Every finding on record at Edgewater Health and Rehabilitation

Based on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure kitchen staff appropriately cleaned thermometers before and after use. Findings include:I. Improper cleaning of food thermometerA. Professional referenceAccording to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved 9/2/25 from:, revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. Equipment, food-contact surfaces and utensils shall be cleaned before using or storing food temperature measuring devices. (4-602.11)B. Facility policy and procedureThe Food Temperatures policy, undated, was provided by the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. It read in pertinent part, To take temperatures, a clean, rinsed, sanitized and air-dried thermometer that is metal stem type. To take hot food temperatures, insert the thermometer at a 45-degree angle to the middle of the food item, taking care not to touch the container or bone if it has one. Wait for the thermometer to rise to the maximum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clean and sanitize.C. ObservationsDuring a continuous observation of the lunch meal on 8/26/25, beginning at 11:30 a.m. and ending at 12:10 p.m., the following was observed:At 11:30 a.m. the cook (CK) was cleaning a thermometer to take a temperature before serving. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe square and the packaging. He then ran the alcohol wipe and the packaging up and down the thermometer probe. He obtained the temperature of the beans and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe. At 11:32 a.m. the CK took the temperature of pureed quesadillas. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe square. He then ran the alcohol wipe and the packaging up and down the thermometer probe. He obtained the temperature of the quesadillas and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe.At 11:35 a.m. the CK took he temperature of pureed beans. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe square. He then ran the alcohol wipe and the packaging up and down the thermometer probe. He obtained the temperature of the beans and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe.At 11:37 a.m. the CK took the temperature of sour cream. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. He then ran the alcohol wipe and its packaging up and down the thermometer probe. He obtained the temperature of the sour cream and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe.-The CK failed to open the alcohol wipe diagonally, inserting the thermometer probe into the opening and cleaning the probe without the packaging touching the probe. D. Staff interviewsThe CK was interviewed on 8/26/25 at 11:40 a.m. The CK said he was taught to poke the thermometer through the alcohol wipe packaging to disinfect the thermometer.The dietary manager (DM) and the NHA were interviewed together on 8/27/25 at 9:30 a.m. The DM showed how she was taught to clean a thermometer. She took an alcohol wipe out to clean the thermometer and she poked the thermometer through the middle of the alcohol wipe square. She then ran the alcohol wipe and its packaging up and down the thermometer probe. -The DM failed to open the alcohol wipe diagonally, inserting the thermometer probe into the opening and cleaning the probe without the packaging touching the probe.

Based on observations, record review 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 disease and infection on one of two units. Specifically, the facility failed to:-Ensure housekeeping staff performed appropriate hand hygiene when cleaning residents' rooms,-Ensure staff performed appropriate hand hygiene when performing incontinence care for Resident #23; and,-Ensure staff wore appropriate personal protective equipment (PPE) during high contact resident care for Resident #23 and Resident #4, who were on enhanced barrier precautions (EBP).Findings include: I. Failed to ensure housekeeping staff performed appropriate hand hygiene when cleaning residents' roomsA. Professional reference According to The Centers for Disease Control And Prevention's (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers (February 2024), retrieved on 9/2/25 from: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, Recommendations to clean your hands include immediately before touching a patient, before performing an aseptic technique, before moving from work on a soiled body site to a clean body site, after touching a patient or patient's surroundings, after contact with body fluids and immediately after glove removal.B. ObservationsDuring a continuous observation on 8/26/25, beginning at 1:30 p.m. and ending at 1:50 p.m., the following was observed: Housekeeper (HK) #1 was cleaning resident room [ROOM NUMBER]. HK #1 began by putting gloves on her hands. She retrieved bottles of chemicals out of a housekeeping cart and set them inside the room. She removed her gloves and donned (put on) clean gloves without performing hand hygiene. HK #1 removed a dust pan from the housekeeping cart and set it up inside the room. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 removed a broom and mop from the housekeeping cart and set them up inside the room. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 sprayed a chemical solution onto a rag and wiped down the television remote on side A of the room and disposed of the rag in the cart. She removed her gloves and donned clean gloves without performing hand hygiene. She then sprayed the chemical onto a clean rag and wiped down the bedside table on side A before disposing of the rag in the cart. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 next sprayed a glass cleaner chemical onto a rag and wiped the mirror in the bathroom before disposing of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 then scrubbed the toilet with a brush and put it back into the cart. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 next sprayed the toilet with a chemical. She removed her gloves and donned clean gloves without performing hand hygiene. She swept the room and disposed of the contents in the dust pan. She removed her gloves and donned clean gloves without performing hand hygiene. She removed the fall mat on side A of the room and swept where the mat was. She removed her gloves and donned clean gloves without performing hand hygiene. She wiped down the toilet with a rag and disposed of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. She got a clean rag and wiped the inside of the toilet and disposed of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. She wiped the mirror with a clean rag and disposed of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 put away the glass cleaner. She removed her gloves and donned clean gloves without performing hand hygiene. She attached a clean mop head to the mop and mopped the bedroom. She disposed of the mop head. She removed her gloves and donned clean gloves without performing hand hygiene. She attached a clean mop head to the mop and mopped the bathroom. She disposed of the mop head. She removed her gloves and donned clean gloves without performing hand hygiene. She attached a new mop head to the mop and mopped the entryway of the room. She removed her gloves and donned clean gloves without performing hand hygiene. She swept the entryway of the room. She removed her gloves. HK #1 said she was finished cleaning the resident's room. -HK #1 changed her gloves 18 times throughout the course of cleaning resident room [ROOM NUMBER], however, she failed to perform hand hygiene with each glove change, including after cleaning the toilet and prior to cleaning other areas of the room.II. Failed to ensure staff performed appropriate hand hygiene when performing incontinence care for Resident #23 A. Observation During a continuous observation on 8/26/25, beginning at 12:40 p.m. and ending at 1:30 p.m., the following was observed: At 1:15 p.m. the call light in Resident #23's room was turned on. At 1:18 p.m. certified nurse aide (CNA) #1 went into the room. CNA #1 donned clean gloves and began to check Resident #23's brief. She removed the soiled brief and performed perineal (area between the genitals) care on Resident #23. She put a clean brief on Resident #23. Without changing gloves and performing hand hygiene, CNA #1 pulled Resident #23's skirt over her legs and assisted her to sit up in bed. CNA #1 put shoes on Resident #23 and put a gait belt around her waist. CNA #1 transferred Resident #23 to her wheelchair. CNA #1 put Resident #23's oxygen cannula in her nose and secured the oxygen tubing behind her ears. CNA #1 then removed her gloves and, without performing hand hygiene, removed the bag of trash from the trashcan. CNA #1 put Resident #23's sweater on her and proceeded to wheel Resident #23 out of the room. CNA #1 stopped to throw away the trash and perform hand hygiene and then wheeled Resident #23 into the living room. -CNA #1 failed to change her gloves and perform hand hygiene after changing the resident's soiled brief and prior to touching the resident's clothing, shoes, a gait belt, the resident's oxygen nasal cannula and tubing and the handles of the resident's wheelchair.-Additionally, CNA #1 failed to don a gown prior to performing high-contact resident care for Resident #23, who had a wound on her left shin (see additional EBP failures below).III. Failed to ensure staff wore appropriate PPE during high-contact resident care for Resident #23 and Resident #4, who were on EBPA. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Frequently Asked Questions about EBP in Nursing Homes (6/28/24), retrieved on 9/2/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally-inserted central catheters (PICCs), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. The presence of an indwelling device is a major risk factor for being colonized with or acquiring a MDRO. Therefore, the safest practice would be to wear a gown and gloves for any care (such as dressing changes) or use (injecting or infusing medications or tube feeds) of the indwelling medical device.B. Facility policy and procedure The Enhanced Barrier Precautions policy and procedure, revised June 2024, was received from the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. It documented in pertinent part, EBP should be used during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their multi-drug resistant organism (MDRO) status. Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care.C. ObservationsDuring a continuous observation on 8/25/25, beginning at 12:15 p.m. and ending at 4:05 p.m., the following was observed: At 12:49 p.m. Resident #23 was sitting in her wheelchair in the living room. CNA #1 went up to Resident #23 and wheeled her into her room. There was a sign for EBP precautions on the door of Resident #23's room. CNA #1 put gloves on, took Resident #23's sweater off and assisted Resident #23 into bed. Resident #23 had a large bandage on her left shin. CNA #1 took Resident #23's shoes off and covered her up with a blanket. -CNA #1 failed to don a gown prior to transferring Resident #23 into bed. At 3:04 p.m. CNA #2 and CNA #3 went into Resident #23's room. CNA #3 put gloves on but no gown. CNA #2 did not put a gown or gloves on. CNA #2 sat Resident #23 up in bed and put socks on her feet. CNA #3 put a gait belt around Resident #23's waist. CNA #2 and CNA #3 transferred Resident #23 into her wheelchair. CNA #2 put on Resident #23's sweater and shoes and wheeled her into the living room. -CNA #2 and CNA #3 failed to wear appropriate PPE during high-contact resident care for Resident #23. On 8/26/25 at 11:30 a.m. registered nurse (RN) #1 was providing tube feeding for Resident #4. RN #1 gathered supplies and went into Resident #4's room. There was an EBP sign outside of Resident #4's room. RN #1 donned clean gloves and explained the procedure to Resident #4. RN #1 unclamped the feeding tube, administered warm water into the feeding tube, administered the feeding tube formula and administered more warm water to flush the tube. RN #1 clamped the tube closed and threw the supplies away. She cleaned out the syringe and removed her gloves. RN #1 washed her hands.-RN #1 failed to don a gown prior to performing Resident #4's tube feeding. IV. Staff interviews The environmental services director was interviewed on 8/26/25 at 2:00 p.m. The environmental services director said housekeepers should change their gloves when they were soiled while cleaning residents' rooms. She said gloves should be changed a minimum of five times during cleaning one room. She said hand hygiene should be performed after each glove removal. RN #1 was interviewed on 8/27/25 at 9:25 a.m. RN #1 said residents with bacteria in their urine, foley catheters, feeding tubes and wounds required EBP. She said EBP required wearing a gown and gloves when performing high-contact care. She said she was not sure if she should wear a gown when administering tube feeding formula to a resident's feeding tube and said she had not received any education about that. The infection preventionist (IP) was interviewed on 8/27/25 at 11:00 a.m. The IP said hand hygiene should be completed when entering the dining room, removing gloves, coming out of a resident's room and between handling room trays. She said gloves should be changed when moving from a dirty to clean area during care. She said this included after performing perineal care on a resident. She said the importance of hand hygiene was for infection control. The IP said residents with indwelling medical devices, including a gastric feeding tube, residents with wounds and residents with MDROs were placed on EBP. She said this meant staff should wear a gown and gloves during high contact resident cares such as showers, transfers and perineal care. She said Resident #23 was on EBP because of a wound. She said EBP included the administration of tube feedings and medications through a gastric feeding tube. She said the importance of following EBP was for infection control. She said RN #1 should have put on a gown before working with Resident #4's tube feeding. The director of nursing (DON) was interviewed on 8/27/25 at 11:20 a.m. The DON said hand hygiene should be completed after moving from a dirty task to a clean task during resident care and after glove removal. She said the importance of this was to prevent the spread of infection. She said wounds, foley catheters, intravenous catheters (IVs) and gastric feeding tubes qualified a resident to be placed on EBP. She said staff should wear a gown and gloves when providing care to these residents. She said the importance of this was to prevent infection.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for one (#13) of five residents reviewed for personal funds accounts out of 34 sample residents.Specifically, the facility failed to notify Resident #13, who was Medicaid funded, or her legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit.Findings include:I. Record reviewA review of Resident #13's current trust account balance revealed the resident had $2,631.92 in her account, which was $631.92 over the allotted limit of $2,000.00 for Medicaid-funded residents.II. Staff interviewsThe financial coordinator and the nursing home administrator (NHA) were interviewed together on 8/27/25 at 9:30 a.m. The financial coordinator said she notified residents or residents' representatives when the residents' personal funds accounts reached $2,000. The financial coordinator said she was unaware that the residents or their representatives needed to be notified when their personal funds account reached $200.00 less than the eligibility resource limit. The financial coordinator said residents were at risk of losing their Medicaid-funded benefits when their personal funds account reached $2,000. The NHA said the facility had been in contact with Resident #13's representative to spend down the resident's personal funds account once the account reached the allotted limit. -However, the facility was unable to provide documentation to indicate communication with Resident #13's representative had taken place in regards to the account balance of the resident's personal funds account.

