Every finding on record at Columbine Care Center

Based on interviews and record review, the facility failed to ensure one (#59) of three sample residents received notification of changes in eligibility for Medicare or Medicaid covered services, what the resident's financial responsibility may be, and their appeal rights.Specifically, the facility failed to ensure Resident #59 were provided with a Notice of Medicare Non-Coverage (NOMNC) when their skilled nursing benefits ended timely.Findings include:I. Facility policy and procedureThe Notice of Changes policy, revised on 4/1/26, was received from the nursing home administrator (NHA) on 4/16/26 at 3:52 p.m. It read in pertinent part, Residents will be told when charges will occur to their bills. The facility will fully inform the resident of services and related charges. The NOMNC form is given by the facility to all medicare beneficiaries at least two days before the end of a Medicare covered part A stay or when all of part B therapies are ending, The NOMNC informs beneficiaries of the right to expedite review by a quality improvement organization.II. Resident #59 A. Resident statusResident #59, age greater than 65, was admitted on [DATE] and discharged on 2/9/26. According to the February 2026 computerized physician orders (CPO) diagnoses included fracture of the left femur (broken bone of the upper leg), Parkinson's disease (a neurodegenerative disorder impacting movement and function of the body), hypertension (high blood pressure) and dementia (cognitive decline affecting memory, communication and impaired reasoning). The 2/9/26 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for metal status (BIMS) score of 12 out of 15.The MDS assessment documented Resident #59 was a planned discharge to home/community. B. Record reviewThe NOMNC for Resident #59 identified services were to end on 2/9/26. Resident #59 signed the NOMNC on 2/9/26. It also documented the resident was deciding to leave prior to the two day notice. -However, the facility failed to provide the resident two day notice of end of coverage on 2/9/26. A nursing behavior progress note, dated 1/28/26 at 9:47 p.m., documented Resident #59 was upset and argumentative while the nurse was on the phone with the resident's family member. Resident #59 was saying that the wife needed to come pick him up and that he was being discharged . The nurse spoke with the family member and explained that discharge planning would include her and required physician's orders and appropriate paperwork and the facility would contact her when plans were finalized. The family member stated this was the usual communication style of the resident. The nurse provided reassurance to the resident about safety and that discharge would not occur without appropriate planning and communication. Resident #59 was redirected and accepted reassurance and returned to bed. Resident #59 was resting comfortably in bed with no further agitation. -However, the facility failed to issue the NOMNC timely, despite the resident's plan to discharge. A plan of care note, dated 2/4/26 at 5:55 p.m., documented a referral for home health was declined by the resident and family. -However, despite the facility being aware of the resident's upcoming discharge, the facility failed to issue the NOMNc timely. A late entry care management note, dated 2/9/26 at 9:34 a.m., documented the resident elected to discharge home and continued to have skilled nursing days available. Review of Resident #59's electronic medical record (EMR) did not reveal any physician's notes documenting the resident was requesting to discharge the facility prior to the 2/9/26 discharge. The discharge care plan, dated 1/2/26, revealed Resident #59 had a discharge plan and wished to return to the community. III. Staff interviewsThe social service director (SSD) and the admission coordinator were interviewed on 4/16/26 at 9:24 a.m. The SSD said once they received notification a resident's services would be ending they provided the resident with notification. The SSD said the notification was to allow 48 hours prior to end of services so the resident could appeal the decision if they feel they needed to remain on services longer. The SSD said she assisted the resident if needed to appeal the decision. The SSD said a resident may choose to leave prior to the last covered date if they choose too. The admission coordinator said at the time of Resident #59's discharge, she was holding double duty assisting with admissions and discharges. The admission coordinator said the administrator at the time had instructed them to give all residents a NOMNC regardless of their status at time of discharge. The admission coordinator said she was not the staff member who issued the NOMNC to Resident #59 on 2/9/26.The SSD said Resident #59 did not receive his notice timely in order to provide him 48 hours notice.The NHA joined the interview at 9:35 a.m. She said the facility had been working on improving the process for issuing the NOMNCs. The NHA said it was identified prior to the survey, but the facility had not created a performance improvement plan at that time. The NHA said she would create a performance improvement plan for NOMNC after the interview.IV. Facility follow upOn 4/16/26 at 3:52 p.m. after survey exit the facility provided a copy of the performance improvement plan, undated, for failure to properly issue and /or manage the NOMNC process in accordance with medicare requirements. On 4/17/26 at 9:59 a.m the NHA provided an attestation from Resident #59 physicians dated 4/16/26. It indicated throughout the residents' stay he made notable and frequent requests for discharge despite his ongoing disability. After several weeks of Resident #59's behavior, the facility finally arranged for discharge home with home health, despite his preference to remain in the facility longer. The wife picked up the resident on 2/9/26 at discharge. -There were no physician's notes indicating the physician had conversation with Resident #59 or family about residents wanting to leave prior to the 2/9/26 discharge (see record review above).

Based on observations and interviews, the facility failed to ensure residents were treated with respect and dignity was provided in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life in one of one dining rooms. Specifically, the facility failed to ensure the residents did not have to wait in a long line to place their meal orders prior to entering the dining room and being seated for meals. Findings include:I. Facility policy and procedureThe Resident Dining Services policy, revised 4/29/25, was provided by the nursing home administrator (NHA) on 4/16/26 at 3:52 p.m. The policy read in pertinent part, The facility has an established process to ensure food is served in accordance with professional standards for food service and in a safe, clean, homelike environment. Dining services will include foods served timely and appropriate assistance provided to meet the individual needs of the residents to create a pleasant experience. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.II. ObservationsOn 4/13/26 at 11:55 a.m. the residents were lined up in the dining room hallway to place their meal orders with an unidentified dietary aide (DA) standing by a desk. Two residents were standing in the hallway without an assistive device, three residents were standing with their walkers, and several residents were seated in wheelchairs. The line went down to the main hallway by the kitchen entrance door and blocked the hallway. At 11:58 a.m. Resident #33 turned around his four-wheel walker and sat on it while waiting in line.On 4/14/26 at 5:27 p.m. the residents lined up in the dining room hallway to place their diner orders with an unidentified DA. The line wrapped outside into the main hallway by the dining room.During a continuous observation on 4/15/26, beginning at 11:40 a.m and ending at 12:20 p.m., the following was observed:At 11:40 a.m. several residents were lined up to enter the dining room to place their meal order prior to sitting down at a table. At 11:50 a.m. there were seven residents waiting in line with the line wrapping outside into the main hallway by the dining room. Resident #33 who was third in line was swaying and shaking his head. Resident #33 then turned his four wheel walker around and sat down on the seat the walker had built in to wait for his turn to give the unidentified dietary aide his lunch order. On 4/16/26 at 11:53 a.m. the residents lined up in the dining room hallway to place their meal orders with a DA. The line wrapped outside into the main hallway by the dining room.III. Resident interviewResident #33 was interviewed on 4/13/26 at 1:53 p.m. Resident #33 said he ate lunch in the dining room and dinner in his room. He said placing meal orders took longer when he had to wait in line. Resident #33 said wait times varied depending on what time he arrived at the dining room. He said he did not like waiting in line.IV. Additional interviewA frequent visitor was interviewed on 4/13/26 at 8:30 a.m. The frequent visitor said she had concerns regarding residents lining up in the dining room to place their meal orders, because they were having to wait in long lines. V. Staff interviewsDA #1 was interviewed on 4/16/26 at 9:58 a.m. DA #1 said the dietary aides or certified nurse aides (CNAs) assisted the residents who ate meals in their rooms with filling out meal order tickets the night before. He said residents who ate meals in the dining room placed their meal orders upon arrival in the dining room. DA #1 said the residents lined up and a DA assisted them with placing meal orders. He said the facility had used this meal ordering process for almost a year. DA #1 said he was unsure about the choice of ordering meals in the dining room, but the facility planned to change the process the following month so residents could complete their meal order tickets the night before. He said the change would, in his view, ease the meal process for both residents and kitchen staff. DA #1 said residents had not complained about the process. The dietary manager (DM) was interviewed on 4/16/26 at 10:18 a.m. The DM said the CNAs assisted the residents who ate meals in their rooms with completing the meal orders the night before. He said the residents who ate meals in the dining room placed their meal orders when they arrived in the dining room. The DM said the facility implemented the process of residents lining up because in the past residents entered the dining room and sat randomly at tables. He said it was hard for the DAs to determine which residents arrived first or later for meal service. The DM said residents had complained about arriving at the dining room first but being served last. He said the facility had used the process of residents lining up to place meal orders in the dining room for almost two years. He said there had been no identified safety hazard concerns associated with the process and residents had not complained about it. The DM said the facility intended to continue the process because it had been effective.The NHA was interviewed on 4/16/26 at 11:56 a.m. The NHA said the facility had not seen the residents lining up as a problem. She said the residents had not complained about it. The NHA said it had been a proper process where residents could connect among them and were excited about it. She said the DM informed her the frequent visitor had raised concerns regarding the process. The NHA said as long as the residents believed the process was still good for them, the facility would continue to follow residents' preferences rather than the ombudsman's concerns. The NHA said she had not observed any negative consequences associated with residents lining up. The NHA returned at approximately 1:00 p.m. and clarified the frequent visitor had raised that concern to the DM one year ago.

Based on record review and interview, the facility failed to designate an interim infection preventionist (IP) that completed specialized training in infection prevention and control. Specifically, the full-time IP was on leave from the facility from 9/13/23 to 9/29/23 and 10/4/23 to 10/9/23. On 9/13/23 a resident tested positive for COVID-19, which led to a facility outbreak of COVID-19. From 9/13/23 to 10/2/23, twenty residents tested positive for COVID-19. The interim IP had not completed the education and training requirement prior to assuming the duties of the position. Findings include: I. Facility policy The Infection Prevention policy, dated 5/19/23, was received by the IP on 10/11/23 at 10:23 a.m. The policy documented in pertinent part, Our facility has an infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible. The facility has systems for the prevention, identification, reporting, investigation and control of infection and communicable diseases of residents, staff, and visitors. The system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. General procedures. Assign one or more individuals with training in infection control to provide on-site management of the infection control program. The individual designated will meet the qualification requirements outlined in F882. II. Record review On 10/11/23 the full-time IP provided documentation she completed specialized training for infection prevention on 3/19/23 and she was hired 2/23 as the facility ' s IP. -However, the IP was on 9/13/23 to 9/29/23 and 10/4/23 to 10/9/23 during the time there was a COVID-19 outbreak. The director of nursing (DON), who was interim infection preventionist, was unable to provide documentation she completed specialized training for infection prevention. Cross-reference F880 for failures with infection control. III. Interviews The IP and DON were interviewed together on 10/11/23 at 10:23 a.m. The IP said she received her IP certificate for completed training on 3/19/23 and was a registered nurse. She said she worked full-time in the facility except for the dates of her leave. The IP said requirements for IP included primary professional training in nursing, work at least part-time for the facility and have completed specialized training in infection prevention and control. The DON said when the full-time IP was on leave, she was assigned to work as the interim IP. The DON had completed some classes on infection prevention but had not met requirements to obtain an IP certificate.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases. Specifically, the facility failed to: -Ensure the facility had a way to test water for the growth of Legionella by using expired Legionella test kits; -Ensure staff properly disposed of personal protective equipment (PPE) when the facility had an outbreak of COVID-19; and, -Ensure staff properly maintained respiratory supplies by failing to change oxygen cannulas weekly for two residents when the facility had an outbreak of COVID-19. Cross-reference F882 infection preventionist qualifications Findings include: I. Facility policy The Infection Prevention and Control program and plan, dated [DATE], was received [DATE] by the infection preventionist (IP) and read in pertinent part, The facility has an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible. The facility has systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. General procedures. Assign one or more individuals with training in infection control to provide on-site management of the infection control program. The facility administration and infection preventionist should ensure that current infections control standards of practice are based on recognized guidelines and facility assessment. The facility has established/implemented a surveillance plan, based on a facility assessment, for identifying, tracking, monitoring, and/or reporting of infections, communicable disease and outbreaks. The program includes early detections, management of a potentially infections, symptomatic resident that requires laboratory testing and/or the implementation of appropriate personal protective equipment (PPE). Ensure staff follow the infection control plan standards, policies, and procedures (appropriate use of PPE). II. Water testing failure A. Manufacturer package insert information The manufacture website for Lovibond water testing kits was accessed on [DATE] at https://www.lovibond.com/usa-en/water-testing/support-service/download-center. The manufacture package insert read, test kits expired 18 months from the date of manufacture and all test kits were marked with a printed expiry date. B. Facility plan The Water Management Plan, dated [DATE], was received on [DATE] by the nursing home administrator (NHA). -The plan failed to include a schedule to test the facility water for Legionella. C. Record review On [DATE] the environmental services director (ESD) provided copies of Legionella testing he completed on [DATE], [DATE] and [DATE], which showed the facility water was negative for Legionella. -However, the test kits used were Lovibond rapid test for Legionella pneumonia and were marked with expiration date of [DATE]. C. Staff interviews The ESD was interviewed on [DATE] at 12:10 p.m. He said the Legionella test kits had expired on [DATE]. He said he was unaware he used an expired test kit and an expired test kit could lead to an inaccurate test result. The ESD was unable to locate an unexpired test kit on [DATE] to complete an immediate water test for Legionella. The NHA was interviewed on [DATE] at 12:25. He said he was unaware water testing was completed with expired test kits. He said testing for Legionella in the facility water supply was necessary so that the facility could intervene to prevent illness. D. Facility follow-up On [DATE] at 3:15 p.m., the ESD said he ordered new testing kits for Legionella and will complete testing when the kits were delivered. II. PPE disposal failure A. Professional reference The Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated [DATE], retrieved on [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#r2 read in pertinent part, HCP (health care provider) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. B. Observation On [DATE] at 11:45 a.m. a lunch tray for the resident in the room was placed on the top of the PPE set of drawers and the top drawer with clean PPE supplies was left opened. A used PPE gown was draped across the top of the set of drawers and had direct contact with the resident's lunch tray, items on the tray, the top surfaces of the drawers and the clean PPE items inside the opened top drawer. C. Staff interviews The director of nurses (DON) was interviewed on [DATE] at 11:49 a.m. She observed the used PPE gown draped across the clean surfaces and said the used PPE should be placed in a trash bin designated for used PPE and not placed on top of the clean PPE distribution area. Certified nurse aide (CNA) #3 was interviewed on [DATE] at 11:57 a.m. She said she had the PPE gown on and was prepared to enter the resident's room but was interrupted. She said she removed the gown and placed it on the PPE set of drawers. She said since she had not entered the resident's room, the gown was clean. The CNA said that she had worked on the hallway and had provided care for other residents and said her dirty clothing contaminated the PPE gown. The CNA said she had received education and training from the infectionist preventionist (IP) but had not seen the IP for several weeks. III. Respiratory equipment A. Facility policy The Oxygen Administration/Safety/Storage/Maintenance policy, dated [DATE], was received by the NHA on [DATE]. The policy read in pertinent part, Infection Control: change oxygen supplies weekly and when visibly soiled. Equipment should be dated when setup or changed out. B. Observation On [DATE] at 11:27 a.m., the nasal cannula oxygen tubing for two residents (#40 and # 8) was observed labeled [DATE]. Both oxygen concentrators had a plastic zip lock bag taped to the concentrator to hold the cannula when not in use. Each bag was labeled [DATE]. C. Staff interviews CNA #2 was interviewed on [DATE] at 11:39 a.m. He said the facility policy was for the CNA to change oxygen cannulas and tubing every Sunday. He said a new oxygen tubing should be labeled with the date the equipment was provided to the resident. The CNA said the date was used to verify equipment was changed. The NHA was interviewed on [DATE] at 12:35 p.m. He said CNAs were assigned the task to change the oxygen tubing and equipment weekly and he was unaware the oxygen cannulas had not been replaced weekly as required. He said the staff member that attached the new zip lock plastic bag to the oxygen concentrator failed to provide the resident with a clean oxygen cannula and tubing. The NHA acknowledged using old respiratory tubing could contribute to respiratory illness. D. Facility follow-up On [DATE] at 3:22 p.m., the DON said Resident #40 and #8 were provided clean oxygen supplies.

