Every finding on record at Colorado Veterans Community Living CTR at Homelake

Based on observations, record review and interviews, the facility failed to provide services for two (#15 and #7) of two residents reviewed out of 23 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #15's and Resident #7's vital signs, specifically the resident's blood pressure and pulse, were monitored and assessed prior to the administration of a blood pressure medication. Findings include: I. Professional reference According to Kizior, R. J. [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse in 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. According to Kizior, R. J. [NAME], K. J. (2023). Amlodipine. [NAME] Nursing Drug Handbook. Elsevier. P. 60. Assess B/P, if systolic B/P is less than 90 mmHg, withhold medication, contact physician. According to Kizior, R. J. [NAME], K. J. (2023). Lisinopril. [NAME] Nursing DrugHandbook. Elsevier. p. 703. Obtain B/P, apical pulse immediately before each dose in addition to regular monitoring, be alert to fluctuations. II. Facility policy and procedure The Medication Administration policy and procedure, revised 10/20/23, was provided by the nursing home administrator (NHA) on 10/16/24 at 4:56 p.m. It read in pertinent part, Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the provider's prescribed parameters. III. Resident #15 A. Resident status Resident #15, age 80, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), the diagnoses included Parkinson's disease (brain disorder that causes tremors), orthostatic hypotension (low blood pressure after standing or sitting up) and syncope (fainting). The 7/18/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 13 out of 15. He was dependent with toileting, personal hygiene, required substantial/maximal assistance with bed mobility, transfers and required supervision with eating. B. Observations On 10/16/24 at 7:35 a.m. registered nurse (RN) #2 was observed dispensing and administering Metoprolol 12.5 milligrams (mg) to Resident #15. RN #2 checked the certified nurse aide (CNA) 10/16/24 vital sign record sheet for that morning (10/16/24), which indicated the resident's blood pressure was 93/60 mmHg. -RN #2 did not check the vital sign record sheet or the resident's medical record for a pulse rate. -RN #2 did not check the order for blood pressure or pulse parameters prior to the administration of the Metoprolol medication to Resident #15. C. Record review The October 2024 CPO documented a physician's order of Metoprolol succinate ER (extended release), give 12.5 mg once a day for heart rate, ordered on 11/3/22. -The October 2024 CPO did not document any vital signs parameters for when to hold the Metoprolol medication or when to notify the physician of irregular vital sign results for that medication. The October 2024 (10/1/24 to 10/16/24) vital signs summary revealed Resident #15's pulse was only assessed on 10/4/24, 10/5/24, 10/7/24, 10/11/24, 10/12/24, 10/13/24 and 10/14/24 and not daily at the time the resident was given the prescribed Metoprolol tablets. IV. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, the diagnoses included diabetes mellitus (DM) and hypertension. The 7/25/24 MDS assessment revealed the resident had cognitive impairment with a BIMS score of five out of 15. She required partial/moderate assistance with personal hygiene, transfers, supervision with toileting, set up assistance with eating and was independent with bed mobility. B. Observations On 10/16/24 at 8:00 a.m. RN #2 was observed dispensing and administering: -Amlodipine 10 mg (blood pressure medication); and, -Lisinopril 40 mg (blood pressure medication). -RN #2 did not assess the resident vital signs, including the resident's blood pressure and pulse, check the order for blood pressure parameters or review the resident's record for the resident's most recent vital signs prior to the administration of Almodipine or Lisinopril. C. Record review. The October 2024 CPO documented a physician's order of Amlodipine 10 mg once a day for hypertension (high blood pressure), ordered on 9/18/24. The October 2024 CPO documented a physician's order of Lisinopril 40 mg once a day for hypertension, ordered on 9/6/23. -The October 2024 CPO did not document any vital sign parameters for when to hold the Amlodipine or Lisinopril or when to notify the physician of irregular vital sign results. -The October 2024 (10/1/24 to 10/16/24) medication administration record (MAR) and treatment administration record (TAR) did not document how often the resident's vital sign should be checked. The September 2024 (9/1/24 to 9/30/24) and October 2024 (10/1/24 to 10/16/24) vital sign summary revealed Resident #7's blood pressure was only assessed on 9/5/24, 9/16/24, 9/19/24, 9/20/24, 9/21/24, 9/27/24, 10/9/24 and 10/16/24. The September 2024 (9/1/24 to 9/30/24) and October 2024 (10/1/24 to 10/16/24) vital sign summary revealed Resident #7's pulse was only assessed on 9/5/24, 9/12/24, 9/19/24, 9/20/24, 9/21/24 and 9/26/24. V. Staff interviews RN #2 was interviewed on 10/16/24 at 8:15 a.m. RN #2 said if a physician's order did not indicate parameters to hold the medication he would only check the blood pressure if the resident was symptomatic. He said a blood pressure of 93/60 mmHg was normal for Resident #15. He said vital signs were not routinely checked unless there were ordered parameters for medications. RN #1 was interviewed on 10/16/24 at 11:00 a.m. RN #1 said residents that were on a new medication had their vital signs checked daily. She said certain medications had ordered parameters to check vital signs. She said when residents were on medications and did not have parameters she would decide on her own whether or not to take the resident's vital signs. The director of nursing (DON) was interviewed on 10/16/24 at 12:00 p.m. The DON said vital signs were taken by certified nurse aides (CNA) and the nurses when there were parameters ordered. She said blood pressure medications should have blood pressure and pulses taken before administration, even if there were no parameters ordered. The DON was interviewed again on 10/16/24 at 2:00 p.m. The DON said she was working on nursing education regarding checking vital signs before administering blood pressure medications and knowing when to hold and consult the physician if there were no parameters in place, according to standards of practice. V. Facility follow up The Hypertensive Medication Parameters, dated 10/16/24, was received from the NHA on 10/17/24 at 1:33 p.m. It documented nursing education was provided on 10/16/24 (during the survey) to include when receiving physician's orders for hypertensive medication to notify physician to obtain orders for parameters. It documented the DON did a chart audit for all residents on medications affecting blood pressure and heart rate and their associated parameters on 10/16/24 (during the survey). It documented a weekly audit would be done of blood pressure medications with parameters for compliance. It documented audit reports to quality assurance and performance improvement (QAPI) every month to start 10/31/24.

Based on record review and interviews, the facility failed to maintain complete and accurate resident resuscitation choices in the medical record for three (#141, #13 and #32) of fourteen residents out of 23 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place for a do not resuscitate (DNR) for Resident #141, who wished to be a DNR per the resident's Medical Orders for Scope of Treatment (MOST) form; -Ensure documentation of a MOST form was in place for Resident #13; and, -Ensure the MOST form was discussed with and signed by Resident #32, who was cognitively intact. Findings include: I. Facility policy and procedure The Advanced Directives and Resident Rights to Refuse Treatment policy and procedure, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 8:00 a.m. It read in pertinent part, On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. Copies of living wills or advanced directives will not be scanned into the medical record but instead, kept in a binder in a designated area. Physician order will be entered in the electronic medical record (EMR) that reflects the resident's wishes and corresponds to the MOST form or other legal documents related to advanced directives or living will. II. Resident #141 A. Resident status Resident #141, age 92, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic kidney disease (CKD), macular degeneration (eye disease that causes vision loss) and bilateral cataracts. The[DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required setup assistance with eating and was independent with toileting, personal hygiene, bed mobility and transfers. B. Record review Review of Resident #141's EMR revealed a MOST form which was signed on [DATE] and documented Resident #141's wishes for DNR status. -Review of the [DATE] CPO failed to reveal documentation of a physician's order for the resident's DNR status. III. Resident #13 A. Resident status Resident #13, age 72, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included traumatic brain injury, hemiplegia (paralysis of one side of the body) and abdominal aortic aneurysm (AAA). The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. He required substantial/maximal assist personal hygiene, partial/moderate assistance with toileting, transfers, setup assistance with eating and was independent with bed mobility. B. Record review A review of Resident #13's [DATE] CPO revealed the following physician's order: DNR, see MOST form, ordered [DATE]. -A comprehensive review of the facility's MOST form binder failed to reveal a completed MOST form for Resident #13. IV. Resident #32 A. Resident status Resident #32, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included traumatic ischemia of muscle (direct tissue damage with decrease in blood supply), Parkinson's disease (degenerative movement disorder) and chronic respiratory failure. The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial/maximal assistance with one person for shower/bathing, upper/lower body dressing, personal hygiene, sit to stand transfers, and chair to chair transfers. B. Record review A review of Resident #32's [DATE] CPO revealed the following physician's order: Do Not Resuscitate (DNR), see MOST form, ordered [DATE]. According to the resident's MOST form, the resident was marked as No CPR: do not attempt resuscitation. The MOST form was signed by Resident #32's medical power of attorney (MPOA). The area on the MOST form that revealed if the decision was discussed with the resident was marked no. -However, Resident #32 was cognitively intact with a BIMS score of 15 out of 15 indicating the resident was capable of making his own decision about his resuscitation status and therefore should have signed his own MOST form. The care plan, initiated [DATE], revealed the resident planned to stay at the facility for short term care. -The care plan did not identify the resident's resuscitation wishes according to the MOST form. V. Staff interviews The director of nursing (DON) and the NHA were interviewed together on [DATE] at 2:59 p.m. The DON said the facility used the MOST forms for the residents' resuscitation wishes. She said the admitting nurse initiated the MOST form when the residents were admitted and the form was reviewed quarterly and when the residents' chose to change their resuscitation wishes. She said the physician was at the facility a minimum of once a week and would sign the MOST forms. She said residents that came to the nursing home from the domiciliary (the independent resident cottages) brought their MOST forms with them. The DON said Resident #141 was admitted on [DATE]. She said a physician's order for DNR status had not been obtained for Resident #141 until [DATE] (during the survey) because it was caught during a MOST form audit the facility conducted. She said, in an emergency situation, staff referred to the MOST form binder to check for residents' resuscitation statuses. She said it was important to have MOST forms filled out and physician's orders documented timely in case of any emergency situations. The DON said she did not know why Resident #13's original MOST form was missing out of the facility's MOST binder. She said there was a MOST form for Resident #13 uploaded into the EMR, but she said the facility's process during an emergency situation was to check the MOST binder and the original MOST form. She said the original MOST form was where the staff would document when a review of the MOST form was conducted and document with residents that the MOST form continued to accurately reflect their wishes. She said the facility would create a new MOST form for Resident #13 and verify if the DNR status was still his wish for resuscitation. 43950

Based on record review and staff interviews, the facility failed to ensure one (#1) of four residents reviewed for abuse out of four sample residents was kept free from abuse. Resident #2 and Resident #1 were involved in an altercation on 11/7/23. Resident #2 attacked Resident #1 and Resident #1 had injuries that included a scratch to his left forehead that was cleaned, a scratch on his nose, an abrasion to his left face/cheek, left jawline, left ear and bruising to the top of his left shoulder. There was redness around his neck and Resident #1 complained of severe left shoulder pain. Interventions added after the altercation were to move Resident #2 to a different hall and the resident was to be in the staff's line of sight. However, those interventions were not effective due to another altercation that occurred on 1/3/24. According to Resident #1, on 1/3/24 Resident #2 pulled him down and hit him. Resident #2 had redness/possible bruising to the right hand at the base of the third finger knuckle and an abrasion on the back of his left hand. Resident #1 sustained a bloody nose, a skin tear to his nose and left hand and two abrasions to the forehead. He also sustained a fracture to one of the fingers on his right hand. Resident #1 was sent to the hospital for evaluation and treatment. The facility failed to implement measures to protect Resident #1 from abuse perpetrated by Resident #2, who was known to be physically aggressive. Findings include: I. Facility policy The Abuse policy, revised 10/16/23, was provided by the nursing home administrator (NHA) on 2/13/2024 at 4:05 p.m. It documented in pertinent part, It is the policy of the (corporation) to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent mistreatment, abuse, neglect and exploitation. The (facility) will take necessary precautions to prevent resident abuse by anyone including staff members, other residents, volunteer, contracted staff, family members, resident representatives, visitors, and other individuals. II. Resident-to-resident altercation involving Resident #1 and Resident #2 on 11/7/23 According to the investigation, Resident #2 entered the room that adjoined his and went to the bed where Resident #1 was sleeping and began attacking him. Resident #2 attempted to choke Resident #1 but the Resident #1 was able to make enough noise to alert staff of the situation. Staff reported a certified nurse aide (CNA) attempted to pull the Resident #2 from Resident #1 and when she did, Resident #2 pushed her away from him. The CNA called for assistance and when staff entered the room they were able to get the Resident #2 away from Resident #1 and out of the room. Resident #2 was brought to the rotunda (common area) where he slept for the next hour. The medical doctor (MD), the NHA, the director of nursing (DON), the social services staff and family were notified of the incident. Law enforcement was notified at 5:20 p.m. Resident #1 sustained a scratch to his left forehead that was cleaned, dried and covered with protective dressing. He had a scratch on his nose, an abrasion to his left face/cheek, left jaw line, left ear and bruising to the top of his left shoulder. There was redness around his neck and the resident complained of severe left shoulder pain. The facility's action for the assailant was to add Resident #2's behaviors to the care plan and implement an intervention for the resident to be in the line of sight of the staff. Resident #2 was moved to a different hall. The conclusion of the internal investigation documented Resident #2 attacked and choked Resident #1. Resident #1 did not remember the incident. The CNA witnessed the incident and separated the residents immediately. III. Resident-to-resident altercation involving Resident #1 and Resident #2 on 1/3/24 According to the investigation, there was an unwitnessed altercation between Resident #1 and Resident #2 on 1/3/24. Resident #1 thought Resident #2 may have punched him. The registered nurse (RN) in charge thought maybe Resident #1 attempted to stand up and fell and hit his nose and side of his head due to injury marks and where he was found. A CNA observed what she thought was a resident had fallen. Resident #1 was mostly out of his wheelchair next to the wall with Resident #2 holding him by his shirt collar. The CNA redirected Resident #2 down to his hallway and called a RN to assess injuries in both residents. Resident #1 was interviewed by a police officer and, due to the resident having an abrasion to head, he was sent to the emergency room for further evaluation. The nature of suspected abuse was physical with hitting and Resident #1 having a fractured finger. The facility's action for Resident #2 was for the resident to be in the line of sight of the staff. Resident #2 was moved to a room at the end of the hall. The facility documented the incident was inconclusive due to the cognition of the residents. -However, the CNA did witness the resident being pulled by his collar which caused the fall and injuries to Resident #1 (see progress notes below). In addition, Resident #2 had redness/possible bruising to the right hand at the base of the third finger knuckle and an abrasion on the back of his left hand. IV. Resident #1 A. Resident status Resident #1, age 87, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), dementia and age related physical disability, According to the 1/25/24 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident had verbal and physical behaviors directed towards others. B. Resident observation and interview Resident #1 was interviewed on 2/13/24 at 9:50 a.m. Resident #1 was lying down in his bed looking out the window. He said he stayed in his room most of the time as he liked to spend time alone. Resident #1 said, I don't want to talk about it but I tell you if I would not have been lying down I would have let him have it because I know [NAME] arts. C. Record review The care plan, initiated 5/15/23 and revised 1/25/24, identified the resident had impaired cognition function/dementia or impaired thought processes and dementia with behaviors. Interventions included keeping resident's routine consistent and trying to provide consistent caregivers as much as possible and monitor/document/report as needed any changes in cognitive function, specifically changes in decision making ability. The nurse note dated 1/3/24 at 7:53 p.m. documented in pertinent part, This nurse heard a CNA yelling for a nurse. Upon arrival to the hallway the resident was found lying on the floor with his head against the wall with nose bleeding, skin tear to nose and skin tear to left hand with two abrasions to the forehead. The resident was stating another resident made him fall and hit him. The resident complained of shoulder pain which was chronic. Administration and medical doctor notified with order to send the resident to the emergency room (ER) for evaluation. Social service notified as well as family of possible altercation. The Sheriff's office notified and came into the facility to interview residents. The ambulance arrived to transport to hospital. Report called to nurse at hospital. The resident was alert smiling and talking to emergency medical technicians (EMT). The EMT asked the resident if he hit his head and he stated, 'I don't remember as my memory isn't very good anymore'. The 72-hour follow up notes dated 1/4/24 at 6:31 a.m. documented in pertinent part, The resident was back from hospital altercation with another resident. The resident received his tetanus shot, had some lacerations, bruising and a fracture to his finger on the right hand. The resident complained of pain and received medication without complications. The physician note dated 1/6/24 at 3:54 p.m. documented in pertinent part, Follow up ER visit from 1/3/24. Unwitnessed incident resulted in skin tear, abrasions and fracture that is not displaced of the finger. Splint on for at least three weeks. V. Resident #2 A. Resident status Resident #2, age 76, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included dementia and adult failure to thrive. According to the 12/7/23 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident had no behavioral symptoms. B. Record review The care plan, initiated 7/22/22 and revised 12/7/23, identified the resident had potential to be physically aggressive. Interventions include providing physical and verbal cues to alleviate anxiety and give positive feedback. Document observed behaviors and attempt interventions and behaviors. When the resident becomes agitated, intervene before agitation escalates. Guide way from source of distress, engage calmly in conversation. If the response was aggressive, the staff were to walk away calmly and approach later. The behavior note dated 11/7/23 at 10:47 a.m. documented in pertinent part, The resident made verbal threats toward this registered nurse (RN) while rounding on him this morning. This RN left the room immediately to de-escalate the situation. Later this resident was apologetic towards this RN. Social services staff notified. The 72 hour follow up note dated 11/8/23 at 6:23 a.m. documented in pertinent part, The resident stood in the door of his room wrapped in his blanket peeking down the hallway for a while during the night. He later came toward the rotunda and went down the blue hall entering another resident's room where he was caught just before attempting to get into an occupied bed. He was redirected back to his room where he stayed for about an hour. During this time, the CNA attempted to assist him with his clothing as he had his pants on backwards and he raised his hand at her and stated, 'Don't tell me what to do.' The CNA felt unsafe so she left the room. After she left he exited his room and went toward the rotunda. She exited another room and saw him attempting to enter a female resident's room. He was again redirected and brought to the rotunda and offered a snack and apple juice. He ate and then fell asleep in a recliner in the rotunda. The nurse note dated 1/3/24 at 7:53 p.m. documented in pertinent part, Resident #2 wandered at night and was half way down the hall and a CNA came out of another room seeing Resident #2 was leaning over the other resident with his hands on his sweater to try and lift the resident up. Resident #1 was lying on the floor against the wall next to the wheelchair. Resident #1 was assisted by CNA to the rotunda. Resident #2 said, 'I was trying to help him up.' Resident #2 was observed to have redness/possible bruising to the right hand at the base of the third finger knuckle and abrasion on the back of his left hand. VI. Staff interviews CNA #1 was interviewed on 2/13/24 at 10:52 a.m. CNA #1 said Resident #1 did not like to go out of his room as he did not feel comfortable around others. She said the resident had his good and bad days but was good with her and she had no problems with him. CNA #2 was interviewed on 2/13/24 at 11:02 a.m. CNA #2 said she was familiar with Resident #2. She said the resident had a lot of behaviors especially when providing care. She said he would yell and cuss at staff and did not like to be bothered. She said she was not working any of the times any of the resident incidents happened but she was told of the resident to resident altercations between Resident #1 and Resident #2. She said the residents did not have any interventions or guidelines to follow that she was aware of to prevent further altercations. She said she would find out. CNA #2 was interviewed again on 2/13/24 at approximately 11:15 a.m. CNA #2 said the interventions for Resident #2 were to monitor him and keep him within line of sight. RN #1 was interviewed on 2/13/24 at 11:15 a.m. RN #1 said he was familiar with both Resident #1 and Resident #2 and was aware of the resident to resident altercations between them. He said the residents did not have any interventions in place. He said Resident #2 did not have any behaviors. The social service director (SSD) and NHA were interviewed together on 2/13/24 at 1:29 p.m. The SSD said he was the abuse coordinator for the facility. He said the resident to resident altercation on 11/7/23 between Resident #1 and Resident #2 was substantiated as it had been witnessed by staff. He said he was called into the facility for the second incident on 1/3/24. He said the two residents were found together and a CNA witnessed Resident #2 grabbing the collar of Resident #1 while he was on the ground. He said Resident #1 was sent to the hospital due to his injuries and Resident #2 had reported no injuries but after the nurse assessed Resident #2 he had some bruising ]and scraped knuckles on his hands. He said both residents were confused and they were not really with it. He said the investigation identified Resident #1 was hit but he could not recall the specifics of the incident. The NHA said Resident #1 had short term memory because he could not remember what happened five minutes ago. She said Resident #1 could not recall the incidents but would not say what really happened.

Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, 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 items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations On 3/13/23 at 8:41 a.m., dietary aide (DA) #1 was preparing French toast. She grabbed four slices of bread and held each piece of bread on her palm. She proceeded to use a brush to put the egg mixture onto the bread. She repeated this for all four slices of bread. She used her gloved hand to place them onto the grill and reach over and grab a spatula. She allowed the French toast to cook and while grabbing a plate and continuing serving meals. She then wiped her gloved hand on the side of her pants. DA #1 did not perform hand hygiene during this process. Observation of the meal service was conducted on 3/15/23 at 10:47 a.m. The cook was observed preparing mechanical soft and puree meals. The cook went toward the front of the kitchen and retrieved several cans of soup. The cook grabbed several slices of bread to add them into the pureed meal. The soup cans had a flip top lid. She opened the can of soup and placed the contents in the blender. She then moved over to the trash can and utilized her forearm to lift the lid of the trash can and discarded the can. She returned to the puree station and proceeded to puree the broccoli soup. She then reached down and retrieved a small metal pan and proceeded to spray the metal pan with spray oil. She then poured the soup into the metal container and placed it on the counter in front of the oven. The cook was wrapping the metal container with aluminum foil. The temperature of the soup was going to be taken. She proceeded to grab a thermometer and several sanitizing wipes. She took the temperature of the soup and then wiped the thermometer with the alcohol wipe. She wrapped the soup with aluminum foil and reached into her pocket and grabbed a marker. She wrote soup on top and grabbed the oven handle with her hand and placed the small container into the oven. She then grabbed the used alcohol wipes and again lifted the trash can with her forearm and discarded the wrappers into the trash. She proceeded to remove the blender container and placed it into the sink. She ran water into the blender container. She then grabbed a metal container of mixed vegetables and poured them into another blender container. The cook did not perform hand hygiene during this process. DA #1 was observed entering the kitchen from the dining room and going directly to the washed dishes on the south side of the dishwasher. She started removing clean dishes and placing them on the clean metal rack. DA #1 again exited the kitchen and returned to the clean dish area and proceeded stacking the clean dishes on the metal rack. DA #1 did not perform hand hygiene during this process. DA #2 entered the kitchen from the dining room. She proceeded to the large mixer and started to make a whipped topping for a cake she was preparing. She placed all ingredients into the metal bowl and proceeded to mix the ingredients. She went to the shelf and grabbed a small container of food coloring and placed several drops into the mixing bowl. As she was leaning over into the mixing bowl her lanyard went into the bowl. DA #2 grabbed her lanyard and flipped it toward her back. She then proceeded to grab a large metal bowl and proceeded to scrap the whipped topping into the bowl. She placed the bowl onto the counter and wrapped it with plastic wrap. She reached into her pocket and grabbed a marker and wrote the date on top. She grabbed the handle of the walking and placed the container into the walk-in refrigerator. She removed all the metal whisk and metal bowl from the mixer and proceeded to take the items to the dishwashing area. She proceeded to rinse them and placed them into the dishwasher. She exited the kitchen area again and returned removing the whisk and the metal pan. She returned to the mixer and reinstalled all of the items. DA #2 did not perform hand hygiene during this process. DA #1 was observed making a peanut butter and jelly sandwich. She grabbed a bag of bread and removed two slices of bread with her gloved hand. She proceeded to walk in front of the serving line and grabbed several containers of peanut butter. She returned to the serving line and proceeded to make the sandwich. She placed a slice of bread onto her gloved hand and then opened the container of peanut butter. She grabbed a table knife and spread the peanut butter on the bread while in her gloved hand. She repeated this on the other slice of bread. She then placed the sandwich on the large cutting board and grabbed a knife and cut the sandwich into two pieces. She grabbed the sandwich with her gloved hand and proceeded to place them on a plate on the shelf of the serving line. DA #1 did not perform hand hygiene during this process. DA #1 was observed preparing a hamburger for meal time. DA #1 was observed grabbing a hamburger bun out of the bag with her gloved hand. She placed the hamburger bun onto the large cutting board. She then grabbed a slice of cheese with her gloved hand from the sandwich preparation area and placed it on the bun. She then grabbed the hamburger and placed it onto the bun with her gloved hands. She grabbed the hamburger with her gloved hands and proceeded to place it on the plate. She then grabbed a pair of metal tongs and placed some French fries onto the plate and placed it on the top shelf of the serving line. DA #1 did not perform hand hygiene during this process. C. Staff interview The dietary manager (DM) was interviewed on 3/15/23 at 3:17 p.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. She said staff should never touch ready to eat foods with their bare hands. She said they should use serving tongs even if they have gloves on. Staff should also wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash their hands between tasks to avoid cross contamination. II. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36 Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. B. Observations and staff interview On 3/15/23 at 10:47 a.m., the cook was observed preparing mechanical soft and puree meals of broccoli cheese soup, mixed vegetables and lasagna that was being held for lunch service. The cook proceeded to the front of the kitchen and retrieved several cans of mushroom soup. She placed them into the blender and proceeded to puree the broccoli and cheese soup. She grabbed a small metal container and sprayed it with cooking oil. She poured the pureed soup into the metal container and placed it on the container. She proceeded to start wrapping aluminum foil on the container. The surveyor requested for the cook to take temperatures of the puree food. The cook stated the temperature of the soup was 124 degrees F. She then placed it into the warming oven. She proceeded to complete the same process for the mixed vegetables. After she was done pureeing the mixed vegetables she placed them in a small metal pan and took the temperature of the mixed vegetables, which read 106 degree F. She wrapped them with aluminum foil and placed them into the oven. She then placed four large pieces of lasagna into the blender and proceeded to pure the lasagna. After getting it to the correct consistency she grabbed another metal pan and poured the puree into the pan. She placed it on the counter and took the temperature, which was 129 degrees F. She wrapped it with aluminum foil and placed it into the oven. -At 11:05 a.m., the cook was asked if she checked the temperature of the pureed foods after pureeing them. The cook said, No, I do not, but I would take the temperatures before serving them. -At 11:22 a.m., the cook took the temperatures of the broccoli and cheese soup, mixed vegetables, and the lasagna. The temperature of the broccoli cheese soup was at 123 degrees F. The mixed vegetables was 131 degrees F, and the lasagna was at 143 degrees F. -At 11:31 a.m., the cook again took the temperature of all items listed above. The broccoli and cheese soup was at 167 degrees F. The mixed vegetables temperature was at 169 degrees F, and the lasagna was at 170 degrees F. C. Additional interview The DM was interviewed on 3/15/23 at 3:17 p.m. She said she was aware that the temperatures of the modified food dropped at times. She said It's my expectation that the food was ok as long as it reached 165 degrees F before serving. She said dietary staff would be educated immediately to ensure the modified consistency food reached proper temperatures and time frames.

Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for three (#91, #38 and #25) of five residents reviewed for vaccinations of 29 sample residents. Specifically, the facility failed to ensure Residents #91, #38 and #25 were offered and/or received pneumococcal immunization. Findings include: I. Professional reference According to the Center for Disease Control and Prevention (CDC), reviewed 11/21/22, retrieved on 3/27/23 from https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. For persons aged [AGE] years (or older), the following quadrivalent influenza vaccines are recommended: high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine. If not available, standard-dose IIV may be given. In the majority of seasons, influenza vaccines will become available to long-term care facilities beginning in September, and influenza vaccination should be offered by the end of October. Informed consent is required to implement a standing order for vaccination, but this does not necessarily mean a signed consent must be present. Although vaccination by the end of October is recommended, influenza vaccine administered in December or later, even if influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons because the duration of the season is variable, and influenza activity might not occur in certain communities until February or March. According to the CDC Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2023, retrieved on 3/27/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part, The pneumococcal vaccine was to be administered to immunocompetent adults aged [AGE] years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23. For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals aged 19-[AGE] years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23. II. Facility policy The Pneumococcal Vaccine policy, revised 12/20/22, was provided by the nursing home administrator (NHA) on 3/15/23 at 1:01 p.m. the policy included, Policy: Facilities will offer and provide vaccinations against pneumococcal diseases in accordance with the (CDC) recommendations and guidance. Procedures/Process: -Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine the date of immunization or type of vaccine received. -Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved 'standing orders.' -Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. a. The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. b. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding. -The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. -The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. -Usually only one (1) pneumococcal polysaccharide vaccination (PPSV) is needed in a lifetime. However, based on an assessment and practitioner recommendation, additional vaccines may be provided. -A pneumococcal vaccination is recommended for all adults [AGE] years' and older and based on the following recommendations: a. For adults [AGE] years' or older who have not previously received any pneumococcal vaccine: Give 1 dose of PCV15 or PCV20. i. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. ii. If PCV20 is used, a dose of PPSV23 is NOT indicated. b. For adults [AGE] years' or older who have only received a PPSV23: Give 1 dose PCV15 or PCV20. i. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. ii. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. c. For adults [AGE] years' or older who have only received PCV13: Give PPSV23 as previously recommended. -For adults 19 to [AGE] years' old who have only received PPSV23: Give 1 dose of PCV15 or PCV20. a. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. b. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. -For adults 19 to [AGE] years' old who have received PCV13 with or without PPSV23: Give PPSV23 as previously recommended. -The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. III. Resident #91 Resident #91, age 90, was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination outside of the facility and his pneumococcal vaccination information provided prior to admission had been documented non compliant. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. IV. Resident #38 Resident #38, age above 90, was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination at the facility and his pneumococcal vaccination was not up-to-date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Resident #25 Resident #25, age 86, was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination at the facility and her pneumococcal vaccination was not up-to-date. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. VI. Interview The director clinical operations (DCO) was interviewed on 3/14/23 at 4:00 p.m. She said when the request was made for vaccination records, the facility had identified the problem with pneumococcal vaccination status. She said the facility was currently conducting an audit of the residents and would be contacting the providers. She said it would be important to offer the vaccine to help prevent pneumonia.

Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#15) of four residents reviewed for supplemental oxygen use out of 22 sample residents. Specifically, the facility failed to ensure physician's order was in place for Resident #15's continuous oxygen use. Findings include: I. Facility policy and procedures The Oxygen Therapy policy and procedure, revised February 2/23/23, was provided on 3/14/23 at 4:00 p.m., by the nursing home administration (NHA). It read in pertinent part, It is the policy of the (name of the facility) that oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the residents' goals and preference. It is the policy of this facility to administer oxygen in a safe manner. II. Resident status Resident #15, age 86, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease, sleep apnea, and dementia. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. The resident had no behaviors. He required extensive assistance for bed mobility, transfers, grooming, and toilet use. The MDS assessment revealed the resident did not receive oxygen therapy. III. Record review The care plan, initiated 4/21/21 and revised 3/9/23, identified the resident had COPD. Interventions include the resident refusing to wear oxygen during the day. Continuous positive airway (CPAP) discontinued on 11/17/21. The resident refuses to wear oxygen discontinued on 6/23/22. The April 2022 CPO included an oxygen order for O2 at 2 liters per minute (LPM) via nasal cannula. Check oxygen saturation (SAT) daily. Notify a medical doctor (MD) if SAT is lower than 89%. Discontinued 4/18/22. -The March 2023 CPO did not include a physician's order for oxygen. IV. Observation and interview On 3/13/23 at 10:46 a.m., the resident was lying in bed with no oxygen on. Resident #15 had an oxygen concentrator and CPAP machine at the foot of his bed. No oxygen tubing or nasal cannula were observed. -At 3:30 p.m. Resident #15 was observed sleeping in bed with no oxygen on. On 3/14/23 at 9:00 a.m., the resident was lying in bed with no oxygen on. On 3/15/23 at 3:04 p.m. Resident #15 was lying in bed sleeping. He had oxygen at 2 liters per minute (LPM). Registered nurse (RN) #3 observed Resident #15 lying in bed sleeping with his oxygen on. RN #3 said Resident #15 always slept with his oxygen on. RN #3 said Resident #15 had an order for oxygen while laying down in bed. RN #3 was shown the discontinued order for resident's oxygen and CPAP. RN #3 walked to his medication cart and reviewed the resident CPO. RN #3 said Resident #15 should have had a physician's order prior to the use of continuous oxygen. He said he would get the physician order updated. V. Staff interviews The ADON was interviewed on 3/15/23 at 2:24 p.m. She said, I don't consider oxygen to be a medication because as a nurse I can put oxygen on a resident if they need it. She said the facility missed the order and the oxygen was ordered for Resident #15.

Based on observations, record review, and interviews, the facility failed to provide special eating equipment and utensils for residents who need them for one (#20) of two residents reviewed for adaptive equipment out of 22 sample residents. Specifically, the facility failed to ensure the physician ordered weighted utensils, Dycem placement, sippy cup and scoop plate was positioned correctly during all meals for Resident #20. Findings include: I. Resident status Resident #20, age 79, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included Parkinson's, gastro-esophageal reflux disease and chronic kidney disease. According to the 6/10/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had wandering behaviors. He required extensive assistance for bed mobility, transfers, grooming, and toilet use. The MDS revealed the resident required supervision, encouragement and set up for meals. B. Record review The care plan, initiated 3/29/21 and revised 3/9/23, identified the resident had nutritional problems related to Parkinson disease, dysphagia (swallowing difficulty), difficulty chewing and risk for weight loss. Intervention included: Monitor/document/report as needed any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. Provide, serve, diet as ordered. Regular mechanical soft thin liquids. Monitor intake and record meals. -The resident did not have a care plan identifying use of assistive devices. The March 2023 CPO included: For all meals and snacks: weighted utensils with built-up handles, scoop dish, Dycem placemat, and sippy cup with handles. Revision date 4/24/21. C. Observations On 3/14/23 at 11:53 a.m. Resident #20 was in the main dining room eating his lunch. The resident did not have his weighted utensils, Dycem place mat, and sippy cup with handles. The resident did have his scoop plate but the raised lip of the scoop plate was at the two o'clock position. Resident #20 was right hand dominant and was observed scooping his meal from right to left and was observed to have food spilling over the top of the scoop plate. -At 4:32 p.m. Resident #20 was observed in the main dining room eating his dinner. The resident did not have his weighted utensils, Dycem place mat, and sippy cup with handles. The resident did have his scoop plate but the raised lip of the scoop plate was at the three o'clock position. Resident #20 was observed scooping his meal from right to left and was observed to have food spilling over the top of the scoop plate. On 3/15/23 at 11:43 a.m. Resident #20 was observed in the main dining room eating his lunch. The resident did not have his weighted utensils, Dycem place mat, and sippy cup with handles. The resident did have his scoop plate but the raised lip of the scoop plate was at the 12 o'clock position. Resident #20 was observed scooping his meal from right to left and was observed to have food spilling over the top of the scoop plate. IV. Interviews Registered nurse (RN) #3 was interviewed on 3/15/23 at 11:51 a.m. RN #3 observed Resident #20's plate. RN #3 said the high lip of the resident's scoop plate was at the top of the scoop plate. RN #3 said he was not familiar with the correct placement of the scoop plate but would check on its placement. Certified nurse aide (CNA) #9 was interviewed on 3/15/23 at 11:59 a.m. She said Resident #20's scoop plate should have been at the left side of the resident. CNA #9 said, I changed it to the correct position. CNA #9 said dietary staff would serve the residents' meals and sometimes would just place them in front of the residents. CNA #9 said she was aware Resident #20 utilized a scoop plate but was not aware of the other assistive devices. The dietary manager (DM) was interviewed on 3/15/23 at 3:17 p.m. She said the dietary staff are aware of any assistive devices required for all residents. She said Resident #20 should have been provided with all assistive devices to ensure adequate food intake during all meals. She said he would provide training for the dietary staff immediately. The registered dietitian (RD) was interviewed on 3/17/23 at 4:32 p.m. via telephone after exit. She said she was familiar with Resident #20. She said the dietary department had all of the assistive devices and should have been using them. The RD was told of the observations above. She said, That doesn't make sense. She said Resident #20 was not getting 100 percent of his meal and it probably was taking longer to eat. She said a negative outcome would be his food getting cold and losing its palatability and possible weight loss.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision and assistance devices to prevent accidents were provided for one (#27) of three residents reviewed for accidents out of 22 sample residents. Specifically, the facility failed to provide supervision during meals for Resident #27 who required supervision due to choking/coughing. Findings include: I. Resident status Resident #27, age 98, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included malignant neoplasm (cancer) of the bladder, age related cognitive decline, bradycardia (slow heart rate) and anemia. According to the 12/15/22 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident had physical behaviors directed toward others. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident required supervision for eating. The MDS assessment revealed swallowing disorder of coughing or choking during meals or when swallowing medications. II. Observations On 3/13/23 at 11:32 a.m., Resident #27 was sitting in the rotunda eating his lunch by himself. No staff were observed while the resident was sitting in his wheelchair eating his meal. The resident was observed to be vigorously coughing during his meal. Resident #27 continued to cough and started to gasp for air as he tried to catch his breath. Resident #27 continued to cough and he was unable to eat his meal. An unknown certified nurse aide (CNA) approached Resident #27 and asked him if he was done with his meals. The CNA placed the plate cover over the resident's plate and removed the plate taking it to the kitchen. The assistant director of nursing (ADON) was getting a drink of water in the rotunda and observed Resident #27 having difficulty and asked how he was doing. Resident #27 requested a cup of coffee which the ADON said she would get from the kitchen. On 3/14/23 at 11:29 a.m., Resident #27 was eating his lunch in the rotunda by himself. The nursing home administrator came from the Special Forces hall and exited the rotunda area. No other staff were observed in the area. Resident #27 again started to vigorously cough but was unable to clear his throat. Resident #27 continued to cough trying to clear his throat. Resident #27 was slumped over coughing trying to catch his breath. His eyes were shut tight as he gasped for air. This surveyor was going for assistance when a CNA #2 walked into the rotunda and observed Resident #27 choking. She asked Resident #27 if he was okay with which he did not respond. CNA#2 then asked Resident #27 if he got it out. CNA #2 then called registered nurse (RN) #1. RN #1 started helping Resident #27 to catch his breath. Resident #27 was spitting up into a napkin. RN #1 threw three napkins into the trash while observing the napkins content. RN #1 then requested Resident #27 to blow his nose to help him clear his airway. RN #1 continued to monitor Resident #27 and check vitals while ensuring the resident's safety. The director of clinical operations (DCO) was also assisting with Resident #27. -At 12:35 p.m. CNA #2 was observed coming out of Resident #27's room. The resident was lying in bed in a 30 degree incline and continued to have a cough. The DCO was sitting next to Resident #27 while he was resting in bed. -At 12:47 p.m. RN #3 was observed monitoring Resident #27 who continued to still have a cough. III. Record review The care plan, initiated 10/15/21 and revised 3/2/23, identified the resident had a chewing and swallowing problem. The resident would cough with beverages during meals or swallowing medication. Swallowing assessment results by speech therapy to evaluate. The resident refuses one-to-one care and assistance at times related to independence and right to self-determination. Interventions include diet to be followed as prescribed of regular mechanical soft, thin liquids, and may have regular diet as needed per resident's request. The resident had a risk benefit diet consent form signed and reviewed. Have resident sit at the assist table as needed. Monitor/document/report any signs or symptoms of dysphagia: pocketing, choking, Coughing, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat, appears concerned during meals. Refer to Speech therapist for swallowing evaluation. Nurse log note dated 3/9/23 at 1:50 p.m. documented in part Residents complaining about resident's cough during meals times. Will follow up with an interdisciplinary team. Nurse log note date 3/14/23 at 12:45 p.m , documented in part this resident coughing in the rotunda where he was having lunch. Was able to clear his secretions. Coughed off and on x 10 minutes while this RN had him under direct observation. Drank a little lemon lime soda and calmed himself. No signs or symptoms of distress, asked to return to his room. States that he is done with his lunch. Chatted with resident at his bedside x 10 minutes, respirations even and unlabored, and no signs/symptoms of distress. Was joking around with this RN and staff nurse. Denied any further needs Nurse note date 3/15/23 at 11:35 a.m., documented in part the resident was offered snacks this morning in the rotunda. The resident chose potato chips. The resident began coughing and was given a soda. The coughing subsided and the resident did not want to give staff his chips, initially but later offered to give them up for another snack. Staff at the side of the resident during the entire event. The resident continues to be monitored. IV. Interviews RN #1 was interviewed on 3/14/23 at 1:15 p.m. RN #1 said she was familiar with Resident #27. She said Resident #27 would eat in the rotunda because it had been reported that he was disturbing other residents in the dining room with his excessive coughing. She said other residents were disgusted by his continuous coughing. She said Resident #27 had a history of aspiration as he chewed his food too fast and he choked. She said Resident #27 was very particular about his food and did not like anyone to touch his food. She said generally the facility would have staff close by for Resident #27 and would be in line of sight while he was eating in the rotunda. She said Resident #27 was spitting up chunks of broccoli and sputum while she was monitoring Resident #27. She said Resident #27 had a history of coughing but today obviously was much worse than normal. She said a negative outcome of not monitoring Resident #27 while he was eating in the rotunda could be life threatening. CNA #2 was interviewed on 3/14/23 at 1:29 p.m. CNA #2 said Resident #27 would eat in the rotunda as other residents were getting upset with his coughing and it was affecting the others during meal time. She said Resident #27 had a history of coughing and choking. She said this past Sunday 3/12/23, Resident #27 had a severe coughing fit while he was eating. She said she would make sure the resident was okay and then she would offer him a drink of Sprite. She said she was assisting another resident at the end of Blue heaven hall when she observed Resident #27 having a hard time with his meal. She said she observed the resident's plate and the broccoli was whole and the sweet potatoes were definitely not mechanical soft size. She said she would compare the size of the food to a fifty cent piece. The social service director (SSD) was interviewed on 3/14/23 at 1:31 p.m. He said Resident #27 eats in the rotunda on a daily basis but that was his preference. He said Resident #27's medical power of attorney (MPOA) requested Resident #27 eat in the rotunda. He said Resident #27 was supposed to be in line of staff while eating in the rotunda. The physical therapist (PT) was interviewed on 3/14/23 at 1:48 p.m. He said Resident #27 eats in the rotunda because other residents would complain about his coughing. He said it was taking away the ability of others to enjoy their meals. He said Resident #27 had a history of aspiration and choking when eating his meals. He said therapy had tried on several occasion to do an evaluation with Resident #27 but Resident #27 would always be non-compliant and refuse any type of evaluation. So the facility medical power of attorney and the resident filled out a risk benefit form documenting Resident #27 had chosen to go against medical advice and not eat a pureed meal diet and thicken liquids taking full responsibility for his choices. He said Resident #27 should be in line of sight of staff and in a safe environment while eating his meals. The dietary manager (DM) was interviewed on 3/14/23 at 1:59 p.m. She said Resident #27 eats his meal in the rotunda due to complaints by other residents in the dining room about his coughing. The DM was told of the observation in the rotunda while eating and the size of the broccoli and sweet potatoes. She said the mechanical soft diet should be bite size pieces. She said she would educate dietary staff again on the procedure of special diets. She said a negative outcome of residents not receiving a correct diet could be choking and/or death. The DCO was interviewed on 3/14/23 at 2:13 p.m. She said she was somewhat familiar with Resident #27. She said, It was my understanding that Resident #27 was to receive supervision or in line of sight and today he did not receive any while he ate. She said a negative outcome would be choking and aspiration. The ADON was interviewed on 3/14/23 at 2:24 p.m. She said Resident #27 was asked daily if he wanted to eat in the dining room in the rotunda. She said he was independent with eating his meals. She said staff were always in the area of the rotunda and staff who were in their offices who would hear anyone if they were choking. She said Resident #27 did have a history of coughing and he did have one episode of aspiration and the staff did keep an eye on him during meals. The ADON was told of the observation above of Resident #27 coughing/choking while he was eating his meals and no staff responded until CNA #2 came into the rotunda. The ADON said Resident #27 could not be identified as aspirating as aspiration required a diagnosis by a physician. She said Resident #27 had such a strong cough he could clear himself most of the time. The ADON said Resident #27 was to be in line of sight of staff while eating but it was not always 100 percent of the time. The NHA was interviewed on 3/14/23 at 3:45 p.m. She said Resident #27 had the option of eating in the dining room or the rotunda but he liked eating in the rotunda. She said Resident #27 had the right to choose where he wanted to eat and if he was having a coughing episode he also had the option of going to his room. She said the facility would ensure he was safe while he was eating. She said Resident #27 had signed a risk benefit statement form choosing to not eat a puree diet and he chose what he wanted to eat. She said he would not sit at the assisted dining table either and that was his choice. She said a negative outcome of not having supervision or in line of site during meals Resident #27 could get pneumonia, choke and/or death. The registered dietitian (RD) was interviewed on 3/17/23 at 4:32 p.m. via telephone after exit. She said she was familiar with Resident #27. She said Resident #27 had a history of excessive coughing, choking and aspiration. She said Resident #27 refused to eat a pureed meal and chose to eat what he wanted to eat. The RD said if the resident was eating at the assisted table or in the dining room, he should be monitored. She said if Resident #27 was eating in the rotunda he should have definitely been monitored closely by staff. The RD was told of observations above during lunch and the size of the resident's food. The RD said the mechanical soft food should be bite size and not whole pieces of broccoli and sweet potatoes.

Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (#20 and #27) of three residents reviewed for oxygen therapy out of 22 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Professional reference According to Potter/Perry, Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Facility policy The Oxygen Therapy policy, no revision date, provided by medical records (MR) on 11/30/21 at 10:58 a.m. included: Oxygen therapy will be available in the Nursing Home, under nursing supervision, by order if the attending doctor to include liter flow rate. III. Resident status A. Resident #20 Resident #20, age 74, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/7/21 minimum data set (MDS) assessment revealed the resident had no impairment with a brief interview for mental status (BIMS) score of 14 out of 15. He had no behaviors or rejections of care. He was identified as using oxygen. B. Record review The care plan, initiated 8/27/19 and revised on 2/25/2020, identified the resident had impaired gas exchange related to [CONDITION(S)]. Interventions included: -Administer oxygen at one liter via nasal cannula to maintain saturation > 89% as needed. Observe oxygen precautions. The November 2021 CPO included: -Oxygen per nasal cannula at one liter to maintain oxygen saturation > 89%. Ordered on 1/29/2020. The 7/28/21 care plan conference summary included: -Resident #20 continues to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Observations and interviews On 12/1/21 at 9:50 a.m. Resident #20 was in the hallway walking toward his room. He said he received two liters of oxygen. He said he had been on two liters of oxygen for a while. The portable tank he was using was set to two liters. On 12/1/21 at 9:51 a.m. certified nurse aide (CNA) #2 said he used two liters of oxygen. She said he had always used two liters of oxygen. On 12/1/21 at 9:53 a.m. registered nurse (RN) #3 said he received oxygen at two liters. When she looked up the order, she said his order was for one liter. She said she would contact the provider and correct the orders. IV. Resident #27 A. Resident status Resident #27, age 97, was admitted on [DATE]. According to the November 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/20/21 MDS assessment revealed the resident was not able to complete the BIMS assessment. She had no behaviors or rejections of care. She was identified as using oxygen. B. Record review The care plan, revised on 9/30/2020, identified the resident used oxygen therapy for ineffective gas exchange. Interventions included oxygen settings for oxygen via nasal prongs at two liters continuous. The November 2021 CPO included: -Oxygen two liters via nasal cannula. Check oxygen saturation every day. Ordered on 9/30/2020. The October 2021 oxygen saturation levels taken daily were within normal parameters (above 89%). The November 2021 oxygen saturation levels taken daily were within normal limits without oxygen administration. The 7/18/21 care plan conference summary noted, Resident #27 continues to use oxygen at two liters via nasal cannula to maintain saturations > 89%. C. Observations and interviews On 11/30/21 at 1:25 p.m. Resident #27 was observed in the dining room sitting at a table during an activity with no oxygen on. On 11/30/21 at 2:20 p.m.CNA #1 said Resident #27 did not wear oxygen. She said she would yank off the nasal cannula. On 11/30/21 at 2:40 p.m. RN #2 said Resident #27 did not wear oxygen and did not have an order. When she checked the orders, she said Resident #27 did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she would not wear it. She said she would contact the provider and let them know. V. Interview The director of nursing (DON) was interviewed on 11/30/21 at 2:50 p.m. She said Resident #27 would not wear oxygen nasal cannula due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/1/21 at 1:00 p.m. the DON said Resident #20 used two liters of oxygen. She said she was not aware the order read one liter and she would ensure the staff would contact the provider and review his orders and ask the provider to change the order. She said the facility going forward will work on education regarding oxygen orders and following the provider's orders or contact the provider for new orders.

Based on observations, record review and interviews, the facility failed to prepare and serve food in accordance with professional standards for food safety. Specifically the facility failed to: -Measure temperatures for mechanically altered food at the beginning of each meal service; and, -Monitor holding temperatures for all food textures during the meal service. Findings include: A. Professional standards According to the Colorado Retail Food Establishment Rules and Regulations (CRFERR) effective January 1, 2019, preface page ii, Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: improper holding temperatures; inadequate cooking, such as undercooking raw shell eggs; contaminated equipment; food from unsafe sources; and, poor personal hygiene. According to the CRFERR, effective January 1, 2019, page 91, Except during preparation, cooking, or cooling .time/temperature control for safety food shall be maintained .at 135ºF or above .or at 41ºF or less. B. Observations and interviews The 10/1/2020 lunch meal service was observed between 11:00 a.m. and 12:30 p.m. The menu consisted of a main selection of navajo tacos; shredded lettuce, tomato and onion; shredded cheese; and, avocado. The alternate meal was a reuben sandwich; french fries; and a cucumber and tomato salad. The dessert was rice pudding. Food containers of regular and mechanically altered temperatures were placed on the steam table and temperatures were measured and recorded by dietary staff (DS) #1. DS #1 and DS #2 filled lunch orders for the domiciliary (cottages on the campus for persons not requiring long term care services) and began filling orders for nursing facility residents at approximately 11:55 a.m. Metal containers of pureed food, consisting of one main meal selection and one alternative, were placed in a larger container of water and held on the stove. The temperatures of each pureed container were not measured after being blended or prior to being served. As the pureed food was being plated, DS #1 was asked to measure the temperature of the food slurry. The temperature of each container was taken and measured above 165 degrees. -DS #1 did not record the temperature and continued to fill meal orders. The temperature log was for the lunch meal on 10/1/2020 was observed when approximately 25% of the food being held for service remained. There were no holding temperatures recorded. DS #2 was asked to measure the temperature of the food containers on the steam table. One item, french fried potatoes, was measured at 130 degrees and was below the minimum temperature for hot holding. DS #1 said holding temperatures were not always measured. She said temperature measurements for mechanical soft and pureed foods were not recorded because there was not a space to enter measurements on the temperature logs. C. Record review A review of meal temperature logs completed between 9/1/2020 and 9/30/2020 revealed holding temperatures were recorded for breakfast on 9/5/2020. No other holding temperatures were recorded. Additionally, beginning temperatures for mechanical soft and pureed foods were absent for all meal entries between 9/1/2020 and 9/30/2020. D. Staff interviews The dietary manager (DM) was interviewed on 10/1/2020 at 4:24 p.m. The DM said staff should measure and record temperatures for all food consistencies prior to the meal service. She said she found a previous temperature form that allowed staff to record temperatures for all foods and would re-educate staff and begin using the form to prompt measurements immediately. The DM said staff should remeasure temperatures at some point after the meal has started to ensure proper holding temperatures remained throughout the service. She said foods held (outside of the safe zone) improperly could become unsafe for residents to eat.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one (#16) of three residents reviewed for accidents out of 28 sample residents. Specifically, the facility failed to: -Monitor the resident for choking during meals in accordance with the assessment and care plan; and, -Identify new approaches to prevent falls when previous interventions were ineffective. Findings include: I. Resident status Resident #16, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. According to the 7/21/2020 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had clear speech, made self understood and understood others. The resident did not experience [MEDICAL CONDITION] or [MEDICAL CONDITION] and did not exhibit behaviors of concern, including rejection of care. Assessment of the resident's activities of daily living (ADLs) revealed the resident required extensive assistance from one person for bed mobility, transferring, walking in her room, toileting and personal hygiene. The resident required supervision, described as oversight, encouragement and/or cueing, to eat. The resident had a history of [REDACTED]. II. Choking risk A. Observations and resident interview The resident was observed on 9/28/2020 at 5:17 p.m. She was reclined flat on her bed, alone in her room. The resident stretched her neck forward to eat soup from a small bowl that she balanced on her chest with her left hand. The resident laid her head back on her pillow as she swallowed the soup. The resident said she ate most of her meals alone since her husband stopped visiting her. The resident returned the bowl of soup to the table after several more bites. Staff did not check on the resident during the visit which lasted approximately 20 minutes. The resident was observed on 9/30/2020 at 1:30 p.m. She was seated in a wheelchair in her room. Registered nurse (RN) #3 placed a meal tray on an over-the-bed table in front of the resident and left the room. Staff did not check on the resident for the entirety of the meal, approximately 45 minutes. The resident was observed on 10/1/2020 at 8:50 a.m. She was seated in a wheelchair in her room. A breakfast tray was placed on an over-the-bed table next to the resident. The resident said staff never come to check on her and just leave her alone to eat. At 9:10 a.m., certified nurse aide (CNA) #5 entered the resident's room and offered to cut up the resident's breakfast. The resident began eating her meal as the CNA left the room. The resident's television was playing loudly and could be heard at the top of the hallway where the staff room was located. Several staff entered the resident room directly across the hallway from the resident but did not look in on Resident #16 or otherwise monitor her eating. The resident coughed and cleared her throat several times during the meal but staff did not respond. B. Record review The comprehensive nutrition care plan identified the resident was at risk for unplanned/unexpected weight loss due to acute illness, poor intake and dysphagia. One goal, initiated on 2/6/2020 by the dietitian and revised on 9/30/2020 by the director of nursing (DON) was to have no choking or aspiration during the next review date. Pertinent interventions included monitor at meals for difficulty swallowing or coughing during meal time. A review of progress notes completed between 7/1/2020 and 9/30/2020 revealed the resident's condition was declining. She experienced weight loss, an increase in weakness and an increase in anger and anxiety. There were no choking incidents documented during this time. C. Staff interviews CNA #5 was interviewed on 10/1/2020 at 8:40 a.m. CNA #5 said she was familiar with the resident and her needs. She said the resident could feed herself and until recently, her husband was always with her to make sure she ate safely. The CNA said she was not aware of the assessment for supervision or the care plan for monitoring but said staff check on the resident every 15 minutes or so to see if she needed anything. CNA #2 was interviewed on 10/1/2020 at 3:49 p.m. CNA #2 said the resident was supposed to sit up when she ate in bed. The CNA said the resident was independent with eating but staff needed to check on her at least twice per meal to make sure she was not choking. RN #1 was interviewed on 10/1/2020 at 4:11p.m. The RN said staff were supposed to conduct frequent rounding to check on the resident's safety. He said support for the resident while eating was complicated. The RN said the resident and her husband eat and snack together when the husband was in the facility. He said the husband will leave for a few days whenever the couple has a dispute. The RN said the resident needed more support, reassurance and set up help with the husband's absence. The director of nursing (DON) was interviewed on 10/1/2020 at 4:55 p.m. The DON said all residents who eat in bed should be helped to position themselves to avoid choking. The DON said, based on the assessment and the care plan, staff should monitor the resident's meals more closely and, if not in line of sight, should be nearer the resident to listen for swallowing or choking issues. III. Fall risk A. Observation and interviews The resident was observed on 9/28/2020 at 5:17 p.m. as she reclined on her bed. The bed was in an elevated, horizontal position. (see care planned fall interventions below). On 9/30/2020 at 12:50 p.m., the resident's room door was open. Her wheelchair was in the middle of the room and the call light cord and button were on the floor. The bathroom door was closed and the light/fan was on. CNA #5 was summoned to the room. The CNA checked on the resident who transferred herself from the wheelchair and ambulated to the bathroom. The CNA reminded the resident she needed to use the call system to ask for assistance. The resident was apologetic. B. Record review 1. Orders [DIAGNOSES REDACTED]. The September CPO included orders for -Right hip x-ray for fall with pain (9/24/2020). -Discharge from occupational therapy; functional plateau and refusal to adhere to safety recommendations (8/30/2020). -Non-skid mat at beside to aid with stability (8/25/2020). 2. Care plans The care plan for impaired physical mobility related to a [MEDICATION NAME] fracture, decreased strength and endurance, surgical repair of her back requiring intervention and assistance, initiated 2/6/2020 and revised 7/16/2020 and 9/30/2020, identified the resident required limited assistance for bed mobility and transfers. The plan required monitoring, documentation and reporting of any signs and symptoms of immobility including fall related injuries. The fall risk care plan, initiated on 2/6/2020, identified the resident was at high risk for falls related to impaired mobility, incontinence, use of psychoactive and antihypertensive medication. Interventions included: -Physical therapy evaluation and treatment, initiated 2/6/2020. -Anticipate and meet resident needs, initiated 2/6/2020. -Assessment environment for safety hazards, initiated 2/6/2020. -Be sure call light is within reach and encourage resident to use it, initiated 2/6/2020. -30 minute fall precaution checks, initiated 7/16/2020. -Low bed, initiated 7/16/2020. -Padded floor mat, initiated 7/16/2020. -Anti-rollback device on the wheelchair, initiated 7/21/2020. - Visual cue reminding resident to alert staff for assistance/not to stand by self, initiated 9/24/2020. -Staff to ensure resident's spouse did not bring extra items for sitting/positioning without checking with staff, initiated 9/29/2020. 3. Post fall reports The 8/25/2020 post fall report documented the resident reported hearing a knock at her window and fell near the bathroom. She did not alert staff for assistance. Resident provided re-education on the importance of using her call light (intervention initiated 2/6/2020). Padded mat placed by bed (intervention initiated 7/16/2020). The 9/24/2020 post fall report documented the resident reported she was on the way to the bathroom and her feet slipped from under her. She was found seated on the toilet and had used the call light to summon assistance when in the restroom. She told staff she was too stubborn to use the call light for assistance. Staff reviewed the importance of using the call light (intervention initiated 2/6/2020) and visual cues were added to remind the resident to alert staff for assistance/not stand alone. The 9/25/2020 post fall report documented the resident tried to get out of bed to use the bathroom and became tangled in her oxygen tubing, causing her to fall. She attempted to use her wheelchair but it rolled away. Recommended safety interventions included frequent checks and monitoring and clipping call light close to her. The care plan was not revised to include new interventions which were not otherwise described. C. Staff interviews CNA #2 was interviewed on 10/1/2020 at 3:49 p.m. The CNA said the resident was not steady like she used to be. The CNA said the resident used the call light sometimes and she would provide stand-by assistance as the resident transferred herself. The CNA said, other times, the resident was found out of her wheelchair at the sink or in the bathroom. She said fall interventions included reminding the resident to use her call light. She said the resident sometimes was stubborn and refused to use the call light. The CNA said staff do half hour checks on the resident. She said the resident was good about cooperating when her husband was at the facility but it was hard to keep an eye on her when he was not present. RN #1 was interviewed on 10/1/2020 at 4:11 p.m. The RN said the resident was hard to redirect. He said staff had to do frequent rounding and encourage the resident to spend as much time in her room as possible. The RN said the resident was cooperative when she was in a good mood but would not use her call light when she was anxious or upset. The RN said the resident needed more supervision to prevent falls. The DON was interviewed on 10/1/2020 at 4:55 p.m. The DON said the resident had a history of [REDACTED]. She said the resident did not receive line of sight supervision but noted the hall was staffed with one CNA to two residents. She said the staff work station was recently moved to the end of the hall for safety reasons. The DON said the resident was in a private room at the opposite end of the hall so she could receive [MEDICATION NAME] visits from her husband due to her terminal condition. The DON said continuing to remind the resident to use her call light was something staff should do but agreed the interdisciplinary team needed to identify other interventions to prevent or reduce the pattern of falls since the resident was usually non-cooperative in using the call light system.

