Every finding on record at Brookdale Greenwood Village

Based on record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#28) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure supervision was provided, as determined in an assessment, to prevent a fall for Resident #28 that resulted in fractures. Resident #28 was admitted on [DATE] with diagnoses of sepsis (infection of the blood), unsteadiness on feet, generalized muscle weakness, repeated falls and other Alzheimer's disease.Resident #28, was identified as a fall risk and had a history of repeated falls. Resident #28 was found outside by facility staff on 3/29/26. Resident #28 was bleeding from her mouth and had pain when trying to bend her knees. Resident #28 was sent to the emergency department, where it was determined that Resident #28 had sustained a fracture to her coccyx and facial bones. Resident #28 did not return to the facility. Findings include:I. Facility policy and procedureThe Falls Management policy, March 2026, was provided by the nursing home administrator (NHA) on 4/13/26 at 11:07 a.m. It read in pertinent part, Residents should be evaluated for the risk of falling so that interventions may be considered in order to promote resident safety, promote appropriate clinical and interdisciplinary (IDT) assessment of falls and fall risk factors, and coordinate management of acute and recurrent falls. Fall risk data collection should be completed at admission, the evaluation may include: history of falls, cognitive status/behavior symptoms, vision status, continence, mobility, balance, vital signs, age, health conditions/risk factors, and medications. If the resident fall score is equal to or above 10, they should be considered a high risk for falls. The IDT should implement a fall prevention plan to assist with reducing falls related to risk factors and history of falls. Initial interventions may include, but are not limited to room set up, reviewing the resident's balance, footwear review, lighting, call system orientation, personal items within reach.II. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE] and was discharged to the hospital on 3/29/26. According to the March 2026 computerized physician's orders (CPO), diagnoses included sepsis, unsteadiness on feet, generalized muscle weakness, repeated falls and other Alzheimer's disease.The 3/25/26 minimum data set (MDS) assessment revealed Resident #28 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #28 required the use of a walker when ambulating and required substantial to maximal assistance with toilet transfers and partial to moderate assistance with walking 50 feet. The assessment documented walking on uneven surfaces was not attempted due to medical conditions and going up and down a curb was not attempted. The MDS assessment indicated Resident #28 had at least one fall with no injury in the last two to six months prior to admission.B. Facility investigation of Resident #28's fall on 3/29/26Review of the facility's investigation of Resident #28's fall on 3/29/26 revealed the NHA interviewed multiple staff members between the dates 3/30/26 and 4/3/26. The investigation documented registered nurse (RN) #3 was interviewed. RN #3 said he was outside of the building and found Resident #28. He said he was planning on checking on her anyway because she had communicated with him that she was going outside. He said it was about 6:30 p.m. He said when he found her, she was lying on her back, holding a newspaper. He said she was fully clothed and had her shoes on. He said, during his assessment, he noticed she was bleeding from her mouth. He said she had told him she tripped while she was walking and landed on her face. He said he saw Resident #28's walker close to the sidewalk nearby. RN #3 said he asked qualified medication administration person (QMAP) #1 to go get RN #4 from the second floor. He said when he attempted to get Resident #28 to sit up, she complained of pain. He said he had her remain in the lying position and did not note any other scrapes, cuts, or bruises other than the bleeding from her mouth. He said he stayed with Resident #28 until RN #4 and emergency services arrived. He said he then went upstairs to start transfer paperwork. The investigation documented RN #4 said QMAP #1 had notified her of the situation. RN #4 said she immediately responded to the location and took over from RN #3. She said she did a head to toe assessment and asked Resident #28 if she could move her legs. Resident #28 said she could not move her legs due to pain. Resident #28 told her she had hit her head and RN #4 noted Resident #28 was bleeding from her mouth. RN #4 said that she and RN #3 stayed with Resident #28 until emergency services arrived. She said she stayed with Resident #28 when emergency services took over. She said when Resident #28 left in the ambulance she went back upstairs to help with notifications and paperwork. She said the last time she saw Resident #28 before she fell was at medication pass at about 6:00 p.m. The investigation documented licensed practical nurse (LPN) #5 was interviewed. LPN #5 said she was not involved in the situation, but RN #4 had told her about the fall. She said the last time that she had seen Resident #28 was about 5:30 p.m. She said she had been sitting in a chair near the nurses' station. She said she had seen Resident #28 go outside at times during the day and she would come back up with no issues. She said she had only done that a few times.The investigation documented certified nurse aide (CNA) #4 was interviewed. CNA #4 said she had last seen Resident #28 sitting in a chair at the nurse's station around 6:30 p.m. or 6:45 p.m.The investigation documented QMAP #1 (who worked in the assisted living residence on the same campus as the skilled nursing facility) was interviewed. QMAP #1 said a family member came to the assisted living residence door and told him about Resident #28 outside. He said he ran outside and saw that RN #3 was already out there with Resident #28. He said RN #3 told him to run and get RN #4. He said after he got RN #4, he stayed outside until emergency services arrived, then went back to his building. -None of the above interviews had a date or time documented on them that indicated when they were conducted. The investigation documented the NHA interviewed the director of rehabilitation on 3/31/26. The interview documented the director of rehabilitation said Resident #28 required stand-by assistance to contact guard assistance for transfers, depending on how tired she was. She said she was walking with a four wheel walker and ambulating 200 feet prior to the fall. She said Resident #28 was safe to ambulate alone. She said Resident #28 was safe to go outside alone and sit near the patio table but not much further than the table. She said as long as Resident #28 stayed in that area, she would be fine. -However, review of physical therapy notes revealed Resident #28 was not independent with ambulation and was not safe to ambulate alone outside (see record review below). An interview with the director of rehabilitation revealed Resident #28 was not independent with ambulation or safe to ambulate outside independently ( see staff interviews below). The facility investigation included an IDT post event analysis. The analysis revealed Resident #28 went outside unaccompanied and was found on her back on the ground in the parking lot. The analysis documented Resident #28 said she went for a walk and fell. The resident reported she hurt all over. The analysis documented she was not using an assistive device at the time of the fall, and contributing factors to the fall was she was unaccompanied outside. The analysis documented Resident #28 was on frequent checks at the time of the fall and had one to two falls in the past 90 days. The analysis documented Resident #28 ambulated with no problems with the use of a device. C. Record reviewThe resident at risk for falls care plan, initiated 3/21/26, indicated that Resident #28 was at risk for falling. Pertinent interventions included placing the call light within reach and encouraging Resident #28 to use the call light, placing a call don't fall sign in the resident's room, encouraging proper footwear when ambulating, placing floor mats on either side of the bed when Resident #28 was in bed, completing frequent checks, providing frequent toileting, placing the bed in lowest position, and providing cueing/supervision/assistance as indicated. The special instructions listed at the top of the care plan indicated Resident #28 was at risk for falls. -However, neither the care plan or special instructions indicated how much supervision Resident #28 required when ambulating. A review of Resident #28's electronic medical record (EMR) revealed the following:A nursing admission note, dated 3/20/26 at 11:48 p.m., documented Resident #28 arrived at the facility in a wheelchair and was alert and oriented by two or three at admission. Resident #28 was admitted to the skilled facility after a urinary tract infection (UTI) and sepsis. A comprehensive nursing note, dated 3/21/26 at 8:56 p.m., documented Resident #28 required skilled observation and assessment. The note documented Resident #28 needed one-person assistance with her activities of daily living (ADL). The functional assessment, dated 3/21/26 at 11:10 a.m., documented Resident #28 used a front wheel walker and was a contact guard assist (a level of assistance where a caregiver or therapist maintains physical contact with a resident to provide stability and safety during tasks) with walking on level surfaces and was dependent on staff when walking on uneven surfaces. The note documented the plan of treatment was to work on gait training to normalize gait pattern and facilitation of swing through. The note documented therapeutic activities to work on gross motor coordination, transfer training to increase functional task performance and bed mobility activities to increase functional skills. A comprehensive nursing note, dated 3/23/26 at 10:11 p.m., documented Resident #28 was working with physical therapy (PT) and occupational therapy (OT) for strengthening. The note documented Resident #28 used a wheelchair for her mobility. A comprehensive nursing note, dated 3/24/26 at 10:42 p.m., documented Resident #28 was on frequent room checks due to getting up unassisted, walking with her walker unassisted or holding on to furniture to walk. The note documented Resident #28 was reeducated multiple times on calling for staff assistance with transfers. Resident #28 needed frequent reminders that staff needed to be with her to walk. The physical therapy note, dated 3/24/26 at 11:44 a.m., documented Resident #28 participated in gait training and was able to walk 100 feet with a front wheel walker and contact guard assist for safety. The note documented Resident #28 required verbal cueing to maintain focus on the task, posture and step placement. The note documented Resident #28 also participated in physical therapy, focusing on transfer training. The note documented Resident #28 worked on transfers from the wheelchair using her front wheel walker with contact guard assist. She performed toilet transfers with minimal assistance and constant cueing. The note documented Resident #28 demonstrated impulsive transfer behavior despite maximal verbal cues and physical cues. A social services progress note, dated 3/25/26 at 11:46 a.m., documented Resident #28 required contact guard assist for all of her mobility. The noted documented Resident #28 walked 125 feet with a front wheel walker with a contact guard assist. The physical therapy note, dated 3/29/26 at 6:17 p.m., documented Resident #28 worked on gait training throughout the facility with stand-by assist. Resident #28 performed gait training with head turns, obstacle navigation, change in gait speed to facilitate dynamic standing balance (ability to maintain stability while moving or shifting weight in an upright position) to reduce the risk of falling. The note documented Resident #28 participated in seated therapy exercises to facilitate lower extremity strength to help improve low functional activity tolerance for community distance gait training. -Review of the physical therapy notes did not reveal Resident #28 was able to ambulate safely independently or was able to ambulate independently outside on uneven surfaces. Am eInteract SBAR (situation, assessment, background, recommendation) note, dated 3/29/26 at 7:21 p.m., documented a change in condition of a fall for Resident #28. The note documented she was sent to the emergency department. A nursing progress note, dated 3/29/26 at 7:21 p.m., documented staff notified the RN that a resident was found on the ground outside. The RN responded immediately and requested assistance from another RN for further assessment. Upon assessment, Resident #28 was noted to be lying on her back with both legs extended towards the north and her head towards the south. Blood was observed coming from her mouth. The resident stated she had hit her head. Emergency services were notified. A nursing progress note, dated 3/30/26 at 6:25 a.m., documented Resident #28 was found outside of the facility approximately 30 feet to the left of the front door. Resident #28 was fully clothed and had shoes on and had a newspaper in her hand. The note documented her mouth was bloody and no teeth were noted to have been broken. The note documented no abrasions, cuts or bruises were visible. When the RN asked Resident #28 to sit up, Resident #28 complained of back pain. The RN asked for Resident #28 to stay in place and called 911. A hospital progress note, dated 3/31/26 at 3:14 p.m., documented Resident #28 was admitted to the hospital on [DATE] due to a fall. The progress note documented the results of a computed tomography (CT) scan for Resident #28 as loosening of AD 9-11 (upper left central incisor #9, upper left lateral incisor #10, and upper left canine #11) with fractures of the anterior walls of those sockets. The CT scan also documented a closed fracture of the coccyx. III. Staff interviewsCNA #1 was interviewed on 4/8/26 at 10:56 a.m. CNA #1 said Resident #28 had been admitted to the facility prior to her most recent admission on [DATE]. She said Resident #28 was able to walk, but needed assistance. She said there were times when Resident #28 had to use the wheelchair when she was really tired or had lots of pain. She said there were times when she was resistant to care due to pain. She said she could not remember if she was a fall risk, but she said she needed assistance from one person. She said Resident #28 was not supposed to walk alone outside. She said Resident #28 needed assistance. LPN #3 was interviewed on 4/8/26 at 11:08 a.m. LPN #3 said Resident #28 was a one- to two-person assist when she first came to the facility. She said she was a one-person assist when she ambulated with her walker. She said she never saw Resident #28 go outside. She said Resident #28 was not supposed to go outside unattended. She said she had heard that Resident #28 had gone outside and fell. She said she heard it happened during shift change, which may have been how she had gotten outside. CNA #1 was interviewed a second time on 4/8/26 at 1:26 p.m. CNA #1 said she received information regarding the residents from the shift report and also by looking at the special instructions in the computer system. She said the special instructions did not always indicate if a resident was a fall risk or what kind of assistance the residents required. CNA #6 was interviewed on 4/9/26 at 5:46 a.m. CNA #6 said he was informed if a resident was a fall risk during shift change and the nurses would also communicate with him. He said sometimes when a resident was admitted from the hospital, he would see their fall risk wristband on the resident's wrist. He said interventions that the facility always had for fall risk residents were low bed and fall mats. LPN #4 was interviewed on 4/9/26 at 6:41 a.m. LPN #4 said Resident #28 was not independent and was not to go outside alone. She said she was a one-person assist when ambulating. Emergency medical services was interviewed on 4/9/26 at 9:08 a.m. He said they received the call regarding Resident #28 on 3/29/26 at 7:22 p.m.RN #4 was interviewed on 4/9/26 at 9:15 a.m. RN #4 said she started her shift on 3/29/26 at 5:30 p.m. She said at the start of her shift she got report and then did medication pass at 6:00 p.m. She said when she went to give Resident #28 her medications, she remembered seeing Resident #28's visitor leaving with her small dog. She said a little bit later, QMAP #1 came up to get her saying that another RN was asking for her help. She said she went downstairs and outside and saw that Resident #28 was lying on her back. She said she saw blood coming from her mouth. She said when she touched the resident, she screamed in pain. She said when she asked her to move her feet, the resident screamed out in pain. She said RN #3 called 911 from his phone and she ran back upstairs to grab some paperwork and when she had come back, the emergency services were already there. She said that evening was the first time she had worked with Resident #28. The director of rehabilitation was interviewed on 4/9/26 at 10:33 a.m. The director of rehabilitation said physical therapy completed assessments on all of the new residents who came in for rehabilitation. She said that the therapy team used a facility form called therapy to nursing forms to communicate fall interventions, how a resident transferred, ambulated, and if the resident used any assistive devices. She said if a resident had a fall, the fall was discussed during the morning meeting. She said if there were any new interventions or orders, nursing staff would implement the interventions and put in new orders. She said there were also whiteboards that were used in residents' rooms that therapy would use to communicate transfer status and if the resident was independent for ambulating. The director of rehabilitation said Resident #28 was walking 125 feet twice with a stand-by assist with her front wheel walker. She said Resident #28 required stand-by assistance when getting in and out of bed. She said Resident #28 was not cleared to go outside by herself because therapy had not worked with her on uneven surfaces or with navigating curbs. She said that was not a goal of Resident #28's. She said Resident #28 had not been cleared to walk independently in the hallways. She said Resident #28 was not independent with ambulation. She said if Resident #28 was released to be independent, it would have been documented in the physical therapist's notes. RN #3 was interviewed on 4/9/26 at 12:33 p.m. RN #3 said he had not worked with Resident #28 prior to that day (3/29/26). He said he did not witness the fall, but did her first assessment. He said he did not recall a visitor being with her at the time of the fall. He said she was bleeding from her mouth and she had told him that she had fallen forward. He said Resident #28 was lying next to the curb. He said the person that had informed him of Resident #28 outside was someone who worked in the assisted living residence (QMAP #1). He said QMAP #1 called him outside. He said he left Resident #28 with another resident's family members to go and get the nurse that had just come on shift. -However, the facility investigation documented RN #3 said he stayed with her until the RN #4 and emergency services arrived (see facility investigation above). RN #4 was interviewed a second time on 4/9/26 at 4:00 p.m. RN #4 said QMAP #1 was the person who had come to get her and told her she was needed outside. She said QMAP #1 worked in the assisted living residence. She said RN #3 was there when she arrived and he had not left Resident #28. The NHA and the regional clinical resource were interviewed together on 4/9/26 at 5:08 p.m. The NHA said she was the one who did the investigation regarding the fall on 3/29/26. She said at one point on 3/29/26, Resident #28 was seen with one of her family members before she fell. She said that Resident #28 had let a staff member know that she was going outside. She said that a family member of another resident who was going to the assisted living residence had told QMAP #1 that there was a resident on the ground outside. She said by the time QMAP #1 had gone outside, RN #3 was already with Resident #28. She said Resident #28 had the basic fall care plan and fall precautions (fall mat, low bed). She said Resident #28 ambulated with a walker and her balance was unsteady. She said to her knowledge, Resident #28 had gone outside by herself once or twice since her admission. She said she was unsure of where she had gotten the newspaper. She said she was unsure of what Resident #28 had tripped on. She said she was unsure of the time that the RN called 911. She said the facility did not have cameras to verify times. She said that they called 911 and they arrived very quickly. She said 6:30 p.m. and 6:45 p.m. were the times that Resident #28 was last seen before RN #3 found her outside. She said she was unsure why RN #3 reported during the interview that he had left Resident #28 with another family. She said she was unsure why she was told that Resident #28 was independent to ambulate if she was not.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent and treat pressure injuries for one (#20) of two residents out of 34 sample residents.Resident #20, who was dependent on staff for all care and mobility and was known to be at risk for skin breakdown, was admitted to the facility on [DATE] with a right hip surgical incision, but did not have any pressure injuries. The facility did not implement interventions to offload the resident's heels or provide a low-air loss mattress upon the resident's admission to the facility.Additionally, the facility failed to conduct a Braden Scale assessment (a tool utilized for predicting pressure ulcer injury risk) upon the resident's admission to the facility.On 4/6/26, seventeen days after the resident's admission to the facility, Resident #20 developed a stage 3 pressure injury to her right heel. Following the development of Resident #20's right heel pressure injury, the facility implemented an intervention to offload the resident's heels at all times. However, multiple observations during the survey revealed the resident's heels were not consistently offloaded.Specifically, the facility failed to implement interventions in a timely manner to prevent the development of a right heel stage 3 pressure injury for Resident #20.Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved from on 4/9/26 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate'at risk' individuals (a heralding sign of risk).Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpableUnstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as'the body's natural (biological) cover' and should not be removed.Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.II. Resident #20A. Resident statusResident #20, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included a displaced intertrochanteric fracture of the right femur, dementia with behaviors and cognitive communication deficit. The 4/3/26 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental stats assessment. According to the staff assessment for mental status, the resident had long term and short term memory problems and her cognitive skills for daily decision making were moderately impaired. The resident had impairment on one side of her lower extremities and was dependent on staff for all activities of daily living (ADL).The MDS assessment indicated the resident was at risk for developing pressure injuries.B. Observations and staff interviewDuring a continuous observation on 4/7/26, beginning at 11:42 a.m. and ending at 2:20 p.m., the following was observed:At 11:42 a.m. Resident #20 was transferred from her bed to her wheelchair by physical therapy (PT) staff. At 12:10 p.m. Resident #20 was transferred to her recliner and left with her heels resting on the recliner's surface. At 2:20 p.m. Resident #20 was transferred from the recliner to the bed and left with her heels against the mattress.During a continuous observation on 4/8/26, beginning at 9:40 a.m. and ending at 1:00 p.m., the following was observed:At 9:40 a.m. Resident #20 was in bed covered with a blanket. At 10:20 a.m. an unidentified certified nurse aide (CNA) offered to assist with changing the resident, but the resident's family member who was present in the room said it was not necessary. At 11:07 a.m. Resident #20 was wearing socks and was observed to have a bandage on the right heel. The resident had a pillow under her feet and her heels were not touching the mattress. -However, the resident was not repositioned.At 11:40 a.m. PT staff checked on the resident and tried to help her get out of bed, but they were unable to. The resident remained lying on her back. At 1:00 p.m. two unidentified CNAs transferred Resident #20 to the recliner. -However, Resident #20 was not repositioned from lying on her back for three hours and 20 minutes. Additionally, the resident's heels were left touching the recliner surface after the CNAs transferred her to the recliner.On 4/9/26 at 5:00 a.m. Resident #20 was in bed. The resident's heels were not offloaded. There was a pillow on the floor by her bed, but the resident's heels were lying directly on the mattress.During a continuous observation on 4/9/26, beginning at 5:18 a.m. and ending at 6:27 a.m., the following was observed:At 5:18 a.m. Resident #20 bent her legs and moved her heels back and forth on her bed.At 5:28 a.m. an unidentified staff member entered the resident's room, moved something on the resident's dresser and left the room. Resident #20 was still in bed and the unidentified staff member did not attempt to offload the resident's heels. At 5:45 a.m. another unidentified staff member entered the resident's room, brought water for the resident and did not attempt to offload the resident's heels.At 6:04 a.m. Resident #20 was changed, but her heels remained resting directly on the bed after staff completed the brief change. At 6:14 a.m. a nurse checked on Resident #20 but did not attempt to offload the resident's heels.At 6:27 a.m. two unidentified staff members checked on the resident but did not attempt to offload the resident's heels.On 4/9/26 at 8:36 a.m. Resident #20's right heel wound care was observed with the registered nurse (RN) #2, who was the second floor unit manager, and the director of nursing (DON). The resident did not have an air mattress on her bed. After performing hand hygiene, RN #2 removed the dressing from Resident #20's right heel. Yellow slough (a yellowish, soft, or moist devitalized tissue (dead tissue) that adheres to the wound bed, acting as a physical barrier to healing) was observed in the center of the resident's wound with red granulated tissue (new, healthy connective tissue and microscopic blood vessels that form in the base of a healing wound) around the edges of the wound. Reddish drainage was observed coming from the wound. RN #2 cleansed the wound with wound cleanser. She then applied alginate (wound treatment) to the wound, placed an abdominal pad (ABD - a highly absorbent, sterile, multi-layered pad designed for heavily draining wounds) over the alginate and wrapped the resident's heel with Kerlix (high absorbency cotton gauze used for wound dressings). When she was finished applying the dressing to the resident's heel, RN #2 put the resident's sock back on her foot and offloaded the resident's heels.RN #2 said she Resident #20's wound had black eschar (a thick, dry, black or brown layer of dead tissue (necrosis) that forms over severe wounds) present in the wound bed when the wound was initially identified (on 4/6/26) and she thought the wound was going to be an unstageable wound.C. Resident #20's family member interviewResident #20's family member was interviewed on 4/8/26 at 1:07 p.m. The family member said Resident #20's right heel pressure ulcer was found by the facility staff two days ago (4/6/26). She said the facility staff had helped her to schedule an appointment for the resident with the wound care physician.D. Record reviewThe skin care plan, initiated on 3/21/26, revealed Resident #20 had potential for impairment to skin integrity. The resident was admitted with a surgical incision to the right hip. Interventions included assisting the resident with turning and repositioning as needed, reducing friction and shearing with the use of transfer sheets, completing Braden Scale assessments as required, dietary consults for nutritional review, encouraging good nutrition and hydration to promote healthier skin, evaluating the resident's skin condition every week and as needed, providing incontinence care as needed and using caution during transfers and bed mobility to prevent striking all body surfaces against any sharp or hard surfaces.The 3/20/26 nursing admission data collection assessment documented Resident #20 had no history of skin issues.The 3/24/26 nutritional risk review progress note documented the resident had no pressure ulcers.The 3/25/26 comprehensive nursing progress note documented the resident had no pressure ulcers. The 4/7/26 Braden Scale assessment indicated Resident #20 was at moderate risk for developing pressure injuries.-However, the assessment was not completed until after the resident developed the right heel stage 3 pressure injury. Review of Resident #20's April 2026 CPO revealed the following physician's order:Offload the resident's heels at all times, ordered 4/6/26.Wound care: Right heel, cleanse with normal saline/wound cleanser, apply honeygel (wound treatment) to wound bed, cover with bordered foam dressing daily and every four hours as needed for soiled/displaced dressing, ordered 4/6/26 at 2:30 p.m.The 4/6/26 comprehensive nursing assessment note, dated 4/6/26 at 2:57 p.m., revealed the resident's surgical incision site was checked and had no signs/symptoms of infection. The note did not identify that Resident #20 had a new pressure injury to her right heel.-However, a physician's order for wound care to the resident's right heel was entered into the resident's electronic medical record (EMR) on 4/6/26 at 2:30 p.m. (see physician's order above).The 4/8/26 wound care physician note revealed the wound care physician assessed Resident #20's right heel wound on 4/8/26. The wound care physician documented the following wound dimensions: 2.5 centimeters (cm) by 2.0 cm by 0.4 cm. It was described as a right heel stage 3 pressure injury and had 80% (percent) granulation and 20% slough in the wound bed. The wound care physician note documented Resident #20's right heel wound should be listed as unavoidable due to the resident's poor oral intake, non-compliance with offloading the heel, a diagnosis of dementia and she recently had major right hip surgery less than three weeks prior According to the note, the facility had all interventions in place (air mattress, offloading heels, education) prior to the resident developing the wound.-However, observations during the survey revealed no air mattress on Resident #20's bed and multiple observations of the resident's heels not being offloaded and no attempts made by staff to offload the resident's heels (see observations above).-Additionally, there was no physician's order in place to offload the resident's heels until 4/6/26, after the identification of the right heel wound (see physician's orders above).III. Staff interviewsThe wound care physician was interviewed on 4/8/26 at 2:15 p.m. The wound care physician said he understood Resident #20 had previous hip surgery, had postsurgical pain and decreased mobility, and a diagnosis of dementia. He said that with this combination of comorbidities, it was not uncommon for a pressure wound to develop. The wound care physician said the wound on Resident #3's right heel was unstageable and unavoidable due to her dementia and inability to understand the required need to keep pressure off of her heel. -However, the facility failed to implement appropriate interventions prior to the development of the wound (see record review above).-Additionally, the wound care physician's 4/8/26 visit note documented the resident's wound was a stage 3 pressure injury (see record review above).CNA #2 was interviewed on 4/9/26 at 11:32 a.m. CNA #2 said he was unaware of Resident #20's right heel pressure ulcer. CNA #2 said the staff would report to the nurses immediately if they found skin lesions, such as pressure wounds. CNA #2 said he checked residents' skin every time he changed or repositioned the residents and during showers. CNA #2 said he received new directions from the nurses and checked the Kardex (comprehensive tool utilized for providing consistent resident care) for updates on interventions for residents, but he said the Kardexes were usually not updated.Licensed practical nurse (LPN) #3 was interviewed on 4/9/26 at 12:00 p.m. LPN #3 said Resident #20 had new treatment orders for her right heel pressure injury that were initiated on 4/8/26, and new interventions were communicated to the CNAs. LPN #3 said she was unaware of the development date of the resident's pressure ulcer and was unable to provide documentation with interventions related to Resident #20's pressure ulcer before 4/8/26. LPN #3 said the only intervention in place for the resident before 4/8/26 was keeping the resident's feet from touching the recliner's surface while she was sitting in it. LPN #3 said residents' skin assessments were usually done once a week. LPN #3 said Resident #20 did not have a pressure ulcer in the first weeks after the resident was admitted to the facility. The DON was interviewed on 4/9/26 at 3:55 p.m. The DON said the wound care physician assessed Resident #20's right heel wound on 4/8/26. The DON said the nurses were currently following the physician's orders for dressing changes to the resident's right heel and the wound care nurse was also monitoring the wound. The DON said she saw Resident #20 crossing her right leg and moving her heel against the mattress, so protective boots were requested.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in two of two kitchenettes. Specifically, the facility failed to ensure staff used proper hand hygiene during meal service. Findings include: I. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/16/26. It revealed in pertinent part, The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)II. Facility policy and procedureThe Handwashing and Glove Use policy and procedure, revised 4/15/2020, was received from the nursing home administrator (NHA) on 4/13/26 at 11:07 a.m. it read in pertinent part, Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substances (raw chicken to fresh fruit) and following contact with any unsanitary surface (touching hair, sneezing, opening doors). Hand washing procedure, wet hands, apply soap, lather vigorously rubbing hands together for 20 seconds, rinse hands to remove soap and debris, dry hands with disposable paper towel, discard paper towel into waste container without touching the container. Gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching ready-to-eat food. When gloves are used, handwashing must occur prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed. Gloves may be used for one task only. It is important to remember that gloves can often give a false sense of security and can carry germs the same as our hands.III. ObservationsDuring a continuous observation on 4/6/26, beginning at 11:32 a.m. and ending at 11:53 a.m., the following was observed during meal service in the third-floor kitchenette:At 11:32 a.m. cook (CK) #1 opened a hamburger bun while wearing gloves, he placed the hamburger bun on the plate. He then used tongs to grab a piece of lettuce and placed the lettuce on the hamburger bun. He grabbed the meal ticket with his gloved hand. He took off his gloves and put them in the trash. At 11:36 a.m. without washing his hands, CK #1 put on new gloves. With gloved hands CK #1 used a spoon to scoop yogurt out of a container and onto a plate. He then used his gloved hands to place the plate and a meal ticket onto a meal tray. While wearing the same gloves CK #1 picked up another meal ticket and plate. He opened the microwave and placed the plate inside that included a hamburger, closed the microwave and pushed buttons with his right gloved hand. He then opened the microwave door and took the plate out using his gloved right hand. While wearing the same gloves he opened the hamburger bun. He then picked up and tore lettuce with the same gloves and placed the lettuce on the hamburger bun. While wearing the same gloves, he used tongs to pick up a fresh tomato slice and placed the tomato slice on the hamburger with his gloved hands. He then placed the top of the bun on the burger with the same gloved hands. While wearing the same gloves he then cut the burger holding it with the gloved hand. He then placed the plate and the meal ticket on the tray to be served to the resident. At 11:38 a.m. CK #1 discarded his gloves and washed his hands. CK #1 washed his hands for approximately 10 seconds. He put on new gloves. With his gloved hands he grabbed meal tickets and began putting them into the ticket holder. He grabbed more tickets and put them in the ticket holder. He kept one ticket in his hand and opened the reach-in refrigerator. He then put a plate on the counter and began scooping food with utensils. CK #1 continued to wear the same gloves and touch meal tickets and assemble plates. At 11:45 a.m. with the same gloved hands CK #1 was scooping and assembling a plate with the same gloves. At 11:46 a.m. CK #1 was assembling plates with the same gloves and used a food processor with both gloved hands. At 11:47 a.m. CK #1 was assembling a plate he had put in the microwave and then removed from the microwave wearing the same gloves. At 11:48 a.m. CK #1 removed his gloves and washed his hands for approximately seven seconds. At 11:48 a.m. CK #1 put on new gloves and began assembling plates and scooping food. He then placed two hamburger buns on a plate with his gloved hands and placed them in the microwave. He took the buns out of the microwave and opened the buns with his gloved hands. He then picked up a meal ticket with the same gloves. While wearing the same gloves, he used a spatula to put mayonnaise on the bun, holding a bun with his free hand. He placed two hamburger patties on another plate and used his gloved hands to put cheese on the buns, he then placed the plate with the burger patties in the microwave. He opened the microwave with his right hand and used tongs to place the hamburger patties on the bun. While wearing the same gloves, CK #1 picked up pieces of lettuce and placed some on each of the burgers. With the same gloved hands he picked up slices of fresh tomato and placed them on the burgers, then placed the top of the buns on the burgers. During a continuous observation on 4/6/26, beginning at 11:50 a.m. and ending at 12:22 p.m., the following was observed during meal service on the second-floor kitchenette:At 11:50 a.m. an unidentified dietary aide (DA) assisted a male resident in the dining room, the DA touched the resident with her gloves and went back to prepping room trays. She did not change her gloves. With the same gloved hands, she began covering desserts and drinks with plastic wrap While covering the drinks with plastic wrap, she was touching the rim of the glass where residents put their mouths. At 12:04 p.m. the same unidentified DA was cutting pieces of plastic wrap and placing them on the table that other staff members had touched with their bare hands. The table had not been wiped or sanitized. She then used the plastic wrap to cover desserts and drinks for room trays.At 12:09 p.m. the same unidentified DA reached inside of her pocket and brought out a key to open the kitchen door. She went inside of the kitchenette, disposed of her gloves. When she reentered the dining room she put on new gloves without washing her hands. At 12:13 p.m. the same unidentified DA approached a resident in the dining room with the same gloved hands. She bent down to talk to the resident and put her gloves hands on her knees. The unidentified DA went back to preparing more room trays without changing her gloves. At 12:22 p.m. the same unidentified DA continued to prepare room trays with the same glove hands. During a continuous observation on 4/9/26, beginning at 7:27 a.m. and ending at 8:27 a.m., the following was observed during meal service in the third floor kitchenette: At 7:27 a.m. DA #2 brought the food from the main kitchen to the second floor kitchenette, she did not wash her hands upon entering the kitchenette. At 7:29 a.m. without performing hand hygiene DA #2 began to uncover the food and place it in the steam table. At 7:30 a.m. DA #2 washed her hands. At 7:31 a.m. DA #2 opened the ice machine, used the ice scoop to scoop ice into a cup to calibrate the thermometer. She then took the temperatures of the food. At 7:36 a.m. DA #2 washed her hands, put on gloves and opened the microwave. She pulled out a stack of bowls from the microwave with the gloves on. She then grabbed a muffin and took the paper wrapper off and put it on the plate. She chopped bacon and sausage and placed the chopped meats on the plate with her gloved hands. She touched four pieces of bread and placed them in the toaster to make toast, with the same gloved hands. At 7:41 a.m. DA #1 moved two souffle cups of brown sugar by placing her bare fingers inside of the cups, from one tray to another tray. At 7:42 a.m. with the same gloved hands DA #2 picked up a muffin paper off the muffin. She then pulled a piece of toast out of the toaster and put the toast on the cutting board. She then put butter on the toast, cut the toast and placed the toast on the plate, while wearing the same gloves She then placed more toast on the cutting board using the same gloves. At 7:43 a.m. DA #2 was using small tongs to place meal tickets on the trays. She used one of her gloved fingers and tongs to separate the tickets. At 7:44 a.m. with the same gloved hands, DA #2 chopped sausage on the cutting board, cut and buttered toast on the cutting board.At 7:46 a.m. DA #2, with the same gloved hands, grabbed a muffin and took the paper wrapper off of the muffin and placed the muffin on a plate with the sausage and toast. At 7:47 a.m. with the same gloved hands, DA #2 cracked two eggs. She got raw egg on her gloves. She made two fried eggs. With the same gloved hands, she grabbed bread and put it in the toaster, turned the toaster on. She did not change her gloves. At 7:51 a.m. with the same gloved hands, DA #2 cracked one egg. She got raw egg on her gloves. She made one fried egg. She did not change her gloves. At 7:53 a.m. with the same gloved hands, DA #2 peeled a banana. She used the same gloved hands to chop the banana. She placed the banana peel on the cutting board. She was wearing the same gloves.At 7:54 a.m. with the same gloved hands, DA #2 cracked two eggs. She got raw egg on her gloves. At 8:00 a.m. with the same gloved hands, DA #2 opened the reach-in refrigerator, grabbed a pudding and placed the pudding on a plate. She took off her gloves, washed her hands and put on a new pair of gloves. At 8:07 a.m. DA #2 placed a piece of bread in the toaster and turned the toaster on. At 8:11 a.m. with the same gloved hands, DA #2 cracked three eggs, she held the shells in her left hand. The clear liquid from the egg was dripping from her gloved hand to the counter and floor, she took the banana peel from the cutting board and threw the egg shells and banana peel away. With the same gloved hands, she then grabbed toast from the toaster with her left hand, buttered the toast and served the toast. At 8:15 a.m. with the same gloved hands, DA #2 grabbed another piece toast from the toaster, cut the toast and buttered the toast. At 8:16 a.m. DA #2 opened a bag of small bagels, cut the bagel and placed it in the toaster. She then took off her gloves, washed her hands, and put new gloves on. At 8:21 a.m. DA #2 grabbed toast out of the toaster, buttered the toast, cut the toast and placed the toast on a plate. She then touched a hard-boiled egg, cut the hard-boiled egg. At 8:22 a.m. with the same gloved hands, DA #2 cracked two eggs. While cracking the egg, the raw egg got on her gloves. She did not change her gloves. At 8:23 a.m. with the same gloved hands, DA #2 touched a muffin and took the paper wrapping off the muffin.IV. Staff interviewsDA #2 was interviewed on 4/9/26 at 8:29 a.m. She said she only changed her gloves when she left the service line, or touched things like the reach-in refrigerator, or anything outside of the service line. She said she did not change her gloves when she would crack eggs to make for fried eggs. She said she did not change her gloves because that was part of her service line. The executive chef was interviewed on 4/9/26 at approximately 8:40 a.m. He said the DAs should change their gloves anytime they change tasks such as touching raw meat, and then switching to a cooked meat, they should wash their hands and put on new gloves. He said staff should be changing their gloves and washing their hands when they were cracking eggs and making fried eggs. He said staff should take off their gloves, wash their hands with soap and water, dry their hands, then put on new gloves.