Based on observations, record review and interviews, the facility failed to store, prepare and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure potentially hazardous foods were monitored, held and cooled at appropriate temperatures; and, -Ensure dish room sanitation was maintained and dish room walls were a smooth cleanable surface. Findings include: I. Potentially hazardous foods monitored, held and cooled at appropriate temperatures A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 10/16/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, The person in charge shall ensure that: Employees are properly maintaining the temperatures of time and temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures; employees are using proper methods to rapidly cool time/temperature control for safety foods that are not held hot or are not for consumption within four hours, through daily oversight of the employees' routine monitoring of food temperatures during cooling. Cooked time and temperature control for safety food shall be cooled within two hours from 135 degrees fahrenheit to 70 degrees fahrenheit and within a total of six hours from 135 degrees fahrenheit to 41 degrees fahrenheit or less. Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 135 degrees fahrenheit or above, or at 41 degrees fahrenheit or less. Time and temperature control for safety food includes cut leafy greens. B. Facility policy and procedure The Keeping Hot Food Hot and Cold Food Cold inservice, undated, was provided by the nursing home administrator (NHA) on 10/12/23 at 10:28 a.m. It revealed in pertinent part, Not only is it important for us to keep food safe during delivery, storage and preparation but we must also ensure that standard practices are followed during the holding of hot and cold food items. Bacteria grow at a much higher rate at room temperature. Therefore, we should keep hot food hot and cold food cold. Ensure that cold items placed in the dining rooms but not immediately served to the residents are held at 40 degrees fahrenheit or lower. C. Observations and record review On 10/11/23 at 11:02 a.m. the following items were observed in the walk-in refrigerator: -A full size two inch deep steam table pan on the bottom shelf of the walk in refrigerator. The pan was covered with aluminum foil and written on the foil in black marker was pot roast for lunch 10/10/23. -A six inch deep third size steam table pan with cooked sausage patties in liquid and covered with clear plastic wrap. The date 10/11/23 was written with black marker on the plastic wrap covering the pan. -A six inch deep sixth size steam table pan was observed with cooked, ground sausage and covered with clear plastic wrap. The date 10/11/23 was written with black marker on the plastic wrap covering the pan. On 10/11/23 at the following observations were made during lunch service in the dining room: -At 11:44 a.m. three full size baking sheet pans containing individually sliced and plated lemon meringue pies were on a baking rack in the dining room. Throughout service, the individually sliced pie pieces were held at room temperature and served to residents in the dining room or covered with foil and placed on resident room trays to be delivered. -At 11:45 a.m. battered fish was placed in the hot food holding steam table. Cook (CK) #1 took the internal temperature of the battered fish and the temperature was 162 degrees fahrenheit. -At 12:35 p.m. CK #1 lifted the top lid on half size deli refrigerator, reached into the pan of sliced lettuce and placed the sliced lettuce on a hamburger. The hamburger was then served to a resident. -At 12:38 p.m. a full size baking sheet pan of individually sliced and plated lemon meringue pies was still on the baking rack in the dining room. Room tray carts for two resident halls remained in the dining room with a total of 13 room trays not yet assembled including dessert. -At 12:46 p.m. eight pieces of battered fish were still in the hot holding steam table. A digital food thermometer was inserted into two different pieces of the battered fish and the internal temperature of the fish was 124 and 127 degrees fahrenheit. CK #1 said she would put a lid on top of the battered fish, and placed a metal lid over the pan that contained the battered fish. CK #1 then continued to serve resident meals. -At 12:57 p.m. a slice of lemon meringue pie was removed from the baking rack. A digital food thermometer was inserted into the piece of lemon meringue pie and the temperature was 50.6 degrees fahrenheit. The pie was placed on a test tray, and at 1:07 p.m. the temperature of the same piece of pie was 54 degrees fahrenheit. On 10/11/23 at 2:29 p.m. the box of lemon meringue pie revealed the lemon meringue pie was made with egg white, a time and temperature controlled for safety ingredient. The label on the lemon meringue pie container revealed the pie was to be stored frozen, served chilled, and not held at room temperature. -The lemon meringue pie served at lunch on 10/11/23 was held at room temperature for the duration of lunch service, the temperature of the pie was not monitored during service and the pie served reached a temperature above 40 degrees fahrenheit. -The temperature of the cut lettuce served at lunch was not monitored before or after lunch service. The temperature of the fish dropped below 135 degrees fahrenheit, the temperature of the fish was not monitored or held at the appropriate hot temperature. D. Record review Food temperature logs dated 8/28/23 to 10/12/23 were reviewed on 10/12/23. The food temperature log documented, Cold foods should be at 40 degrees fahrenheit or below and hot foods should be at 140 to 170 degrees fahrenheit. Temperatures are recorded before food is served. If food temperatures are not within these ranges, corrective action must be taken before food is served to residents. Record the temperature of all hot and cold foods. -Food temperature cooling logs were requested but were not provided. Cooling temperature logs were not used to monitor and record cooling temperatures and times for the roast beef, sausage patties and ground sausage in the walk in refrigerator. -The initial temperature of the lemon meringue pie and sliced lettuce served on 10/11/23 was not recorded on the temperature log. The temperature log did not have a column for recording temperatures of food at the end of the meal to verify foods were held correctly. E. Staff interviews CK #1 was interviewed on 10/11/23 at 12:05 p.m. CK #1 said she had not taken the temperature of the lemon meringue pie. She said the dietary staff removed the cold food out of the walk in refrigerator and took the temperature of foods served at the end of meal service but did not write the temperatures down. CK #1 was interviewed on 10/11/23 at 1:00 p.m. CK #1 said if the hot holding temperatures were too cold on food held in the steam table she would ask for more food to be cooked in the kitchen and brought to her. She would then serve the hot food instead of the food that was below the correct temperature. CK #1 said she did not know the temperature of the sliced lettuce had to be monitored. CK #1 and CK #2 were interviewed on 10/11/12 at 2:20 p.m. CK #1 and CK #2 said to cool the cooked food, the food was set on the table in the kitchen while other tasks were completed. CK #1 and CK #2 said the time and temperature of the leftover cooked foods was not monitored or recorded on a log before putting the leftover food in the walk in refrigerator. CK #1 and CK #2 said they did not know the temperatures of potentially hazardous cooked foods had to be monitored. CK #1 said she used the leftover sausage from breakfast to make ground sausage for the next breakfast meal for residents on mechanical soft diets. The nutrition services manager (NSD) was interviewed on 10/12/23 at 10:00 a.m. The NSD said the dietary staff have to monitor food holding temperatures. He said staff made him aware if food in the steam table was not at the correct holding temperature during meal service and the dietary staff made new food quickly. The NSD said he did not think the dietary staff took a beginning and end food temperature at every meal and he did not think the staff knew monitoring holding temperatures was required. The NSD said the dietary department did not reuse and reheat a lot of food leftover food. -However, the facility did have leftovers (see observations above). II. Dish room cleanliness and maintenance A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 10/16/23 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, toilet rooms, mobile food establishment servicing areas, and areas subject to flushing or spray cleaning methods. Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Walls and ceilings that are of smooth construction, nonabsorbent, and in good repair can be easily and effectively cleaned. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude (prevent) accumulation of soil residues. B. Observations On 10/9/23 at 9:25 a.m. the dish room was observed. Multiple dried food spots and debris were on the wall tile under the dish machine table. Dried food splatters were on the ledge of the dish machine table. The corner of the floor in the dish room had sticky black build up. The dish room entrance and walls inside the dish room consisted of ceramic tile, with multiple tiles missing from the wall inside the dish room and at the entrance to the dish room. Four coving (curved tile at the wall and floor juncture) tiles were missing under the dish machine table. A piece of fiberglass reinforced polymer wall section was placed in front of a section of wall tile under the dish machine. The fiberglass reinforced polymer wall section was not flush with the tile, but covered some of the tiles and the bottom and side edges of the fiberglass reinforced polymer wall section were not sealed. On 10/11/23 at 11:11 a.m. the dish room was observed. Multiple dried food spots and debris were on the wall tile under the dish machine table. Dried food splatters were on the ledge of the dish machine table. The corner of the floor in the dish room had sticky black build up. Four tiles were missing from the wall inside the dish room next to the dish machine leaving the wall underneath exposed that was porous with small holes. Eight tiles were missing from the wall to the dish room entrance leaving the material behind the tiles exposed with what appeared to be dried glue or adhesive. Four coving (curved tile at the wall and floor juncture) tiles were missing under the dish machine table. One piece of coving tile was leaning against another coving tile instead of being sealed to the wall. A piece of fiberglass reinforced polymer wall section was placed in front of a section of wall tile under the dish machine. The fiberglass reinforced polymer wall section was not flush with the tile, but covered some of the tiles and the bottom and side edges of the fiberglass reinforced polymer wall section were not sealed. The bottom of the fiberglass reinforced polymer wall section was in front of the coving tile instead of flush with the top edge the coving tile and sealed. C. Record review The Daily Nutrition Services Cleaning Schedule was provided by the NSD on 10/12/23 at 10:30 a.m. The cleaning scheduled included to wipe down dish room counters but did not include to wipe down the dish room walls. D. Staff interviews The registered dietitian (RD) was interviewed on 10/11/23 at 11:15 a.m. She said the dish room was going to be remodeled. The environmental services director (ES) was interviewed on 10/11/23 at 1:15 p.m. The ES said he had reached out locally to get some vendors to fix the dish room tile and floor and possibly fix the grout in the dish room floor but had difficulty getting a return call from the vendors. He said he did not have any quotes yet for the items that needed repair in the dish room. The NSD was interviewed on 10/12/23 at 10:00 a.m. He said the corporate vice president (CVP) called a vendor who was scheduled to come the following week to the facility and fix the tiles in the dish room. The NSD said the cleaning task for the dish room was on the evening dishwashing position task sheet and/or the staff working the position knew what they should be doing. The NSD said he was unsure why the dish room cleaning was not being completed.

Based on record review and staff interviews, the facility failed to ensure four (#44, #103, #203 and #47) of seven out of 28 sample residents were provided services that meet professional standards of quality. Specifically, the facility failed to: -Clarify physician's orders and obtain dose information prior to administration of topical skin medication for Residents #44, #103 and #203; -Hold Digoxin (to treat heart failure) when Resident #47's heart rate was below 60; and, -Ensure consents and black box warnings were in place for the use of antidepressants before administration for Resident #47. Findings include: I. Topical skin medication orders A. Professional reference The Voltaren (Diclofenac) gel drug information was accessed on 10/11/23 on the Physicians Drug Reference website at https://www.pdr.net/drug-summary/Voltaren-XR-diclofenac-sodium-2033. Diclofenac is a nonsteroidal anti-inflammatory (NSAID) medication that could be prescribed in intravenous, oral, topical, and ophthalmic formulations. The use of analgesic and antipyretic properties increases the risk of serious gastro-intestinal events and may increase serious cardiovascular events; use the lowest dose of the shortest time. The topical dosage of diclofenac gel is prescribed as four grams (four and one half inches) topically four times a daily, with a maximum of 16 grams a day per lower extremity joint) and/or two grams (two and one fourth inches) topically four times daily per upper extremity joint. Do not exceed a total dose of 32 grams over all affected joints. B. Facility policy The Medication Administration policy, dated 8/24/23, was received by the nursing home administrator (NHA) on 10/16/23. The policy stated in pertinent part: Staff who are responsible for medication administration will adhere to the Rights of Medication Administration; Right dose. Check the medication administration record and the doctor's order before medication. Use standard measuring devices such as syringes, graduated cups, or scaled droppers. If there is any doubt about the dose on the medication administration, required considerations including the purpose, diagnosis or indication for use is required for administration of medication. A physician order that includes dosage, route, frequency, duration, and other record or if there is a question on the drug, stop and verify all information before administering. C. Record review Resident #44 had a physician order Voltaren gel one percent. The order directed the medication to be applied every 12 hours as needed for pain and failed to include a dose. The resident received the medication on 10/9/23 and 10/10/23. Resident #103 had a physician order for Diclofenac gel one percent. The order directed the medication to be applied every eight hours as needed for pain and failed to include a dose. The resident received the medication on 10/1/23, 10/2/23 and 10/3/23. Resident #203 had a physician order for Voltaren gel one percent. The order directed the medication to be applied every 12 hours as needed for pain and failed to include a dose. The resident received the medication on 10/10/23. D. Interviews Registered nurse (RN) #1 was interviewed on 10/11/23 at 3:03 p.m. She said she was aware Voltaren gel was a medication that required a measured dose. She said if a medication order was missing a dose the nurse should contact the physician to clarify the order. The RN said Voltaren gel was received packaged from the manufacturer with a dose guide for accurate measurement. The director of nursing (DON) was interviewed on 10/11/23 at 3:20 p.m. She said every medication order was expected to include a dose as prescribed by the physician. The DON said if a medication dose was missing the nurse was to contact the physician and clarify the medication order prior to medication administration. The DON said was she was unaware the three medication orders for Resident #44, #103 and #203 were missing dose information. E. Facility follow-up On 10/11/23 at 3:55 p.m., the DON completed a record audit of physician's orders for Voltaren gel. She clarified physician's orders and obtained dose information for Volaren gel for Residents #44, #103 and #203. 40960 II. Resident #47 A. Resident status Resident #47, age above 65, was admitted on [DATE]. According to the October 2023 CPO, the diagnoses included chronic atrial fibrillation and anxiety disorders. The 7/12/23 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She had no behaviors and did not reject care. All her activities of daily living only occurred once or twice. She used oxygen and received antidepressants daily. B. Record review The October 2023 CPO documented Resident #47 was ordered: -Lexapro (antidepressant) 15 mg (milligrams) by mouth one time a day for depression; -Cymbalta (antidepressant) 60 mg by mouth at bedtime for depression: and -Digoxin 125 mcg (micrograms) one time a day on Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday. The digoxin was administered on 9/23/23. Her heart rate was 58. The digoxin was administered a second time on 9/27/23. Her heart rate was 57. There were no consents and black box warnings for the two antidepressants administered daily. Care Plans The antidepressant medication care plan, initiated 7/15/23. It documented the resident used the antidepressant medication for depression. The interventions included educating resident/family/caregivers about risks, benefits and the side effects and /or toxic symptoms. There was no care plan in place related to the use of digoxin. C. Staff interviews Registered nurse (RN) #1 was interviewed on 10/12/23 at 10:08 a.m. She said consents should be signed for antidepressants before administration of the medication. She said the consent consisted of potential side effects and special attention for a resident with heart disease. She said it was important for the consents to be signed so the resident/family would be aware of the risks of taking the medication. She said Digoxin should never be given if the resident's heart rate was below 60. She said it could cause low heart rate and Digoxin toxicity. The director of nursing (DON) was interviewed on 10/12/23 at 2:06 p.m. She said consents should be signed before administering an antidepressant. She said the resident/family should be aware of possible side effects and adverse reactions. She said Digoxin should not be given if a resident's heart rate was below 60. She said parameters should have been put into place to always check the resident's heart rate before administering Digoxin. She said if the heart rate was below 60 and the resident was given the medication, it could drop the heart rate even lower and cause an adverse event. The regional director of clinical services (RDCS) was interviewed on 10/12/23 at 3:59 p.m. She said the social worker was not aware that she was responsible for getting consents signed. She said the facility had completed an audit to make sure all consents for psychotropic medications were in place.

Based on observations, record review and interviews, the facility failed to ensure two (#17 and #47) of 10 residents who required respiratory care received the care consistent with professional standards of practice out of 28 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place for the use of oxygen for Resident #17; and, -Ensure Resident #17 and Resident #47 received oxygen therapy as ordered. Findings include: I. Facility policy The Oxygen Administration policy, last revised 8/2/21, was provided by the nursing home administrator (NHA) on 10/11/23 at 2:31 p.m. It read in pertinent part: Oxygen will be administered in accordance with physician orders and current standards of practice. All facility staff will be educated on oxygen administration, safety, and storage upon hire, annually, and as indicated thereafter. Oxygen administration helps relieve hypoxemia (low oxygen levels)and maintains adequate oxygenation of tissues and vital organs. Verify the practitioner's order for oxygen therapy because oxygen is considered a medication or therapy and requires a prescription. II. Resident #17 A. Resident status Resident #17, age above 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), chronic atrial fibrillation (irregular heart beat), congestive heart failure, essential hypertension (high blood pressure) and dependence on supplemental oxygen. The 7/14/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 11 out of 15. He had no behaviors and did not reject. He required limited assistance with bed mobility, dressing, toilet use, and personal hygiene. Supervision with transfer and eating. He used oxygen. B. Observations Resident #17 was observed on 10/9/23 at 11:21 a.m. laying in bed wearing an oxygen nasal cannula. The oxygen concentrator flow rate was set at 3.5LPM (liters per minute). Resident #17 was observed on 10/10/23 at 9:34 a.m. asleep in his wheelchair at the end of the hall. The portable oxygen flow rate was set at 4 LPM. Resident #17 was observed on 10/11/23 at 2:02 p.m. sleeping in bed. The oxygen concentrator flow rate was set at 3.5 LPM. Resident #17 was observed on 10/12/23 at 8:56 a.m. in the dining room eating breakfast.The portable oxygen flow rate was set at 4 LPM. C. Record review The resident's CPO was reviewed on 10/9/23 at 11:21 a.m. and revealed the resident did not have a physician's order for oxygen therapy. -A physician's order was obtained for the oxygen on 10/9/23 at 5:15 p.m. The order was for oxygen at 3 LPM continuously via nasal cannula. The Emphysema/COPD care plan initiated on 7/15/23 included oxygen as ordered. -The care plan failed to include the amount of oxygen to administer and the route (nasal cannula/mask. III. Resident #47 A. Resident status Resident #47, age above 65, was admitted on [DATE]. According to the October 2023 CPO, the diagnoses included COPD, tobacco use, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. The 7/12/23 MDS assessment revealed, the resident was cognitively intact with a BIMS of 15 out of 15. She had no behaviors and did not reject care. All her activities of daily living only occurred once or twice. She used oxygen. B. Observations Resident #47 was observed on 10/9/23 at 9:35 a.m. laying in bed wearing an oxygen nasal cannula. The oxygen concentrator flow rate was set at 3.5 LPM. Resident #47 was observed on 10/10/23 at 9:29 a.m. sleeping in bed. The oxygen concentrator flow rate was set at 3.5 LPM. Resident #47 was observed on 10/12/23 at 8:55 a.m. sleeping in bed. The oxygen concentrator flow rate was set at 3.5 LPM. C. Record review A physician's order dated 8/29/23 revealed the resident was ordered oxygen at 2 LPM continuously per nasal cannula. The Emphysema/COPD care plan was initiated on 7/15/23. The interventions included oxygen as ordered. -The care plan failed to include the amount of oxygen to administer and the route (nasal cannual/mask). D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 10/12/23 at 10:01 a.m. The CNA said the nurses let the CNAs know how many liters of oxygen a resident was on. Registered nurse (RN) #1 was interviewed on 10/12/23 at 10:08 a.m. She said the nurse received oxygen orders from the physician to include the amount of oxygen to administer and the route. She said a physicians order should have been in place before Resident #17 was placed on oxygen on 7/15/23. She said the resident should have been at 4 LPM at all times. She said she was not sure why he was at 3.5 LPM. -However, the resident's oxygen order required 3LPM (see order above). She said Resident #47's oxygen should have been set at 2 LPM. She said she was not sure why it was set at 3.5LPM. She said too much oxygen was not good for residents with COPD since it could lead to oxygen toxicity very quickly. The director of nursing (DON) was interviewed on 10/12/23 at 2:06 p.m. She said a physician's order should be in place before administering oxygen to a resident since it was considered a medication. She said the nurse should have followed the physician's orders for the amount of oxygen to be administered. She said a resident with COPD could have negative effects on the brain and respiratory distress if given too much oxygen.

