Every finding on record at Cheyenne Manor

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five certified nurse aides (CNA).Specifically, the facility failed to complete annual performance reviews for CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6 in order to determine potential training needs. Findings include:I. Facility policy and procedureThe Performance Evaluation policy, undated, was provided by the nursing home administrator (NHA) on 10/28/25 at 3:51 p.m. It read in pertinent part, The performance evaluation process provides a means for discussing, planning and reviewing the performance of each employee. Performance expectations are set with employees and measured throughout the year. Performance Evaluation process is designed to help managers and their employees define their objectives and goals that align with the Mission, Vision, and Values of [NAME] Manor. Performance results are highlighted in the process and areas of development will include guidance for improvement. All employees are provided an annual performance review and consideration for merit pay increases as warranted.Performance reviews are done on an annual basis. In addition to the annual review, a supervisor may initiate a Performance Improvement Plan (PIP) if deterioration in performance has taken place or if the employee needs additional, specific direction. Evaluations are performed by immediate supervisors. Performance reviews allow employees an opportunity to provide input as part of the performance process.II. Record reviewAnnual performance reviews were requested on 10/28/25 at 10:10 a.m. for CNA #1 (hired 3/12/12), CNA #3 (hired 4/24/24), CNA #4 (hired 4/12/23), CNA #5 (hired 11/17/1998) and CNA #6 (hired 2/8/07).-The facility was unable to provide documentation indicated CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6 had annual performance evaluations.The NHA said the five CNAs did not have annual performance reviews and had not completed annual in-service education based on the outcome of their reviews.III. Staff interviewThe NHA was interviewed on 10 /28/25 at 2:29 p.m. The NHA said the facility did not conduct annual performance reviews. She said the CNA raises were based on the cost of living and decided by the board of directors. She said performance evaluations were not conducted and regular in-service education based on the outcome of the reviews was not provided.

Based on record review and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for one (#17) of four residents reviewed for grievances out of 17 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to individual grievances for Resident #17.Findings include:I. Facility policy and procedureThe Grievance policy, undated, was provided by the nursing home administrator (NHA) on 10/29/25. It read it pertinent part, The person designated to resolve complaints will confer with persons involved in the incident and other relevant persons within three days of the grievance and shall provide a written explanation of the findings and proposed remedies to the complainant. Where appropriate due to a mental or physical condition of the complainant or aggrieved party, an oral explanation shall accompany the written ones. II. Resident #17A. Resident statusResident #17, age greater than 75, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included anxiety, osteoarthritis of the right shoulder and unspecified dementia. The 10/20/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed the resident required moderate staff assistance with dressing, transfers, and bathing. B. Resident interviewResident #17 was interviewed on 10/27/25 at 1:45 p.m. Resident #17 said her toilet was too low and she needed a toilet seat riser to use her toilet comfortably. She said she had requested a toilet seat riser from the facility for a few months but had not received one and had reported this grievance at least three times. Resident #17 said she had also filed a grievance about her window blinds that she was unable to close because she could not raise her arms. She said she had requested curtains so she could let light in or block the light. Resident #17 said she had also filed a grievance regarding the activities assistant because the assistant would set up an activity and then leave the activity.-During the interview with Resident #17 in her room, no toilet seat riser or curtains were observed. C. Record reviewThe comprehensive care plan, revised 7/29/25, the resident had complaints of pain in her wrists and hands due to chronic arthritis, right wrist carpal tunnel syndrome and osteoarthritis in both shoulders. Interventions, dated 7/29/25, included providing the resident with one person staff assistance with activities of daily living (ADL). A review of Resident #17's electronic medical record (EMR) failed to reveal documentation indicating Resident #17's grievances had been addressed.On 10/29/25 at 9:45 a.m., grievances submitted for Resident #17 were requested from the social services director (SSD). The facility was unable to provide any grievances from the resident.III. Staff interviewsThe SSD was interviewed on 10/29/25 at 1:00 p.m. The SSD said the facility's process for grievances was that when a resident had a grievance, the resident was encouraged to report the concern to the SSD. She said she then would talk to the resident, family, and any staff that were involved and take the concern to the department manager who was responsible for the department pertaining to the grievance. The SSD said depending on the grievance, she would also offer to schedule a meeting with the third party resident advocate. The SSD said she did not use formal grievance forms and the facility did not have specific grievance forms. She said she would type up the details of the resident's grievance in a word document and save the documentation. She said if another department resolved the grievances, the SSD would include in her word document what the department manager did to resolve the grievance. The SSD said there was no written documentation provided to the resident or complainant and no documentation was signed by the resident or complainant to show a resolution was provided. The SSD said she did not have any written grievances for Resident #17. She said the facility had provided the resident with a new toilet and several different toilet risers, but she said there was no documentation of that. She said she was unaware of any grievances for Resident #17 related to the window or activities. The NHA was interviewed on 10/29/25 at 1:45 p.m. The NHA said the facility did not have a formal grievance process which included grievance forms for complainants to complete and documentation to be provided back with the resolution. She acknowledged the facility needed to improve their process to ensure grievances were documented, responded to timely, and resolved in a satisfactory way for the complainant.

Based on record review and interviews, the facility failed to ensure one (#12) of three residents reviewed for abuse out of 17 sample residents were free from abuse. Specifically, the facility failed to protect Resident #12 from caregiver neglect when a staff member refused to provide the resident care.Findings include:I. Facility policy and procedureThe Resident Abuse policy, undated, was provided by the nursing home administrator (NHA) on 10/27/25 at 12:21 p.m. It read in pertinent part, During an active investigation any employee who is an 'alleged perpetrator' will be immediately suspended without pay and sent home until an investigation is completed. II. Resident #12A. Resident statusResident #12, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included traumatic brain injury, vascular dementia and stroke. The 8/13/25 minimum data set (MDS) assessment revealed Resident #12 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The resident required moderate to extensive staff assistance with activities of daily living (ADL) and required a mechanical lift to transfer from the bed, chair, or toilet. Resident #12 had impairments to his right side with a contracture to the right hand related to his stroke. B. Resident and resident's representative interview Resident #12's spouse was interviewed on 10/28/25 at 2:15 p.m. He said in September 2025, he went to the nurses' station and certified nurse aide (CNA) #1 was at the nurses' station with registered nurse (RN) #3. He said when he asked CNA #1 to transfer Resident #12, she ignored him and refused to transfer Resident #12 even after being asked by RN #3. He said CNA #1 used profanity at him when he complained about her not providing care to Resident #12. He said RN #3 had to find another CNA to transfer Resident #12.Resident #12 was interviewed on 10/29/25 at 9:00 a.m. Resident #12 said he did not like the drama between his spouse and the staff. He said he just wanted to go home with his spouse and became emotional. He said he no longer wanted to discuss the incident. C. Record reviewThe ADL care plan, revised 8/19/25, revealed Resident #12 had an ADL deficit related to a stroke and required staff assistance for transfers with a mechanical lift. III. Staff interviewsRN #3 was interviewed on 10/29/25 at 11:08 a.m. RN #3 said on 9/4/25, Resident #12's spouse came to the nurses' station and asked CNA #1 to transfer Resident #12 from his recliner. RN #3 said that CNA #1 ignored the spouse twice. RN #3 said when the spouse told RN #3 that CNA #1 had ignored him, she asked CNA #1 to go and transfer Resident #12. RN #3 said CNA #1 replied that she was busy charting notes. RN #3 said Resident #12's spouse then became upset and said he was going to report CNA #1. She said CNA #1 responded by using profanities and telling the spouse she did not care what he did and she would do what she wanted. RN #3 said she had to find a different CNA to provide care to Resident #12, because CNA #1 was unwilling to assist. RN #3 said if a caregiver refused to provide care to a resident, that would constitute neglect. She said she reported the incident to the director of nursing (DON) right after she ensured Resident #12 was transferred. CNA #1 was interviewed on 10/29/25 at 12:19 p.m. CNA #1 said that Resident #12's spouse had previously accused her of being mean to the resident and yelling at him, so she would not interact with the spouse any longer. CNA #1 said that when the spouse would come into the facility, he would direct her to do things for the resident. She said she was aware of her responsibilities, therefore she would ignore him. She said she felt after he made accusations against her, she had the right to not respond to him. CNA #1 said that she did not have to speak to anyone that she did not want to speak to and she had the right to choose to ignore him when he spoke to her. She said on the day of the incident, the spouse had come to the nurses' station demanding that she transfer Resident #12 and she told the nurse she would transfer the resident. CNA #1 said she did ignore the spouse initially, but after being asked by the nurse, she went to complete the transfer. -However, according to interviews with, RN #3 and the DON two other CNAs completed the transfer, because CNA #1 refused to provide assistance. CNA #1 said there was never an investigation done against her, nor at any time was she ever suspended or removed from providing care to Resident #12.The social services director (SSD) was interviewed on 10/29/25 at 1:00 p.m. She said the facility's process for investigating potential resident abuse included interviewing other residents to determine if they had experienced anything similar to the allegation, interviewing all the employees present along with any other employees that may have worked in the same area and suspending the employee alleged in the abuse. The SSD said the reason for suspending any employees that had been named in an abuse allegation was to ensure the resident's safety and that no retaliation would occur. The SSD said the definition of caretaker neglect was not giving the resident care to ensure their well-being and safety. The SSD said if an employee refused to provide care to a resident, that would constitute caretaker neglect. The SSD said she had not been notified of CNA #1 refusing to provide care to Resident #12. She said if she had been notified, she would have investigated the incident as potential abuse to determine if CNA #1 had refused to care for any other residents. She said using profanity at a family member and refusing to provide care was not a customer service issue but potential neglect of a resident's needs. The NHA and the DON were interviewed together on 10/29/25 at 1:45 p.m. The DON said that staff received abuse training during their onboarding and annually. She said examples of caregiver neglect included ignoring call lights, not providing care that was needed and not responding to a resident's needs. The DON said if a caregiver responded to a write-up or a complaint by lashing out or not taking care of the resident involved, this would be considered retaliation. The DON said there had been a build up of negativity between CNA #1 and Resident #12's spouse. The DON said the two did not get along. She said on 9/4/25, the spouse came to the front desk and asked CNA #1 for assistance transferring Resident #12. The DON said CNA #1 did not respond to him. The DON said when the spouse told her he was going to file a compliant, CNA #1 began using profanity and told him she did not care what he did. She said two other CNAs went to assist Resident #12. The DON said CNA #1 had told her that she did not want to have contact with the spouse because of disagreements the two have had in the community outside of the facility. The DON said CNA #1 expressed she did not want anything to do with the spouse. She said CNA #1 was never suspended, investigated, or removed from Resident #12's hall. The DON said the potential impact of CNA #1 refusing to respond to Resident #12's spouse when he requested care for the resident was that the resident may not receive care or his care may be delayed.The NHA said the facility's process when suspected abuse of any kind occurred was to suspend the potential staff involved, interview other staff and interview other residents that the staff member may have been providing care for. She said after the disciplinary write up on 9/4/25 with CNA #1, the facility checked in with Resident #12 to ensure he was receiving care from CNA #1. The NHA said the facility also checked in with the staff. She said there had not been an investigation regarding the incident on 9/4/25. The NHA said the staff and other residents were not interviewed to determine if this was a pattern or if there had been other potential victims, because she had viewed the incident as a customer service issue. The NHA said the refusal to provide care should have been treated as potential neglect and the facility should have conducted an investigation.

Based on record review and interviews, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#2) of three residents reviewed for quality of care of six sample residents. Resident #2 had a diagnosis of type 2 diabetes and was at risk for skin impairment to his feet according to his plan of care. The resident had skin impairments noted to his toe on 4/1/22 indicated by certified nurse aides identified during bathing. The resident had weekly skin assessments which identified reddened, and scabbed areas on both of his feet as early as 4/21/22. The facility failed to implement interventions, monitor and treat the skin impairments to his toes/feet were identified in early April 2022. The resident's shoes were rubbing his toes identified by progress notes and new shoes were not ordered timely. Due to the facility's failures, the resident experienced a change of condition 5/26/22 and was sent to the hospital on 5/27/22 for treatment which resulted in an infection, and an amputation of his great toes on both of his feet. Findings include: I. Facility policy and procedure The Foot Care policy, last revised March 2018, was provided on 12/21/22 at 11:00 a.m. by the director of nursing (DON). The policy read in pertinent part, Residents will receive appropriate care and treatment in order to maintain mobility and foot health. Residents will be provided with foot care and treatment in accordance with professional standards of practice. Overall foot care will include the care and treatment of medical conditions associated with foot complications (diabetes, peripheral vascular disease). Trained staff may provide routine foot care (clipping) within professional standards of practice for residents without complicating disease processes. Certified nursing assistants will provide routine nail care. Registered nurses or licensed practical nurses will provide diabetic nail care. Residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals. II. Failure to ensure the resident's feet were monitored and treated timely A. Resident status Resident #2, age 69, was discharged on [DATE] to the emergency department. According to the May 2022 computerized physician orders (CPO) diagnoses included vascular dementia, diabetes mellitus with diabetic nephropathy, restless leg syndrome, personal history of transient ischemic attack (TIA), and cerebral infarction (stroke) without residual deficits, cellulitis (skin infection) of right toe, and other skin changes. The 5/6/22 minimum data set (MDS) assessment showed the resident's cognitive skills for daily decision making was severely impaired-never/rarely made decisions. The MDS assessment indicated the resident required total assistance with activities of daily living, which included bathing. The MDS assessment showed the resident had no pressure injuries. The MDS assessment showed that other skin problems or lesions were abrasions and bruises. The MDS assessment showed that skin treatments were a pressure relieving device(s) for chair, pressure relieving device(s) for bed, and a turning/repositioning program. The MDS assessment showed that foot problems and care were limited to nails and calluses being trimmed during the last 90 days. The 4/12/22 care plan identified the resident had a diagnosis of diabetes mellitus type 2. Pertinent approaches included to monitor his feet during dressing for any open areas, redness and from cracks, apply lotion. -The resident had skin impairments noted to his feet/toes (see below) that was not updated on his care plan with new interventions. B. Failure to monitor the resident's feet 1. Shower sheets The shower sheets provided from April 2022 through May 2022 indicated resident's bilateral feet began to show reddened areas and scabbed areas. However, the facility failed to monitor, assess, track and evaluate the interventions of the wounds. The May 2022 CPO showed an order for skin assessment to be completed weekly. The review was as follows: The shower sheets were completed by the certified nurse aide (CNA) providing the shower, however, the sheets were also cosigned by the licensed nurse. A skin assessment was then completed by the licensed nurse weekly. The 4/1/22 shower sheet documented the left great toe identified by a circle on the front of the diagram Scab. There was no evidence of the measurements or any tracking of the scab. The 4/3/22 shower sheet circled all toes for left and right foot on front of diagram reading, scab with additional information in comment section reading, Little redness on scabs on both great toes. The 4/5/22 shower sheet circled all toes circled for left and right foot on front of diagram read, red over great toe. The 4/7/22 shower sheets All toes circled for left and right foot on front of diagram reads, red and scabbed area. The 4/14/22 shower sheet circled all toes circled for left and right foot on front of diagram read, scabs on great toes. The 4/21/2022 shower sheet showed both great toes circled for right and left foot on front of diagram read, Old scabs. Shower sheets dated 4/22/22, 4/23/22, 4/24/22, 4/25/22 and 4/26/22 documented no new skin issues were present. The 5/5/22 shower sheet documented, all toes circled for left and right foot on front of diagram read, scabbed and red x 6 toes. The 5/6/22 shower sheet documented, all toes were circled for left and right foot on front of diagram read, scabs on toes. The 5/7/22 shower sheet documented, all toes circled for left and right foot on front of diagram read, scabbed red toes. -However, there was no indication of which toes. The 5/8/22 shower sheet documented, all toes circled for the left and right foot on front of diagram read, scabbed red toes. The 5/10/22 shower sheet documented, Line through all toes for left and right foot foot on diagram reads, old scabs on toes. 2. Weekly skin assessments completed by licensed nurse The licensed nurse weekly skin assessment showed the following: The 4/7/22 weekly skin check failed to identify any redness or scabbing to the toes on bilateral feet. The 4/14/22 weekly skin check described a scabbed area to bilateral great toes. -However, there was no documentation to include the monitoring, or further assessment of the bilateral feet. The 4/21/22 weekly skin check failed to identify any redness or scabbing to bilateral feet. The 4/28/22 weekly skin check identified breaks in skin as toes. -However, there was no indication of which foot and which toe. The 5/5/22 weekly skin check revealed scabbed great toes, and redness noted to toes bilateral feet. The 5/19/22 weekly skin check revealed scabs noted to great toes and red areas to toes on bilateral feet. The 5/26/22 weekly skin check revealed the area on the right great toe has black scab measuring 2.5 centimeters (cm) by 1.5 cm and redness to the right great toe. -The resident's medical record failed to show the weekly skin assessments completed by the licensed nurse had measured and monitored the resident's skin impairments to the toes/feet. The physician and the legal representative were not notified of the change of condition in the resident's bilateral feet (cross-reference F580). III. Failure to put identified interventions in place A. Record review The progress note dated 5/2/22 read in pertinent part,Resident has red and scabbed areas to top of both great toes, both long toes and both of the 3rd toes. Resident's shoes are rubbing on the toes. The progress note dated 5/3/22 read the nurse left social services staff a note asking for new shoes for the resident due to the condition of his toes and shoes being too big for the resident. B. Interviews The social services director (SSD) was interviewed on 12/7/22 at 2:00 p.m. The SSD said if she was left a note on her desk she would have informed the nursing department that measurements were needed for new shoes. -However, the SSD was unable to provide any evidence that she informed the nursing department that measurements were needed. Licensed practical nurse (LPN) #1 was interviewed on 12/7/22 at 2:30 p.m The LPN said she was the nurse who was responsible to order the shoes for Resident #2. She said she had ordered him shoes in the past, but could not recall when they were last ordered. She said that he did need to get a new pair, as he had recent weight loss, and his current shoes were too big. She said when shoes were ordered then a note was placed in the resident's medical record. She said the business office would order the shoes after his feet were measured. She could not recall if she had measured his feet recently. The business office manager was interviewed on 12/7/22 at 3:00 p.m. The BOM said she had not purchased any shoes for the resident recently. She reviewed the records and provided a receipt of purchase for the Pedora shoes dated 12/29/21. She said she had no other receipts. She did provide a note from the family which documented, permission to purchase any item Resident #2 needed. The legal representative was interviewed on 12/13/22 at 4:42 p.m. She said the facility informed her of a need for new shoes in April 2022 during a care conference as his toes were rubbing on his shoes. She said she was under the impression they were going to order him wider shoes. She said she approved of them ordering shoes. She said she did not believe that shoes were ever ordered. She said the hospital informed her (5/28/22) that the occurrence with the feet of Resident #2 was indicative of his feet rubbing on his shoes. IV. Change of condition The resident's right foot showed a change of condition starting on 5/26/22. The progress note dated 5/26/22 read in pertinent part, When skin assessment done this am (morning) noted larger black scabbed area on right great toe with redness of great toe itself. Area is not warm to touch but does appear to cause discomfort when touched due to resident pulls foot away when foot dried this morning with shower. The progress note dated 5/27/22 written at 5:38 a.m documented in pertinent part, CNA (certified nurse aide) reported to nursing that a scab to the great left toe was seeping. Bruising and swelling noted to the right great toe and redness to top of left foot. Documentation continued to inform that the right great toe was inspected as well, it was noted to have bruising, swelling, and redness to the top of foot. A second progress note was entered on same day 5/27/22 at 7:50 p.m. revealing that facility physician had been notified of the right great toes appearance and that Resident #2 had a temperature of 101. It was also noted that the right great toe continued to have swelling and bruising. In response to notification the facility, the physician provided telephone order instructions that Resident #2 be sent, non-emergent, to the emergency room the following morning. The physician provided a diagnosis of cellulitis (skin infection) of foot and toe, and instructed nursing staff to give Tylenol for temperature and Resident #2 be encouraged to drink fluids. -The physician was asked on 12/21/22 about any correspondence regarding feet prior to 5/27/22, no response was received. The resident was sent to the emergency department (ED) on 5/28/22. The progress note dated 5/28/22 at 9:43 a.m specified, to have right great toe evaluated. The 5/28/22 hospital records documented, Gangrene right great toe. Large scab present to right great toe. Left toe abrasion. ED notes continued to read the course of action was to transport Resident #2 to a different hospital so the toe could be amputated due to gangrene. The resident was transferred to another hospital on 5/28/22. Records were requested from the hospital and were not received. V. Interviews Certified nurse aide (CNA) #2 was interviewed on 12/8/22 at 3:00 pm. CNA #2 said when a resident received a shower, a shower sheet was completed. The sheets were a means to document the skin changes. She said then the sheets were provided to the licensed nurse, and the licensed nurse would complete the skin assessment and sign off on the sheet. The director of nursing (DON) was interviewed on 12/8/22 at 1:00 p.m. The DON reviewed the resident's medical record and said the resident had scabbed areas on his feet. The DON said that she had seen his feet prior to his discharge to the hospital. The DON said that the root cause was concluded to be shearing and rubbing on his shoes from healing his toe wounds. The DON said that measurements would not be done on the affected area, as only open wounds were measured. She said after reviewing the resident's medical record, it could not be determined when the scabs from his feet were actual open wounds. The legal representative was interviewed on 12/13/22 at 4:42 p.m. She said that she was not notified about the resident's feet until the day he was transferred to the hospital. She said she received a call that the resident was being transferred to the hospital. She said the physician at the hospital told her he had an infection in his foot, and that he needed to be transferred to another hospital for surgery, as his great toe had gangrene and an infection, and would need to be amputated. She said he was transferred to another hospital. She said after he was admitted to the other hospital, both of his great toes were amputated on both feet. Registered nurse (RN) #1 was interviewed on 12/21/22 at 11:00 a.m. She said that skin checks were conducted weekly and they were head to toe. She said that a certified nursing aide was instructed to inform the licensed nursing staff of any skin concerns. She said a resident with diabetes would be at risk and their skin was to be assessed for redness, non-blanchable areas, and any areas warm to the touch. She said the nurses would take measurements of the areas and document it in the resident's record. The primary care physician was contacted on 12/21/22, however, no response was received.