Based on record review and interviews, the facility failed to complete grievance forms consistently to address and promptly resolve resident grievances.Specifically, the facility failed to effectively address, resolve, and demonstrate the facility's response to group grievances. Findings include:I. Facility policy and procedureThe Grievance policy and procedure, reviewed March 2018, was provided by the nursing home administrator (NHA) on 4/6/2 at 9:00 a.m. It revealed in pertinent part, A resident, his/her representative, family member, visitor or advocate may file a verbal or written comment, grievance or complaint concerning resident rights, treatment, abuse, neglect, harassment, medical care, behavior of other residents, theft of property without fear of threat or reprisal in any manner. Such grievances or complaints may be made anonymously. For a written grievance or complaint, complete an accurate and detailed complaint/grievance form located at the nurse's station or community designated area. Return the completed complaint/grievance form to the administrator, who is the community's grievance official. The complaint or grievance may also be given to the administrator, the grievance official, verbally.The outcome of the investigation will be reported to the resident and responsible party generally within seven working days of the resident submitting the written or verbal grievance. Progress on investigations will continue at each scheduled morning stand up meetinguntil resolution. Any alleged violation of neglect, abuse, including injuries of an unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the community shall be reported to the administrator. If an alleged violation of the resident's rights is confirmed by the facility or if an outside entity having jurisdiction confirms a violation for any of these residents' rights within its area of responsibility, the community shall take the appropriate corrective action in accordance with state and federal law.II. Resident group interviewA group interview was conducted on 4/7/26 at 3:36 p.m. with four Residents (#12, #19, #62, and #63) residents who were identified as alert and oriented through facility and assessment. Resident #62 and Resident #63 said they were recently admitted to the rehabilitation unit. They said they were not informed of how to submit a grievance.Resident #19 and Resident #63 said the call light wait times depended on how many certified nurses aides (CNAs) were staffed. Resident #19 said sometimes the staffing was worse on the night shift, but low staffing happened on all shifts. Resident #19 said that she asked for more CNAs during resident council meetings for the three years that she has been here. She said that the facility did not do anything about it.The residents said on most weekends the facility had only one CNA for three halls.Resident #63 said she had waited for up to an hour and a half for her call light to be answered. She said the facility had even less staff over the Easter holiday.The residents said staffing was an issue at the facility because they had to wait a long time when they called for assistance and it was worse at night. III. Resident interviewsResident #4 was interviewed on 4/6/26 at 11:23 a.m. Resident #4 said the facility was understaffed. She said she had to wait 45 minutes on the toilet for help. Resident #68 was interviewed on 4/6/26 at 4:37 p.m. Resident #68 said it often took over 30 minutes for staff to respond to her call light. Resident #8 was interviewed on 4/6/26 at 4:48 p.m. Resident #6 said there was only one CNA for an entire shift one weekend. IV. Record reviewGrievances for the last three months were requested during the survey from the nursing home administrator (NHA) on 4/8/26 at 10:26 a.m. The NHA sent an email on 4/8/26 at 4:48 p.m., which documented that the facility did not have any staffing grievances for the last three months.-However, the residents in the group interview and the staff indicated they had ongoing concerns with staffing (see interviews). V. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 4/8/26 at 1:30 p.m. CNA #5 said sometimes there was not enough staff to help with showers, changing/repositioning residents every two hours, or getting people up timely. CNA #5 said the staff had to assist residents who needed meal assistance, deliver room trays, and get residents ready to go to the dining room. She said sometimes this made it so the food got cold. CNA #5 said it led to thirty-minute waits when residents used their call lights. CNA #2 was interviewed on 4/8/26 at 2:17 p.m. CNA #2 said each CNA took care of one hallway and split another hall between two CNAs, which caused showers to get neglected, because when residents needed two people for transfers, they had to wait too long for the other staff member to come to help. CNA #2 said sometimes the staff had to offer a bed bath instead of a full shower. CNA #6 was interviewed on 4/9/26 at 5:46 a.m. CNA #6 said residents frequently complained that the facility did not have enough staff, and this complaint was reported to nursing. A staff member who wished to remain anonymous was interviewed on 4/9/26 at 5:55 a.m. The staff member said they did not think there were enough staff overnight to get work completed because of the resident's needs on the floor. The staff member said the residents complained it took too long to get their call lights answered. The staff member said the staff had to complete showers, baths and meals. The staff member said they were not sure if the managers knew the residents were complaining about staffing issues but the staff member did not fill out a grievance for staffing and asked the families to fill out the grievance form themselves.Licensed practical nurse (LPN) #3 was interviewed on 4/9/26 at 12:00 p.m. LPN #3 said the facility did not have enough staff, and the residents frequently complained about it. LPN #3 said the nursing staff could not focus on the residents the way they should because of this issue, and some staff members quit because of it. LPN #2 said the management was aware of the concerns. LPN #3 said the staff had talked to the management regarding needing more help to provide care to the residents. The assistant director of nursing (ADON) was interviewed on 4/9/26 at 9:47 a.m. The ADON said residents complained about the facility's staffing on weekends. The ADON said when a grievance was filed, it was provided to the NHA. The ADON said residents also complained about long call light times.-However, a request was made for grievances regarding staffing and the NHA said there were no documented grievances (see record review above).The NHA was interviewed on 4/9/26 at 6:27 p.m. The NHA said she was not aware that staff were adjusting their tasks to give residents bed baths instead of showers. She said the staff had reported it was hard to complete all of their tasks including meal service, vital signs and showers. She said the staff had not told her that the residents were complaining about their care. The NHA said the grievances were used to track and trend facility issues and to support process improvement. The NHA said the grievance forms were on both floors by the nurses' stations, and the front desk should have them as well. The NHA said she had talked to the staff regarding their work glow. She said she was not aware of the resident concerns.

