergency or power outage could cause harm to the patients during a power outage. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 110: Standard for Emergency and Standby Power Systems, 2010 Edition - Chapter 7 Installation and Environmental Considerations 7.3 Lighting. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. Findings include: Observations while on tour on July 01, 2024, revealed the automatic transfer switch room was not equipped with battery-operated emergency lighting. The facility installed the equipment on the day of this discovery. Management acknowledged during the walk down and at the exit conference that the ATS room was not equipped with battery-operated emergency lighting.

Based on observations while on tour of the sprinkler riser room revealed, the hydraulic plate was missing. Failure to ensure the plate is present could cause the sprinkler calculation to be inaccurate during a system modification. No quarterly inspector testing was completed for the sprinkler system. Failure to conduct necessary inspections of the sprinkler system could lead to system problems being missed resulting in possible system failure in the event of an emergency. NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition - Chapter 5 Sprinkler Systems 5.2.6 * Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. 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. Findings include: Based on observations while on tour on July 01, 2024, revealed the following; 1) there was no hydraulic plate attached to the system riser and could not be located in the riser room 2) no quarterly sprinkler reports were provided upon request Facility management confirmed there was not a hydraulic plate in the riser room as well as no quarterly sprinkler reports.

Based on observation the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. Findings include: Observations made while on tour on July 01, 2024, revealed the facility failed to have a fire extinguisher installed within 50 feet of the generator. During the exit conference on July 01, 2024, the above finding were again acknowledged by the management team.

Based on observation while on tour the facility failed to provide a protective guards on light bulbs. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage."In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. Findings include: Based on observation while on tour July 1, 2024, revealed the following; 1) missing light covers in the equipment storage area 2) missing light covers in the records room 3) missing light covers in the maintenance room During the exit conference conducted on July 1, 2024, the above findings were again acknowledged by the management team.

Based on record review and staff interview the facility failed to have written documentation of the annual inspection and testing of door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protectives." Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients. NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code." NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing." Findings include: Based on record review and staff interview on July 2, 2024, revealed the he facility failed to provide written records for the annual fire door inspection per NFPA 80. Facility management confirmed during the tour that no door inspections had been performed in the last year.

Based on interview and record review the facility failed to conduct, maintain and document electrical receptacle testing in patient care areas specifically to the patient care rooms throughout the facility. Failing to test the receptacles could lead to an ignition hazard in a patient care area resulting in fire and/or injury to the patients. NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction. NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. Findings include: Based on interview and record review on July 2, 2024, revealed the facility failed to provide documentation on the annual receptacle testing. The facility was unable to provide documentaion that the 100 and 200 halls of the facility had annual receptacle testing. The last documentation was April 1, 2023. During the exit conference on July 2, 2024, the above finding was again acknowledged by the management team.

Based on observations, staff interviews, and facility policy review and the Centers for Disease Control and Prevention (CDC), the facility failed to ensure infection control standards related to enhanced barrier precautions were followed for one resident (#78) with catheter and wound. Findings include: Resident #78 was admitted on May 28, 2024 with diagnoses of obstructive and reflux uropathy, type 2 diabetes mellitus, emphysema, dementia, anxiety, and benign prostatic hyperplasia with lower urinary tract symptom. The care plan dated May 28, 2024 revealed that an indwelling catheter was in place for uropathy. Interventions included enhanced barrier precautions (EBP), catheter care per shift, change catheter as needed a 16FR (French) 10cc (cubic centimeter) and checking tube for kinks each shift. A physician order dated May 29, 2024 revealed an order for an indwelling catheter size 16 French with a 10cc bulb. The minimum data set (MDS) assessment dated June 1, 2024 revealed the resident had a diagnosis of obstructive uropathy and a Brief Interview for Mental Status (BIMS) score was 8 which indicated the resident had moderate cognitive impairment. The MDS also included that the resident had an indwelling catheter in place and had open lesion(s) skin condition. A review of the care plan dated June 23, 2024 revealed the resident had an open area on coccyx, left and right buttocks. Intervention included to treat per facility protocol. A progress note dated June 23, 2024 included that the resident had open areas to coccyx, left and right buttocks, and a deep tissue injury (DTI) on the right heel. A physician order dated June 25, 2024 revealed stage 2 pressure ulcer to coccyx. An observation was conducted on June 25, 2024 at 1:59 p.m. revealed that there were no EBP signs posted outside of the resident room and there were no PPE (personal protective equipment) readily available for use. An interview with resident #78 and family was conducted immediately following the observation. The family stated that the resident had sacral wound. A second observation was conducted on June 26, 2024 at 9:06 a.m. There continued to be no signs posted outside of the resident's room the use of enhanced barrier precautions and continued to have no PPE (personal protective equipment) readily available for use. An interview with director of nursing (DON/staff #108) was conducted on June 27, 2024. The DON stated that the criteria for putting residents on EBP included residents with an indwelling catheter, chronic wound, and multi-drug resistant organisms. She stated that she misinterpreted the CMS guidelines regarding EBP; and that, resident #78 should be placed on EBP and was not. Further, the DON said that the facility also needed to update their policy on this. A review of the policy titled Enhanced Barrier Precautions with a revision date of June 12, 2024 included that enhanced barrier precautions are indicated for residents with any of the following: wounds and/or indwel