Based on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#105) out of 10 residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to ensure Resident #105 was assessed by a registered nurse (RN) after a fall. Findings include: I. Resident status Resident #105, age above 65, was admitted on [DATE] and discharged [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included vascular dementia, weakness, unsteadiness on feet, difficulty in walking, non-traumatic acute subdural hemorrhage (brain bleed), lack of coordination and muscle weakness. The 4/14/23 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of one out of 15. He had physical and verbal behavioral symptoms directed towards others as well as other behavioral symptoms not directed at others, which put the resident at significant risk for physical illness or injury. He wandered daily. He had a worsening in his behavior. He required extensive assistance with bed mobility, transfers and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. He used a wheelchair. The resident had two or more falls since admission with injury and one with major injury. II. Record review The fall care plan, initiated 11/23/22 and revised 5/1/23, documented the resident was at risk for falls related to a history of falls and dementia. The goal was for the resident not to sustain serious injury requiring hospitalization . According to a progress note dated 3/9/23 at 1:30 p.m. the housekeeping staff witnessed Resident #105 fall in his room and get himself up off of the floor. The note was written by a licensed practical nurse (LPN). According to a progress note dated 3/16/23 at 12:47 p.m. Resident #105 was found on the floor by ancillary staff near his bed. The resident's head and neck areas were intact. His grip strength was equal to both sides and his range of motion was within normal limits. The note was written by a LPN. According to a progress note dated 3/25/23 at 11:34 a.m. a certified nurse aide (CNA) witnessed Resident #105 fall in his room next to his bed. The resident's head and neck areas were assessed and intact. His grip strength was equal to both sides and his range of motion was within normal limits. The note was written by a LPN. According to a progress note dated 4/7/23 at 1:11 p.m. Resident #105's roommate witnessed him fall out of bed while trying to ambulate on his own. The note was written by a LPN. -The note did not include an assessment for injuries. According to a progress note dated 4/16/23 at 12:24 a.m. the nurse was called to Resident #105's room and found him lying on the right side of the floor in the doorway to his room. The resident was noted to have a skin tear to his right forehead above his eyebrow, skin tear to his right hand second knuckle, and a skin tear to his right elbow. Neurological checks were initiated and upper and lower extremity strength were equal. The note was written by a LPN. According to a progress note dated 4/17/23 at 9:15 p.m. Resident #105 passed out and fell out of his wheelchair onto the lobby floor. Blood was noted in his catheter and vomit coming from his mouth. He had a skin tear to his left elbow. The note was written by a LPN. -A full review of the residents medical record was conducted on 10/11/23. The medical record did not reveal documentation of the resident being assessed by a RN after each of the above falls. III. Staff Interviews Certified nurse aide (CNA) #1 was interviewed on 10/12/23 at 10:01 a.m. She said if a resident had a fall, the CNA would report it to the nurse and start neurological checks on the resident. She said Resident #105 had many falls and was impulsive. RN #1 was interviewed on 10/12/23 at 10:08 a.m. She said an RN should assess a resident, no later than two hours, after a fall. She said after each fall, a resident should have interventions in place to prevent further falls. She said Resident #105 had many falls and interventions were put into place after every fall. She said she was not sure why an RN did not assess him for injury after each fall. The director of nursing (DON) was interviewed on 10/12/23 at 2:06 p.m. She said licensed practical nurses could not assess residents after a fall, because it was not in their scope of practice. She said a RN was required to assess a resident for injuries after a fall.

Based on observations, record review and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and the spread of foodborne illness, in one of one kitchens Specifically the facility failed: -To ensure the food was stored and labeled properly, and to discard leftover food after the use by date; -To ensure jewelry was not worn during food serving; -To ensure appropriate hand hygiene by food service staff; and, -To ensure the dishwasher maintained sufficient levels of sanitizing solution. Findings include: I. Labeling food A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) 3-701, 4 a-d. pg. 104, 4 a-d. It read in part, A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Using calendar dates, days of the week, color coded marks or other effective marking methods. B. Observations and interviews On 10/17/22 at 8:44 a.m. during the initial tour of the kitchen items stored in the walk-in refrigerator that were not labeled included: one metal container of sweet potatoes, one metal container of chili, and one metal container containing something brown in color. On 10/17/22, items stored in the walk in refrigerator that were dated 10/14/22 included: one metal container of green chili, metal container of mashed potatoes, and a metal container of green beans. On 10/18/22 at 7:41 a.m. items stored in the walk-in refrigerator that were not labeled included: one metal container of sweet potatoes, one metal container of chili, and one metal container containing something brown in color. On 10/18/22, items stored in the walk in refrigerator that were dated 10/14/22 included: one metal container of green chili, metal container of mashed potatoes, and a metal container of green beans. On 10/19/22 at 11:00 a.m., items stored in the walk in refrigerator that were dated 10/14/22 included: one metal container of green chili, metal container of mashed potatoes, and a metal container of green beans. On 10/19/22, items stored in the walk in refrigerator that were dated 10/14/22 included: one metal container of green chili, metal container of mashed potatoes, and a metal container of green beans. Dietary staff (DS) #3 said the staff knew what the items were by looking at it and she did not think they needed to be labeled because they were served daily. She said the food in the walk in refrigerator should have been dated. C. Record review The use by dates-refrigerator items checklist read in pertinent part, All foods must be dated/labeled when opened. You must toss any items past their use by date. All items opened should be sealed in a secured container with lid or in a zip lock bag. Leftover prepared food has a 3 day shelf life. D. Staff interview The dietary manager (DM) was interviewed on 10/19/22 at 11:43 a.m. She said all food should have been labeled to include the item and date. She said by doing so, it identified the product, so staff knew what they were grabbing and it was the correct product. She said it was important to date the items so the staff knew when to discard them. She said the proper time frame was no more than three days on leftovers. She said the potential risk of not labeling was serving an incorrect food item and serving food past three days from the day the item was prepared, opened or pulled out of the freezer to thaw. II. Jewelry A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) 2-303-11, pg. 50, read in part, Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. B. Observation On 10/17/22 at 12:02 p.m. dietary aide (DA) #1 was observed serving the residents meals. DA #1 had several pieces of gold jewelry on her wrists as well as four rings on her fingers. DA #1 was observed touching the jewelry on her wrist while serving residents ' meals. C. Staff interview The dietary manager (DM) was interviewed on 10/19/22 at 11:43 a.m. She said she was not aware of staff not being able to wear jewelry while performing food service tasks. She said she would have staff members remove jewelry prior to food services. III. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.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. The Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46, details for appropriate hand cleaning procedure included: 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 Observation of meal service was conducted on 10/17/22 at 12:02 p.m. Observations in the primary dining room included: DA #1 was observed preparing resident meals. She was observed grabbing the resident order slip with her ungloved hand. She placed the meal slip on the tray and touched the side of her hair placing the pieces of hair behind her ear. DA #1 was observed touching her hair several times and touching her hat. DA #1 continued to plate the residents ' meals. DA #1 was observed reaching into the cabinet above the sink and removing a glass of liquid and drank from it. She replaced the glass in the cabinet and returned to serving meals. DA #1 was observed serving meals and handing the plated meals to the serving staff. DA #1 was observed placing her fingers into her mouth and resumed serving the resident's meals. DA #1 was observed wiping her hands on the side of her pants. DA #1 proceeded to prepare the lunch meal. DA #1 did not wash his hands or change gloves during this process. Observation of meal service was conducted on 10/18/22 at 12:05 p.m. Observations in the primary dining room included: DA #2 was observed entering the dining room. She did not wash her hands. DA #1 was observed preparing a plate of meatball sandwiches. DA #2 was observed opening the bun with her bare hand and proceeded to plate the meal. DA#2 was observed touching the bun with her hands two more times. DA #2 was observed taking the temperatures of the meals. DA #2 proceeded to grab a food thermometer with her bare hand. She placed the end of the thermometer into the food and took the temperature. She placed the thermometer on the counter and grabbed a sanitized wipe and proceeded to wipe the end of the thermometer. She wiped her hand on the side of his pants. She checked the temperature of another food item with the food thermometer. She grabbed another sanitizing wipe and wiped the end of the thermometer. DA #2 repeated the same process on the second food item. DA #2 did not sanitize or wash her hands during this process. C. Staff Interview The dietary manager (DM) was interviewed on 10/19/22 at 11:43 a.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. Staff washed their hands when they were completing a different task. The DM said it was her expectation all dietary staff would have been washing their hands between tasks to avoid cross contamination. IV. Chemical Sanitization A. Professional Reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 132-137, read in part, Cleaning and sanitizing may be done by spray-type, immersion ware washing, or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils. Chemical sanitizing ware washing machines (single-tank, stationary-tank, door-type machines and spray-type glass washers) may be used provided that: 1) The temperature of the wash water shall not be less than 120 F (49 C); 2) The wash water shall be kept clean; and 3) Chemicals added for sanitization purposes shall be automatically dispensed; and 4) Utensils and equipment shall be exposed to the final chemical sanitizing rinse in accordance with the manufacturer's specifications for time and concentration; and 5) The chemical sanitizing rinse water temperature shall not be less than 75 F (24 C) nor less than the temperature specified by the machine's manufacturer. B. Observation and interviews On 10/19/22 at 3:30 p.m., DA #3 started to wash the dishes from the afternoon meal. She said the water temperature of the dishwasher was supposed to be above 120 degrees Fahrenheit (F). DA #3 said the chemical solution was tested three times a day and the results were written daily. DA #3 said it was supposed to be between 50 and 100 parts per million (PPM). DA #3 took a reading of the sanitation level of the dishwasher. DA #3 ran a wash cycle, took a test strip from the container, and placed the strip into the dishwasher machine. DA #3 read the strip and it was zero. DA #3 then repeated the process three more times with the same result of zero PPM. DA#3 checked all of the sanitizing solutions and found the large container of sanitizing solution was empty. She removed the empty container and replaced it with a full container. She then ran another load of dishes with the same result of zero PPM. At 3:40 p.m. the DM told DA #3 that she had to prime the dishwasher after replacing the sanitizer. The DM had DA #3 ran another load of dishes and had her test sanitation level. It read zero PPM. The DM had DA #3 ran another cycle and had her prime the system again. The DA #3 continued to prime the sanitizing solution and ran two more loads with the level being zero. She again primed the dishwasher and then ran another load which showed a level of over 100 PPM. The DM stated all dishes would be washed again, which staff proceeded to do immediately. The DM was interviewed on 10/19/22 at 3:50 p.m. The DM said the dishwasher was checked three times a day for water temperature and sanitization levels. She said it was her expectation that the water temperature would be over 120 degrees F and the sanitizing solution (chlorine) would be at 50-100 PPM. She said the importance of proper sanitization was to keep from spreading food borne illness and protect the residents. She said sanitization was the first line of defense.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 12 of 22 resident rooms, three of three hallways. Specifically, the facility: -Failed to ensure walls, floors, and walls were repaired, painted and properly maintained and resident rooms were clean; and, -Failed to ensure oxygen concentrators were plugged into electrical outlets instead of a power strip. Findings include: I. Ensure walls, floors, and walls were repaired, painted and properly maintained and resident rooms were cleaned A. Initial observations Observations of the resident living environment conducted on 10/19/22 at 9:33 a.m. revealed: Room D-14: The floor underneath the resident's bed was dirty with trash and papers. The floor in the restroom had dried urine stains and dark stains around the base of the commode. Room D-11: The wall in the restroom had four pea size holes from the grab bar being removed and not replaced. The wall in the closet had a section approximately 12 inches and five inches wide, which had peeling and chipped paint. The floors were dirty with trash and papers. Room D-9: The wall next to the sink had damaged sheetrock approximately seven inches high by four inches wide. The floors were dirty with trash and papers. The commode had feces and tissue on the toilet riser. Room D-10: The floors were dirty with trash and papers throughout the room. Room D-7: The floors were dirty with trash and papers. There were dirty clothes and other personal belongings underneath the resident's bed. Room D-3: The floors were dirty with trash and papers. The bathroom floor had urine stains. Room C-1: The bathroom floor was dirty with urine stains and tissue. Room C-6: The wall in the bathroom had chipped and peeling sheetrock approximately eight inches by eight inches. The carpet had trash and paper throughout the room. Room C-5: The carpet next to the sink had a large area which had a water stain approximately 24 inches wide by 24 inches wide. The wall next to the sink had peeling and chipped sheetrock approximately 12 inches high by four inches wide. The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. Room C-8: The wall next to the resident's bed had peeling and fading paint. The toilet had feces on the seat riser. The toilet had a water leak with standing water. Room A-1. The wall next to the sink had peeling and chipped sheetrock approximately 10 inches high by four inches wide. The wall in the restroom had damaged sheetrock from the wheelchair hitting the wall approximately three feet high by four feet wide. The bed side table had the laminate trim missing approximately two inches wide by 24 inches long. Room A-6: The floors were dirty with trash, papers and clutter. B. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) and housekeeping supervisor (HSK) on 10/20/2022 at 10:30 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The HSK said she has been short staffed and she was working on her own trying to keep all rooms clean but it had been difficult. The MS said he did not have any repair requisition requests for the above-mentioned items from staff. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner. II. Ensure oxygen concentrators were plugged into electrical outlets instead of a power strip. A. Observation On 10/19/22 at 9:33 a.m., Room C-6, C-9, A-5, A-1, and A-6 had the residents' oxygen concentrators plugged into a regular power strip. It was not a medical grade power surge. On 10/20/22 at approximately 10:00 a.m., all oxygen concentrators continued to be plugged into the non-medical power surge. B. Staff interview The maintenance supervisor (MS) was interviewed on 10/20/22 at 10:30 a.m. The MS said all staff know that all oxygen concentrators should be plugged into the wall outlets. He said it was to ensure the environment was safe. -At 11:00 a.m. the MS stated all oxygen concentrators had been plugged into the wall and staff were educated again on oxygen concentrators and outlet placement.

Based on record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to the facility and/or residents. Specifically, the facility failed to have a process for tracking and securely documenting the COVID-19 vaccination status of all staff and agency staff. Findings include: I. Facility policy and procedure The COVID-19 Vaccination Program for Associates policy and procedure, revised 9/6/22, was provided by the nursing home administrator (NHA) via email on 10/19/22 at 10:16 a.m. It read in pertinent part: The facility will ensure that individuals who provided any care, treatment or other services for the facility and/or its residents will be fully vaccinated against COVID-19, unless otherwise exempted by a medical or religious exemption. This included individuals under contract with the facility. The facility should track the following for elements related to associate vaccinations: -each staff member's vaccination status (this should include the specific vaccine received, and the dates of each dose received, or the date of the next scheduled dose for a multi-dose vaccine); -any staff member who has obtained any boosters (this should include the specific vaccine booster received and the date of the administration of the booster); -any staff who have been granted an exemption from vaccination (this should include the type of exemption and supporting documentation); -staff for whom COVID-19 vaccination must be temporarily delayed. For temporary delays, facilities should track when the identified staff can safely resume their vaccination. Additionally, facilities' tracking mechanisms should clearly identify each staff's role, assigned work area, and how they interact with residents. This includes staff who are contracted, volunteers, or students. The facility should ensure those staff who are not yet fully vaccinated, or who have a pending or been granted an exemption, or who have a temporary delay as recommended by the CDC (Centers for Disease Control), adhere to additional precautions that are intended to mitigate the spread of COVID-19. There are a variety of actions or job modifications a facility can implement to potentially reduce the risk of COVID-19 transmission. II. Record review The vaccination matrix, provided by the NHA on 10/19/22 at 9:35 a.m., documented a list of facility staff members. It indicated each staff member's vaccination status, including if any exemptions had been approved. It included 50 skilled staff in the nursing, laundry, housekeeping, dietary, therapy, activities, and administration departments. -The vaccination matrix did not include all providers, such as six agency staff, hospice staff, medical director, housekeeping, two dietary staff, speech therapist, eight facility certified nurse aides (CNA), one facility registered nurse (RN), and one facility licensed practical nurse (LPN). III. Staff interviews The interim director of nursing (IDON) was interviewed on 10/19/22 at 2:03 p.m. He said he had only been the IDON since September 2022 and did not know who was responsible for tracking staff COVID-19 vaccinations. The clinical consultant (CC) was interviewed on 10/19/22 at 2:34 p.m. She said the payroll department entered the new staff into the computer with their vaccination status and she checked them daily Monday through Friday. She said the matrix should include physicians, nurse practitioners, agency and hospice staff. She said the infection preventionist (IP) was responsible for tracking new staff vaccination status' and she reviewed the matrix daily. She said the NHA or DON were responsible for updating it. She said she did not know why so many staff members were not on the matrix but she would immediately make sure all staff were on the matrix and enter them manually. The NHA was interviewed on 10/20/22 at 10:45 a.m. She said the prior DON was responsible for reviewing vaccination cards and tracking staff vaccinations. She said when the prior DON left her position, no one took over her role. She said the corporation of the facility implemented a new tracking program and it just did not integrate well. She said going forward the payroll department would be responsible for making sure all staff was on the matrix and vaccinations were being tracked.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of two medication carts. Specifically, the facility: -Failed to discard an expired bottle of [MEDICATION(S)] tablets; -Failed to date a [MEDICATION(S)] flex pen when opened; and, -Failed to date a Breo inhaler when opened. Findings include: I. Professional references According to the Breo Ellipta inhaler website, retrieved 10/19/22 from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Breo_Ellipta/pdf/BREO-ELLIPTA-PI-PIL-IFU.PDF, Safely throw away BREO ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads '0', whichever comes first. Write the date you open the tray on the label on the inhaler. According to the [MEDICATION(S)] [MEDICATION(S)] website, retrieved 10/19/22 from: https://www.novo-pi.com/[MEDICATION(S)].pdf, The [MEDICATION(S)] [MEDICATION(S)] you are using should be thrown away after 28 days, even if it still has insulin left in it. II. Observations and interview The medication cart for hall C was reviewed on 10/17/22 at 10:00 a.m. The cart contained a Breo inhaler with no open date, a [MEDICATION(S)] [MEDICATION(S)] with no open date, and a bottle of [MEDICATION(S)] tabs with an expiration date of March 2022. Licensed practical nurse (LPN) #1 said the Breo should have been dated when opened. He said the [MEDICATION(S)] [MEDICATION(S)] should have been dated when it was opened. He said he did not check the expiration date on the [MEDICATION(S)] tablets, but did identify the expiration date was March 2022. He said he would discard the medications. III. Administrative interview The director of nursing (DON) was interviewed on 10/18/22 at 1:45 p.m. He said medications that were expired should be discarded, and medications needed to be dated when opened. He said the facility would provide more education to the staff. He said it could be unsafe to administer expired medications.