Based on observations, record review, and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections on two of two units.Specifically, the facility failed to:-Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP);-Ensure an effective process was in place to ensure staff were aware of which residents were on EBP; and,-Ensure nursing staff cleaned blood pressure cuffs between residents. Findings include: I. EBP failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 4/9/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. B. Observations During a continuous observation on 4/9/26, beginning at 5:00 a.m. and ending at 6:37 a.m., the following was observed: At 5:30 a.m. two unidentified staff members entered Resident #20's room. They provided the resident incontinence care. They failed to put on gowns. The resident's door sign said: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident activities: dressing, transferring, changing linen, providing hygiene, changing briefs, or assisting with toileting, wound care, and an open wound requiring a dressing change. C. Staff interviews A CNA who wished to remain anonymous was interviewed on 4/9/26 at 5:55 a.m. The CNA said she had not received any training on the new EBP sign posted on Resident #20's door. The CNA said she did not know why the EBP supplies were there. The CNA said gowns were not available in the PPE hanging on the door anyway. The director of nursing (DON) was interviewed on 4/9/26 at 3:55 p.m. The DON said she was not aware of staff members not using EBP to assist Resident #20, who had a right heel stage 3 pressure wound. The nursing home administrator (NHA) was interviewed on 4/6/26 at 6:30 p.m. The NHA said she thought the facility staff were trained on EBP within the last month. She said the staff received infection control training through the online training platform that the facility used. D. Additional observations On 4/8/26 at 9:55 a.m. Registered Nurse (RN) #1 removed the gauze wrapped on the left leg for Resident #34 while he was sitting in his wheelchair. RN #1 had on gloves on but no gown. There was a sign on the door that indicated Resident #34 was on EBP. On 4/9/26 at 5:05 a.m. certified nurses aide (CNA) #3 was emptying the Resident #30 colostomy bag and changing his bedsheets. The resident's abdomen was exposed while he was lying in his bed, and care was being provided by the staff. There was a sign on the resident's door that indicated the resident was on EBP. CNA had on gloves and a face mask. E. Additional staff interviews The assistant director of nursing (ADON) was interviewed on 4/7/26 at 12:27 p.m. She said she observed a housekeeping staff member enter a resident's room who was on precautions without donning a gown. She said she started education for the staff on infection precautions. CNA #3 was interviewed on 4/9/26 at 5:10 a.m. She said the reason she did not have on a gown on when providing care to Resident #30, because she did not see the sign on the resident's door. She said she should have worn a gown in addition to her gloves because the resident was on EBP. She said the facility provided education regarding the importance of EBP to prevent infections for residents. The infection preventionist (IP) was interviewed on 4/9/26 at 7:22 a.m. The IP said the sign on Resident #30's door should have been changed to contact precautions when he came back from the hospital. The IP said was diagnosed with methicillin resistant staphylococcus aureus (MRSA) while he was at the hospital. She said it was her responsibility as the IP to change the sign on the resident's door and ensurePPE was available. The IP, the NHA and the regional clinical resource were interviewed together on 4/9/26 at 1:31 p.m. The IP said part of her role at the facility included providing staff education regarding donning appropriate PPE for residents on EBP. She said any resident who had an indwelling foley catheter, wound, intravenous device would require being on EBP. She said CNA #3 should have donned a gown before providing care to resident #30. She said donning the correct PPE was important to prevent the spread of infection. The NHA said she would start education immediately for staff regarding procedures and requirements when a resident was on EBP. II. Blood pressure cuff failures A. Observations On 4/9/26 at 6:46 a.m. licensed practical nurse (LPN) #2 took the blood pressure for Resident #46 using an electronic blood pressure cuff before administering medication. On 4/9/26 at 7:02 a.m. LPN #2 took the blood pressure for Resident #12 before administering medication during morning medication pass. -LPN #2 failed to disinfect or sanitize the blood pressure cuff after taking Resident #46's blood pressure and prior to taking Resident #12's blood pressure. B. Staff interviews LPN #2 was interviewed on 4/9/26 at 7:06 a.m. He said he used an electric blood pressure cuff when checking the blood pressure of the facility residents. He said he used the same blood pressure cuff on all residents. He said the residents in the facility did not have an individual blood pressure cuff. He said that if the nurses were using the same device between residents, the blood pressure cuff should be sanitized after each use on residents. He said he forgot to sanitize the blood pressure cuff after it was used on the previous resident. He said the nursing staff were responsible for sanitizing the blood pressure cuffs after each use on a resident. The IP was interviewed on 4/9/26 at 1:31 p.m. The IP said the facility did not provide residents with individual blood pressure cuffs. The IP said the nursing staff used one blood pressure cuff for multiple residents. The IP said nursing staff were responsible for sanitizing the blood pressure cuff after each use on a resident. The IP said blood pressure cuffs should be sanitized after each resident to prevent bacterial contamination.

Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#4) of five residents reviewed for unnecessary medications out of 34 sample residents. Specifically, the facility failed to ensure informed consents, which included risks versus benefits and side effects of prescribed psychotropic medications. Findings include:I. Facility policy and procedureThe Psychotropic Drug Management policy, revised March 2026, was provided by the nursing home administrator (NHA) on 4/13/26 at 11:07 a.m. It read in pertinent part, Nursing shall not administer the psychotropic medication until informed consent has been obtained from the resident and/or legal representative, except in emergency situations. Informed consent should be obtained from the resident and/or legal resident representative for increase in dose, or PRN (as needed) extension with documented rationale or re-evaluation as indicated.II. Resident #4A. Resident statusResident #4, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included delusional disorders, cognitive communication deficit, depression, anxiety disorder, and post-traumatic stress disorder.The 3/29/26 minimum data set (MDS) assessment revealed Resident #4 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed Resident #4 was dependent on staff for most of her activities of daily living (ADL). The assessment indicated Resident ##4 received antipsychotic medications, antidepressant medication, and hypnotic medication. B. Record reviewThe March CPO revealed the following physician's orders:Clonazepam (antianxiety) .5 milligram (mg) at bedtime for anxiety. Ordered on 3/19/26. Mirtazapine (antidepressant) oral tablet 7.5 mg, give one tablet at bedtime for major depressive disorder. Ordered on 3/19/26. Venlafaxine (antidepressant) oral capsule, give 150 mg by mouth one time a day for major depressive disorder. Ordered on 3/20/26. Olanzapine (antipsychotic) oral tablet 2.5 mg, give one tablet by mouth two times a day for depression. Ordered on 3/19/26. Review of Resident #4's medication administration record (MAR) revealed the following: The first dose of clonazepam was given on 3/19/26. The first dose of mirtazapine was given on 3/19/26.The first dose of venlafaxine was given on 3/20/26.The first dose of olanzapine was given on 3/19/26. A review of Resident #4's electronic medical record (EMR) revealed the following:The informed consent for clonazepam was signed by Resident #4 on 3/23/26. The informed consent for mirtazapine was signed by Resident #4 on 3/23/26. The informed consent for venlafaxine was signed by Resident #4 on 3/23/26. The informed consent for olanzapine was signed by Resident #4 on 3/23/26.-All the informed consents were signed after the medications had been given. C. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 4/9/26 at 9:29 a.m. He said the nurses were in charge of getting the medication consents signed. He said the consents should be signed when the nurses received the medication order. He said it was important for the consents to be signed before the resident starts to take the medication so they know what they were taking and were informed of the side effects of the medication. LPN #3 was interviewed on 4/9/26 at 9:34 a.m. She said nurses were in charge of getting medication consents signed. She said they got them signed during the admission process. She said sometimes the consents would get passed on to the next shift because they could not get everything finished during their shift. She said psychotropic medications needed consents and the consents should be signed before giving the medication because the residents needed to know the purpose of the medication and the side effects. The director of nursing (DON) was interviewed on 4/9/26 at approximately 10:30 a.m. She said the admitting floor nurse was responsible for getting the medication consents signed. She said there was a blue folder with all of the consents and additional information inside. She said the admitting nurse would then go over the consents with the family and resident. She said she or the UM would go over the contents of the folder to ensure the consents were completed. She said once the consents were signed they were scanned into the EMR. She said the medication consents should be signed at admission or when the medication order changes, or if one was added. She said medications should not be given before the consent was signed. She said it was important for the resident and their family members to know the risks and benefits and side effects of the medication. She said the floor nurses, the unit manager and herself were in charge of ensuring the consents were signed before medications were administered. She said Resident #4's psychotropic medications were given prior to her signing the consents. She said the medications should not have been administered before the consents were signed because she needed to know the clinical side effects and the risks versus benefits of the medications.

Based on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in one of five medication carts.Specifically, the facility failed to ensure expired and discontinued medications were removed from the medication cart and disposed of. Findings include:I. ObservationsOn [DATE] at 11:23 a.m. The second floor north medication cart was observed with licensed practical nurse (LPN) #3 and contained the following:The drawer on the medication cart for Resident #29 contained the following: Hydrocodone/acetaminophen (pain medication) oral tablet 5 milligram (mg)/325 mg. The order was on [DATE]. The drawer on the medication cart for Resident #22 contained the following: Hydromorphone (pain medication) oral tablet 2 mg. The order was discontinued on [DATE]. The drawer on the medication cart for over the counter medications contained the following: An opened bottle of senna (laxative) oral tablet 8.6 mg that did not have an expiration date on the bottle. An opened bottle of Simethicone Oral tablet 80 mg that expired on [DATE]. II. Staff interviews LPN #3 was interviewed on [DATE] at 11:30 a.m. She said the nursing staff were responsible for checking the medications in the medication cart every day. She said medication carts need to be checked every day to ensure there were no expired or discontinued medications were left in the medication carts. She said when medications expire, the nursing staff would discard the medication immediately. She said she would remove the medication from her medication cart and advise the director of nursing (DON) to dispose of the medication.The assistant director of nursing (ADON) was interviewed on [DATE] at 12:21 p.m. The ADON said the nursing staff and unit managers were responsible for ensuring that there were no expired or discontinued medications. She said she would immediately provide education to the floor nurses and the unit managers regarding the facility's responsibility of immediately discarding expired and discontinued medications.

Based on record review and interviews, the facility failed to meet all requirements for the provision of hospice are for one (#7) of one resident reviewed for hospice out of 34 sample residents. Specifically, the facility failed to demonstrate adequate communication with the hospice staff and facility staff regarding care that the hospice staff provided during visits. Findings include: I. Facility policy and procedureThe Hospice Care policy and procedure, revised October 2016, was provided by the nursing home administrator (NHA) on 4/6/26 at 12:47 p.m. It read in pertinent part, Hospice progress notes shall be included in the resident's medical record and nursing associates shall be informed of any changes recommended by the hospice staff.II. Resident #7A. Resident statusResident #7, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included dementia, acute kidney failure, and acute chronic respiratory failure with hypoxia (lungs cannot adequately transfer oxygen to the blood). The 2/11/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The assessment revealed she was dependent on staff for all of her activities of daily living (ADL). The assessment indicated the resident was receiving hospice care services. B. Record reviewThe April 2026 CPO documented Resident #7 was admitted to hospice care services on 2/2/26. A review of Resident #7's electronic medical record (EMR) revealed the only documentation from the hospice agency was a verbal medication order for baclofen (muscle relaxant) 5 milligrams (mg) dated 3/23/26.-However, review of the resident's EMR failed to reveal documentation of routine hospice care visits provided to the resident. A review of the hospice binder at the nurse's station revealed Resident #7's hospice team, her hospice care plan, notes on the days that the certified nurse aide (CNA) came and gave Resident #7 a bath and skin checks. The binder contained verbal orders from the physician from 2/2/26, medication report dated 2/2/26. The binder revealed a sign in sheet for the hospice registered nurse (RN). The RN had signed in on the following days: 2/12/26, 2/16/26, 2/19/26, 2/23/26, 2/26/26, 3/2/26, 3/6/26, 3/9/26, 3/12/26, 3/23/26, 3/26/26, 3/27/26, 3/30/26, 4/2/26, and 4/6/26. -However, the binder contained one hospice care visit note from 2/2/26. There was no documentation that communication occurred between the hospice staff and the facility staff regarding the care that was provided on 2/16/26, 2/19/26, 2/23/26, 2/26/26, 3/2/26, 3/6/26, 3/9/26, 3/12/26, 3/23/26, 3/26/26, 3/27/26, 3/30/26, 4/2/26, and 4/6/26.III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 4/8/26 at 10:11 a.m. He said that Resident #7's hospice CNA asked him for his help at times because Resident #7 refused care. He said Resident #7's hospice team communicated verbally. He said that the hospice team would write things in the hospice binder. He said he did not look in the binder. He said hospice will fax over any new orders. He said he was unaware of any hospice notes being uploaded into the EMR. The health information specialist and the NHA were interviewed together on 4/9/26 at 5:08 p.m. The health information specialist said her process for obtaining hospice care notes was to reach out to the hospice care company. She said she got any updates from either the DON or the unit manager if they were in need of any notes. She said once she received the notes she uploads them into the EMR. The NHA said that Resident #7's hospice care company did not send visit notes over regularly, she said there was not a standing deal where they would send over the resident's records. The NHA said there were barriers at times to getting records. She said there were times when they had to fill out record request forms in order to receive the hospice notes. She said the facility had not reached out to the hospice care company to fix the record request situation.

Based on record review and interviews, the facility failed to develop and implement policies and procedures related to immunizations for two (#2 and #7) of five residents reviewed for immunizations out of 34 sample residents.Specifically, the facility failed to:-Ensure the COVID-19 vaccine was provided to Resident #2 after she received education and gave consent; and,-Ensure Resident #7's medical record documented if the resident was offered the COVID-19 vaccine when available and documentation documented if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Findings include:I. Professional referenceAccording to the Centers for Disease Control's (CDC) Staying Up to Date with COVID-19 Vaccines, updated 11/19/25, retrieved on 4/14/26 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, read in pertinent part, Getting the 2025-2026 COVID-19 vaccine is important because:-Protection from the COVID-19 vaccine decreases with time;-Immunity after COVID-19 infection decreases with time; and,-COVID-19 vaccines are updated to give you the best protection from the currently circulating strains. Getting the 2025-2026 COVID-19 vaccine is especially important if you:-Never received a COVID-19 vaccine;-Are ages 65 years and older;-Are at high risk for severe COVID-19; and,-Are living in a long-term care facility.II. Facility policy and procedureThe COVID-19 Vaccine and Reporting policy, revised August 2023, was provided by the nursing home administrator (NHA) on 4/6/26 at 1:50 p.m. It read in pertinent part, COVID-19 vaccines are effective at protecting people from getting seriously ill, avoiding hospitalizations, long-term health outcomes, and death. The COVID-19 vaccine resources should be offered to eligible residents as recommended by the Centers for Disease Control and Prevention (CDC). Resident/Resident Representatives and associates should be provided education regarding the benefits and potential side effects associated with the COVID-19 vaccines. The community should maintain documentation to reflect the required COVID-19 vaccine education was provided, and receipt or declination of the vaccine. A person is up-to-date with COVID-19 vaccines when the current Centers for Disease Control and Prevention (CDC) recommendations have been followed. Prior to COVID-19 vaccine, eligible residents and associates should be provided current educational information regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine. The nurse/designess should document in the resident's medical record the education to the resident or the resident's representative regarding the benefits and potential risks associated with the COVID-19 vaccine; and documentation of the COVID-19 vaccine dose(s) administered, historical COVID-19 vaccinations, medical contraindication or declination. If administered by a community nurse, a COVID-19 informed consent should be completed.III. Resident #2 A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (weakness and paralysis on one side), long-term use of anti-coagulants, chronic respiratory failure and high blood pressure. The 4/3/26 minimum data set assessment (MDS) documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15.The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not received.B. Record reviewA review of Resident #2's immunization record in the electronic medical record (EMR) failed to reveal documentation that the facility offered the SARS-COV-2 (COVID 19) vaccination to the resident.IV. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included dementia, acute kidney failure, acute respiratory failure, and anxiety. The 2/11/26 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of four out of 15.The assessment documented the resident's COVID-19 vaccination was not up to date and did not include if the vaccine was offered or the reason why the vaccine was not received.B. Record reviewA review of Resident #2's immunization record in the EMR failed to reveal documentation that the facility offered the SARS-COV-2 (COVID 19) vaccination to the resident or their representative.IV. Staff interviewsThe infection preventionist (IP) and the NHA were interviewed together on 4/9/26 at 12:30 p.m. The IP said she had recently implemented a spreadsheet to track resident vaccination status in the facility. The IP said she was reviewing all the resident vaccination consent forms to ensure they were uploaded to the resident's medical record and residents who consented to receiving the vaccine would have their vaccine ordered for administration.The NHA said residents were offered a vaccine upon admission, but with a change in the staff at the IP position they were reviewing the residents vaccine information. She said when the residents signed consent or declination forms, the forms were previously sent to a medical records staff member for upload instead of the IP for tracking. She said the IP had created a spreadsheet that would improve their tracking of resident vaccines going forward.V. Facility follow upThe NHA provided documentation of informed consent for the COVID-19 vaccine for Resident #2 and Resident #7 on 4/9/26 (during the survey) at 12:33 p.m. The NHA said Resident #7's representative declined the COVID-19 vaccine when it was offered on 4/9/26 (during the survey) and Resident #2 consented to receiving the COVID vaccine. The documentation indicated the vaccine would be ordered from the pharmacy and administered to Resident #2 once the facility received the vaccine.

Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#6 and #30) of five residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to:-Ensure Resident #6 received the pneumococcal vaccine when consent was given; and,-Ensure Resident #30 was offered the flu vaccine. Findings include:I. Professional Reference According to the Centers for Disease Control and Preventions (CDC) Flu, revised 9/5/24 and retrieved 4/14/26 from https://www.cdc.gov/flu/highrisk/65over.htm, Flu vaccination is especially important for people 65 years and older because they are at higher risk of developing serious flu complications. While flu seasons vary in severity, during most seasons, people 65 years and older bear the greatest burden of severe flu disease. CDC and the Advisory Committee on Immunization Practices (ACIP) preferentially recommend the use of higher dose flu vaccines (including high-dose inactivated and recombinant) or adjuvanted inactivated flu vaccine over standard-dose unadjuvanted flu vaccines for people 65 years and older. CDC recommends prompt flu antiviral treatment for people who have flu or suspected flu and who are at higher risk of serious flu complications, such as people 65 years and older. Having the flu increases your risk of getting pneumococcal disease. Pneumococcal pneumonia is an example of a serious flu-related complication that can cause death. People who are 50 years and older also should be up to date with pneumococcal vaccination.II. Facility policy and procedureThe Influenza Vaccine policy, revised March 2026, was provided by the nursing home administrator (NHA) on 4/6/26 at 1:50 p.m. It read in pertinent part, The resident/resident representative should be offered the influenza vaccine annually to encourage and promote the benefits associated with immunizations against influenza. Influenza can occur at any time, but most influenza occurs from October through May. Residents should be immunized as soon as the vaccine becomes available and continue until influenza is no longer circulating in your geographic area, unless the vaccination is medically contraindicated or the resident declines the vaccine due to personal, religious or medical reasons. Obtain a written order from the health care provider. Obtain written, informed consent upon admission and annually from the resident or resident representative. The informed consent for influenza vaccine form includes education associated with the benefits and potential side effects or adverse effects if receiving the vaccine. Appropriate entries should be documented in the resident's medical records indicating the date of the receipt or refusal of the annual influenza vaccination, indicating the date of the receipt or medically contraindicated or declination.The Pneumococcal Vaccine policy, revised March 2026, was provided by the NHA on 4/6/26 at 1:50 p.m. It read in pertinent part, Resident/Resident representative should be offered the pneumococcal vaccine in order to maintain up to date status. Before receiving a pneumococcal vaccine, the resident or resident representative should receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Obtain informed consent from the resident or resident representative. Pneumococcal vaccines should be offered and administered to residents (unless medically contraindicated, already given, or refused). If refused, appropriate entries should be documented in the resident's medical record. Vaccinations should not be delayed due to a lack of a written immunization record. If immunization records are not available, it is acceptable to rely on the resident's or resident representative's verbal immunization history to determine if pneumococcal vaccine is indicated.III. Resident #6 A. Resident statusResident #6, age greater than 65, was admitted to the facility on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses including pancreatic insufficiency, depression, and dysphagia (difficulty swallowing).The 3/19/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment indicated the resident was not up-to-date with pneumococcal vaccination due to the vaccine not being offered by the facility.B. Record reviewA review of Resident #6's electronic medical record (EMR) revealed Resident #6 signed a pneumococcal vaccine consent form, marked that he received information about the vaccine and understood the risk and benefit and consented to receiving the vaccine by signing the form. -However, the specific vaccine being offered was not marked on the form and the date the form was signed was not completed, and there was no documentation in the resident's EMR to indicate the pneumococcal vaccine had been administered to the resident.The facility obtained a second consent for the pneumococcal vaccine from Resident #6 on 4/8/26 (during the survey). The form was signed by the Resident's representative, documented the specific vaccine information provided and that the resident did not consent to receiving the vaccine at that time.IV. Resident #30 A. Resident statusResident #30, age less than 65, was admitted on [DATE]. According to the April 2026 CPO diagnoses included hemiplegia or hemiparesis (weakness and paralysis), diabetes mellitus type II, and depression.The 3/29/26 MDS assessment documented the resident had a short term and long term memory problem, was moderately impaired to make decisions regarding tasks of daily life, and cueing and supervision was required.The assessment documented the resident did not receive the influenza vaccine in the facility for this year's influenza vaccination season and that the vaccine was not offered.B. Record reviewA review of Resident #30's EMR revealed the resident did not receive the influenza vaccine. There was an influenza vaccine informed consent form with Resident #30's name on the bottom of it. The form was not signed by the resident or resident's representativeV. Staff interviewsThe infection preventionist (IP) and the NHA were interviewed together on 4/9/26 at 12:30 p.m. The IP said she had recently implemented a spreadsheet to track resident vaccination status in the facility. The IP said she was reviewing all the resident vaccination consent forms to ensure they were uploaded to the resident's medical record and residents who consented to receiving the vaccine would have their vaccine ordered for administration.The NHA said residents were offered a vaccine upon admission, but with a change in the staff at the IP position they were reviewing the residents vaccine information. She said when the residents signed consent or declination forms, the forms were previously sent to a medical records staff member for upload instead of the IP for tracking. She said the IP had created a spreadsheet that would improve their tracking of resident vaccines going forward.V. Facility follow upThe NHA provided additional documentation on 4/8/26 at approximately 4:30 p.m. that the facility followed up with Resident #30's representative for a history of Resident #30's vaccination status. The resident's representative said she would get back to the facility with the information.