Based on observations, record review, and interviews, the facility failed to ensure one (#69) of four residents reviewed for activities of daily living (ADLs) out of 34 sample residents received the necessary services to maintain good nutrition and personal care. Specifically, the facility failed to provide meal assistance for Resident #69. Findings include:I. Resident #69A. Resident statusResident #69, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD) , essential hypertension (high blood pressure), and hypothyroidism (low thyroid function).The 8/13/25 minimum data set (MDS) assessment revealed Resident #69 had a memory problem and and was moderately impaired cognitive skills for daily decision making per staff assessment. She required maximum assistance of one staff member with meals and one-person assistance with transfers and personal hygiene. B. ObservationsDuring a continuous observation on 8/24/25, beginning at 11:30 a.m. and ending at 12:25 p.m., the following was observed: At 11:30 a.m. Resident #69 received her meal, which consisted of a pureed diet. The food was placed on the table, within her reach. Two unidentified certified nurse aides (CNA) were next to the resident and the other two residents who were at the same table. The unidentified CNAs assisted the other residents, but Resident #69 was not assisted. The staff encouraged the resident to eat, but they did not provide any physical assistance. Resident #69 had a third of a glass of milk and her plate remained full when she left the dining room at 12:25 p.m.During a continuous observation on 8/25/25, beginning at 11:25 a.m. and ending at 12:00 p.m., the following was observed: At 11:30 a.m. Resident #69 received her meal, which consisted of a pureed diet. The food was placed on the table, within her reach. An unidentified CNA was next to the resident and fed another resident who was at the table, but Resident #69 was not assisted. Resident #69 had three-quarters of a glass of milk and her plate remained full when she left. At 11:58 a.m. the unidentified CNA assisted Resident #69 out of the dining room and to a common area. C. Record reviewThe nutrition care plan, revised 7/4/25, revealed Resident #69 required a modified texture diet consisting of pureed foods with thin liquids, fortified foods, one-on-one assistance during meals and verbal cues to encourage swallowing after taking bites or sips to prevent pocketed food. The care plan indicated staff were to offer the resident one food item at a time.D. Staff interviewsCNA #4 was interviewed on 8/27/25 at 9:51 a.m. CNA #4 said Resident #69 was usually able to communicate with others during meals. CNA #4 said the staff set Resident #69 up at the table and prepared the resident's food. CNA #4 said when the resident was unable to eat, the staff provided some cueing assistance with reminders and occasionally physically helped her with her food. CNA #4 said Resident #69 did not eat well and often had a snack between meals. CNA #4 said if the resident refused to eat her meals, the staff could not force her to eat. Registered nurse (RN) #3 was interviewed on 8/27/25 at 11:01 a.m. RN #3 said Resident #69 had cognitive impairments, but was able to communicate at times. RN #3 said Resident #69 lost some weight lately, so the staff continued to try to assist her, but she repeatedly refused help.-However, observations revealed staff did not attempt to physically assist the resident with eating (see observations above).The medical director (MD) was interviewed on 8/27/2025 at 12:21 p.m. The MD said Resident #69 had impaired cognition and needed one-on-one assistance during her meals.

Based on observations, record review and interviews, the facility failed to ensure one (#56) of two residents out of 34 sample residents received proper respiratory care and services in accordance with professional standards of practice, the resident's care plan and the resident's choice. Specifically, the facility failed to:-Ensure Resident #56's continuous oxygen setting was set at the prescribed flow rate; and,-Ensure Resident #56 was provided with continuous oxygen supplementation per physician's orders.Findings include:I. Facility policy and procedureThe Oxygen Titration policy and procedure, reviewed 1/14/25, was provided by the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. via email. It read in pertinent part, Oxygen will be administered per physician orders and nursing evaluation. Evaluation of thecontinued need for oxygen will be based on diagnoses, history and clinical presentation,including titration results. Continuous oxygen orders will include the liter flow, route andfrequency for oxygen use, frequency of pulse oximetry, titration parameters and diagnosis. Oxygen titration orders will consist of the frequency of pulse oximetry and parameters for titration.II. Resident #56A. Resident statusResident #56, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbances, respiratory failure with hypoxia, chronic obstructive pulmonary disease and cognitive communication deficit.The 5/7/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required maximum assistance with activities of daily living (ADL). The MDS assessment revealed that the resident required continuous oxygen at 2 liters per minute (LPM) with a nasal cannula.B. ObservationsOn 8/24/25 at 9:30 a.m. Resident #56 was observed sitting in her room. The resident's oxygen concentrator was set to 4.5 LPM.-However, Resident #56 oxygen flow rate was supposed to be 2 LPM, per physician's orders (see record review below).At 2:45 p.m. Resident #56 was observed sitting in her room. The resident's oxygen concentrator remained set at 4.5 LPM.On 8/25/25 at 9:55 a.m. Resident #56 was observed sitting in her room with her oxygen concentrator set at 4.5 LPM.At 1:20 p.m. the Resident #56's oxygen concentrator remained set at 4.5 liters LPM.At 3:01 p.m. Resident #36 was observed sitting in her wheelchair in the activity room. She was not wearing any supplemental oxygen.At 4:00 p.m. Resident #56 was taken to the dining room for dinner. She was not provided with any supplemental oxygen.On 8/26/25 at 9:00 a.m. Resident #56 was observed asleep in her room. The resident was not using any supplemental oxygen.At 11:24 am, the resident remained asleep in her room without supplemental oxygen.C. Record reviewThe respiratory care plan, dated 4/19/24, documented that the resident had a diagnosis of acute respiratory failure and was at risk for hypoxia. The interventions included the use of supplemental oxygen at 2 LPM continuously. Review of Resident #56's August 2025 CPO revealed the following physician's order:Oxygen at 2 LPM continuously via nasal cannula, ordered 4/19/24.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/26/25 at 11:25 a.m. LPN #1 said Resident #56 was prescribed 2 LPM of oxygen continuously via nasal cannula, per the physician's order. LPN #1 entered Resident #56's room and confirmed the resident was not wearing her nasal cannula and therefore was not receiving oxygen. LPN #1 checked Resident #56's oxygen saturation (level of oxygen in the blood), which read 91% (percent) on room air LPN #1 placed the oxygen on the resident via nasal cannula at 2 LPM.LPN #1 said it was the nurse's responsibility to ensure residents were on their appropriate oxygen liter flow rates. LPN #1 said he did not realize Resident #56 was not wearing the oxygen when he administered her morning medications.The director of nursing (DON) was interviewed on 8/26/25 at 12:50 p.m. The DON said each resident's oxygen should be checked three times per day to ensure the resident was receiving the correct amount of oxygen. She said it should be documented in the treatment administration records (TAR), along with the resident's oxygen saturation. The medical director (MD) was interviewed on 8/27/25 at 12:30 p.m. The MD said it was appropriate for Resident #56 to receive oxygen at 2 LPM via nasal cannula continuously. He said he would continue to monitor the resident to determine if her oxygen flow rate needed to be adjusted.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#10) of one resident out of 34 sample residents. Specifically, the facility failed to:-Obtain a physician's order that addressed Resident #10's medical symptoms; -Ensure ongoing safety risk assessments were completed for the use of restraints for Resident #10; and,-Ensure that the least restrictive measures attempted and proven unsuccessful for Resident #10 were documented. Findings include:I. Facility policy and procedureThe Restraint Assessment and Consent policy and procedure, revised October 2024, was provided by the director of nursing (DON) on 8/27/25 at 9:55 a.m. It read in pertinent part, A physical restraint free or least restrictive environment will be the standard for resident care. If restraints are present, the interdisciplinary team will make every effort to reduce and then eliminate restraints. Purposes for restraint use include resident safety, injury prevention and protection of a medical device. When evaluating restraints, a risk benefit of device use will be completed. The following will be documented on the evaluation/consent form:-Alternative measures tried prior to device use, with trial results;-Evaluation of self-release ability and potential movement or access to body restriction;-Observations of device effect on resident;-Identification of potential risks and benefits of device; and,-Medical symptoms. A physician's order will be obtained for restraints. This order will include the type and purpose of the restraint and duration of application, as well as a diagnosis for the restraint. If the restraint is determined to be appropriate, a long term care plan will be implemented, including a plan for interdisciplinary team restraint reduction. Restraints will be evaluated and reported on a monthly basis as part of the quality assurance process and with any potential change of condition. This evaluation is located on the back of the consent form. If a significant change of condition is identified, the restraint evaluation will be re-done.II. Resident #10A. Resident statusResident #10, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included cerebral palsy (a congenital disorder of movement and muscle mass) and depression.The 7/31/25 minimum data set (MDS) assessment revealed Resident #10 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated a trunk restraint and limb restraints were used daily.B. ObservationsOn 8/24/25 at 9:00 a.m. Resident #10 was observed wearing a seatbelt and foot straps while seated in her wheelchair.On 8/25/25 at 10:30 a.m. Resident #10 was observed wearing a seatbelt and foot straps while seated in her wheelchair.On 8/26/25 at 1:18 p.m. Resident #10 was observed wearing a seatbelt and foot straps while seated in her wheelchair.C. Record reviewOn 10/14/24, a physical restraint evaluation and consent were completed. The evaluation documented Resident #10 was trialed without the use of foot straps, however both feet were not able to be positioned independently and the resident needed the staff to place both feet back on the foot pedals. It documented Resident #10 had an increased risk for injury without the foot straps.On 11/19/24, a physical restraint evaluation and consent were completed. The evaluation documented Resident #10 was trialed without the use of the wheelchair seatbelt however it was not successful. The evaluation documented the resident benefited and required a seatbelt for midline, upright positioning in her custom power wheelchair.-Review of Resident #10's electronic medical record (EMR) did not reveal the facility completed ongoing evaluations (after 11/19/24) to ensure the resident's use of the seatbelt and foot straps were still appropriate for use, including a trial without the straps and the seatbelt. -Review of Resident #10's EMR did not reveal documentation indicating less restrictive interventions were attempted prior to the use of the seatbelt and foot straps.Review of Resident #10's August 2025 CPO revealed the following physician's order:Apply a wheelchair seatbelt and foot straps when the resident is seated in her wheelchair. Staff need to release the straps every shift, as needed and at the request of the resident, ordered 11/20/24.-However, the physician's order failed to identify the medical symptom the seatbelt and foot straps were used for. Resident #10's activities of daily living (ADL) care plan, revised 8/7/25, revealed the resident had impaired ADL function due to cerebral palsy. The care plan documented the resident used a motorized wheelchair with a seatbelt and foot straps, which she was unable to release. The seatbelt and foot straps were being used for positioning due to a diagnosis of cerebral palsy. Interventions included applying the seatbelt and foot straps when she was seated in her wheelchair and releasing the seatbelt and foot straps every shift, as needed and at the resident's request.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/26/25 at 1:15 p.m. LPN #1 said Resident #10 liked to stretch backwards and the seatbelt helped with positioning Resident #10 in her wheelchair correctly. LPN #1 said Resident #10 was unable to undo the straps herself. He said the staff only released the straps when she was getting out of her chair. The DON was interviewed on 8/27/25 at 9:32 a.m. The DON said per policy, the staff were supposed to release Resident #10 from her seatbelt and foot straps every two hours. She said Resident #10 requested the seatbelt and foot straps and the resident knew it was a restraint because Resident #10 was unable to release them herself. She said assessments needed to be completed every quarter for the restraints and that therapy usually completed the assessments. The DON said the restraints and the resident not being able to release the restraints had been documented in Resident #10's care plan.