Based on record review and interviews, the facility failed to follow requirements for extending the use of a [MEDICAL CONDITION] medication on an as-needed basis (PRN) for one (#16) of five residents reviewed for medication use out of 28 sample residents. Specifically, the facility failed to: -Consistently attempt non-pharmacological interventions prior to administering a PRN antianxiety medication; -Have the resident's physician document the rationale for extending the use and indicate the duration of a PRN antianxiety medication. Findings include: A. Resident status Resident #16, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. According to the 7/21/2020 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had clear speech, made self understood and understood others. The resident did not experience [MEDICAL CONDITION] or [MEDICAL CONDITION] and did not exhibit behaviors of concern, including rejection of care. The resident received daily antidepressant medication and was administered antianxiety medication one out of seven days. B. Record review 1. Physician orders The September 2020 computerized physician orders [REDACTED].) 0.5mg every 12 hours as needed (PRN) for anxiety related to [MEDICAL CONDITION], start date 9/8/2020. The September 2020 CPO also listed non-pharmacological interventions related to [MEDICATION NAME] use for anxiety including redirect, 1 on 1, ambulate, activity, return to room, toilet, give food, give fluids, change position, encourage rest and backrub. 2. Care plan The care plan for medication side effects related to [MEDICATION NAME] use was initiated on 2/6/2020 and revised on 2/18/2020. Pertinent approaches included administer anti-anxiety medications as ordered by the physician; monitor/document/report (specified side effects); monitor/record occurrence of target behavior symptoms including symptoms of worsening anxiety and document; physician weighs risk versus benefits of medication usage during each [MEDICAL CONDITION] reduction committee meeting; and, review use of [MEDICAL CONDITION] medication at least quarterly. The care plan for non-pharmacological interventions, initiated 9/1/2020 and revised 9/30/2020, identified staff should attempt at least two interventions prior to administering a [MEDICAL CONDITION] or pain medication. Approaches included heat or cold; massage; relaxation and breathing techniques; imagery and distraction techniques; repositioning; aromatherapy; therapeutic touch and massage; offer snack or something to drink; redirect to an activity; offer independent activity supplies; offer to call a loved one; offer to go outside and sit with the resident as needed; offer to provide bath or shower; active listening; and, validation. The care plan for psychosocial wellbeing, initiated 2/6/2020 and revised 9/30/2020, identified the resident had an actual problem due to anxiety, cancer and [DIAGNOSES REDACTED]. 3. Medication administration and behavior tracking The August 2020 Medication Administration Record [REDACTED]. The PRN [MEDICATION NAME] was administered on 8/4/2020, 8/6/2020, 8/9/2020, 8/17/2020, 8/21/2020, 8/22/2020, 8/23/2020, 8/24/2020, 8/27/2020, 8/29/2020 (twice) and 8/31/2020. An 8/24/2020 nurse's note revealed [MEDICATION NAME] was administered at the resident's request. No symptoms or behaviors were documented. The September 2020 MAR indicated [REDACTED]. Behavior tracking and nurses' notes for September 2020 revealed [MEDICATION NAME] was administered in the absence of documented non-pharmacological interventions on 9/2/2020, 9/5/2020, 9/8/2020, 9/13/2020, 9/14/2020, 9/17/2020, 9/18/2020, 9/20/2020, 9/22/2020, 9/23/2020, 9/25/2020 and 9/26/2020. -9/8/2020, 9/9/2020, 9/13/2020, 9/14/2020 nurse's notes revealed [MEDICATION NAME] was administered at the resident's request. No symptoms or behaviors were documented. According to the September 2020 MAR, behavior tracking and nurses' notes, [MEDICATION NAME] was administered on 9/26/2020 in the absence of documented symptoms or behaviors. 4. [MEDICAL CONDITION] medication review Notes for the July 2020 [MEDICAL CONDITION] medication review committee revealed the resident received [MEDICATION NAME] prior to admission but the medication was discontinued when she was hospitalized for [REDACTED]. A handwritten note on the committee review form indicated the resident was actively declining and to continue all medications, scheduled and PRN. An 8/6/2020 pharmacy medication regimen review report and a quarterly peer review for, signed on 8/17/2020, documented the pharmacy recommendation/request for the resident's physician to put an end/stop date on PRN [MEDICATION NAME]. The physician rejected the recommendation replying the resident was on end of life, palliative care. Review of nurses' notes and physician notes, failed to reveal the facility followed up with the physician to obtain a rationale and duration for the continued PRN use of [MEDICATION NAME] following the 8/17/2020 communication (noted above). C. Staff interviews Registered nurse (RN) #1 was interviewed on 10/1/2020 at 4:11 p.m. The RN said he administered PRN [MEDICATION NAME] to the resident frequently for feelings of elevated anxiety. He said he did not recall ever administering the medication solely at the resident request. He said staff should never administer PRN medications without attempting at least two non-pharmacological interventions. The RN said he always tried to de-escalate the resident and sit and talk with her before dispensing the antianxiety medication. The director of nursing (DON) was interviewed on 10/1/2020 at 4:55 p.m. The DON said she recognized the order for PRN [MEDICATION NAME] was not time limited and contacted the physician on 9/30/2020 to obtain an order to administer the antianxiety medication on a routine basis. The DON said she was aware the physician had not provided a duration for the PRN use of [MEDICATION NAME] but was worried that a regularly scheduled dose might be too much for the resident to handle. The DON said the resident's condition had worsened to the point the facility and her physician thought she would succumb to her acute illnesses. The DON said staff were expected to attempt non-pharmacological interventions before administering PRN medications and in the presence of target behaviors or symptoms.

Based on observations, record review and interviews, the facility failed to ensure foods were prepared by methods that conserve nutritive value, flavor and appearance. Specifically, the facility failed to prepare and serve pureed foods separately and at a proper consistency. Findings include: A. Professional standard According to the International Dysphagia Diet Standardisation Initiative, September 2020, A puree should have a smooth consistency with very fine particles so that chewing is not required. The pureed food is held together with just enough structure and is slippery enough so that it can be moved from the front of the mouth to the back and swallowed with minimal effort . Retrieved 10/1/2020 from https://iddsi.org/focus-on-puree/. B. Observations and interviews The dietary manager (DM) was interviewed on 9/28/2020 at approximately 10:45 a.m. She said there were two residents at the facility that required pureed foods, however this was for meat only. She said all other foods eaten by the two residents could be served with a mechanical soft texture. The 10/1/2020 lunch meal preparation and service was observed beginning at 11:00 a.m. The menu consisted of a main selection of navajo tacos; shredded lettuce, tomato and onion; shredded cheese; and, avocado. The alternate meal was a reuben sandwich; french fries; and a cucumber and tomato salad. The dessert was rice pudding. At 11:10 a.m., dietary staff (DS) #1 was observed preparing pureed meal items. DS #1added a bean and meat mixture, a portion of fry bread, lettuce, tomatoes and onions to a food processor and blended the items together. The consistency of the slurry was noticeably thin as the DS poured the mixture into a small metal container. The DS said the consistency of pureed foods should be nectar thick. At 11:14 a.m., DS #1 was observed pureeing the alternate meal. The DS added a cooked sandwich, made with corned beef, bread and sauce, and sauerkraut to the food processor and blended the items together. The DS added broth to the mixture and blended the items again. The consistency of the slurry was noticeably thin as the DS poured the mixture into a small metal container and covered it with foil. C. Resident interview The pureed indian fry bread meal was served to Resident #27 on 10/1/2020 at 12:12 p.m. The thin slurry was topped with shredded cheese and had continued to spread further across the plate. Resident #27 was interviewed on 10/1/2020 at 2:00 p.m. He said his meal was okay for what it was. He thought it had too much pepper but could not distinguish the food items included in the mixture. D. Staff interviews The DM was interviewed on 10/1/2020 at 4:24 p.m. The DM said nectar consistency for pureed foods was too thin. She said staff should be looking for a consistency similar to pudding. The DM said staff should follow the recipe and extensions when preparing pureed foods. She said, because the two residents were pureed meat only, the staff could have blended the meat and then placed on top of the bread. She said peas (which were also served from the steam table for the 10/1/2020 lunch) could have been added or substituted to the pureed lunch to make a more complete meal. The DM said foods should not be combined in order to make meals more palatable and appetizing for the residents.

Based on observations and interviews, the facility failed to maintain an infection and prevention control program to provide a safe environment to help prevent the development and transmission of COVID-19 for two of two neighborhoods in the facility. Specifically, the facility failed to: -Encourage, assist to properly wear, and/or provide residents with, protective masks when in common areas. -Store residents' protective masks in a safe manner. -Encourage or assist residents with hand hygiene prior to meal service. - Encourage, assist to properly wear, and/or provide residents with, protective masks, or tissue to cover their nose and mouth when within less than six feet of them. -Ensure hand hygiene was completed appropriately. -Ensure residents' personal use items were stored in a way to prevent cross-contamination and/or spread of infection. Findings include: I. Face masks for residents A. Professional reference The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (4/30/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations. html#minimize, (Update April 13, 2020) Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. B. Observations On 4/29/2020 at 11:31 a.m., an observation revealed while in a common area, Resident #1 had his mask under his chin and Resident #4 had his mask under his nose. Staff walked through the area and did not stop to assist or encourage them to cover their nose and mouth with their masks. On 4/29/2020 at 11:46 a.m., an observation revealed restorative aide (RA) and did not provide, encourage, or assist Resident #12 to cover his nose and mouth with a protective mask, or a tissue, when she was within less than three feet of him as she interacted with him. On 4/29/2020 at 12:10 p.m., an observation revealed while in a common area, Resident #3's mask laid face down on the bedside table in front of her as certified nurse aide (CNA) #1 sat next to her to provide feeding assistance for lunch. CNA #1 did not remove her mask from where it laid. In the same common area Resident #4's mask laid face down on the bedside table in front of him as CNA #1 sat next to him to provide feeding assistance for lunch. CNA #2 did not remove his mask from where it laid. An observation on 4/29/2020 at 12:21 p.m. revealed CNA #3 entered Resident #5's room did not provide, encourage, or assist him to cover his nose and mouth with a protective mask, or a tissue, when she was next to him as she interacted with him. An observation on 4/29/2020 at 12:26 p.m. revealed dietary aide (DA) placed a lunch tray on Resident #4's bedside table next to his mask which laid face down on the bedside table. DA left the mask where it laid. CNA #2 began to feed Resident #4 and did not remove his mask from where it laid. An observation on 4/29/2020 at 12:29 p.m. revealed Resident #6 wore his mask under his nose while in a common area; CNA #4 sat next to him and did not encourage, or assist him to cover his nose and mouth with his mask. An observation on 4/29/2020 at 12:31 p.m. revealed the accountant (ACCT) did not provide, encourage, or assist Resident #7 with a method to perform hand hygiene when she served her a lunch tray. Resident #7 proceeded to eat her lunch without performing hand hygiene. An observation on 4/29/2020 at 12:33 p.m. revealed the transportation (TRANS) staff did not provide, encourage, or assist Resident #8 with a method to perform hand hygiene when he served him a lunch tray. Resident #8 proceeded to eat his lunch without performing hand hygiene. An observation on 4/29/2020 at 12:35 p.m. revealed CNA #3 did not provide, encourage, or assist Resident #9 with a method to perform hand hygiene when she served her a lunch tray. Resident #9 proceeded to eat her lunch without performing hand hygiene. An observation on 4/29/2020 at 12:38 p.m. revealed the TRANS staff did not provide, encourage, or assist Resident #10 with a method to perform hand hygiene when he served him a lunch tray. Resident #10 proceeded to eat his lunch without performing hand hygiene. An observation on 4/29/2020 at 12:41 p.m. revealed Resident #5 was in the hallway and did not have a mask or tissue to cover his nose and mouth. The certified occupational therapist assistant (COTA) approached him, and did not provide, encourage, or assist Resident #5 to cover his nose and mouth with a protective mask, or a tissue, when she was less than three feet of him as she interacted with him. CNA #3 approached him, and did not provide, encourage, or assist Resident #5 to cover his nose and mouth with a protective mask, or a tissue, when she was less than three feet of him as she interacted with him. An observation on 4/29/2020 at 12:45 p.m. revealed CNA #5 entered Resident #11's room and did not provide, encourage, or assist her to cover his nose and mouth with a protective mask, or a tissue, when she was less than three feet of her as she interacted with her. An observation on 4/29/2020 at 12:52 p.m. revealed Resident #2's mask hung behind her on wheelchair handle while she was in a common area. Staff walked by her and did not get her mask and encourage, or assist her to cover his nose and mouth with her mask, or with a tissue. C. Staff interviews The director of nursing (DON) was interviewed on 4/29/2020 at 1:35 p.m. She said the facility planned to store residents' masks in paper bags for storage to prevent the spread of infection. The DON said the resident's hands should be washed prior to meals. She said staff should encourage the residents to use the face mask when staff were talking to residents. The nursing home administrator (NHA) was interviewed on 4/29/2020 at 1:40 p.m. She said she did not want residents' masks placed on any surface, she wanted them to be properly stored in a manner to prevent the spread of infection. II Storage of personal items A. Observations: Random rooms were observed throughout the facility. On 4/20/2020 beginning at 11:52 a.m., the following rooms had unmarked toiletry items stored incorrectly in shared rooms: -room [ROOM NUMBER] had an unmarked toothbrush siting directly on the sink. -room [ROOM NUMBER] had an unmarked bar of soap sitting directly on the towel dispenser. -room [ROOM NUMBER] had a green cup which had unmarked toothbrushes. The cup also did not have a name on it. --room [ROOM NUMBER] had an unmarked toothbrush laying directly on the sink. The laundry aide was observed to wash her hands at the sink with the toothbrush laying directly on the sink. -room [ROOM NUMBER] had two unmarked white toothbrushes laying on the sink. -room [ROOM NUMBER] had a unmarked white toothbrush, blue denture brush and a shaver laying near the sink. -Room # 205 had an unmarked hair brush on the shelf near the sink, and a unmarked comb laying on the sink. On 4/29/2020 begging at 12:26 p.m., the director of nurses (DON) toured the rooms and observed the rooms (see above) with the unmarked personal items in the shared rooms. B. Interview The DON was interviewed on 4/29/2020 at 12:30 p.m. The DON said the certified nurse aides were to label the personal items. The personal items were to be stored in a baggie and then stored in the resident's night stand. The DON said she would provide training to the staff. III. Hand washing A. Professional reference According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. B. Observations On 4/29/2020 at 12:02 p.m., an unidentified CNA washed her hands at a sink, however, she only washed her hands for 13 seconds On 4/29/2020 at 12:10 p.m., the dietary aide #1 was serving lunch to residents in their rooms. She was observed to use the ABHR between the trays after being served to residents. However, she only hand rubbed for 12 seconds. On 4/29/2020 at 12:12 p.m., an unidentified staff member was observed to wash his hands at the sink for 10 seconds. On 4/29/2020 at 12:28 p.m. revealed after he served Resident #4 his lunch tray, DA #2 rubbed ABHR in his hands for less than 10 seconds and proceeded to serve another resident a lunch tray. Interview The DON and the NHA were interviewed on 4/29/2020 at 1:23 p.m. The NHA said the hands should be washed for 20 seconds and the DON said the hands should be hand washed with the ABHR for a minimum of 20 seconds.

Based on observations and staff interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchen. Specifically, the facility failed to: -Ensure food service staff used appropriate hand hygiene; -Prevent potential cross-contamination during meal preparation; and -Sanitize food thermometers before use. Findings include: I. Observations Observations of meal preparation in the primary production kitchen, conducted on 3/6/19 from 10:55 a.m. to 12:10 a.m., revealed the following: Dietary aide (DA) # 4 was observed preparing the pureed meals. DA #4 walked over to the oven and retrieved a container of tuna casserole. DA #4 placed four scoops of the tuna casserole into the blender and then walked over to the oven. She opened the door with her right hand and placed the pan of tuna casserole back into the oven. She wiped her hands on the side of her pants. She proceeded to puree the meal. She lifted the lid with her hand, wiped her hand on the side of her apron and replaced the lid. She grabbed a plastic spatula from a drawer and proceeded to empty the tuna casserole into a metal container. She reached above the preparation table and grabbed a thermometer. She did not sanitize the thermometer prior to placing it in the tuna. She placed the thermometer into the tuna and documented the food temperature. She then grabbed an alcohol wipe and wiped the thermometer. She placed the dirty alcohol wipe into the trash can, touching the lid of the trash can with her hand. She then placed aluminum foil over the metal container. She grabbed a large metal pan from the rack and proceeded to fill it with water from the sink and place it on the oven. She then walked over and placed the pureed tuna casserole in the oven in the water with the same contaminated hand. She returned to the food preparation area, removed the container from the blender and went to the small two-compartment sink next to the food preparation area. She turned the water on and proceeded to rinse the blender container. She used her hand to wash the side of the glass container. She rinsed the glass container and placed it back onto the base of the blender. She walked over to the oven and retrieved a container of beef stew off the top burner of the stove. She placed four scoops of the beef stew into the blender and then walked over to the stove. She replaced the metal pot of beef stew on the stove top. She wiped her hands on the side of her pants. She proceeded to puree the meal. She lifted the blender lid with her hand to check the consistency of the pureed meal, replaced the lid, and wiped her hand on the side of her apron. She grabbed a plastic spatula from a drawer and proceeded to empty the beef stew into a metal container. She reached above the preparation table and grabbed a thermometer. She did not sanitize the thermometer prior to placing it in the beef stew. She placed the thermometer into the beef stew and documented the food temperature. She then grabbed an alcohol wipe and wiped the thermometer. She placed the dirty alcohol wipe on the counter in front of the blender. She then placed aluminum foil over the metal container. She walked over to the oven and placed the pureed beef stew on the oven in the water with the same contaminated hand. She returned to the food preparation area, removed the container from the blender, and went to the small two-compartment sink next to the food preparation area. She turned the water on and proceeded to rinse the blender container. She used her hand to wash the side of the glass container. She rinsed the glass container and placed it back onto the base of the blender. She grabbed a paper towel, wiped her hands and threw it in the trash. She did not wash or sanitize her hands during this process. DA #1 was observed chopping lettuce. She had several heads of lettuce and cut them into quarters. She chopped each piece using her hand to hold the lettuce as she chopped it. She was observed scratching her arms while chopping lettuce. After finishing the lettuce, DA #1 exited the food preparation area and opened the large walk-in refrigerator with her right hand. She entered and exited with several tomatoes. She proceed to cut the tomatoes on the same cutting board as the lettuce. DA #1 was again observed scratching her arm. She exited the food preparation area and entered the walk-in refrigerator. She exited the walk-in with a box of green bell peppers. She proceed to slice the bell peppers on the cutting board. DA #1 used her right hand to wipe her face while cutting the peppers. She did not wash or sanitize her hands during this process. DA #2 was observed running dirty dishes through the dishwasher. She rinsed the dirty dishes in the sink and then placed them on a plastic rack. She then pushed them through the dishwasher. The clean dishes came out on the other side. She took the clean dishes and stacked them on the clean dish rack and returned to the dirty dish side. She repeated this process several times. She exited the kitchen with clean dishes in hand, returned to the clean dish rack, and finished stacking the clean dishes. She did not wash or sanitize her hands during this process. She had contaminated the clean dishes by failing to wash her hands between handling dirty and clean dishes. II. Staff interview The dietary manger (DM) was interviewed on 3/6/19 at 3:30 p.m. She said all kitchen staff needed to wash their hands between every task. She said all staff must wash their hands before handling or serving food. Staff should also wash their hands when they left the kitchen area and upon returning. The DM was told of the staff observations above during meal service. The DM said staff should be washing their hands every time they performed a different task. The DM said staff should wash their hands before they touched the clean plates, utensils, etc. The DM said good hygiene was necessary to avoid cross-contamination.