Based on observations, record review and interviews, the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional food safety standards in the main kitchenSpecifically, the facility failed to ensure:-The kitchen was kept in a sanitary manner;-Perishable foods were properly labeled, stored, and maintained; and, -The ice machine was maintained in a sanitary condition. Findings include:I. Failure to ensure the kitchen was kept in a sanitary mannerA. Professional referenceAccording to the U.S. Food and Drug Administration Food Code (Effective 2022) retrieved on 10/1/25, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. (3-178) After cleaning and sanitizing, equipment and utensils: Shall be air-dried or used after adequate draining before contact with food. (chapter 4) Physical facilities shall be maintained in good repair. (chapter 6) Physical facilities shall be cleaned as often as necessary to keep them clean. (chapter 6)B. Facility policy and procedureThe Kitchen Cleaning policy, effective July 2024, was provided by the nursing home administrator (NHA) on 9/23/25 at 5:20 p.m. It read in pertinent part, All kitchens and food preparation areas must be cleaned according to federal, state and local regulations. Kitchen areas (walls, cupboard doors, ceiling, lights and vents) are clean, free from dust and in good repair (free of cracks and holes).C. ObservationsThe initial kitchen tour was conducted on 9/22/25 at 10:50 a.m. The following was observed:-The paper towel dispenser over the hand washing sink was soiled with smudges and had white and brown dried debris on it. -The walls behind the handwashing station, and the walls around the walk-in refrigerator had dime sized brown and yellow streaks and splatters across their surfaces.-The drying rack had multiple food storage bins and pans stacked on top of each other, trapping moisture. Between two of the pans on the clean drying rack were unidentifiable food debris.II. Ensure perishable foods were labeled and stored and stored appropriatelyA. Professional referenceAccording to the Colorado Retail Food Establish Regulations (3/16/24) retrieved on 9/25/25, A date marking system that meets the criteria marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. (chapter 3) Except for containers holding food that can be readily and unmistakablyrecognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. (chapter 3) Food shall be protected from contamination by storing the food: In a clean, dry location; Where it is not exposed to splash, dust, or other contamination; and at least 15 cm (centimeters) (6 inches) above the floor. (chapter 3) A food specified in shall be discarded if it: Is inappropriately marked with a date or day that exceeds a temperature and time combination. (chapter 3) The food in unmarked containers or packages, or marked with a time that exceeds the six (6) hour limit shall be discarded. (chapter 3)B. Facility policy and procedureThe Food Storage policy, revised June 2024, was provided by the NHA 9/23/25 at 5:20 p.m. It read in pertinent part, The storerooms and walk-ins should be maintained free from dirt, dust, insects, rodents or any potential sources of contamination. All foods should be stored on storeroom shelving that is no less than six inches from the floor. Dented cans must be marked with a large X and set aside in a separate area so that theywill not be used.C. ObservationsThe initial kitchen tour was conducted on 9/22/25 at 10:50 a.m. The following was observed in the dry storage area:-An opened bag of chips.-A container of pastries and pies that were uncovered and undated.-A bag of expired popcorn.-A dented can was on the same shelf as non-dented cans.-The flour bin lid had smudges and dried debris on it. There was a use-by date of 8/1/25 written on it. -Boxes of food were on the floor.In the main kitchen the following was observed:-Under the food preparation counter there was a bin of grains that was left open without a lid and did not have a use-by date on it. In the walk-in refrigerator the following was observed:-Food boxes were stacked on the floor in the walk-in refrigerator and dry storage room. -A box of carrots was in the freezer and was left open.-A separate bin of carrots in the walk-in refrigerator was labeled as watermelon and had an expiration date of 8/1/25 on it. III. Ensure the ice machine was maintained in a sanitary conditionA. Professional referenceAccording to the U.S. Food and Drug Administration Food Code (Effective 2022) retrieved on 10/1/25, In equipment such as ice makers, a frequency specified by the manufacturer, or the absence of manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. Ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. (chapter 4)B. ObservationsThe initial kitchen tour was conducted on 9/22/25 at 10:50 a.m. The ice machine had debris across the front and sides of the machine. There were dark smudges, brown splatters and a crusted white substance were visible on the outside and inside door of the ice machine. The inside door-flap of the ice machine had similar smudges, splatters and debris. C. Record reviewAccording to the 2025 Ice Machine Cleaning Log was for the year 2025 provided by the NHA on 9/23/25 at approximately 3:20 p.m.On the top of the log it read, The ice machine should be cleaned and sanitized at least once a month and cleaned and sanitized by a professional service provider every six (6) months. Please refer to your ice machine's manual for cleaning instructions. The ice machine log documented a monthly cleaning being completed by the facility from January 2025 through August 2025. According to the log, a professional service provider came on 5/27/25 for a repair to the ice machine in the main kitchen. IV. Staff interviews The dietary manager (DM) was interviewed on 9/23/25 at approximately 1:00 p.m. The DM said that he recognized that many food items had expired or lacked food labels and that he would monitor expiration dates closely in the future. He said the kitchen staff tried to deep clean the kitchen every Sunday. The DM said the kitchen recently got a new power washer and he would schedule the kitchen for a deep cleaning using the power washer. The DM said he was unable to provide documentation that the main kitchen's ice machine was been deep-cleaned by a professional service provider in the last six months and said that the facility no longer contracted with the outside service to provide the deep sanitation and chemical disinfection for the ice machine (see ice machine cleaning record above). The NHA was interviewed on 9/23/25 at 4:22 p.m. The NHA said that she conducted weekly walkthroughs of the kitchen and that her last walkthrough was last week. The NHA said that her expectation of the kitchen was for it to be clean and to have all food items dated properly. The NHA said she understood why kitchen staff was confused about the process for servicing kitchen equipment, specifically the malfunctioning ice machine in the main kitchen that did not keep ice frozen. She said that the kitchen staff was to place a work order for the maintenance department. From there the maintenance department was responsible for contacting the equipment vendor or completing the maintenance themselves.

Based on observations, record review and interviews, the facility failed to ensure two (#1 and #4) of three residents who required respiratory care received care consistent with professional standards of practice out of seven sample residents.Specifically, the facility failed to:-Ensure Resident #1 and Resident #4 were provided their physician-ordered continuous positive airway pressure (CPAP) treatment consistently; and, -Ensure Resident #4's CPAP machine was cleaned and stored properly. Findings include:I. Facility policy and procedureThe admission Data Collection and Orders policy, revised September 2025, was provided by the director of nursing (DON) on 9/23/25. It read in pertinent part, The charge nurse who admits the resident is responsible for completing the nursing admission data collection, verifying orders are present for admission, additional corresponding data collections, and reviewing the information sent by the discharging community, hospital, and/or attending physician.The CPAP/BiPAP (bilevel positive airway pressure policy, revised September 2017, was provided by the DON on 9/23/25. It revealed in pertinent part, Review and follow health care provider's orders and manufacturer's instructions for CPAP/BiPAP support, machine setup and oxygen delivery. CPAP therapy is used to improve arterial oxygenation in residents with respiratory (oxygen) insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. To promote resident comfort and safety. Review and follow the health care provider's orders and manufacturer's instructions for CPAP/BiPAP support, machine setup and oxygen delivery. Use distilled water for the humidification chamber, interior filter, tubing, and mask cushion. Filtered or tap water should not be used. Storage and cleaning: make sure the machine and parts are kept out of direct sunlight. Use mild detergent and a damp cloth to wipe the surface of the machine, then dry it thoroughly with a lint-free towel. Never submerge the machine in water. Wash the mask daily in mild, fragrance-free soap and warm water, then rinse well in warm water and air dry. Soak mask weekly in one part vinegar to three parts water for 20 minutes, followed by a rinse in distilled water. The sturdy plastic or soft fabric part of the mask should be cleaned weekly in warm soapy water.II. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included metabolic encephalopathy (brain dysfunction caused by metabolic imbalances), end stage renal disease, dependence on renal dialysis, obstructive sleep apnea (OSA), type II diabetes and hypertension (high blood pressure).The 7/2/25 minimum data set (MDS) assessment revealed the resident required substantial assistance for activities of daily living (ADL). The MDS assessment revealed the resident required oxygen use. B. Resident #1's representatives interviewResident #1's representative was interviewed on 9/23/25 at 11:24 a.m. The representative said they saw Resident #1 on 7/10/25 and the resident told the representative that she had not been assisted in using her CPAP machine. The representative said on the day of admission, the staff asked the family to bring in the CPAP machine and did so without delay. The representative said when at home, Resident #1 was compliant about wearing her CPAP at night. C. Record reviewThe preadmission paperwork, dated 6/24/25, indicated Resident #1 was on two liters of oxygen per minute (LPM) and utilized a CPAP machine at home (prior to admission). The hospital referral and Discharge summary, dated [DATE], identified that Resident #1 had a diagnosis of OSA and required the use of CPAP therapy. Review of the June 2025 CPO revealed respiratory orders for oxygen at two LPB via nasal cannula every shift for hypoxia.-However, the June 2025 MAR did not document any order to administer CPAP therapy, although the hospital documentation indicated the use of the CPAP. Review of the July 2025 CPO revealed a physician's order for the use of the CPAP and indicated the settings with oxygen at 14 centimeters (cm) water (H2O) at bedtime for OSA, ordered on 7/8/25. -However, Resident #1 was admitted on [DATE] and the CPAP orders were not implemented until 7/8/25.III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the September 2025 CPO, diagnoses included arthritis due to other bacteria in the right knee, idiopathic gout (inflamed arthritis), chronic kidney disease and obstructive sleep apnea (OSA).The 9/19/25 MDS assessment revealed Resident #4 was cognitively intact with a BIMS score of 15 out of 15. Resident #4 required a CPAP machine and was dependent on staff for ADLs.B. ObservationsResident #4 was interviewed on 9/22/25 at 2:47 p.m. Resident #4 said the nursing staff assisted him every night and every morning with his CPAP machine. Resident #4 said the staff filled the water reservoir with distilled water in the morning. The resident said if there was water left over, the staff left the water in the machine and topped it off the next morning. During the interview, Resident #4's CPAP mask was sitting on the resident's nightstand, uncovered and exposed to potential contaminants on the surface of the stand. Resident #4 was interviewed on 9/23/25 at 8:45 a.m. Resident #4 said the nursing staff did not place the machine or mask under any covering. Resident #4 said the mask and machine sat on the nightstand next to his bed. Resident #4 said he had not seen any staff members clean the machine, tubing or mask since his admission to the facility (9/15/25).During the interview, Resident #4's CPAP machine was placed on the nightstand and the mask was not on any protective surface or under a protective covering.C. Record reviewReview of Resident #4's baseline care plan on 9/25/25, revealed the facility failed to implement a baseline care plan until 9/18/25. Review of the September 2025 CPO revealed a physician's order for the CPAP mask to be soaked weekly on Sunday, day shift in one part vinegar to three parts water for 20 minutes, followed by a rinse in distilled water, ordered on 9/21/25. -However, RN #1 said in an interview she was unaware that she was to use vinegar to clean the resident's CPAP (see interview below). IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 9/23/25 at 10:33 a.m. RN #1 said she washed Resident #4's CPAP mask in warm soapy water and dried it with a towel before putting it back next to Resident #4's bed side every morning. RN #1 said the CPAP did not come with a manual or instructions, she just knew to clean the machine because of working in the hospital. RN #1 said the masks could smell like mildew if they were not properly cleaned. RN #1 said she would not store the CPAP in a bag because the moisture would make it so the mask would not dry. RN #1 said any nurse could assist with a CPAP. She said physician's orders should be obtained at the time of admission. The DON was interviewed on 9/23/25 at 3:17 p.m. The DON said the RN that was on duty at the time of admission was responsible for completing the new admission paperwork. The DON said depending on how many admissions the facility was getting in a day, the facility would have an RN scheduled to assist with the admissions. The DON said admission paperwork could be completed by either an RN or licensed practical nurse (LPN). The DON said that at the time of admission, the care plan should be initiated. The DON said the staff needed to have the baseline care plan completed within 24 hours of the resident's admission. The DON said he thought the baseline care plan needed to be completed within 48 to 72 hours. The DON said he was filling in for the DON position currently. He said he had just started working at the facility a month ago. He said he was not aware of any recent training provided to nursing staff on the proper use and cleaning of CPAP machines. The DON said the vinegar was being used to clean the masks. The DON said the vinegar should be kept at the nurses' station. The DON said the staff reported when Resident #1 was admitted to the facility on [DATE], the family member did not bring the CPAP machine in until July 2025.-However, Resident #'1 representative said she brought it in upon admission, (see interview above).RN #1 was joined the DON interview on 9/23/25 at 3:17 p.m. RN #1 said she obtained a large container of vinegar from the kitchen and was taking it up to the nurses' station to be stored for use to clean residents' CPAP machines. RN #1 was interviewed on 9/23/25 at 3:26 p.m. RN #1 said she did not know where the vinegar was stored. She said she did not know what the vinegar was used for. LPN #1 and certified nurse aide (CNA) #1 were interviewed together on 9/23/25 at 3:29 p.m. LPN #1 said she did not know what vinegar would be used for. CNA #1 said she would use the vinegar to clean a catheter bag. LPN #1 unlocked the medication room and looked in the room for vinegar, she confirmed that there was no vinegar. LPN #2 was interviewed on 9/23/25 at 3:31 p.m. LPN #2 said she did not have vinegar stored at the nurses' station or in the medication room. LPN #2 said she could go to the kitchen staff and ask them for it so that the nursing staff could use it to clean the residents' CPAP machines.

Based on record review and interviews, the facility failed to ensure one (#2) of three residents received the highest practicable treatment and care in accordance with professional standards of practice of seven sample residents.Specifically, the facility failed to ensure all prescribed medications including medications to treat cirrhosis of the liver (scarred and damaged liver that prevents it from working properly), high blood pressure, and a chronic mental health disorder were ordered and obtained from the pharmacy to administer to the resident upon admission. Findings include:I. Facility policy and procedureThe admission Process policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 9/22/25 at 11:31 a.m. The policy read in pertinent part, Admissions will follow a process so that the community can appropriately meet the clinical and financial needs of residents. Once the community gives verbal acceptance of a resident, the admission Department will notify the appropriate department managers to ensure necessary clinical services and room arrangements are anticipated. The Admission/Nursing Department will obtain the state-specific transfer form so that proper discharge orders from the previous community were obtained.The admission Data Collection and Orders policy and procedure, revised September 2025, was provided by the NHA on 9/22/25 at 11:31 a.m. The policy read in pertinent part, The nursing department is responsible for recording specific clinical data in the medical record upon a resident's admission to the community. The designated pharmacy should be notified of the new admission and order confirmation of pharmacy supplied items.The Medication Management Overview policy and procedure, revised April 2025, was provided by the NHA on 9/22/25 at 10:30 a.m. It read in pertinent part, Medicine shall be administered as prescribed by the health care provider. Medication management services include but are not limited to:-Delivering medications to residents within acceptable time parameters.-Maintaining written or electronic records of medication orders and administration.II. Resident #2A. Resident statusResident #2, age [AGE], was admitted to the facility on [DATE] and discharged on 6/4/25. According to the June 2025 computerized physician orders (CPO), diagnoses included cirrhosis of the liver, hypertension, bipolar disorder (mental illness) and diabetes mellitus.The 6/3/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 and no behavioral issues. B. Record reviewReview of the June 2025 CPO revealed the following physician's orders:-Rifaximin oral tablet 550 milligrams (mg) with instructions to give one tablet by mouth two times a day, for cirrhosis of the liver, ordered 5/29/25.-Risperidone oral tablet 4 mg with orders to give one tablet by mouth at bedtime for bipolar disorder, ordered 5/29/25.-Midodrine oral tablet 10 mg with instructions to give one tablet by mouth three times a day for hypotension, ordered 5/29/25.Review of May 2025 and June 2025 medication administration records (MAR) revealed the facility did not have all medications on hand to administer them to the resident, as ordered by the resident's physician.Resident #2 was not administered the following ordered medications:-Rifaximin on 5/29/25 or 5/30/25 because the medication was not available. -Risperidone on 5/29/25 at bedtime because it was not available.-Midodrine on 5/29/25 because it was not available.Review of Resident #2's progress notes confirmed that the medications as listed above were not provided because they were unavailable. A physician assistant's note, dated 6/9/25, documented the resident had multiple comorbidities requiring medication management that required frequent clinical evaluations. The note documented without regular monitoring and management, the resident was at moderate to high risk of symptom exacerbation and complications resulting in hospitalization or death. The resident required multiple medications (polypharmacy), which required close monitoring to avoid any drug related adverse events.C. Resident representative interviewResident #2's representative was interviewed on 9/23/25 at 12:52 p.m. The representative said she visited the resident at the facility daily with a few exceptions, and met regularly with staff. She said the staff did not notify her about changes in Resident #2's care, instead they informed her only after the facts occurred. She said an unidentified registered nurse (RN) on the third floor told her the facility decided to discontinue Rifaximin, a medication Resident #2 had been prescribed for liver disease. She said Rifaximin was prescribed to remove toxins from the resident's body. She said if he did not take it the toxins could go to his brain. The representative said the facility told her they were discontinuing the medication because they were not able to obtain it from the pharmacy. Resident #2's representative said she brought in Resident #2's medications from home to the facility including the Rifaximin because she suspected the resident missed prescribed medications. The representative said the facility nurse would not accept and administer the medications to the resident.E. Staff interviewsRN #1 was interviewed on 9/23/25 at 11:20 a.m. RN #1 said the admitting nurse received the admission paperwork from the hospital and verified all ordered medications were on the MAR as ordered and in stock from the pharmacy. RN #1 said their pharmacy provided all medications per the physician's orders. RN #1 said when there were delays in medications from the pharmacy, the nurses could access the emergency backup medication kit to obtain a one time dose of prescribed medication to give to the resident. She said if a specific medication was not available, the physician might provide a medication order for a comparable one. RN #1 said medications brought in by family would not be used. She said instead the pharmacy was required to provide the medications. She said sometimes they could use a medication supplied from the family if there was an urgent need for the medication to be administered, like an inhaler to treat asthma. The consultant pharmacist was interviewed on 9/23/25 at 1:54 p.m. The consultant pharmacist said the order for Rifaximin was received on 5/29/25 at 7:00 p.m. and delivered on 5/31/25 at 12:07 a.m. She said the order for Trizepatide was received on 5/29/25 at 7:30 p.m., but she did know the reason for the delay in providing the medications. She said she would speak with the pharmacy operation director and call back with more information. She said she could not comment on potential risks or consequences of not administering Resident #2's Rifaximin for two days without first reviewing Resident #2's clinical records.The pharmacy operation director was interviewed on 9/23/25 at 2:20 p.m. The pharmacy operation director said the delivery of Rifaximin was delayed because the order was rejected by the resident's insurance provider and required the facility to agree to submit a written agreement to cover the cost of the medication before the order could be processed. The pharmacy operation director said it took two days for the facility to provide the agreement. The pharmacy operation director said he could not comment on what could happen to Resident #2 if he missed Rifaximin for two days. The pharmacy operation director said not administering Rifaximin for two days might not cause major adverse events, but it could cause some cognitive issues. The pharmacy operation director said the Trizepatide was not delivered because the provider had placed the order on hold per a note provided by the facility, but there was no documentation of why the order was placed on hold. The director of nursing (DON) was interviewed on 9/23/25 at 3:17 p.m. The DON said when a resident was admitted , the nurse on duty would fill the role of the admission nurse and would review the hospital orders with the on-call physician and the resident's medical provider. He said all the medications would be verified. He said the orders were then sent to the pharmacy to be filled.The DON said he was not sure how long medication delivery would take but he estimated the ordered medications would be filled and delivered to the facility within a couple hours. He said the facility would not administer medications brought in by family because they could not verify the accuracy of the medications. The DON said he did not know why Resident #2's missed several medications after admission or why the delivery was delayed. The DON said he would look into the medication delays. The DON said Resident #2 was administered Trizepatide at the hospital on 5/29/25 prior to his admission to the facility. The DON said the next dose was scheduled for 6/5/25, however Resident #2 was transferred to the hospital on 6/4/25. He said that was the reason the medication was not administered at the facility.