Based on observations, record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent the development of pressure injuries for one (#31) of two residents out of 26 sample residents reviewed for pressure injuries. Resident #31, who was receiving hospice services related to his diagnosis of senile dementia, was known to be at risk for developing pressure injuries. The resident was admitted to the facility on [DATE] without any pressure injuries. On 10/6/23, a weekly skin assessment was conducted for Resident #31 and documented the resident had no new skin issues. The facility failed to conduct a skin assessment between the dates of 10/6/23 and 10/18/23. On 10/18/23, multiple pressure wounds were noted to Resident #31's left foot. The wounds included an unstageable left lateral malleolus (outside ankle) wound which later evolved to reveal a stage 3 pressure injury, an unstageable lateral (outside) left heel wound, an unstageable lateral left foot wound which later evolved to reveal a stage 4 pressure injury, and an unstageable left fifth metatarsal head (joint between the foot and the small toe) deep tissue injury (DTI). The left fifth metatarsal wound resolved on 11/28/23 and reemerged as a DTI on 1/8/24. On 1/18/24, the left fifth metatarsal wound evolved into an unstageable pressure wound. On 10/22/23, the resident developed an unstageable pressure injury to his left hip. The facility had initiated a skin integrity care plan for the resident on 5/27/22, however, interventions, such as implementing a specialty air mattress and repositioning the resident, were not implemented until after Resident #31 developed the pressure injuries to his left hip and left foot. As a result of the facility's failures to implement timely pressure injury interventions, Resident #31 developed multiple advanced pressure injuries to his left foot and left hip. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/15/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Wound Prevention and Skin Management policy and procedure was provided by the nursing home administrator (NHA) on 2/14/24 at 10:52 a.m. It read in pertinent part, Based on the resident's history, clinical status, head to toe skin assessment, and Braden scale, an acute temporary care plan should be initiated per definition and policy. Interventions to promote healing and/or prevent breakdown may include incontinence management, a turning and repositioning plan, initial treatment(s), off loading devices and any other pressure relieving strategies and resident goals for treatment. All residents are provided with pressure reducing mattresses. Special support surfaces (such as pressure relieving specialty mattresses or cushions) will be utilized as part of the treatment plan when residents are identified to be at higher risk for skin breakdown or having existing breakdown. Weight shifts may be implemented as part of both prevention and treatment for pressure wounds. When possible, weight shifting and off loading, which allows sufficient capillary refill and tissue perfusion may be implemented. III. Resident #31 A. Resident status Resident #31, age 90, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic kidney disease and peripheral vascular disease. The 12/29/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He was dependent with toileting, personal hygiene, bed mobility, required substantial/maximal assistance with transfers and supervision with eating. The assessment indicated the resident had one unhealed stage 3 pressure ulcer and four unhealed unstageable pressure ulcers not present on admission and was at risk for developing pressure ulcers. B. Observations On 2/13/24 at 12:30 p.m. licensed practical nurse (LPN) #1 was observed removing the dressing on Resident #31's left hip. A small amount of serosanguinous (yellowish with a small amount of blood) drainage was observed on the dressing. The wound bed was difficult to visualize due to the depth of the wound. There was no redness noted around the wound site. Resident #31 was observed on an air mattress. On 2/13/24 at 12:40 p.m. LPN #1 was observed removing soft heel boots from Resident #31's left foot for wound care. The left lateral malleolus (outside ankle bone) wound bed appeared pink without drainage or redness noted around the wound site. The left lateral heel wound bed appeared pink with a small amount of yellowish material and a small amount of brown black material. The left lateral foot wound bed appeared red with a small amount of red material. The left fifth metatarsal wound bed had brown black material. C. Record review The skin integrity care plan, initiated 5/27/22 and revised 12/20/23, indicated Resident #31 had actual and the potential for skin breakdown due to dementia, decreased mobility, fluctuating nutritional intake and incontinence. Interventions included air mattress, toileting regularly, encourage optimal nutrition and hydration, float heels, heel protectors to bilateral heels when in bed and wheelchair, keep skin clean and dry, outside wound care to follow for weekly wound management, nutritional supplements, reposition frequently in bed and wheelchair and weekly skin checks. The hospice care plan, initiated 5/27/22 and revised on 12/21/23, indicated the resident was receiving hospice services due to senile dementia. Interventions included work cooperatively with the hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. Further review of the comprehensive care plan revealed turn and reposition frequently was initiated on 5/27/22 and reinitiated on 10/23/23, the air mattress was initiated on 9/13/22 and reinitiated on 10/25/23 and floating bilateral heels was initiated on 11/17/23. The February 2024 CPO documented physician orders: -An order for hospice services, ordered 3/15/23; -Float heels while in bed, ordered 5/13/22 and reordered 10/19/23 (after the wounds developed); -Left heel protector, ordered 6/14/22 and discontinued 7/6/22; -Left heel protection boot, ordered 7/6/22; -Air mattress, ordered 10/18/23 (after the wounds developed); -Bilateral heel protectors, ordered 10/19/23 (after the wounds developed); -Turn and reposition resident frequently in bed and in wheelchair, ordered 10/23/23 (after the wounds developed); -Left lateral malleolus, cleanse wound with wound cleanser or normal saline, pat dry and apply skin prep around the wound and leave open to the air every day and as necessary, ordered 1/31/24; -Left lateral heel, cleanse wound with wound cleanser and apply liquid medihoney and cover with bordered gauze. Change dressing every other day and as necessary, ordered 1/31/24; -Left lateral foot, cleanse wound with wound cleanser and apply wound with liquid medihoney and bordered gauze. Do not cover other wounds with this dressing, ordered 1/31/24; -Left hip, cleanse wound with wound cleanser, express drainage from wound and pack loosely with Dakins moistened 1/4 inch packing strips and cover with ABD (thick abdominal type dressing) and secure with medipore tape. Change dressing twice a day and as necessary, ordered 1/31/24; and, -Left lateral metatarsal, cleanse wound with wound cleanser. Apply skin prep around the wound and leave it open to air, ordered. -Review of the February 2024 CPO revealed the float heels while in bed, air mattress, bilateral heel protectors and repositioning orders were not implemented until after the identification of the pressure wounds. The 10/20/23 Braden Scale Assessment (a tool used to predict the risk of pressure ulcers) indicated Resident #31 was at a severe risk for developing pressure ulcers. The 10/6/23 weekly comprehensive nursing skin observation documented Resident #31 had no new skin issues and a boot for heels for heel redness. -There was no documentation to indicate a weekly skin assessment had been conducted between 10/6/23 and 10/18/23 (a period of 12 days). A 10/18/23 nursing progress note documented a hospice certified nurse aide (CNA) alerted a registered nurse (RN) to new wounds on Resident #31's left foot. The measurements to the wounds were 1.5 centimeters (cm) by 0.5 cm, 1.5 cm by 0.9 cm and 2.0 cm by 1.0 cm. The wounds were cleansed with a wound cleanser and bandages were applied. The director of nursing (DON), power of attorney (POA), physician and the hospice provider were notified. -The nursing progress note failed to document a detailed description regarding the location of each wound on Resident #31's left foot and which measurements pertained to each wound identified. The stage of the wound was not identified. A 10/18/23 change of condition note documented the identification of new foot wounds for Resident #31. The 10/22/23 nursing progress incident note documented a certified nurse aide reported a skin breakdown on the left hip. The measurements were 3.5 cm by 2 cm by 0.2 cm by 0.5 cm by 1 cm. It documented the hospice provider, the DON and the power of attorney (POA) were notified. -The incident note did not identify the stage of the wound. The 10/24/23 interdisciplinary team (IDT) progress note documented a referral to a wound physician for weekly wound management and wound treatment orders. -A comprehensive review of Resident #31's electronic medical record (EMR) failed to reveal documentation of turning and repositioning prior to the identification of the resident's wounds Review of the wound care physician assistant's (WCPA) notes revealed the PA initially evaluated Resident #31's wounds on 10/23/23 and continued to provide weekly wound care visits. The WCPA's initial visit note on 10/23/23 documented the following wounds: The left hip wound was documented as a shearing friction wound. The measurements were 6 centimeters (cm) by 3.5 cm by 0.1 cm. The wound bed had 50% slough (yellow/white material in the wound bed) and 50% eschar (black brown collection of dead tissue in the wound bed). The left lateral malleolus wound was documented as an unstageable pressure wound. The wound measurements were 2 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 1.8 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral foot pressure wound was documented as an unstageable pressure wound. The measurements were 1.1 cm by 1.4 cm by 0 cm. The wound bed had 100% slough. The left fifth metatarsal pressure wound was documented as a DTI. The measurements were 0.4 cm by 1.1 cm. The wound was a non blanchable deep red, maroon or purple discoloration. The 10/31/23 IDT progress note documented interventions for frequent turning and positioning, air mattress and floating heels. -However, the interventions were implemented after the wounds were identified and assessed by the wound care PA. According to the most recent wound care notes dated 2/5/24, the WCPA documented the resident still currently had the five wounds with the following changes: The left hip wound was documented as an unstageable pressure wound. The measurements were 0.7 cm by 0.7 cm by 0.7 cm. The wound was documented as undermining. The wound bed had 100% granulation. The left lateral malleolus wound was documented as a stage 3 pressure wound (evolved from the initial unstageable classification). The measurements were 1.1 cm by 0.5 cm by 0 cm. The wound bed had 100% epithelialization. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 0.5 cm by 0.7 cm by 0.1 cm. The wound bed had 80% slough and 20% eschar. The left lateral foot pressure wound was documented as a stage 4 pressure wound (evolved from the initial unstageable classification). The measurements were 1.7 cm by 1.7 cm by 0.1 cm. The wound bed had 70% granulation, 15% slough and 14% epithelialization. The left fifth metatarsal head wound was documented as an unstageable pressure injury. The measurements were 1.1 cm by 2.0 cm. The left fifth metatarsal wound healed on 11/28/23 and reemerged on 1/8/24 as a DTI which evolved into an unstageable pressure wound on 1/18/24. -Although the WCPA had followed the wounds weekly since 10/23/23, after the wounds were identified, the facility failed to prevent them from occurring initially, despite knowing the resident was at risk of developing pressure injuries and there were not enough preventative measures put in place to prevent them from developing. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 2/14/24 at 1:35 p.m. She said Resident #31 had multiple pressure wounds on his left hip and bilateral feet. She said she did not remember if he was on a pressure mattress before the identification of his wounds. She said he did have his heel protector boots on because of previous issues with wounds on his feet. She said since he was a dependent resident, was stiff and had previous skin issues, he should have had preventative measures in place and be frequently repositioned at least every two hours. The primary care physician (PCP) was interviewed on 2/14/24 at 10:23 a.m. He said he had been taking care of Resident #31 and the resident had previous issues with wounds about one year ago. He said Resident #31 was bed and wheelchair bound, on hospice and was at risk for developing pressure wounds. He said there was no guarantee he would not have developed the wounds, however, he said there was an absolute guarantee the wounds would develop if preventative measures were not in place. He said preventative measures should include an air mattress, special cushions, heel protectors, weekly skin assessments, nutritional interventions and frequent repositioning. The WCPA was interviewed on 2/14/24 at 10:52 a.m. She said she saw Resident #31 in October 2023, after he developed multiple pressure wounds. She said when she saw him an air mattress was in place and he was wearing heel boots. She said, with his comorbidities, he was at a high risk of developing pressure wounds and preventative measures would have helped decrease the risk of developing the wounds. She said preventative measures included air mattresses, heel boots, frequent repositioning and nutritional interventions. She said the resident's pressure wounds were improving. The director of nursing (DON) was interviewed on 2/14/24 at 3:45 p.m. He said he was the wound care coordinator who rounded with the wound care consultants. He said a full nursing assessment with a skin assessment was completed on all residents upon admission. He said skin assessments were done on a weekly basis and scheduled for each resident. He said if a new skin issue was identified it was reported to the physician, hospice and the DON. He said a risk report, such as a change of condition or situation, background, assessment, response (SBAR) was completed. The skin issue was discussed with the IDT, a root cause analysis completed and interventions to prevent further deterioration were implemented. He said the Braden Scale Assessment score acted as a guide for preventative measures. The DON said residents who were dependent and at risk should be put on an air mattress, special cushions for wheelchairs, heels should be floated and frequent repositioning should be done. He said Resident #31's wounds developed in October 2023 and the majority of interventions were put into place after the wounds were identified. He said Resident #31 was not on an air mattress before the wounds were identified. He said at risk residents should be frequently repositioned. He said there was no set frequency of how often residents were repositioned. He said the facility did not have a repositioning program and did not document how often or when a resident was repositioned.