Based on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed in one of one dining rooms for three of three residents who received pureed foods. Specifically, the facility failed to ensure menu items were not omitted from the lunch menu service for resident that received a pureed diet. Findings include: I. Lunch meal on 3/6/19 A. Record review The menu included a main entree consisting of tuna noodle casserole, Capri vegetable, choice of bread and Boston cream pie. The alternative menu included a main entree of eight ounces of homemade beef stew, biscuit, one-quarter cup of cottage cheese and fruit. Pureed diet: The menu called for an eight-ounce bowl of stew, biscuit, one-quarter cup of cottage cheese and fruit. B. Observations During observations of the tray line service in the main dining room, biscuits, cottage cheese and fruit were not observed to be served. Pureed biscuits were not observed on the tray line. The biscuit, cottage cheese and fruit were omitted from the pureed diet meal. C. Staff Interviews Dietary aide (DA) #4 was interviewed on 3/6/19 at 2:26 p.m. She said, She had spoken with the other cook earlier, as she had forgotten to provide the cottage cheese and fruit to all of the pureed meals. She said she did not prepare or puree any biscuits, as she did not know the bread/biscuit should have been part of the meal. She confirmed the biscuit, cottage cheese and fruit was not served with the noon meal. The dietary manager (DM) was interviewed on 3/6/19 at 3:30 p.m. The DM was told of the meal observations on 3/6/19. She said they did not serve bread with all of the puree meals, as the cook did not prepare them. She said they could make bread slurry. She confirmed staff served the meals with no biscuits, cottage cheese or fruit. She said staff needed to ensure all menu items were served for all diet orders, which included bread.

Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for three (#4, #22 and #39) of five residents reviewed for oxygen therapy out of 24 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders [REDACTED].#22 and #39. Findings include: I. Professional references According to Potter/Perry, Fundamentals of Nursing, ninth edition, Elsevier, Canada, (YEAR), p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Resident #4 A. Resident status Resident #4, age 88, was admitted on [DATE], and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 2/12/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident received supplemental oxygen therapy. B. Record review The care plan, initiated 3/13/17, identified impaired gas exchange. Interventions included administration of four liters per minute (LPM) by nasal cannula (NC) while in bed. The (MONTH) 2019 CPO oxygen order dated 2/18/19 identified 4 LPM by NC continuously. The care plan did not identify the correct LPM or the continuous need for oxygen. C. Observations The resident was observed on 3/4/19 at 9:13 a.m. in his room with his portable oxygen tank set at 6 LPM. The resident was observed on 3/5/19 in his room at 9:21 a.m. and in the dining room at 10:17 a.m. with his portable oxygen tank set at 6 LPM. The resident was observed on 3/6/19 at 8:40 a.m. in his room with his portable oxygen tank set at 6 LPM. D. Interviews Certified nurse aide (CNA) #1 was interviewed on 3/6/19 at 8:56 a.m. She said the resident's portable oxygen tank was supposed to be set at 6 LPM. She said the nurses let the aides know what the liter flow needed to be set at each day. Registered nurse (RN) #1 was interviewed at 9:01 a.m. She said the resident's order was 4 LPM, and should not be set at 6 LPM. She said she turned down the liter flow and would check the oxygen saturation periodically to ensure he did not drop to an unsafe oxygen saturation level. She said she would contact the provider to report the elevated oxygen liter flow. She said it was important to have the correct oxygen flow to make sure he was at his best oxygenation with the least amount of oxygen assistance. The interim director of nursing (IDON) was interviewed on 3/6/19 at 9:19 a.m. She said the resident should have his portable oxygen tank set at the prescribed dosage. She said if the resident needed more oxygen the provider would be notified. She said she would provide education to the staff about having the oxygen set at the prescribed dosage. III. Resident #22 A. Resident status Resident #22, age 76, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the 1/3/19 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident had minimal depression, scoring three of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. B. Observations On 3/4/19 at 9:46 a.m., the resident was in his room sitting in his recliner with his oxygen not on. The resident's portable oxygen was on the back of the front wheeled walker (FWW) and the oxygen concentrator was next to the resident's bed. On 3/5/19 at 9:42 a.m., the resident was in his room sitting in his recliner with his oxygen not on. The resident's portable oxygen concentrator was in the same location. Certified nurse aide (CNA) #4 entered the resident's room to inquire if the resident needed anything. Resident #22 said, No. CNA #4 exited the resident room without asking about his oxygen. -At 5:00 p.m., Resident #22 was observed sitting in the dining room. He did not have his portable oxygen tank on his FWW or oxygen on. On 3/6/19 at 8:39 a.m., Resident #22 was observed in the dining room. He did not have his portable oxygen tank on his FWW or oxygen on. On 3/7/19 at 8:39 a.m., the resident was observed walking down the hall with no portable oxygen tank or oxygen on. C. Record review The (MONTH) 2019 CPO included instructions to apply oxygen at two liters per nasal cannula, check oxygen saturation (SAT) daily, notify medical doctor if SAT less than 89 percent, one time a day for [MEDICAL CONDITION], start date 10/17/18. The care plan, initiated 3/21/17 and revised 1/2/19, identified the resident had impaired gas exchange related to (R/T) [MEDICAL CONDITIONS] as evidenced by (AEB) [MEDICAL CONDITION]. Interventions included administer oxygen at two liters via nasal cannula. Observe oxygen precautions. Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for signs and symptoms (s/sx) of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath (SOB) at rest, cyanosis, and somnolence. Monitor/document/report as needed (PRN) any s/sx of respiratory infection: fever, chills, increase in sputum (document the amount, color and consistency), chest pain, and increased difficulty breathing, increased coughing and wheezing. Saturations via pulse oximetry daily and as needed. Notify physician if less than 89%. D. Resident interview Resident #22 was interviewed on 3/5/19 at 9:32 a.m. He said he did not need his oxygen on all the time. He said they checked his oxygen SAT level daily and if it was low, they would put it on him. He said it did get low, especially when he was in physical therapy, but he managed. E. Staff interviews CNA #4 was interviewed on 3/5/19 at 9:42 a.m. He said the resident only used his oxygen at night. He said he did not check the resident's SAT. He said the nurse would check as the resident was walking past the medication cart. -At 10:49 a.m., registered nurse (RN) #2 was interviewed. She said the resident would wear his oxygen whenever he felt he needed it. She said he would wear it if his saturation levels were below 89 percent, which did not happen very often. She said the physician's orders [REDACTED]. RN #3 was interviewed on 3/7/19 at 8:47 a.m. She the resident did fine with room air and as long as he was in his room, he was okay. She said he has been walking more and he had been doing fine. RN #3 reviewed the physician's orders [REDACTED]. She said the doctor should have been contacted to let him know the resident was not wearing his oxygen so that the order could be clarified. The physical therapist (PT) was interviewed on 3/7/19 at 8:58 a.m. She said the resident did have shortness of breath while in physical therapy but she monitored it closely. She said his O2 saturation did get below 88 percent, especially if he was on the exercise bike or walking. She said the goal had been to wean him off his oxygen but not right now. The director of nursing (DON) was interviewed on 3/7/19 at 9:14 a.m. She said Resident #22 should wear his oxygen per physician's orders [REDACTED]. She said she would contact the physician immediately to clarify the oxygen order. IV. Resident #39 A. Resident status Resident #39, age 70, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the 1/31/19 MDS assessment, the resident was not administered the BIMS. His cognitive skills for daily decision-making were severely impaired. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had moderately severe depression with the resident scoring 18 of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. The resident received oxygen therapy. B. Observations On 3/4/19 at 9:30 a.m., Resident #39 was in his room sleeping in his wheelchair. He was slumped over with his oxygen hanging off his face. -At 11:09 a.m., the resident was in his room sleeping in his wheelchair. The resident's oxygen was lying on the floor next to him. He was not easily aroused when spoken to. CNA #4 was notified and called RN #2 and RN #4. RN #4 replaced the resident's nasal cannula without cleaning it or exchanging it for a new one. RN #4 continued to try to wake the, which took some time. RN #4 was able to speak to Resident #39 and instructed the resident he needed to keep the oxygen on at all times. The resident did not acknowledge the nurse as he was nonverbal. RN #4 took the resident's vitals. His blood pressure was 97/61, pulse 50-54. CNA #4 said his 02 saturation was 89 percent. On 3/5/19 at 8:20 a.m., the resident was in his room sleeping in his wheelchair. He was slumped over with his oxygen hanging off his face. CNA #4 measured the resident's oxygen saturation. The levels varied from 86% to 87%. CNA #4 said he had reported the resident's SAT to the nurse and she would be following up with the resident. C. Record review No documentation was found for the two observations, on 3/4/19 and 3/5/19 (above), when the resident was found without his oxygen on, that his oxygen level was checked, and the nurse re-checked his oxygen level to ensure his oxygen saturations stayed above 90%. The (MONTH) 2019 CPO included an order for [REDACTED]. The care plan, initiated 2/6/15 and revised 1/30/19, identified impaired gas exchange R/T ventilation perfusion imbalance AEB [MEDICAL CONDITION]. Interventions included administer oxygen at two liters via nasal cannula at night. Observe oxygen precautions. Monitor and report signs of [MEDICAL CONDITION] (cyanosis, tachypnea, dyspnea, confusion, and restlessness, nasal flaring, elevated blood pressure, increased respirations, and increased pulse). Monitor for s/sx of respiratory distress and report to physician PRN: respirations, pulse oximetry, increased heart rate ([MEDICAL CONDITION], restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. Monitor oxygen saturation pulse oximetry daily and as needed. Notify physician if less than 89 percent. D. Interviews CNA #4 was interviewed on 3/5/19 at 9:42 a.m. He said Resident #39 had experienced a decline in his health and he tried to check on him frequently. He said when he found the resident without his oxygen, he reported it immediately to the nurse. -At 10:49 a.m., RN #2 was interviewed. She said the resident's oxygen should have been on him. RN #2 said the resident would take off his oxygen throughout the day and he forgot to put it back on. She said the only time they would call the physician would be if the resident's oxygen level did not go above 90%. RN #3 was interviewed on 3/7/19 at 8:47 a.m. RN #3 said the resident should have had his oxygen on. She said the resident did remove his oxygen regularly. She said a negative outcome for the resident not wearing his oxygen could affect his mental status, cause shortness of breath, wheezing and cough. RN #4 was interviewed on 3/7/19 at 9:30 a.m. She said when she went into the resident's room to check on him, it took some time to arouse him. She said she immediately put his oxygen back on him. She said it took him awhile to get going, so she had to check possible skin issues. He was hard for me to wake up, so she was talking to him and checking vitals. The director of nursing (DON) was interviewed on 3/7/19 at 9:14 a.m. She said the staff was supposed to check oxygen saturation levels when a resident was found without their oxygen. The DON said the staff were supposed to measure the oxygen saturation levels again when the oxygen had been on for a few minutes; the doctor was notified of the levels if they would not increase and asked what to do. She said an RN was able to adjust liter flow and then follow up with the medical provider. The DON said it was important for staff to ensure residents had supplemental oxygen as ordered to reduce the risk of altered mental status, dizziness, falls, and hypoxic events.

Based on observation and staff interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility: -Failed to ensure dietary staff followed accepted hand hygiene practices; and -Failed to properly cover and store kitchen equipment. The findings included: 1. Hand Hygiene A. Professional References According to the Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13) pp. 23-24, 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 Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13) page 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 . B. Observations The initial kitchen tour was conducted on 6/5/17 at 10:05 a.m. During the observation, dietary aide (DA) #3 took used cooking utensils and bowls to the dish room and returned to the preparation area to finish making meatloaf. DA #2 entered the kitchen and went to the walk-in refrigerator to retrieve a banana for a resident. Neither DA washed their hands upon entering the kitchen. A continuous observation was conducted during the breakfast meal on 6/7/17 from 6:55 a.m. to 8:50 a.m. DA #1 entered the kitchen preparation area through the dish room, she retrieved boiled eggs from the reach in refrigerator and took the eggs to the service line. DA #1 went back to the dish room to start washing dishes and then to the food service line to retrieve food trays for delivery to residents in the dining room. She returned to the dish room each time, sometimes with dirty dishes, this occurred numerous times throughout the observation. DA #1 replaced clean plates on the food line from the dish room. She was not observed washing or sanitizing her hands. DA #7 entered the kitchen through the dish room looking for a knife to cut an orange for a resident, he put a pair of gloves on, cut the orange on a cart in the dish room's clean area and delivered to a resident in the dining room. He removed glassware from the dining room with fingers inside, took to the dish room counter, walked out to the front to place a meal card in the rack and pick up a tray of food to deliver to a resident. DA #7 entered the dish room, kitchen and area to retrieve trays of food to deliver to residents numerous times throughout the observation. He was not observed washing or sanitizing his hands prior to putting the gloves on or the numerous entries to the kitchen either through the dish room or the other end of the line. DA #2 entered the dish room with DA #1; then both went to the dining area to retrieve dirty dishes. DA #1 then put clean dishes away on the racks. DA #2 went back to the kitchen preparation area with DA #3 assisted with lunch preparation. DA #2 went to the dish room to check the dish washing machine and soap for the machine exited the area and returned to retrieve a cart to take out to the dining room for dirty dishes. DA #2 re-entered the kitchen through the dish room and assisted DA #4 behind the serving line, she cooked eggs, French toast, pancakes, and served items from the steam table for the residents. She was not observed washing or sanitizing her hands throughout the observation. C. Interviews DA #7 was interviewed on 6/7/17 at 1:47 p.m. He said he received training for hand hygiene upon hire. The DA said he was supposed to wash his hands every time he entered the kitchen, even the dish room. He said he was supposed to wash his hands after taking dirty dishes to the dish room, if he entered the preparation area or the walk in or freezer. DA #7 said staff had to wash their hands or sanitize a lot throughout the shift. He said it prevented him and other staff from passing germs to the residents and each other. The dietary manager (DM) was interviewed on 6/8/1/7 at 1:48 p.m. She said staff were supposed to wash their hands upon entry to the kitchen from either of the two entrances especially from the dirty dish room side to the clean side or kitchen. The DM said staff should also wash their hands when donning and doffing gloves, from surface to surface especially if handled a food item to serve or if touching door handles, drawers and other areas in the kitchen where germs may exist. The DM said it was important for staff to wash their hands during meal service. She said they multi-tasked and cleared dirty dishes from tables when the residents left the dining room, staff was supposed to wash after taking to the cart or into the dish room. The DM said it was important for dietary staff to wash or sanitize their hands for infection control, prevent cross contamination and getting residents sick. 2. Kitchen Equipment A. Professional Reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended November 21, 2012, effective March 1, 2013) pg 69. Cleaned and sanitized utensils and equipment shall be stored at least 6 inches (15.24cm) above the floor in a clean, dry location in a way that protects them from contamination by splash, dust and other means. The food contact surfaces of fixed equipment shall also be protected from contamination. Equipment and utensils shall not be placed under sewer lines or water lines that are not protected to intercept potential drips, including leaking automatic fire protection sprinkler heads, or under lines on which the water has condensed .Utensils shall be . stored in a self-draining position. B. Observations The initial kitchen tour was conducted on 6/5/17 at 10:05 a.m. The following large kitchen items were observed uncovered: the large Hobart mixer near the dish room, the mixer on top of the preparation counter across from the walk in refrigerator and freezer, and the meat slicer on the preparation table across from the reach in refrigerator. The above items were also observed uncovered on 6/7/17 from 6:55 a.m. to 8:50 a.m. and from 10:55 a.m. to 11:38 a.m. C. Interview The DM was interviewed on 6/8/17 at 1:48 p.m. She said kitchen equipment to include the mixers and meat slicer should be covered when not in use or when stored. The DM said staff should cover them to prevent dust, food debris and other contaminants off the equipment. She said it was an infection control issue, the germs could stick to the equipment and potentially get the residents sick.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments. Specifically the facility failed to keep medication carts locked when not directly attended by authorized staff. The findings included: A. Observation The facility medication carts were observed on 6/7/16 at 5:20 a.m. The medication cart on the 200 hall was unlocked and was left unattended by the medication nurse. Seated in the approximate vicinity of the cart were three residents. Upon returning to the cart, registered nurse (RN) #4, who was the only nurse in the area on duty, was asked if she was aware the medication cart was unlocked. She said she was not. The treatment cart on the 300 hall was discovered unlocked on 6/7/17 at 5:25 a.m. RN #4 said she was also unaware the treatment cart was unlocked. She said both carts should have been locked to prevent access to medications and other potential hazards. B. Interview The director of nursing (DON) was interviewed on 6/8/17 at 9:15 a.m. She said all medications should be stored properly and kept under lock and key. The DON said the carts should have been locked to prevent unauthorized access (or access by residents).