Based on record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#2) of three residents reviewed for accident hazards/ falls out of seven sample residents.Specifically, the facility failed to:-Ensure Resident #2, who had a history of falls, was appropriately assessed at admission to determine needed interventions to prevent ongoing falls; -Ensure appropriate fall prevention interventions were in place; and,-Ensure all clinical staff were educated on Resident #2's orthostatic hypotension diagnosis (a sudden drop in blood pressure that happens when a resident changes position from lying or seated position to a standing position causes dizziness and/or fainting) which puts the resident at a high risk for falls. Findings include:I. Professional referenceAccording to [NAME] M, [NAME] A, Taraborrelli P, Panagopolous D, Torocastro M, [NAME] R, Lim PB. Orthostatic Hypotension in Older People: Considerations, Diagnosis and Management, 3/21/21. Retrieved on line 11/17/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC8140709/ Orthostatic hypotension is very common in older people and is encountered daily in emergency departments and medical admissions units. It is associated with a higher risk of falls, fractures, dementia and death, so prompt recognition and treatment are essential. Orthostatic hypotension is defined by a drop of greater than 20 mmHg (millimeters of mercury, a unit of measurement for pressure, to measure blood pressure) in systolic blood pressure (BP) or greater than 10 mmHg diastolic BP after standing for three minutes. Immobility and associated deconditioning, cognitive decline, and dementia are major causes of orthostatic hypotension. It is thus essential that it is identified, and that the consequences are anticipated and managed. Non-pharmacological measures (include but not limited to): -Fluid repletion (hydration); -Physical exercise, leg exercises; -Compressing the venous beds in the abdomen and legs is also effective. Evidence is strongest for abdominal compression. Conclusion: Orthostatic hypotension is a common, persistent and disabling condition which is encountered daily in general medical practice. It drastically impairs quality of life and results in rapid and progressive deconditioning and functional deterioration, often resulting in institutionalization. When orthostatic hypotension co-exists with supine hypertension (high blood pressure when lying down), careful consideration of short- and medium-term risks should be balanced and discussed with the patient. Using simple, effective, practical measures to diagnose, monitor and alleviate it can have a major impact in maintaining independence in older people.II. Facility policy and procedureThe Falls Management policy and procedure, revised August 2025, was provided by the nursing home administrator (NHA) on 9/22/25 at 11:31 a.m. The policy read in pertinent part: Residents should be evaluated for the risk of falling so that interventions may be considered in order to: Promote resident safety, Promote appropriate clinical and interdisciplinary assessment of falls and fall risk factors and coordinate management of acute and recurrent falls. Early identification of risk for falls and reduction of multiple falls may enable residents to maintain their dignity and maximize their level of independence. Fall Risk Data Collection should be completed upon admission, quarterly, and after a significant change of condition. Resident Centered Approaches:1. The IDT (interdisciplinary team) should implement a fall prevention plan to assist with reducing falls related to risk factors and history of falls.2. If the fall risk evaluation identifies several possible risk factors, the IDT may choose to prioritize interventions. (try one or a few at a time, rather than many at once.)3. Initial interventions may include, but are not limited to, room setup, reviewing the resident's balance, footwear review, lighting, call system orientation, personal items within reach, etc.4. If a fall occurs with interventions in place, IDT should review the resident to determine if additional or different interventions should be implemented.III. Resident #2A. Resident statusResident #2, age [AGE], was admitted to the facility on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included orthostatic hypotension, repeated falls, and unsteadiness on the feet.The 6/3/25 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15 and no behavioral issues. The assessment documented the resident was dependent on staff to complete toileting and showering tasks and required maximal assistance where staff completed more than half the effort to complete personal hygiene tasks and lower body dressing.The resident had repeated falls before admission and one fall while a resident of the facility. B. Resident's representative interviewResident #2's representative was interviewed on 9/23/25 at 12:52 p.m. The resident's representative said she visited the facility daily with few exceptions, and met regularly with staff to discuss the resident's care needs. She said staff did not notify her about changes in Resident #2's care. The resident's representative said the resident had sudden drops in blood pressure causing him to be unsteady on his feet; she asked nursing staff to make sure he wore his physician prescribed abdominal binder to aid his body prevent his blood pressure from dropping and making him unsteady with an increased risk of falling. Nursing staff assured her the abdominal binder would be applied, but it was not. The resident representative said she frequently observed Resident #2 without the prescribed abdominal binder.The resident representative said Resident #2 fell in the facility's care on 6/2/25. Resident #2 was in the bathroom without the abdominal binder in place, and no staff were present to assist him. As a result, Resident #2 fell. The representative said one of the facility's registered nurse (RN) called her and told her Resident #2 fell but was uninjured. Resident #2's representative said when she arrived at the facility she found that Resident #2's glasses were broken and he had blood coming from his nose. She said she immediately questioned nursing staff about his fall, injuries and why he was not wearing his prescribed abdominal binder. C. Record review1. Resident's preadmission historyThe 5/22/25 hospital progress notes revealed Resident #2, with a history of recurrent falls with a direct connection to orthostatic hypotension and low blood pressure. The note documented that the resident presented at the hospital after a fall at home. Emergency medical response services (EMS) responded to the resident medical alert and found him on the floor of his apartment bathroom in front of the toilet. EMS assessment revealed the resident was confused and hypotensive (having extremely low blood pressure) Later at the hospital, after initial treatment, Resident #2 said he fell twice before EMS arrived. He said he fell from his bed before he fell in the bathroom. The 5/27/25 hospital assessment revealed Resident #2 had several skin tears and abrasions on his elbows and knees from his falls, and presented with decreased activity tolerance, strength, and functional mobility. Resident #2 was assessed to need skilled nursing services to restore independence and reduce his risk for falls.-However, the facility failed to take into account the hospital diagnostics findings when developing the resident's care plan to implement appropriate fall prevention interventions upon Resident #2's admission to the facility. The resident's orthostatic hypertension diagnosis connection to his falls was not care planned. The primary care physician hospital discharge special instructions, dated 5/29/25, documented: You came to the hospital after another fall, and we suspect this was due to your blood pressure dropping when you stand up and also possibly due to dehydration. We placed an order for compression stockings on your left leg and an abdominal binder to be worn prior to standing.Be sure to wear your stocking and abdominal binder if you stand. If you are able to find a larger stocking for your right leg then also wear a compression stocking on our right leg.2. Record review Comprehensive nursing note, dated 6/2/25 at 4:13 a.m,. documented nursing observations, evaluation, and recommendations: after arriving to Resident #2's room the resident was found on the bathroom floor with the following positioning. His head near the bathroom door, feet near the toilet. The resident was observed to have bleeding on the back of his right forearm. The RN was called to assess the resident immediately: all extremities were within normal limits. The resident denied hitting his head and experiencing pain.A change of condition note dated 6/2/25 at 9:45 a.m. documented the resident's blood pressure: was 106/64 while sitting.-The resident's standing blood pressure was not assessed to rule out orthostatic hypotension drops in blood pressure as a potential factor of a related cause of the resident's fall. The change of condition note revealed that the RNs physical assessment resulted in positive findings for the resident experiencing increased confusion (e.g. disorientation) but no changes in functional status. The primary care provider recommendations included: apply steri-strips to skin tear and an appointment with the physician. Nursing progress note dated 6/2/25 at 10:02 a.m. documented : The RN was informed at 9:45 a.m.by the resident's attending nurse that the resident was on the floor in his bathroom in front of his toilet laying on his right side. The RN assessed the resident for injuries a skin tear was noted on the resident's right wrist; the resident denied pain and refused pain medication. The resident said he was attempting to transfer off the toilet without assistance and fell. Initial neurological checks are without changes to the resident's baseline and the first set of vitals were within normal limits.Physician assistant exam note, dated 6/2/25, documented Resident #2 was seen sitting upright in bed alert, comfortable, no distress with his daughter by his side. Nursing staff reported a fall this morning. The resident denied headaches, vision changes, nausea, or vomiting following the fall. The resident sustained a small skin laceration on the right hand which was cleaned and steri-strips placed. The resident was attempting to ambulate to use the restroom on his own when he fell. Discussed fall precautions and the resident understood. Additionally, his daughter requested to add an order for use of an abdominal binder for orthostatic hypotension as the resident was found to have low blood pressure when he was found down.The physician note documented the resident had multiple comorbidities requiring medication management that necessitated frequent clinical evaluations. Without regular monitoring and management, the resident is at moderate to high risk of symptom exacerbation and complications resulting in hospitalization or death. The resident has functional impairments with potential high risk for frequent falls, bowel or bladder complications, and new or worsening wounds and requires frequent monitoring.The post fall investigation, dated 6/2/25, documented Resident #2 was assessed to continue to be a fall risk. The IDT reviewed the fall assessment and fall interventions. Interventions in place included providing call light in; encouraging appropriate footwear; providing occupational and physical therapy as needed. The resident's fall care plan, initiated 5/29/25 and revised 6/2/25, identified Resident #2 was at risk for falls. Pertinent intervention included:-Keeping the call light in reach; encourage resident to use the call light when he needed assistance, initiated 5/29/25; -Providing occupational and physical therapy evaluation and treatment, as ordered, initiated 5/29/25-Encouraging the resident to wear appropriate footwear when ambulating or mobilizing in wheelchair, initiated 5/30/25After the 6/2/25 fall the following interventions were added:-Providing rest periods as needed initiated, 6/2/25; -Ensuring the resident was wearing an abdominal binder when out of bed for hypotension management, initiated, 6/2/25.-Despite Resident #2 being diagnosed at the hospital preadmission with orthostatic hypotension as a correlating factor to be the cause of the Resident #2's falls interventions to manage his orthostatic hypertension was not initiated as a care plan focus or factor of the resident's falls until after the 6/2/25 fall. -The abdominal binder was not implemented as an intervention to prevent the resident from experiencing orthostatic hypertension and falling related to the symptoms of experiencing orthostatic blood pressure until after the resident fall on 6/2/25 and the resident representative requesting there was an order for the binder so staff would consistently apply the device. The resident activities of daily living (ADL) care plan, initiated 5/29/25, documented Resident #2 had an ADL self care performance deficit. -The care plan failed to document the resident transfer care and assistance needs. Progress note, dated 6/2/25, documented Resident #2 had functional impairments with potential high risk for falls, bowel or bladder complications, and new or worsening wounds and required frequent monitoring. Review of May 2025 and June 2025 Resident #2's point of care task record, accessed and maintained by the certified nurse aides (CNA), revealed that Resident #2 was dependent on staff for all transfers. Review of June 2025 medication administration record (MAR) revealed documentation abdominal binder was not applied prior to the fall incident on 6/2/25 despite the hospital discharge orders giving instructions for the resident to wear an abdominal binder when standing to help to prevent falls (see preadmission hospital records above).IV. Staff InterviewsCNA #1 was interviewed on 9/23/25 at 11:05 a.m. CNA #1 said when a resident refused a care plan task she would return later to encourage them to participate in completing the care task. CNA #1 said if the resident still refused, she would document it in the residents' record. She said if she noticed a resident had a condition change or had a fall , she would call for assistance, notify the nurse on duty or another CNA. She said she would take vital signs and based on the assessment results, they would call 911, if needed. CNA #1 said she would also report the change of condition to the director of nursing (DON). She said she attended training on fall prevention.RN #1 was interviewed on 9/23/25 at 11:20 a.m. RN #1 said if a resident was identified as a fall risk upon admission, she would place them in the room closest to the nurses' station so the nursing staff could monitor the resident more closely. She said she would also assess the resident's mobility level and orientation. RN #1 said standard interventions included a fall mat placed by the resident's bed and ensuring their personal belongings were within reach. She said she would keep their door open so she could see them during her rounds.RN #1 said if a fall occurred, she would call for help, take vital signs and initiate neurological check and look for injuries. RN #1 said she would ask the resident how they were feeling, notify the physician, and call the family and notify them about the fall and resident status. RN #1 said if a resident had a diagnosis of orthostatic hypotension, she would train the CNAs on how to safely assist the resident to prevent related falls. She said she would show CNAs how to conduct a position transfer from sitting to standing making sure that the resident was transferred safely. RN #1 said the CNAs should not let the resident stand abruptly because this could result in the resident losing balance and falling. RN #1 said she would educate the resident how to complete safe transfers to prevent falls and on how to perform self assessments to know when to take more care when transferring. RN #1 said she would always ensure a gait belt was used when assisting any resident to transfer safely. The DON was interviewed on 9/23/25 at 3:17 p.m. The DON said if a resident was identified as high risk for falls upon admission, the facility would put interventions in place including placing the call light and resident personal items within the resident's reach. The DON said the facility would customize the interventions based on each resident. He said if a resident had orthostatic hypotension, the nurse would communicate with the CNA regarding specific care instructions.The DON said if a resident fell, the nurse would conduct an assessment, and would gather information from the CNA or any witnesses. The nurse would implement basic interventions. The DON said if an injury was identified, the nurse would notify the physician and might provide care at the facility or, if necessary, 911 may be called. The DON said the IDT would review the incident, and had to notify the family.The DON said Resident #2 was assessed to be a fall risk due to his orthostatic hypotension and the resident's fall prevention measures were initiated and implemented based on his fall history upon admission. He said the floor nurse would have provided step-by-step instructions to the resident and CNA's, for safe transfers and walking.The DON said there had been no formal training provided for staff, specifically for CNAs, on orthostatic hypotension fall prevention. He said all residents in the facility were considered at risk for falls, and staff were aware of the general fall prevention measures in place.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two satellite kitchens. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely; and -Ensure ready to eat foods were handled appropriately. Findings include: I. Food was labeled and dated and disposed of timely A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 4/9//24 from:https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Observations On 3/27/24 at 11:23 a.m. the refrigerator in the satellite kitchen on the second floor was observed. There was one opened carton of soy milk with an expiration date of 1/21/24. The manufacturer label said the milk stayed fresh for seven to ten days after opening. There was no date when the carton was opened. There were two opened Hormel thick and Easy Clear thickener drinks plastic cartons. There was no date when the cartons were opened. The manufacturer label said to discard if not used within 10 days. The cartons were reviewed with the dietary manager (DM) and he discard the soy milk and thickener cartons in the trash. C. Staff interview The registered dietitian (RD) was interviewed on 3/28/24 at 2:53 p.m. The RD said opened containers should have an open by and used by date. She said food and beverages should be discarded by the expiration date. The thickener liquid drinks should have an expiration date and the soy milk should have been discarded on or before 1/21/24. II Ready to eat foods A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 4/4/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view Except when washing fruits and vegetables as specified, food employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment B. Observations Third floor satellite kitchen On 3/27/24 beginning at 11:28 a.m. the tray line was observed. Dietary aide (DA) #1 began serving the noon meal. DA #1 placed the serving utensils into the pans on the tray line with bare hands. Prior to donning the gloves she failed to perform hand hygiene. DA #1 was observed to leave the tray line to get something from the refrigerator. She began service by touching the handles of the utensils, which were placed into the pans touched by her bare hands. She took hotdog buns out of the bag and separated the bun with her gloved hands and placed the hotdog onto the bun. DA #1 failed to change her gloves throughout the meal service. -At 12:03 p.m. DA #1 began to remove the dinner rolls from the package with the same gloved hands. She did not use utensils or clean gloved hands to remove the ready to eat food. -At 12:26 p.m. she placed her gloved hand over a sandwich and cut the sandwich in half. C. Staff interview The DM was interviewed on 3/28/24 at 4:18 p.m. He said ready to eat foods should have be handled with a utensil or clean gloves.

Based on observations, record review and interviews, the facility failed to provide accessible dining equipment and utensils for residents who need them for three (#22, #18, and #1) of three residents reviewed for adaptive equipment out of 35 sample residents. Specifically, the facility failed to: -Provide adaptive drinking equipment for Resident #22 and Resident #18; and, -Provide plate guards for Resident #1. Findings include: I. Facility policy The Adaptive Equipment policy, revised May 2010, was received from the director of nursing (DON) on 3/28/24 at 6:01 p.m. It read in pertinent part: The Dining Services Management should ensure residents who require adaptive equipment to enhance independence and/or support habilitation during dining will be provided equipment. II. Resident #22 A. Resident status Resident #22, age 89, was admitted to the facility on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included dysphagia and Alzheimer's disease. The 3/5/24 minimum data assessment (MDS) assessment showed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident was dependent for most activities of daily living (ADL) and required substantial maximal assistance with eating. B. Observations On 3/27/24 at 2:26 p.m., Resident #22 had a cup with no lid and handles, a Styrofoam cup, and a soda can with a straw in it on her bedside table. On 3/28/24 at 11:21 a.m., Resident #22 was given a cup of water without handles and with a straw in it by an unidentified facility staff member. At 11:49 a.m., Resident #22 was assisted to the dining room. Resident #22 had a cup without handles and a straw in it on the table in front of her. C. Record review The comprehensive care plan, initiated 8/30/21 and revised 9/1/22, revealed Resident #22 was at nutritional risk due to dysphagia. Pertinent interventions included using a nosey cup (an adaptive cup with a cut out for the resident's nose) for cold liquids and a two handled mug for hot liquids. A dietary meal ticket from 3/28/24 revealed Resident #22 was to be provided with handled cups as available. III. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included dysphagia, parkinsonism, and dementia. The 12/24/23 MDS assessment showed the resident had severe cognitive impairment with a BIMS score of seven out of 15. The resident was dependent with most ADLs and required partial or moderate assistance with eating. B. Observations On 3/27/24 at 5:19 p.m., Resident #18 had two beverages served in glass goblets with a straw in each goblet. On 3/28/24 at 11:48 a.m., Resident #18 was given a soda can with a straw in it. C. Record review The nutrition care plan, initiated 8/15/23, revealed Resident #18 had a nutritional problem due to dysphagia. Pertinent interventions included having occupational therapy screen the resident and provide adaptive equipment for feeding as needed. A dietary meal ticket from 3/28/24 revealed Resident #18 required Kennedy cups (a spill-proof cup that is designed to be used with a straw) as available and a plate guard. IV. Resident #1 A. Resident status Resident #1, age 70, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included multiple sclerosis. The 3/15/24 MDS assessment showed the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident was dependent for most ADLs and required substantial maximal assistance with eating. B. Observation On 3/28/24 at 11:55a.m. Resident #1 was given a plate of food during lunch service without a plate guard on it. C. Record review The nutrition care plan, initiated 11/6/19 and revised 1/10/24, revealed Resident #1 was at risk of nutritional decline due to multiple sclerosis. Pertinent interventions included assisting Resident #1 with meals and liquids as needed. Review of the comprehensive care plan further revealed Resident #1 was at risk for hot liquid injury. Pertinent interventions included cueing and assisting Resident #1 with meals and snacks as needed. -Neither Resident #1's care plan or the March 2024 CPO revealed any interventions put into place for adaptive equipment to assist the resident with eating or drinking. A dietary meal ticket from 3/28/24 revealed Resident #1 required handled cups as available, a plate guard and light-weight built up handles for eating utensils. V. Staff interview The registered dietician (RD) was interviewed on 3/28/24 at 2:31 p.m. The RD said staff members in the therapy and the dietary divisions provided accessible devices such as plate guards. The RD said dietary and nursing staff were both responsible for making sure residents got the equipment they needed during dining service. The RD said the facility was running low on Kennedy cups and they had done the best they could. In lieu of Kennedy cups, the RD said the facility had been putting plastic wrap over the mouth of cups served to residents with a straw through the plastic wrap and using coffee mugs with handles on them.

Based on record review, observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections on two of two units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned from cleaner to dirtier areas; -Ensure housekeeping changed gloves and performed hand hygiene between cleaning the bathroom and bedroom; -Provide accurate isolation precaution and appropriate use of personal protective equipment (PPE); -Ensure staff performed hand hygiene; -Ensure residents were offered hand hygiene prior to eating; and, -Follow the water management plan I. Housekeeping failures A. Professional reference According to The Centers for Disease Control (CDC) Environment Cleaning Procedures, (5/4/23), retrieved on 4/9/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Observation and interview On 3/27/24 at 9:11 a.m., the housekeeping supervisor (HSKS) was cleaning room [ROOM NUMBER]. She donned gloves before entering the room. She swept the floor and returned the broom to the cart. She took the cleaning supply caddy from the cart. She sprayed disinfectant on the toilet seat, the exterior of the toilet, the grab bars and the sink in the bathroom. She took a dry cloth and sprayed disinfectant on the cloth. She proceeded to clean the dresser, nightstand and phone in the resident's room. She returned to the bathroom and wiped down the toilet seat, the exterior of the toilet, the grab bars and the sink of the bathroom. Without changing her gloves, she returned the cleaning supply caddy to the cart. She used a clean mop head, which she attached to the mop handle with the same gloves she had been wearing throughout the cleaning of the entire room, to mop the bedroom area and then replaced the mop head before cleaning the bathroom. After mopping the bathroom, the HSKS exited the room, removed her gloves and performed hand hygiene. -The HSKS failed to clean the bathroom from a cleaner area to a dirtier area when she wiped the toilet before wiping the sink. -The HSKS failed to change her gloves and perform hand hygiene after wiping the toilet and before wiping the sink. -The HSKS again failed to change her gloves and perform hand hygiene after cleaning the bathroom and before picking up the cleaning caddy, returning it to the cart and grabbing a clean mop head. C. Staff interview The HSKS was interviewed on 3/27/24 at 9:38 a.m. The HSKS said she changed gloves and performed hand hygiene only between resident's rooms. She said she received training from the facility's infection preventionist (IP). The IP was interviewed on 3/28/24 at 3:05 p.m. The IP said housekeeping should perform hand hygiene and change gloves between cleaning the residents' bathroom and the bedroom. The IP said it was important to perform hand hygiene and change gloves because it prevented the potential spread of bacteria or viruses. II. Isolation precautions/PPE failures A. Professional references According to the Centers for Disease Control and Prevention (CDC) Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 pandemic (revised 7/2024), retrieved on 4/9/24 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/Isolation-guidelines-H.pdf, If they (N95 masks) are used during the care of patients for which a NIOSH (National Institute for Occupational Safety and Health) Approved respirator or facemask is indicated for personal protective equipment (PPE), they should be removed and discarded after the patient care encounter and a new one should be donned. Place a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection in a single-person room. The door should be kept closed. HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). According to the CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings (revised 11/29/22), retrieved on 4/9/24 from https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhicpac%2Frecommendations%2Fcore-practices.html, Remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area. If a respirator is used, it should be removed and discarded after leaving the patient room or care area and closing the door. Ensure that healthcare personnel have immediate access to and are trained and able to select, put on, remove, and dispose of PPE in a manner that protects themselves, the patient, and others. B. Observations On 3/25/24 at 11:51a.m., room [ROOM NUMBER], which was a COVID-19 positive resident's room, was observed. An unidentified certified nurse aide (CNA) donned a gown, gloves and eye protection. -The CNA put a surgical mask on, but failed to don a N95 mask. She said she was ready to go into the room to serve the meal. The CNA she said she did not know she needed to put the N95 on when she was just passing a tray. On 3/26/24 at 9:17 a.m., room [ROOM NUMBER] was observed again. Two unidentified staff members prepared to enter the room. Both staff members donned a gown, gloves and eye protection. One staff member removed her surgical mask and placed an N95 before entering the room. -The other unidentified staff member had a surgical mask on and placed a N95 mask over the surgical mask before entering the room. C. Staff interviews The IP was interviewed on 3/28/24 at 3:05 p.m. The IP said staff should put on a N95 mask prior to entering a COVID-19 positive room. The IP said if staff were wearing a surgical mask they should remove the surgical mask prior to donning a N95 mask. III. Hand hygiene failures A. Professional reference The CDC Hand Hygiene in Healthcare Settings (1/30/2020), retrieved on 4/9/24 from https://www.cdc.gov/handhygiene/providers/guideline.html, included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 4/4/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped singled service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after caring for or handing service animals or aquatic animals, after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands. B. Observations On 3/25/24 at 11:51 a.m., CNA #5 delivered a meal tray to a resident in room [ROOM NUMBER]. -CNA #5 failed to offer hand hygiene to the resident prior to the meal being served. -At 11:53 a.m., CNA #5 delivered a meal tray to the resident in room [ROOM NUMBER]. -CNA #5 failed to offer hand hygiene to the resident prior to the meal being served. On 3/25/24, during a continuous observation of the third floor dining room beginning at 11:44 a.m. and ending at 12:20 p.m., staff was delivering lunch meals to residents seated at the tables. -None of the residents in the dining room were offered hand hygiene prior to being served their lunch. On 3/27/24 at 11:45 a.m., the dining services supervisor (DSS) grabbed and adjusted a resident's wheelchair wheel. The DSS proceeded to rearrange Resident #18's silverware. -The DSS failed to perform hand hygiene after touching the resident's wheelchair and before touching Resident #18's silverware. On 3/27/24, during a continuous observation of the third floor dining room beginning at 11:33 a.m. and ending at 12:37 p.m., staff was delivering lunch meals to residents seated at the tables. -None of the residents in the dining room were offered hand hygiene prior to being served their lunch. C. Interviews The dietary manager (DM) was interviewed on 3/28/24 at 4:18 p.m. He said the DSS should have performed hand hygiene after she adjusted the wheelchair wheel before touching Resident #18's silverware. The IP and director of nursing (DON) were interviewed on 3/28/24 at 3:05 p.m. The IP said handwashing should be offered to residents before and after meals, after using the bathroom and when they got dressed in the morning. The DON said hand wipes were previously used before meals and she did not know when hand wipes stopped being offered to residents. IV. Water management plan A. Professional reference According to theCDC Legionella (Legionnaires Disease and Pontiac fever) (reviewed 3/25/21), retrieved on 4/9/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team -Describe the building water systems using text and flow diagrams -Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them -Establish ways to intervene when control limits are not met -Make sure the program is running as designed (verification) and is effective (validation) -Document and communicate all the activities. Principles: In general, the principles of effective water management include: -Maintaining water temperatures outside the ideal range for Legionella growth - Preventing water stagnation -Ensuring adequate disinfection -Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. According to the CDC Controlling Legionella in Potable Water Systems (reviewed 2/3/21, retrieved on 4/1/24 from https://www.cdc.gov/legionella/wmp/control-toolkit/potable-water-systems.html, Store hot water at temperatures above 140 degrees fahrenheit (F) and ensure hot water in circulation does not fall below 120 degrees F. Recirculate hot water continuously, if possible. Store and circulate cold water at temperatures below the favorable range for Legionella (77 degrees F to 113 degrees F)); Legionella may grow at temperatures as low at 68 degrees F. B. Facility policy The Legionella Water Management Program policy, revised February 2022, was provided by the nursing home administrator (NHA) on 3/27/24 at 3:00 p.m. It read in pertinent part, Our community is committed to the prevention, detection and control of water-borne contaminants including Legionella. The water management program includes the following elements: an interdisciplinary water management team, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. A diagram of where control measures are applied. A system to monitor control limits and the effectiveness of control measures. C. Record review The NHA provided the Legionella water management plan on 3/27/24. The water management plan was updated on 3/21/24. The program team listed the director of nursing and nursing home administrator. -The names listed on the plan for the DON and NHA did not match the names of the facility's current DON and NHA. The water system flow diagram was a chart that showed the receiving (the boiler room), the cold water distribution, the heating, the hot water distribution and waste. -The diagram did not include a facility map of where the boiler was located, where the distribution points, heating points and hot water distribution points were located. -The diagram did not state how many hot water distribution points were in the facility. -The water management plan did not include when the cold and hot water systems were last verified and when the due date was for next verification. D. Staff interview The NHA and interim maintenance director (IMD) was interviewed on 3/28/24 at 3:49 p.m. The NHA said the IMD was responsible for reviewing the water management plan. He said the staff that were listed on the previous plan revision had not been at the facility for a while. The IMD said the temperatures were documented in an electronic system. The IMD said the water layout and flow was located in the kitchen, everywhere that there were chemicals, laundry, housekeeping, janitor's closet and nurses stations. There was a main ice maker in the kitchen and each satellite kitchen (two) had an ice machine. The NHA said they would review and update the water management plan to make sure that it was specific to their facility and met the regulations.