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure thawed nutritional supplements and thickened liquids were dated appropriately; -Ensure food was labeled and dated in the nourishment refrigerators; and, -Ensure expired food was discarded in the nourishment refrigerators. Findings include: I. Professional reference The (2019) Colorado Retail Food Establishment Rules and Regulations, retrieved from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on [DATE], read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified; or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. The Hormel Health Labs Thick & Easy(R) Thickeners, Tea, and Coffee date information sheet, dated [DATE] and retrieved from https://www.hormelhealthlabs.com/wp-content/uploads/2022-HHL-Code-Date-Information.pdf on [DATE], read in pertinent part, Thick and easy 46 oz hydrolyte clear thickened water had a shelf life of up to 10 days refrigerated. The shelf life of a refrigerated hormel mighty shake is 14 days thawed. II. Facility policy and procedure The Food from Outside policy and procedure, reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:59 p.m. It revealed in pertinent part, The purpose of this policy is to establish a guideline that allows patients to adhere to usual food practices and ensure that safe food handling procedures are observed. The food shall remain in the original container, labeled with the name, room number and date and stored in the resident neighborhood refrigerator located on their respective floor. The food should be consumed in ,d+[DATE] hours or it will be discarded by designated staff. III. Observations and interviews On [DATE] at 9:15 a.m., the Bronco unit nourishment refrigerator was observed with the director of nursing. The following item was found:, A 32 ounce (oz) container of oat based creamer with an expiration date of [DATE]. At 9:18 a.m., an unidentified staff member placed approximately 12 four ounce Hormel health shakes in the Bronco unit nourishment refrigerator. Printed on each health shake carton was store frozen. -There were no pull dates or expiration dates written on the health shake cartons that indicated when the shakes were pulled from the freezer or the shelf life of the thawed product. On [DATE] at 9:20 a.m., the Peaceful unit nourishment refrigerator was observed with the director of nursing (DON). The following items were found: Two 46 oz containers of commercially produced hormel thickened water, both approximately half full. One bottle of the thickened water had a date of [DATE] written in black marker on the bottle. The other bottle of thickened water had no written open date or expiration date on the bottle. Four four vanilla and one strawberry four ounce Hormel health shakes. Printed on each health shake carton was store frozen. -There were no pull dates or expiration dates written on the health shake cartons that indicated when the shakes were pulled from the freezer or the shelf life of the thawed product. A container of whipped cream cheese with an expiration date of [DATE] and a name written on the lid in black marker. The DON discarded the two containers of thickened water from the nourishment refrigerator on the Peaceful unit. The DON was interviewed on [DATE] at 9:23 a.m. The DON said the expired container of cream cheese belonged to a resident at the facility and the resident's name was written on the container. The DON said he was unsure of the shelf life of an opened 46 oz container of thickened liquids. The DON said the nurses used the health shakes in the nourishment refrigerator as needed for residents who had a supplement ordered. On [DATE] at 8:15 a.m., the Bronco unit nourishment refrigerator was observed again. The following items were found: 32 vanilla and strawberry Hormel health shakes with the words store frozen printed on each health shake carton. -There were no pull dates or expiration dates written on the health shake cartons that indicated when the shakes were pulled from the freezer or the shelf life of the thawed product. On [DATE] at 2:30 p.m., the Peaceful unit nourishment freezer was observed. The following items were found: Two individually wrapped ice cream sandwiches wrapped together in foil. -There was no resident name written on the ice cream sandwiches and no date indicating when the food was placed in the freezer or an expiration date. A clear ziploc bag of unidentifiable food items. -There was no resident name written on the ziploc bag and no date indicating when the food was placed in the freezer or an expiration date. A beef and broccoli commercially prepared stir fry. -There was no resident name written on the ice cream sandwiches and no date indicating when the food was placed in the freezer or an expiration date. A Therapearl back wrap (ice gel pack) with a velcro strap was in the freezer with the food items with a resident's name written on the gel pack in black marker. License practical nurse (LPN) #1 was interviewed on [DATE] at 2:35 p.m. LPN#1 said ice gel packs used on a resident's body part should not be in a freezer stored with resident food. LPN #1 discarded the gel pack. IV. Additional staff interviews Registered nurse (RN) #2 was interviewed on [DATE] at 8:15 a.m. RN #2 said nurses went to the kitchen to get more health shakes from the dining team and put the health shakes in the nourishment refrigerators. RN #2 said she thought dietary staff and nursing staff checked the refrigerators for expired products. She said the task of checking for expired foods was not assigned to a specific position and all nursing staff could check the product. The dietary manager (DM) was interviewed on [DATE] at 9:00 a.m. The DM said the dietary staff checked the nourishment refrigerators. The DM said he knew there was a 10 day shelf life for 46 oz bottles of opened thickened drinks. Certified nurse aide (CNA) #1 and LPN #1 were interviewed together on [DATE] at 2:30 p.m. CNA #1 said the residents' food stored in nourishment refrigerators should have the resident's name and a date the food items were put in the refrigerator or freezer. CNA #1 said she was not sure who was responsible for removing the expired food from the nourishment refrigerators. LPN #1 said the residents' food stored in nourishment refrigerators should have the resident's name and a date the food items were put in the refrigerator or freezer. The DON and assistant director of nursing (ADON) were interviewed together on [DATE] at 3:31 p.m. The DON said staff should label the foods in the nourishment refrigerators with the residents' name and date. The DON said ice gel packs used on the body should not be stored with the food in the nourishment freezers. The ADON said ice gel packs used on the body should not be stored in the nourishment freezers with food.

Based on record review, and observations, the facility failed to ensure six of seven residents out of 36 sample residents received food and fluids prepared in a form designed to meet their needs per speech therapy recommendation, physician orders, and the resident's care plan. Specifically, the facility failed to ensure the puree textures produced were consistent with the International Dysphagia Diet Standard Initiative (IDDSI) level four puree texture (PU4) for residents prescribed a puree diet. Findings include: I. Professional standard The International Dysphagia Diet Standard Initiative (IDDSI) effective July 2019 and retrieved 2/15/24 from https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf revealed in pertinent part, A level four puree texture (PU4): is usually eaten with a spoon (a fork is possible); should not require chewing if presented in this form; falls off the spoon in a single spoonful when tilted and continues to hold shape on a plate; and has no lumps. No biting or chewing is required and the food is smooth with no lumps. II. Facility policy and procedure The Diet Textures policy and procedure, reviewed December 2021, was provided by the nursing home administrator (NHA) on 2/13/24 at 3:43 p.m. It revealed in pertinent part, The puree texture diet: all food is puree consistency. III. Menus and puree recipes A review of the lunch menu on 2/13/24 revealed it included barbecue pork loin, mashed potatoes, mixed vegetable blend and banana parfait. The recipe instructions for puree menu items read in pertinent part: Mashed potatoes for a level four puree diet ingredients included 28 ounces (oz) dehydrated mashed potatoes and one gallon of water. Prepare according to the manufacturer packaging. Level four puree diet: serve smooth texture with no lumps. Mixed vegetable blend for a level four puree diet ingredients included two and a half quarts of the mixed vegetable blend and a half cup of food thickener. Prepare the mixed vegetable blend recipe as directed. Place the portions needed in the food processor and process until fine in consistency. Slowly add reserve liquid and thickener as needed and process until smooth. IV. Observations The following observations were made on 2/13/24 during lunch service. The temperatures of the menu items served for lunch on 2/13/24 were taken at 11:18 a.m. Cook (CK) #1 inserted his thermometer into a pan of food and said the food was pureed vegetables. The puree vegetables were green in color with small pieces of orange chunks visible inside the puree vegetables. The vegetable blend for the regular diet included green beans and sliced round carrots. Lunch service started for the dining room at 11:33 a.m. At 11:38 a.m. CK #1 placed a plate of pureed food in the serving window. Small pieces of carrot were visible in the pureed green vegetable. The meal card placed under the plate revealed the resident had a puree texture diet. The dietary manager (DM) picked up the plate and meal card and delivered the plate to a resident seated at a dining room table. The DM was notified after serving the resident that the puree vegetables on the plate had visible pieces of carrot in the puree vegetable. The DM said the blender used to puree food was an issue and he was unsure what guidelines were included in the menu program the facility used for puree diets. Five more plates with puree foods were served to residents during the lunch shift at 11:45 a.m., 11:46 a.m., 11:47 a.m., 11:51 a.m. and 11:52 a.m. CK #1 placed each of the plates containing puree food in the serving window with their corresponding meal cards. All five meal cards indicated a puree diet on the card and all five plates had puree green vegetables with visible pieces of orange carrot inside the puree vegetable. A four ounce portion of mashed potatoes was sampled at 12:27 p.m. after residents had been served lunch. The mashed potatoes were portioned from the mashed potatoes that were served to the residents on a puree texture diet for lunch. -The mashed potatoes were not smooth and had lumps of potatoes in each bite sampled. V. Staff interviews The DM was interviewed on 2/14/24 at 9:00 a.m. The DM said the instant dry potato mix should be used for puree diet potatoes and fresh potatoes were used for mashed potatoes served to residents on a regular diet. The DM said fresh potatoes were used for the mashed potatoes served for lunch on 2/13/24 instead of instant dry potatoes. The DM said puree recipes were on the kitchen counter for use prior to meal service. The DM said the staff did check puree items before meal service and taste the puree items for texture variances. The DM said he had not checked the puree items served at breakfast that morning (2/14/24) to see if the puree items were the appropriate texture. The DM and (CK) #1 were interviewed together on 2/14/24 at 1:00 p.m. CK#1 said he used the blender to puree the food items for the lunch meal service on 2/13/24. He said the blender had stopped working and he had used the food processor to finish the puree items, however, he said the food processor blade was not sharp enough to make the puree smooth. CK #1 said he did not see the carrot pieces in the puree vegetable during meal service. The DM said the new blender was smaller then the previous one so the staff were not able to put the same amount of puree food into the blender as the previous one. The DM said he did not see pieces of carrot in the puree green beans prior to lunch because he was busy. The DM said the puree foods with lumps were a choking hazard for residents on a puree diet. He said puree foods could be run through a sieve if needed to remove the lumps in puree food.