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, and failed to have an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility: -failed to ensure staff followed accepted handwashing practices during personal cares; -failed to sanitize a glucometer between residents; and, -failed to establish an effective antibiotic stewardship program. The findings included: 1. Professional References According to the Centers for Medicare and Medicaid Services (CMS) Publication 100-07, Transmittal 55 12/2/09, Hand hygiene continues to be the primary means of preventing the transmission of infection. Situations that require hand hygiene include, in pertinent part: -Before and after eating or handling food; -Before and after assisting a resident with meals; -After blowing or wiping nose; -After contact with .mucous membranes and body fluids or excretions; -After performing (staff) personal hygiene; and, -After removing gloves and aprons. CDC Control and prevention, Hand Hygiene Basics, http://www.cdc.gov/handhygiene/Basics.html (3/29/17). 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). World Health Organization, Glove Use Information Leaflet, http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf (3/29/17). Glove use and the need for hand hygiene: When an indication for hand hygiene precedes a contact that also requires glove usage, hand rubbing or hand washing should be performed before donning gloves, when an indication for hand hygiene follows a contact that has required gloves, hand rubbing or hand washing should occur after removing gloves., when an indication for hand hygiene applies while the health-care worker is wearing gloves, then gloves should be removed to perform handrubbing or handwashing. According to Potter and Perry's Fundamentals of Nursing, 8th edition, 2013, Chapter 28, Infection prevention and control, page 411- Cleaning, disinfection, and sterilization. Reusable objects need to be cleaned thoroughly before reuse and then either disinfected or sterilized according to manufacturer recommendation. Failure to follow manufacturer recommendations transfers liability from manufacturer to health care facility or agency if an infection results from improper processing. 2. Product Information Wipes Plus disinfecting wipes information: http://wipespluswipes.com/wp-content/uploads/2014/01/Efficacy-Sheet-Disinfecting-Wipes- .pdf (6/7/17). . CONTACT TIME: Use a four minute contact time for disinfection against all virus, bacteria, and fungi claimed . 3. Failures A. Hand Hygiene Certified nurse aides (CNA) #4 and #8 were observed providing peri-care to resident #32 in his room on 6/6/17 at 12:58 p.m. CNA #4 washed her hands. CNA #4 and #8 donned disposable gloves. The resident was lifted off the wheel chair and slowly rolled into the bathroom with an EZ-lift stand. Upon removal of the adult brief, it was discovered the resident was incontinent of bowel and bladder. The soiled clothing was removed and peri-care was provided. CNA #8 cleansed the area with disposable wipes. The aides placed him on the toilet. CNA #4 removed her soiled gloves, washed her hands, donned a new set of gloves and retrieved a clean set of lower clothing, a new adult brief and barrier cream. CNA #8 provided peri-care when the resident was lifted off the toilet with the EZ-stand, then utilized disposable wipes to clean the soiled areas on the resident. CNA #8 asked CNA #4 for the barrier cream. CNA #8 applied the barrier cream. The clean clothing and a clean brief were applied to the resident. The resident was placed back into the wheel chair at 1:10 p.m. CNA #8 reapplied supplemental oxygen by placing the oxygen tubing in the resident's nares. CNA #4 removed her gloves and washed her hands before leaving the room with the resident. CNA #8 removed her gloves, gathered up the trash bag containing the disposable wipes that were utilized for the resident's peri-care and tied closed the bag. CNA #8 left the room. Upon exit from the resident's room CNA #8 was asked about handwashing. She said she should have changed gloves between peri-care and cream application, and before O2 application. She said she should have washed her hands between glove use and before leaving the room. B. Sanitizing Equipment Registered nurse (RN) #4 was observed 6/7/17 at 5:35 a.m. leaving resident #15's room after taking a blood glucose level (BG). She returned the glucometer to the medication cart on the 200 hall. At 5:53 a.m., RN #4 took the glucometer to resident #3's room and took his BG. RN #4 then returned the glucometer to the medication cart on the 100 Hall. RN #4 did not sanitize the glucometer between each resident use. She said she had not sanitized the glucometer and did not know how long sanitizer needed to be on the glucometer to be effective. C. Antibiotic Stewardship 1. Resident #8 Resident #8, age 93, was admitted on [DATE]. According to the June 2016 computerized physician's orders [REDACTED]. A physician's orders [REDACTED]. A progress note written on 2/1/17 at 9:27 p.m. read, .Resident was acting different then prior report. Physician informed, urinalysis (UA) obtained. Resident has had a history of [REDACTED]. Order for [MEDICATION NAME] 500mg x 1 dose then 250mg every (q) 48hrs total 7days. First dose given. UA will be sent out tonight. The lab note dated 2/2/17 at 8:57 p.m. included, . Received Urinalysis following abnormal: Blood 1+ Protein 2+ [MEDICATION NAME]-positive Leukocytes 3+ UWBC-25-50/HPF URBC-5-10/HPF Bacteria-Many Mucus-few Culture to follow. Physician informed. The lab note dated 2/3/17 at 3:52 p.m. read, Received UA culture results, physician notified of results. The lab final report identified the specimen was collected 2/2/17, and the final UA report was at 3:16 a.m. The final report for the urine culture was dated 2/3/17 and it identified an intermediate sensitivity to [MEDICATION NAME]. The facility failed to notify the provider the antibiotic (ABO) ordered only had an intermediate sensitivity to the bacteria to obtain an order for [REDACTED]. The Feb. 2017 medication administration record (MAR) identified the resident began the ABO on 2/1/17 before results of the UA or culture were reported to the facility. The facility completed an infection surveillance guide (ISG) utilizing the McGeer criteria to determine if the resident met the criteria for a UTI on 4/1/17. According to the ISG, the resident did not meet the criteria. The order note dated 3/31/17 at 8:37 p.m. included, Physician informed resident has complained of (c/o) dysuria and reported confusion. Per physician order, Keflex capsule 500 mg by mouth two times a day for UTI for seven days, urine culture and sensitivity (C&S). Start 4/1/17, end 4/8/17. The lab note included, Received urinalysis results from RGH laboratory 4/1/17. Physician informed of results. Abnormal as follows: Appearance cloudy, trace of blood, 1+ protein, 3+ Leukocytes, Moderate bacteria, UWCB 25-50, URBC 0-5. The final report for the urine culture dated 4/3/17 at 9:24 a.m. identified, no growth in 24 hours. The April 2017 MAR listed Keflex 500 mg by mouth twice a day for seven days. The complete dosage was given after the lab results concluded there was no bacterial growth. The facility failed to stop an ABO ordered for a UTI when it was determined the resident did not have a UTI. 2. Resident #54 Resident #54, age 86, was admitted [DATE] and readmitted [DATE]. According to the June 2016 computerized physician's orders [REDACTED]. The order note dated 1/19/17 at 3:39 p.m. included, .Cipro tablet 500 mg, give one tab by mouth two times a day for UTI for seven days . The lab note dated 1/19/17 at 10:17 p.m. included, Lab results from urinalysis received via fax from RGH. Res [MEDICATION NAME] shift. The final report from the lab dated 1/22/17 for the urine culture identified an intermediate sensitivity to Cipro. The Jan. 2017 MAR [MEDICATION NAME] mg was administered six times over three days. The order was ended on 1/22/17. The order note dated 1/22/17 at 1:35 p.m. included, C&S back for urinalyses [MEDICATION NAME] effective for current UTI.[MEDICATION NAME] and new order for Keflex 500mg BID x7days. The Jan. 2017 MAR noted Keflex 500 mg by mouth two times a day for seven days for UTI. The medication was administered 1/22/17 thru 1/30/17. The lab note dated 2/2/17 at 11:58 a.m. included, Received UA and physician notified of results. The order note dated 2/2/17 at 12:37 p.m. included, [MEDICATION NAME] Tablet 500 MG. Give 1 tablet by mouth one time a day for UTI for 5 Days. The final report from the lab dated 2/4/17 for the urine culture identified an intermediate sensitivity to [MEDICATION NAME]. The facility failed to notify the provider that the ABO ordered only had an intermediate sensitivity to the bacteria to obtain an order for [REDACTED]. The Feb. 2017 MAR noted the resident received [MEDICATION NAME] 500 mg by mouth once a day for five days. The facility failed to have an effective ABO stewardship program. D. Interviews CNA #7 was interviewed on 6/8/17 at 8:55 a.m. She said everyone should wash their hands when entering a resident's room, in between glove use, and when leaving the resident's room. She said it was important to wash hands to prevent the spreading of germs. CNA #2 was interviewed on 6/8/17 at 9:00 a.m. She said all staff should wash their hands when going into a room, between glove use, and before they leave a room. She said handwashing is the number one way to stop the spreading of germs. RN #2 was interviewed on 6/8/17 at 9:05 a.m. She said staff should wash their hands every time they do anything with a resident. She said staff needed to wash hands when going into a room to help a resident, in between glove use and when leaving the room to help prevent infections. She said it's to protect the resident and the staff. She said the glucometers are sanitized daily, she was not sure if it was sanitized between residents. She said the sanitizer needed to be left on for one minute or until dry. She said she did not know that the wipes in the cart needed four minutes to be effective. The director of nursing (DON) was interviewed on 6/8/17 at 9:15 a.m. She said she expected the aides to wash their hands after every step, and upon entering and exiting the room. She said it was not acceptable to put on a resident's oxygen with dirty gloves. She said the glucometers were to be cleaned with Clorox wipes that were kept in the med room. She said there was no wait time with the Clorox wipes, however she said the glucometer should have been sanitized between residents. She was interviewed again at 1:10 p.m. She said the facility was working on ABO stewardship and it was a work in progress. She said the ABO that was ordered and labs revealed no infection and was not stopped due to staff, following a physician's orders [REDACTED].