Based on record review and interviews, the facility failed to offer choices to residents for two (#1 and #23) of three residents reviewed for activities of daily living (ADL) out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and #23 received showers consistently according to their choice of frequency. Findings include: I. Record review The 3rd floor shower schedule was obtained from certified nurse aide (CNA) #3 on 3/28/24 at 1:22 p.m. It documented odd numbered rooms' residents were to receive showers on day shift and even numbered rooms' residents were to receive showers on the night shift. It documented specific days each room number would be showered. According to the shower schedule, Resident #1's room was to receive showers on Tuesdays and Fridays and Resident #23's room was to receive showers on Wednesdays and Saturdays. II. Resident #1 A. Resident Status Resident #1, over the age of 65, was admitted on [DATE]. According to the March 2024 computerized physician order (CPO), diagnoses included multiple sclerosis (MS), respiratory failure and neuromuscular dysfunction of the bladder (bladder unable to be controlled by the resident). According to the 3/15/24 minimum data set (MDS) assessment Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The assessment documented the resident was dependent on staff assistance for bathing. B. Resident Interview Resident #1 was interviewed on 3/25/24 at 4:20 p.m. Resident #1 said she did not have a choice of when she bathed. Resident #1 said that she had to take her bed bath when it was offered to her or it would not be done. Resident #1 pointed to a sign in her room that said her bath days were on Tuesday and Friday in the morning, which was selected by the facility. Resident #1 said if her bath was not completed it was not re-offered to her. III. Resident #23 A. Resident Status Resident #23, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included heart failure, respiratory failure, cataracts and arthritis. According to the 3/7/24 MDS assessment Resident #23 was cognitively intact with a BIMS score of 13 out of 15. The assessment documented the resident was dependent on staff assistance for bathing. B. Resident Interview Resident #23 was interviewed on 3/26/24 at 9:18 a.m. Resident #23 said her shower days were assigned to her. Resident #23 said if she did not accept her shower at the assigned time she would not get a shower. Resident #23 said she felt she didn't have any choice about how she would prefer to shower and it was dependent on staff workload instead of her preferences. Resident #23 said that she was not comfortable with the current shower assignments. IV. Staff interviews CNA #2 was interviewed on 3/27/24 at 2:31 p.m. CNA #2 said bathing was assigned to residents. CNA #2 said if one resident preferred a different bath day nursing staff would have to switch another resident's schedule to try to accommodate the resident's request. CNA #3 was interviewed on 3/28/24 at 10:40 a.m. CNA #3 said residents did not choose when they received a shower and their showers were scheduled upon admission based on which room the residents were admitted to. CNA #3 said the shower schedule was arranged by room number so staff could get everyone's showers done appropriately. CNA #3 said the shower schedule was determined by the facility and resident rooms were assigned specific days and times for bathing. The director of nursing (DON) was interviewed on 3/28/24 at 11:15 a.m. The DON said residents got choices for when they bathed. The DON said the shower assignment sheet was a guideline to help ensure nursing staff completed bathing for residents and residents could choose other days to shower if they wished. -However, based on resident and staff interviews, residents' shower days and times were assigned to residents according to their room numbers.

Based on observation, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for two (#49 and #23) of four residents reviewed for services to maintain highest practicable quality of life out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #49 received assistance for nail care; and, -Ensure Resident #23 received assistance to maintain oral hygiene. Findings include: I. Facility policy and procedure The Oral Health Care and Dental services policy, dated November 2017, was received from the director of nursing (DON) on 3/28/24 at 5:41 p.m. It documented in pertinent part, Nursing associates will conduct oral health assessments on admission and at least quarterly to assure that each resident receives adequate oral hygiene. -The nail care policy was requested but was not received by the end of the survey. II. Resident #49 A. Resident status Resident #49, age 77, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included alcohol abuse and adult failure to thrive. The 2/6/24 minimum data assessment (MDS) assessment showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required partial to moderate assistance with all activities of daily living (ADL). B. Observations On 3/25/24 at 11:12 a.m., Resident #49's fingernails were observed to be long and discolored. Resident #49's fingernails were visibly soiled and had a dark substance under several nails. On 3/28/24 at 5:16 p.m., Resident #49's fingernails continued to be long and visibly soiled. A dark substance was still present under several nails. C. Resident interview Resident #49 was interviewed on 3/25/24 at 2:07 p.m. Resident #49 said he tried to trim his own nails but had difficulty doing so. Resident ##49 said the facility staff had not offered to trim his nails. D. Record review The comprehensive care plan, initiated on 12/1/23 and revised on 12/12/23, revealed Resident #49 had an ADL self care performance deficit. Pertinent interventions included checking nail length, trimming and cleaning nails on bath day and as necessary and notifying nursing staff of any changes. The comprehensive care plan further revealed Resident #49 had potential for impairment to skin integrity. Pertinent interventions included keeping the resident's fingernails short. The 1/10/24 progress note from the social services director (SSD) revealed Resident #49 needed nail care and the certified nurse aide (CNA) and nurse on staff were notified. The 1/31/24 skin evaluation revealed Resident #49 had long fingernails and had multiple scratches on his legs. E. Staff interviews CNA #2 was interviewed on 3/27/24 at 2:31 p.m. CNA #2 said CNAs at the facility trimmed residents' nails whenever they needed them to be trimmed. CNA #2 said the residents were due for a nail trim whenever the nails started to look longer but some residents declined having their nails trimmed. CNA #3 was interviewed on 3/28/24 at 2:27 p.m. CNA #3 said CNAs could cut the fingernails of nondiabetic residents whenever they saw they were long. LPN #5 was interviewed on 3/28/24 at 5:16 p.m. LPN #5 said Resident #49's fingernails looked bad and they needed to be trimmed. LPN #5 said Resident #49's fingernails did not look clean and were too overgrown. 50314 IV. Resident #23 A. Resident status Resident #23, over the age of 65, was admitted on [DATE]. According to the March 2024 computerized physician order (CPO), diagnoses included heart failure, respiratory failure, cataracts and arthritis. According to the 3/7/24 MDS assessment, Resident #23 was cognitively intact with a BIMS score of 13 out of 15. The assessment documented the resident required substantial or maximum assistance with oral hygiene. B. Resident interview Resident #23 was interviewed on 3/26/24 at 9:18 a.m. Resident #23 said she needed help with setting up her oral care supplies and she did not always get assistance with that Resident #23 said staff helped her brush her teeth now and then but it was often forgotten. Resident #23 said she hated how her teeth felt when they were not brushed and said she felt forgotten. C. Record review -Review of the comprehensive care plan, initiated 3/11/24, failed to document Resident #23's oral care assistance needs. -Review of the CNA tasks in Resident #23's electronic medical record (EMR) revealed the resident was to receive oral hygiene assistance, however, there was no documentation to indicate Resident #23 had received the assistance she needed. D. Staff interviews CNA #4 was interviewed on 3/28/24 at 9:15 a.m. CNA #4 said she was unable to locate oral care documentation for Resident #23. CNA #4 said Resident #23 required set-up assistance with oral care. LPN #6 was interviewed on 3/28/24 at 9:19 a.m. LPN #6 said she could not find oral care documentation for Resident #23. LPN #6 said Resident #23 required one person assistance with oral care. The DON was interviewed on 3/28/24 at 9:31 a.m. The DON said there was no oral care documentation for Resident #23. The DON said Resident #23's oral care documentation did not include the proper question to document oral care properly.

Based on record review and interviews, the facility failed to ensure two (#47 and #16) of three residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the failed to: -Assess and document Resident #47's blood pressure and heart rate consistently prior to administering blood pressure medications; and, -Obtain weights according to the physician's orders for Resident #16. Findings include: I. Resident #47 A. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK532906 on 4/1/24. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockage of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. According to Kizior, R. J., [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier, p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P (upper number) is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. B. Resident status Resident #47, age 70, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included type two diabetes mellitus, hypertension (high blood pressure) and heart disease. The 3/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set-up assistance for eating, oral hygiene and personal hygiene. He required supervision assistance with toileting and showering. C. Record review The March 2024 CPO documented a physician order of Metoprolol Tartrate Oral Tablet 25 mg (milligrams), give 25 mg by mouth every 12 hours related to essential hypertension, hold for SBP (systolic blood pressure) <110 (less than) or HR (heart rate) <55, ordered 2/28/24. The February 2024 and March 2024 vital signs summary revealed Resident #47 blood pressure and heart rate were not assessed for the morning dose of Metoprolol on Resident #47's blood pressure and heart rate were not assessed prior to the administration of Metoprolol on 3/11, 3/14, 3/16, 3/17 and 3/23/24. Review of the medication administration record (MAR) revealed the Metoprolol was held for the morning dose of Metoprolol on 3/18/24 due to the resident's vitals not being within parameters. -However, there was no documentation in the resident's medical record that indicated the resident's blood pressure and heart rate were assessed prior to the medication being held. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/27/24 at 4:04 p.m. LPN #1 said blood pressure and pulse should be taken prior to administering blood pressure medications. LPN #1 said most physician orders for blood pressure medications had parameters indicating when to hold the medication. LPN #1 said when administering a blood pressure medication the electronic charting system typically prompted the nurse to document the resident's blood pressure and pulse prior to administering the medications. LPN #1 said Resident #47's order for Metoprolol was not imputed correctly into the electronic charting system and was not alerting the nurses to document the resident pulse and blood pressure. The director of nursing (DON) was interviewed on 3/28/24 at 9:58 a.m. The DON said she recently implemented having the physician orders for blood pressure medications requiring the blood pressure and pulse to be taken and documented on the MAR prior to administration of the medication. The DON said if the vital signs were not documented in the resident's medical record she assumed they were not completed. The DON was interviewed again on 3/28/24 at 12:39 p.m. The DON said she followed up with the licensed nurse who held Resident #47's Metoprolol on 3/18/24 due to the resident's vitals not being within the parameters in the physician's order. The DON said the licensed nurse recalled seeing the vital signs documented by a certified nurse aide (CNA) on a piece of paper. The DON said she was unable to locate the piece of paper that had the documented vital signs. The DON said she would begin immediate education to the CNAs on the importance of documenting vital signs and ensuring blood pressure and pulse were taken prior to the administration of blood pressure medications. 48112 II. Resident #16 A. Facility policy and procedure The Weight and Height policy, was received by the registered dietitian on 3/28/24 at 4:07 p.m. It read in pertinent part: Residents should be weighed upon admission/re-admission, weekly for three weeks, and as needed. Residents will be weighed on admission/readmission and then weekly for three weeks, monthly or as needed thereafter. For 2 pound weight variance, conduct re-weigh as needed for accuracy. Notify the charge nurse of weight variances as indicated. B. Resident status Resident #16, [AGE] years old, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included hemiplegia and hemiparesis (paralyzed and and weakness) following cerebral infarction (disruption in blood flow) affecting right dominant side, diabetes mellitus type two, seizures, heart failure, cardiac pacemaker and muscle weakness. The 2/13/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. She required substantial assistance with oral hygiene and personal hygiene. She was dependent with toileting, showering, dressing. She had no behaviors or rejections of care. C. Record review The nutrition care plan, revised 2/14/24, revealed the resident was at nutritional risk as evidence by varied meal intakes and weight loss. Interventions included monitor weights as ordered. The February and March 2024 medication administration record (MAR) was reviewed. It revealed the following orders: -Weight on admission and repeat weekly for three weeks every day shift for weight monitoring. Start 2/14/24. -The resident refused on 2/6/24 and 2/21/24. -The 2/14/24 weight was 134.8 pounds. -The MAR documented not applicable for 2/28/24. -There was no documentation that the provider or registered dietitian (RD) was notified that the weights were not obtained. Resident #16's weight history revealed the following: -On 2/7/24, the resident weighed 134.8 pounds; -On 2/14/24, the resident weight 134.8 pounds; and -On 3/1/24, the resident weighed 129.8 pounds. -There was no reweigh documented with the weight change of more than two lbs from 2/14/24 to 3/1/24. D. Staff interviews The DON was interviewed on 3/28/24 at 12:44 p.m. She said if a resident refused to be weighed, the staff should attempt to weigh the resident the next day. The RD should be notified. The registered dietitian (RD) was interviewed on 3/28/24 at 2:32 p.m. She said there would be weekly weights ordered at time of admission for most residents because of the resident's comorbidities like congestive heart failure and diabetes. If there was a discrepancy, she would ask the certified nurse aide (CNA) to re-weigh the resident and check to see if the scale malfunctioned. She said if a resident refused a weight, the staff should attempt again within 24 hours. She said the provider and she should be notified during morning meetings. She said weights were important because it helped give a better understanding of the resident's health. The RD said Resident #16 was at the facility over six months ago. She had c-difficile (a germ that causes diarrhea). She lost weight from her previous admission so that was a trigger for weight loss. She said she had the order for weekly weights in the first month.

Based on record review and interviews, the facility failed to protect one (#1) resident, out of three residents reviewed in a sample of five residents, from neglect. Specifically, the facility failed to assess Resident #1 after she reported a fall to a staff member. Resident #1, was admitted to the facility on [DATE] after falling at home and sustaining multiple fractures. She had a history of [REDACTED]. In the morning of 2/17/2020 the resident reported to her registered nurse (RN) #1 that she fell at night and was picked off the floor by a staff member. RN #1 did not assess resident for injury. In the afternoon of 2/18/2020 (24 hours after the reported fall) when a resident experienced increased pain and swelling of her arm, she was sent to the emergency room where she was diagnosed with [REDACTED]. Cross-reference to F689: failure to assess the resident after the fall which caused a major injury. Findings include: I. Facility policy and procedure A copy of the facility's policy and procedure on Abuse Prevention with revision date 10/2018 was provided by the nursing home administrator (NHA) on 3/9/2020. The policy read in part, Neglect means failure to provide goods and services necessary to avoid physical harm, or mental anguish. II. Resident #1 A. Resident status Resident #1, age 80, was admitted on [DATE]. According to the January 2020 computerized physician orders [REDACTED]. The 2/6/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not display any behaviors, hallucinations, and did not reject the care. She required limited assistance of one person for bed mobility, dressing, and personal hygiene. She required extensive assistance of two people for transfers, locomotion, toilet use, and bathing. Her balance during transition and walking was not steady, she was able to stabilize with staff assistance. She used a walker and wheelchair for mobility. She was occasionally incontinent of bowel and bladder, and she was not on the toileting program. B. Facility record review The care plan (CP) initiated on 1/31/2020, and revised on 2/24/2020, revealed the resident was at risk for falls. Interventions included: to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and to encourage the resident to wear appropriate footwear when ambulating. The admission assessment dated [DATE] indicated the resident was at risk for falls. There was no documentation found that RN #1 assessed Resident #1 or reported her fall to administration in the clinical record. C. Facility investigation On 3/9/2020 facility investigation was provided by NHA. The summary of the investigation read: On Monday morning 2/17/2020 at 7:00 a.m. (Resident #1) reported to registered nurse (RN #1) that she fell during the night and a tall black man picked her up. No injury was noted at this time. (RN #1) notified (physician assistant PA#1) who saw the resident who had no complaints during her assessment. On Tuesday morning 2/18/2020 swelling was noted in the left upper arm with mild pain. (RN#1) reported to (primary care physician PCP) who at this time suggested resident to be sent to the hospital. (PCP) stated family declined at this time. (PCP) saw resident later in the day and observed left arm very swollen and painful. (PCP) sent resident to the hospital. Resident was found to have a fractured left humerus. There was no conclusion at the end of the investigation. Immediate actions included: resident evaluation and treatment, resident transferred to the hospital, suspension of associated staff members. Certified nurse aide (CNA#1) who found Resident #1 on the floor on 2/17/2020 was suspended from his work until he received corrective action notice on 2/29/2020 prior to returning to work. He was re-educated to notify the nurse about the accident, not to move resident until he or she was assessed by a registered nurse, and to complete appropriate documentation prior to leaving after shift. RN #1 and other clinical staff were re-educated regarding timely assessment after an accident and proper documentation. The investigation was not signed or dated by NHA. D. Staff interviews RN #1 was interviewed on 3/9/2020 around 2:00 p.m. She said on Monday, 2/17/2020 when she came to work in the morning, she noticed that the resident was hallucinating, and around 9:00 a.m. in the morning the resident told her that she fell last night and was picked off the floor by a tall balck male. RN #1 said that she thought that was a part of her hallucination because the resident wouldn't be able to get up by herself, and she did not get any reports about falls. RN #1 said she did not assess resident for injury at that time. -Around 11:00 a.m. when a physician assistant (PA) #1 was in the building, RN #1 asked her to look at the resident because she was hallucinating about people in her room. She said PA #1 spoke with the resident and her daughter who was present in the room and ordered labs and urine tests to rule out infection. -Later during the day, the physical therapist (PT#1) reported to RN #1 that Resident #1 was not able to walk during therapy due to the pain and swelling in her left arm. RN #1 stated that she did not assess resident's arm, but she contacted primary care physician (PCP)to report the pain. PCP told her that the resident previously complained about pain in that arm and it was probably from the last fall. Resident #1 was recently started on the [MEDICATION NAME] for pain that should help. No other orders were given by PCP. RN #1 said during the day when the resident complained of pain, the pain was worse than before and it was in the left arm. She said she gave the resident her pain medication, but did not look at her arm. She said most of the arm was visible because the resident was wearing a nightgown with a short sleeve. She said she did not assess the resident's shoulder. -The next morning, 2/18/2020 when she came back for the next shift, the night nurse called her attention to look at the resident's arm because it was bruised and swollen closer to the elbow area. She said she reported that to assistant director of nursing (ADON) and called PCP. She said she did not do a full body assessment at that time. The PCP told over the phone that he was on his way to the facility and the family agreed to wait for him. When PCP came around noon, he gave an order to send resident to the emergency room for evaluation. RN #1 said because the resident's mental status changed she did not realize that what she was telling about the fall at night was true. She said because the resident could not tell her anything more except that she fell and was picked up by a tall black man off the floor she did not believe her story. She said she should have assessed the resident when the resident told her that she had a fall. PA #1 was interviewed on 3/9/2020 around 3:00 p.m. She said on the late morning of 2/17/2020 she was approached by a nurse and a CNA (certified nurse aide) who told her that Resident #1 was having hallucinations. She said she made a call to the resident's PCP who clarified that the resident had recent changes in medications. She said when she looked at the resident, she was comfortable in bed and her hallucinations cleared. The resident said she saw animals and people in the room and they were pleasant and not harmful and she was comfortable. She said she was not aware that the resident's arm was swollen, or that the resident reported a fall to a nurse. She discussed pain medications with her daughter and they decided to continue current medications. PT #1 was interviewed on 3/9/20 at 3:51 p.m. She said on 2/17/2020 she approached the resident in her room around 3:00 p.m. The resident's daughter was present the entire time during the session. She said at some point during the therapy, resident reported to her that she had a pain in her left wrist. PT#1 said she looked at her wrist but did not see any deformity or injury. A few minutes later the resident stated that pain was in her shoulder and that she fell last night and was picked off the floor by a tall black male. The daughter was present in the room and she told that it was the first time she was hearing about the fall. PT#1 stated she looked at the resident's shoulder that appeared to be swollen and painful with motion. She said she measured the swelling and compared it to the other hand, the swelling was significant. She said they continued to do exercise with the resident that did not require the movement of her arms and the resident was guarding her left arm when she was sitting down. PT #1 stated she reported to the nurse her findings (swollen shoulder) and the story that resident shared. The PCP was contacted over the phone on 3/9/2020 at 3:23 p.m. He said he received a call from nursing staff on Monday (2/17/2020) evening regarding increased pain for Resident #1. He said they reported to him that the resident was having hallucinations and was talking about the fall. He said her story about the fall was not collaborative and the resident was confused at baseline. He said the resident had recent falls and was receiving multiple pain medications for pain. -On Tuesday (2/18/2020) morning he received another call from a nurse stating that the resident had a swollen arm and was complaining of pain. He said he told the nurse that he was on his way to the facility and they should send the resident to the emergency room for evaluation. He said the resident's daughter was present at the time and decided to wait for his arrival. Upon his arrival and assessment of the resident's arm he made a decision to send the resident to the hospital because her arm was bruised, swollen and the way it looked was consistent with a fracture. The DON was interviewed on 3/9/2020 around 11:30 a.m. She said she found out about the fall the next day, when the resident was having a lot of pain and the physician sent her to the emergency room . The facility investigated the incident. The findings were that RN #1 did not complete the full body assessment for Resident #1 and did not document her notes timely. She (RN #1) was re-educated regarding change of condition assessment and proper documentation. CNA #1 who was working the night shift and fit the description that the resident provided, was suspended during the investigation and re-educated before he returned to work. CNA #1 communicated to the DON that Resident #1 was found on the floor during the night shift around 5:00 a.m. He said he went looking for the nurse and after he was not able to locate her, he put the resident back to bed. He said he told night shift nurse at the end of the shift that Resident #1 had a fall. The DON said that night shift nurse told her that she was never told about the fall. The NHA was interviewed on 3/9/20 around 2:30 p.m. He said neglect was defined as failure to follow policy and procedures of the facility. He said in above situation policies were not followed when CNA #1 picked the resident off the floor before assessment was completed, and by RN #1, who did not complete a full assessment after the resident reported the fall. He said the incident was investigated and reported to appropriate agencies. He said the allegation of neglect was not substantiated because it did not meet the reporting criteria of being wilful per reporting guidelines.