Based on record review and interviews, the facility failed to inform the physician and the resident's legal representative of changes in condition with two (#1 and #2) out of three residents out of six sample residents. Specifically, the facility failed to: -Notify the physician for Resident #2 and Resident #1 when their was a change in condition; and, -Notify the resident representative of a change in condition for Resident #2. Findings include: I. Facility policy and procedure The Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 3/14/11, was provided by the director of nursing (DON) on 12/7/22 at 2:00 p.m. The policy read in pertinent part, under cause identification, 1. The Physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. 2. The Physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing. The director of nursing (DON) was interviewed on 12/22/22 at 12:00 p.m. The DON said the facility did not have a specific policy on notification to the physician or the resident's legal representative. II. Resident #2 A. Resident status Resident #2, age 69, was admitted to the facility on [DATE]. According to the May 2022 computerized physician orders (CPO) diagnoses included; vascular dementia, diabetes mellitus with diabetic nephropathy, restless leg syndrome, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, cellulitis (skin infection) of right toe, and other skin changes. The 5/6/22 minimum data set (MDS) assessment showed cognitive skills for daily decision making as severely impaired-never/rarely made decisions. He was totally dependent on the assistance of one staff member to physically assist with dressing and bathing. No Braden scale completed on MDS assessment. The MDS assessment showed the resident did not have any pressure ulcers. The MDS assessment showed that other skin problems or lesions were abrasions, bruises. The MDS assessment showed that skin treatments were a pressure relieving device(s) for chair, pressure relieving device(s) for bed, and a turning/repositioning program. The MDS assessment showed that foot problems and care were limited to nails and calluses being trimmed during the last 90 days. B. Representative interview The legal representative of Resident #2 was interviewed on 12/13/22 at 4:42 p.m She said she was contacted by facility on morning of 5/28/22 and was informed that Resident #2 was heading to the emergency room because of an infection in the toes. She said the nursing facility had not provided her with any information prior to this in regards to concerns with the feet of Resident #2. C. Record review The nursing facility face sheet listed wife of Resident #2 as primary decision maker. The progress note dated 5/2/22 read in pertinent part, Resident has red and scabbed areas to top of both great toes, both long toes and both of the 3rd toes. Resident's shoes are rubbing on the toes. The 5/5/22 weekly skin check revealed scabbed great toes, long toes bilateral feet and redness noted to toes bilat feet. Foot problems and care revealed that nails/calluses were trimmed during the last 90 days on weekly skin assessment. The progress note dated 5/26/22 documented in pertinent part, When skin assessment done this am noted larger black scabbed area on right great toe with redness of great toe itself. Area is not warm to touch but does appear to cause discomfort when touched due to resident pulls foot away when foot dried this morning with shower. When checking last skin check noted there was scabbed areas on great toe. Area of black scab measures 2.5 cm (centimeter) by 1.5cm and is irregular. The emergency department (ED) progress note on 5/28/22 read, Gangrene right great toe. Large scab present to the right great toe. Left toe abrasion. ED notes continued to read course of action was to transport Resident #2 to a different hospital so that toe could be amputated due to gangrene. -The resident's medical record failed to show the physician was notified of the changes of condition in the resident's skin prior to the resident's transfer to the emergency department on 5/28/22. In addition, Resident #2's representative was not notified of the condition of his skin prior to him being transferred to hospital. C. Interviews Certified nursing aide (CNA) #2 was interviewed on 12/8/22 at 2:00 p.m CNA #2 said that she was familiar with Resident #2 and often provided care with activities of daily (ADL). She said the resident's toes were red and this was reported to the charge nurse. She was unable to provide specific dates. The director of nursing (DON) interviewed on 12/21/22 at 1:00 p.m The DON reviewed the resident's medical record and confirmed the resident had a significant change to his left foot. She said the physician and legal representative should be notified when there was a change of condition. 47536 III. Resident #1 A. Resident status Resident #1, over the age of 90, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO) diagnoses included heart failure, rheumatoid arthritis osteoporosis, chronic pain, and hypertension. The 9/5/22 minimum data set (MDS) assessment revealed the resident's brief interview for mental status (BIMS) with a score of 15 out of 15. The resident was totally dependent on staff to complete activities of daily living (ADL) including assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for developing pressure injuries; had no pressure ulcer/injuries, and used a pressure relieving device for bed, turning/repositioning program, application of ointments/medications, and other preventive or protective skin care. B. Change of condition The resident experienced a change of condition in her skin with the start of 9/24/22 with an open area to her right and left buttocks (Cross-reference F686 pressure injury). On 10/13/22 she had a pressure injury on her left coccyx and resolved redness and irritation on the right side of her back. On 10/26/22 the resident had a new open area o n her right side of back, two areas on her coccyx and the left side of her back. On 11/10/22 the resident had a left hip area classified as a stage 1 pressure injury. -The resident's medical record failed to show evidence the primary care physician was notified of the changes in the skin check findings of the open area, and treatment provided since 9/24/22. C. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 12/8/22 at 2:00 p.m. The LPN stated when a new problem was identified during the skin assessment the process was to notify the family and physician. She said a note would be documented in the progress notes to indicate both the family and the physician were notified. The director of nurses (DON) was interviewed 12/8/22 at 3:00 p.m. The DON said the physician should always be notified timely when a change of condition occurs with a resident. She reviewed Resident #1's record and could not find any evidence that the physician was notified. She said in the past a text message was utilized to the physician's phone. -However, she was unable to show evidence that a text message was used.

Based on observations, record review and interviews, the facility failed to prevent development of pressure ulcers for one (#1) three residents reviewed for pressure ulcers of six sample residents. Specifically, the facility failed to prevent avoidable pressure injury and to provide necessary services to promote healing and prevent new injuries from developing. The facility failed to ensure the resident's pressure ulcer had physician orders for monitoring and treatment, and failed to ensure the pressure ulcers were staged correctly for Resident # 1. Due to the facility's failures, Resident #1 developed open areas on her skin, including two stage 2 pressure ulcers. Findings include: I. Professional reference The NPUAP Pressure Injury Stages,The National Pressure Ulcer Advisory Panel, was retrieved on 1/4/22 at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (retrieved 11/22/22): Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. Individuals with a medical device are at a high risk of pressure ulcers related to the device. These pressure ulcers often conform to the pattern or shape of the device and develop due to prolonged, unrelieved pressure on the skin, often contributed to by associated moisture around the device, impaired sensation or perfusion and/or local edema, as well as systemic factors. Assessment of skin that is placed at risk due to a medical device is highlighted. II. Facility Policy The Pressure Ulcer/Skin Breakdown -clinical protocol policy, dated 3/14/11, was received on 12/8/22 from the director of nurses (DON). The policy read in pertinent parts, The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition the nurse shall assess and document/report the following: a Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue c. Pain assessment d. Resident's age and sex e. Resident's mobility status f. Current treatments, including support surfaces g. All active diagnoses. The physician and staff will examine the skin of a new admission for ulcerations or indications of a stage I pressure area that has not yet ulcerated at the surface. The physician will help the staff define the type and character of the ulceration. The physician will authorize pertinent orders related to the wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound. II. Resident #1 A. Resident status Resident #1, over the age of 90, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO) diagnoses included heart failure, rheumatoid arthritis, osteoporosis, chronic pain, and hypertension. The 9/5/22 minimum data set (MDS) assessment revealed the resident's brief interview for mental status (BIMS) with a score of 15 out of 15. The resident was totally dependent on staff to complete activities of daily living (ADL) including assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for developing pressure injuries; had no pressure ulcer/injuries, and used a pressure relieving device for bed, turning/repositioning program, application of ointments/medications, and other preventive or protective skin care. The comprehensive care plan, revised 10/11/22, identified the resident was at risk for developing pressure ulcers and had a history of healed pressure ulcers on her coccyx. The interventions were to assist Resident #1 with peri-care after each incontinent episode, conduct a systematic skin inspection once a week, report any signs of any further skin breakdown (sore, tender, red, or broken areas), encourage the resident to off-load coccyx area when in bed and when sitting in recliner chair, if a pressure ulcer developed, may consult with consultant wound nurse for treatment recommendations. B. Observations and interview On 12/7/22 at 1:15 p.m., the resident was lying on her back in her bed in a semi-reclined position. The bed had a pressure reducing mattress. On 12/8/22 at 2:00 p.m., the resident's weekly skin assessment was observed with licensed practical nurse (LPN) #1. The resident was lying in her bed in a semi-reclining position. The resident had one pillow positioned beneath each hip. LPN #1 proceeded to uncover the resident to observe the resident. The resident had one open area on her lower back and one open area on her left hip. Both open areas were uncovered and a small amount of red blood tinged drainage was visualized on each wound and there was a small amount of dried drainage noted on the bottom sheet. LPN #1 said all the wounds were improved and clarified that was based on her observations from previously assessing the pressure ulcers which was approximately three times a week during November and December 2022. The LPN measured each wound using a clear plastic overlay designed for wound measurements. The wounds were open, not infected with red and pink tissue visualized. After completing the skin assessment, the LPN completed wound care which consisted of washing the pressure wounds with soap and water and after the wounds were dry, she applied hydrocolloid barrier cream. During the skin assessment, the resident said that the pressure wounds were not painful. The resident also stated she could not recall if staff had told her that repositioning can help heal and prevent pressure ulcers. Resident #1 stated she wanted to stay in her bed and can sometimes tolerate repositioning with pillows or a blanket but that she needed help from staff for repositioning. C. Record review The 9/24/22 progress note documented the resident had red and open areas on her right and left buttocks. The areas were massaged, cleansed with soap and water and silicone barrier cream was applied. The resident had three open areas of left buttocks measured 3.5 cm (centimeters) x 4 cm, 1 cm x 1 cm and 1 cm x 1 cm. Two red areas, and one open on the right hip measured 3.5 cm x 3.5 cm. -A description of the open areas was not included in the progress note. A review of the record revealed there was not a notification to the physician regarding the development of the open areas on the resident's skin. On 9/30/22 the monthly MDS assessment indicated the resident had four stage 1 pressure ulcers. Interventions in place on 9/30/22 included; pressure relieving device for bed, turning/repositioning program, application of ointments/medications, and other preventive or protective skin care. A change in condition MDS was completed on 10/5/22.The assessment showed the resident had one stage 1 pressure ulcer and two stage 2 pressure ulcers. The resident's ADL status was unchanged. -The record failed to show the primary care physician was notified regarding the regarding the staging and open areas on the resident's skin. (Cross-reference F580). -The record review revealed there were no physician orders were obtained for application of ointments/medications, or pressure ulcer preventive or healing interventions. The 10/6/22 skin check marked completed, was blank. On 10/11/22 the physician completed a 60-day summary. The summary indicated the skin had no rashes, and that no new issues were present for evaluation. The 10/13/22 skin check indicated the resident had breaks in her skin on the left coccyx area and had resolving redness and irritation on the right back. -A review of the resident's record revealed there was not a notification to the provider regarding the staging and open areas on the resident's skin. The 10/26/22 1:54 p.m. progress note indicated the resident had new open areas on her skin. The open areas listed were: right side of back measured 4 cm x 4 cm, two on the coccyx measured 1.2 cm x 2 cm, 2 cm x 2 cm, and left side of back 1 cm circular. The nurse documented the areas were cleansed with soap and water and silicone barrier cream was applied. -A review of the resident's progress notes revealed documentation did not include wound descriptions, a notification to the physician regarding the skin check findings of the open area, and treatment orders were not located in the medical record. The 10/27/22 skin check marked completed, was blank. On 11/1/22, the resident's care plan was updated and included, the resident was at risk for skin breakdown and pressure ulcers related to the desire to lay on the back and not off-load. Interventions included, use pillows or blankets to assist resident with positioning, assist with toileting, hygiene, and repositioning, the resident declined an air mattress and/or air-overlay mattress topper, Resident declined to be repositioned or to off-load bony prominences and that resident and medical power of attorney were aware of the high risk for skin breakdown status, and the resident requested to lay in bed at all times. The 11/10/22 skin check indicated the Resident had two areas of redness and irritation: the coccyx and left hip. The left hip area was classified as a stage 1 decubitus ulcer and a description of the ulcer was not included. -A review of the resident's record revealed there was not a notification to the physician regarding the skin check findings of the open areas and redness. The 11/5/22 MDS assessment indicated the resident had 2 stage 2 pressure ulcers, treatments in place were pressure relieving device for bed, turning/repositioning program, interventions to manage skin problems, application of ointment/medications. The 11/24/22 skin check indicated the resident had open areas on her right back and coccyx and noted the coccyx had a decubitus ulcer but did not include a description or measurement of the ulcer. -A review of the resident's record revealed there was not a notification to the provider regarding the staging and open areas on the resident's skin. The 12/2/22 skin check indicated the resident had open areas on her coccyx and her left hip area. The coccyx was classified as a decubitus. A description, measurements, and staging were not included in the documentation. -A review of the resident's record revealed there was not a notification to the provider regarding the staging and open areas on the resident's skin. The 12/3/22 MDS assessment indicated the resident had 2 stage pressure ulcers. Treatments in place were; pressure relieving device for bed, turning/repositioning program, application of ointment/medications. The 12/5/22 physician progress note revealed an evaluation of the resident's skin was not included. The physician documented the nurses reported on 10/11/22 and 12/5/22 the resident was stable. The 12/8/22 skin check indicated the resident had breaks in her skin: coccyx area 1 cm x 1.5 cm, stage 2 left hip 1 cm x 1 cm, and left hip 2 cm x 2 cm, each stage 2. -A description of the pressure wounds was not included. On 12/8/22, after the start of the survey, the physician was contacted by the nurse regarding the pressure ulcers. The documentation indicated the physician was notified the resident had two pressure ulcers; one on the left hip, stage 2, and on the coccyx, and stated it was almost a stage 1 pressure ulcer. The physician then ordered to cleanse the area with normal saline, hydroguard, and off-loading. On 12/14/22 a mobile wound nurse completed an evaluation of the pressure ulcers. The coccyx wound measured 1.00 cm x 1.50 cm x < 0.2 cm and was classified as a stage 2 pressure ulcer. The left hip wound #1 measured 2 cm x 2 cm x <0.2 cm and was classified as a stage 2 pressure ulcer and left hip wound #2 measured 1 cm x 1 cm x <0.2 cm and was classified as a stage 2 pressure ulcer. The three wounds had 100 % red, dermal base and had well defined edges. The wound nurse recommended treatment for the three wounds included: clean the wound per physician order and apply hydrocolloid dressing and to change the dressing every other day or as needed. On 12/14/22 the physician orders were updated and included, cleanse the pressure ulcer areas with normal saline, apply hydroguard, cover with a silicone hydrocolloid dressing to promote autolytic debridement, and change the dressing every other day or as needed. An order was also obtained to measure the wound on the resident's coccyx and left hip weekly with skin measurements. D. Staff interview LPN #1 was interviewed on 12/8/22 following the skin assessment and treatment at 2:00 p.m. She said the current treatment for the pressure ulcers was to clean the areas with soap and water and then a thin layer of hydrocolloid barrier cream was applied. The LPN was unable to refer to physician orders for wound care and stated the current product used was one they have used for a long time. LPN #1 said the nurse would select the product and treatment that was appropriate for the condition and resident comfort and was based on the nurse's experience. The LPN said when a new problem was identified during the skin assessment the process was to notify the family and physician. If new orders are obtained after physician notification, the order and notes are downloaded from one system and then entered into the resident's electronic health record. The director of nurses (DON) was interviewed 12/8/22 at 3:00 p.m. The DON said nursing staff and the attending physician assess and document the risks for developing pressure ulcers. The care plan was to include the resident's risk for skin breakdown and pertinent approaches were put into place. The DON said when a pressure ulcer developed a full assessment, which included location, stage, measurement, and description of tissue should be included in the assessment. She said the resident had a weekly skin assessment completed. The DON said the resident was at high risk for developing pressure ulcers. The DON stated once a concern for a skin condition was identified the nurse would select a treatment product in stock, taking into consideration the resident's status, such as activity level, fluid status, diet ordered, or condition of circulation. The DON stated the application of hydraguard barrier cream to open pressure ulcer was current practice and the current treatment for the resident did not include application of protective or preventive dressings. The DON confirmed there was no physician order for the treatment which was provided to the resident's wounds. She said when the wound was open and or bleeding the wound should have a dressing on it. The DON stated the physician should be contacted to help define the type of wound and to help determine treatments, considering the resident's condition and other diagnoses. The DON stated by including the physician, the physician can then authorize the nursing staff to treat and manage skin conditions. The DON stated the purpose of completing a weekly skin assessment is to assess the current status of the resident's skin and to determine whether or not current treatments are effective. When the current treatments were not effective, the nurse completing the assessment should contact the physician, provide the assessment information, and then changes to care could be considered. Registered nurse (RN) #1 was interviewed on 12/21/22 at 11:00 a.m. RN #1 said that she had a conversation with the resident on the importance of being repositioned frequently and not lying in the same position. She said that after she explained the importance to the resident she understood and was more cooperative.