Based on resident interview, staff interview and record review, the facility failed to ensure two of four sample residents (#1, #2) received care and services to prevent pressure sores and those with pressure sores received the necessary treatment and services to promote healing, prevent infection, and prevent further breakdown. Specifically: Sample resident #2 was admitted with an "unstageable" sacral pressure ulcer from another nursing facility and was totally dependent on staff. While at this facility, the resident then developed ischial breakdown with necrotic areas and these developed into multiple ulcerated Stage IV areas that required surgery (,[DATE]). The facility stated the resident was non-compliant. The hospital physician stated per telephone on [DATE] at 10:56 a.m., "This (pressure sore) was the result of poor nursing care. The resident can't do anything for himself. This was not just a small Stage II, but a 10 cm diameter to 4 cm to the bone infected Stage IV." The facility failed to consistently measure the wound as per policy, timely reassess the wound treatments, and timely put interventions in place. Sample resident #1 was admitted without any pressure ulcers and developed a stage II pressure ulcer on his right ankle while under the care of the facility. The findings included: Facility Policy The facility policy entitled "Pressure Sore Prevention", last revised on [DATE], was requested and received from the Director of Nursing (DON) on [DATE]. The policy in pertinent parts read: "Purpose: To identify those individuals with pressure sores and those individuals who are at risk for pressure sore development so the treatment and prevention strategies may be implemented . . . Policy: It shall be the policy of the (name of the facility) all residents admitted to the facility without pressure sores would not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable . . . During the admission assessment, completed by the Registered Nurse (RN) within 8 hours of admission, the resident's skin will be assessed for [MEDICAL CONDITION] or integrity problems. Any integrity problems will be noted on the admission assessment. Pressure sores shall be staged using the Stage ,[DATE] convention. Wounds shall not be reverse-staged . . . A nurse will observe the condition of the resident's skin each week. This shall be recorded in the resident record. Certified Nurses Aides (CNA's) (sic) shall immediately notify the RN in charge of any resident skin problem they encounter . . . Residents who have pressure sores will have a "Weekly Pressure Progress Report" initiated by the nurse discovering the pressure sore. This document shall be placed in the treatment book. It shall be updated weekly until the sore is healed. The form will then be filed in the resident's record. Wounds will be measured and recorded in centimeters. . . . Upon discovery of a pressure sore, the attending physician will be contacted for instructions for treatment. The resident's significant other is to be notified of the wound. The Dietary manager will be informed, as will the Director of Nursing. This will be recorded in the resident's record . . . Wounds that do not appear to be responding to treatment, appear to be infected, or appear to be worsening shall be promptly brought to the attention of the attending physician. This notification shall be recorded in the resident's record. . ." Resident Status 1. Sample resident #2, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident scored a 15 of 15 in the Brief Interview for Mental Status (BIMS) indicating the resident was independent in cognitive skills for daily decision-making. The resident was coded as total dependent on two or more staff members for bed mobility, transferring, bathing, and with toilet use and needed extensive assistance of two staff members for dressing. The resident used a wheelchair for locomotion. The MDS coded the resident as always incontinent of bowel and bladder. The resident was 71 inches tall and weighed 144 pounds. The MDS indicated the resident had a sacral unstageable pressure ulcer that measured 2.0 cm x 4.0 cm x 0.2 cm with slough. The resident was care planned for impaired physical mobility related to [MEDICAL CONDITION] and [MEDICAL CONDITION] joint disease, chronic discomfort due to metastatic [MEDICAL CONDITION], impaired urinary elimination related to [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder with sensory deficit as evidence by incontinence, volume fluid deficit, constipation related to impaired mobility, use of narcotic [MEDICATION NAME] and less than 1500 ml per day fluid intake, and at risk for decreased nutritional status secondary to refusing supplements, poor intake, low [MEDICATION NAME] 2.6. There was no care plan or care plan updates for behaviors. In addition, a psychological evaluation was completed on [DATE] and the resident was not identified with behaviors. The psychologist documented that he was unsure why the resident was being seen in mental health. "Possibly an error in scheduling. No medications recommendations at this time." The care plan last updated, on [DATE], indicated the resident was at an increased risk for skin breakdown related to his impaired mobility, incontinence and nutritional deficits. He had current breakdown to his sacrum. He was followed by the wound care specialist for treatment. He had a wheelchair cushion and an air overlay mattress on his bed. The care plan upon admission indicated the resident had skin breakdown and was at risk for further skin breakdown related to [MEDICAL CONDITION], incontinence, nutritional deficits as evidence by a stage II pressure ulcer right sacrum. The goal was that the resident would not develop any additional pressure ulcers and currently had an open area on the sacrum. Some of the interventions listed included: --Assist to change position every ,[DATE] hours, and as needed. A handwritten note was added on [DATE] that the resident "frequently declined." --Provide pressure reducing chair cushion and air mattress overlay, --Skin assessment weekly and as needed. Observe skin while providing care and report changes to charge nurse. --Keep clean and dry as possible. Minimize skin exposure to moisture, --Provide incontinence care after each incontinent episode. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin; avoid friction to the skin. --Appointment with wound care specialist as indicated. Handwritten additions to the care plan included; -[DATE] "In use-air mattress, roho cushion, alternating with gel cushion." -No date "and necrotic areas ischial." -On [DATE] the pressure ulcer was a "stage III." -On [DATE] the pressure ulcer was described as a "stage IV." Resident Failures -The [DATE] admission skin assessment indicated the resident had a stage II pressure ulcer that measured 4 cm x 2.2 cm x 0.3 cm. -[DATE] admission orders [REDACTED]. The ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) -[DATE] physician orders [REDACTED]." This was to be done every three days. Progression of the Wound and New Wounds. The "Wound Assessment Guide" was a facility one page form divided into four parts (week one, week two, week three, and week four) and was intended for charting for one month. However, the "Wound Assessment Guides" described below sometimes contained documentation for more than a month, especially when a weekly wound assessment was not documented as done. See below. Review on [DATE] of the "Wound Assessment Guide," the wound consultant's documentation, nurse's notes, and the physician's progress notes revealed the following documentation. -[DATE] - "Wound Assessment Guide" - Week one. The site was described as coccyx/sacrum Stage II and the measurements were documented as approximately 8 cm in length, 7.5 cm in width and 0.2 cm in depth. There was no eschar, the exudate was serosanguinous, and there was 5 to 10% slough. -[DATE] - There was no evidence that a weekly wound assessment was completed as per policy. -[DATE] - Week two. The site was described as Stage II and the measurements were documented as approximately 3.4 cm in length, 4.4 cm in width and 0.2 cm in depth. There was no eschar, no exudate, and there was 30% slough. -[DATE] - Week three. The site was described as Stage II and the measurements were documented as approximately 3.2 cm in length, 4.0 cm in width and 0.2 cm in depth. There was yellow brown exudate, no eschar, and there was 40% slough. Documentation included 10% granulation and 20% [MEDICATION NAME]. -The resident was referred to the wound consultant on [DATE], a month after admission. The wound consultant documented the following: "Sacral wound c (with) island in center forming to (sic) separate wounds - 1.4 x 3.4 x .2. Both wounds have a sm (small) amt. (amount) of necrotic slough & edges open, periwound skin clear. Treated today c (with) [MEDICATION NAME], if this is available, use [MEDICATION NAME] and change every 3 days and prn (as needed). If not, use Santyl ointment, covered without saline moistened gauze & change daily, up in chair for meals only. Diagnosis: [REDACTED]. F.U. (Follow up) in a month." -[DATE] - Week one. The documentation indicated the coccyx had healed into two separate wounds. L (left) coccyx was approximately 1.5 cm x 2.0 cm x 0.1. Wound bed is beefy red-small amount of exudates-Slough resolved. R (Right) wound is worse-noted opening 1 cm in diameter and 1.6 cm in depth. Wound consultant notified and new order obtained. Resident was incontinent-wound culture obtained. Resident refusing supplement and oral medications. According to the physician progress notes [REDACTED]. -[DATE] - Week two. The measurements were documented as left 0.6 cm x 0.6 cm x less than 0.1 cm and the right as 1.4 cm x 1.6 cm x 2.7 cm. -The wound consultant documented on [DATE], the following: "Tunneling to coccyx area of 2.7 cm narrow in diameter. Appears to be clean and free of necrotic tissue. Packed today c silver alginate rope. Left sacral area has a wound .6 x .6 x .1. Also very clean. Please start the silver calcium alginate packing with daily dsg (dressing) changes. Cover c sponge dressing. F.U. in 1 mo. Pt was asked to be up in chair for meals only. Diagnosis: [REDACTED]. [MEDICAL CONDITION]." Physician's note dated [DATE] indicated the resident's wound was infected [MEDICAL CONDITION]/[DIAGNOSES REDACTED] and the resident was put on Bactrim DS twice a day for 30 days. -[DATE] - Week three. Stage II Measurements were 1.4 cm x 1.2 cm x 3.4 cm. Tunneling at 3:00 and 11:00 with yellow/brown drainage. -[DATE] - Week four. Stage II with measurements 1.5 cm x 1.5 cm x 3.2 cm. Tunneling at 12:00, 6:00 and 10:00. Pink/yellow with trace blood noted-unable to view all. Exterior visible only. -[DATE] - Week one. Stage II with measurements 1.5 cm x 1.5 cm x 3.4 cm. Tunneling at (no description given). Yellow with trace blood. Granulation inside wound-unable to determine %. [MEDICATION NAME] 10%. -[DATE] nurse's note included documentation that the resident often refused to stay out of w/c to relieve pressure. Air mattress on bed at this time. Staff continues c (with) contact precautions r/t wound culture. -[DATE] - Week two. Stage II with measurements 1.5 cm x 1.5 cm x 3.4 cm. Tunneling at (no description given). Yellow/brown. Granulation inside wound bed-unable to determine %. [MEDICATION NAME] noted to exterior of wound opening. -[DATE] - Week three. The resident was out of facility for a wheelchair evaluation. Per review of the record, the resident did not see the wound consultant as ordered on [DATE] per scheduling conflicts. There was no wound documentation until [DATE], almost one month later. Documentation now describes the wound as a stage III. -[DATE] - Week four. Stage III with measurements 1.0 cm x 1.0 cm x 2.8 cm. Tunneling at (no description given). Serosanguinous exudate. Granulation visible to inner wound - unable to determine %. [MEDICATION NAME] visible to inner wound. Surrounding skin is red/irritated. -[DATE] - Week one. Stage III with measurements 1.0 cm x 1.0 cm x 2.4 cm. Tunneling at (no description given). Yellow/blood tinged. Granulation inside wound bed-unable to determine %. [MEDICATION NAME] noted to interior of wound. -[DATE] nurse's note - "Resident compliant c wound care daily and PRN (as needed.) -The wound consultant documented on [DATE], the following: "Wound - 1.4 x .7 x 1.6 cm c (with) 4.2 cm tunnel. Wound appears clean. Continue c the [MEDICATION NAME] and packing gauze, changing q (every) 3 days. Avoid shearing action c transfers & turning - F.U. 1 mo. Pt. is requesting wound care eval (evaluation) at the (name of facility) in (name of town). Diagnosis: [REDACTED]." -[DATE] - Week two. Stage III with measurements 1.0 cm x 1.0 cm x 2.4 cm. Tunneling at (no description given). Exudate marked as "yes", however; there was no description documented. Granulation unable to determine the %. [MEDICATION NAME] unable to determine the %. -[DATE] (ten days later) - Week three. Stage III (healing) with measurements 1.1 cm x 0.9 cm x 2.4 cm. Tunneling at 2:,[DATE].5 cm. No exudate. Granulation visible inside wound. [MEDICATION NAME] visible inside wound. -[DATE] - Week four. Stage III (healing) with measurements 1.1 cm x 0.9 cm x 2.2 cm. Tunneling at (no documented description). No exudate. Granulation (no documented description). [MEDICATION NAME] (no documented description). -The wound consultant documented on [DATE], the following: "Wound looks clean. - 1.6 x 1 x .5 cm c (with) 2.5 cm & 4 cm tunnels. Please change packing to silver calcium alginate & cover c a sponge dsg. May use [MEDICATION NAME] around wound opening. Chg dressing daily. F.U. 1 mo. Diagnosis: [REDACTED]." A handwritten note dated [DATE], written by the facility read that the wound consultant had been phoned and clarified the stage IV was actually a healing stage III. In addition the order was changed to [MEDICATION NAME] and [MEDICATION NAME] instead of the calcium alginate due to "previous issues." The note also indicated the "variation in the measurements likely due to different positioning." -On [DATE] at 2 p.m., a nurse documented that "per clarification the wound was actually a healing stage three. Variations also noted to wound measurements due to the fact that she (the wound consultant) measures him leaning over in the w/c - Measurements at facility done c (with) resident in bed-laying on R side. . ." -A [DATE] nurse's note documented that the resident had decided to stay with the current wound consultant because of the long distance to travel to the other wound clinics. -A [DATE] nurse's note documented at 7:00 a.m., "Resident pleasant & compliant with personal care. . ." -There was no wound description or measurements documented until [DATE], almost a month after the above ([DATE]) note. The wound consultant documented on [DATE], the following: "Wound cont. (continued) to be clean. Skin is excoriated. Measurements difficult to take in w/c (wheelchair). - 1 x 1 x 1 c (with) 4 cm tunnels. Cleansed & tx (treated) c collagen. Covered c Allevyn sponge. Please place the collagen in the wound bed-Cut into strips and pack. Chg (Change) q (every) ,[DATE] days, while in bed use dry gauze to cover wound & apply [MEDICATION NAME] to peri wound skin. Diagnosis: [REDACTED]. F.U.1 mo." A handwritten clarification note on the bottom of the sheet indicated the [MEDICATION NAME] was changed to antiseptic. -A [DATE] nurse's note revealed the resident "now has a new motorized scooter and fitted wheelchair from the (name of the organization.)" This was almost three months after the resident went for the w/c evaluation. -A [DATE] nurse's note indicated that new open areas were found on the right buttock crease that measured approximately 1.5 x 2.5 x less than 0.1 and slightly bruised area to left crease with open area that measured 0.5 x 0.5 x less than 0.1. -A nurse's note dated [DATE] indicated (by a diagram) the resident had three current wounds on the buttock. The first wound located on the sacrum was documented as 1.4 x 0.8 x 1.4 and the wound was described as clean with no odor. The second wound located on the right ischial tuberosity was documented as 1.5 x 2.9 x 0.1 with no exudates and the third open area on the left ischial tuberosity was documented as 1.5 x 1.2 x 0.1. -On [DATE] the nurse's note described the sacral area as "1.2 x 1.0 x 1.2 with tunneling approximately 1 cm to 1:00-minimal serosanguinous exudates. Granulation observed to wound . . . Continues to have open areas to B (both) buttock creases. Duoderm applied per order." -On [DATE] the nurse's note described the sacral wound as "1.2 x 0.8 x 1.2 with tunneling to 1:00 . . . Continues to have open areas to B (both) butt/thigh crease which are pink c (with) serosanguinous exudate. Trace slough to R buttock crease . . ." -On [DATE] at 3 p.m., a nurse's note included, "Sacral wound very clean c new skin around perimeter-outer opening is 1.1 cm x 0.6 cm x 1.1 cm c tunneling to 1:00 c 1.4 cm in depth. Wound very clean- 0 (no) s/sx (signs/ symptoms) of infection. Wounds to B (both) buttock creases have worsened- L buttock/thigh crease is 3 cm x 3.2 cm x 0.1. Has areas of slough and black necrotic tissue-area 2 cm x 1.3 cm x that is bloody- new orders for [MEDICATION NAME] & nonadherent. R buttock thigh crease is 3.2 cm x 4 cm x 0.1 cm -also has slough and necrotic tissue. Serosanguinous exudates present . . . Resident encouraged to rest in bed to offload buttock area-and we may need to evaluate lift as well as it may be causing decline in B (both) wounds." There was no evidence that the physician was notified that the wounds were worsening. -On [DATE], a nurse documented the sacral wound area was "1.1 cm x 0.6 cm x 1 cm - wound filling in nicely granulation present to wound. - eschar to wound-area from 4 o'clock to eight o'clock is beefy red-new pink skin is forming to wound edge. 0 (no) odor. Area cleaned, [MEDICATION NAME] applied and area covered per order. L left buttock thigh crease is 4.4 x 4.1 x 0.2-area has eschar as well-wound edges pink. 0 (no) odor to wound and 0 (no) exudates - (wounds seen after bath). Resident in bed to offload buttocks. . ." -On [DATE], a nurse described the sacral wound as "1.5 cm x 0.5 cm x 0.25 c (with) tunnel to 1:00. Wound is healing nicely-very clean-granulation visible to inner wound. Next, R buttock wound is pressure as it has progressed to bony area. Wound is 4 cm x 3.4 cm x .2 cm-wound is necrotic c some odor-edges are pink-tissue surrounding wound is red and blanchable at this time. Necrotic tissue consists of grey/brown tissue at this time. L buttock wound is 4 cm x 5.9 x 0.2 and also necrotic-Pressure II-appears as the other wound. Slight odor noted to area. 0 (no) exudates noted when cleaning areas. Resident has air mattress, once was on supplement but would not take. Resident being encouraged to offload buttocks frequently as he sits in electric w/c for extended periods of time. F/U (follow up) with name of wound consultant for wounds has been scheduled." There was no evidence that the physician was notified that the wounds were worsening. -On [DATE] - A nurse documented the wound consultant was not available today. -On [DATE] - A nurse's note documented, "Discussed need for protein for healing of wounds-resident has refused supplements in the past but has agreed to try Unjury q (every) day." (According to the website www.unjury.com/y, UNJURY? is a great-tasting protein supplement that provides the highest quality protein. One serving of UNJURY provides 20 grams of protein - as much as 3 eggs - without the fat and cholesterol.) -On [DATE] - The nurse documented the wound consultant was in the facility on [DATE] and the wound "was debrided-wet to dry dressing x 4 days then continue Santyl to wounds." -On [DATE] - The nurse documented the resident was seen by the wound consultant in the facility. "Notes requested. New orders." -On [DATE], the facility wound nurse documented the following about the three wounds. 1. Healing Stage III-Wound - "Wound clean s (without) exudates- o (no) c/o complaints of pain to area-wound packed with collagen and covered." Measurements were 1.4 x 0.5 x 0.4. 2. Non-stageable right ischial wound - "has odor - area cleaned and wound care per order - wound bed necrotic-area moist s (without) maceration." Measurements were 6.6 cm x 3.8 x 0.8. 3. Non-stageable left ischial wound - "L lateral part of wound edge is new pink tissue-remaining 80% of wound is necrotic - wound care per order." Measurements were documented as 4.3 x 6.0 x 1.2. -On [DATE], the facility wound nurse documented the following about the three wounds. 1. Healing Stage III-Wound - "Wound clean s (without) exudates- o (no) c/o exudates or s/sx of infection." Measurements were 1.0 x 0.6 x 0.7. 2. Non-stageable left ischial wound - Measurements were 7.1 cm x 4.6 x 0.9. "Wound 100% necrotic - Resident to be sent to (name of hospital) wound clinic. Wound consultant did not come yet this week to assess the wound. Resident currently on wet to dry dressings." 3. Non-stageable right ischial wound - Measurements were documented as 3.2 cm x 1.0 cm x opening to middle of wound surrounded by necrotic tissue. 7.9 x 7.1 with total wound depth of 1.8 cm. Wound smells - outer lip of wound is 0.5 inner depth 1.8 cm. The resident was sent to the hospital wound clinic on [DATE]; almost three months after these areas were discovered and deteriorated. Review of the hospital outpatient wound clinic's notes received per fax on [DATE], revealed, "Due to the severity of his wounds, the patient will require admission with surgical treatment of [REDACTED]. The patient is paralyzed from the waist down from what he states is a [MEDICAL CONDITION] metastasis complication." The hospital operative report dated [DATE] revealed, "The right and the left ischial wounds were large, deep and showing extensive necrotic tissue throughout with a few areas of granulation tissue where the wound had previously been healing. The debridement was done to the bone on both sides using scapel for extensive debridement. This was to remove necrotic tissue . . . with the sacral decubitus wound down to the subcutaneous tissue layer and requiring debridement into the subcutaneous tissue layer. . ." Summary of After Facility Wound Progression The resident was sent to another hospital for wound care after the surgical debridement. The resident was interviewed at this hospital. On [DATE] at 8:40 a.m., the resident's current hospital record was reviewed. According to the documentation, the resident was admitted to the long term acute care hospital (LTAC) on [DATE]. He had previously been admitted to an acute care hospital on [DATE] for treatment of [REDACTED]. The history and physical (H&P), dated [DATE], documented the resident was a very pleasant and cooperative [AGE] year male. He was at a different hospital prior to the LTAC where "his wounds were debrided on [DATE] down to bone bilaterally and to the sacrum." He also developed an infection. Under the assessment and plan, of the H&P, documentation showed the resident had the bilateral ischial and sacral wounds. The notes read, "He was using an electric wheelchair, from the (long term care) facility, and apparently was not getting off of that." A suprapubic catheter was in place to keep the area clean of urine. Due to the location of the wounds, there was question whether a diverting [MEDICAL CONDITION] may be necessary. Review of the wound care progress notes, dated [DATE], revealed the left ischium wound was a stage IV measuring 10.8 cm x 7 cm x 2.5 cm deep, with 1.5 - 3.4 cm undermining. The wound bed was 5% bone. The right ischium wound, also a stage IV measured 6.9 cm x 5.2 cm x 3 cm deep with 2 - 2.7 cm undermining. The wound bed was 5% bone. Wound progress notes, dated [DATE], revealed the left ischium measured 10.5 cm x 4.6 cm x 2.1 cm deep, with ,[DATE].3 cm undermining and bone noted up into the undermining. The right ischium measured 8 cm x 4 cm by 2.5 cm deep, with 1 - 2.7 cm undermining and bone noted in undermining. The coccyx wound, on [DATE], was a stage III measuring 2 cm x 1.5 cm by 1.1 cm deep and no undermining. Nurse's notes, dated [DATE] and [DATE], documented the resident was alert and oriented x 4. On [DATE] at 9:15 a.m., the resident was interviewed from his hospital bed. He was receiving intravenous (IV) medications and fluids. A nasogastric tube (NG) was also in place. He was positioned in bed lying towards his right side. The resident said he was admitted to the LTAC from another hospital following his stay at the long term care facility, where he had been for about six months. He said he was paralyzed and had significant wounds to his bottom. He stated the long term care facility employed, "insufficient personnel and there was insufficient padding in my chair." He said, "They just come in and do the job and then just left me sit there for sometimes 6 hours." He stated he was not given the right padding for his chair until right before he was sent to the first hospital. He said, "Staff are not sufficiently trained, and weekends are especially bad." The resident stated the staff were not watching him closely enough and said, "They should have got on it, like hey, this guy needs attention." He said there were big failures in administration and they did not hire qualified people. "They were not turning me at all. They were very late in getting the right supplies and equipment. It took months to get the right chair and padding." He said when he was released from the LTAC, he preferred to go to a different place. Other Interviews On [DATE] at 4:19 p.m., the nursing home administrator (NHA) was interviewed. The NHA stated the resident was very non-compliant with the ulcer care. He would not use his special roho cushion. He would not lay down to rest. He was up in the wheelchair most of the day. On [DATE] at approximately 8 a.m., the facility wound nurse was interviewed. She stated the resident was unable to walk and turn in bed. She went on to say that the resident had compliance issues, however had a great attitude. The wound nurse stated the resident preferred his own cushion. He on occasion would off-load after the dressing change. He would eat breakfast and sit out in the breezeway. Before he received his motorized wheelchair, he would stay in bed. Once he received this new wheelchair, he preferred to be up. We would try. The wound nurse explained that the wound consultant was the only person in this area they had for a resource. She stated the wound consultant would encourage the resident to lie down. She went on to say that the wound consultant, before he was sent out, used a mirror to show the resident his wounds because he did not feel them. She had no explanation for the missing wound assessments and measurements. On [DATE] at 9:21 a.m., a Certified Nursing Assistant (CNA) that had taken care of resident #2 was interviewed. He stated the resident was a very nice gentleman. He went on to say that he would get up early, eat breakfast and then would sit outside with his camera and his video camera. He stated he would sit outside all day. He added when asked, that the resident did not refuse to be changed. He added they would try and encourage him to lay down, however, he just wanted up in his chair. The restorative nurse was interviewed on [DATE] at 11:30 a.m. She stated the resident could eat on his own. She went on to say that the resident preferred the gel cushion which they checked very often. She added that the resident was very non-compliant, however would lie down to be changed. "There was no problem with that." The restorative nurse stated the resident preferred to sleep on his back. She went on to say that he would not use the high end roho cushion he had, would not use the wedge they had, and liked to be up for long periods of time. The Director of Nursing (DON) was interviewed on [DATE] at approximately 1:00 p.m. She stated the facility did not have a lot of resources in "rural America." The wound consultant was the only person in this area they had. She added the wound nurse saw the resident once a month at the office and before the resident went to the hospital, the wound nurse came to the facility. She was the one that ordered the treatments for the wounds and the physicians depended upon her expertise. She added that the resident was a difficult resident in that he wanted to be up a lot once he received his motorized wheelchair. She stated the resident could not feel his wounds since he was paralyzed from the waist down. She added that when his wounds worsened, the facility wanted to send him out and received a referral to the wound clinic affiliated with the hospital. 2. Closed record review revealed sample resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was readmitted on [DATE] after suffering from an acute [MEDICAL CONDITION] infarction. On [DATE] he was placed on comfort care and expired on [DATE]. The [DATE] care plan indicated the resident was at high risk for falls, at risk for fluid volume deficit, was on an antidepressant, had severe cognitive impairment due to dementia, was incontinent occasionally, on oxygen, had a decline in his nutritional status due to his poor intake and weight loss was anticipated. His wife had passed recently. The resident was also care planned for being at high risk for skin trauma (abrasions, bruising, skin tears) related to the use of [MEDICATION NAME], fall risk, impaired mobility, incontinence, and poor nutrition. Some of the approaches included incontinence care, offer Ensure (supplement) twice daily, skin assessment weekly and as needed, and keep skin lubricated. His skin was intact upon readmission. A temporary care plan was added on [DATE] that documented a pressure area to the right lateral ankle. The approaches listed were monitor the skin weekly, dressing per order, and observe for changes to the area. Review of the weekly skin assessment on [DATE] revealed inconsistent or lack of documentation of weekly skin assessments. The ,[DATE] skin assessments were completed on ,[DATE], ,[DATE], and on [DATE]. The ,[DATE] weekly skin assessments were completed on ,[DATE], ,[DATE], and [DATE]. There was no evidence the weekly skin check was completed from ,[DATE] to [DATE], a period of 21 days. The "Wound Assessment Guide" indicated the pressure wound onset date was [DATE]. The form was divided into four parts for each week's documentation for that month. The form contained the following documentation. -Week one, dated [DATE], Stage unknown. The documented measurements were 1.8 x 2.0 x unknown. The necrotic tissue was described as 0.3% red eschar. The resident denies pain. The surrounding skin was intact. The facility wound nurse documented the area was red and non-blanchable with a dark (0.3 x 0.3) scab to the middle. An order was received to cover the area with [MEDICATION NAME] and change every other day. Staff was encouraged to reposition the resident, "able to move back. " -Week two, dated [DATE] (13 days later). The stage was left blank. The documented measurements were 2.6 x 2.2 red blanchable area with open