Based on record review and interviews, the facility failed to ensure a proper pneumococcal immunization program for two (#30 and #39) of five residents reviewed for pneumococcal vaccine administration out of 17 sample residents. Specifically, the facility failed to offer and provide the pneumococcal vaccine to Resident #30 and Resident #39. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations (updated 1/22/22), retrieved from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html, accessed on 10/15/22, CDC recommends routine administration of pneumococcal conjugate vaccine (PPSV23) for all adults [AGE] years or older. In addition, CDC recommends PCV13 based on shared clinical decision-making for adults [AGE] years or older who do not have an immunocompromising condition, [CONDITION(S)], or cochlear implant and have never received a dose of PCV13. Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose. For adults [AGE] years or older, administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later. If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose. II. Facility policy and procedure The Influenza and Pneumococcal Vaccine policy, revised 8/22/22, was provided by the nursing home administrator (NHA) via email on 10/19/22 at 10:16 a.m. It read in pertinent part: Each resident is offered a pneumococcal immunization. On admission the facility should determine the vaccination history of the resident and if the resident had previously been vaccinated with one or both of the Pneumococcal vaccines. Education was provided to the resident and/or the representative regarding benefits and side effects or risks and a consent form was signed. The resident and/or responsible party was provided with the vaccine. III. Resident #30 A. Resident status Resident#30, age greater than 65, was admitted on [DATE]. According to the October 2022 computerized orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/7/22 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of four out of 15. It documented the resident's pneumococcal vaccine was offered but declined. Resident #30's immunization record revealed the informed consent for the pneumococcal vaccine had been signed on 10/29/2020 and consent was given for the resident to receive the vaccination. -However, the vaccination was not administered. The interim director of nursing (IDON) was interviewed on 10/19/22 at 2:03 p.m. The IDON verified that Resident #30 did consent for the pneumococcal vaccination 10/29/2020. He said he was not sure why the resident did not receive the vaccination. He said he would immediately get the vaccination ordered for the resident. IV. Resident #39 Resident #39, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/21/22 MDS assessment revealed, the resident was cognitively intact with a BIMS of 15 out of 15. It documented the resident's pneumococcal vaccine was up to date. Resident #39's immunization record revealed the pneumococcal vaccination (dose one) had been given on 10/9/17 and the informed consent for the pneumococcal vaccine (dose two) had been refused. -The IDON was unable to provide the refused consent. There was no documentation in the resident ' s electronic medical record to show the resident was offered, given, or refused the pneumococcal vaccination. The IDON was interviewed on 10/19/22 at 2:03 p.m. The IDON verified that there was no consent for the pneumococcal vaccination (dose two) or documentation that it had been offered. He said he was not sure why the vaccination was not offered. V. Staff interviews The IDON was interviewed again on 10/19/22 at 2:51 p.m. He said he offered Resident #39 the second dose of the pneumococcal vaccination and he gave consent to receive the vaccination. He said the wound nurse started a facility audit of vaccination consent forms. He said the infection preventionist (IP) was responsible for tracking resident vaccination, but the facility did not have a designated IP at the time of survey. The NHA was interviewed on 10/20/22 at 10:13 a.m. She said when a resident was admitted the facility would ask the resident their vaccination history and offer vaccinations needed. She said after the consent and education were provided, the nurse would get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said they would audit all the residents' medical records to verify all residents were offered up to date vaccinations.

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 one (#15) of three residents reviewed for the use of supplemental oxygen of 17 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. Resident #15 A. Resident status Resident #15, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the October 2022 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/11/22 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of eight out of 15. She had no identified behaviors or rejections of care during the assessment period. She was identified using oxygen. B. Record review The care plan, initiated 4/26/21, identified Resident #15 had [CONDITION(S)] and coronary artery disease. Interventions included oxygen (O2) at three liters per minute (lpm). The care plan, initiated 5/2/22, identified Resident #15 had altered cardiovascular status. Interventions included O2 at three liters continuous. The care plan, initiated 4/10/19 and revised 7/19/21, identified Resident #15 had oxygen therapy. Interventions included O2 via nasal prongs at three liters continuous. The October 2022 CPO included: -Oxygen at three liters per minute continuously. Ordered on 12/2/18. C. Observations and interview Resident #15 was in her room on 10/17/22 at 11:56 a.m. She said her oxygen was to be set at three liters. The concentrator was set at five liters. Resident #15 was in her room on 10/18/22 at 9:32 a.m. Her concentrator was set at five liters. Licensed practical nurse (LPN) #1 was interviewed on 10/18/22 at 9:35 a.m. He said her order was for three liters. He said certified nurse aides (CNAs) were not allowed to alter the oxygen flow by adjusting the concentrator. He said he did not know how the concentrator had been adjusted to a higher oxygen level. He adjusted the concentrator to the ordered liter flow of three. He said oxygen was a medication and should only be administered with a provider order. He said he would let the director of nursing (DON) know of the wrong liter flow setting on the concentrator. D. Administrative interview The DON was interviewed on 10/18/22 at 1:45 p.m. He said the concentrator should have been set to the prescribed liter flow. He said oxygen was an ordered treatment and needed to be administered as ordered. He said education would be provided to the nursing staff.

Based on observations, record review and interviews, the facility failed to ensure one (#35) of five residents reviewed for quality of care out of 17 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure ted hose (stockings to help prevent blood clots) were placed on Resident #35 in the morning and taken off in the evening as prescribed by the provider. Findings include: I. Resident #35 A. Resident status Resident #35, age 88, was admitted on [DATE]. According to the October 2022 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/26/22 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. She had no identified behaviors. B. Record review The care plan, initiated 3/10/22, identified the resident had an ADL self-care performance deficit. Interventions included she requires supervision by one staff for dressing. The October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Ted hose on every morning, and off every evening for swollen legs. The order date was 8/23/22. The October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Observations Resident #35 was in the dining room on 10/17/22 at 12:17 p.m. She was not wearing ted hose. Resident #35 was in her room on 10/18/22 at 1:00 p.m. She was not wearing ted hose. D. Interviews Certified nurse aide (CNA) #1 and licensed practical nurse (LPN) #1 were interviewed on 10/18/22 at 1:15 p.m. CNA #1 said she did not know Resident #35 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] LPN #1 said he was not aware of the order, but said Resident #35 was very independent and would not be cooperative with the order. -However, no refusals or rejection of care were documented. The director of nursing (DON) was interviewed on 10/18/22 at 1:45 p.m. He said if Resident #35 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he would contact the provider to get clarification on the order to see if it was still needed.

Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#34) of two residents reviewed for activities out of 17 sample residents. Specifically, the facility failed to ensure Resident #34 was invited and encouraged to attend activities of her preference. Findings include: I. Facility policy and procedures The Therapeutic Activities Program policy and procedure, revised 11/2/21, was provided on 10/20/22 at 3:36 p.m., by the clinical consultant (CC). It read in pertinent part, The facility activities program will be directed by a qualified activities director. The director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activity ' s component of the comprehensive assessment. II. Resident #34 A. Resident status Resident #34, age 96, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 9/17/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of three out of 15. The resident had no behaviors. She required supervision assistance for bed mobility, transfers, grooming and toilet use. The resident ' s assessment of daily and activity preferences revealed it was somewhat important to be around animals, and to do things in groups of people. B. Record review The care plan, initiated 9/30/21 and revised 9/23/22, identified the resident as independent for meeting emotional, intellectual, physical, religious, and social needs. Interventions include resident needs 1:1 (one-to-one) bedside/in-room visits and activities if unable to attend out of room events. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Provide activities that are compatible with physical and mental capabilities, and compatible with known interests and preferences. Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and age appropriate. The activity calendar for 10/18/22 listed the following: -9:00 a.m. greetings -10:00 a.m. trivia -11:30 a.m. one to one -1:00 p.m. food committee -2:00 p.m. Dominos The activity calendar for 10/19/22 listed the following: -8:00 a.m. greetings -9:00 a.m. balloon toss -10:00 a.m. crossword -11:30 a.m. one to one C. Observations Observations on 10/18/22 revealed the resident did not have any meaningful activity. The resident was sitting in her recliner at the following times: 8:45 a.m., 9:35 a.m., 10:45 a.m., 10:24 a.m., 11:18 a.m., 12:45 p.m., 2:28 p.m. and 2:37 p.m. -At 8:45 a.m., Resident #34 was sitting in her recliner with the blanket over her head sleeping. -At 9:35 a.m., certified nurse aide (CNA) #6 provided care for Resident #34. -At 9:46 a.m., Resident #34 was sitting in her recliner next to her bed. -At 10:45 a.m., Resident #34 was still in her recliner next to her bed. The resident was sleeping in her recliner bed from 12:50 p.m.-2:22 p.m. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. Observations on 10/19/22 revealed the resident did not have any meaningful activity. The resident was sitting in her recliner at the following times: 8:20 a.m., 9:38 a.m., 10:00 a.m., and 11:32 a.m. -At 8:20 a.m., Resident # 34 was sitting in her recliner with the blanket over her head sleeping. -At 9:40 a.m., certified nurse aide (CNA) #5 provided care for Resident #34. -At 9:46 a.m., CNA #5 reentered resident #34 ' s room with a cup of tea. -At 10:00 a.m., Resident #34 was sitting in her recliner sleeping. -At 10:55 a.m., activity director walked past Resident #34 ' s room. She did not enter the resident's room or interact with Resident #34. -At 11:32 a.m., Resident #34 was sitting in her recliner sleeping. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. D. Interviews The activity director (AD) was interviewed on 10/19/22 at 1:54 p.m. The AD was informed of the observations above. She said all residents' should be encouraged and invited to all activities. She said, I need to do better on inviting all residents to activities and encouraging them to participate. She said the negative outcome for residents not participating in activities could be boredom, isolation, depression and negative behaviors and wandering.

Based on observations and interviews, the facility failed to ensure medications were secured properly in one out of one medication storage room. Specifically, the facility failed to ensure the medication room was locked in a secured manner on two occasions. II. Facility policy The Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 10/28/19, was provided by the nursing home administrator (NHA) on 8/5/21 at 11:30 a.m. via email. The policy was read and revealed in pertinent part: Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. III. Observations On 8/2/21 at 7:15 p.m. the facility medication storage room door was visibly slightly opened, ajar. The door was not pulled shut to lock the door. The door had two locks. One lock was in the door knob and another lock was at the top of the door on the right side. The door remained unlocked from 7:15 p.m. until 7:30 p.m. -At 7:25 p.m. Resident #24 approached the medication storage room door and reached for the door knob. Certified nurse aide (CNA) #1 saw Resident #24 reached for the door knob and offered him a cookie. CNA #1 assisted the resident in his wheelchair and escorted him away from the door knob to a common area for the residents. CNA #1 did not pull the door shut to lock it and it remained slightly opened. -At 7:30 p.m. licensed practical nurse (LPN) #1 walked to the medication room door. LPN #1 lifted her keys in her right hand to unlock the top lock. She did not put the key in the lock when she realized the door was slightly opened. She pushed the door open with her opened right hand and entered the medication storage room. She closed and locked the door after she entered the medication room. LPN #1 was interviewed on 8/2/21 at 7:30 p.m. She said the door was supposed to always be locked. She said anyone who entered the room was instructed to make sure the door was securely locked at all times. She said the nurses were the only staff members with keys that evening to the medication storage room. She said if anyone saw it open and walked by the door it should have been pulled shut. She said there were medications including narcotics in the room which needed to be secured behind a locked door. She said the door to the medication storage room was left open and she would lock the door immediately. -At 7:38 p.m. LPN #1 left the medication room and pulled the door behind her and checked that the door was locked as she left. RN #1 was interviewed on 8/2/21 at 7:40 p.m. She said the facility's medication room was always locked. She said the room contained medications including narcotics. She said only the nurses had keys to the medication storage room. -At 7:42 p.m. registered nurse (RN) #1 unlocked the door to the medication room with a key after LPN #1 had locked the door. At 7:44 p.m. RN #1 walked out of the medication room and did not pull the door to lock it. The door was slightly opened, visibly ajar, and unlocked until 7:49 p.m. -At 7:49 p.m. RN #1 was interviewed again. She said after she grabbed medication for a resident from the medication room she thought she had locked the medication storage room door when she left the room. She said she did not lock the door. She said the door should always remain locked. RN #1 was seated in the nurses room for charting that was across the hallway from the medication storage room. She stood up and walked to the medication storage room and pulled the door closed to the locked position. IV Administrative interview The director of nursing (DON) was interviewed on 8/5/21 at 11:00 a.m. She said the facility had only one medication room which contained many drugs which required the room to be locked. She said the door should always remain locked. She said the nursing staff had been taught to lock the door and that the staff should know it was a regulation that medication storage rooms were to be kept locked. She said if the door was open, staff, residents or visitors would be able to walk right in the secured area.

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19 in three of three neighborhoods. Specifically, the facility: - Failed to ensure staff wore surgical face masks in resident care areas; - Failure to ensure laundry staff wore a surgical mask while in the clean laundry area; and - Failed to ensure staff was actively screened before their shift. Findings include: I. Failure to ensure dietary staff wore surgical masks while in resident rooms A. Facility policy and procedure The Coronavirus (COVID-19) infection prevention control policy, revised 5/22/20 was provided by the director of nursing (DON) via email on 6/8/20 at approximately 6:00 p.m. It read in pertinent parts, Cloth face coverings are not considered personal protective equipment (PPE) and should not be worn by health care professionals (HCP) when PPE is indicated. B. Professional reference According to the Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of Face Masks, last updated 4/3/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html#contingency-capacity: In settings where facemasks are not available, HCP (healthcare personal) might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. C. Observations On 6/9/20 at 9:20 a.m., the dietary manager (DM) was observed wearing a cloth mask in the facility in the resident's room. She was pushing a cart on the unit. On the cart were snacks (milk shakes) for the residents. She entered several residents' rooms as she spoke to the residents and asked if they would like a milkshake. She served the residents with the milk shake. D. Interviews The DM was interviewed on 6/9/20 at 9:25 a.m. She said she was the dietary manager and was offering snacks to the residents. She said she was provided two masks (a cloth and a surgical mask) by the facility. She said she would wear either mask. She said she was not aware that she needed to wear a surgical mask when she was in the resident's room. She said she had a surgical mask and was going to wear it while in the resident's room. The DON and the nursing home administrator (NHA) were interviewed together on 6/9/20 at 10:45 a.m. They said all staff in the facility should wear a surgical mask. They said the DM should have worn a surgical mask while in the resident's rooms. The DON said it was important to wear a surgical mask to prevent any potential spread of the COVID-19 infection. The NHA said the DON had already started re-educating the DM on the use of surgical masks in residents' care areas. II. Failure to ensure laundry staff wore a surgical mask while in the clean laundry area A. Facility policy and procedure The facility policy COVID-19 [MEDICAL CONDITION], updated 5/22/2020, was provided by the director of nursing (DON) on 6/8/2020 at 5:00 p.m. It read in pertinent part: Per CMS directive issued 4/2/2020, all facility associates should wear a facemask/face covering while they are in the facility for the duration of the state of emergency in their state. If the facility is not located in a state that has declared a state of emergency and COVID-19 is present in the facility or ongoing community transmission is present in the facility, the associate will utilize face mask or other forms of facial coverings to reduce respiratory droplet spread to residents and other staff within the facility. HCP should wear a facemask at all times while they are in the healthcare facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. B. Observations Laundry assistant (LA) #1 was observed on 6/9/2020 at 8:15 a.m. She was observed in the clean laundry area tending the clean laundry without a face mask on. C. Staff interviews LA #1 was interviewed on 6/9/2020 at 8:15 a.m. She said she received personal protective equipment (PPE) training in mid-March when the facility began their COVID-19 training. She said she wore a surgical mask when outside of the laundry room. The environment services director (ESD) was interviewed on 6/9/2020 at 9:15 a.m. She said laundry staff was to always wear a surgical mask while in the building. She said this was important because it prevents contaminating clean laundry. The DON and NHA were interviewed on 6/9/2020 at 9:38 a.m. They said surgical masks were to be worn in the facility at all times by all staff. They said it was especially important to wear a mask in the clean laundry area to prevent contamination. III. Failure to ensure staff was actively screened before their shift. A. Facility policy and procedure The facility policy COVID-19 [MEDICAL CONDITION], updated 5/22/2020, was provided by the director of nursing (DON) on 6/8/2020 at 5:00 p.m. It read in pertinent parts; All associates will be actively screened at the beginning of their shift in accordance with current guidance from CDC, CMS, and local and state health departments. This screening will include questions about COVID-19 symptoms, and if they work in another location where COVID-19 has been identified. The associate must also have their temperature actively taken to rule out a fever. B. Observations LA #1 was observed on 6/9/2020 at 7:40 a.m. She was observed filling out her screening questions and taking her own temperature and recording it on her log sheet. The employee clock-in area was observed on 6/9/2020 at 10:10 a.m. A sign was posted underneath the time clock that staff was to clock in then report immediately to the receptionist or Side 1 (one) nurses station for screening and temperature check. This employee area was directly across the common area from the Station 1 (one) nurses station. C. Staff interviews LA #1 was interviewed on 6/9/2020 at 7:40 a.m. She said she logged her answers to the screening questions then took her own temperature and logged it onto her sheet. She said the nurses at the nurse's station told her not to bother them when they were passing meds and do the screening herself. She said she screens herself before her night shifts as well. She said the night nurses also told her they did not have time to screen her before her shift. She said she received no training on how to screen herself in before each shift. Certified nurse aide (CNA) #1 was interviewed on 6/9/20 at 8:01 a.m. She said when staff came to work in the morning., the receptionist who was responsible to screen staff was not available at the desk. She said in the morning when the receptionist was not available, they were instructed to go to the nurse to be screened. She said when they went to the charge nurse to be screened, the nurse would instruct them to screen themselves because she was busy passing out medications to residents. Registered nurse (RN) #1 was interviewed on 6/9/20 at 8:05 a.m. She said after hours the receptionist was not at the front desk to screen the staff. She said staff then would screen themselves. She said the staff was instructed to report to the nurse any screening questions that they answered yes and if they had a fever. She said the receptionist was at the desk from 8:00 a.m to 5:00 p.m. She said after 5:00 p.m all staff would screen themselves. The ESD was interviewed on 6/9/2020 at 9:15 a.m. She said the receptionist was usually at the desk. She said if the receptionist was not present staff were to screen in with another staff member to verify their screening and temperature. She said the staff was to not screen themselves in alone. The DON and NHA were interviewed on 6/9/2020 at 9:38 a.m. They said the charge nurse was to screen employees after hours. They said the staff was to report to the nurse's station after clocking in and be screened there before the start of their shift. They said there was a sign up at the time clock instructing employees to go to nurse station 1 (one). The receptionist was interviewed on 6/9/2020 at 10:06 a.m. She said after the employees enter through the employee entrance they were to come to the receptionist desk of the nurse station to be screened. She said the screening question and temperature log were kept at the receptionist's desk during their working hours and kept at the nurse's station during off-hours. D. Record review The Coronavirus Screening (for Associate) forms were provided by the DON on 6/9/2020 at 10:30 a.m. The dates of 6/7/2020, 6/8/2020, and 6/9/2020 were reviewed. Of the 52 forms reviewed, 17 documented the employee was actively screened before their shift and 35 documented employees had screened themselves before starting their shift. IV. Facility follow-up The NHA and DON said facility re-training and LA #1 were re-educated about screening self and wearing a surgical mask at all times while in the facility on 6/9/2020 at 10:00 a.m.