Based on observations, and interviews, the facility failed to ensure effective infection control practices were maintained to provide a safe, sanitary and comfortable environment to help prevent the transmission of Coronavirus (COVID-19) and other communicable diseases and infections for three of three units. Specifically, the facility failed to: -Ensure residents were monitored for COVID-19 symptoms per the federal recommended guidelines; and -Properly store PPE (personal protective equipment). Findings include: I. Status of COVID-19 in the facility A. Interview The nursing home administrator (NHA) provided the status of COVID-19 in the facility on 12/8/2020 at approximately 11:45 a.m. She said the resident census was 21. The facility had a dedicated COVID-19 positive unit. The facility currently had two COVID-19 positive residents, and one with COVID-19 symptoms. One COVID-19 positive resident was currently in the hospital. The NHA said they currently had two staff who were out with COVID-19 symptoms. The staff were tested twice weekly for COVID-19. The NHA said she worked with the County Health Department. She had weekly calls with them. II. Failure to ensure residents were monitored for Covid-19 symptoms per the federal recommended guidelines II Monitoring for COVID-19 symptoms A. Professional references The Centers for Disease Control and Prevention (updated 4/30/2020) Responding to Coronavirus (COVID-19) in Nursing Homes, retrieved on 12/17/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html. It read in pertinent part, Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least three times daily to identify and quickly manage serious infections. Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms. B. Facility policy and procedure The COVID-19 Prevention and Treatment policy, 4/8/2020, was provided by the assistant director of nursing (ADON) via email on 12/8/2020 at 1:31 p.m. It read in pertinent part, Purpose: to prevent COVID-19 from entering this facility, prevent outbreak if it does enter this facility, and treat residents if they do become infected with COVID-19. Monitor staff and residents for fever and symptoms of respiratory infection. Nursing staff are actively monitoring residents twice daily. In the morning, a full set of vital signs are obtained including temperature, blood pressure, heart rate, respiratory rate, pulse-oximetry, and assessed for symptoms of respiratory illness. At night, resident's temperature and pulse-oximetry are obtained and they are assessed for symptoms of respiratory illness. C. Resident #1 1. Resident status Resident #1, age 87, was admitted [DATE]. According to the December 2020 clinical physician orders [REDACTED]. The 9/12/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. 2. Record review Review of Resident #1's progress notes revealed the resident tested positive for COVID-19 on 11/26/2020 and transferred to the facility's COVID-19 unit. The positive result was delayed from a nasal swab obtained on 11/17/2020. Progress notes revealed Resident #1 received a nasal swab on 11/24/2020 which resulted as negative for COVID-19 on 11/27/2020. The resident remained on the COVID-19 unit. A progress note on 11/29/2020 revealed the resident was transferred back to her previous room off the COVID-19 unit, but she would remain in isolation for an undetermined amount of time. Further review of the progress notes revealed the following: -There was no documentation related to assessing the resident for symptoms of respiratory illness or other symptoms of COVID-19 prior to 11/26/2020; -There was no day shift documentation related to assessing the resident for symptoms of respiratory illness or other symptoms of COVID-19 on 11/30, 12/2, 12/3, 12/4, 12/5, 12/6, or 12/7/2020; -There was no night shift documentation related to assessing the resident for symptoms of respiratory illness or other symptoms of COVID-19 on 12/2, 12/4, 12/5, 12/6, or 12/7/2020; and -There was no documentation indicating the resident was assessed at least three times per day for symptoms of respiratory illness or other symptoms of COVID-19. Review of the Infection Control Event (an electronic medical record (EMR) charting tool utilized for acute issues) revealed Resident #1 was COVID-19 virus positive on 11/26/2020. However, the Event was not created in the EMR until 12/8/2020 at 1:33 p.m. and was backdated to 11/26/2020 at 6:32 p.m. Review of Resident #1's vital signs documented in the EMR from 11/8/2020 until 12/8/2020 revealed the following: -There were no temperatures documented for the resident on 11/8, 11/10, 11/11, 11/13, 11/20, 11/21, 11/22, 11/23, 11/24, 11/26, and 12/7/2020; -The resident's temperature was only documented once on 11/29, 11/30, 12/1, 12/2, 12/4, 12/5, and 12/6/2020; -There were no oxygen saturations documented for the resident on 11/8, 11/9, 11/10, 11/11, 11/13, 11/14, 11/15, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/29, and 12/7/2020; -The resident's oxygen saturation was only documented once on 11/30, 12/1, 12/2, 12/4, 12/5, and 12/6/2020; -There were no respiration rates documented for the resident on 11/8, 11/9, 11/10, 11/11, 11/13, 11/14, 11/15, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, and 11/29, and 12/7/2020; The resident's respiration rate was only documented once on 11/30, 12/1, 12/2, 12/4, 12/5, and 12/6/2020; -There were no pulse rates documented for the resident on 11/8, 11/9, 11/10, 11/11, 11/13, 11/14, 11/15, 11/20/, 11/21, 11/22, 11/23, 11/24, 11/25, 11/29, and 12/7/2020; -The resident's pulse rate was only documented once on 11/30, 12/1, 12/2, 12/4, 12/5, and 12/6/2020; -There were no blood pressures documented for the resident on 11/8, 11/9, 11/10, 11/11, 11/13, 11/14, 11/15, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, and 11/29, and 12/7/2020; -The resident's blood pressure was only documented once on 11/30, 12/1, 12/2, 12/4, 12/5, and 12/6/2020. The paper daily vital sign logs were provided by the ADON via email on 12/10/2020 at 4:40 p.m. The logs revealed from 11/8/2020 through 12/8/2020, Resident #1 had a full set of vital signs recorded each morning, and a temperature and oxygen saturation recorded each evening. However, the logs contained the vital signs for all residents on one page each shift and were not part of the EMR. The logs were kept in the ADON's office once they were completed. Nursing staff did not consistently enter the vital signs from the paper logs into the EMR for Resident #1, which did not allow nursing staff or medical providers to monitor the resident's history of vital signs for symptoms of COVID-19. Review of both the paper vital sign logs and Resident #1's EMR revealed monitoring was not increased to at least three times per day for all vital signs after she tested positive for COVID-19 on 11/26/2020. D. Resident #2 1. Resident status Resident #2, age over 90, was admitted [DATE], and discharged to the hospital on [DATE]. According to the December 2020 CPO, [DIAGNOSES REDACTED]. The resident tested positive for COVID-19 on 11/29/2020. The 10/17/2020 MDS assessment revealed the BIMS was not conducted as the resident was rarely/never understood. According to the staff assessment for mental status, his cognitive skills for daily decision making were severely impaired. 2. Record review Review of Resident #2's progress notes revealed the resident tested positive for COVID-19 on 11/29/2020 from a nasal swab obtained on 11/27/2020. He was transferred to the facility's COVID-19 unit on 11/29/2020. Further review of the progress notes revealed the following notes : -11/22/2020 at 8:48pm: Resident took medications without difficulty this night then 15 minutes later the resident had a small emesis. Resident now coughing occasionally with audible crackles noted with expiration sounds like in throat, water offered a couple sips taken po (orally). Lung sounds clear bilaterally all lobes. Resident in bed on left side, call light within reach. -11/23/2020 at 12/24pm: This nurse was notified by aide to report to the resident's room. Upon entering the room, this nurse noted that the resident was using accessory muscles to breathe and an audible sound similar to a seal was heard during expiration when the resident would lean forward. When the resident would lean slightly back, audible sound would diminish. Lung sounds were clear in all four quadrants. Bowel sounds were active in all four quadrants. Vitals are WNL (within normal limits) with the exception of respirations at 24. O2 (oxygen) is 95% on two liters. This nurse notified provider for directions. Provider stated to continue to monitor and if resident worsens, further action will be needed. Provider also advised that suctioning may be needed. This nurse will continue to monitor resident with the assistance of the CNA's. At this time, resident is sitting in wheelchair with respirations of 20 and O2 of 95% on 2 liters. Heart rate of 84 and BP of 114/74. -11/24/2020 at 1:36am: This nurse checked resident lungs and respirations before going to bed. Apical pulse 84 and strong, respirations 20 equal and unlabored, SP02 (oxygen saturations) 94% RA (room air), temperature 97.9. No audible wheezing noted. LS (lung sounds) clear all lobes per auscultation. CNAs reported resident had audible wheezing when assisting resident with HS (bedtime) cares and into bed that lasted only a few minutes and again when they turned resident at 10:30 p.m. No audible wheezing noted at this time. Resident is currently in bed resting quietly with eyes closed, call light within reach. There were no further progress notes related to assessing the resident for symptoms of respiratory illness or other symptoms of COVID-19 prior to 11/29/2020. There was no documentation indicating the resident was assessed at least three times per day for symptoms of respiratory illness or other symptoms of COVID-19. The progress notes revealed Resident #2 was transferred to the hospital on [DATE] at 4:23 p.m. and admitted with pneumonia due to Covid-19 per provider. Review of the Infection Control Event revealed Resident #2 was COVID-19 virus positive on 11/29/2020. However, the Event was not created in the EMR until 12/8/2020 at 1:28 p.m. and was backdated to 11/29/2020 at 1:28 p.m. Review of Resident #2's vital signs documented in the EMR from 11/8/2020 until 12/8/2020 revealed the following: -There were no temperatures documented for the resident on 11/11, 11/13, 11/16, 11/18, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/27, and 11/28/2020; -The resident's temperature was only documented once on 11/10, 11/12, 11/14, 11/15, 11/17, 11/19, and 11/26/2020; -There were no oxygen saturations documented for the resident on 11/11, 11/13, 11/14, 11/15, 11/16, 11/18, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/27, and 11/28/2020; -The resident's oxygen saturation was only documented once on 11/10, 11/12, 11/17, 11/19, and 11/26/2020; -There were no respiration rates documented for the resident on 11/11, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/27, and 11/28/2020; The resident's respiration rate was only documented once on 11/29/2020; -There were no pulse rates documented for the resident on 11/11, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/20, 11/21, 11/22, 11/23, 11/24, and 11/25/2020; -There were no blood pressures documented for the resident on 11/11, 11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/27, and 11/28/2020; -The resident's blood pressure was only documented once on 11/29/2020. The paper daily vital sign logs were provided by the ADON via email on 12/10/2020 at 4:40 p.m. The logs revealed from 11/8/2020 through 12/8/2020, Resident #2 had a full set of vital signs recorded each morning, and a temperature and oxygen saturation recorded each evening. However, the logs contained the vital signs for all residents on one page each shift and were not part of the EMR. The logs were kept in the ADON's office once they were completed. Nursing staff did not consistently enter the vital signs from the paper logs into the EMR for Resident #2, which did not allow nursing staff or medical providers to monitor the resident's history of vital signs for symptoms of COVID-19. Review of both the paper vital sign logs and Resident #2's EMR revealed monitoring was not increased to at least three times per day for all vital signs after he tested positive for COVID-19 on 11/29/2020. E. Resident #3 1. Resident status Resident #3, age over 90, was admitted [DATE]. According to the December 2020 CPO, [DIAGNOSES REDACTED]. The resident tested positive for COVID-19 on 11/27/2020. The 9/13/2020 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of 4 out of 15. 2. Record review Review of Resident #3's progress notes revealed the resident tested positive for COVID-19 on 11/27/2020 from a nasal swab obtained on 11/24/2020. She was transferred to the facility's COVID-19 unit on 11/27/2020. Further review of the progress notes revealed the following: -There was no documentation related to assessing the resident for symptoms of respiratory illness or other symptoms of COVID-19 prior to 11/27/2020; -There was no night shift documentation related to assessing the resident for symptoms of respiratory illness or other symptoms of COVID-19 on 12/2, 12/3, or 12/5/2020; -There was no documentation indicating the resident was assessed at least three times per day for symptoms of respiratory illness or other symptoms of COVID-19. Review of the Infection Control Event revealed Resident #3 was COVID-19 virus positive on 11/27/2020. However, the Event was not created in the EMR until 12/8/2020 at 1:14 p.m. and was backdated to 11/27/2020 at 10:13 a.m. Review of Resident #3's vital signs documented in the EMR from 11/8/2020 until 12/8/2020 revealed the following: -There were no temperatures documented for the resident on 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/18, 11/19, 11/20, 11/21, 11/22, 11/24, and 11/25/2020; -The resident's temperature was only documented once on 11/15, 11/16, 11/17, 11/23, and 11/26/2020; -There were no oxygen saturations documented for the resident on 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/18, 11/19, 11/20, 11/21, 11/22, 11/24, and 11/25/2020; -The resident's oxygen saturation was only documented once on 11/9, 11/16, 11/17, 11/23, and 11/26/2020; -There were no respiration rates documented for the resident on 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/24, and 11/25/2020; The resident's respiration rate was only documented once on 11/28, 11/29, and 12/3/2020; -There were no pulse rates documented for the resident on 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/24, and 11/25/2020; -There were no blood pressures documented for the resident on 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/24, and 11/25/2020. The paper daily vital sign logs were provided by the ADON via email on 12/10/2020 at 4:40 p.m. The logs revealed from 11/8/2020 through 12/8/2020, Resident #3 had a full set of vital signs recorded each morning, and a temperature and oxygen saturation recorded each evening. However, the logs contained the vital signs for all residents on one page each shift and were not part of the EMR. The logs were kept in the ADON's office once they were completed. Nursing staff did not consistently enter the vital signs from the paper logs into the EMR for Resident #3, which did not allow nursing staff or medical providers to monitor the resident's history of vital signs for symptoms of COVID-19. Review of both the paper vital sign logs and Resident #3's EMR revealed monitoring was not increased to at least three times per day for all vital signs after she tested positive for COVID-19 on 11/27/2020. F. Resident #4 1. Resident status Resident #4, age 73, was admitted [DATE]. According to the December 2020 CPO, [DIAGNOSES REDACTED]. The 9/5/2020 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. 2. Record review Review of Resident #4's progress notes revealed all of the resident's tests for COVID-19 had been negative. Further review of the progress notes revealed there was no documentation related to assessing the resident for symptoms of respiratory illness or other symptoms of Covid-19. Review of Resident #4's vital signs documented in the EMR from 11/8/2020 until 12/8/2020 revealed the following: -There were no temperatures documented for the resident on 11/8, 11/9, 11/13, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/25, 11/30, 12/2, 12/3, 12/5, 12/6, and 12/7/2020; -The resident's temperature was only documented once on 11/11, 11/14, 11/15, 11/23, and 11/26/2020; -There were no oxygen saturations documented for the resident on 11/8, 11/9, 11/11, 11/13, 11/14, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/25, 11/30, 12/2, 12/3, 12/5, 12/6, and 12/7/2020; -The resident's oxygen saturation was only documented once on 11/12, 11/24, 11/26, 11/29, 12/1, and 12/4/2020; -There were no respiration rates documented for the resident on 11/8, 11/13, 11/14, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/25, 11/30, 12/2, 12/3, 12/4, 12/5, 12/6, and 12/7/2020; -There were no pulse rates documented for the resident on 11/8, 11/13, 11/14, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/25, 11/30, 12/2, 12/3, 12/4, 12/5, 12/6, and 12/7/2020; -There were no blood pressures documented for the resident on 11/8, 11/13, 11/14, 11/15, 11/16, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/25, 11/30, 12/2, 12/3, 12/4, 12/5, 12/6, and 12/7/2020. The paper daily vital sign logs were provided by the ADON via email on 12/10/2020 at 4:40 p.m. The logs revealed from 11/8/2020 through 12/8/2020, Resident #4 had a full set of vital signs recorded each morning, and a temperature and oxygen saturation recorded each evening. However, the logs contained the vital signs for all residents on one page each shift and were not part of the EMR. The logs were kept in the ADON's office once they were completed. Nursing staff did not consistently enter the vital signs from the paper logs into the EMR for Resident #4, which did not allow nursing staff or medical providers to monitor the resident's history of vital signs for symptoms of COVID-19. G. Interviews The nursing home administrator (NHA), director of nursing (DON), and ADON were interviewed together on 12/9/2020 at 9:00 a.m. The ADON said all residents were getting a full set of vital signs monitored and documented every morning to include temperature, oxygen saturation, respiratory rate, pulse rate, and blood pressure. She said all residents were getting a temperature and oxygen saturation monitored and documented every evening. The ADON said the vital signs were recorded on paper logs and then should be entered into the EMR for each resident. She said she kept the copies of the paper logs in her office and compared them daily to the vital signs that were documented in the EMR. The ADON confirmed that there were vital signs not documented on several dates in the EMR. She said resident monitoring should be documented in the progress notes at least once a day, and twice a day if they were positive for COVID-19. The NHA said the facility kept all of the daily logs of vital signs, but she said the vital signs should be entered into the EMR. She said there was no reason the vital signs had not been entered consistently into the EMR except that staff had been concentrating on taking care of the residents. The DON said when a resident tested positive for COVID-19, the charge nurse should open an Infection Control Event because it was a change in condition for the resident. She said the Event would trigger the nursing staff to document on the resident more frequently. She said the Event should be opened on the date the resident tested positive. III. Failure to properly store PPE A. Professional references The Centers for Disease Control and Prevention (updated 11/23/2020) Optimizing the Supply of N95 Respirators in Nursing Homes, retrieved on 12/20/2020 from https://www.cdc.gov/coronavirus/2019-ncop/hcp/respirators-strategy/index.html. It read in pertinent part, Data suggest limiting the number of reuses of N95 respirators to no more than five uses (five donnings) per device by the same health care personnel (HCP) to ensure an adequate respirator performance. HCP should always inspect the respirator upon donning a re-used respirator. Respirators soiled or grossly contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients should be discarded. One potentially effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to patients with [DIAGNOSES REDACTED]-CoV-2 ([MEDICAL CONDITION] that causes COVID-19) infection a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and store them properly each day. This amount of time in between uses should exceed the 72 hour expected survival time for [DIAGNOSES REDACTED]-CoV-2. If this strategy is used, the total number of donnings should still not exceed five times before discarding the respirator. B. Facility policy and procedure The COVID-19 Optimizing the Supply of Face Masks policy, 4/2/2020, was provided by the assistant director of nursing (ADON) via email on 12/9/2020 at 12:12 p.m. It read in pertinent part, All employees will be given two masks and two paper bags. Employees must write their name on each bag and store their facemasks inside of the bag. Then place the paper bag on the wall in the entrance. Staff are introduced to wear one mask during their shift unless the mask becomes soiled, defective or hard to breath in. When reusing a mask staff will place their used mask in a paper bag and store it for AT LEAST 24 HOURS. Alternate use of masks between every other shift. Staff should label their bag to keep track of when the mask was last used. C. Observations On 12/08/2020 at 1:00 p.m., certified nurse aide (CNA) # 1's personal protective equipment (PPE) container was observed. There were four surgical masks in the container, a N95 she said was too small for her but she kept it and a paper bag with her name on it with a new N95 in it. Her paper bag had her name on it but there was no date. D. Interviews CNA #1 was interviewed on 12/8/2020 at 1:00 p m. She said the N95 masks go in the paper bags at the end of the shift. She said she thought the N95 could be worn for five shifts and then needed to be thrown away. They work three 12 hours shifts, they wear one mask for that time, if they work more than three shifts then they can still wear the N95 for two more shifts. She said the masks could not be worn more than five days. If the mask became dirty or soiled then a new one would be obtained before the five days. She said she sprayed her N95 with disinfectant prior to putting it away. The food service manager (FSM) was interviewed on 12/8/2020 at approximately 1:00 p.m. The FSM said she wore her N95 mask for multiple shifts. She said that prior to storing it in a brown paper bag, she would spray it with a disinfectant. She said she did not know if she was supposed to spray it. The infection preventionist was interviewed on 12/9/2020 at 9:00 a.m. She said the staff should not be spraying their masks with anything prior to storing. The staff should put their N95s in a paper bag for storage and then place the bag in the plastic boxes that were kept outside by the entrance. The NHA said we would never tell the staff to spray down their N95s with anything.