Based on personnel file review, staff interviews, facility assessment and policy review, the facility failed to ensure one Certified Nursing Assistant (CNA /staff #64) had the cardiopulmonary resuscitation (CPR) certification to provide nursing and related services. Findings include: The Facility Assessment dated January 26, 2024 revealed the staffing plan included 13 licensed nurses, and 27 CNA's to provide direct care for an average of 86 residents every day including emergencies. The assessment also revealed the resources the facilities needed to provide competent support and care for their resident population every day and during emergencies. A review of the personnel record for CNA (staff #64) revealed a hire date of August 24, 2023 and had no evidence of current CPR certification. An interview was conducted on June 26, 2024 at approximately 8:35 AM with the business office manager (BOM/staff #12), who stated that it was the facility's responsibility to ensure that staff and individuals under contract have the necessary licenses and certifications to fulfill their job roles as outlined in the job description. The facility's policy titled, License and CPR Certification Verifications revealed that the facility has the responsibility to ensure that all associates that require a license or certification as part of their delivery and management of health services as well as provide necessary information to comply with all application statutes, laws, and regulatory licensing board/agencies. The policy also included that it is their responsibility to ensure that the associates and persons under contract have the necessary licenses and certifications needed to fulfill their job role as outlined in the job description for that role. The Compliance department assist the facility with monitoring professional licensure, they monitor the licenses and certifications of nurses, and CNA's who are employed by the facility.

Based on observation, staff interviews, and policy review, and review of current facility practice, the facility failed to ensure care plan was developed and implemented to meet the assessed need for one resident (#78). The deficient practice could result in the resident receiving the care they need. Findings include: Resident #78 was admitted on 05/28/2024 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, dysphagia, and unspecified protein-calorie malnutrition. The mini nutritional assessment signed and dated 05/29/2024 revealed that the resident had a score of 6 indicating the resident was malnourished. The Residents at Risk meeting notes dated 05/29/2024 revealed that resident was a new admission and was on a mechanically altered diet on 05/29/2024. The weight record on 05/29/2024 was 221.5 lbs. (pounds). A nutritional assessment dated on 05/31/2024 revealed the resident had a diet of regular mechanically altered texture and thin liquid consistency; and had an overweight status for age. The documentation also included that the resident was at risk for malnutrition or was currently diagnosed with malnutrition related to age and diagnosis of dysphagia. Further, the documentation included that the care plan was reviewed/revised or implemented. The physician order dated 06/03/2024 included for a regular diet, mechanically altered texture, thin consistency, with no added salt. It also included an order for 1:1 supervision for all meals and for fortified foods three times a day. The Residents at Risk meeting notes dated 06/13/2024 revealed that the resident triggered for weight loss and had varied oral intake. Per the documentation, the resident was still overweight; and had a mechanically altered diet and was on an assisted diet. Further, the not included that the resident had an extremely strict diet per family request. The weight record for 6/19/2024 was 201.4 lbs. which was approximately 20 lbs. weight loss since admission. Despite documentation of the resident's nutritional risk, there was no evidence found that a care plan with interventions put in place was developed and implemented until 6/26/2024. The care plan dated 6/26/2024 included that the resident had an unplanned/unexpected weight loss related to an acute illness, poor intake and recent hospitalization. The goal was that the resident will maintain weight at 197 lbs. +/- 5%. Interventions included to evaluate weight loss, determine percentage lost, follow facility protocol for weight loss, give supplements as ordered and alert dietician if consumption was por for more than 48 hours. In an interview with the registered dietitian (RD/staff #144) conducted on 6/26/24 at 4:22 p.m., the RD stated she would expect that the resident's nutritional status be in the care plan for any residents with or was experiencing significant weight loss. Regarding resident #78, the RD stated that resident #78 triggered for we