Based on observations, record review and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for rooms on three of seven hallways in the facility. Specifically, the facility failed to maintain temperatures between 71 and 81 degrees Fahrenheit (F) on the three of seven hallways and rooms on Dandelion Drive hallway, Aspen hallway and Cherry Blossom hallway. Findings include: [NAME] Observations and interviews On 2/19/2020 at 8:55 a.m. the temperature, according to the thermostat on the Dandelion Drive hallway, was 68 degrees F. The temperature in Room D11 at the end of this hallway was 67 degrees F. Resident #2 resided in Room D11-2 and was wearing a t-shirt under a sweatshirt with sweatpants and was sitting in her chair with three blankets over her. She said she was very cold. She said she had complained to management but they don ' t care. Resident #1 resided in Room D11-1. She was sitting on the edge of the bed trying to eat her breakfast on the table in front of her. She was covered with blankets and said it was too cold to eat. On 2/19/2020 at 8:58 a.m. the temperature, according to the thermostat on the Cherry Blossom hallway, was 71 degrees F. The temperature in Room C9 at the end of this hallway was 67 degrees F. Resident #3 resided in Room C9-2. She complained of the room being ice cold. She was wearing two t-shirts, a sweatshirt, compression stockings, sweat pants, socks and slippers. She was sitting in her chair with two blankets covering her. She said the cold made her Parkinson ' s symptoms worse. She said her tremors were worse and even her jaw was shaking. She said she had told management but they had not done anything. On 2/19/2020 at 9:15 a.m. Resident #4 was sitting in her wheelchair outside the dining room. She said the temperatures in the dining room were always cold especially if you had to sit by a window. She said sometimes the staff even had to wear their coats in the dining room because it was so cold. On 2/19/2020 at 9:20 a.m. the temperature, according to the thermostat on the Aspen hallway, was 66 degrees F. On 2/19/2020 at 10:28 a.m., the temperature in Room A3, on the Aspen hallway, was 68 degrees F. Resident #5 resided in A3-1. He was lying in bed with a hooded sweatshirt. The hood was over his head and he had the covers of his bed pulled up under his chin. He said he was cold. On 2/19/2020 at 10:29 a.m., the temperature in Room A7 was 68 degrees F. Resident #6 resided in A7-1. He was lying in bed with the blankets pulled up to his chin. He said it was cold in his room. On 2/19/2020 at 10:32 a.m. the temperature on Dandelion hallway was 69 degrees F and 67 degrees F on Aspen hallway. On 2/19/2020 at 11:30 a.m. the temperatures were taken by the maintenance director (MD) using his infrared thermometer. The temperatures fluctuate depending on the surface the thermometer was directed at. In Room D11 the temperatures fluctuated between 70-71 degrees F. In room C9, the temperature fluctuated between 66-69 degrees F. The dining room was 71 degrees F and the Aspen hallway was 69 degrees F. B. Record review Review of the (MONTH) 2019 Resident Council meeting notes revealed the executive director (ED) had addressed the temperature fluctuations in some of the rooms. He stated that they were currently working on the room temperature and to speak to the MD if they had any concerns. According to a 2/6/2020 concern form submitted by Resident #2 the resident reported being cold and was requesting to call the state. The resident stated it ' s been too cold for days - feels it ' s elderly abuse. The temperature on the D-hall was 64 degrees F. The resident was given a heater for her room. (This heater was not in the room on 2/19/2020). According to concern forms submitted by Resident #7 ' s family on 12/17/19 and 1/30/2020, the resident ' s room was very cold. On 12/17/19 the facility weather stripped the windows. On 1/30/2020 a work order was put in. The work order was requested from the facility and not provided. According to a 12/18/19 concern form submitted by Resident #8 ' s family, Room C9 was very cold and in the last few days even colder. The resident was offered and accepted a room change. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/19/2020 at 10:35 a.m. He said the resident often complained of being cold especially when they were in the dining room. He said they tried to dress the resident ' s warmer. He said the building was old and the temperature was difficult to adjust. He said he thought the management was trying to do what they could. The ombudsman was interviewed on 2/19/2020 at 10:45 a.m. She said temperatures in the building had been an ongoing complaint she got from the residents in the facility. She said she noticed the back halls were usually colder than the front ones and when they would turn up the heat in the back it would make the front too hot. She said it was such an old building that the facility had a hard time regulating the temperature. The director of nursing (DON) was interviewed 2/19/2020 at 11:20 a.m. She said she did not know the temperature was so low in some of the resident ' s rooms and she felt bad that they were uncomfortable. She said they would have to figure out something in order to make the residents more comfortable. The MD was interviewed on 2/19/2020 at 11:26 a.m. He said temperatures in the building should be between 71 and 78 degrees F. He said building temperatures were checked every morning but he did not always log the results. He said the building was old and difficult to manage the temperatures. He said they only had a boiler for heat so adjustments had to be made to the boiler with 180 degrees being the highest they could put it. He said all the thermostats in the building should be set to 78 degrees F but staff were often adjusting the thermostats based on the temperature of the day. He said, for example if it was warm outside, the staff would adjust the thermostat to 72 degrees F but the heaters would not start until the temperature was five degrees below the set temperature so it would be 67 degrees F before the heater would turn on. He said they had put locked covers over the thermostats to try and prevent others from adjusting the temperature and provided staff education to not touch the thermostats but they were still getting changed. He said they had put weather stripping on some of the windows and by the door at the end of Cherry Blossom hall hoping it would help with the draft.

Based on record review and interview, the facility failed to ensure certified nurse aides and nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to complete staff competencies for cares identified in residents' care plans for five (#5, #3, #2, #11 and #12) of 24 certified nurse aides (CNAs); two (#2 and #1) of six licensed practical nurses (LPNs), and one (#3) of seven registered nurses (RNs). Findings include: I. Resident care plans Resident #23 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Her care plan identified interventions included: administer medications as ordered, assess bowel sounds, blood sugar checks as needed, assisting with activities of daily living (ADLs), weigh per facility protocol, and [MEDICAL CONDITION] care with suctioning daily. Resident #4 was admitted on [DATE]. His [DIAGNOSES REDACTED]. His care plan identified interventions included: assist with mobility and ADLs as needed, administer medications as ordered, provide mouth care daily, and peri care as needed. Resident #1 was admitted on [DATE] and readmitted [DATE]. Her [DIAGNOSES REDACTED]. Her care plan identified interventions included: provide mouth care daily, assess bowel sounds, weigh resident per facility protocol, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, and suction as needed. II. Competency records A. CNA competency records revealed: CNA #5 did not have evidence of competencies for transfers (including mechanical lifts), personal protective equipment (PPE), ADLs to include feeding, showering, and dressing, and vital signs (VS). CNA #3 did not have evidence of competencies for transfers (including mechanical lifts), PPE, foley catheter care, ADLs to include feeding, showering, and dressing, and VS. CNA #2 did not have evidence of competencies for transfers (including mechanical lifts), PPE, ADLs to include feeding, showers, and dressing, and VS. CNA #11 did not have any competencies completed. CNA #12 did not have evidence of competencies for transfers (including mechanical lifts), PPE, ADLs to include feeding, showers, and dressing, and VS. B. LPN and RN competency records revealed: LPN #2 did not have evidence of competencies of wound care, PPE, and [MEDICAL CONDITION] care. LPN #1 did not have evidence of competencies of wound care, PPE, and [MEDICAL CONDITION] care. RN #3's competency record did not have evidence of competencies of wound care, PPE, and [MEDICAL CONDITION] care. III. Interview The director of nursing (DON), who was also acting staff development coordinator, was interviewed on 5/2/19 at 1:45 p.m. She said the facility had a skills fair and the competencies were completed during the fair. She said she did not know why some of the forms only had the signature of the staff and not of the evaluator ensuring a correct demonstration was performed. She said some of the records had been destroyed by a disgruntled former employee. She said all the staff should be proficient for care provided to all the residents, including specific needs such as [MEDICAL CONDITION] care.