Based on observations, record review and interviews, the facility failed to ensure one (#6) of 13 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to timely and appropriately assess resident #6's right lower extremity bruise. The findings included: Resident #6, age 99, was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the 7/19/17 minimum data set (MDS) assessment, the resident had clear speech, was understood and able to understand others. Her cognition was intact with a brief interview for mental status (BIMS) score of 15 out of 15. No hallucinations, delusions or rejection of care behavior were noted. She required extensive assistance with bed mobility, dressing; limited assistance with transfers, personal hygiene and toilet use. She was independent with eating and walking. According to the comprehensive plan of care, the resident's skin should be monitored daily for any new bruises when care was provided. Staff were to report to the charge nurse any action by staff or the resident that might cause a bruise. The physician's annual history and physical (H&P), dated 9/20/17, documented, Skin: Normal moisture & temp(erature). No rash. Very thin (with) bruising noted on ankles and shins. Observations: The resident was observed on 8/2/17 at 3:30 p.m. in her room, sitting in a reclining chair. A dark bluish oblong bruise, approximately 5 cm x 3 cm, was observed on the resident's right anterior lower leg, above her ankle. The resident said she did not remember how long she had the bruise and that she probably bumped into something when she was walking. On 10/4/17 at 9:30 a.m., the resident was observed in her room, resting on her reclining chair. The bruise on her right lower leg was exposed. Review of the resident's medical record, including nursing notes, nursing assessments and the treatment administration record (TAR) revealed no documentation addressing the bruise on the resident's right lower extremity. Staff Interviews: The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 10/4/17 at 10:00 a.m. The DON said she did not know about the resident's bruise. The ADON said the resident bruised easily and frequently. The registered nurse (RN#1) was interviewed on 10/4/17 at 10:15 a.m. She said the resident told her the bruise had been there (on the anterior aspect of the right lower leg) for quite some time. On 10/4/17 at 3:40 p.m., the resident's physician (MD) was interviewed in the presence of the resident. She said when she assessed the resident (9/20/17) she documented all of her findings in her note. She confirmed the resident's current bruise on the right lower part of her shin, on the bony prominence. On 10/4/17 at 4:20 p.m., the DON and the ADON were interviewed in the presence of the NHA. The DON said the resident's bruise should be reported by staff, evaluated and treated in a timely manner. Facility follow up: On 10/4/17 at 10:51 a.m. the DON documented in nursing notes: It is noted that Res(ident) has areas of red discoloration on her shins and at times gets this on her arms. Res(ident) has a hx (history) of bruising and bruises very easily and has fragile skin. The red discoloration is baseline for Res(ident). Res(ident) denies any pain or discomfort in her shins. Res(ident) denies any abuse or trauma. Res(ident) stated, 'This has been there for quite some time.' Encouraged Res(ident) to be cautious during ADLs (activities of daily living) and activities to be aware of her extremities and to try to prevent injury such as bumping them on something.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food under sanitary conditions. Specifically, the facility failed to: -Follow accepted hand hygiene practices; and -Ensure cutting boards were free from being scored and stained. The findings include: 1. Hand Hygiene Professional References According to the Colorado Retail Food Establishment Rules and Regulations (CRFERR), pg. 13-14, Food employees shall clean their hands and exposed portions of their arms for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, area between the fingers, hands and arms for at least 15 seconds, followed by: thorough rinsing under clean, running, warm water; and immediately follow the cleaning procedure with thorough drying of cleaned hands and arms . 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 . after handling soiled equipment or utensils. Also, according to the CRFERR (effective March 1, 2013) pg. 34 .single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed . a. Observations 6/24/15 -At 12:15 p.m., cook # 2 was observed making sandwiches. The cook grabbed a tomato with her hand and proceeded to slice the tomato with a knife. She then went over to the sink and grabbed a sanitized rag, lifted the knife off the counter, wiped the counter with the rag and placed the knife back on the counter. She grabbed several slices of bread with her gloved hand and preceded to make four bacon lettuce and tomato sandwiches. She grabbed a slice of bread with her hand and left the preparation area to grab a spatula. She then opened the lid to the condiments and sandwich preparation area with her gloved hand. She then spread the mayonnaise onto several slices of bread. She then grabbed several slices of bacon with her gloved hand and placed them onto the bread. She then grabbed several pieces of lettuce and tomato and placed them onto the sandwiches. She did the same process for the total of four sandwiches. She then utilized the same knife she used earlier to slice the tomato ' s to cut the sandwiches in half. She then grabbed a flat pan and placed the sandwiches into the pan. She then grabbed a pen out of her pocket, wiped her hand on her apron and then covered the sandwiches with aluminum foil and wrote the date on the foil. She then reached down opened the small refrigerator door with her gloved hand and placed the pan of sandwiches in the refrigerator. She proceeded to fill an ice chest with ice and exited the kitchen area. She did not change her gloves or wash her hand during this process. At 12:20 p.m., Cook# 3 was observed placing a plate into the microwave oven. She took the plate out of the microwave and then left the serving area to grab a thermometer to check the temperature of the food. She set the plate down, opened a sanitizing wipe from its packet, cleaned the thermometer and then threw it into the trash. She then placed the plate back into the microwave with her gloved hand. She then removed the plate again from the microwave completed the process of temping the food and wiping the thermometer with the sanitizing wipe and then sent the food out for the resident. She then proceeded to serve the residents their food. She did not change her gloves or wash her hand during this process. At 12:22 p.m., Cook #2 was asked to prepare a plate of mechanical soft barbeque ribs for a resident. She grabbed a food processing container and then opened the oven grabbed several pieces of cooked barbeque meat and placed them into the food processor. Cook #2 then poured the mechanical altered meat onto a plate and handed it to Cook #3. Cook # 2 then took the dirty metal processor container into the dirty dish room. Cook #2 did not change her gloves or wash her hand during this process. At 12:24 p.m., Cook #3 would ring her hands and rub her forehead with the back side of her gloved hand. Cook #3 did not change her gloves or wash her hand during this process. At 12:26 p.m., Cook #2 was asked to get a resident a cup of vegetable soup. Cook # 2 exited the cooking perpetration area and went into the dry storage area and retrieved a large can of vegetable soup. Cook #2 opened the can with the manual can open grabbed a large pan and placed the contents into the pan. She threw the metal container into the trash and then reached over and grabbed a metal whisk and stirred the soup. She then grabbed a rag from the sink and wiped the counter. She then poured a cup of soup into a cup, grabbed the thermometer, and handed the cup of soup to cook #3. Cook # 2 then utilized the sanitizing rag to wipe off the thermometer and placed the thermometer back on the shelf. Cook #2 did not change her gloves or wash her hand during this process. b. Interviews On 6/24/15 at 12:50 a.m., the dietary manager (DM) said all kitchen staff should wash their hands between every task. She also said all staff must wash their hands before handling or serving food, and when they left the kitchen area or returned to the kitchen. The DM said it was his expectation that all dietary staff would wash their hands and/or change gloves between tasks. The findings include: 1. Cutting Board Surfaces According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated March 1, 2013), Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. a. Observation On 6/23/15 10:30 a.m., the initial kitchen tour revealed three cutting boards were scored and stained. b. Staff Interview On 6/24/15 at 11:45 a.m., the dietary manager (DM) said she was supposed to replace the cutting boards. She looked at the stains on all the cutting boards and said Yes they pose a potential problem for bacteria and we will replace all of the cutting boards; they do need replacing.

Based on observations and staff interview, the facility failed to provide a safe, functional, and comfortable environment for residents, the staff and the public. Specifically, the facility failed to ensure a backflow device was present on two hand held showers in A and B-Hall shower rooms. Findings include: Professional Standard In pertinent part, Colorado Retail Food Establishment Rules and Regulations, effective July 1, 2013, section 5-202 (C) (4), pp. 73-74, read in part: Hose bibs, sillcocks, and threaded faucets where a hose can be attached shall be equipped with a proper backflow prevention device in accordance with 5-202 (B) (2) and (3). This paragraph shall not apply to water heater and boiler drain valves that are provided with hose connection threads and that are intended only for tank or vessel draining, or to water supply valves intended for connection of clothes washing machines where backflow prevention is otherwise provided or is integral with the machine. Observations An environmental tour was conducted on 6/25/15 beginning at 9:30 a.m. with the environmental director (ED). --At 9:45 a.m., the shower room on C-Hall had a hand held shower. There was not a back flow valve observed on the hand held sprayer. --At 9:50 a.m., the shower room on B-Hall had a hand held shower. There was not a back flow valve observed on the hand held sprayer. Interviews: The ED was interviewed on 6/25/15 at 10:00 a.m., and said that the shower rooms had been recently remodeled and the hand held shower were new. The ED said she was not aware that the hand held shower required a backflow valves installed on them. The ED said she would install backflow valves immediately.