Based on observation, resident and staff interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents, for six of 13 sample residents (#3, #4, #5, #6, #7, #10) and one supplemental sample resident (#14). Specifically, the facility failed to: -Implement adequate fall prevention measures for residents #3, #5, #6, #7 and #10; -Provide adequate supervision and interventions to prevent choking for resident #5; -Assess for the safe use of bed rails for residents #3, #4, and #10; and -Repair or replace a torn wheelchair arm for resident #14; and repair torn dining room booth upholstery, which created skin tear hazards. The facility's failure to provide adequate supervision, monitoring, and safety devices contributed to resident #6 sustaining a fractured hip during an unsafe self-transfer. The findings included: A. Failure to assess and implement adequate fall prevention measures 1. Resident #6 - Fractured hip Interviewable resident #6, an [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. a. Risk for injury According to the admission Nursing Assessment, dated 2/23/10 at 3:45 p.m., resident #6's prior living arrangement was at home alone where she had been enrolled in a Hospice program since 11/09. She was documented to be oriented and to be able to ambulate independently with a wheelchair or walker. Her vision was adequate if wearing glasses. The 3/07/10 Minimum Data Set (MDS) assessment (14 days later) revealed the resident required extensive assistance for bed mobility and transfers, and was unable to move off of or return to the unit. She was not able to attempt balance while standing and required partial physical support for balance testing while sitting. Resident #6 needed supervision with toileting. She was not noted to have abrasions, bruises or falls. The physician's orders [REDACTED].? to 1 ml, by mouth as needed, and multiple bowel management medications. A 3/31/10 Physician's Telephone Order prescribed Lorazepam 0.5 mg, every four hours, as needed for restlessness, and Phenergan 25 mg, by mouth, every six hours, as needed for nausea and vomiting. Review of her Temporary Nursing Care Plan, dated 2/23/10, revealed the resident had a potential for weakness and shortness of breath due to her cardiac condition. The care plan goal read, "Comfort" and the approaches included: -Assist with ADL (activities of daily living) secondary to Hospice. The care plan was void of information or instructions regarding supervision to provide transfer assistance by staff to promote safety and to prevent injury. (Cross-reference F279 Comprehensive Care Plans.) A 3/01/10 Fall Risk Evaluation documented a score of "20" (a resident who scores 10 or higher is at risk). b. Right hip fracture - failure to adequately intervene Review of resident #6's clinical record on 4/19/10 at 4:15 p.m., revealed a Nurse's Notes as follows: 4/03/10 at 11:30 p.m. "Resident found lying on right side on floor with her head toward the side of the bed and her feet in the doorway. Resident complained of right hip pain and there was increased pain with range of motion. Resident sent to emergency room for examination." A hospital History and Physical, dated 4/04/10, read in part: "-Chief Complaint: Right hip pain. -History of Present Illness: Resident has a significant history of [DIAGNOSES REDACTED]. The resident has multiple frequent syncopal episodes secondary to the [DIAGNOSES REDACTED]. The resident states that today she was getting up from the bathroom, turned around the corner, and had a mechanical fall." -Assessment: "Right femoral subcapital intertrochanteric fracture." The facility failed to implement and monitor interventions to prevent resident #6 from sustaining a fracture to her right hip. Even after the resident sustained [REDACTED]. c. Observation On 4/19/10 at approximately 2:05 p.m., resident #6 was observed by the surveyor seated in her room in her recliner chair, disrobed from the waist down. Resident #6 had a bandage on her right upper hip incision site. (Cross-reference F241, Dignity.) d. Interviews On 4/19/10 at 1:30 p.m., during a quality of life interview with resident #6, she was asked to describe her injury. She stated, "I fell right over there (she pointed to the end of her bed), going around the end of the bed." When asked if she had called for staff assistance, resident #6 said, "I wanted to see what I can do before I called for help." The surveyor asked resident #6 if the staff checked on her periodically. Resident #6 responded, "They will come if I call them." On 4/19/10 at approximately 3:00 p.m., the Hospice RN was interviewed with regard to resident #6. The RN said, "(Resident #6) has episodes of passing out so she couldn't stay at home alone any longer. I see her once a week here at the facility." During an administrative meeting on 4/20/10 at 3:00 p.m., with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the surveyor requested documentation and follow-up regarding the investigation of resident #6's 4/03/10 injury. The 4/03/10 "Accident/Incident" provided on 4/21/10, read in part, "Resident lying on right side on floor with head toward the side to the bed and her feet in the doorway. Resident calling for help." The investigation revealed the incident had occurred at 10:00 p.m. and staff that had worked between those hours was interviewed. Staff reported, "Resident was slightly confused but oriented and was trying to go to the toilet." The investigation concluded, "Incident not witnessed. Resident mobility status: Balance and/or gait abnormality, left extremity weakness and resident unable to balance self independently." On 4/19/10 at 2:15 p.m., a certified nurse aide (CNA) who regularly worked on the 200 Hall where resident #6 lived was asked what care the CNA provided for resident #6. The CNA said, "She uses the call bell if she needs something. (Resident #6) is not supposed to do things on her own." A Fall Committee interview was conducted on 4/21/10 at 11:45 a.m. with the DON, and the physical therapist (PT) with regard to resident #6's therapy involvement. The PT said, "When she fell she wasn't using her walker and went to reach with her right hand. I don't have her on therapy because she is in Hospice." On 4/22/10 at 11:30 a.m., the Medical Director was interviewed with regard to resident #6's fracture. The Medical Director said, "I am not familiar with this particular resident's fall. You say her fall was two months after her admission? I will review the record." On 4/22/10 at 12:30 p.m., when informed of the findings, the NHA made no additional comment. There was no evidence the facility provided adequate supervision or monitoring to ensure resident safety prior to resident #6's injury. Although the facility was aware of the resident's [DIAGNOSES REDACTED]. Even after her hip fracture, there was no evidence that these measures were assessed and put in place. 2. Resident #7 - Failure to provide adequate interventions to prevent repeated falls. Non-interviewable resident #7, a [AGE] year-old male, was admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. a. Risk for injury A Physical Therapy Progress Note quarterly assessment, dated 1/26/10, read in part, "Resident has a high risk for falls and has had several falls over past 90 days. Handgrip bars placed throughout room as well as transfer poles to help prevent falls. Uses wheelchair to assist with mobility." The 2/01/10 MDS revealed the resident was moderately impaired for cognitive skills, making poor daily decisions. He understood, but was rarely understood, and required cues and supervision from staff. Resident #7 required limited assistance for transfers and was able to move off of or return to the unit. He was not able to attempt balance while standing and required partial physical support for balance testing while sitting. Resident #7 had full loss of range of motion on one side. He was coded to have falls in the past 30-180 days, abrasions, and bruises. The physician's orders [REDACTED]. His Nursing Care Plan, revised 2/04/10, identified a problem of high risk for falls related to his seizure disorder, right hemiparesis, cognitive deficits, psychoactive medications, and hypotension. The care plan goal read, "Absence of trauma, injury, fracture, or falls" and the approaches included: -PT/OT to evaluate and treat as needed, -Assess environment for safety, -Transfer pole at bedside and by sink, -Keep call light in reach at all times, -Keep bed in lowest position and brakes locked, -Level III Restorative nursing for ambulation with hemi-walker, -Resident moved to (new room) on 4/02/10, closer to activity and to assist with right-sided hemiparesis. b. Repeated falls - failure to adequately intervene Review of resident #7's clinical record on 4/20/10 at 8:30 a.m., revealed in his Temporary Care Plans that resident #7 had incurred unobserved falls on 1/01, 1/17, 2/16, 2/27, 3/17, and 3/20, and an observed fall was recorded on 2/03/10. The resident was documented to have experienced seven falls. A Monthly Nursing Summary, dated 3/30/10, related to falls read, "Had four falls in past month. Family, doctor, and other staff visiting with resident and a room change so resident will be a little closer to activity and helpful devices will be on the side resident can help himself move with. Resident obtained minor bruising and abrasion to heel. All healed without problems. Neuro-checks stayed within normal limits. Encouraged to use hemi-walker and call for assist as needed. The resident is reluctant to accept any changes at present. Will keep trying." The facility failed to implement and monitor interventions to prevent repeated falls for resident #7. c. Observation On 4/19/10 at approximately 4:50 p.m., resident #7 was observed by the surveyor as he self-propelled on the 200 Hall while seated in his wheelchair. His right foot was elevated on a leg rest. The resident smiled and waved, but did not speak. d. Interviews During an administrative meeting on 4/20/10 at 3:00 p.m., with the Nursing Home Administrator (NHA) and Director of Nurses (DON), the surveyor requested documentation and follow-up regarding the investigation of resident #7's multiple falls (please see dates above). The "Accident/Incident" documentation was provided on 4/21/10, and revealed falls had occurred in the resident's bathroom, and four falls had occurred when the resident attempted self-transfers to/from his bed. A Fall Committee interview was conducted on 4/21/10 at 11:45 a.m. with the DON and physical therapist (PT) with regard to resident #7's repeated falls. The PT said, "The resident isn't cooperative. He didn't want the transfer pole placed on his good side, so we put it on his affected side." The PT was asked by the surveyor to clarify that the transfer pole had been placed on the resident's affected side, where the resident was not able to access the transfer pole. The PT said, "The doctor had to talk to him about moving the pole because the resident is so resistive. We changed rooms to see if that would help." On 4/22/10 at 11:30 a.m., the Medical Director was interviewed with regard to resident #7's repeated falls. The Medical Director said, "PT felt early in the process that a move to a more left handed room was recommended. I believe I'm correct that after the room change, the falls improved. (Resident #7) has a deformity of the right ankle that he was referred to a podiatrist for bracing in 2009. The ankle has worsened progressively over the past 18 months. He also has a significant visual deficit. My understanding in talking with PT is that PT has plans for him, but the resident remains resistant." On 4/22/10 at 12:30 p.m., when informed of the findings, the NHA made no additional comment. There was no evidence the facility provided adequate interventions to prevent resident #7 from repeated falls. 3. Resident #5 - Failure to implement measures to prevent repeated falls Resident #5, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations During the initial tour of the facility, which commenced at 1:50 p.m. on 4/19/10, resident #5 was sitting in his wheelchair in his room with the door closed. On 4/19/10 at 4:45 p.m., he was observed in the dining room waiting for dinner. He exhibited involuntary movements of his hands and arms. He was observed on 4/20/10 at 9:20 a.m. and 1:45 p.m., again in his room with the door closed. On 4/21/10 at 9:40 a.m., he was in his room with the door closed. Efforts to interview resident #5 were unsuccessful. Resident #5's 3/2/10 MDS identified him as having modified cognitive skills for daily decision-making. He was independent in bed mobility, locomotion, toilet use, and personal hygiene. He needed supervision and set-up help for eating, and limited one-person assistance with bathing. He required partial physical support during the standing balance test. His primary mode of locomotion was a wheelchair, and he had bed rails for bed mobility or transfers. He was continent of bowel and bladder. He had fallen in the past 30 days and the past 31-180 days. Care Plan Resident #5's care plan identified,"Actual falls r/t (related to) antipsychotic & antidepressant med uses, non compliance with recommended interventions." Approaches included: "provide assistive aids as needed" and "allow for and encourage safe activities when scheduled or desired." An approach, dated 9/30/09, stated,"encourage to ask for assist when/if needed." An approach, dated 12/21/09, stated, "Dycem mat under mattress to reduce sliding." An approach, dated 1/1/10, stated,"PT/OT (physical therapy/occupational therapy) eval & treat as needed." The care plan was void of reference to increased supervision to prevent falls. The care plan did not state that the resident preferred to keep his door closed. The care plan was void of reference to the possibility the resident suffered a seizure on 1/2/10. No approaches were added after 1/1/10. Fall Risk Evaluation Fall risk assessments completed on 8/19/09, 9/29/09, and 11/19/09 resulted in scores of 14, 16 and 16 respectively (10+ = at risk for falls). Assessments completed on 1/2/10, 1/18/10 and 2/17/10 all resulted in scores of 20. Incident Reports In response to this surveyor's request, the facility provided copies of incident reports on 4/20/10, which revealed as follows: On 9/29/09 at 1:00 p.m., the resident was found by a CNA "down in bathroom on butt (with) legs crossed facing toilet & pants down." With the exception of a reddened area on the right kneecap, no injuries were noted. The section, "Actions Taken," noted that Alert Charting was started and the care plan was reviewed. The section, "Follow-up," stated, "Encourage resident to ask for assistance when needed. (Check) bathroom for safety bars. Med review. Resident gets increased paranoia (with) use of safety devices, refuses to use." On 12/20/09 at 2:00 p.m., resident #5 was found sitting on the floor beside his bed and wheelchair with his legs outstretched. The incident report stated the resident was transferring from his wheelchair to his bed and the mattress slipped on the frame. No injuries were noted. "Actions Taken" stated the resident was on the therapy caseload, and his care plan was reviewed. "Follow-up" stated the resident had increased tremors after a hospitalization in mid-December, that adaptive equipment would be introduced in the dining room, and that Dycem was placed under the mattress to prevent slipping. On 1/2/10 at 8:40 a.m., resident #5 was found on the floor with the right side of his head against the bedpost. He sustained a small abrasion on the right side of his head and bruising to the right hip and right arm. The fall was unwitnessed. The floor was wet with possible vomitus. The resident's mobility status was identified as "balance and/or gait abnormality" and "unable to balance self independently." A summary of the investigative facts stated, "Res(ident) not feeling well - (increased) weakness, fell to floor off bed. S/P (status [REDACTED]. "Follow-up" stated the resident was sent to the emergency room for evaluation at 9:10 a.m. due to weakness and confusion. On 1/18/10, resident #5 was found "lying on (left) hip and (left) shoulder blade, head lying on floor." The resident's roommate discovered the resident on the floor. The activity at the time of the incident was "transferring to go to bathroom." The only injury reported was redness to the shoulder blade. The response from the resident's physician was to "get another mat for other side of bed." Physician Notes Resident #5's physician documented extensive notes regarding the resident's fall on 1/2/10. The resident was admitted to the hospital on that date related to a fall with concussion. The physician stated the reason for the resident's syncope was not clear, and he questioned whether it was related to postural hypotension or if the resident had a seizure. Nurse's Notes -1/1/10, 4:00 p.m., "Resident found sitting on bathroom floor (with) right shoulder leaning against w/c & feet between toilet & east wall. Redness to right shoulder blade but no scrapes...Neuro (checks) (WNL) within normal limits...Resident remains weak & currently cooperative with O2. Alert charting started." -1/2/10, 8:20 a.m., "Res found on floor next to bed. His head was up against a post in the bottom of the bed. His head was bent forward on the post ... Res alert, speech clear but drooling. Shirt was soaked (with) vomitus. B/P (blood pressure) 78/40. Res incontinent of stool ... Res also had a fall last nite." Rehabilitation Services A post-fall screening tool, completed by the physical therapy aide (PTA) on 1/22/10, stated the resident was found lying on the floor in his room on 1/18/10 at 8:30 p.m. He had been trying to self-transfer. No injuries were reported. Recent changes were identified as a decline in abilities, transfer techniques and strength. The resident was on the rehabilitation PT caseload due to increased weakness, inability to tolerate an alarm, refusal to call for help or wear hip protectors, and the discontinuation of a bedside floor mat. A rehabilitation care plan identified that the goals of treatment were met on 3/15/10. Goals included safe room transfers. Falls Committee Falls Committee members (DON, restorative RN, PTA, and two restorative CNAs) were interviewed by surveyors on 4/21/10 at 11:10 a.m. When asked to define "alert charting," an action implemented after falls, the DON stated this referred to staff being alert to a resident's need for close monitoring. The DON stated there was no written expectation or guideline for high alert, or alert monitoring. She said the nurse on shift would be responsible to instruct staff on what monitoring was needed. No information was available regarding the "alert charting" status for resident #5, initiated after his fall on 9/29/09. Nurse's notes did not reflect any additional monitoring or supervision for falls. 4. Resident #10 Resident #10, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He underwent knee replacement surgery on 11/16/09. Resident #10's 3/10/10 MDS identified him as having modified independence in cognitive skills for daily decision-making. No memory problems were identified. No behavioral symptoms or indicators of depression were identified. He required limited one-person assistance with transfers and supervision/set up help for ambulation. He needed extensive two-person assistance with toileting and physical help with part of bathing. He was continent of bowel and bladder. Modes of locomotion were identified as cane/walker/crutch, wheeled self, and wheelchair as primary mode of locomotion. He was lifted mechanically and used bed rails for bed mobility or transfers. He had fallen within the past 31-180 days. Care Plan Resident #10's care plan identified, "Impaired physical mobility r/t left hemiparesis AEB requiring limited to extensive assist with toileting, transfers & bathing. Use of Sara lift for toileting." Approaches included enabler bar for repositioning in bed and transfer, and Level II restorative nursing for strength and endurance. The problem area, "Actual falls r/t left hemiparesis, antidepressant use, h/o (history of) fall, orthostatic hypotension," included generic approaches such as assessing the environment, reminding resident to change positions slowly, PT/OT eval and treat as needed, and encourage resident to ask for assist with transfers. The single individualized approach stated, "Resident refuses to have transfer pole." Fall Risk Evaluation Fall risk assessments completed on 9/2/09 and 12/10/09 resulted in scores of 18, with a score of 10 or higher indicative of a risk for falls. Assessments completed on 1/10/10, 1/31/10, 3/1/10 and 4/6/10 resulted in scores of 15, 16, 20 and 18, respectively. Restorative Progress Notes The restorative RN entered the following notes: -12/10/09, "Res significant change assessment complete. Res has high risk for falls, (no) falls past 90 days. Has had recent total knee replacement, does not attempt ambulation or transfers (without) assist, (no) fall interventions needed @ this time. Uses w/c (wheelchair) for assist (with) mobility...is not working with restorative." -3/1/10, "Res quarterly assessment complete. Res has risk for falls, is s/p (status [REDACTED]." Incident Reports Resident #10 was "found between bed & w/c on his butt" on 1/10/10 at 7:00 p.m. He sustained two skin tears on his left arm. The incident report stated the front wheels on his wheelchair "don't lock." The summary of investigative facts stated, "res was attempting to transfer to bed & did not lock brakes, sat on floor." The follow-up plan included, "getting a transfer pole for bedside, Will get a vision (check). Bed bolts were covered (with) plastic cover (due to) possible rough edges." On 1/31/10 at 6:15 p.m., resident #10 was observed, "sitting on the floor against the bed, w/c to the left of resident, LFA (left forearm) skin tear." The summary of investigative facts stated, "weakness, missed bed (with) transfer." Alert charting was initiated. The follow-up plan was to look at the position of the enabler bar for transfer assist versus wheelchair positioning as the resident approached the bed. On 4/6/10 at 7:10 p.m., resident #10 was found on the floor in his room, on his left side. He sustained a skin tear to the left shoulder. He was reportedly trying to get into bed at the time of the incident, and the brakes on the wheelchair did not lock. His care plan was reviewed and alert charting was started. The follow-up plan was to continue with restorative for strength and endurance and to check his room for safety. Nurse's Notes A nurse's note entered on 1/31/10 at 6:30 p.m. stated, in pertinent part, that after the resident's fall, a CNA noticed three bottles of whiskey in his drawer. The nurse spoke to the resident about notifying his physician to request an order for [REDACTED]. The resident stated he would have his daughter pick up the whiskey as he did not want to worry about the rules. The medical chart was void of other reference to alcohol use, other than the restorative nurse's note that the resident's three falls were possibly ETOH-related. Resident Interview Resident #10 was interviewed in his room on 4/21/10 at 4:00 p.m. When asked about his falls, he demonstrated that when he locked the brakes on the large wheels of his wheelchair, the small front wheels did not lock and would spin and move the chair when he attempted to transfer. He said this would cause him to lose his balance and fall. He said he had told staff this, but no adjustments were made to the wheelchair. He stated he solved the problem himself by shoving the small front wheels under the side of the bed frame so they "stuck on that metal bar." He said this kept the wheels from spinning and allowed him to transfer without falling. He had an enabler bar on his bed but said he did not feel safe transferring with it. 5. Resident #3 Resident #3, an [AGE] year-old female, was admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. The record documented resident #3 had fallen on 2/01/10, dislocating the right shoulder, and fracturing her right humerus and right patella. According to her 2/11/10 significant change MDS, she was moderately cognitively impaired, had short and long-term memory problems, required extensive assistance of two people for transfers and toileting, and extensive assistance of one person for dressing. The resident was coded for having falls in the past 30 days, and 31-180 days. She was experiencing an acute episode or a flare-up of a recurrent or chronic problem, and had an unsteady gait. Review of Nurses Notes, a Temporary Care Plan summary, and the facility's investigative reports, revealed resident #3 had fallen on 6/05/09, 7/03/09, 9/13/09, 10/10/09, 11/28/09, 2/01/10, 2/10/10, and 3/29/10. A summary of the falls revealed: -6/05/09 - attempted to open closet and fell over shoes; -7/03/09 - resident found lying on back with head against door. "Red spot on back of head"; -9/13/09 - resident found sitting on the floor in dining room; -10/10/09 - resident found sitting on ground outside. "Was trying to catch the bus. Abrasion to nose." The facility documented the resident had been pushed by another resident; -11/28/09 - resident on floor, found on knees. Resident stated she slipped due to her shoes. A later assessment found the right knee was red; -2/01/10 - "caught flooring with walker, fell in front entry." A History and Physical from the hospital, dated 2/02/10, revealed the resident had a dislocated right shoulder, and fractured right humerus and patella; -2/10/10 - the resident attempted to get out of bed without assistance and was found sitting on the floor; -3/29/10 - the day before this fall, the nurse documented the resident was full weight bearing and self-propelling her wheelchair. The resident was found in the common area lying on the floor in front of her wheelchair. The investigative report documented the resident attempted to reach for an object on the floor and fell out of her wheelchair. The facility's follow-up included changing out the resident's wheelchair and cushion, for proper position. The investigative reports included a place for staff to document if, "Fallguard in use?" Staff consistently documented "no," except for the fall on 9/13/09. The type of Fallguard in use was not included in the report. Nurses notes did not include documentation for use of a Fallguard on 9/13/09. Nurses notes on 2/10/10 documented the bed was in the low position and a call light in reach. The resident's mental status, prior to each fall, was documented as "confused," or "alert and confused," "normal per condition," or "hx: dementia/confusion." There were telephone orders, dated 2/04/10, for a low bed and alarming mat, and on 2/10/10 for a concave mattress, floor mat, and bed alarm. Review of the printed Care Plan revealed: Under High Risk for Falls, updated on 1/30/09, the facility's approach included assessing the resident's mobility & stability, muscle weakness, cognitive limitations, balance or gait difficulties, assess environment for safety hazards, lighting, physical therapy evaluation, and assist the resident to change positions slowly. There was a handwritten note, dated 3/29/10, "Assess w/c (wheelchair) positioning q (every) day & PRN (as needed)." The resident's care plan was not updated after her falls. (Cross reference F279, Comprehensive Care Plans.) Assessments: The facility's "Fall Risk Evaluations" reviewed from 7/21/09 through 3/29/10, revealed the resident's lowest score was a "20" on 7/21/09. The resident's score progressed to a "30" on 10/01/09. The enabler bar was not included on the care plan, and there was no evidence in her record that she had been assessed for safe use of the enabler bar. When asked if an assessment had been completed, the restorative registered nurse (RN) provided a copy of the assessment for safe use of the enabler bar. The assessment was dated 4/20/10. The April 2010 medication administration record (MAR) included a place for the nursing staff to document, three times a day ("a.m., p.m., noc"), that the resident was on a concave mattress. Nursing staff consistently documented the presence of the concave mattress, with the exception of the p.m. shift on 4/19/10. There was a blank on the MAR and there was no documentation on the back of the MAR to explain the blank. Observations: Observation of the resident's room, on 4/19/10 at 1:45 p.m., revealed a low bed, a regular mattress, a fall mat, folded up on both sides of the bed, and an enabler bar. A tab alarm was observed on a bedside table. The resident was observed sitting in a wheelchair in the common area of the facility. A device to alert staff the resident was trying to get up unassisted, was not observed. The same findings were observed on 4/20/10 at 8:00 a.m. The resident was observed in her wheelchair at the breakfast table. She was eating independently and a device to alert staff the resident might try to get up unassisted was not observed. Interviews: The restorative registered nurse (RN) reviewed the room with the surveyor, on 4/20/10 at 2:15 p.m., and confirmed that the bed contained a regular mattress and not a concave mattress. She also stated that the enabler bar was new to her. She thought that the maintenance department must have just switched out the bed for a new one. During interview with the maintenance director and maintenance assistant, on 4/20/10 at 2:40 p.m., the assistant stated that the beds had been changed out "two to three weeks ago." He did not know anything about the mattresses needing to be changed on the bed. The RN provided the surveyor with the documentation book, where the restorative aides reviewed and dated when they had last checked a resident's room for placement of safety devices. Review of the documentation revealed it had been checked last on 4/01/10, and that a low bed and concave mattress and mats were pres