Based on personnel file review, staff interviews, facility assessment and policy review, the facility failed to ensure one Certified Nursing Assistant (CNA /staff #64) had the cardiopulmonary resuscitation (CPR) certification to provide nursing and related services. The deficient practice could result in staff not able to to safely meet resident needs during an emergency. Sample size was one. Facility census was 81. Findings include: The Facility Assessment dated January 26, 2024 revealed the staffing plan included 13 licensed nurses, and 27 CNA's to provide direct care for an average of 86 residents every day including emergencies. The assessment also revealed the resources the facilities needed to provide competent support and care for their resident population every day and during emergencies. A review of the personnel record for CNA (staff #64) revealed a hire date of August 24, 2023 and had no evidence of current CPR certification. An interview was conducted on June 26, 2024 at approximately 8:35 AM with the business office manager (BOM/staff #12), who stated that it was the facility's responsibility to ensure that staff and individuals under contract have the necessary licenses and certifications to fulfill their job roles as outlined in the job description. The facility's policy titled, License and CPR Certification Verifications revealed that the facility has the responsibility to ensure that all associates that require a license or certification as part of their delivery and management of health services as well as provide necessary information to comply with all application statutes, laws, and regulatory licensing board/agencies. The policy also included that it is their responsibility to ensure that the associates and persons under contract have the necessary licenses and certifications needed to fulfill their job role as outlined in the job description for that role. The Compliance department assist the facility with monitoring professional licensure, they monitor the licenses and certifications of nurses, and CNA's who are employed by the facility.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to maintain a clean kitchen; and failed to ensure food items were dated when opened. The deficient practice could result in residents having food-borne illness. Findings include: An observation of the kitchen was conducted on June 24, 2024 at 11:25 a.m. with the cook (staff #92). The large walk-in refrigerator had a 5lb opened and undated bag of green leaf lettuce that was exposed; and, the lettuce heads were wilted and discolored. Inside the bag of lettuce was a white plate with food covered by a plastic film. Staff #92 stated that the food items on the white plate were turkey, chicken and potato salad; and, she did not know how the plate got in the lettuce bag or why the bag of lettuce was left open. There was also an opened and exposed three-pound box of cream cheese; and the end of the cream cheese had dried out and was left open in the box. The refrigerator floor had spilled milk. The walk-in freezer area had approximately two cups of frozen corn kernels on the freezer floor and an opened 12-quart bucket of frozen mashed potatoes. Further observation of the kitchen revealed there were opened two loaves of bread that were open and exposed to air but did not have a use by or open dates. There was a package of open dinner rolls with no open or use by date on the packaging. The area above the cooking area over the stove had three lamps had stringy particles hanging and were covered with dust and dark brown grease/grime. The observation continued at 12:45 p.m. of the area next to the stove that had an open two-quart container of butter with no open or use by date. Staff #92 stated she had taken the container of butter from the refrigerator at approximately 11:00 a.m. to prepared the grilled cheese sandwiches. There was also an open gallon zip lock bag with shredded cheese and a package of sliced cheese that were now melting found on this cooking area. Further, the shredded cheese had no open or use by date. Another observation of the kitchen was conducted on June 26, 2024 at 8:30 a.m. with another cook (staff #128). The walk-in refrigerator had a five quart container of strawberries that was partially open with no open or use by date. There was a container with 9 visibly wilted and shriveled cucumbers; and, a container with 14 lemons mixed in a container with three large tomatoes that were soft and wilted. The large 5-lb bag of green leaf lettuce that was found on June 24 continued to be in the refrigerator; and, the three light lamps over the cooking range continued to have stringy particles hanging and covered with dust and dark brown grease. Staff #128 stated it was the cook's responsibility to wipe down the lamps to prevent the dust and grease from falling into the food while cooking; and that, there was a risk of food contamination associated with this. Staff #128 further stated that having open exposed foods in the refrigerator had the risk