Based on observation; resident, family and staff interview; and record review, the facility failed to provide sufficient nursing staff to provide care and services for 11 of 17 sample residents (#1, #3, #4, #5, #6, #7, #10, #11, #14, #15 and #17) to attain the highest practicable physical, mental and psychosocial well-being of each resident. As a result, residents expressed feeling angry, frustrated and helpless and, per resident and staff interviews, experienced episodes of incontinence. Cross Reference F312, assistance with activities of daily living The findings included: 1. Resident Census and Condition Report The facility Resident Census and Condition Report signed by the director of nursing (DON) on 2/5/15 documented a census of 83 residents. The residents' functional, mental and psychosocial needs were described as follows: -76 residents needed assist of one or two staff for bathing; 63 residents needed assist of one or two staff for dressing; 55 residents needed assist of one or two staff for transferring; 58 needed assist of one or two for toilet use; and 17 needed assist for eating. -60 residents were occasionally or frequently incontinent of bladder; 26 residents were occasionally or frequently incontinent of bowel; 56 residents were on urinary toileting programs; and 27 residents were on bowel toileting programs. -55 residents were in a chair all or most of the time; 32 residents had contractures; one resident was restrained; and 26 residents ambulated with assistance or assistive devices. -49 residents had dementia or [MEDICAL CONDITION] and 13 residents had behavioral healthcare needs; 29 residents were on psychoactive medications; three residents were on antipsychotic medications; seven residents were on antianxiety medications; and 24 were on antidepressant medications. -42 residents received respiratory treatments; 61 residents were on pain management programs; 19 residents had unplanned significant weight changes; 81 residents received preventative skin care; and two residents had pressure ulcers, one of which was present upon admission. 2. Resident Council Meeting Minutes Resident Council Meeting minutes, reviewed for November-January, revealed the following: -On 11/24/14, the director of nursing and administrator were "unavailable." Residents were asked if there were any comments, concerns or questions, and none were mentioned. -On 12/29/14, residents mentioned the need for more CNAs and asked about the showers. The DON stated they had more staff and ongoing CNA classes had graduated four new CNAs with five more enrolled. Showers were "twice weekly per resident, with resident preferences taken into consideration." -On 1/26/15, the DON was unavailable and it was reported that "nursing was working out the shower schedules." Social services was also unavailable and the administrator was not mentioned. 3. Observations and interviews were conducted throughout the facility on 2/4/15 and 2/5/15. Administration and nursing staff were asked about the staffing schedules, resident activity, safety and ability to meet the resident needs as outlined in their individual plans of care. Residents were observed gathered in the common areas, many in wheelchairs, sleeping or staring straight ahead, unengaged in conversation or activities. This was observed upon entrance to the facility at approximately 4 p.m. on 2/4/15, during the evening after dinner on 2/4/15, upon arrival to the facility at 7:35 a.m. on 2/5/15, and before and after lunch on 2/5/15. 4. Resident Interviews and Observations Nine residents, identified by the facility and by cognitive assessment as interviewable, stated during interviews that the facility did not provide sufficient nursing staffing to meet residents' care and services needs in a timely manner. Resident interviews, conducted throughout the facility, revealed the following: Resident #4 was interviewed the afternoon of 2/4/15. She was asked if the facility had sufficient staff to ensure residents did not have to wait too long for things they needed. She said, "No, not for anybody who can't take themselves to the potty ... I think sometimes they take too long to help people who need it. They (staff) say, 'I'll be right back.' Half an hour later they're still not back, and the patient is crying ... I can't understand why you would walk away (from a resident who needed assistance)... Help to the bathroom is poor and bad." Resident #5 was interviewed on 2/4/15 at 5:20 p.m., 2/5/15 at 10:30 a.m., and 2/5/15 at 2:30 p.m. She said she often had to wait "a long time to get into the bathroom," and had "waited more than an hour." The resident said, "I called my daughter, it was so long. She had to get dressed, get up in the middle of the night, come out here and help me herself." The resident said her daughter had called the facility and nobody answered the phone, so she came out herself and helped the resident to the bathroom. -The resident said, "I did have a little spot on my sheet the other day ... probably from waiting. I just worried about what it could do to your body when you wait so long (to go to the bathroom)." -The resident had food crumbs all over her bedside table and recliner during the interview on 2/4/15 at 5:20 p.m. When asked about this, the resident said, "They could do better, because they just came in and got the lunch tray... It's not the way I'd do it at home, but you can't complain. Sometimes you're talking to them and all of a sudden they're gone." -The resident said she missed the one shower that was scheduled for her the previous week. -She said, "There's just not enough people - I know that." Asked how she felt when her call light was not answered in a timely manner, she said, "You just feel like you're nothing. And your body isn't very happy about it." -Resident #5 was observed on 2/5/15 at 10:30 a.m. Her breakfast tray sat on her bedside table, which was still covered with food crumbs from the evening before, and needed to be cleaned. She still had crumbs on the quilt in her recliner. There were white food stains and a dried liquid stain on the cushion sitting in her recliner on top of her quilt. On 2/5/15 at 2:30 p.m., the resident's bedside table, recliner, quilt, and cushion were in the same condition. (Cross-reference F312.) Resident #6 was interviewed the evening of 2/4/15. She said she knew there were not enough staff, and she knew this because staff were "slow getting around sometimes" to answer the call lights. The resident's bed was observed to have a brown smear on the fitted sheet. Resident #11 was interviewed the evening of 2/4/15. He said that he waited "too long for pain meds, about once every two days," and sometimes received "one shower per week, and it should be two." When asked if showers were a problem, he said it "depends on how many staff" were available. The resident had no ice water in his water pitcher. His family member, who was visiting, went to get ice water for resident #11 and his roommate. Resident #10 was interviewed the evening of 2/4/15. He said there were "not enough" staff and he waited "too long to get stuff ... sometimes it seems like forever. They have one nurse and one CNA for everybody else. There should be more of them. At times I get exasperated and perturbed." -The resident said, "Showers are kind of sketchy. I told them I only needed one (per week). I like it a certain day and time, and not at ten o'clock at night ... That's the only problem - they just don't have enough people and they keep quitting." Resident #7 was interviewed on the evening of 2/4/15. The resident said she did not believe nursing staffing was sufficient. She said when she moved from the rehabilitation side to the skilled nursing side of the building, they told her she would only get two showers per week, and she had three per week on the rehab side. -The resident said they provided "no ice water in the evenings" like "on the other side." The resident had two water pitchers on the table in her room. Both pitchers were about one-quarter full of water, and no ice. -The resident gestured toward her unmade bed and said, "As you can see they didn't make the bed today. It's been like that all day. When my kids come in, they do it." -The resident asked for assistance from a certified nurse aide (CNA) in the hallway. The CNA pointed to another resident and responded, "Let me take her first, okay?" Resident #1 was interviewed on 2/5/15 at 9:45 a.m. and made the following comments: -"It seems there's a delay to get some stuff done, like go to bed and get up in the morning. In my case, I need help to get up and get dressed ... I have to wait 30 minutes for that." -"Usually it's 30 minutes before I get an answer to a call light for whatever reason." -The resident said he had bowel incontinence accidents after waiting too long for call light response. Asked how that felt, he said he felt angry and added, "It makes me feel kind of stupid and helpless." -Regarding showers: "I think it would be good to do it the way it was before - one CNA doing the showers ... When I heard they were going to stop using the same (bath aide) all the time I thought that's a mistake." -The resident said he required two staff with a gait belt to transfer him, but occasionally it was one person. Asked if that was safe, he said it "depends on who's doing it." (Cross-reference F312.) Resident #15 was observed on 2/5/15 at 8:11 a.m., holding her call light, sitting in her wheelchair next to her bed, which was stripped of linens revealing a bare mattress. Asked if she needed anything, the resident said the CNA was going to come back and give her a shower. -At 10:22 a.m., resident #15 was observed lying in her bed. She said, "What else am I going to do?" The resident said she did not get her shower. A CNA said she had had to "put someone else in front of her" and resident #15 would get her shower next. . At 10:25 a.m., the CNA asked resident #15 if she wanted her shower, and indicated she was ready to assist her. The resident responded, "Are you sure?" (Cross-reference F312.) Resident #3 was interviewed on 2/5/15 at 11:11 a.m. Asked if there were enough staff, she said, "No. One night (CNA's name) worked all by herself on all of side one. I asked her, 'Who's here to help you?' She said, 'I'm the only one.' ...I had to sit and wait and wait on the light. That's how I kept falling. I get impatient and get up by myself. That's how I broke my rib six months ago." 5. Family and Visitor Interviews Resident #17's family was interviewed on 2/5/15 at 9 a.m. after he was observed feeding the resident her breakfast. During the family interview, resident #17 was sleeping in her wheelchair, with her head, neck, and upper back leaning forward, almost to her knees, unsupported. The family made the following comments: -"I would like to see her laid down after breakfast, but they say it's too much jostling. I know her neck and her back get to hurting her. They say they'd lay her down and after a short time they'd just have to get her back up. It may be an issue of short staff, which has been an ongoing problem here, honestly." He said it could be hectic with call lights going off and waiting for staff to respond. "At night is when there's a problem." -The family member added that resident #17 "eats better when she gets her naps. Today she just couldn't stay awake. If we're sleepy we're not going to eat, we just want to sleep. At this point why can't she nap? You don't cheat the residents out of what they need. My mother's worked hard all her life. I'd like to see her eat a lot better. (If) they were laying her down for a morning nap she'd eat better at lunch. (The residents) have to get up really early because (staff) have to get everybody up and ready for breakfast." -The family member said they would "actually start waking people up at 4 or 4:30 in the morning ... When you've got 18 other residents, and to get them to breakfast on time, what are you going to do? (Staff) work their tails off and they're conscientious, (but) I rarely hear a CNA say (to a resident), 'Would you like to lie down?' They're busy - they have to answer the call lights." (Cross-reference F312) Resident #14's family was interviewed on 2/5/15 at 11:45 a.m., and made the following comments: -"The real concern for me is when you put the light on. Response time is sometimes 20 minutes or so. We know they're busy and understaffed, but if that light goes on, I think (staff) should go and check." -"Sometimes we do smell urine. Maybe they could check closer on that. We're concerned about the diaper being changed, and (staff) checking on her. Those are our two big concerns." -"Mom would want to go to bed and she'd be waiting about 20 minutes. It didn't seem like they were doing it purposely, because they were awful nice..." (Cross-reference F312) Resident #15's family was interviewed on 2/5/15 at approximately 12:15 p.m. and made the following comments: -"There is not enough help - response is not what it should be. Mom is not always getting a shower every week. Mom did not have a shower last week because I suppose, there again, not enough help." -"She also tells me that if they don't go to the dining room in the evening they forget to bring them any dinner. She's told me about that three times. Mom said neither she or (her roommate, resident #14) got anything to eat last night." -"A few days ago she mentioned to them that she hadn't eaten and they offered her dinner at 8 p.m. and she said, 'Not now.'" -"Showers: she didn't get her shower last week. She got a shower today, they'd been promising her all day yesterday that she would, and she didn't yesterday. She's getting once a week now when she gets it. She usually opted for once (a week in her previous facility)." -"Basically it comes down to lack of help ... The only time she'll ring is when she's ready for her nap - that's been around 15 to 20 minutes (wait time). Sometimes you have to go round somebody up and they'll say they're busy. They should answer the call light and at least respond in a timely fashion to assess the situation." (Cross-reference F312) A frequent facility visitor was interviewed on 2/5/15 at 8:45 a.m. She said during her visits she would see five call lights going off at once. She added, "Whenever I go (resident #15) is lying down. I only see her up when her daughter is there. I'm concerned there is not enough staff to help (residents) get up and lie down (when they prefer) ... Residents have brought up short staffing in recent meetings when I'm there. During meals there's no (staff) in the hallway. I walk past ... and see three CNAs at the nurses' station charting while call lights are going off, and (they and other staff are) not responding." 6. Staff Interviews CNAs nterviewed on 2/4 and 2/5/15 made the following comments: -"We're short staffed. Residents are going to the bathroom without assistance, having to wait longer than they'd like. ... Some residents can't hold it while we go get help. Ice and snacks could be done earlier." -"I don't like to hear call lights going off at night ... There are lots of residents who need two-person assist. Residents complain about not getting showers ... Water pass is only done once down on side one - we can't do it all." -"We are always short staffed here. We rush, can't take our time. Twice I've been the only CNA on side one. Showers are a problem. A couple of residents don't like evening showers. We were told we'd always have an evening person to do showers, but that didn't work out." -"One nurse wanted me to do showers in the mornings. We start getting residents up at 4 a.m. There are a couple that we have to wake up, and one resident, I don't think he likes it." -"There are not enough staff for getting people to bed, washing wheelchairs ... There are a lot of two-person residents, for transfers to bed and the toilet. That takes time, so you have to go find another CNA to transfer. That makes it stressful, for us and the residents. They get upset because a lot of attention goes to (the residents who need) two-person assist." -"I hate asking residents to wait five to ten minutes and I try not to go over that. Lots of residents are wanting to go to bed at the same time .... -"I've had residents have incontinence or try to transfer themselves when I tell them I'll be right back and that makes me feel bad .... Tonight (a resident) was incontinent when I went to get her ready for bed." The CNA said the resident could see that staff were busy so she did not ask staff for help. -"With our new shower schedule, we're trying to coordinate as best we can. Sometimes it's 8, 9 or 10 o'clock at night before we can ask (if they want a shower) and they refuse." -"I feel I'm not able to properly meet their needs because I don't have enough partners. They pulled the bath aides to the floor because they needed help out on the floor. We're giving showers at 10 or 11 at night." -"The residents are used to having their showers before dinner. They ask me why they couldn't have showers just before or after dinner and I have to tell them we have a different shower schedule now ..." -"This is not person-centered care: (it is not) showers as they prefer, going to bed when they prefer, and answering a call light in a timely manner. I've had a lot of resident complaints lately." -"We've had residents call family members because they don't get call light response." -"We literally have a get-up list to get residents up before 6 a.m. Most of them really can't talk that well. It starts at 4 a.m. It used to be 3 a.m. We get them up, sit them in a circle, no TV, no entertainment. Day shift comes in and starts getting people up." -"What are residents doing without? (Timely) call light response, showers and baths, bathroom assistance, peri care, two-hour check and changes, denture care, oral care, skin care, lotion. It is a dignity issue. Staffing is an extreme problem." 7. Daily Staffing Reports and Census Reports a. Review of the 2/3/15 daily staffing report in comparison to the 2/3/15 daily census report revealed the resident census was 84, with the following resident needs and staffing levels: Side One: -56 residents resided on side one, designated as the long term skilled nursing side. Per MDS review, 23 of those residents required two-plus-person assistance for ADLs. --Six CNAs plus a restorative aide were assigned to work the day shift, 6 a.m. to 6 p.m. --One CNA was assigned to work the evening shift, 9 a.m. to 9 p.m. --Three CNAs were assigned to work the night shift, 6 p.m. to 6 a.m. Side Two: -28 residents resided on side two, designated as the rehabilitation side. Per MDS review, 10 of those residents required two-plus-person assistance for ADLs; --Two CNAs plus a shower aide were assigned to work day shift, 6 a.m. to 6 p.m. --Two CNAs were assigned to work the night shift, 6 p.m. to 6 a.m. Nursing hours scheduled for side one were 2.73 Nursing hours scheduled for side two were 4.69 Total nursing hours per patient day (PPD) was noted as 2.96 b. Review of staffing documentation, 11/1/14 through 2/5/15, revealed shifts were overlapped as follows: -Day shift 6 a.m. to 6 p.m. -Evening shift 9 a.m. to 9 p.m. -Night shift 6 p.m. to 6 a.m. However, review of staffing schedules revealed only one or two additional staff members were typically scheduled on the 9 a.m. to 9 p.m. shift when residents were preparing for midday and evening meals, and preparing for bed. No additional staff members were scheduled for mornings when residents wanted to get up, have coffee, get dressed, and go to the dining room for breakfast. One shower aide was typically scheduled on side two, and one restorative aide was typically scheduled for the entire building. 8. Director of Nursing Interview The director of nursing (DON) was interviewed on 2/5/15 at 3 p.m. She said they had a job fair, ran ads in the paper, and held a CNA class which was "our best option for staff in this area." She said, "I totally agree we do need more staff ... I hate that we're not already there, for the residents. I tell them it's getting better." The nursing home administrator (NHA) was a corporate regional director who had been in the facility for two weeks on an interim basis. During an interview on the afternoon of 2/5/15, he said they were working on the staffing issue, had made administrative changes, a new administrator would start soon, and they were trying to improve the staffing problem.

Based on record review and resident, family and staff interviews, the facility failed to provide adequate assistance with activities of daily living (ADLs) for five of 17 sample residents (#1, #5, #14, #15 and #17), including bathing, toilet use, incontinence care, and transfer assistance to get up and lie down when needed and requested. Residents expressed feeling angry, frustrated and helpless and, per resident and staff interviews, experienced episodes of incontinence. Cross-Reference F353, failure to provide sufficient nursing staffing to meet resident needs. The findings included: 1. Resident #5, age 80, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident Status: According to the 12/17/14 Minimum Data Set (MDS), the resident had a BIMS (cognition) score of 14, indicating she was cognitively independent with no mood or behavioral symptoms. She required extensive assistance with transfers and dressing, physical assistance with part of bathing, was continent of bowel and bladder, and used a wheelchair for mobility. The care plan, dated 8/1/12, identified in part: "Risk for occasional urinary incontinence due to poor balance and weakness due to progression of MS, uses wheelchair and has required assist of 1-2 supervision to EA (extensive assist) for transfers/toileting at times. Diuretic use regularly for LE (lower extremity) [MEDICAL CONDITION]." Approaches included: "Remind and assist to toilet as needed ... Encourage resident to call for assistance with toileting if needed. Keep call light within easy reach ... Answer call light promptly." The self care deficit care plan, dated 3/2/12, included: "Assist with showers twice weekly and/or as requested." Record Review: Review of ADL sheets from 1/1/15 through 2/4/15 revealed the resident received baths on 1/16 and 1/23, and refused a bath on the evening of 2/4/15. No other bathing was documented, and no other refusals were noted. Resident Interview: Resident #5 was interviewed on 2/4/15 at 5:20 p.m., 2/5/15 at 10:30 a.m., and 2/5/15 at 2:30 p.m. She said she often had to wait "a long time to get into the bathroom," and had "waited more than an hour." The resident said, "I called my daughter, it was so long. She had to get dressed, get up in the middle of the night, come out here and help me herself." The resident said her daughter had called the facility and nobody answered the phone, so she came out herself and helped the resident to the bathroom. -The resident said, "I did have a little spot on my sheet the other day ... probably from waiting. I just worried about what it could do to your body when you wait so long (to go to the bathroom)." -The resident said she missed the one shower that was scheduled for her the previous week. -She said, "There's just not enough people - I know that." Asked how she felt when her call light was not answered in a timely manner, she said, "You just feel like you're nothing. And your body isn't very happy about it." 2. Resident #1, age 75, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident Status: According to the 1/29/15 MDS, the resident was cognitively intact with a BIMS score of 15. He required extensive, two-plus-person assist with bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. He had a catheter and was continent of bowel. He used a wheelchair for ambulation. Resident Interview: Resident #1 was interviewed on 2/5/15 at 9:45 a.m. and made the following comments: -"It seems there's a delay to get some stuff done, like go to bed and get up in the morning. In my case, I need help to get up and get dressed ... I have to wait 30 minutes for that." -"Usually it's 30 minutes before I get an answer to a call light for whatever reason." -The resident said he had bowel incontinence accidents after waiting too long for call light response. Asked how that felt, he said he felt angry and added, "It makes me feel kind of stupid and helpless." -The resident said he required two staff with a gait belt to transfer him, but occasionally it was one person. Asked if that was safe, he said it "depends on who's doing it." 3. Resident #14, age 90-plus, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident Status: According to the 11/23/14 MDS, the resident had severe cognitive impairment and required extensive assistance with transfers and toilet use (two-plus persons); and extensive assistance with dressing, eating, and bathing. She was occasionally incontinent of bowel and bladder. She used a wheelchair for mobility. Record Review: The resident was noted to have received only three baths from 1/1/15 through 2/4/15: on 1/17, 1/21 and 1/24/15. There was no documentation of refusals. The resident was noted as changed or assisted to the toilet an average of every three hours (over 31 days in January). Although the resident was assessed as occasionally incontinent (see MDS), according to ADL records, she was frequently (i.e. more often than not) discovered incontinent per documentation. Meal intake documentation revealed the resident refused dinner and ate nothing on 2/3/15. She also refused and ate nothing for dinner on 1/3, 1/6, 1/10, 1/18, 1/22, 1/26, 1/29, 1/30 and 1/31/15 (see resident #15's - roommate's - family interview below). Family Interview: Resident #14's family was interviewed on 2/5/15 at 11:45 a.m., and made the following comments: -"The real concern for me is when you put the light on. Response time is sometimes 20 minutes or so. We know they're busy and understaffed, but if that light goes on, I think (staff) should go and check." -"Sometimes we do smell urine. Maybe they could check closer on that. We're concerned about the diaper being changed, and (staff) checking on her. Those are our two big concerns." -"Mom would want to go to bed and she'd be waiting about 20 minutes..." 4. Resident #15, age 90-plus, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident Status: According to the 11/23/14 MDS, the resident's BIMS score was six indicating severe cognitive impairment. The resident needed extensive assistance with transfers, dressing, and toilet use; and supervision and setup assistance with eating. She was occasionally incontinent of bowel and bladder. The care plan, dated 11/29/14, identified self care deficits and included, "Assist with showers twice weekly and/or as requested." -The 11/29/14 care plan identified occasional incontinence due to decreased mobility, and noted, "Uses toilet or check and change for toileting needs." Approaches included: "Observe for non-verbal cues that the resident may need to use the toilet ... Encourage resident to call for assistance with toileting if needed. Keep call light within easy reach. Answer call light promptly." -The 11/25/14 care plan identified nutritional risk and actual weight loss on 12/19/14. An intervention added on 12/19/14 read, "Assist with meals. Transfer to regular chair for meals." Record Review: The resident was noted to have received only two showers from 1/1/15 through 2/4/15: 1/14 and 1/26/15. She refused showers on 1/21 (day), 1/24 (day) and 1/25/15 (night). The resident's meal intake records revealed she refused to eat and ate nothing for dinner on 2/2 and 2/3/15. Likewise, she ate nothing for dinner on 1/4, 1/13, 1/14, 1/19, 1/21, and 1/30/15. Family Interview: Resident #15's family was interviewed on 2/5/15 at approximately 12:15 p.m. and made the following comments: -"Mom is not always getting a shower every week ... She didn't get her shower last week. She got a shower today, they'd been promising her all day yesterday that she would, and she didn't yesterday. She's getting once a week now when she gets it. She usually opted for once (a week in her previous facility)." -"She also tells me that if they don't go to the dining room in the evening they forget to bring them any dinner. She's told me about that three times. Mom said neither she or (her roommate, resident #14) got anything to eat last night." -"A few days ago she mentioned to them that she hadn't eaten and they offered her dinner at 8 p.m. and she said, 'Not now.'" 5. Resident #17, age 82, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident Status: According to the 1/22/15 MDS, the resident was severely cognitively impaired. She required extensive two-person assist with transfers, toilet use, personal hygiene and bathing; and extensive one-person assist with dressing, ambulation with a wheelchair, and eating. She was incontinent of bowel and bladder. Family Interview: Resident #17's family was interviewed on 2/5/15 at 9 a.m. after he was observed feeding the resident her breakfast. During the family interview, resident #17 was sleeping in her wheelchair, with her head, neck, and upper back leaning forward, almost to her knees, unsupported. The family made the following comments: -"I would like to see her laid down after breakfast, but they say it's too much jostling. I know her neck and her back get to hurting her. They say they'd lay her down and after a short time they'd just have to get her back up. It may be an issue of short staff, which has been an ongoing problem here, honestly." He said it could be hectic with call lights going off and waiting for staff to respond. "At night is when there's a problem." -The family member added that resident #17 "eats better when she gets her naps. Today she just couldn't stay awake. If we're sleepy we're not going to eat, we just want to sleep. At this point why can't she nap? You don't cheat the residents out of what they need. My mother's worked hard all her life. I'd like to see her eat a lot better. (If) they were laying her down for a morning nap she'd eat better at lunch. (The residents) have to get up really early because (staff) have to get everybody up and ready for breakfast." -The family member said they would "actually start waking people up at 4 or 4:30 in the morning ... When you've got 18 other residents, and to get them to breakfast on time, what are you going to do? (Staff) work their tails off and they're conscientious, (but) I rarely hear a CNA say (to a resident), 'Would you like to lie down?' They're busy - they have to answer the call lights." 6. Staff Interviews CNAs, interviewed on 2/4 and 2/5/15, made the following comments (in pertinent part) about residents' ADL cares: -"We're short staffed. Residents are going to the bathroom without assistance, having to wait longer than they'd like. ... Some residents can't hold it while we go get help." -"Residents complain about not getting showers ... We can't do it all." -"Showers are a problem. A couple of residents don't like evening showers. We were told we'd always have an evening person to do showers, but that didn't work out." -"One nurse wanted me to do showers in the mornings. We start getting residents up at 4 a.m." -"There are not enough staff for getting people to bed ... There are a lot of two-person residents, for transfers to bed and the toilet. That takes time, so you have to go find another CNA to transfer. That makes it stressful, for us and the residents." -"I've had residents have incontinence or try to transfer themselves when I tell them I'll be right back and that makes me feel bad .... Tonight (a resident) was incontinent when I went to get her ready for bed." -"With our new shower schedule, we're trying to coordinate as best we can. Sometimes it's 8, 9 or 10 o'clock at night before we can ask (if they want a shower) and they refuse." -"They pulled the bath aides to the floor because they needed help out on the floor. We're giving showers at 10 or 11 at night." -"What are residents doing without? ... showers and baths, bathroom assistance, peri care, two-hour check and changes, denture care, oral care, skin care, lotion. The director of nursing (DON) was interviewed at 3 p.m. on 2/5/15. She acknowledged the facility was short staffed, and said they were working hard to resolve the problem. She said they did not want residents to go without their dinners, showers, or the assistance they needed. The interim nursing home administrator acknowledged the findings reported to him on the afternoon of 2/5/15. He said the facility had made administrative changes, a new administrator would be starting soon, and they were working on improvements.