Based on record review, observations and interviews, the facility failed to provide an ongoing program of activities designed to meet the resident's activity needs, as care planned, for two (#11 and #16) of three residents out of 17 sampled residents who were interviewed for activities. Specifically, residents #11 and #16 were not offered activities to meet her needs. The findings include: Resident #11 Resident Status Sample resident #11, age 96, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses, according to the facility face sheet, of [MEDICAL CONDITIONS] reflux disease, and depression. The 4/1/15 annual minimum data set (MDS) assessment revealed the resident had minimal difficulty with hearing and highly impaired vision. The resident had clear speech and acceptable receptive and expressive speech. The residents ' cognition was severely impaired as evidenced by a score of five of out of 15 on the brief interview for mental status. The preference for customary routine and activities revealed it was very important to the resident to have books, newspapers, and magazines to read, and to be around animals such as pets. The 4/7/15 care plan revealed the resident was at risk for deficit in activities related to (R/T) dementia. She socialized with other residents, enjoyed socials and regular visits from daughter, as well as a volunteer who read to her. The resident would receive one to one (1:1) programming four times a week as evidenced by participating in at least one activity per month. The care plan goal was for the resident to demonstrate participation in activities as evidenced by participating in at least one activity per month plus 1:1 programming four times per week over the next 90 days. The interventions were as follows: -A volunteer came to read to the resident every week as she had always enjoyed reading, and activity staff would also read to the resident during 1:1 activity. -Encourage resident to attend activities and participate by listening and visiting with others. -The resident could socialize and enjoy the activity, ensure she was participating to the best of her ability even if she was not able to participate at the same level as others. -Inform the resident of upcoming activities by providing calendar, verbal reminders, escort and encourage the resident. -Provide assistance to and from activities as needed; -Provide materials of interest such as audio books or television shows the resident could listen to. The resident also liked to listen to swing kings or 40 ' s music on television. Observations: The 6/24/15 activity events calendar listed the following events for that day: 9:30 a.m., Sittercise; 10:30 a.m., Bible study; 1:00 p.m., manicures; and 3:00 p.m., the sweet summer rain. On 6/24/14 The resident was observed continuously from 8:55 a.m. to 3:35 p.m. During the observations the resident did not receive any staff, resident or volunteer interaction or sensory type activities. The resident was not invited to attend either of the scheduled activities. The observations were as follows: --At 8:55 a.m., the resident was sitting in her recliner sleeping. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 9:20 a.m., the resident was sleeping in his recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 9:40 a.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 10:00 a.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 10:40 a.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 11:10 a.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 11:30 a.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 12:55 p.m., the resident was taken from the dining room to her room and placed in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 1:15 p.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 1:35 p.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 1:55 p.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 2:15 p.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. --At 2:45 p.m., the resident ' s daughter came into the facility with her dog to visit with the resident. The residents ' daughter was in facility for 20 minutes. --At 3:00 p.m., the resident was asleep in her recliner. The resident did not receive any staff, resident, or volunteer interaction or sensory-type activities. Interviews: The activity director (AD) was interviewed on 6/25/15 at 11:15 a.m. The AD was informed of the continuous observations (see above). The AD stated the resident would choose her own activities to attend and required cueing and reminders to attend activities of interest. The AD stated the resident should have been invited to all of the activities. 2. Resident #16 a. Resident Status Sample resident #16 was an [AGE] year-old male whose last admission was 4/19/14. According to the facility face sheet his [DIAGNOSES REDACTED]. The 5/26/15 quarterly review Minimum Data Set (MDS) assessment revealed the resident had adequate hearing and vision with corrective lenses. The resident had clear speech and sometimes made himself understood and usually understood others. The resident ' s cognition was severely impaired as evidenced by a score of three out of 15 on the Brief Interview for Mental Status (BIMS). His preference for customary routine and activities on the 2/28/15 annual MDS assessment revealed it was somewhat important for the resident to have books, newspapers, and magazines to read, keep up with the news and do things with groups of people. However, it was very important to the resident to go outside to get fresh air when the weather is good and participate in religious services or practices. b. Observations On 6/24/15, the scheduled activity at 9:30 a.m. was sittercise in the living room. The following observations of the resident were made: -9:18 a.m. The resident was in his room sitting in his wheelchair without any visual or audio stimulation. -9:35 a.m. the resident was in his room in his wheelchair completing a breathing treatment without any visual or audio stimulation. -9:46 a.m. the resident was wheeled to the living room where sittercise was in progress. The activity assistant did not acknowledge the resident ' s arrival nor did she encourage him to participate in the activity; however the resident attempted to participate to the best of his ability. -9:54 a.m. the sittercise activity had finished and the resident was left sitting in same area while a western movie played on the television (TV). -10:20 a.m. the activity assistant asked residents if they wanted to attend bible study. She did not ask resident #16, who remained in the same area facing the TV. 10:30 a.m. the resident was in his chair nodding off, sleeping in his wheelchair in front of the TV. -11:11 a.m. the resident was in his wheelchair, his chin was down on his chest and his eyes were closed, he appeared to be sleeping in front of the TV. -12:00 p.m. staff assisted the resident into the dining room for lunch -1:00 p.m. manicures was the scheduled activity. There were three female residents in the common area with the activity assistant. There were no other activities occurring at the time and the other residents were not involved in an activity. The activity director was in her office. -1:10 p.m. the resident was observed to leave the dining room. He stated he liked to attend bible study, I didn ' t have time to go today , and he could not answer why. He also stated he played BINGO, but does not go as much as he should. He was unable to state his likes and dislikes due to a declined thought process. -1:26 p.m. a certified nurse aide (CAN) took the resident to his room from the living room. -1:50 p.m. the resident was in his room on his bed with his eyes closed. -2:27 p.m. the resident was in his room on his bed with his eyes closed and mouth opened and he was snoring. -3:00 p.m. The scheduled activity was Sweet Summer Rain. The same four residents, who were in the common area for the manicure activity, were present. The television was on, there was one resident sitting on the couch, and one male resident sitting near the nurses ' station. -3:05 p.m. The resident was in his room, on his bed with his eyes closed and mouth opened and he was snoring. -3:42 p.m. the resident was in his room, on his bed with his eyes closed and mouth open. -4:17 p.m. the resident was in his room, on his bed with his eyes closed and mouth open. -4:42 p.m. the resident was in his room, on his bed with his eyes closed and mouth open. -5:06 p.m. the resident was taken to the dining room for dinner. 6/25/15 -9:00 a.m. the resident was in the living room area-during sittercise-he was not participating and staff did not encourage him to participate in the activity. -9:33 a.m. the resident was in his room, sitting in his wheelchair with a nebulizer (breathing) treatment. -10:00 a.m. the scheduled activity was Christian bible study. The activity did not occur. -10:15 a.m. the resident was back in the living room area, sitting in his wheelchair, his eyes were closed and he was seated in front of the TV. There were 12 females residents at tables eating coffee cake with a volunteer. There were no other activities that occurred at that time. c. Record review: Care Plan The 3/3/15 care plan revealed the resident had an activity deficit or potential activity deficit, related to dementia and a change of cognition, as evidenced by not being able to finish his thoughts without some prompting and a lot of time to express himself. He enjoyed watching westerns on the western channel and enjoyed parties, socials, music, and participated in exercise and BINGO to the best of his ability. Additioanlly, he attended bible study and church three to four times a week. The goal was for resident #16 to participate in activities as he chooses. The approaches included in pertinent part: -activity staff would do informal one to one visits as needed at that time=rather than formal one to one programming as he attended many of the group activities and was out and around when awake. -Assist and encourage the resident to participate in activities of his choice. -Does participate in exercise to the best of his ability; however he needed encouragement to do each movement. -Inform resident of activities and provide assistance to the activity. Provide assistance at all activities, as needed and encourage him to participate to the best of his ability. -Invite and encourage him to attend bible study and church as this is an important activity he enjoyed. Assist him to and from the activity as needed. -Resident enjoyed watching western movies on television. Staff would turn the TV in living room to the western channel when he was in the living room and if no one was watching something else on the television. Activity Progress Notes: On 6/1/15 at 3:15 p.m. a quarterly note revealed the resident was doing his best in activities. He participated in activities of his choice. He liked socials and parties. He liked to wheel himself around the facility in his chair. He also liked to watch westerns in the living room and to be around people. He enjoyed having people greet him and shake his hand. He did not say much, but he liked to listen to conversations and be a part of the group; although, at times, if it was just women, he would decline to attend. However, at times such as happy hour or church, when the minister came in, he participated. He said he gets tired easily and liked to take naps in the afternoon. There were no other changes noted at that time. (Note: there were no other progress notes from 4/1/15 to 6/25/15 recorded). One to One Program Logs The One to One program logs dated 4/1/15 to 6/23/15 were reviewed and failed to include what time of the day the visit occurred. The documentation read in pertinent part: 5/4/15: Sat with the resident and talked about his sister. He wanted to go lie down, but it was 12:20 p.m. and the girls were still in the dining room, so we chatted a while until they got done (approximately 20 minutes). 5/13/15: The resident grabbed my hand and said he was not feeling good, but he did not want a nurse. The staff member convinced resident to let them get her and then came back to escort him to his room, where they sat until the nurse showed up. CNA ' s came to lie him down within approximately 10 minutes 6/22/15: The resident was asked if he would like to participate in sittercize and he said he would have to think about it. (Note: The above documentation was concerning care provided to the resident. Participation Records According to the activities, participation records dated 4/1/15 to 6/23/15 the resident participated in the following activities: April 2015 There were several items checked between the 1st through the 5th of the month; however it did not reveal if the resident was an active participant. Additionally, the resident was noted to have watched TV from the 1st through the 29th of April 2015 May 2015 -5th - the resident was noted to actively participate in the glamour activity; however there was no glamour activity on the activity calendar. -7th - The resident refused massage -21st - The resident refused massage -28th - The resident was noted to refuse a massage; however there was no massage listed on the activity calendar. There was no activity participation (blank) recorded for the 10th and 24th of May 2015. June 2015 Church or bible study - did not attend-documentation does not indicate refusal Other activities documentation did not coincide with the activity calendar for June 2015 and were as follows: -2nd - No glamour activity on the activity calendar; however the resident was noted to be an active participant. -4th - the Resident refused massage -7th - Dominoes were not on the activity calendar; however the resident was noted to be an active participant -10th - A one to one visit showed the resident was an active participant; however the one to one was not recorded on the one to one program logs (see above). -16th -Trivia was not on the activity calendar; however the resident was noted to have refused the activity. -16th -18th social hour was not on the activity calendar; however the resident was noted to have been an active participant and he refused the event on the 23rd There was no participation (blank) recorded for the 11th through the 15th, 19th, and 21st of June 2015. Interviews: On 6/24/15 at 1:10 p.m., the Resident was interviewed and acknowledged that he liked to attend bible study, followed up with he didn ' t have time to go today; however he was unable to state why he didn ' t have time to attend bible study today. He stated he liked to play bingo; however not as much as he should. He was unable to state why he does not go or what he liked to do. He started to say play, but he could not finish his thought. On 6/25/15 at 11:20 a.m., the activity director (AD) was interviewed and stated her staff included a full time and part time assistant. She had volunteers to read to the resident ' s and provide one to one programs. The consultant was in the facility once a month, but if she was unable to visit, she could review charts remotely. The AD explained the full time assistant was responsible for trivia type things, 30 minutes or so after lunch, three times a week along with manicures. She stated manicures took all afternoon and that was time to reminisce with the residents during that time. She indicated there were times the men would attend and get their nails trimmed and filed. Addtionally, the full time assistant provided light massage therapy on Thursdays in the resident rooms, completed the activity calendar monthly and brought them to her for approval. The AD explained the part time assistant would conduct group activities on Thursdays during massages. According to the AD Most of the time, some (residents) don ' t want to come to religious activities, some do not want to come to activities. We don ' t invite them if we know they will not attend. She stated they ask quarterly, because, occasionally they will change their mind. She stated Resident #16 participated in activities to the best of his ability. She stated he looked at the staff and smiled. The AD said he usually watched TV, she, and her staff ask him what he would like to do. She did not know if he had been invited to the activity on 6/24/15 at 3:00 p.m., because she was not in the facility. She stated the resident usually joined the afternoon activity; he enjoyed listening if he was comfortable. He gets nervous due to difficulty expressing himself. She explained when she is in the building she will assist and ask residents ' if they want to attend. She stated maybe they need to change the calendar a bit during manicures in regards to reminiscing so all residents could be invited.

Based on interview, observation and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#3) of one resident out of 18 sample residents. Specifically, the facility failed to meet the dental needs of the resident who wanted dentures The findings include: Resident Status Sample Resident #3 was an [AGE] year-old female whose latest admission was 1/13/15. According to the facility face sheet the admission [DIAGNOSES REDACTED]. The 5/27/15 quarterly review Minimum Data Set (MDS) assessment revealed the resident had adequate hearing and vision. She usually understood others and was usually understood. The resident ' s cognition was moderately impaired as evidenced by a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). She was independent with eating. She required extensive assistance with one-person assist for personal hygiene including combing hair, brushing teeth, washing/drying face and hands. The resident had a five percent (%) or more weight loss in the last month and was not on a physician prescribed weight loss regimen. She required a therapeutic diet. The oral/dental status did not indicate the resident had dental problems. Observation/ Resident Interview On 6/23/15 at 2:23 p.m., the resident was in her room she did not have dentures. The resident stated she lost her dentures down a commode and that they had not been replaced. She did not know who would pay for them to be replaced. She stated she had not been to a dentist and would like dentures. On 6/24/15 at 3:33 p.m., the resident was in the living room area she did not have dentures. The resident stated she would like dentures so that she could eat steak and chicken easier. She said she had trouble eating some things, but she was used to not having teeth. Record Review The computerized physicians' orders (CPOs) dated 5/27/15, for the month of June 2015, revealed the resident was on a regular diet with regular portions. The resident's care plan was reviewed on 6/8/15 and failed to identify the resident ' s dental status. The resident care conference reports dated 6/16/14 through 6/8/15 were reviewed and there was no indication the facility had discussed the resident ' s dentures or dental status. The resident's clinical record, which included nurses ' progress notes, physician notes, consultations, and social services from 4/1/15 to 6/25/15 did not reveal the facility had discussed the resident ' s dentures or dental status. However, a progress note from the previous year (5/15/14) revealed the facility was aware the resident lost her upper dentures and staff was working on getting the resident new dentures. C. Interviews On 6/25/15 at 11:39 a.m., the social services director (SSD) stated it depended if the residents had dentures and if they wanted an exam. If the resident had dentures, they did not need to see a dentist and could opt out. At times, it depended on the family or responsible party if a resident went to see the dentist. The SSD explained there was not a dental provider who accepted Medicaid, who had been in since December. She was trying to get dental appointments set up in the closest city that had Medicaid providers. She stated if a resident lost or broke their dentures she would take them to the dentist to get fixed or replaced. She stated documentation was completed on a pink form, and she knew because she took the residents to appointments. Ancillary services to include dental are discussed at the quarterly care plan and the residents were asked if they wanted to see the dentist and was documented in the care conference report. The SSD acknowledged resident #3 had not been to the dentist that she was aware of. She stated the resident had dentures and would not wear them so her power of attorney (POA) took them home. She was not aware of the resident wanted her dentures. The SSD said, she changes her mind and says she doesn ' t need them. she recalled trying to take the resident to the dentist more than a year ago, during the previous survey, because the resident brought up her dentures at that time. She stated an appointment was made and the resident did not want to go and she did not pursue another appointment for the resident. The SSD provided a progress note dated 5/8/08, which indicated the resident sent her denture home because she was afraid she would lose them or they would get stolen. The SSD stated because she sent her dentures home they had not discussed dentures any further until the resident stated last year that she wanted her dentures. The SSD stated she would talk to the resident again.