Based on observation, record review and interviews, the facility failed to ensure that residents were kept free from significant medication errors for two (#54 and #47) of six residents out of 26 sample residents. Specifically, the facility failed to: -Ensure an antipsychotic medication for Resident #54 was obtained and administered according to physician's orders; -Notify resident #54's physician that the resident's antipsychotic medication was not refilled which resulted in the resident missing administration of the medication three days; -Ensure Resident #47 received all ordered doses of her prescribed antibiotic medication; and, -Notify Resident #47's physician when the resident did not receive the antibiotic medication. Findings include: I. Professional reference According to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 599 - 609. Nurses play an important role in patient safety, especially in the area of medication administration. The safe administration of medications is also an important topic for current nursing researchers. As a nurse you need to know how to calculate medication doses accurately and understand the different roles that members of the health care team play in prescribing and administering medications. The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. -Preventing medication errors is essential. -Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. Professional standards such as scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors follow the seven rights of medication administration consistently every time you administer medication. -The right medication; the right dose; the right patient; the right route; the right time; the right documentation; and right indication. The Food and Drug Administration (FDA) Combating Antibiotic Resistance (10/29/19), https://www.fda.gov/consumers/consumer-updates/combating-antibiotic-resistance#:, retrieved on 2/15/24 at 1:59 p.m., documented in pertinent part, Take the antibiotics as prescribed. It is important to take the medication as prescribed by your doctor. If treatment stops too soon, the remaining bacteria may become resistant to the antibiotics that you have taken. Do not skip doses. Antibiotics are most effective when they are taken as prescribed. II. Facility policy and procedure The Medication Administration Guidelines policy and procedure was provided by the nursing home administrator (NHA) on 2/14/24 at 10:52 a.m. It read in pertinent part, The 6 (six) rights of medication administration will be followed to include: the right resident, the right drug, the right dosage, the right time, the right route, the right documentation. III. Resident #54 A. Resident status Resident #54, under age 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder, depression and bilateral below knee amputation. The 12/1/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with eating, oral hygiene, toileting hygiene, upper and lower body dressing and personal hygiene. He needed moderate assistance with bathing. The MDS assessment documented Resident #54 received antipsychotic medication on a regular basis. B. Resident interview Resident #54 was interviewed on 2/14/24 at 2:00 p.m. Resident #54 said he did not receive Clozapine (an antipsychotic medication) for a few days. Resident #54 said facility staff told him the laboratory did not communicate his lab work results to the pharmacy on time for his medication to be refilled. Resident #54 said he was stressed about not having his medication and he felt like he was sweating more, experienced cold sweats and started to cough without the medication. C. Record review A review of Resident #54's February 2024 CPO revealed the following physician orders: -Clozapine 200 milligrams (mg) to be administered by mouth daily at bedtime for schizoaffective depressive disorder, ordered 11/20/23; -Complete blood count (CBC) with differential (specific blood cell type count) draw every two weeks for Clozapine use. Ensure requisition is completed and placed in the laboratory book, ordered 12/5/23; and, -Fax the results of the CBC with differential to the pharmacy every 14 days to reorder Clozapine, ordered 12/5/23. A review of Resident #54's January 2024 medication administration record (MAR) revealed the following: A CBC with differential blood draw and results sent to the pharmacy was documented as completed on 1/22/24. Resident #54 did not receive Clozapine on 1/23/24, 1/24/24 and 1/25/24. The chart code used all three days to document the reason Resident #54 did not receive his medication was Other/See progress notes. A progress note written on 1/23/24 at 9:10 p.m. documented the Clozapine was reordered from the pharmacy. -There was no further documentation to indicate Resident #54's physician was notified the resident's medication was unavailable. -There was no documentation to indicate further attempts were made by facility staff to call the pharmacy to follow up on Resident #54's Clozapine medication status on 1/24/24 or 1/25/25. A review of the submission record from Resident #54's electronic medication record documented Resident #54's Clozapine was reordered at 9:10 p.m. on 1/23/24. D. Staff interviews The director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 2/13/24 at 2:30 p.m. The DON said the Resident #54 had a physician's order for a blood draw every two weeks for Clozapine use and said Resident #54's Clozapine was ordered on 1/23/24. The DON said laboratory blood work results were sent to the pharmacy from the facility each time the blood work was completed. He said the resident's bloodwork results were sent to the pharmacy on 1/22/24. The ADON said staff should have notified notified the physician when Resident #54 was without his antipsychotic medication. The ADON said the pharmacy would not refill a medication order if lab work results were not received prior to the medication order. She said if that occurred, the medication order would have to be resent again to the pharmacy once the lab work results were received. The consulting pharmacist (CP) was interviewed on 2/14/24 at 2:38 p.m The CP said the pharmacy received the order to refill Resident #54's antipsychotic medication order on 1/23/24. She said the order was processed on the 24th and the medication arrived at the facility on 1/25/24. The CP said from what she could see in the pharmacy system, the pharmacy did not receive Resident #54's lab work results on 1/22/24. The CP said if the facility forgot to reorder a medication, the facility could call the pharmacy. The CP said if the facility would have called the pharmacy it would have facilitated the process to refill Resident #54's medication timely. The DON and ADON were interviewed again on 2/14/24 at 3:31 p.m. The DON said he should be notified when a resident was out of antipsychotic medication for three days. The ADON said the facility was going to adjust Resident #54's laboratory blood work schedule to give the facility more time to get the medication refilled. The ADON said the facility staff should notify the physician that a resident was without medication in case the resident had an adverse reaction from not receiving the medication as prescribed. 47350 IV. Resident #47 A. Resident status Resident #47, age 71, was admitted on [DATE] readmitted on [DATE]. According to the February 2024 CPO, diagnoses included parainfluenza virus pneumonia and metabolic encephalopathy. The 1/27/24 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required supervision with personal hygiene, bed mobility, transfers, toileting and was independent with eating. B. Record review The February 2024 CPO revealed an order for Cefuroxime (an antibiotic medication) 500 milligrams (mg) twice a day for pneumonia for three days. The February 2024 medication administration record (MAR) revealed the following: -A dose of Cefuroxime was given on 2/7/24 at 5:00 p.m. -A dose of Cefuroxime was held on 2/8/24 at 8:00 a.m. and 5:00 p.m. -A dose of Cefuroxime was given on 2/9/24 at 8:00 a.m. and 5:00 p.m. -A dose of Cefuroxime was given 2/10/24 at 8:00 a.m. -Resident #47 received only four of the six doses of the prescribed antibiotic medication. -There was no documentation to indicate the resident's physician had been notified the resident did not receive both scheduled doses of the antibiotic medication on 2/8/24. C. Staff interviews The assistant director of nursing (ADON) was interviewed on 2/13/24 at 4:30 p.m. She said Resident #47's antibiotic was not given for two doses due to a delay in receiving the medication from the pharmacy. She said the administering nurse notified the provider of the delay in receiving the antibiotic from the pharmacy, however, she said there was no documentation the provider was aware the resident did not receive two doses of the antibiotic. The ADON said she did not know why the resident was able to receive the first dose and not the next two doses. The director of nursing (DON) was interviewed on 2/13/24 at 4:40 p.m. He said there was a back up supply of the Cefuroxime in the automated dispensing system. He said he did not know why Resident #47 received the first dose but did not receive the next two doses since the facility had the medication in the dispensing system. He said it was important to receive antibiotics as they were ordered to effectively treat an infection. The DON said the physician or provider should be notified if a medication was not given because it was not available.

Based on observations, record review and interviews the facility failed to ensure one (#33) of four residents reviewed received treatment and care in accordance with professional standards of practice out of 24 sample residents. Specifically, the facility failed to have a wound care order in place prior to treatment being provided for Resident #33. Findings include: I. Facility policy and procedure The Pressure and Wound Prevention and Skin Monitoring policy, revised April 2020, was provided by the administrator in training (AIT) on 11/2/22 at 3:40 p.m. It read in pertinent part, Identification, prevention, and treatments will be based on National Pressure Ulcer Advisory Panel (NPUAP) definitions, recommendations, and practice of standards. The Nurse identifying a new wound should obtain treatment order based on the resident individualized needs. II. Resident #33 A. Resident status Resident #33, age 82, was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnosis included heart failure, chronic kidney disease, venous thrombosis and embolism. The 9/12/22 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of nine out of 15. He required extensive two-person assistance with bed mobility, transfers, dressing, personal hygiene and toileting. B. Resident observations and interviews Resident #33 was observed on 10/31/22 at 2:25 p.m. with a soiled bordered gauze dressing to his left wrist. The dressing had dried blood, no date or nurse initials. Resident #33 stated a certified nurse aide (CNA) was helping him a few days ago when he received the injury to his left wrist. Resident #33 was observed on 11/1/22 at 10:20 a.m. the dressing to left wrist was soiled with dried blood, no date or nurse initials. C. Record review Review of the October and November 2022 CPO revealed no treatment orders for the left wrist. The incident note dated 10/29/22 documented Resident #33 received skin tear to the left wrist during a transfer in the shower. Change of condition charting for Resident #33's left wrist was initiated on 10/29/22. III. Staff interview and wound observation on 11/2/22 Licensed practical nurse (LPN) #1 was interviewed on 11/2/22 at 9:06 a.m., she said the resident had a dressing to left wrist as a preventative measure. -At 9:11 a.m. LPN #1 was observed changing Resident #33's dressing to his left wrist. The old border gauze dressing was removed and was observed to have dried blood. Resident #33's left wrist began to actively bleed when the dressing was removed. The area was cleansed with alcohol wipe and covered with dry border gauze dressing. Skin tear edges well approximated measuring approximately one inch in length, and no redness noted to surrounding skin. LPN #1 stated she would return to date and sign dressing. -At 9:26 a.m. LPN #1 was interviewed a second time. She then said the dressing that was applied was for a skin tear Resident #33 received on 10/29/22. She was unable to locate a wound care order in the residents' treatment orders. She stated there should have been an order for treatment and would ask the Director of nursing (DON) as to why it was not in the resident's record. IV. DON interview The DON was interviewed on 11/2/22 at 9:40 a.m., she was also unable to locate a wound dressing order in the physician orders and said there should have been an order in place prior to a treatment being provided to a resident. She said a dressing should also include date and nurse initials in order to know when and by who it was last changed by.