Based on record review and interviews, the facility failed to ensure two (#1 and #3) of three residents reviewed for accidents remained free from falls. Resident #1 had a history of [REDACTED]. The resident sustained [REDACTED]. She reported to the nursing team her second fall during the night, her fall was never investigated as nursing staff did not believe the resident. More than 24 hours later, she was sent to the emergency room for increased pain, swelling and bruising of the left arm, where she was diagnosed with [REDACTED]. Resident #3 had a history of [REDACTED]. The resident was not properly assessed for fall risk by nursing staff on admission, and subsequently, due to the lack of proper interventions resident sustained [REDACTED]. Additional failures included the facility failed to ensure the care plan was updated with the residents specific interventions before the resident fell , followed through with new interventions, and failed to complete a thorough investigation after the fall. Cross reference F600: Failed to protect Resident #1 from neglect. Findings include: I. Facility policies and procedures The Fall Prevention Program policy with revision date on 10/2018 was provided on 3/9/2020 at 10:12 a.m., by the nursing home administrator (NHA). The policy revealed all residents would be assessed for a fall risk as part of the nursing assessment on admission and after a change of condition. Those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Residents experiencing a fall would receive appropriate care and investigation of the cause. II. Resident #1 A. Resident status Resident #1, age 80, was admitted on [DATE]. According to the January 2020 computerized physician orders [REDACTED]. The 2/6/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not display any behaviors, hallucinations, and did not reject the care. She required limited assistance of one person for bed mobility, dressing, and personal hygiene. She required extensive assistance of two people for transfers, locomotion, toilet use, and bathing. Her balance during transition and walking was not steady, she was able to stabilize with staff assistance. She used a walker and wheelchair for mobility. She was occasionally incontinent of bowel and bladder, and she was not on the toileting program. B. Family interview The resident's daughter was interviewed on 3/5/2020. She said when her mother was admitted to the facility, staff were aware she was at high risk for falls. She said she saw her mother the day before and she was able to move in bed and work with physical therapy. On the morning of 2/17/2020 around 11:00 a.m. she found her mother hallucinating. She said staff told her that her mother might have a urinary tract infection and they were going to test her urine. Later that morning, a physical therapist came in to work with her mom. She said her mother was not able to work well with therapy and complained of the pain in her left arm. After physical therapy looked at the arm, it was discovered that the resident's left arm was swollen. Resident stated she fell at night and was picked off the floor by black male. Nursing staff stated the resident was hallucinating and arm pain was from the previous fall. She said staff disregarded her mother's statement about the fall and did not assess her condition after the fall. C. Facility record review The care plan (CP) initiated on 1/31/2020, and revised on 2/24/2020, revealed the resident was at risk for falls. Interventions included: to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and to encourage the resident to wear appropriate footwear when ambulating. The admission assessment dated [DATE] indicated the resident was at risk for falls. D. Fall #1 on 2/5/2020 According to the Situation, Background, Assessment, Recommendation (SBAR) form, the resident had a fall on 2/5/2020 in her room. According to the incident report, the resident had a fall on 2/5/2020 at 10:00 a.m. in the resident's room. She was ambulating with a four wheel walker in the room in the presence of family. She lost her balance and fell . The fall was witnessed by the daughter who was in the room. The resident was complaining of increased pelvic pain after the fall. Interventions included an x-ray of hip and pelvis. No other interventions. According to the physician note on 2/6/2020 With regard to repeated falls the patient has been having episodes of falls and patient reports that it is related to her [MEDICAL CONDITION]. Patient had (an) episode of fall yesterday when she was attempting to go to the bathroom. The incident report did not document any other interventions to address resident's ambulation without staff assistance. E. Fall #2 on 2/17/2020 According to the late entry nurses progress note created on 2/18/2020 at 6:00 p.m., with an effective date of 2/17/2020 at 3:00 p.m Resident reported to (the) writer this morning that she fell at some point in the night and a tall black man picked resident up. Now is complaining of (left) shoulder pain. Some slight swelling noted. [MEDICATION NAME] administered at this time. (Physician) called at this time notifying him of alleged fall. No new orders at this time. Resident was hallucinating seeing people in her room. (Physician assistant) evaluated this morning ordering some blood work in addition to the (urine test). Patient's family by bedside most of the day. Aware of health status. According to the physician assistant (PA) note on 2/17/2020, she was asked to assess the resident on 2/17/2020 due to onset of new hallucinations. Staff noted (the) patient was seeing people this morning and she herself tells me they looked so real. She recently started on [MEDICATION NAME] for pain and [MEDICATION NAME] . Visual hallucinations discussed with (a) primary care physician and daughter who was in the room. Could be adverse reaction to new medications, but need to rule out infection as well. Will order labs and (urine test) without hold of medications for now as pain still considerable. According to the physical therapy (PT) note on 2/17/2020, resident complained of increased left upper extremity pain, limited shoulder mobility and swelling. Attempted passive range of motion on left shoulder all painful and significantly limited. (Resident) unable to rate pain, primary symptoms today left upper extremity pain in the shoulder. Swelling noted, widening of the humerus by 6 centimeters (cm) compared with right circumference. Resident stated she fell out of bed today and was assisted up by staff member. Reported to the nurse. According to the late entry nurses progress note created on 2/19/2020 at 2:00 a.m., with an effective date of 2/18/2020 at 9:30 p.m. Received report from (day nurse) that (resident) may have fallen on a previous shift but not sure per (resident's) report. The resident has had increased confusion and hallucinations. Family member came to (the) nurses station and reported her concerns regarding patients increased confusion and swelling in (her) arm. I noted (resident's) mentation has decreased since I took care of her last Wednesday shift and noted left arm swelling and bruising. (Resident) reports no pain at this time as she takes scheduled pain medication. Left arm elevated on pillow for comfort. When the day nurse came in following (day), I asked her to evaluate (residents') arm alongside with me. There were no further notes in the resident's medical record. All late entry nurses notes regarding the events on 2/17/2020 were documented after the resident was hosptalized on [DATE] around 2:00 p.m. (more than 24 hours after the resident reported her fall to staff). According to hospital admission note on 2/18/2020, the resident was admitted with (left) hand bruising, per x-ray Acute displaced [MEDICAL CONDITION] proximal humerus. Probable elbow joint effusion which may indicate occult fracture in the setting of trauma. The director of nursing (DON) was asked for an incident report regarding this fall on 3/9/2020 at 10:30 a.m. She said they did not have an incident report about the fall on 2/17/2020 because she found out about the fall much later. She said they had an investigation regarding lack of assessment by the nurse after the fall. The investigation dated 2/18/2020 revealed that on 2/17/2020 in the morning, resident reported to RN #1 that she fell during the night and tall black man picked her up. On 2/18/2020 the swelling was noted on the left upper arm, the resident's hand was assessed by a primary care physician, and the resident was sent to the hospital. Resident was found to have a fractured left humerus. -The immediate actions that were documented as following: resident evaluation, transfer to the hospital, suspension of associated staff members. In-service training to staff members. Police, state agency and ombudsman were notified. There was no conclusion written at the end of the investigation. F. Staff interviews RN #1 was interviewed on 3/9/2020 around 2:00 p.m. She said on Monday, 2/17/2020 when she came to work in the morning, she noticed that the resident was hallucinating, and around 9:00 a.m. in the morning she (Resident #1) told her that she fell last night and was picked off the floor by a tall balck male. RN #1 said that she thought that was a part of her hallucination because the resident would not be able to get up by herself, and she did not get any reports about falls. RN #1 said she did not assess the resident for injury at that time. -Around 11:00 a.m. when physician assistant (PA) #1 was in the building, RN #1 asked her to look at the resident because she was hallucinating about people in her room. She said PA #1 spoke with the resident and her daughter who was present in the room and ordered labs and urine tests to rule out infection. -Later during the day, the physical therapist (PT) #1 reported to RN #1 that Resident #1 was not able to walk during therapy due to the pain and swelling in her left arm. RN #1 stated that she contacted primary care physician (PCP)who told her that the resident previously complained about pain in that arm and it was probably from the last fall. Resident #1 was recently started on the [MEDICATION NAME] for pain and that should help. No other orders were given by PCP. RN #1 said when the resident complained of pain, the pain was worse than before and it was in the left arm. She said she gave the resident her pain medication, but did not look at her arm. She said most of the arm was visible because the resident was wearing a nightgown with a short sleeve. She said she did not assess the resident's shoulder. -The next morning, 2/18/2020 when she came back for the next shift, the night nurse called her attention to look at the resident's arm because it was bruised and swollen closer to the elbow area. She said she did not do a full body assessment at that time. She said she reported that to assistant director of nursing (ADON) and called PCP. The PCP was on his way to the facility and the family agreed to wait for him. When PCP came around noon, he gave an order to send resident to the emergency room for evaluation. RN #1 said because the resident's mental status changed she did not realize that what she was telling about the fall at night was true. She said because the resident could not tell her anything more except that she fell and was picked up by a tall black man off the floor she did not believe her story. She said she should have assessed the resident when the resident told her that she had a fall. She said she documented all her notes the next day, on 2/18/2020 because she was too busy to do so earlier. PA #1 was interviewed on 3/9/2020 around 3:00 p.m. She said on the late morning of 2/17/2020 she was approached by a nurse and a CNA (certified nurse aide) who told her that Resident #1 was having hallucinations. She said she made a call to the resident's PCP who clarified that the resident had recent changes in medications. She said when she looked at the resident, she was comfortable in bed and her hallucinations cleared. The resident said she saw animals and people in the room and they were pleasant and not harmful and she was comfortable. She said she was not aware that the resident's arm was swollen. She discussed pain medications with her daughter and they decided to continue current medications. PT #1 was interviewed on 3/9/20 at 3:51 p.m. She said on 2/17/2020 she approached the resident in her room around 3:00 p.m. The resident's daughter was present the entire time during the session. She said at some point during the therapy, resident reported to her that she had a pain in her left wrist. PT#1 said she looked at her wrist but did not see any deformity or injury. A few minutes later the resident stated that pain was in her shoulder and that she fell last night and was picked off the floor by a tall black male. The daughter was present in the room and she said that was the first time she was hearing about the fall. PT#1 stated she looked at the resident's shoulder that appeared to be swollen and painful with motion. She said she measured the swelling and compared it to the other hand, the swelling was significant. She said they continued to do exercise with the resident that did not require the movement of her arms and the resident was guarding her left arm when she was sitting down. PT #1 stated she reported to the nurse her findings (swollen shoulder) and the story that the resident shared. The PCP was contacted over the phone 3/9/2020 at 3:23 p.m. He said he received a call from nursing staff on Monday (2/17/2020) evening regarding increased pain for Resident #1. He said they reported to him that the resident was having hallucinations and was talking about the fall. He said her story about the fall was not collaborative and the resident was confused at baseline. He said the resident had recent falls and was receiving multiple pain medications for pain. -On Tuesday (2/18/2020) morning he received another call from a nurse stating that the resident had a swollen arm and was complaining of pain. He said he told the nurse that he was on his way to the facility and they should send the resident to the emergency room for evaluation. He said the resident's daughter was present at the time and decided to wait for his arrival. Upon his arrival and assessment of the resident's arm he made a decision to send the resident to the hospital because her arm was bruised, swollen and the way it looked was consistent with a fracture. The DON was interviewed on 3/9/2020 around 11:30 a.m. She said she found out about the fall the next day, when the resident was having a lot of pain and the physician sent her to the emergency room . The facility investigated the incident. The findings were that RN #1 did not complete the full body assessment for Resident #1 and did not document her notes timely. She (RN #1) was re-educated regarding change of condition assessment and proper documentation. CNA #1 who was working the night shift and fit the description that resident provided, was suspended during the investigation and re-educated before he returned to work. CNA #1 communicated to the DON that Resident #1was found on the floor during the night shift around 5:00 a.m. He said he went looking for the nurse and after he was not able to locate her, he put the resident back to bed. He said he told night shift nurse at the end of the shift that Resident #1 had a fall. The DON said that night shift nurse told her that she was never told about the fall. III. Resident #3 A. Resident status Resident #3, age 86, was admitted on [DATE]. According to the March 2020 CPO, [DIAGNOSES REDACTED]. According to the 2/15/20 MDS assessment, the resident had mild cognitive impairment with a BIMS score of nine out of 15. He did not exhibit any behaviors of inattention or disorganized thinking. He required extensive assistance of two people with bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. His gait not stable, he was able to stabilize with staff assistance only. He used a walker and wheelchair for ambulation. Resident was frequently incontinent of the bladder, and always continent of bowel, he was not on the toileting program. He had a history of [REDACTED]. B. Record review 1. Failure to accurately assess the resident for fall risk on admission According to the nursing admission data collection completed by licensed practical nurse (LPN) #1 on 2/15/2020, resident had falls in the last 90 days, he required assistance with bowel and bladder, he was ambulating with problems with assistive devices, he was not steady without physical assistance, and he took three or more medications that placed him at risk for falls. The instruction at the end of the assessment read If resident's total score is 10 or more, initiate fall risk interventions and document on the Interim Care Plan. Even though the actual (manual) calculation of total score for the resident was above 10, the resident was marked as no risk for falls. 2. Failure to develop a care plan for falls with resident specific interventions to address his known fall risks and to keep him safe from additional falls and injury. The resident did not have a care plan for falls at the time of the admission on 2/15/2020. The CP for falls was initiated on 2/19/2020 (after the first fall), and revised on 3/4/2020, revealed the resident was at risk for falls. Interventions included to be sure call light was within reach and encourage resident to use it for assistance as needed. Prompt response to all requests for assistance, to educate resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to wear appropriate footwear when ambulating or mobilizing in a wheelchair. a. Fall on 2/18/2020 According to the SBAR form, the resident had a fall on 2/18/2020 in the bathroom. Resident was observed sitting on buttocks on the floor next to bed and w/c (wheelchair). Resident stated he was going to the bathroom. 1.5 cm (centimeters) skin tear noted and cleaned and steri strips and dressing applied. Denied pain or discomfort. Range of motion done without pain or discomfort. RN assessed. Two staff members assisted him up and into bed. Message left for doctor and resident responsible for self. Educated importance of using call light. Contributing factors listed as poor safety awareness. The fall investigation did not include any interventions. Resident's bathroom needs were not incorporated into his care plan. The Fall data risk collection completed on 2/19/20 after the fall, revealed the resident was at high risk for falls with a score of 16. b. Staff interviews CNA #2 was interviewed on 3/9/2020 at 12:15 p.m. She said the resident required one person assistance with everything. She said he has not had any falls since he was admitted , and he was not on any fall precautions. LPN #1 was interviewed on 3/9/2020 at 12:23 p.m. He said the resident was mildly confused, required one person assistance with transfers, dressing, and other activities of daily living. He did not know if the resident had any falls, he said he was not on any fall precautions currently. He said the resident was using his call light inconsistently and was at times incontinent of the bladder. He said he did not know if the resident was on the toileting program. LPN #2 was interviewed on 3/9/2020 at 12:55 p.m. She said she was the unit manager. She said all residents were assessed for fall risk on admission, quarterly and with any changes in condition. She said all falls were reviewed by an interdisciplinary team (IDT) that developed interventions and updated the care plans. -She reviewed fall assessment on admission for Resident #3 and stated it was completed incorrectly. She said based on the answers that were given, such as the history of falls, unstable gait and use of medications, the resident should have been marked as at risk for falls. She said she did not know why the nurse marked it the wrong way. She said it was not part of her responsibilities to review assessments. -Regarding the falls, she said she did not review incident reports either, they were completed by staff nurses and sent directly to DON for review. She said care plan updates were also not her responsibility, it was DONs responsibility, because DON reviewed incident reports and was supposed to document interventions in the care plan. She said resident #3 was not on a toileting program and she did not know if he should or should not be on one. LPN #3 was interviewed on 3/9/2020 at 1:01 p.m. She said she completed the fall assessment for Resident #3 on admission. She said the resident answered all the questions she asked him and because he was alert and oriented she marked him as not at risk for falls. She said she worked in the building only for the last two months and had not done any admissions before. She said she did not receive any training on completing admissions and that day she was splitting the care and workload of this resident with another nurse. She said she did not read the instructions on the form and did not know the fall score should be calculated manually. The ADON was interviewed on 3/9/2020 around 4:00 p.m. in the presence of DON. She said all residents were assessed for fall risk on admission and after a fall. She was not aware that the form the facility utilized required manual calculation of the fall risk score. She said they would review all current forms they utilized and make sure staff were familiar with them and used them appropriately. She said the accurate fall assessment would trigger a care plan for falls which did not happen with Resident #3. She said all falls were reviewed during an IDT meeting and care plan updates were a team effort. The DON stated staff would be re-educated on proper documentation of progress notes and care plans. IV. Facility follow-up: Facility provided supporting documents demonstrating that following actions were taken after the incident on 2/17/2020. - 2/19/2020 12 RNs, including RN #1 and other nurses were educated on proper assessment and documentation on change of condition; -Corrective action for CNA #1 was implemented on 2/29/2020 as a first reminder. The education was provided if a resident was found on the floor to report to a nurse and not move the resident until the resident was assessed by RN; and, -Education on routine clinical documentation for all nurses on 2/13/2020. In addition, on 3/10/2020 at 4:07 p.m., the facility submitted by email a Success Plan that included a summary of actions that were taken by the facility. Such as, -2/17/2020 inservice education/training to nurses regarding Change in Condition process and Falls Management; and, -2/24/2020 and 2/27/2020 all staff meeting regarding fall management/prevention and reporting. The facility stated they completed education on Change of Condition and Falls prevention and reporting, and have additional education planned with the nurses and CNAs on 3/12/20.