Based on interview, observation and record review the facility failed to ensure two (#21 and #17) of two residents out of 18 sample resident ' s received the care and services necessary to attain and or maintain their highest practicable level of well being. Specifically the facility failed to -provide an appropriately fitted wheelchair for resident #21. -Thoroughly assess and evaluate interventions for resident #17 to determine the least restrictive therapeutic diet. The findings include: A. Record review Sample Resident #21 was an [AGE] year-old female, who admitted to the facility on [DATE]. According to the facility face-sheet her [DIAGNOSES REDACTED]. According to the 4/26/15 quarterly Minimum Data Set (MDS) assessment the resident had minimal difficulty hearing and she used a hearing appliance. She was able to make herself understood and usually understood others. The resident ' s cognition was moderately impaired, as evidenced by a score of nine out of 15 on the Brief Interview for Mental Status (BIMS). She had a walker and wheelchair for mobility. Request for Physician order [REDACTED].>On 5/4/15 a request for an order for [REDACTED]. On 5/5/15, the physician order [REDACTED]. Home Health Measuring Worksheet On 5/5/15 the PT's recommendation for the resident wheelchair was complete. Resident Progress Notes (RPN) The resident progress notes dated 5/1/15 through 6/23/15 were reviewed from 5/1/15 to 6/23/15. The progress notes revealed the following: 5/6/15 at 10:00 a.m., read in part, this nurse talked with the residents' power of attorney (POA) about purchasing a wider wheelchair for the resident, per the recommendations from PT. Explained to her that the resident did not want to purchase a wheelchair. The wheelchair she was currently in did not fit her well and she sat Sacral in the chair due to this and had [MEDICAL CONDITION] (swelling) of her legs. The POA stated to go ahead and purchase the wheelchair for the resident and she would talk to her (resident) about this. She (POA) also asked about a larger recliner for the resident and the nurse told her it would be a good idea to look for a larger recliner, because the resident gained over 50 pounds since her admission and did not wish to lose weight. Will order wheelchair according to PT measurements. The assistant director of nursing (ADON) signed the entry. On 5/6/15 at 1:04 p.m., the Physical therapist looked at two different wheel chairs in the facility for the resident to use, one was too small, and one was too large. He was supposed to bring over a size 22 wheel chair to see if that would work for her. The resident continued to have bilateral [MEDICAL CONDITION] in her lower legs, left was worse than the right and the left knee was very [MEDICAL CONDITION]. The resident did not put her feet up during the day and stated that she gets tired of keeping them up. It was explained to the resident that it does increase the [MEDICAL CONDITION] by having them down all day. The resident did take diuretics at that time and recently had them increased for one week with no change noted. On 6/25/15 at 11:33 a.m., a purchase order was provided. It was dated 5/27/15 to the company; it did not identify whom the resident was or what was being purchased. It read 22 wide x 24 depth then the dollar amount. There was no further documentation regarding what the facility was doing regarding the purchase of the new wheelchair. B. Observation On 6/23/15 at 2:27 p.m., the resident ' s wheelchair appeared too small and she was not sitting the entire way back in the wheelchair. She appeared very uncomfortable. On 6/24/15 at 9:46 a.m., the resident was in the living room with other residents during sittercize, she was not participating. She was in her wheel chair, she was not sitting all the way back and her elbows were in close to her sides. She appeared uncomfortable. 6/25/15 at 1:16 p.m., the resident was in the living room after lunch. She was in her wheelchair, propelling herself around the room. She was not sitting back in the chair and her elbows were at her sides. She stated she was not comfortable and sometimes it hurt. C. Interviews On 6/25/15 at 9:00 a.m., the POA explained the facility told her they were going to measure and order a wheelchair for the resident. She stated she visited on 6/21/15 and she did not have a new chair yet. She said, I assumed they were going to order a new one after they called me a few months ago. On 6/25/15 at 9:37 a.m., the director of nursing (DON) explained the process for evaluation and measuring of residents' who need equipment. She stated they go through the physician for an order, have PT evaluate for the proper equipment and size. The facility provided equipment, it was purchased through Medicaid or if they had the proper size, they could use it while in the facility. Residents who are private pay were responsible to purchase their own; however, they could borrow one until the new one came in. She stated if they had to order a wheelchair, it took about two weeks, if they had the proper size they would have it immediately. The DON stated resident #21 had a wheelchair on order, approximately two to three weeks ago. The ADON was responsible for follow though and completing the order through the supplier. She thought the ADON had called the supplier and left a message, but it was not documented. She was not sure if there was documentation when the wheelchair was ordered and referred to the ADON. On 6/25/15 at 9:44 a.m., the ADON stated she had to look for the purchase order to clarify when the wheelchair was ordered. She stated she submitted a form with specific measurements for the resident. She was not able to locate additional notes regarding ordering the wheelchair or communication with PT or the family since the initial order was received. She stated she usually contacted the family if she had difficulty getting wheelchairs. She stated she called the supplier on 6/24/15, then stated she sent an e-mail and had not received a response, she did not document. On 6/25/15 at 9:55 a.m., the PT explained the process in which a resident was evaluated and measured for adaptive equipment based on observation, assessment, history and comfort level as well as the reason they want to change out the wheelchair or walker. He stated the method he used to fit the resident was a measuring tape and have them try the device for sizing. He stated he followed the proper guidelines of 2 all the way around the resident in the adaptive equipment. He said it could take a week to ten days to complete the assessment. The facility orders the wheelchairs or other equipment. They have spare wheelchairs here to try out for proper fit and they can use them until the wheelchair arrives. He stated he borrowed a wheelchair from the hospital to check for comfort level, they did not keep it for the resident. The PT was not sure if the wheelchair had been ordered, the ADON provided updates, but he had not received updates and thought it was a long time-but not sure how long it takes to order. He said the wheelchair was a bigger size, not extravagant or out of the ordinary. 2. Resident #17 A. Resident Status Resident #17, [AGE] years old, admitted to the facility on [DATE] according to the face sheet with the following Diagnoses: [REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had short and long term memory difficulties and was unable to complete the Brief Interview for Mental Status (BIMS). Staff described the resident's cognitive skills for daily decision making as moderately impaired and indicated she required cues and supervision to make decisions. The resident experienced [MEDICAL CONDITION] described as inattention and disorganized thinking. She required extensive assistance with eating. According to the assessment, the resident weighed 120 pounds and she had not had a significant weight gain or loss in the last six months. The MDS also noted the resident did not experience difficulty chewing or swallowing and indicated she did receive a mechanically altered diet. B. Resident Observations On 6/23/15 at 12:05 p.m., the resident was observed sitting at a dining room table with two other residents. She was positioned in her wheelchair facing left away from the windows in the dining room. Certified Nursing Assistant (CNA) #2 sat slightly behind her right shoulder. The CNA scooped part of her pureed food into a smaller cup, poured milk into the food and stirred. The consistency of the food in the cup did not appear to be nectar thick. The CNA did not measure the amount of milk she added to the food. The CNA proceeded to place the cup up to the resident's mouth and pour food into her mouth. She repeated this process throughout the meal. On several occasions the CNA wiped food off of the resident's mouth with the cup. The CNA did not converse with the resident during the meal. She placed the cup up to the resident's mouth and on several occasions startled her because she was not sitting within the resident's line of vision. The resident tried to push the drink away from her mouth but the CNA pushed the resident's hand down and placed the cup up to the resident's mouth and gave her a drink. At no time did the CNA allow the resident the opportunity to eat on her own nor did she attempt to assist the resident to eat her meal with a spoon. On 6/24/15 at 12:10 p.m. the resident was observed sitting at the dining room table with two other residents. She was sitting in her wheelchair facing left away from the windows in the dining room. CNA #2 was again sitting to the right side of the resident. The CNA scooped part of the pureed food into a smaller cup, added milk to the food in the cup and stirred. The consistency of the food in the cup did not appear to be nectar thick. The CNA did not measure the milk prior to adding it to the food. There was little conversation with the resident during the meal. On several occasions the CNA used the cup to scoop food off of the side of the resident's mouth. The CNA attempted to reposition the resident in the wheelchair by pulling her over using her shoulders. The resident shook her head away from the cup several times but the CNA proceeded to give her a drink of the food. At no time during the meal did the CNA attempt to feed the resident with a spoon or encourage the resident to eat or drink herself. On 6/25/15 at 12:05 p.m. the resident was observed sitting at the dining room table with two other residents. After sharing the observed concerns with the Director of Nursing (DON) on 6/25/15 at 11:15 a.m. the CNA was sitting on the resident's left side facing her. She was assisting the resident to eat her meal with a spoon. The resident was participating in the meal and eating from the spoon without any difficulties. C. Record Review Care Plan The activities of daily living (ADL) care plan (CP), dated 2/23/15, and indicated the resident was at risk for deterioration in her ADL performance due to dementia. -The resident's goal was to participate in ADLs to her highest functioning level. -Approaches included: assist with meals; offer set-up help; encourage her to feed herself; and, to provide assistance with her meals as needed. The nutritional CP, dated 2/23/15, documented the resident was at risk for weight loss related to dementia. -The resident's goal was to maintain her current body weight of 119 pounds. -Approaches included: provide a pureed diet with a nectar thick consistency so she could drink her meal; encourage her to eat her meals; provide her as much time as needed to complete meals; and, provide assistance with meals as needed. The comprehensive CP did not include goals and approaches related to the resident's identified difficulty with swallowing (refer to 5/6/15 nutritional assessment described below). Physician Orders The physician telephone order (TO) dated 1/15/15 read to change the pureed diet to liquid nectar thick puree diet and nectar thickened fluids. There was no documentation in the resident's chart to indicate why the diet was changed. The June 2015 computerized physician orders [REDACTED]. She could have large portions at meals and she could use a regular spoon. Assessments The annual nutritional assessment dated [DATE] revealed the resident received a regular, pureed diet with regular consistency fluids. It revealed she had chewing problems because she was edentulous. There were no signs or symptoms of a swallowing disorder identified on the assessment. The DM indicated that a referral to the RD was recommended because of a four pound weight loss. A DM progress note of the same date revealed the RD had been faxed the resident's information, which included the weight loss and her diet information. It revealed the writer was waiting for a response from the RD. No further documentation was found to show the RD had responded or provided any recommendations. No quarterly nutritional assessment was found in the residents' chart for 11/14. According to the DM, the nutritional assessment must be completed on a quarterly basis. Progress Notes The nurses' progress note dated 1/7/15 at 6:27 a.m. revealed the resident's breath sounds were diminished with scattered light crackles and occasional expiratory wheezes. It noted the resident would not take fluids. The resident would only take a few sips of water and then just turn her head away when water was offered. No further documentation was found to show the resident continued to have problems taking fluids. The physician progress notes [REDACTED]. She had been sleeping a lot and had a low grade fever and a persistent runny nose, but no signs of chest congestion or shortness of breath. The physicians' note indicated the resident had an upper respiratory infection, likely [MEDICAL CONDITION], and she was to complete the course of [MEDICATION NAME]. The physicians note also noted she had failure to thrive due to her not eating well, which was related to her dementia. There was no documentation from the physician about changes in the residents swallowing or changing the resident's fluid consistency. The nurses' progress note dated 1/12/15 at 2:06 p.m. revealed the resident had an increased temperature on and off for several days and it was difficult to assess her breath sounds. A new order for antibiotic treatment was received from the physician for the [DIAGNOSES REDACTED]. The nurses' progress note dated 1/19/15 at 8:44 a.m. revealed the resident continued on the antibiotic therapy for pneumonia. It indicated she was assisted with breakfast and her appetite was good. The physician progress notes [REDACTED]. She was eating some and sleeping well. The [DIAGNOSES REDACTED]. She was stable but required help with all her activities of daily living (ADL's). She recommended continue with the current medications and level of care. The quarterly nutritional assessment dated [DATE] revealed the resident was on a pureed diet with nectar thickened liquids. She had no chewing or swallowing problems identified and received a mechanically altered diet. There was no documentation showing the reason for the change in the liquid consistency and the DM failed to identify the resident with chewing or swallowing problems. The RD progress note dated 2/18/15 revealed the resident was on a puree diet with nectar thick liquids due to being edentulous. There was no documentation the RD assessed the residents need for thickened liquids or a reason why there was a change in the liquid consistency. The nurses' progress note dated 4/10/15 at 5:03 a.m. revealed the resident had clear nasal drainage and an elevated temperature. The resident looked flushed and moaned slightly with movement. It noted the information would be passed onto the next shift to monitor and follow up with the physician if needed. The next nurses' progress note dated 4/14/15 revealed the resident continued to have a loose cough with audible wheezing noted. The physician was notified and a new order for an antibiotic was received for an upper respiratory infection. The quarterly nutritional assessment dated [DATE] revealed the resident received a pureed diet with nectar thick liquids and food. It revealed she had a chewing problem because she was edentulous. It noted she showed signs and symptoms of a swallowing disorder by holding food in her mouth/cheeks or residual food was in her mouth after meals. The RD progress note dated 5/14/15 revealed the resident was on a pureed diet with several supplements served throughout the day. She was assisted with meals and was on a pureed diet because she had no teeth. She documented that no new problems were noted. There was no documentation to show that her swallowing disorder had been evaluated or assessed by the RD. D. Staff Interviews On 6/24/15 at 1:45 p.m. CNA #2 stated the kitchen would make the resident's pureed food thicker so that staff could add milk and she could drink the food. She reported that the resident would eat off of a spoon on occasion. She stated she tried to feed the resident with a spoon once in a while. She verified that she had not tried to use a spoon with the resident during her lunch meal on 6/23/15 or 6/24/15. She reported that she had not had any training about how much milk to add to the resident's food to make it a nectar consistency but she had been a CNA for [AGE] years and she knew what nectar thick consistency was. On 6/24/15 at 3:00 p.m. the RD reported that she was not aware that the kitchen was making some pureed foods thicker so that staff could add milk to allow the resident to drink her food. She was also unaware that staff was adding milk to the pureed food and giving it to her by cup. She reported that she would recommend a speech therapy (ST) evaluation if a resident was coughing, having difficulty swallowing or eating, or was holding foods in their mouth. She reported that she was not familiar with the resident On 6/24/15 at 3:04 p.m. the Dietary Manager (DM) stated that the resident's pureed food was prepared thicker so that the staff could add milk. She denied that the staff had been educated about how much milk to add to the food to maintain the nectar consistency. She reported the CNA's were educated about nectar thick consistency foods during their CNA training. She reported that she would contact the RD right away if there was a change in a resident's condition. She stated the nutritional assessments were to be completed on a quarterly basis. On 6/25/15 at 9:10 a.m. CNA #1 reported she had worked for the facility for ten years. She stated that the resident was totally dependent upon staff for eating. She reported that she had been drinking her meals for the past three to four months. She stated the staff would add milk to the pureed food to make it between nectar and honey consistency. On 6/25/15 at 11:15 a.m. the DON reported she did not feel a ST evaluation would be appropriate for resident #17 because she had dementia and could not follow commands. She reported the staff would evaluate changing a resident's diet if the resident was losing weight, having difficulty swallowing, choking, or if food was running out of the resident's mouth. She reported that if the resident voiced complaints or concerns then the dietary department would be consulted. She stated that the physician would be consulted and the RD would make recommendations. She reported the RD visited monthly. She stated the RD was contacted by phone when needed. She reported that all RD consultations and recommendations should be documented in the resident's chart. She stated the RD was able to document off site in the charting system. She reported that a regular, puree nectar thick diet was a regular diet but pureed foods were a nectar consistency. She verified that the diet was not listed as a diet that the facility used. She agreed that the staff should engage with the resident's during meals and encourage independence. She confirmed the resident should have been given the opportunity to eat with a spoon during meals.

Based on record review, resident observations, and staff interviews, the facility failed to ensure that the residents' environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to identify risks and implement interventions to reduce the risk of elopement for one (#5) of two residents out of 18 sampled residents. I. Facility's Policy and Procedure The undated Elopement, Risk Prevention, and Management of a missing resident policy read the facility strived to promote resident safety and protect the rights and dignity of the residents. The facility would maintain a process to assess all residents for the risk for elopement, implement prevention strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission, and conduct a missing resident procedure. It defined elopement as the ability of a resident who was not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way. A facility approved risk assessment tool (Elopement risk assessment) would be utilized. The Elopement Risk Assessment procedure dated ,[DATE] read a score of 10 or greater on the risk assessment indicated the resident was an elopement risk. The elopement risk assessment was to be completed by the nursing staff on all residents on admission, quarterly, and upon a change of condition. Elopement risk was divided into two categories: elopement watch and elopement warning. Elopement watch read the resident would be placed on a wander system to alert staff. Activities would be in full view of staff at all times and be adjusted to include the wanderer and maintain their interest. Staff would document the status of the resident each shift. Residents who actually succeeded in eloping would be placed on elopement warning. Elopement warning included the following actions: Resident would have one-to-one supervision for 24 hours and until the determination had been made that the resident was no longer a flight risk. The physician would be notified for evaluation and a more suitable facility found as necessary. II. Resident #5 Resident #5, an [AGE] year old was admitted to the facility on [DATE], according to the face sheet with the [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] revealed her brief interview for mental status (BIMS) score was nine out of 15, which indicated she was moderately cognitively impaired. She had periods of disorganized thinking and had delusions. She did not display a behavior of wandering. She was independent with walking and locomotion on and off the unit with the use of a walker. The cognitive impairment care plan dated [DATE] read the resident had occasional delusions related to the [DIAGNOSES REDACTED]. The goal read the resident would not sustain serious injury due to her memory/recall deficit. The approaches directed staff to educate and remind her to not go outside the building without someone to assist her. If she was seen near an exit door, staff was to ask her if she needed assistance and re-direct her to another area of the building such as her room or the common area. Redirect her when she entered unsafe areas. A. Record Review The elopement risk assessment dated [DATE] read the resident was ambulatory and she was disoriented but did not wander. She was uncomfortable with placement in the facility at times but her behaviors were easily redirected. She received one antipsychotic or mood altering medication and she had two or more of the following diseases present: dementia or any type of mental illness. The resident's score was 16, which indicated she was an elopement risk. The quarterly elopement risk assessment for ,[DATE] was not completed. The physician progress notes [REDACTED]. It read the Effexor (antidepressant) had recently been increased and the physician was unsure if her confusion was related to the Effexor increase or a worsening of her dementia. No new orders were received. On [DATE] at 6:09 p.m. the nurses' notes read the resident was observed walking in the hall without her walker and had asked for a ride to Tribune. She stated her parents lived there and she needed to visit them. On [DATE] at 11:39 p.m. the nurses' note read the resident came out of her room dressed and wanting to go find her mother. She was confused to time, place, and situation. The resident stated she wanted to go home for awhile. On [DATE] at 4:12 p.m. the nurses' note read the residents' daughter had been informed of her increase in confusion. It was reported that she had been looking for her mother, father, and husband, all of whom were deceased . The resident would often think that she needed to go to Tribune and she would look for her car. It read the staff had noticed an increase in her confusion since there had been an increase in her Effexor. On [DATE] at 2:21 a.m. the nurses' notes read the resident was up asking about her husband and upset that he was late picking her up. On [DATE] the physician progress notes [REDACTED]. A new order was written to decrease Effexor and start the resident on Wellbutrin (antidepressant). On [DATE] at 10:13 p.m. the nurses' note read at 9:45 p.m. the resident left her room fully dressed and ready for the day. She was confused to the time and situation. On [DATE] at 4:15 p.m. the nurses' note read the resident went out of the front door that afternoon, which was reported by a visitor. The resident stated to the nurse that she thought she saw her daughter's pickup truck and was trying to see for sure. The resident stayed on the sidewalk and came back in to the facility without problem. On [DATE] at 9:30 p.m. the nurses' note read the resident walked out the front door of the facility. A staff member assisted her back into the facility. The resident stated she was going out to see the staff member who was outside at the time. On [DATE] at 8:53 p.m. the nurses' note read the resident was confused to place and situation. She stated she was looking for some of her family. On [DATE] at 9:01 p.m. the nurses' note read the resident was confused to place, time and situation. She stated that she needed to find her mother as they were going somewhere. On [DATE] at 8:55 p.m. the nurses' note read the resident was confused to place, time, and situation. The resident stated she needed to call her Aunt to tell her she was staying the night. On [DATE] at 10:34 p.m. the nurses' note read at 9:30 p.m. the resident was up walking in the hallway and stated she was looking for her husband, mother and father. On [DATE] at 9:01 p.m. the nurses' note read the resident was confused to place, time and situation. She stated she was looking for her husband and a co-worker. On [DATE] at 9:46 p.m. the nurses' note read the resident was confused to place, time, and situation. She was looking and waiting for her husband and concerned that her grandmother's family was coming. On [DATE] at 11:04 a.m. the nurses' note read the activities staff reported that morning that the resident had gone out the front door twice the night before looking for her family. On [DATE] at 10:29 p.m. the nurses' note read the resident was confused to place, time, and situation. The resident believed she was going home and had her hat on and some of her items packed. On [DATE] at 10:31 p.m. the nurses' note read the resident came out of her room with her items and her hat on again. She stated she was going home. B. Resident Observations On [DATE] at 9:09 a.m. the resident was observed lying in bed sleeping. At 12:47 p.m. she ambulated to her room from the dining room and lied down in bed. At 2:10 p.m. she was observed to ambulate to the common area, stood for a few minutes and then returned to her room. At 3:00 p.m. she was observed sitting in the common area on her walker waiting for her nails to be done. On [DATE] at 12:30 p.m. the resident was observed exiting through the West door at the end of the A hall. The resident had the door open and her walker partially out the door. There was no staff in the hallway at the time and no alarms sounded to alert the staff the resident was exiting the building. The door exited onto the side of the facility, which was not an enclosed area. The Director of Nursing (DON) observed the resident exiting and went down the hall to redirect her back into the facility. C. Staff Interviews On [DATE] at 12:06 p.m. certified nursing assistant (CNA) #4 reported she had worked at the facility for four years. She reported that if she observed a resident outside she would go out and try to talk the person into coming back in. She stated she would stay out with the resident until they had calmed down. She reported that the facility did have an alarm system and some residents had an alarm on their wheelchairs. She reported the residents' care plan would have the interventions used for a resident. On [DATE] at 12:09 p.m. CNA #3 reported she had worked at the facility for five years. She reported that if a resident was trying to leave the building she would keep a close eye on them and redirect them as needed. She stated if she saw a resident outside she would let someone know that she was going out to get them and try to get the resident back into the building. She reported that staff was notified upon admission if someone was at risk for elopement or we would figure it out if someone started to try to go out of the building. She reported that the residents had a short term care plan that would identify interventions and the information would also be received in report from the nurse. On [DATE] at 12:15 p.m. Registered Nurse (RN) #1 reported she would try to find out why the resident was trying to leave, visit with them, or call the family. She stated the care plans would identify those at risk for elopement and the interventions to use. She reported there were two residents who currently had an alarm on. On [DATE] at 12:52 p.m. the activity director (AD) reported resident #5 had tried to go outside twice during Bingo on the night of [DATE]. She reported that the resident was looking for her mother. She stated she opened the front door, but had not made it outside before she was redirected in by staff. On [DATE] at 12:55 p.m. the Assistant Director of Nursing (ADON) reported that residents who leave the building without assistance were put on the 24 hour report and a memo would be sent out to the staff identifying the resident as an elopement risk. She reported that two resident had the security alert bracelet on. She stated the elopement assessment form was used to determine if a resident was at risk for elopement. She was unable to give specific guidelines used to determine if a person was at risk for elopement, she stated that it would depend on the resident. She reported that the resident would be discussed in the restraint committee meeting to determine what interventions were needed. On [DATE] at 11:15 a.m. the Director of Nursing (DON) reported that in order to determine if someone was an elopement risk she would review the residents' nurses' notes and talk to the direct care staff to find out if the resident was saying things or had made attempts to go out. She reported if the facility felt someone was at risk for elopement the restraint committee would meet to discuss the concerns. She stated they would also ask the physician and family if the resident was appropriate for the use of an alarm. She reported that the team had discussed resident #5 and the team did not feel that there was enough to alarm her. She was unable to elaborate on what had been discussed. She reported that there was no documentation that the meeting had been held or that resident #5 had been discussed.