Based on observation, resident and staff interview, and record review, the facility failed to provide one of 17 sample residents (#16) the care and services necessary to attain and/or maintain their highest practicable level of well being. Specifically, the facility failed to assess and monitor resident #16's feet. The resident was at high risk for skin complications of her lower extremities due to her [DIAGNOSES REDACTED]. The resident developed an infection of her right toe which was painful and which triggered amputation of the toe within two weeks of discovery of the infection. The findings included: A. Professional Reference regarding [MEDICAL CONDITION] According to "Nurses' role in diabetic foot prevention and care," Journal of Diabetes & Metabolic Disorders 2012, <http://www.jdmdonline.com/content/11/1/24>, accessed 2/2015: "Peripheral [MEDICAL CONDITIONS] and infection are three major factors for [MEDICAL CONDITION] that can lead to gangrene and amputation. However, [MEDICAL CONDITION] is solely responsible for more than 80% of foot ulcers in diabetic patients. ...Nurses' role in diabetic foot care includes foot examination (and) wound dressing ... Diabetic foot examination should be part of all visits. Nurses should ask patients to remove their shoes and socks ... and then examine their feet in order to screen patients at high risk and report to other members of the multidisciplinary diabetic foot team." B. Resident #16 Resident #16, age 86, was admitted to the facility on [DATE] and readmitted from a local acute hospital on [DATE]. [DIAGNOSES REDACTED]. 1. Resident Status According to the 8/11/14 admission Minimum Data Set (MDS), she had severe cognitive impairment with a BIMS (cognition) score of three. She required extensive two-plus person assist with bed mobility, transfers, toilet use, and bathing; and one-person extensive assist with dressing, eating and personal hygiene. She used a wheelchair with extensive one-person assistance for ambulation. Walking did not occur. She had a stage 1 pressure sore upon admission. -The 11/9/14 MDS noted a BIMS score of 11 indicating moderate cognitive impairment. Functional status was the same. There were no pressure ulcers, other ulcers or foot problems. -The 12/11/14 MDS included no BIMS score. There were no pressure ulcers, other ulcers or foot problems noted. The resident's 8/12/14 "activities" care plan identified "several chronic health conditions including diabetes, hypertensive [MEDICAL CONDITION], and kidney disease." Handwritten notes were added to the care plan as follows: -"1/31/15 [MEDICATION NAME] (antibiotic) 500 mg po (oral) qid (four times a day) x 5 days. Cleanse wound with wound cleanser, cover with dressing, check q shift, change dressing q 3 days. Monitor until resolved." (This was noted below a note about a skin tear to the resident's shoulder.) -"2/3/15 Arrange consult with Dr (podiatrist name)." -"2/4/15 Amputation of R (right) 2nd toe & [MEDICATION NAME] 100 mg BID (twice daily) x 7 days." The 8/18/14 care plan identified "risk for skin breakdown ... reduced mobility, needs up to extensive assistance of 2 persons with daily care ... has type II diabetes with [MEDICAL CONDITION] to her feet ... has had weight loss over last 5 months but is within ideal weight range. Fragile skin that bruises, tears easily." Approaches included: "Complete weekly skin assessment and document. Pay particular attention to resident's feet." The 8/18/14 care plan further identified "type II diabetes ... not medicated at this time ... has [MEDICAL CONDITION] and [MEDICAL CONDITION] related to her diabetes." Approaches included: "Monitor feet with weekly skin checks and PRN. Licensed nurse to perform all nail care as needed. Podiatrist intervention as needed." 2. Record Review a. February 2014 physician orders [REDACTED]. However, without orders, the expected frequency and nature of the dressing changes could not be determined. b. All skin assessments were requested from the director of nursing (DON) on the afternoon of 2/5/15. (1) Weekly skin assessments One skin assessment, entitled "Weekly Skin Integrity Data Collection," dated 12/14/14 (date of readmission), was provided. It noted dry skin, right arm bruises, and redness to the left toe and coccyx. On the body map, Xs were drawn on the upper left arm and the tips of both feet. No further details were documented about the condition of the resident's skin. No further weekly skin assessments were provided for 12/14 (12/20 and 12/27/14, 1/3, 1/10, 1/17, 1/24, and 1/31/15). (2) Shower aide skin documentation Shower aide documentation dated 12/3/14 noted, "Bruise L (left) elbow, open area on toe R foot." Shower aide documentation on 1/3/14 noted, "Marks all over arms & legs." There were no notes about the resident's feet. There was no additional shower aide documentation of the resident's skin condition in 12/14 and 1/15. c. Nurses' Notes On 12/14/14 at 5:49 p.m., a nurse noted in part, "Resident arrived at facility ... from (local acute hospital). No injuries incurred during transfer ... The top resident's L (left) 2nd toe noted to be red with a scabbed appearance..." On 12/16/14 at 3:27 p.m., a nurse noted, "Skin check during shower: left foot second toe has a scab between the toes. Covered with a dressing ... Continue to monitor." There were no nurses' notes after 12/16/14 until 1/19/15. On 1/19/15 a nurse noted in part, "Dressings changed to toes and ankle. B/P (blood pressure) has increased during the day. Resident is bed chair bound. Continue to monitor." There was no further assessment, and no accompanying skin assessment. On 1/31/15, "Dressing changed to right and left feet, right foot 2nd toe appears infected, cleaned with wound cleanser, toe is draining, wrapped with small amount of [MEDICATION NAME] and a bandage. Call to (physician), new order [MEDICATION NAME]" On 2/1/15, "Dsg intact to infected toe. Began receiving ABO for infection at HS ... Resident appeared to be in distress during last check and change. B/P and resps noted to be increased... (The resident's temp was 98, pulse 86, respiration 40/min, and blood pressure 197/93.)" On 2/2/15, "Resident c/o pain when redressing her toe or when staff is checking and changing resident." On 2/3/15, "Dressing changed and toe noted to be inflamed and tender the whole length with open sore on nail-bed. Wound cleansed with wound cleanser and soaked with dilute vinegar. (Physician) informed of current wound condition and inspected wound. New order to arrange consult with (podiatrist)." On 2/6/15, "Will be having surgery to remove this toe [DATE] at 2:30 p.m." On 2/10/15, "Resident returned from surgery at 1630 (4:30 p.m.). New orders for [MEDICATION NAME] 50 mg one po q 6 hours for pain. She is to return to (podiatrist) on the 12th for him to change the dressing. The facility is not to change the dressing. No bathing that foot but keep the dressing CDI (clean, dry, intact). She is non weight bearing ... The foot is to be elevated on two pillows x 48 hours." d. physician progress notes [REDACTED]. A physician progress notes [REDACTED]. second toe was red and swollen. The nail bed is raw, and it looks like the toenail may have been inadvertently avulsed (torn away). (Resident) is not able to help us with the details on the injury..." The physician further noted, "[MEDICAL CONDITION] of the right second toe. Start [MEDICATION NAME] 500 mg 3 times daily, arrange consult with (podiatrist) ... The position of the toe renders it quite susceptible to trauma, with a scissor deformity, and there is a possibility that it will need to be amputated, which would simplify her care. In the meanwhile we will keep a bulky dressing over it, and monitor the patient for signs of discomfort." 3. Observations On the evening of 2/4/15, at approximately 6:30 p.m., the resident was observed sitting in her wheelchair in her room. Her oxygen cannula was sitting on top of her nose. She was thin, frail and pale, and had a bloody bandage covering a skin tear in the web of her right hand. The resident's husband who resided in the room with resident #16, said her toe was "infected down to the bone" and they were "going to amputate it tomorrow." He said, "She had a hard day today." On the afternoon of 2/5/15, resident #16 was observed sitting in her wheelchair in the front common area. She was wearing soft slippers with a hole at the top of her right foot near her toes. 4. Director of Nursing (DON) Interview The DON was interviewed on 2/5/15 at 3 p.m. When asked about resident #16's toe, she said the resident had an ingrown toenail and a nurse clipped it. She said, "I don't know how long it went before they looked under her sock. By then it was red and had pus coming out of it." The DON said the resident saw the doctor yesterday, "and they said she's going to have to have that toe amputated." The DON stated, "We need to do a lot more staff education." Preliminary findings were discussed with the nursing home administrator (NHA) late afternoon on 2/5/15. The NHA, DON and corporate consultant were asked to provide any further information by 2/9/15. The DON and NHA both acknowledged the nursing staff should have completed and documented weekly, head to toe skin assessments for resident #16. 5. Information Provided by the Facility 2/9/15 a. On 2/9/15, the interim NHA provided a memo that read in part as follows: "During complaint survey, (the) DON made statement ... that she thought resident toe was caused by toe nail clipping. From interviews with staff and review of documentation, there is not sufficient evidence to support that nature of toe injury occurred in this manner. Resident has had different toe issues related to diabetes since return from hospital in December." -The NHA referred to the attending physician's 2/4/15 exam note, and added: "In interview with (attending physician/medical director) on 2/6/15, he stated that amputation of toe may have been necessary even if injury had not occurred. He believed as stated in his note that toe was susceptible to trauma and that injury could occur easily do to positioning of toe." -"In interview on 2/6/15 with (a licensed practical nurse), she stated that she had known that in mid-January that (a registered nurse) had clipped (resident #16's) toenails. (The RN) had passed on to (the LPN) in report that he completed toe nail clipping. He did not state to her that he had clipped toe nails too short or that he had nicked her during toe nail cutting. He had only reported that he cut toe nails. (The LPN) said she had only speculated to (the DON) that the toe injury could have occurred from (the RN) clipping toe nails." -"(The RN) is no longer employed by facility. Have tried to reach (RN) to validate there were no injuries when trimming toenails, but to date he has not returned phone calls." -"In interview on 2/6/15 with (a certified nurse aide) that resident has had issues with toes in past that she has noted in shower records (see above). She also stated that resident skin is extremely fragile and can easily be bumped and trauma can occur." -"Upon resident's return from hospital on [DATE] there was documentation on skin check that toes on both resident's feet were red. Readmission nurses notes also noted an injury to L 2nd toe that was healing further providing evidence of resident susceptibility to problems with toes." b. A written statement from the LPN dated 2/9/15 read, "I took over next shift after (RN) in mid-January, (RN) reported to me that he did nail care on (resident #16). At no point did he report that he clipped her skin or cut her nails too short." c. A statement from the attending physician/medical director dated 2/9/15 read, "Based on my examination, as referenced in my note on 2/4/15 (above), (resident #16's) toe did not look like it was clipped or nails were cut too short. Most likely cause of toe injury and infection was an inadvertent self-inflicted toenail avulsion. The position of toe makes it susceptible to injury." No additional skin assessments by way of weekly skin assessments, shower aide documentation, or nurses' notes were provided. 6. Podiatrist Report and Interview At approximately 2 p.m. on 2/18/15, the podiatrist provided the resident's progress note, operative report and surgical pathology report which read in pertinent part as follows: a. The progress note dated 2/4/15 read that the resident had a "severely infected 2nd toe, right foot. Apparently, the nursing home staff noticed the infected toe yesterday. The patient relates her toe has been quite sore ... Pedal pulses are decreased. There is a red, swollen 2nd toe of the right foot with a distal ulceration that is 1 cm in diameter. There is exposed distal phalanx (exposed bone) within the central aspect of the ulceration." -The podiatrist's impression was diabetic osteo[DIAGNOSES REDACTED]. The treatment plan was to amputate the resident's toe. b. The operative report showed the amputation was performed on 2/10/15. c. The pathology report dated 2/11/15 noted in part: "The toe measures 4 x 1.5 x 1.5 cm. The toe appears to be amputated at the joint between the metatarsal and the proximal phalanx. The bony margin projects some 1.5 cm beyond the nearest soft tissue. An excoriated [MEDICAL CONDITION] is present on the dorsal-lateral aspect of the toe. The [MEDICAL CONDITION] measures 0.6 x 0.5 cm, and is located 0.3 cm from the skin margin. Cut sections reveal a dark red 0.6 x 0.4 x 0.4 cm intradermal hemorrhagic area that is proximal to the excoriated [MEDICAL CONDITION], and is located 0.1 cm under the surface of the skin. This could represent an avulsed toenail with hyperemic nail bed." -[DIAGNOSES REDACTED]. d. The podiatrist was interviewed by phone on 2/18/15 at 4:30 p.m. He said the resident was diabetic and had [MEDICAL CONDITION]. He was asked about the nature of the resident's infection. Referring to the pathology report, he said, "She actually had bone exposure. To have chronic osteo[DIAGNOSES REDACTED] means there was infection for at least six weeks ... There was exposed bone ... It was ulcerated ..." The podiatrist said the amputation "could have been prevented if they had addressed it earlier." He indicated that to effectively treat the toe without amputation, treatment should have started before the infection spread into the actual bone. He said, "We would debride anything that was infected, get wound cultures, place her on appropriate antibiotics. To be effective it should have started before the infection spread into the actual bone. We cannot cure diabetic bone infection with antibiotics. Looking back at my notes (dated 2/4/15 see above), nursing home staff just noticed it yesterday, so somebody wasn't doing diabetic foot evaluations on a regular basis." The podiatrist said, "I think their delay in treatment led to this toe amputation. This toe looked like a tomato - it was red and swollen and draining. Even the bath aides should have seen this ... The RNs should do weekly skin assessments, but the bath aides look at them twice a week, I would think." The podiatrist said he had seen the resident before, during 7/13, 11/13, and on 3/12/14. When asked if he had recommended another visit, he said, "I made a recommendation to (the facility) I wanted to see her in four months. No, they did not bring her over." The podiatrist said his standard was to see patients every two to four months, depending on their circulation. He said, "These (residents) should not get here when they already have a bone infection. There's so much we can do preventative, before it gets to that point."