Based on observations, interviews, and record review, the facility failed to implement interventions to reduce hazards and risks for falls for one resident (#42) out of four residents reviewed for falls out of 24 sample residents. Specifically, the facility failed to ensure Resident #42 was provided the assisted devices and interventions recommended to prevent repeated and avoidable falls. Findings include: I. Facility policy and procedure The Fall Management policy, revised 5/7/15, was provided by the director of nursing (DON) on 11/2/22 at 2:05 p.m. It read in pertinent part, As part of the admission process, the fall risk evaluation will be completed. If the resident has a history of falls or is a high risk for falls, an acute temporary care plan will be initiated. As soon as possible, following the incident, CNAs will initiate the HUDDLE follow-up. Timeliness of this initial data collection is emphasized to evaluate the environment and identify precipitating events accurately. This evaluation includes:Care plan interventions in place. II. Resident #42 A. Resident status Resident #42, age of 89, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO) diagnoses included Alzheimer's disease, unspecified dementia, osteoporosis, and spinal stenosis. The 10/4/22 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene.The resident required extensive assistance from staff for walking, had unsteady balance requiring assistance to stabilize, and utilized a wheelchair for mobility. The section of the MDS documenting falls prior to admission was blank and the section for post admission falls indicated he had two or more falls without injury. B. Resident interview and observations Resident #42 was interviewed on 11/2/22 at 10:35 a.m. The resident was not able to recall how many falls he had since coming to the facility nor could he explain the reason why he kept falling out of his bed. He denied that it was his preference to sleep on the floor mat instead of his bed (see the comprehensive care plan review below). On 10/31/22 at 2:18 p.m., the resident was observed up in his manual wheelchair in the common area. The resident room was observed and the resident had a fall mat but no other fall interventions as recommended by the interdisciplinary team (IDT) at bedside to include a bolster mattress, body pillow, or soft touch call light. On 11/2/22 at 9:18 a.m., and 11/2/22 at 12:30 p.m., the resident's room was observed, the resident still had none of the recommended interventions in place other then the fall mat for use when the resident was in bed (see above). C. Record review The comprehensive care plan fall focus initiated 5/16/22 and revised 10/12/22 documented that the resident was a fall risk due to history of falls, weakness, dementia, and decreased safety awareness. Interventions initiated 8/1/22 were for a body pillow for tactile cues. Interventions included placing a bolstered mattress for tactile cues to not roll out of bed and a soft touch call light. The care plan stated that it was the resident's preference to sleep on the fall mat (see interviews below for contradictory information about this statement). The November 2022 CPO revealed there were no orders for a bolster mattress. Therapy communication progress notes documented the resident had the following falls: On 5/26/22 at 01:44 a.m., the resident was found on the floor in his room without injury. Providing a fall mat was recommended and put in place. The resident told staff he was trying to do something and it didn't work out but was unable to explain what he meant by that. On 6/9/22 at 10:36 a.m., the resident was found on the floor in his room on the fall mat without injury. Providing a body pillow was recommended at that time. The resident did not provide an explanation to the staff regarding his fall. On 7/22/22 at 11:25 p.m., the resident was found on the floor in his room on the fall mat without injury. Providing a fall mat and keeping the bed in the lowest position were the recommendations. The resident did not provide an explanation to the staff regarding his fall. On 7/30/22 at 12:56 a.m., the resident was found on the floor in his room on the fall mat without injury. Providing a soft touch call light and to move the resident to a room closer to the nurses station were the recommendations. The resident told staff he wanted to get up and it was morning time. He was reoriented to time and put back to bed. On 8/26/22 at 6:44 p.m., the resident was found on the floor in his room on the fall mat wrapped up in bedsheets without injury. Providing a bolstered (lipped edge) mattress was the recommendation. The resident was asleep and when awakened by staff, was not even aware he was out of his bed. On 9/13/22 at 4:53 p.m., the resident was found sitting on the floor in front of his wheelchair in a common area without injury. The resident told staff he had slid out of his wheelchair. An anti-slip chair cushion was recommended and put in place. On 10/4/22 at 3:37 a.m., the resident was found sitting on the floor on the fall mat in his room without injury. The recommendations were to continue with the bolster mattress and to initiate a soft touch call light. When found, the resident told staff he had rolled the wrong way. On 10/24/22 at 11:30 p.m., the resident was found on the floor on the fall mat in his room. The resident was discovered to have abrasions to his left hand. The recommendations were to move the resident closer to the nurses' station when a room became available. The resident told staff that he did not know what he was thinking when found on the floor. -The resident was never relocated to a room closer to the nurses station; facility staff was not able to fully explain why this interventions were not implemented or why an alternative intervention was not sought since the move did not occur (see DON interview below). Physician progress notes dated 5/26/22 to 11/2/22 do not document if the physician was aware that the resident was experiencing recurrent falls. Nor did physician notes provide fall prevention recommendations or document if a medication review was conducted to assess for medications that may have placed the resident at a higher risk for falls. Physical therapy notes dated 10/6/22 revealed the resident had an air mattress that may have contributed to the resident's falls and that the mattress was recommended to be replaced with a standard hospital bed mattress. D. Interviews Certified nursing assistant (CNA) #4 was interviewed on 11/2/22 at 9:16 a.m. The CNA identified the mattress in Resident #42's room as an air mattress and not a bolster mattress. Registered nurse (RN) #2 was interviewed on 11/2/22 at 9:18 a.m. The RN said that the resident falls mostly occurred in the evening time when the resident tried to get out of bed. The resident was not able to verbalize the reason for attempts to get out of bed in the evening. The only fall intervention in place currently was a fall mat next to his bed. RN #2 said that she contacted the resident's physician's office to request a bolster mattress but the resident was still waiting for the mattress to be delivered . Currently the resident was still using an air mattress. Director of nursing (DON) was interviewed on 11/2/22 at 9:28 a.m. The DON was not sure if the resident had a soft call light in place. The DON said that the facility had been waiting a month for hospice to pick up their air mattress so the facility could put in a bolster mattress. The DON thought the resident's physical therapy provider had evaluated the resident for fall prevention but she was not sure. The administrator in training (AIT) was interviewed on 11/2/22 at 9:43 a.m. The AIT was previously the social services director and handled room assignments and room moves within the facility. The AIT said she did not recall a conversation with the interdisciplinary team (IDT), family, or resident regarding moving the resident's room closer to the nurses' station and the resident never moved to a room closer to the nurses station RN #2 was interviewed a second time on 11/2/22 at 9:48 a.m. The RN said that the resident had impaired cognition; he was orientated to himself and knew that he was in a nursing home. The resident was not aware of how to use the call light in his room appropriately and if he needed staff in the evening, the resident would not have known how to use the call light and did not call out for staff to assist when needed. When the resident needed assistance or fell in his room, the resident was dependent on staff to initiate care assistance and had to wait until the staff did their room rounds to provide him assistance. The DON was interviewed with the quality improvement specialist (QIS) present on 11/2/22 at 2:05 p.m. The DON went through each of the resident's falls and the recommendations that had been made after each fall. The interventions according to the DON were as followed; -After the 5/26/22 fall, the resident was to be on frequent checks and be reminded to use his call light. -After the 6/9/22 fall, the resident was to be provided education about his positioning when lying in bed. -After the 7/22/22 fall, a fall mat at bedside was recommended. -After the 7/30/22 fall, a body pillow was recommended as well as looking for a room closer to the nurses' station to move the resident. -After the 8/26/22 fall, a bolster mattress was recommended. -After the 9/13/22 fall, the wheelchair cushion was replaced in his wheelchair. -After the 10/4/22 fall, a soft call light was recommended. -After the 10/24/22 fall, there were no recommendations. The DON said prior to putting a bolster mattress, soft call light and body pillow in the resident's room on 11/2/22 (during the time of the survey) interventions since 10/2/22 were frequent or 15 minute checks. The DON could not explain why interventions were recommended and not put into place prior to 11/2/22. CNA #5 was interviewed on 11/3/22 at 9:40 a.m. The CNA said that the resident tries to get up in the evening and rolls out of bed onto his fall mat. The CNA said that the resident preferred to sleep on the mat but acknowledged that he had not ever verbalized that preference to. The CNA said that she did not know why the resident tried to get up at night or what he was trying to do, because the resident was unable to explain this to the staff due to cognitive impairments. RN #3 was interviewed on 11/3/22 at 9:42 a.m. The RN said that the resident had bolsters on his bed to prevent falls but could not recall when the bolsters were put on. RN #3 said the resident did not verbalize any preference to sleeping on the mat instead of his bed. The RN said that the facility's protocol for resident safety in the evening was for the staff to round and check on each resident every hour through the evening and overnight shift. The nurses and the CNAs were expected to take turns rounding every hour Resident #42 was not on any increased rounds / room checks from that schedule. The resident's power of attorney (POA) was interviewed on 11/3/22 at 11:08 a.m. The POA was not aware of any fall prevention interventions provided other than the fall mat that the facility is using to reduce the resident's falls. The POA said that the resident was unable to explain why he was falling other than the falls were a mistake. The POA did not believe the resident had a preference to sleep on the fall mat instead of in the bed.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for four (#1, #2, #3 and #4) of five out of seven residents. Specifically, the facility failed to: -Ensure Resident #1 received repositioning timely; -Ensure Resident #2 bilateral heels were offloaded; and, -Ensure Resident #3 and #4 wore their pressure relieving boots. Findings include: I. Professional reference The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedure The Pressure Wound Prevention and Skin Management policy, revised 4/1/2020, was provided by the director of nursing (DON) on 6/15/22. It read in pertinent part: The primary purpose of the pressure wound prevention and skin management program is to reduce the occurrence of pressure injuries and promote healing of wounds. Identification, prevention, and treatment will be based on the National Pressure Ulcer Advisory Panel (NPUAP) definition, recommendations, and practice standards. The admitting nurse will complete a head to toe skin assessment within the first eight hours of admission. A Braden Scale will be completed within the first eight hours of admission and weekly for the next four weeks. Based on the Braden score, appropriate interventions will be implemented. Treatment orders will be obtained as part of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Based on resident's history, clinical status, head to toe assessment, and Braden Scale, an acute temporary care plan should be initiated, or wound/skin care plan focus areas may be entered into the long term care plan. Interventions to promote healing and/or prevent breakdown may include incontinence management, a turning and repositioning care plan, initial treatments, off-loading devices and any other pressure relieving strategies and resident's goals for treatment. Based on individual resident preferences and needs a more comprehensive plan for skin management may be initiated. III. Failure to ensure pressure ulcer interventions were implemented. 