Based on observations, record review, and staff interviews, the facility failed to ensure residents who use antipsychotic drugs receive behavioral interventions and failed to ensure each resident's drug regimen was free from unnecessary medications for two (#2 and #4) of five residents reviewed for unnecessary medications out of 18 sampled residents. Specifically the facility failed to attempt non-pharmalogical interventions prior to the administration of an as needed psychoactive medication 1. Resident #4 a. Resident Status Resident #4 was a [AGE] year old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Findings include: The minimum data set (MDS) assessment dated [DATE] scored the brief interview of mental status (BIMS) at 15 out of 15, which indicated the resident was cognitively intact. The active [DIAGNOSES REDACTED]. Record Review: The care plan dated 4/15/15 included: The problem was identified as a [DIAGNOSES REDACTED]. The goal was for the resident not to have adverse outcomes from side effects of taking benzos (benzodiazepines) for anxiety, and not to have side effects related to anxiety. The approaches included: -Monitor for adverse side effects -Monitor for anxiety as needed (PRN) -Staff was to offer non-pharmacological interventions prior to giving [MEDICATION NAME] PRN The signed physician's order [REDACTED]. -[MEDICATION NAME] (benzodiazepine) 0.25 mg tablet half a tablet by mouth at bedtime for anxiety ([MEDICATION NAME]) -[MEDICATION NAME](benzodiazepine) 0.25 mf tablet half a tablet every four hours PRN for anxiety ([MEDICATION NAME]) The 6/17/15 physician ' s progress note included in part: The resident takes [MEDICATION NAME] PRN for anxiety. She reports relief from her anxiety with an occasional, minimal dose. Without [MEDICATION NAME] to break this cycle, she is at high risk for destabilization and exacerbation of her mental illness .Please continue to provide this medication. On 5/9/13 a risk vs. benefit statement for [MEDICATION NAME] was signed by the physician. The facility ' s Policy and Procedures for Antipsychotic Medication use included in part, 9. For acute psychiatric situations, antipsychotic medication use shall meet the following criteria: . c. Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. The dates from April 16th 2015 to April 30th 2015, according to the Medication Administration Record [REDACTED]. The MAR for the month of May 2015 revealed there were three PRN [MEDICATION NAME] doses administered with no non-pharmacological interventions noted. The MAR for the month of June through the 24th revealed there were five PRN [MEDICATION NAME] doses administered with one noted attempt at non-pharmacological interventions prior to the administration of the medication. Interviews: On 6/24/15 at 2:15 p.m. certified nurses' aide (CNA) #4 stated, She really doesn ' t have any behaviors, just that she makes things up sometimes. On 6/24/15 at 2:50 p.m. registered nurse (RN) #1 stated, The resident can get nervous, she has anxiety, she can ' t sit still. When she is anxious we talk to her, offer her fluids and just let her talk if she wants to. She has a PRN of [MEDICATION NAME] also we can give her. We try other things before the PRN. On 6/24/15 at 3 p.m. the director of nursing (DON) stated, On 4/15/15 we implemented the non-pharmacological sheet in the MAR, I guess we need to reinforce the teaching on the use of the form. Every time the PRN [MEDICATION NAME] medication is administered I expect non-pharmacological interventions to be attempted. The provider wants her to have the PRN, but we should only use it when necessary. 2. Resident #2 a. Resident status Resident #2 was a [AGE] year old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Findings include: The minimum data set (MDS) assessment dated [DATE] scored the brief interview of mental status (BIMS) at six out of 15, which indicated the resident had severe cognitive impairment. The resident's active [DIAGNOSES REDACTED]. Record Review: The care plan dated 3/3/15 identified: The problem was potential for complications related to antidepressant and anti-anxiety medication use of [MEDICATION NAME] and [MEDICATION NAME]. The goal was for the resident not to exhibit signs of drug related sedation, [MEDICAL CONDITION], or anticholerginic symptoms. Approaches included: -reduce or discontinue if any signs of adverse consequences emerge -side effects are monitored for and are tracked on the [MEDICAL CONDITION] sheet in the MAR The 5/27/15 signed physicians orders included: -[MEDICATION NAME] 0.25 mg one tablet every eight hours as needed (PRN) for anxiety ([MEDICATION NAME]) The facility ' s Policy and Procedures for Antipsychotic Medication use included in part, 9. For acute psychiatric situations, antipsychotic medication use shall meet the following criteria: . c. Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation. The Medication Administration Record [REDACTED]. The MAR for May 2015 had one signed dose of the PRN [MEDICATION NAME] with no documented non-pharmacological interventions noted. The MAR for June 2015 (only through the 24th) revealed three PRN doses of [MEDICATION NAME] without documentation of non-pharmacological interventions attempted before the [MEDICATION NAME] was given. Interviews: On 6/24/15 at 23:15 p.m. certified nurses' aide (CNA) #4 stated, She can be forgetful and she has dementia, I ' m not aware of her having any behaviors. On 6/24/15 at 2:50 p.m. registered nurse (RN) #1 stated, The resident doesn ' t always know the time or place she is, so she gets anxious and starts to go through her things and throw stuff away. We (the staff) talk to her, offer her fluids, rub her legs, and encourage her to be around other residents. When she does receive a PRN, we document it on both sides of the MAR. On 6/24/15 at 3 p.m. the director of nursing (DON) stated, On 4/15/15 we implemented the non-pharmacological sheet in the MAR, I guess we need to reinforce the teaching on the use of the form. Every time the PRN [MEDICATION NAME] medication is administered I expect non-pharmacological interventions to be attempted. The provider wants her to have the PRN, but we should only use it when necessary.

Based on observations and staff interviews, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in one of one medication carts the facility failed to discard expired medications. Specifically, the facility failed to discard and remove expired eye drops from use. Findings include: Dorzolamide/Timolol Solution (A glaucoma agent) A. Manufacturer requirements In pertinent part the package insert for Dorzolamide/Timolol read, Dorzolamide/Timolol should be used within 28 days after the bottle is first opened. Therefore, you must throw away the bottle four weeks after you first opened it, even if some solution is left. To help you remember, write down the date that you opened it in the space on the carton. On 6/23/15 at 2 p.m. an observation of the medication cart revealed an expired bottle of Dorzolamide/Timolol eye drops that were dated 5/23/15 as being opened. The licensed practical nurse (LPN) #1 stated, The eye drops are expired. If we give expired eye drops the effectiveness might be compromised and it won ' t work like it ' s supposed to. The expired Dorzolamide/Timolol eye drops were still in use for the resident's gluacoma. On 6/25/15 at 9:37 a.m. the assistant director of nurses (ADON) stated, The expired eye drops should have been discarded, using expired medications cannot guarantee the eye drops are effective.

Based on observations and staff interviews, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for two (#3 and #12) of two residents observed during peri-care out of 18 sampled residents. Specifically, the facility failed to require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Professional References: CDC, Hand Hygiene Basics , http://www.cdc.gov/handhygiene/Basics.html (6/29/15): Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). CDC, Infection Control , <http://www.cdc.gov/oralhealth/infectioncontrol/faq/protective_equipment.htm> (6/29/15): Washing of latex gloves with plain soap, [MEDICATION NAME], or alcohol can cause micropunctures. This condition, known as wicking, may allow liquids to penetrate through undetected holes in the gloves. For that reason, washing of gloves is not recommended. Findings Include: Facility In-service Records The following in-services for hand washing were provided by the facility staff and included the following information: The sign-in sheet dated 2/17/15-2/14/15 titled, Your Role in Resident Skin Care included the signatures from certified nurses' aides (CNA) #1 and #4. The sign-in sheet dated 5/28/15 titled, Skin Care and How to pick up extremities of residents included the signatures of CNA ' s #1 and #4. Observations -On 6/24/15 at 3:30 p.m. resident #3 was observed receiving peri-care. CNA #1 placed clean single-use gloves on, prepared the necessary items (wet warm disposable wipes), assisted the resident to a standing position, removed her oxygen (nasal cannula), washed her hands with the gloves on, dried her hands with the same initial pair of single-use gloves on, removed the soiled pad, cleaned the soiled area on the resident, applied a clean disposable pad, pulled up the residents clothing, assisted the resident back into the wheelchair, removed the single use gloves and handed the resident her oxygen tubing, then washed her hands before leaving the room. -On 6/25/15 at 9:26 a.m. resident #12 was observed receiving peri-care. CNA #4 placed single-use gloves on, assisted the resident with peri-care, assisted the resident back into a wheelchair, removed her gloves and left the room with the dirty gloves in her hand. Interviews On 6/24/15 at 4:10 p.m. CNA #1 stated, I did wash my hands with gloves on and I shouldn ' t of. I should of washed my hands before handing her the oxygen tubing so I don ' t spread germs to the tubing. On 6/25/15 at approximately 9:30 a.m. CNA #4 stated, I should have washed my hands before I left the room. On 6/25/15 at 9:37 a.m. the assistant director of nurses (ADON) stated, We just had an in-service on hand washing. The aides should have washed their hands to prevent the possibility of spreading infections before putting on gloves and after removing the gloves.

Based on record review, observations, resident and staff interviews, the facility failed to provide for one (#5) of 14 sample residents appropriate treatment and services to prevent further decrease in range of motion or increase range of motion. Specifically, the facility failed to treat the small finger contracture on the left hand after identification for the need of a splint. The findings include: A. Resident Status The [AGE] year old sample resident #5 was originally admitted from the hospital to the facility on [DATE]. The resident's medical [DIAGNOSES REDACTED]. According to the most recent minimum data set ((MDS) dated [DATE], the resident was understood by others and usually understood others. The resident scored a 12 on the Brief Interview Mental Status (BIMS), indication that the resident cognition status was moderately impaired. The resident experienced delusional behavioral symptoms. The resident was independent with most activities of daily living (ADLs), requiring set up for eating and physical help with bathing only. The resident was ambulatory. The resident was not steady but able to stabilize without human assistance, with moving from seated to standing and walking positions. The MDS indicated that the resident was unable to turn around to face the opposite direction. The MDS indicated that the resident was not steady, but able to stabilize without human assistance with moving on and off of the toilet. The MDS indicated that the resident had no limitation with functional range of motion (ROM) with bilateral upper extremity (although the resident had a contracted left (L) fifth digit/small finger. The resident's mobility devices included a walker. The MDS indicated that the resident was continent of bladder and bowel. The MDS indicated the resident received no occupational therapy (OT), physical therapy (PT) or restorative therapy (RT). The MDS indicated no techniques for ROM, active or passive. The MDS indicated no current use of a splint or brace assistance. The resident's current care plan dated 10/28/13, read in pertinent parts," Problem ...Resident at risk for deterioration in ADLs." The goal indicated that the resident was to experience no deterioration in ADLs evidenced by maintaining ability to complete ADLs mostly independently over the next 90 days. The approaches to the care plan indicated in pertinent parts, "PT to treat Res (resident) as ordered by physician (MD) prn (as needed)." The care plan did not specifically address the resident's contracture to the left small finger/hand. The care plan did not reflect the current condition of the resident, who had a contracted left small finger, with limited range of motion. review of the resident's medical record revealed [REDACTED]. On 5/13/14 at 2:38 p.m., during the staff interview portion of the survey, the Registered Nurse (RN#1) stated that the resident had a contracture to one of her hands due to arthritis. The RN briefly reviewed the resident's medical record and stated that she was not sure which hand may be contracted. B. Record review/staff interviews: On 5/13 and 5/14/14, the surveyor reviewed the resident's medical record and there was no evidence of any documentation of contractures for the resident. On 5/14/14 at approximately 1:45 p.m., the Director of Nursing (DON) was asked for clarification. The DON then presented a completed physical therapy screening form (PTSF), which had not been placed in the resident's medical record during prior record review. The PTSF was dated 4/22/14. The PTSF indicated in pertinent Parts, "Contracture/s (L) fifth finger ...RECOMMENDATIONS: recommend pt (patient) get finger splint for (L) fifth finger, pt is very concerned about contracture. Slight strength resumes in finger extension." The PTSF was noted by the physician (MD) on 4/30/14, for indication that the physician agreed with the PT recommendations for treatment of [REDACTED]. However, there was no documentation in the medical record that indicated PT had followed up with treatment as noted by the MD. Review of the physician orders [REDACTED]. Review of the medical record revealed no further evaluation or treatment by therapies for the left fifth finger contracture. The medical record review also revealed no current documentation of the resident's left fifth finger contracture. In addition, there was no care plan initiated for the resident's contracture and/or treatment to her left 5th finger. C. Staff interview and Observations On 5/14/14 at 2:00 p.m., the DON was asked about the resident's hand/finger contractures as identified in the 5/13/14 staff interview. The DON stated that the resident was usually in the day room. The surveyor followed the DON to the day room, where the resident was observed sitting in a chair. The DON asked the resident if she could see the resident's left hand and the resident agreed. Her fingers on the left hand were observed to be partially contracted but the resident was able to move with difficulty, her thumb and the three fingers next to the thumb. The left fifth finger was observed to be very stiff and contracted and the resident had difficulty in moving that stiff/contracted finger. During this observation, the resident stated as she wiggled the fingers on the left hand, "My fingers are getting worse." The resident further stated that PT saw her and told her that he would evaluate the resident for splinting of the left 5th finger. The resident stated, "PT said he needed to measure (evaluate) me (the left fifth finger) for splinting and has not done that yet. I'm concerned it is worsening... look," as the resident attempted to move that left 5th finger, but could hardly move it. The resident then stated that she needed a splint and would wear the splint to prevent further contracture to her left fifth finger. Again, the resident shared with the DON and surveyor that she was concerned that the left 5th finger contracture was getting worse and there had been no evidence of follow-up in regards to the 4/30/14 physician orders. On 5/14/14 at 2:30 p.m., in the presence of two surveyors, the DON was interviewed for clarification. In that interview, the DON stated in pertinent parts, "She has arthritis in her hand ...the little finger (L 5th finger) is contracted... it (L 5th finger) is partially stiffened ...more than the rest of the (L hand) fingers... I don't know what to call it (stiffness to L fifth finger)... She said she would wear a splint (to L fifth finger)... PT said he would measure her for a splint and it has not happened... He (PT) never went back to measure (evaluate) her." In that same interview, the DON further stated in pertinent parts, "He (PT) told me verbally that he could make something (splint) but he thought that she would not wear it." Yet, during the resident observation/interview above, the resident stated to the DON and surveyor that she was concerned about the contracture and would wear a splint, and was waiting on PT for splint measurements. In that same interview, the DON further stated in pertinent parts, "He (PT) recommended one (splint) on 4/30/14." In another interview with the DON on 5/15/14 at 9:00 a.m., the DON stated that PT would talk to the surveyor, via telephone for clarification on that date. On 5/15/14 at 12:05 p.m., the unit LPN #1, who consistently provided care for the resident, was interviewed. LPN#1 stated in pertinent parts, "since she (resident #5) was admitted she had that contracture (L fifth finger) ... Her left fingers, it appears to me, are contracted ... He (PT name) comes in and does quarterly evaluations ... He (PT) gives a report to the DON then she (DON) goes off that report ... then DON gets orders for restorative ... she (resident #5) has no restorative program... As far as left hand goes, there is no restorative program." On 5/15/14 at 12:30 p.m., in the presence of two surveyors, both the DON and Assistant DON (ADON) were interviewed at the same time. In that interview, the DON stated in pertinent parts, "On admission ...the MD may order therapy/evaluation ... Then all the residents get PT screening quarterly ...The paper (PT documentation for resident #5) dated 4/24/14 was a quarterly screen ...Once we screen them, I give the copy (PT screen) to MD ...He (MD) states he agrees or disagrees with therapy recommendations ...Sometimes they write a telephone order (TO) or write (write orders) on the progress notes or on the PT screen (as on the above recommendation on 4/22/14)." The MD noted the PT recommendations for resident #5 in agreement as indicated above). The DON further clarified and stated in pertinent parts, "Noted by the physician means he (MD) agreed with the PT recommendation ...After the physician agreed ...we asked therapy to get the splints." The DON stated that there were no further notes other than the PTSF dated 4/22/14 which was noted by the MD on 4/30/14, in agreement for treatment of [REDACTED]. The DON stated in pertinent parts, "I don't remember when I asked him (PT) to get a splint ...He (PT) said he did not recommend a splint ... She (resident #5) used to have one at home ...Her finger is already contracted. He (PT) would not recommend (a splint)." However, in the interview above, the resident stated she would wear the splint for prevention of worsening of the contracture. In that same interview on 5/15/14 at 12:30 p.m., the ADON stated, "He (PT) should have made a splint... Because we don't have one (have no splint in the facility)... that is why he (PT) said she (the resident) didn't need it... It's confusing that if you are going to recommend something on paper and then turn around and say she (resident #5) really doesn't need it... I will get a second opinion, because she (resident #5) is concerned about to where it (L fifth finger) is going to tighten up all together." In that interview, the ADON further stated in pertinent parts, "The physician is not aware that resident did not get therapy... We are waiting for clarification from PT as to why he does not recommend a splint... He (PT) was here last Monday (5/12/14), he should have documentation of that recommendation." On 5/15/14 at 1:45 p.m., the PT called and was interviewed via telephone. In the interview, the PT stated that prior to admission, the resident had an old fracture to her wrist and was treated last summer at the community hospital. The PT stated that with that old wrist fracture, the resident experienced muscles damage. The PT acknowledged that he had talked to resident #5 about the 5th finger on left hand (on 4/22/14). The PT stated in pertinent parts, "I talking about splinting it... I was not too sure about damage... We can splint it to get it straight... we could order a splint... the only way to straighten it (L fifth finger contracture) is to splint it... When I'm down there (at the facility), I will talk to the physician to get an order for [REDACTED]. The PT stated in pertinent parts, "The process is to order a splint for the fifth finger." The PT further stated, "I was not aware that the physician okayed it (PT recommendations for a splinting the resident's left 5th finger as recommended on 4/22/14 above)... It (the process) would be to order a splint after the physician okayed the recommendation." No further comments were given. No further documentation was provided at exit on 5/15/14 or shortly after exit.