Based on staff interviews and record review, the facility failed to ensure the resident environment, including the environment for two of 18 sample residents (#9 and #16) remained as free of accident hazards as possible. Specifically the facility failed to: -Provide resident #16 and resident #9 adequate supervision and assistance as care planned and recommended and -Ensure one medication room was locked at all times. The facility failures for resident #16 resulted in a fall with serious injuries. Findings include: A. SUPERVISION AND ASSISTIVE DEVICES 1. Resident #16, age 84, was admitted to the facility on [DATE] with diagnoses, per [DIAGNOSES REDACTED]. According to the resident's most recent Minimum Data Set (MDS), dated [DATE]: -He had no long- or short-term memory problems and no difficulty with cognitive skills, -He understood others and others usually understood him. -His vision was adequate with glasses. -He required extensive assistance from one staff with walking in his room, transferring, toilet use, and personal hygiene, -His primary mode of locomotion was wheelchair and he used a transfer aid, -He exhibited behaviors of verbal abuse and resistance to care, -He was continent of bowel and usually continent of bladder, -He was 60 inches tall and weighed 205 pounds, -He had fallen in the last ,[DATE] days, and -He was receiving oxygen therapy. Orders revealed the resident was ordered to receive oxygen at 3 liters continuously to keep SaO2 (blood oxygen saturation level) above 90%. a. Fall Risk Factors (1) See MDS above; the resident was assessed to require extensive assistance from one staff with walking in his room, transferring, toilet use, and personal hygiene. He was assessed to have fallen in the last ,[DATE] days. (2) Care Plan Resident #16's care plan for fall risk, revision dates unknown, identified he was at risk for falls due to a history of falls, reduced mobility, reduced range of motion, unsteady gait, altered sensation in his feet, pain, COPD, and occasional incontinence. The pertinent approach to minimize the resident's risk for falls was to give verbal reminders to call for assist with transfers as needed. Resident #16's psychotropic drug use care plan, revision dates unknown, also addressed the resident's fall risk. It read, "Encourage resident to request assistance with transfers or ambulation" and "observe resident for adverse side effects/toxicity of medications in current drug regime." (3) Medications Review of resident #16's [DATE] Medication Administration Record (MAR) revealed he had received many medications on at least a daily basis, that had the potential to decrease the resident's mental and physical abilities and therefore, contribute to his fall risk. These medications included: -Oxycontin ER (extended-release) 40 mg at 7:30 a.m. and 12:00 p.m. (started [DATE]), -Oxycontin ER 80 mg at 5:00 p.m. and 8:00 p.m. (started [DATE]), -Lyrica 100 mg at 7:30 a.m. and 12:00 p.m. (started [DATE]), -Lyrica 150 mg at 9:00 p.m. (started [DATE]) -Prilosec OTC 20 mg at 7:30 a.m. and 5:00 p.m. (started [DATE]), -Neurontin 900 mg at 1:00 a.m., 7:30 a.m. and 5:00 p.m. (started [DATE]) -Flexeril 10 mg at 9:00 a.m., 12:00 p.m. and 9:00 p.m. (started [DATE]) -Prozac 20 mg at 7:30 a.m., 12:00 p.m. and 5:00 p.m. (started [DATE]) -Norco ,[DATE] mg (Hydrocodone 10 mg and Tylenol 325 mg) PRN at 1:00 a.m. and 5:00 a.m. According to Lexi-Comp's Geriatric Dosage Handbook, 12th Edition, pgs. 367, 678, 1138, 1160, 1161 and 1284, these medications had the potential side effects of dizziness, weakness, impaired physical/mental ability, confusion and drowsiness. b. Fall With Injury Review of Nurse's Notes on [DATE] at 11:55 a.m. revealed the following documentation: "Pt (patient) called this nurse at 11:30 p.m. and said he thought he had swallowed his Fixodent from his dentures. He proceeded to get out of bed and get into his w/c (wheelchair). He talked to me and coughed a couple of times. I asked him if he wanted his PRN (as needed) Mucinex and a cup of tea. He said yes. Pt then removed his O2 (oxygen) and I asked him why he was removing his O2 and he said, "So I can go to the BR (bathroom)! Pt was alert and oriented, color pink. Resp (respirations) even and unlabored." "This nurse went to the dinning (sp) rm (room) and got a cup of tea and the Med (medication) rm and got Mucinex and picked up the suction machine from the utility rm. When returning to the pts rm pt was found laying (sp) face down in the br (bathroom). CNA (certified nurse aide) was called and told to call side 1 RN (registered nurse) and dial 911." "Pt was non-responsive - after moving electric w/c from the doorway - pt was turned over onto back. Skin was cool and color gray. Using Yankuer (sp) suction a blood clot was noted in back of throat and removed. . . No VS (vital signs) were present . . . Paramedics arrived in the pt's rm at 11:45 p.m. Paramedics called coroner." The Coroner's report, summarized, revealed resident #16 suffered a broken neck and died from a brain hemorrhage due to the fall. c. Failures Review of Nurse's Notes on [DATE] at 11:55 a.m. (see above) revealed the resident was left unattended in the bathroom without his oxygen. Review of the facility's Incident Information form, dated [DATE], revealed resident #16 required extensive assistance of one staff for transfers. Interviews by the facility with the nurse involved in the incident revealed resident's voice quality changed when he began complaining he had something in his throat. The nurse confirmed she left resident's room and did not notify any other staff resident #16 was in a compromised physical condition and was going to use the bathroom; there was no evidence the nurse had offered or provided resident #16 any assistance or supervision when he went to the bathroom. There was no evidence the nurse questioned resident #16's removal of his oxygen before going to the bathroom or considered the effect of the resident's lack of oxygen on his decision-making. d. Interviews The Director of Nursing (DON) was interviewed on [DATE] at approximately 1:00 p.m. She said the nurse was not available for interview because she had been terminated three weeks after the incident. Two staff members, who the DON said were most familiar with resident #16, were interviewed on [DATE] at approximately 1:15 p.m. -One staff member, a certified nurse aide (CNA), described resident #16 as nice and compliant with cares. She said he needed the assistance of one staff for transfers. The CNA said resident #16 was very coherent and compliant with using his oxygen. She said he was very aware he needed to use his oxygen constantly, including when he used the bathroom. The CNA said the staff had provided resident #16 with extra long oxygen tubing on his portable oxygen tank on his wheelchair to enable him to use his oxygen in the bathroom. The CNA said she stood outside the bathroom door while resident #16 was using the toilet. -The other staff member, a licensed nurse, who said she was familiar with resident #16, described him as very regimented due to his military background. She said his compliance with cares depended on his mood but if re-approached later he would usually comply. The nurse said resident #16 was very good about wearing his oxygen - "obsessed" - and she could not remember him not wearing his oxygen. She said resident #16 did require more physical assistance two weeks before his death and he would transfer himself. She said he said had commented to her that he felt physically weaker. The nurse said resident #16 had a "safety issue" and she would not have left him alone in the bathroom. The DON and the Assistant Director of Nursing (ADON) were interviewed on [DATE] at approximately 2:15 p.m. They both agreed resident #16 was not compliant with his cares, would insist on transferring himself, and would order staff out of his room. However, there was no documentation in resident #16's care plan regarding these behaviors and this information conflicted with the information provided by staff identified by the DON as most familiar with the resident. 2. Resident #9, age 88, was admitted to the facility on [DATE] and re-admitted on [DATE], following a fall on [DATE] with hip fracture. The ,[DATE] Computerized physician's orders [REDACTED]. According to the most recent MDS, dated [DATE], resident #9 had short-term and long-term memory problems. The resident was severely impaired with cognitive skills for daily decision-making. The resident exhibited several indicators of delirium - periodic disordered thinking/awareness, such as: easily distracted, periods of altered perception or awareness, episodes of disorganized speech, periods of restlessness. The resident exhibited socially inappropriate/disruptive behaviors that were easily altered. -The resident was documented to need extensive assistance for bed mobility, transfers, walking in the room/hallway, dressing, eating, toilet use, personal hygiene, and total dependence for locomotion on/off the unit and bathing. The resident was documented as frequently incontinent of bowel and bladder. -The resident was documented with unsteady gait as a problem condition and the resident had fallen in the past ,[DATE] days. The resident's weight was documented with 104 pounds at a height of 64 inches. a. Fall risks (1) MDS See above MDS; the resident was severely cognitively impaired, required extensive assistance, was frequently incontinent, had an unsteady gait and had fallen in the past 31 - 180 days. (2) Fall Risk Assessment Review of the resident's Fall Risk Assessment, dated [DATE], revealed that during the last 90 days the resident had: ,[DATE] falls. The resident's score for the fall risk assessment was documented as "24" (A score of 10 or higher indicated at risk and staff were to consider environmental risk factors in resident interventions. The assessment noted the presence of a "Chair (that) prevents rising;" however the subsequent columns (for environmental risks) were blank. (3) History of Falls and Unsafe Behaviors Review of Post-fall investigations (titled Incident Follow-Up & Recommendation Form) revealed the resident fell out of bed on [DATE], and sustained a hip fracture. Additional falls and unsafe behavior were noted in post-fall investigation and/or nurses' notes. On [DATE] (9:00 p.m.), the investigation read that the resident was found on the floor next to her high/low bed. An alarm was in place, but not sounding. Resident noted to have a urinary tract infection. On [DATE] (10:30 a.m.), the investigation read the resident stood up from her wheelchair, sounding the alarm. She fell and hit her back and left side against the wheelchair foot pedal. On [DATE] (5:00 p.m.), the investigation read the resident stood and tripped over foot pedals. She fell on to her left side and hit her head. On [DATE] at 10:30 a.m., nurses' notes read, "... Has continued poor safety awareness ..." On [DATE] at 3:00 p.m., nurses' notes read, "... Pt (patient) still attempting to get up without assist ..." On [DATE] at 9:30 a.m., nurses' notes read, "Resident continues to mobilize self with w/c (wheel chair). (illegible) PT for ambulation training + transfers. ... Has 0 (zero) safety awareness. Continues to have need for ,[DATE] person assist with ADLs (activities of daily living) depending on agitation ..." b. Facility's Response to Risks, Falls and Unsafe Behaviors (1) Care plans Review of the resident's Care Plan (CP), dated [DATE], and last reviewed/revised by the facility on [DATE], revealed the following plans identifying and addressing the resident's risk factors: Problem: Risk for Falls/Injury form falls r/t (related to) dementia with lack of safety awareness; non-compliant at times, hx (history) of falls, R (right) hip # (fracture) from fall [DATE]. Resident is using w/c (wheelchair) for mobility at this time, beginning to takes steps with PT (physical therapy). Takes psychotropic meds (medications) daily. - Goal: Will be free of falls/injury from falls over the next 90 days. - Approaches included: -- Pull tab alarm in bed and wheel chair, -- Anticipate and meet needs in a timely manner, -- Give resident verbal reminders to call for assist as needed, -- Assess resident's need for assistive/supportive device and refer to therapy as indicated, -- Maintain resident environment free of clutter and safety hazards ... -- Falling Star Program (see below). A handwritten addendum dated [DATE] stated "fall [DATE] toilet Resident ,[DATE] minutes post administering suppository. On [DATE] at 11:45 a.m. the facility produced a document titled "Standing Strong Together, Falling Star/Falling Leaf Program" which read that for residents in this program: (1) The care plan is updated to reflect current fall risk status and resident specific interventions designed to reduce occurrence; (2) Staff are educated to recognize residents participating in the program and staff are encouraged to assist residents attempting to stand from the wheelchair or climb out of bed and/or seek nursing assistance/assessment of the resident's needs; (3) Incidents are reported to the charge nurse and reviewed for patterns and trends. Problem: Resident is experiencing communication difficulties related to severe dementia and hard of hearing. Decline since recent hip (fracture) with surgery. She requires others to increase volume of voice - has hearing aids. Speech is clear but resident talks less. Mumbles and hums, rarely speaks in understandable words. - Goal: (Resident's name) will be able to communicate effectively as evidenced by answering simple questions appropriately over the next 90 days. Demonstrate understanding by completing task when requested x (times) 90 days. - Approaches listed included: ... Observe for non-verbal indicators of needs ... Problem: Cognitive Impairment; short and long term memory loss with impaired decision making ability. Resident has poor safety awareness. Processing of information and understanding is complicated by hard of hearing. -- Goal: Resident ' s needs will be met for the next 90 days. -- Approaches listed included: ... Keep environment free from clutter and safety hazards ... Problem: Psychotropic drugs: Resident has an unsteady gait and poor trunk control, fell w/fx (with fracture). Difficulties w/constipation (with constipation). C/O (complaints of) pain - moans and groans. Takes Seroquel, Celexa, and Ativan for dementia, behaviors w/depression and anxiety. - Goal: Have no injury related to medication usage/side effects for the next 90 days. - Approaches listed included: ... Maintain resident environment free of clutter and safety hazards. Encourage resident to request assistance with transfers or ambulation. Keep call light within arm's length of resident and teach resident how to use call light to request assistance - has dementia not able to use call light. Problem: Behaviors: Resident fx (fractured) her hip and can yell out in pain when moved. She will moan and groan in the Common Area s/s (signs and symptoms) of discomfort and pain. Can resist eating, drinking, and being moved. - Goal Resident's c/o pain and discomfort will be minimized or resolved over the next 90 days. Resident will be able to consistently accept care and treatment for [REDACTED]. - Approaches listed included: ... Place resident in area where constant observation is possible ... (2) Post Fall Investigations Review of the "Incident Follow-Up & Recommendation Forms" (post fall investigations) revealed the form was completed for the falls on [DATE], [DATE] and [DATE]. For the fall [DATE] revealed no recommendation or follow-up (see below). For the investigation of the [DATE], the recommendation section read that a suppository had preceded the fall by 15 minutes. For the investigation of the [DATE] fall, the recommendation section read that staff were aware the resident becomes anxious, she needs to be toileted and placed in a recliner. c. Failures in Facility's Response (1) Observations and staff interview - failure to assess resident safety in recliner, failure to place resident in area of "constant supervision." Observations: On [DATE] at 9:05 a.m., two Certified Nurses Aides (CNAs) were observed leaving resident #9's room. Resident #9 was observed sitting in the recliner chair next to her bed. Her legs were elevated by the raised footboard of the chair and the resident legs were covered with a blanket. When spoken to, the resident responded "I love, love, love you." The resident then hummed and spoke random words "tan, tan, say, say" before she stated "Where is the bathroom?" On [DATE] at 9:32 a.m., resident #9 remained in her recliner chair next to her bed with legs elevated. Staff was not within line of sight. On [DATE] at 3:20 p.m., the tabs alarm were sounding from resident #9's room. The resident was observed sitting on the elevated foot rest of her recliner chair. She had her left leg off the side of the recliner and the right leg off the end of the footrest. The resident was trying to balance herself when staff arrived to stabilize and assist her. The first staff member responding, a CNA, tried to hold the resident up and keep her from slipping off the chair. Upon arrival of the Registered Nurse (RN) the staff applied a gait belt to the resident and transferred her to her w/c. The CNA and RN reported the resident was a fall risk and she was not able to lower the footrest of the recliner chair by herself. The CNA reported the resident will try to stand up by herself when sitting up, but not usually when fully reclined. The CNA stated the resident was fully reclined in the recliner chair prior to the incident. Interview: The DON was interviewed on [DATE] at 8:15 a.m., at 10:35 a.m. and again at 1:15 p.m. She stated the facility had not completed a safety assessment for the use of the recliner for resident #9. She stated she had not been notified about the resident trying to climb out of the recliner chair. The DON reported she did not think the resident was able to lower the footrest of the recliner by herself. The DON stated the report of the incident with the resident sitting on the footrest sounded like the resident had been trying to climb out of the recliner chair. A Certified Nurse Aide (CNA) who was assigned to another hallway but occasionally assisted with care on the resident's hallway was interviewed on [DATE] at 9:15 a.m. She reported she had not seen the resident try to transfer out of the recliner by herself prior to the incident on [DATE]. She clarified another CNA had reported it was not unusual for the resident to attempt climbing out of the recliner. She reported the resident was a fall risk and all residents at risk of falling had a tabs alarm. She explained "we put her in the recliner because she gets upset around other people." However, another CNA familiar with resident #9 was interviewed on [DATE] at 9:20 a.m. She reported she had observed the resident attempting to climb out of the recliner chair 2 or 3 times before the incident on [DATE]. The CNA explained the resident would start "scooting" her body forward in the w/c or recliner when she needed to have a bowel movement. The CNA confirmed she had found the resident sitting on the footrest before. The CNA stated the nurse was aware of that. The CNA stated she did not report the incident to the nurse as she knew it was happening. She clarified the CNAs would tell the nurse what had happened and request the resident be assessed for the need of bowel interventions. When asked if the resident could lower the footrest on her own to facilitate a safe transfer from the chair, the CNA shook her head "No". (2) Post-Fall-Investigations to prevent additional falls were incomplete and recommendations, when made, were not carried over to the resident's care plan. Record Review: Review of the post-fall investigations ("Incident Follow-Up & Recommendation Form") for [DATE], revealed for the fall [DATE], no recommendations/follow-up was listed. There was no documentation that the facility was going to follow-up on the finding that the alarm was not sounding. Moreover, there was no documentation identifying the position of the high/low bed at the time of the fall. The form was signed by the DON, the Medical Director (MD) and 7 other staff members. Review of the post-fall investigations ("Incident Follow-Up & Recommendation Form") for the fall on [DATE], revealed the investigation documented a suppository had been administered prior to the fall, but there was no evidence that staff were to be educated about the identified trigger for the resident to stand up from her wheelchair. The document was signed by the Executive Director, DON, MD and 6 other staff members. Review of the post-fall investigations ("Incident Follow-Up & Recommendation Form") for the fall on [DATE] revealed the recommendation (for toileting and recliner when anxious) was not carried over to the resident's care plan. Moreover, the follow-up section was blank. The document was signed by the Executive Director, DON, MD and 5 other staff members. A document titled, "Questions the Fall Team ask after each AM meeting" was attached to the [DATE] fall investigation. This document included 12 questions to be asked to assist in the investigation process, i.e. -"Was enough staff on the floor at the time of the incident? -Was it consistent staff on during the event? -Do staff in the huddle know who is a fall risk at that current moment, are they worried about other residents falling? -Is the family involved and supportive? -Was the resident too hot or cold? Does the resident know how to use the call light? -Is the resident bored? -Is there too much stimulation? -Is the resident anxious?..." Answers to these questions were not documented. The document outlined if the resident could not answer to ask staff. The form also instructed to check a blood sugar, orthostatic blood pressure (blood pressure while laying down, sitting, standing), and list hypnotic, antianxiety and psychotropic medications. The form documented Ativan 1 mg (milligram) and Seroquel. Interview: The DON was interviewed on [DATE] at 8:15 a.m., at 10:35 a.m. and again at 1:15 p.m. The DON confirmed that the recommendation and follow-up section after the fall on [DATE] was left blank. She stated the facility implemented a check of the alarms monthly - but the Plan of Care did not include safety checks related to the alarms. The DON stated other measures such as a pressure alarm mat in the chair and/or bed had not been implemented. B. Medication Room Door According to Fundamentals of Nursing 7th ed (Perry & Potter, 2009) page 703, "Institutions providing nursing care have a special area for stocking and dispensing medications. Special medication rooms, portable locked carts, computerized medication cabinets, and individual storage units next to clients' rooms are examples of storage areas used. Make sure all Medications are in locked containers in a room (i.e. medication room) or are under constant surveillance." Observations: On [DATE] at 12:12 p.m., the medication room door of the station 1 medication room was observed open/unlocked for approximately 5 minutes. A facility nurse was not present to monitor the room. Two locked mobile medication carts were located in the medication room. The cabinets with glass doors above the counter showed multiple blister cards full of medication. Upon checking, the cabinet doors opened and medications stored included Flexeril, and several cardiac medications. Other unlocked cabinets contained large amounts of stock medication including Tylenol, stool softener, vitamins. Several residents were noted in the common area referred to as the "the circle" outside the medication room. On [DATE] at 12:15 p.m., the Nursing Home Administrator (NHA) confirmed the open medication room door. On [DATE] at 1:12 p.m., the Director of Maintenance Service was observed assisting with work on the door of the station 1 medication room. He stated his colleague was putting a door closer on the door. Interviews: The Registered Nurse (RN) was interviewed on [DATE] at 1:10 p.m. She stated the medication room door had to be closed and locked at all times, unless a nurse was present in the medication room. She explained this safety measure was important as there were many medications stored in the medication room. She stated residents or other staff could get into the medication room and gain access to the medications if the door is not secured. The DON was interviewed on [DATE] at 1:15 p.m. She reported the medication room door had to be closed unless a nurse was present in the room. She explained this was to ensure the safety and security of medications and ensure no unauthorized access by residents, staff or visitors.