Based on record review and staff interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (#1) of eight sample residents. Specifically, the facility failed to: -Provide fall intervention of supervision for a resident who was assessed to be a high fall risk during a facility outing; the resident had a fall resulting in a pelvic fracture, pain and an ileus. -Assess the resident for injury after the fall. The findings include: On [DATE], the resident fell while on an outing with other residents and facility staff. The resident walked with a four wheel walker and had refused the use of a wheelchair for the outing. During her admission assessment on [DATE], the resident had been assessed to be a high fall risk and required one person assistance for ambulation. The resident did not receive one person assistance or supervision while on the outing and was out of visual sight of the facility staff for five to ten minutes and fell . The resident was assisted to her feet by zoo personnel and did not receive an assessment for injury or pain after the fall until after she returned to the facility via the facility bus. I. Resident Observation/Interview During the investigation this resident could not be interviewed or observed since she no longer resided in the facility and had passed away at the hospital after the fall. II. Record Review Resident #1, [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE], documented the resident's Brief Interview for Mental Status (BIMS) a score of ,[DATE] which indicated that she was cognitively intact. She required extensive assistance of one person with bed mobility. She required supervision of one person with transfers, ambulation in room and in corridor, locomotion on and off the unit, dressing, toileting, and personal hygiene. Her primary mobility devices were the walker and wheelchair. She had no complaints of pain during this look back period of time. She had no falls during this look back period of time. On [DATE], the Pain Evaluation form documented the resident was at risk for pain due to cirrhosis and ascites but had no complaints of pain. On [DATE], the Fall Risk Evaluation form documented the resident's fall risk score was 12 which indicated a high fall risk. On [DATE], the score was 20 which also indicated a high fall risk. The form documented a score of ten or higher indicated a high fall risk. On [DATE], the Rehabilitation Evaluation Plan of Treatment form documented the resident's gait with a four wheeled walker (4 WW) required staff to provide stand by assistance (SBA). She was independent with ambulation for distances up to 150 feet. She was independent with bed mobility and transfers with decreased safety awareness. On [DATE] (last updated), the Locomotion Care Plan documented the resident was independent with a four wheeled walker (4 WW). The interventions included occasional supervision was required and to provide assistance to the resident for desired locations as needed. On [DATE] (last updated), the Pain Care Plan documented the resident was at risk of pain due to cirrhosis diagnosis. The interventions included gentle range of motion (ROM) with activities of daily living (ADLs) care, medications as ordered, and prompt, frequent rest periods with pillows for support regarding ascites, resident received thoracentesis approximately once to twice a month, diversion type of activities like TV, reading, music, and conversation. On [DATE] (last updated), the Fall Care Plan documented the resident was at risk for falls related to cirrhosis diagnosis. The interventions included the following: - "Keep areas free of obstructions to reduce the risk of falls or injury. - Resident uses 4 WW (four wheeled walker)-occasionally needs supervision secondary to fatigue especially after thoracentesis. - Place call bell/light within easy reach. - Make sure walker in her reach at all times. - Respond promptly to calls for assist to the toilet as needed. - Footwear will fit properly and have non-skid soles. - Resident encouraged to use wheelchair (w/c) during outing however declined on [DATE]." On [DATE], the Rehab/Skilled Care Optimum Life Activity Assessment documented that the resident liked bingo, friend/family visits, reading, and walking. The form was not completed on the "Resident Needs" section; see the activity care plan below which did document that the resident required the activity calendar and assistance to/from activities of choice. On [DATE], (last updated) the Activity Care Plan documented that the resident enjoyed reading, music, bingo, and visits from friends and family. The plan indicated she needed a calendar, reminders, encouragement and assistance to/from activities of interest. The interventions included providing support to/from activities, discussions about activity preferences and allowing choices, encouragement to attend activities that she enjoyed, provide a copy of the activity calendar, and assist the resident to attend/participate as needed. III. Description of the fall during activity outing to zoo with subsequent pelvic fracture, pain, and ileus On [DATE] (no time noted), the Daily Skilled Nurse's Note documented, "Resident left facility around 1030 (10:30 a.m.) to tour (city name) Zoo. Activity's personnel called the facility around noon and reported that the res (resident) had fallen on her bottom and had no c/o (complaints of) pain at that time. Res returned to facility at 1330 (1:30 p.m.), myself and a CNA (Certified Nursing Aide) transferred her from the bus seat to a w/c (wheelchair). Res (Resident) expressed L (left) hip pain at a ,[DATE] and was unable to bear weight. We wheeled her to her room and transferred her to bed. Tramadol 25 mg (milligrams) p.o. (by mouth) given, pain was later a ,[DATE]. Bengay applied per resident request, VSS (vital signs stable). Resident stated she hit her hip and buttocks, did not hit her head. No new bruising or redness was noted during assessment. MD's (medical doctor's) office notified, new orders for STAT (immediate) x-ray of L (left) hip 2 (two) views was ordered. POA (power of attorney) daughter was notified. Called lab for results, results were not yet available as of 1900 (7:00 p.m.). Will cont (continue) to monitor." On [DATE] at 3:00 p.m., the Telephone Orders (T.O.s) documented two view x-ray of the left hip and to evaluate for pain after the fall. STAT (immediately). On [DATE] at 10:00 p.m., the Daily Skilled Nurse's Note documented, "X-ray results lt (left) hip 2 (two) views and resident has non-displaced fracture to inferior pubic ramus, results have been called to Dr. (doctor), she said she was going to send a message to another Dr. and resident to stay in the facility on bed rest. Resident's daughter/POA (power of attorney) was around with her mother and was notified by this writer about the x-ray results and decision made by the doctor. Resident was notified too and was ok with Dr.'s decision. Called MOD (manager on duty) left a message on her voice mail about the x-ray results and Dr.'s decision." On [DATE], the Short-Term Problems Need List documented that the resident had an "inferior pubic ramus fracture secondary to witnessed fall by zoo patron during an outing with activities at the zoo." The approaches included the following: - "MD (medical doctor) notified. - Family notified. - VS (vital signs) Q (every) shift x 72 hrs (for 72 hours). - Keep her comfortable. - Give pain medication as ordered. - Assist with care as much as possible." IV. Pain and Ileus On [DATE] at 4:00 p.m., the Daily Skilled Nurse's Note documented that the resident continued to have left hip pain and Vicodin had been ordered by the physician. On [DATE] at 4:20 p.m., the Daily Skilled Nurse's Note Interdisciplinary Team (IDT) notes documented, "F/U (follow up) to resident's witnessed fall by zoo patron during an outing with activities. Zoo patron who witnessed fall stated that resident fell on her left hip/buttocks. Zoo patron and zoo security assisted resident up and placed in w/c (wheelchair) provided by zoo security. When initially interviewed by activity director resident denied any c/o (complaints of) pain and wanted to continue site seeing at zoo. Later resident c/o left hip pain. Activity Director in turn immediately brought resident back to facility. Licensed staff assessed, obtained orders for x-ray which revealed left pubic fx (fracture). Resident assessed by Kaiser NP (Nurse Practitioner) today. New orders for increased pain medications in place. Resident reports relief. Res (Resident) ambulates independently with WW (front wheeled walker) throughout facility upon notification to resident's daughter. Resident encouraged by daughter to use transport w/c (wheelchair) for outing however she declined. Resident reports that she felt walker was rolling too fast even though brakes were locked. Res walker checked and locked appropriately. Witnessed fall isolated. Plan to continue to monitor resident for increased pain or changes in resident mood. Will assist with ADLs (activities of daily living) as needed." On [DATE], the physician progress notes [REDACTED]. Background: fall resulting in pelvic fx yesterday. On-call started on Tramadol and suggested bed rest. Hip x-ray results: Demineralization and non displaced fracture left inferior pelvis ramus. Physician approved use of Hydrocodone-APAP (Tylenol) as long as NTE (not to exceed) 2 (two) gm (grams) APAP (acetaminophen also known as Tylenol) from all sources/24 hrs (for 24 hours). PT/OT (Physical Therapy/Occupational Therapy) ordered, referral put into Orthopedic clinic ...brown emesis, abd (abdominal) x-ray of [DATE] showed moderate diffuse ileus. Continued on clear liquid diet. Started on Pantoprazole (Protonix), Hydrocodone-APAP (Vicodin or Norco) stopped over concern could make ileus worse. Scheduled Tramadol alternating with APAP at renal hepatic doses. CBC (complete blood count) ordered along with stools for guaiac (testing for blood in stool) x 3 (three times). Goes for peritoneal tap q (every) wk (week) at GI (gastrointestinal) lab ...left pelvic pain ,[DATE] with any movement. Has not gotten out of bed since returning from zoo 3 (three) days ago due to pain. Got 2 (two) doses of Hydrocodone-APAP which helped pelvic pain a lot and also made her very sleepy. While tolerating p.o. meds (medications) and clear liquid diet has little appetite. Asking for Tums PRN (as needed) and Ensure. No cp (chest pain), SOB (shortness of breath), diarrhea. Discussed need to turn and get out of bed to prevent blood clots, pneumonia, and skin breakdown. Patient agreed to get out of bed BID (twice a day) for short periods. Nursing Staff Reports: Had one episode of n/v (nausea/vomiting) yesterday a.m. and none since. Tolerating p.o. clear liquids, asking for Ensure. Had a BM (bowel movement) yesterday and today. Patient refusing to turn or get out of bed ...Plan: Treatment is pain control, therapy and time. Therapy already ordered. Referral already made to Orthopedic Clinic for f/u (follow up) and follow healing in light of demineralization. If Clinic doesn't call to set up appointment by next week, nursing staff to call the appointment desk for appointment ...Will continue alternating Tramadol with APAP until cleared by physician. Liver Cirrhosis: Followed by physician. Concern that any new medication could impact liver puncture. Will forward to physician for review. Physician to decide if and when is safe to use Hydrocodone-APAP for control of new pelvic fx(fracture) pain ...Will need to have transport with w/c (wheelchair) until pelvic fx resolves ...Ileus: Seems to be resolving-active bowel sounds, abd (abdomen) relatively soft and NT (non-tender), having BMs (bowel movements), tolerating p.o. (oral) clear liquids and medication, in no acute distress. Will advance diet to full liquids and if tolerates that back to regular diet. Plan: Advance diet to full liquids. If tolerates full liquids x 24 hrs may advance diet back to usual diet. If develops n/v return diet to clear liquids. Patient to be out of bed at least ,[DATE] (ten to fifteen) min (minutes) BID (twice a day), longer if tolerated. Staff to reposition patient q (every) 2 (two) hrs (hours) WA (while awake). Ice on painful area 20 min (minutes), off x 2 (for two) hrs (hours) PRN (as needed) pain. Tums 500 mg (milligrams) p.o. (by mouth) q (every) 4 (four) hrs PRN-dyspepsia-patient's request. Physician to decide if and when is safe to use Hydrocodone-APAP for control of new pelvic fx pain ...Contact MDPOA (Medical Durable Power of Attorney): Spoke to daughter who voiced was pleased with care and agreed with plan." On [DATE], the physician progress notes [REDACTED]. PT/OT (Physical Therapy/Occupational Therapy) after traumatic fall resulting in left pelvic fx (fracture). Previously was ambulating with 4 WW (four wheeled walker), now bed bound. D/C (discontinue) bed rest, may sit up in chair and go to bathroom-advance activity as therapy allows. Will put in referral to Orthopedic Clinic with request to call LTC (long term care) and help make appointment. Hydrocodone-APAP (Norco) ,[DATE] mg (milligrams) 1 (one) tab (tablet) p.o. (by mouth) q (every) a.m., noon, and HS (hour of sleep) and 1(one) tab (tablet) p.o. (by mouth) q (every) 4 (four) hrs (hours) PRN (as needed) pain 5-,[DATE]. Will hold off starting until hear from physician. Dulcolax supp (suppository) PR (per rectum) now. If no response in 1 (one) hr (hour) give Fleets enema, PR (per rectum) x1 (one time). X-ray of abd (abdomen) 2 (two) views to evaluate vomiting and r/o (rule out) bowel obstruction. Clear liquid diet for now until get results of x-ray. If no bowel obstruction, may resume regular diet. Loratadine 10 mg (milligrams) p.o. (by mouth) qd (every day) x 10 (for ten) days-seasonal allergies [REDACTED]. Called physician and got VM (voicemail), situation described and left CB# (call back number). DTR (daughter) notified that physician was notified of situation." On [DATE] at 4:00 p.m., the Daily Skilled Nurse's Note documented that the resident became confused from taking Vicodin and the Nurse Practitioner (NP) had come in to assess her and discontinued the medication and ordered Tramadol and Tylenol to be alternately given for pain relief. The resident had no further nausea and vomiting but did have one bowel movement. The resident had called her daughter and told her that she was going to the hospital during her confusion. The nurse documented that the daughter was notified that the resident was not being sent out to the hospital and was to remain on bed rest at that time. V. Staff Interviews On [DATE] at 3:10 p.m., the Nursing Home Administrator (NHA) reported that they reviewed this resident's chart specifically, this event, with the Medical Director during their Quality Assurance (QA) meeting because they took this very seriously. On [DATE] at 3:11 p.m., the Medical Director reported that he reviewed the chart in the Quality Assurance (QA) meeting with the Interdisciplinary Team (IDT) members and they concluded the renal failure was not due to the fall. He felt the gastro-intestinal (GI) bleeding caused the acute onset of chronic renal failure due to volume loss. He reported that due to the chronic renal failure this was the cause of death. He reported fall did not cause the GI bleeding and that the GI bleeding could have been caused by the resident's [DIAGNOSES REDACTED]. He reported he would not have expected the facility staff to send the resident immediately to the hospital once they received the x-ray results for the fractured pelvis and ileus. He reported the fractured pelvis would not have required surgery since it was non-displaced and the treatment for [REDACTED]. He felt that the care was prompt and done according to medical standards. On [DATE] at 3:57 p.m., the NHA reported that she was concerned about the training the staff at the zoo had received to be able to provide assistance to the resident when she fell and had called and spoke to the security guard who had helped the resident get up after the fall. The guard told her that they were trained in cardiopulmonary resuscitation (CPR) and first aid. Also, it was standard practice to offer the ambulance to anyone with any type of injury/fall but the resident had refused and told him that she felt she was fine and had no pain so the zoo patron and the security guard had assisted her to her feet. She reported that she had no reports available from the zoo security guard but would inquire to see if she could obtain a copy. (No copies obtained prior to exit from the facility.) On [DATE] at 9:35 a.m., interview with the Activity Director (AD) and the Nursing Home Administrator (NHA) revealed there were a total of five residents, two staff members, two volunteers, and one bus driver who attended the outing at the zoo. The AD reported each person was assigned to each resident in a wheelchair and that no one was directly assigned to resident #1 because she was ambulating independently with her walker. The residents were with each person and doing their own thing. He reported normally a resident would not be without a staff member or volunteer. He reported they moved at a very slow pace and took frequent rest breaks before moving on to the next display. He reported the resident's walker had a seat on it and she would sit when she was tired. He reported he had offered the resident a wheelchair (w/c) prior to the outing but she refused. He reported the resident had stopped to talk on her cell phone. The group had moved on to the next display when they noticed she was separated from group. He reported the resident was out of sight for about five to ten minutes before they noticed she was not in the group. He reported he and the bus driver went to the security office to find her. The security guard had a radio and dispatched a call out to the other security guards to find her. A security guard had found her and brought the resident to them at the front of the zoo in a golf cart. He reported the resident did not complain of pain while sitting in the golf cart. He reported he called the facility to get further instructions from the Director of Nursing (DON). He reported the protocol was to call the DON or manager at the facility to get further instructions. He reported he had followed protocol by calling the DON and had followed the directions the DON gave him which was to offer the resident to go to the hospital for which the resident had refused. He reported the DON had told him what to do for neuro checks like making sure her mentation had not changed and to look at her eyes for pupil changes. He reported to the DON she had none of those issues. He reported at this point the resident had no pain, refused hospital, and had no indications of injury. He reported she was walking and functioning as she did prior to fall. After the evaluation was done, they decided to leave and loaded all residents on the bus and returned to the facility. He reported the bus driver and the guard helped the resident to get on the bus by putting her in seated position on her walker and then lifted the resident onto the bus with the lift and wheeled over to the bus seat and then transferred the resident from the walker seat to the bus seat. He reported the resident complained of pain after she was in her bus seat but reported the pain was soreness not agonizing pain at that point. He reported it took them about 35 to 40 minutes to get back to the facility. Once they arrived to the facility, a Certified Nursing Aide (CNA) and a Nurse got her out off the bus seat and onto a w/c then lifted from the bus and rolled upstairs to her room. On [DATE] at 10:50 a.m., during the interview with the Acting Director of Nursing (ADON) and Executive Director (ED), it was revealed the Activity Director (AD) had reported to the ADON immediately which was the expectation. The ADON reported she had asked the AD about the resident's status and what he could describe to her about her condition. She reported the information received was that the security guard found the resident and that she had not hit her head during the fall. She reported the AD reported to her the resident fell on her left side, was able to stand and transfer to the golf cart, and did not have any complaints of pain at that time. She reported soon after the resident had been in her room the x-ray was ordered for the left hip. Immediately pain management was addressed with the Medical Doctor (MD) and daughter. The vital signs were done according to the protocol for neuro checks. She reported on the day the resident was sent out to the hospital, the resident went from being stable to not being stable within a two hour window of time. She reported nursing noted that the resident had become lethargic and confused so the MD was contacted and ordered laboratory testing to be done. A couple of hours later when the nursing staff noted the resident's vital signs had changed, the MD was notified again and the resident was sent to the hospital. She reported the resident's blood pressure at 2:00 p.m. was normal and by 4:00 p.m., it was ,[DATE], low. She reported she would not have expected the physician to come in to assess the resident on the date of the fall but would expect the resident to be seen by the physician within the next couple of days. In this case the resident was seen the next morning, which she felt was timely. She reported in the days before the resident went to the hospital, she was getting up out of bed with some assistance and she was doing better. The Tramadol and Tylenol seemed to be adequate for pain relief, however, the staff had to encourage her to take it because the resident would not ask for it and at times would refuse it. The Executive Director (ED) reported they had a corrective action plan on this event and educated the staff. She emphasized how much importance they placed on this event. She provided a copy of the action plan/plan of correction. See below. VI. Facility Investigation and Quality Assurance Documentation On [DATE] at 11:56 a.m., the confidential Facility Investigation and Quality Assurance (QA) file on this event was reviewed. No copies were provided. On [DATE], the Investigation Notes documented, "Daughter notified of fall on [DATE] by charge nurse. The daughter stated to charge nurse, "I told her to take a wheelchair but she didn't want to." On [DATE], daughter was in to gather some of resident's belongings and was very tearful stating to the charge nurse that the resident has internal bleeding and all family was coming in because she is not expected to make it out of the hospital. Hospital case managers do not state any connection between fall/pelvic fx (fracture) and GI (gastrointestinal) bleed. This writer (NHA) left voicemail for daughter offering any support on [DATE]. On [DATE], spoke with daughter -she shared that she and accounts assistant had offered wheelchair for outing at zoo and that resident was stating she would feel better just using her walker. She stated she had been checking in with nursing staff after resident fell to see how she was doing and that she was aware that the doc (doctor) had suggested resident be on bed rest, she stated that she was still coming to terms with her mother's passing and shared that resident very much liked the staff here and that staff were very helpful and followed through. She provided the date/time/place of the funeral scheduled for [DATE]." On [DATE], the Complaint/Grievance Report documented the daughter/family had concerns regarding resident #1. She "had questions about how the resident fell and was wondering what the process was for sending to the hospital after a fall." The findings of investigation: "Had lengthy conversation about resident's fall and physician's orders [REDACTED]. She later presented with altered mental status and after NP (Nurse Practitioner) visited, she was sent to hospital for further evaluation. Also, shared option of palliative care involved for help with providing comfort. Paracentesis completed ,[DATE], KUB (kidney, ureters, bladder) on ,[DATE], no acute findings." Fall was not reportable to occurrences. Complainant was satisfied and her remarks were; "The daughter stated she was still coming to terms with her mother's death, but that she and resident had always felt that staff were very caring and responsive. She shared date/place of resident's funeral to pass on to staff." Stapled to this form was an Investigation Note dated [DATE], authored by the Activities Director (AD). "Resident (resident identifying number) was interviewed by Resident Program Coordinator (Activity Director) after her fall and resident denied being in any pain while sitting in the security cart belonging to the zoo. During the interview resident seemed alert and oriented, able to communicate her needs. Her facial expression indicated no grimacing or other symptoms of pain. Resident Program Coordinator immediately contacted the ADON for direction and thus decided to return to the facility with resident denying pain. Resident (resident identifying number) was assisted from sitting on the cart to her walker for the lift and then expressed pain. Upon return resident (resident identifying number) was assisted and transferred by a nurse and CNA (Certified Nursing Aide) into a wheelchair and was escorted up to the 3rd floor." On [DATE], the Investigation Notes documented that the Nursing Home Administrator (NHA) interviewed the security guard at the zoo. "Spoke with ...in security at zoo, who assisted resident after falling at the zoo. She (security guard) stated resident had already been assisted up, when she got to her. She assisted her onto the golf cart and took her to the zoo exit where staff (from facility) assisted from that point. Security guard stated that all security guards are CPR (cardiopulmonary resuscitation), AED (automated external defibrillator) certified and basic first aid certified. She stated they immediately offered paramedics and that resident declined having the paramedics come." On [DATE], the Community Success Plan Quality Assurance Performance Improvement (QAPI) documented the resident had fallen on [DATE] on an outing with injury. Opportunity Identified: "Resident supervision while on outings oversight and monitoring." Plan of Action/Correction: "Education provided to activities personnel including: Assign staff and volunteers to residents to monitor their safe supervision, keep all residents within the line of sight and within the group, place staff and volunteers present and ready to assist before moving resident group, resident check in at least every 15 minutes, community will provide a CNA (Certified Nursing Aide) for ADL (activity of daily living) assistance on outings as needed. Corrective Action completed on Activity Director by the NHA (Nursing Home Administrator) on [DATE]. Review [DATE] fall in QAPI with IDT (interdisciplinary team) on [DATE]. Medical Director record review on [DATE]. Monitor activities are reviewed in daily stand up including participants and level of supervision required with Activity Director immediately and on an ongoing basis. Review falls M-F (Monday through Friday) with IDT immediately and ongoing. Review falls monthly in QAPI with IDT immediately and ongoing." On [DATE], the Education In -Service Form documented the In -Service Education: "Resident supervision while out of facility on outings." Education Given: "Assign staff and volunteers to residents to monitor their safety or assist. Keep all residents in the line of sight and within the group. Place staff and volunteers in front and behind residents. All staff and volunteers present and ready to assist before moving resident group. Residents use wheelchairs. Resident check in at least Q (every) 15 minutes." This was signed by the associate Activity Director and Nursing Home Administrator on [DATE]. On [DATE], the Education In -Service Form documented the In Service Education: "Resident supervision while out of facility on outings." Education Given: "Residents use wheelchairs. Assign staff and volunteers to residents to monitor their safety and assist. Keep all residents within the line of sight and within the group. Place staff and volunteers in front and behind residents. All staff and volunteers present and ready to assist before moving resident group. Resident check in at least Q (every) 15 minutes." This was signed by the assistant activity person and by NHA on [DATE]. On [DATE], the Corrective Action for Activity Director (AD) was marked on the form as a second reminder. Incident Description: "AD, on [DATE] while participating in an Activity Department outing, a resident sustained [REDACTED]. Performance requirements: Implement the following procedures as outline in the Education In -Service of [DATE] to ensure resident safety at all times." This form was signed by AD, NHA, and another staff member on [DATE]. Facility Failures: The facility failed to provide supervision of the resident while on a facility outing even though the resident had been assessed to be a high fall risk at the time of the fall. The facility failed to provide a nursing assessment for injury and pain after a fall until after the resident returned to the facility. The facility failed to provide guidance to the activity and volunteer staff on the appropriate protocol to follow if a resident fell while on an outing.