Based on observations, staff interviews, and facility policy review and the Centers for Disease Control and Prevention (CDC), the facility failed to ensure infection control standards related to enhanced barrier precautions were followed for one resident (#78) with catheter and wound. The deficient practice could result in transmission of multi-drug resistant organisms. Findings include: Resident #78 was admitted on May 28, 2024 with diagnoses of obstructive and reflux uropathy, type 2 diabetes mellitus, emphysema, dementia, anxiety, and benign prostatic hyperplasia with lower urinary tract symptom. The care plan dated May 28, 2024 revealed that an indwelling catheter was in place for uropathy. Interventions included enhanced barrier precautions (EBP), catheter care per shift, change catheter as needed a 16FR (French) 10cc (cubic centimeter) and checking tube for kinks each shift. A physician order dated May 29, 2024 revealed an order for an indwelling catheter size 16 French with a 10cc bulb. The minimum data set (MDS) assessment dated June 1, 2024 revealed the resident had a diagnosis of obstructive uropathy and a Brief Interview for Mental Status (BIMS) score was 8 which indicated the resident had moderate cognitive impairment. The MDS also included that the resident had an indwelling catheter in place and had open lesion(s) skin condition. A review of the care plan dated June 23, 2024 revealed the resident had an open area on coccyx, left and right buttocks. Intervention included to treat per facility protocol. A progress note dated June 23, 2024 included that the resident had open areas to coccyx, left and right buttocks, and a deep tissue injury (DTI) on the right heel. A physician order dated June 25, 2024 revealed stage 2 pressure ulcer to coccyx. An observation was conducted on June 25, 2024 at 1:59 p.m. revealed that there were no EBP signs posted outside of the resident room and there were no PPE (personal protective equipment) readily available for use. An interview with resident #78 and family was conducted immediately following the observation. The family stated that the resident had sacral wound. A second observation was conducted on June 26, 2024 at 9:06 a.m. There continued to be no signs posted outside of the resident's room the use of enhanced barrier precautions and continued to have no PPE (personal protective equipment) readily available for use. An interview with director of nursing (DON/staff #108) was conducted on June 27, 2024. The DON stated that the criteria for putting residents on EBP included residents with an indwelling catheter, chronic wound, and multi-drug resistant organisms. She stated that she misinterpreted the CMS guidelines regarding EBP; and that, resident #78 should be placed on EBP and was not. Further, the DON said that the facility also needed to update their policy on this. A review of the policy titled Enhanced Barrier Precautions with a revision date of June 12, 2024 included that enhanced barrier

Based on observation, staff interviews, and policy review, and review of current facility practice, the facility failed to ensure care plan was developed and implemented to meet the assessed need for one resident (#78). Findings include: Resident #78 was admitted on 05/28/2024 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, dysphagia, and unspecified protein-calorie malnutrition. The mini nutritional assessment signed and dated 05/29/2024 revealed that the resident had a score of 6 indicating the resident was malnourished. The Residents at Risk meeting notes dated 05/29/2024 revealed that resident was a new admission and was on a mechanically altered diet on 05/29/2024. The weight record on 05/29/2024 was 221.5 lbs. (pounds). A nutritional assessment dated on 05/31/2024 revealed the resident had a diet of regular mechanically altered texture and thin liquid consistency; and had an overweight status for age. The documentation also included that the resident was at risk for malnutrition or was currently diagnosed with malnutrition related to age and diagnosis of dysphagia. Further, the documentation included that the care plan was reviewed/revised or implemented. The physician order dated 06/03/2024 included for a regular diet, mechanically altered texture, thin consistency, with no added salt. It also included an order for 1:1 supervision for all meals and for fortified foods three times a day. The Residents at Risk meeting notes dated 06/13/2024 revealed that the resident triggered for weight loss and had varied oral intake. Per the documentation, the resident was still overweight; and had a mechanically altered diet and was on an assisted diet. Further, the not included that the resident had an extremely strict diet per family request. The weight record for 6/19/2024 was 201.4 lbs. which was approximately 20 lbs. weight loss since admission. Despite documentation of the resident's nutritional risk, there was no evidence found that a care plan with interventions put in place was developed and implemented until 6/26/2024. The care plan dated 6/26/2024 included that the resident had an unplanned/unexpected weight loss related to an acute illness, poor intake and recent hospitalization. The goal was that the resident will maintain weight at 197 lbs. +/- 5%. Interventions included to evaluate weight loss, determine percentage lost, follow facility protocol for weight loss, give supplements as ordered and alert dietician if consumption was por for more than 48 hours. In an interview with the registered dietitian (RD/staff #144) conducted on 6/26/24 at 4:22 p.m., the RD stated she would expect that the resident's nutritional status be in the care plan for any residents with or was experiencing significant weight loss. Regarding resident #78, the RD stated that resident #78 triggered for weight loss on 06/19/24; and that, she missed this. An interview was conducted with