Based on record review and staff interview, the facility failed to ensure the drug regimen for one of 14 sample residents (#4) was free from unnecessary drugs. The findings included: Resident #4, [AGE] years old, most recently was re-admitted on [DATE]. The resident's June, 2013 Computerized Physician order [REDACTED]. Minimum Data Set (MDS) -The quarterly/partial MDS of 3/20/13 listed this resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15 correct answers. There were no mood problems. The resident was listed to have [MEDICAL CONDITION] and to have "other" behaviors on 1-3 days of the 7 day review period. -The quarterly MDS of 12/21/12 listed the resident to have a BIMS score of 12 out of 15 correct answers. The resident was listed under "Mood" to be tired or to have little energy on 2-6 days of the 14 day review period. The resident was listed to have [MEDICAL CONDITION]. This MDS review listed no behavior problems. Medical Record Review: (1) Orders The resident's medical record listed in their June 2013 monthly Computerized Physician order [REDACTED]. This order was an increase form the previous order of 10 mg [MEDICATION NAME] daily. (2) Current Care Plan and care planned problems related to mood or behavior a. Problem: [DIAGNOSES REDACTED]. Goal: Long term goal.... The resident will show improved mood over the next 90 days. Approaches: -Brief Interview for Mental Status (BIMS), part of the MDS, and total severity score quarterly per Social services; -Encourage to participate make decisions daily in activities, clothing, food choices grooming and self care; -Invite to activities and socials; -[MEDICATION NAME] (an antidepressant) per physician order; -Monitor every shift on [MEDICAL CONDITION] sheet for behaviors and side effects; -One to ones with Social Services as needed; -Review of medication per [MEDICAL CONDITION] committee quarterly. b. A problem 12/28/12 of having actual or potential for side effects related to taking [MEDICAL CONDITION] medication. Approaches included monitoring of potential side effects, which were listed. c. Problem of exhibiting behavioral symptoms of socially inappropriate behaviors demonstrated by agitating other residents by talking about their personal hygiene, talking too loud and bossing other residents, and hitting staff. The problem had a start date of 12/27/12. The goal was to have less socially inappropriate behaviors. Approaches included: -Be positive and never argue with resident; -Give positive attention when resident is not complaining; -Psychiatric consult as appropriate; -Redirect or take the resident to the proper person to solve the problem, to department head for specific problems, and perception of mistreatment to Social Services; -Remind the resident of inappropriateness of the behavior; -Remind the resident that she is to allow enough time to get her problem resolved before complaining to others including other residents. Remind her that she upsets others when she repeats the same complaints; -Remind the resident to talk in private to Social Services and the Director of Nursing about these issues; -Staff will be aware of behaviors and monitor for, as well as response of other residents; -Total Severity Score (MDS listed behaviors) quarterly; -TSH (a laboratory test) per physician order [REDACTED]. d. Claims of missing items from December 2005 and continues to discuss this as if it just happened. Resident believed that a man was coming into her room and stealing her things. The problem had a start date of 12/27/12. The goal was to have episodes of this inappropriate behavior decrease. Approaches were: -Give positive attention when the resident is not complaining; -If the resident talks about it remind her that this was why she has the locked drawer; -The resident has a locked drawer in her room which she has the key for and which she keeps with her at all times; -The resident was to keep all valuables with the bookkeeper or in her locked drawer; -Remind the resident that this was long ago and it is not a good idea to dwell on the negative past; -Remind the resident to report any missing items immediately to Social Services, Nursing or Administration; -Social Services to take pictures of the resident's rooms, shelves and closets to assist with determining if she has lost items; -Talk with Social Services, Director of Nursing, Assistant Director of Nursing and Certified Nurse Aides as needed; -Visits with the Mental Health Counselor as needed, Social Services will arrange. e. During Activities the resident has at times made rude remarks to other residents The pertinent approach was to encourage good behavior with other residents and staff by offering a bingo prize to redeem. f. The care plan listed the use of an antidepressant medication due to having depression Staff were to encourage participation in daily decisions and activities. The care plan did not identify specific symptoms of depression or address what staff should do if the resident exhibited symptoms of depression other than encourage daily decisions and activities. (3) Mental Health Follow Up According to documentation in the resident's record, the resident was seen by the Mental Health Center on 9/21/12 due to having expressed suicidal statements the day before. There was one follow up visit from Mental Health documented. The Mental Health Center stated in their report from the second visit on 9/28/13, that the resident still thought about suicide but wound not carry through with it. The resident had no specific plan and was depressed due to physical/medical concerns at that time. (4) Monitoring the Resident's Depression Monthly Flow Record for the use of [MEDICATION NAME]/[MEDICATION NAME] for depression. May 2013 Behaviors being tracked were: -paranoia -rudeness to resident/staff -crying about past life None of the tracked behaviors were listed to have occurred in May. April 2013 Behaviors being tracked were: -rude to staff -rude to other resident There were no behaviors listed to have occurred in April. March 2013 Behaviors being tracked: -paranoia -rudeness to other residents and staff There were no behaviors listed to have occurred in March. Staff Interviews: a. The Social Services Director (SSD) was asked on 6/4/13 during an interview starting at 3:07 p.m., about the resident's depression and the use of [MEDICATION NAME], an antidepressant for symptoms of paranoia and rudeness to residents and/or staff. The SSD stated that she had listed in the MDS that the resident had [MEDICAL CONDITION], a fixed false idea, not paranoia. The SSD said the resident's symptoms of depression included the resident becoming more isolative-not wanting to come out of her room. She stated that she could also be tearful and more judgmental/negative toward others. b. On 6/5/13 at approximately 2:00 p.m., the Director of Nursing (DON) was interviewed. She said the resident's symptoms of depression were the resident seldom coming out of her room and increased tearfulness. Failures: While the staff could identify the symptoms of the resident's depression, see above, other than 'crying about past life,' (see May 2013 behavior monitoring above), these behaviors being monitored were not the symptoms of depression identified by staff. Moreover, none of the identified target behaviors for the use of the antidepressant, [MEDICATION NAME], were documented to have occurred between March and May. In spite of having none of the targeted/monitored behaviors listed as having occurred in March, the resident's antidepressant was increased on 3/23/13. Finally, the resident's suicidal ideation, which would be related to the resident's depression, was not being tracked or addressed in the resident's comprehensive care plan for staff identification and follow up. Finally, there was no documentation regarding how an antidepressant medication was to address the resident's depression or would address symptoms of paranoia and rude behaviors and no documentation of an increase in symptoms/behaviors at the time of the increase in the resident's antidepressant.

Based on record review and staff interviews, the facility failed to ensure professional standards were followed for two (#4, #8) of ten sample residents. Specifically, the facility: --failed to follow the physician's orders [REDACTED].#4. --failed to ensure the physician's orders [REDACTED].#4. --failed to document an explanation on the reverse side for circling the nurse's initials on the front of the TAR (Treatment Administration Record) for resident #4. --failed to document an assessment of the resident with a reason for sending resident #8 to the hospital emergency room . --failed to ensure the physician's orders [REDACTED]. The findings include: A. Resident #4 Record review of the face sheet revealed [AGE] year-old resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Record review and interview revealed the physician's orders [REDACTED].#4. Specifically: Review of the 4/12 computerized physician's orders [REDACTED].>157 lbs (call doctor if used two times in a 7-day period and do BMP)." Review of the Weight Tracking Sheet revealed the resident weighed 160.1 lbs on 3/30/12 and documented no [MEDICATION NAME] was administered (even though the weight was more than 3 pounds above 157). The sheet also revealed the resident weighed 161.6 lbs on 3/31/12 and [MEDICATION NAME] was administered. Review of the 3/12 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nursing notes, the physician notes, the laboratory reports and the physician's orders [REDACTED]. The only BMPs in the resident's record were collected on 3/6/12 and 4/9/12. The Assistant Director of Nursing (ADON) was interviewed on 4/18/12 at 12:20 p.m. The ADON said she expected the nurses to follow physician orders. She said the BMP may be in the lab book, rather than in the chart. The ADON said sometimes the nurses call the physician or fax, and that "we'd do a BMP after the 2nd dose." She said she would check and report back. The ADON was interviewed on 4/18/12 at 1:50 p.m. She said she could not find the BMP or evidence of contacting the physician when two doses of [MEDICATION NAME] were administered in a 7-day period. 2. Record review and interview revealed the physician's orders [REDACTED].#4. Specifically: Review of the 3/21/12 physician's telephone order revealed, "1) Clean with wound cleanser, pat dry, 2) Apply skin prep to SDTI (unknown?) and intact blisters, if drainage occurs, apply Xeroform gauze to wound bed and cover (with) bordered foam, change daily." The order did not contain the site of the wound. Review of the 4/12 computerized physician's orders [REDACTED].? lower leg with wound cleanser & pat dry, apply skin prep to SDTI (unknown?) and intact blisters. If drainage occurs apply Xeroform gauze to wound bed and cover with bordered foam. 3/21/12." Review of the 3/12 TAR (Treatment Administration Record) revealed "Clean wound with wound cleanser, pat dry. Apply skin prep to SDTI (unknown?) and intact blisters, if drainage occurs, apply Xeroform gauze to wound bed & cover (with) bordered foam. Change daily. 3/21/12." The ADON was interviewed on 4/18/12 at 12:20 p.m. She said the TO and TAR should specify the site of the wound requiring the treatment to the right lower leg. The ADON confirmed pool staff were used and they would not know where the wound was to change the dressing. She said the wound was not healed and they were still doing the dressing change. 3. Record review and interview revealed no documented evidence of an explanation on the reverse side for circling the nurse's initials on the front of the TAR for resident #4. Specifically: Review of the 3/12 TAR revealed "Clean wound with wound cleanser, pat dry. Apply skin prep to SDTI (unknown?) and intact blisters, if drainage occurs, apply Xeroform gauze to wound bed & cover (with) bordered foam. Change daily. 3/21/12 (see above)." In the boxes for nurse initials from 3/22 to 3/31/12, two of the 10 were blank, two of the 10 were signed as administered, and the remaining six were circled without documenting an explanation on the reverse side of the TAR (the documentation from 3/26/12 had circled initials and a handwritten note on the front "drsg on," without explaining the reason for circling such as another nurse already performed on this date). The ADON was interviewed on 4/18/12 at 12:20 p.m. She said when something was circled on the TAR, there should be written documentation on the reverse side of the TAR with the explanation for circling the treatment (whether it was not done, done at a different time; the reason for circling the initials). The ADON said the wound was not healed and they were still doing the dressing change. She said, "I assume they are circled because they were not done and blank ... should document an explanation," on the back of the TAR. B. Resident #8 1. Professional Standards "The systematic and on-going collection of pertinent health data, the analysis of this assessment data, and the documentation/communication of the data are nursing expectations and responsibilities." See generally: American Nurses Association, Standards of Clinical Nursing Practice, 1998, (ANA Standards). "Assessing is a continuing process carried out during all phases of the nursing process." See: Fundamentals of Nursing, Concepts, Process, and Practice, 4th edition, 1991. 2. Facility Policy The facility policy titled, "Change of Condition" was received from the Assistant Director of Nursing (ADON) on 4/18/12 at 2:45 p.m. and read in pertinent part: "Objective: To provide guidelines for care of resident whose condition has changed. Procedure: Thoroughly assess the resident's condition. Example: VS, level of consciousness, abnormal symptoms, observation of resident's physical changes." 3. Resident Data Resident #8, [AGE] years old, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, that included [MEDICAL CONDITION], chronic ischemic [MEDICAL CONDITION], anxiety state, and hypertrophy of prostate. According to his admission Minimum Data Set (MDS) assessment, completed on 4/5/12, the resident had modified independence with cognitive abilities, was hard of hearing, was totally dependent and required one/two persons' physical assist with transferring, personal hygiene, bathing and dressing. He was able to feed himself with set up only. a. Record Review During the medical record review on 4/18/12, the Colorado Medical Orders for Scope of Treatment (MOST) signed by MDPOA on 3/27/12 and physician on 3/28/12 revealed, under the Medical Interventions, that resident required, "Comfort Measures Only". This Medical Interventions specified: "use of medication by any route, positioning, and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of [REDACTED]. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location." Nurse's notes, dated 4/10/12, read in pertinent part, the resident had an x-ray of his left knee due to an increase in pain. The primary physician saw the resident on 4/11/12 at 5:55 p.m. New medications for pain and tremors were ordered. Doctor (name) requested report of the resident response to new medications and a follow up visit within two weeks. On 4/11/12 at 9:15 p.m., the nurse noted VS (blood pressure 79/48, pulse 111, respiration 30 and oxygen saturation 84%). There were no other notes of comprehensive assessment regarding the resident's physical condition. The resident was transferred to emergency department via ambulance at 9:40 p.m. The nurse documented in the same nurse's notes, that the hospital informed the nursing home via phone, the resident was ready to return to the facility at 10:00 p.m. (45 minutes after the "911" call). The nurse noted the resident's VS, upon return at 10:30 p.m., (BP 89/52, temp 97.7 degrees F, pulse 95, respiration 28, and pulse oxygenation 84%) with [DIAGNOSES REDACTED]. The nursing staff failed to check resident's Medical Interventions (MOST) and did not perform comprehensive assessment prior to sending resident via ambulance to the emergency department. The facility did not follow their policy regarding "Change of Condition" (see above). b. Staff Interview On 4/18/12 at approximately 12:20 p.m., the surveyor brought her observations to ADON's attention. The ADON said the nurse who worked that night was an agency nurse and she would receive in-service training prior to working the next shift. She agreed with the above findings and stated the comprehensive assessment should be done and the residents' wishes (MOST) should be familiar to all staff. 4. Verification of Orders a. Professional Standards According to "Fundamentals of Nursing the Art & Science of Nursing Care" 4th Edition, 2001, (Lippincott), pages 109, 290, 583-586, and 637, "Physician-initiated interventions, or dependent nursing actions, involve carrying out physician prescribed orders. Nurses are legally responsible for carrying out the orders of the physician in charge of the resident." b. Record Review According to admission Medical Administration Record (MAR) dated 3/28/12, resident #8 had an order for [REDACTED]. On 4/11/12, after 45 minutes of hospitalization , the resident's new orders did not reveal any changes to the previous [MEDICATION NAME] order. The resident should have been weighed daily and the medication should have continued to be PRN. However, on 4/18/12, MAR indicated [REDACTED]. There was no supporting documentation or orders to do so. c. Interview On 4/18/12 at approximately 12:00 p.m., the ADON verified the order should not have changed; she called the physician right away and clarified resident #8 orders. The clarified order was noted in medical record and resident's MAR indicated [REDACTED]