1. Resident #1 A. Resident status Resident #1 was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/12/22 minimum data set (MDS) assessment, the resident had cognitive impairment and was unable to participate in the brief interview for mental status (BIMS). The resident required total assistance with activities of daily living. The resident was incontinent of both bowel and bladder. The MDS coded the resident was at risk for pressure ulcers. The MDS coded the resident as not having any behaviors or refusal of care. B. Observations 6/15/22 -At 8:40 am, Resident #1 was in the common area watching television (TV) -At 8:45 a.m.,the resident continued to sit in her wheelchair in the common area. -At 9:10 a.m.the resident remained in the same position. -At 9:30 a.m, the resident continued to watch TV in the common area. The resident was observed continuously from 10:00 a.m. -At 10:00 a.m., the resident remained at the same position. -At 10:05 a.m., the resident was assisted to the outside porch to attend an activity. The resident had not been offered to be offloaded or repositioned. She remained outside at the activity until 11:02 a.m. -At 11:02 a.m.,the activity assistant assisted the resident to the dining room for lunch. She had not been offered to be repositioned or offloaded. -At 11:20 a.m., the resident assisted with her meal. -At 12:10 p.m., an unidentified certified nurse aide (CNA) assisted the resident into the common area. The resident was not offered to be repositioned or offloaded. C. Record review The Braden scale completed on 4/12/22 showed the resident was at high risk for pressure ulcers with a score of 12. The care plan last revised on 4/27/22 identified the resident was at high risk for pressure injuries. Pertinent interventions included, extensive total assistance of one to two staff with frequent positioning in bed. The care plan failed to address the resident's positioning needs while she was in the wheelchair. D. Interviews The director of nurses (DON) was interviewed on 6/15/22 at 1:05 p.m. The DON said the resident was at high risk for pressure ulcers due to the moisture associated skin damage (MASD). She said that she should be repositioned at least every two hours. She said that it was difficult to reposition her in her wheelchair as her legs did not bed and so it had to be done in bed. CNA #1 was interviewed on 6/15/22 at 1:30 p.m. The CNA said the resident was unable to reposition herself. She said that she could only be repositioned when she laid down. She said she had assisted the resident out of bed at 7:00 a.m. The CNA said she had changed the resident's brief around 9:00 a.m., (however, observations revealed the resident was in the same position and had not repositioned). She said otherwise she had not changed her incontinence brief or repositioned the resident as it was a busy morning. 2. Resident #2 A. Resident status Resident #2, age 85, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/28/22 minimum data set (MDS) assessment, the resident had minimal cognitive impairment with a score of 14 out of 15 on the brief interview for mental status (BIMS). The resident required total assistance with activities of daily living. The MDS coded the resident as having an unhealed stage 4 pressure ulcer. She was at risk for pressure ulcers. The MDS coded the resident as not having any behaviors or refusal of care. B. Observation 6/15/22 -At 12:13 p.m., Resident #2 was sitting in her wheelchair. -At 1:00 p.m., the resident was assisted to bed. The resident did not have her heels offloaded or had her boots on her feet. -At 1:30 p.m., the resident continued to lay on her left side. The resident's feet were directly on the mattress. -At 2:06 p.m., the resident remained in the same position. -At 3:23 p.m , CNA #4 observed the resident's feet were not offloaded and they were directly on the mattress with no boots. -At 3:25 p.m., registered nurse (RN) #1 observed the resident did not have her feet off loaded or the boots on her feet. RN #1 was observed to place the pillow under her ankles to offload her heels from the mattress. During this care, the resident was cooperative and friendly with RN #1. RN #1 looked for preventative booties in her room, however, was unable to locate them. C. Record review The June 2022 CPO showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Remove in morning two times a day for skin integrity and to float her heels while in bed as tolerated every. The care plan last revised on 5/5/22 identified the resident was at risk for pressure ulcers. The care plan documented, heel protector booties while in bed and slip-on shoes while in wheelchair to help prevent my heel rubbing on shoes, and float my heels while I am in bed as I tolerate. At times I choose to decline this. The progress notes dated 5/14/22 to 6/14/22, showed no evidence that the resident refused the booties or floating heels. D. Interview RN #1 was interviewed on 6/15/21 at 3:30 p.m. The RN said the resident was at risk for pressure ulcers. He said she currently had a stage 4 on her coccyx. He said there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN said the resident would refuse the boots at times, however her feet should be offloaded with using a pillow. The RN said the boots should be in the room, and when he was unable to locate them, he said he would ask the CNA. The director of nurses (DON) on 6/15/22 at 3:45 p.m. The DON said when the resident refused to wear the multi-podus boots or to float her heels,then the treatment administration record (TAR) would be marked as a refusals and progress notes should report refusals. CNA #2 was interviewed on 6/16/22 at 11:26 a.m. CNA #2 said the resident was required total care with activities of daily living which included transfers and positioning. She said that she was to have boots on her feet while in bed, however, yesterday she was unable to locate the boots. She said the resident was cooperative and that she never refused any care. E. Facility follow-up The DON provided immediate in-service training records on 6/15/22 at 2:10 p.m. The nursing staff were trained, When working with any resident and prior to any care provided, the Kardex, in (electronic record) must be reviewed. If questions surrounding care remain, please ask the nurse on duty or DON prior to proceeding. 3. Resident #3 A. Resident status Resident #3, age 89, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/19/22 minimum data set (MDS) assessment showed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required one person extensive assistance with transfers, bed mobility and toileting. He was at risk for pressure ulcers. Pressure reducing devices for bed. Application of ointments/medications other than to feet. B. Observations 6/15/22 -At 8:30 a.m. the resident was in his wheelchair in the front lobby. He did not have a pressure relieving device to left foot. His left foot was directly on the wheelchair pedal. -At 10:00 a.m. the resident was on the front patio during activities without a pressure relieving device to left foot. -At 11:20 a.m., the resident was assisted into the dining room. He continued to not have the pressure relieving device on his left foot. -At 2:06 p.m. the resident was at the nurse's cart awaiting medications, no pressure relieving device to left foot. -At 2:24 p.m., the resident was assisted to his room room by CNA #2. She then attached the call light to the resident and left the room. The resident was asleep. He was not offered to be offloaded or to place the preventative boot onto his foot. He continued with no device on his left foot .-At 3:12 p.m. the resident remained asleep in his chair. He continued without a pressure relieving device to left foot. -At 3:45 p.m., the DON observed the resident did not have the boot on his foot. The DON asked if he did not like his boot. The resident said he preferred his shoe, however, he would wear it if needed. The DON asked if it could be placed on his foot. He said yes, and the DON placed the boot on his foot. C. Record review The June 2022 CPO included the following orders: -Heel protector to left heel, leave in place except for transfers with a start date of 6/4/22. The care plan, last revised 5/27/22, identified the resident was at moderate risk for skin breakdown due to Alzheimer's disease, and decreased mobility. -The care plan failed to include the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -The care plan failed to show any evidence that the resident had refused care. The Braden scale for predicting pressure sore risk assessment dated [DATE] showed a score of 16 which indicated he was at risk for pressure ulcers. The skin observation tool assessment dated [DATE] identified the resident had left heel redness, treatment in place and had a boot for protection. The weekly wound observation tool dated 6/13/22 documented abrasion-redness to the left heel. 100% epithelial tissue observed. Measurements were 1.0 centimeter (cm) length x 1.0 cm width x 0 cm depth. Treatment orders included, frequent observation of area, off-loading, heel protector on at all times except for transfers. The June 2022 treatment administration record (TAR) documented that the nurse had signed off on treatment to provide heel protector to the left heel for 6:00 a.m. to 6:00 p.m shift on 6/15/22. -However, the documentation was not correct, as observations showed (see above), the resident did not have the heel protector on his left foot. -The resident's medical record failed to show any evidence that the resident refused to wear the left heel protector. D. Interviews The DON was interviewed on 6/15/22 at 3:56 p.m. The DON was advised the resident did not have a left heel protector on. The DON confirmed through observation, that the resident did not have his left heel protector on (see above observation). The DON reviewed the treatment administration record (TAR) and confirmed the TAR was documented as Resident #3 was wearing the heel protector on his left heel. She said the treatment record needed to be accurate and reflect the accuracy of the resident. She said the resident had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She said if he refused to wear it, then a note should accompany the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Registered nurse (RN) #1 was interviewed on 6/16/22 at 11:12 a.m. RN #1 said the resident had redness on his left heel and therefore had to wear the heel protector. He said the resident would refuse the boot at times. The RN said if the resident refused a nurse progress note needed to be written. CNA #2 was interviewed on 6/15/22 at 11:16 a.m. CNA #2 said the resident was cooperative with wearing the boot. She said he had not refused to wear the boot. CNA #3 was interviewed on 6/16/22 at 11:30 a.m. CNA #3 said the resident wore a boot on his left heel. She said the resident was cooperative and did not refuse his left heel protector. 4. Resident #4 A. Resident status Resident #4, age 79, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] showed the resident was cognitively impaired. Staff interviews showed short term and long term memory problems. Staff interviews also showed the resident was only orientated to staff names and faces with moderately impaired decision making. She was incontinent of bladder and bowel and had no toileting program. She required two persons extensive assistance with transfers, bed mobility and toileting. She was at risk for pressure ulcers. She had one unstageable pressure ulcer and skin tears. Pressure reducing devices for chair and bed were indicated. B. Observations Observations on 6/15/22 from 11:45 a.m. to 2:25 p.m. revealed the following: -At 11:45 a.m the resident was sitting in her wheelchair in the dining room. The resident had socks on her feet. She did not have pressure relieving devices on feet. At 12:30 p.m. the resident was taken to the front lobby after lunch. The resident was in the front lobby at 1:10 p.m., 1:25 p.m., and 2:08 p.m. sleeping in her wheelchair. She did not have pressure relieving devices on feet. -At 2:08 p.m., an unidentified CNA came to the front lobby and assisted her to the nurses station. -At 2:25 p.m. RN #1 assisted the resident to her room and instructed CNA #2 to change her top as it was soiled from lunch. The bilateral boots were not offered or provided to the resident. C. Record Review The care plan, last revised 4/1/22, showed the resident was at risk for skin integrity per resident's Braden score. The resident was at risk for altered skin integrity due to incontinence, decreased mobility, [CONDITION(S)], and fragile skin. The resident had stage 2 to left heel 2/7/22 which had changed to unstageable. The resident was cognitively unable to use call light and needs must be anticipated. -The care plan failed to show any evidence that the resident had refused heel protectors. The June 2022 clinical physicians orders (CPO) included the following orders: -Heel protectors at all times as resident tolerates with a start date of 12/22/21. The Braden scale for predicting pressure sore risk assessment dated [DATE] showed a score of 12 which indicated high risk. The weekly wound observation tool dated 6/14/22 documented left heel wound with visible tissue worsening. 20% granulation, 80% slough tissue present and slight odor. Wound 2.5cm length x 4.5cm width x 0.9 depth. Treatment orders included, frequent observation of area and off-loading with pillows or heel protectors at all times. The June 2022 treatment administration record (TAR) documented that the nurse had signed off on treatment to provide heel protectors at all times to bilateral heels for 6:00 a.m. to 6:00 p.m shift on 6/15/22. -However, the documentation was not correct, as observations showed, the resident did not have bilateral heel protectors on feet. -The resident's medical record failed to show any evidence that the resident refused to wear the bilateral feet protectors. D. Interviews CNA #2 was interviewed on 6/16/22 at 9:15 a.m. CNA #2 said and the resident required total assistance for turning, repositioning, and transfers. CNA #2 said that the resident was cooperative with care and did not refuse boots. The CNA said that the resident could only make needs known with yes or no questions and could not use her call light due to cognition.

Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#1) of three residents reviewed out of seven total residents. Specifically, the facility failed to ensure Resident #1 received timely incontinence care. Cross-reference F686 for pressure injuries Findings include: 1. Resident #1 A. Resident status Resident #1, age 88, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/12/22 minimum data set (MDS) assessment, showed the resident was rarely/never understood. Staff interviews showed short term and long term memory problems, resident only orientated to herself with severely impaired decision making. The resident was incontinent of bladder and bowel and had no toileting program. She required two persons extensive assistance with transfers, bed mobility, and toileting. She was at risk for pressure ulcers. B. Observations 6/15/22 -At 8:40 a.m., the resident was in front of the television (TV) in the common area. -At 8:45 a.m., the resident continued to sit in her wheelchair in the common area. -At 9:10 a.m., the resident remained in the same position. -At 9:30 a.m, the resident continued to watch TV in the common area. The resident was observed continuously from 10:00 a.m. -At 10:00 a.m., the resident remained at the same position. -At 10:05 a.m., the resident was assisted to the outside porch to attend an activity. The resident had not been offered to be offloaded or repositioned. She remained outside at the activity until 11:02 a.m. -At 11:02 a.m., the activity assistant assisted the resident to the dining room for lunch. She had not been offered to be toileted or checked and changed for urinary incontinence. -At 11:20 a.m., the resident assisted with her meal. -At 12:10 p.m., an unidentified certified nurse aide (CNA) assisted the resident into the common area. The resident was not offered to be toileted or checked and changed for urinary incontinence. -At 1:05 p.m., the director of nurses (DON) was notified the resident had not been checked or changed for nearly four hours. -At 1:15 p.m., CNA #1 and CNA #2 transferred the resident from her wheelchair to her bed using a Hoyer (mechanical) lift in her room. Once in bed, the CNAs changed the resident's brief. Odor was detected in the room of urine and bowel movement. Once incontinence care was completed, a plastic bag was placed on the floor containing the resident's brief. A second plastic bag was placed on the floor containing pants that the resident had been wearing prior to being changed. -At 1:25 p.m., as CNA #1 left the room with the soiled bag, the incontinent brief was observed and the weight of the bag. The bag was heavy. C. Record review The June 2022 CPO included the following relevant orders: -Order date 06/13/22: Monitor moisture associated skin damage (MASD) to coccyx. Notify MD (medical doctor) of changes. Off load buttock while in bed, alternating with each brief change. The care plan, last revised on 5/11/22, identified the resident was always incontinent of bowel and bladder and was unaware of her toileting needs due to cognitive impairments. The resident had ADL self-care deficit related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Pertinent approaches included, incontinence briefs were worn and were to be checked/changed upon awakening, after meals, before bed, and as needed as the resident unable to make bowel and bladder needs known. The resident required extensive total assistance with two person assistance. The bowel and bladder continence evaluation assessment dated [DATE] documented that the resident was always incontinent of bowel and bladder. She required more than oversight with toileting. The assessment documented the resident required encouragement and cueing. The resident's plan of treatment showed incontinence was not reversible related to dementia. The evaluation directed to continue with the current treatment plan as is with frequent brief check, repositioning and changes as needed. D. Interview The director of nurses (DON) was interviewed on 6/15/22 at 1:05 p.m. The DON said the resident was at high risk for pressure ulcers due to the MASD. She said the resident was incontinent of both bowel and bladder. She said that she should be checked and changed at least every two hours, as the resident was at risk for pressure ulcers. CNA #2 was interviewed on 6/15/22 at 2:30 p.m. After the CNA had changed the resident's briefs, and was asked if briefs contained urine and bowel, the CNA stated very little. When asked if CNA needed to change the resident's clothes, especially her pants, CNA said that her clothes were not changed. CNA #1 was interviewed on 6/15/22 at 1:25 p.m. The CNA #1 said after changing the resident she was incontinent of both bowel and bladder. She said the resident's brief was pretty heavy as she drank a lot of fluid. E. Facility follow-up The DON provided immediate in-service training records on 6/15/22 at 2:10 p.m. The nursing staff were trained, When working with any resident and prior to any care provided, the Kardex, in (electronic record) must be reviewed. If questions surrounding care remain, please ask the nurse on duty or DON prior to proceeding.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for two out of three units/neighborhoods. Specifically, the facility failed to: -Ensure environmental cleaning consisted of working from clean to dirty; -Establish a cleaning process to capture high touch and horizontal surfaces in resident rooms; -Perform hand hygiene when moving from dirty to clean including areas in a resident room, between glove changes; -Clean and disinfect items such as spray bottles and mop handles used between resident rooms; and, -Ensure proper cleaning technique and supplies were used when providing catheter care to Resident #26. Findings include: I. Housekeeping A. Facility policy and procedure The Environmental Cleaning and Disinfecting policy and procedure, last revised on 5/2/21, was received from the nursing home administrator via email on 7/22/21. It read in pertinent part: Purpose: Environmental surfaces can be a source of pathogens in nursing homes. If surfaces are not properly cleaned and disinfected, pathogens from the surface can be transferred to residents and staff. Proper cleaning and disinfection of environmental surfaces is necessary to break the chain of infection. Procedure: Clean and disinfect by moving from clean to dirty surfaces and cleaning from top to bottom of rooms. All equipment must be cleaned after contact. B. Observations and staff interviews On 7/21/21 at 9:40 a.m. observed housekeeper (HSK) #1 cleaning room [ROOM NUMBER] on the Peaceful unit. He started cleaning in the bathroom. He wiped the sink with a clean rag, wiping the inside of the bowl to the counter, back into the bowl then to faucets then along the edge of the counter. While wearing the same gloves, he retrieved a clean rag from the top of the cart. HSK #1 wiped the toilet rim with the clean rag, down the sides of the bowl, under the toilet seat then on top of the toilet seat, along the tank, to the rim of the toilet bowl and down the sides to the floor. He sprayed the toilet with disinfectant and used the toilet brush to clean the toilet bowl and replaced the toilet brush in the container. Wearing gloves he carried the toilet brush container and disinfectant spray bottle in his left hand and used his right hand to reach into his pocket to get keys to unlock the housekeeping cart. Once the cart was opened, he placed the toilet brush container on the bottom shelf. He removed gloves and performed hand hygiene. He did not clean the toilet brush container or spray bottle before placing it in and on the cart. HSK #1 said that he started a couple of months ago and that he did not work in housekeeping before this job. He said he received a lot of training on COVID-19 that he had not received before in other jobs. He said he was learning all new job duties with housekeeping. HSK #1 said he did not have a system of cleaning the mop handles which were used in each resident's room. He said that the broom, dustpan, and mop handles were used in each resident's room but the mop pads were changed with each room. The broom, dustpan, and mop handles were hung on the outside of the cleaning cart. He did not clean them before placing them on the cart and using them in the next room. HSK #1 was observed at 9:51 a.m. cleaning room [ROOM NUMBER]. He gathered trash from the room and replaced the bags. The housekeeping services director (HSD) arrived and said that HSK #1 was new to his position and she was watching his practice and providing ongoing training since he did not have experience doing housekeeping duties. HSK #1 obtained a few rags from the top of the cart and started cleaning in the bathroom. He wiped the top of the counters, then sink bowl, faucets, inside bowl to counter top. He used two rags of the four clean rags that were in his left hand with the spray bottle. He used his right hand to dispose of the dirty rags in the dirty linen bag on the cart. He put the remaining clean rags on the top of the cart and set the bottle on the top of the cart while he doffed gloves and performed hand hygiene. He donned new gloves and picked up the spray bottle and the clean rags he put back on the cart. HSK #1 used a clean rag and wiped the top of the toilet tank, down the sides of the tank, on the top of the seat, under the seat, on the handle to flush, toilet rim, sides of toilet to base, then lowered the lid. He sprayed the toilet with disinfectant and used the toilet brush to clean the toilet bowl and replaced the toilet brush in the container. Wearing gloves, he carried the toilet brush container and disinfectant spray bottle in his left hand and used his right hand to reach into his pocket to get keys to unlock the housekeeping cart. Once the cart was opened, he placed the toilet brush container on the bottom shelf. He removed gloves and performed hand hygiene. He did not clean the toilet brush container or spray bottle before placing it in and on the cart. He donned gloves and put the keys back into his pocket. HSK #1 got the spray bottle of cleaner from the cart and a new rag and wiped the bedside table top off and the end of the bed closest to the window. He set the bottle of spray on the side of the table while he moved items to wipe under. He did not clean any other areas of the resident ' s personal areas like high touch areas such as call light, remotes, dresser handles, door handles and other horizontal surfaces. HSK #1 got a new rag and changed gloves after hand hygiene, sprayed the bedside table and wiped it off for the resident located closest to the door, however set the bottle on the table to move items to clean under. The bottle was not cleaned between setting it on personal surfaces like bedside tables. He did not clean other resident personal areas like call lights, remotes and other highly touched areas. HSK #1 finished mopping the floor in the bathroom when the housekeeping services director (HSD) said that the bathroom was always mopped last. HSK #1 replied he started in the bathroom. The HSD did not respond to his answer. At 10:36 a.m. HSK #2 was observed cleaning rooms on the Bronco unit. She said she had been in her position for a year and a few months. At 10:46 a.m. HSK #2 was observed cleaning room [ROOM NUMBER]. She came out of another room, doffed gloves and used alcohol based hand sanitizer (ABHS) from the hallway dispenser and donned gloves. She used keys that were laying on top of the clean rags on the top of the housekeeping cart to unlock the cart. She started in the bathroom which was working from dirty to clean versus clean to dirty (see HSD interview below). She grabbed the disinfectant spray bottle and toilet brush container from the cart. She sprayed the sink and the toilet bowl and set the spray bottle on the ground while using the toilet brush. She held the toilet brush container in her hand and used the toilet brush inside the toilet bowl then replaced the brush inside the container and set it on the floor. She picked up the spray bottle and moved it to the sink counter. She picked up the toilet brush container and carried it to the cart, used the same gloved hands to use the keys which were tucked under the clean rags on top of the cart, unlocked the cart and stored the toilet brush container in the bottom cart shelf with other spray bottles. She locked the cart again and placed the keys on top of the clean rags. HSK #2 doffed gloves, performed hand hygiene, donned gloves and grabbed several clean rags. She wiped off the top of the sink and into the bowl then on top of the sink the faucets then in the bowl and to the counter, used a clean rag and did it again. She then went to the cart and disposed of dirty rags into a dirty linen bag on the cart. She doffed gloves, performed hand hygiene, donned clean gloves and grabbed several clean rags. HSK #2 wiped the top of the toilet tank then top of seat then under the seat and down the sides and rim to base. She disposed of the dirty rags in the dirty linen bag. She doffed gloves, performed hand hygiene, and donned gloves. HSK #2 emptied trash and replaced the trash bags. She disposed of trash in the trash section of the cart. She doffed gloves, performed hand hygiene, donned gloves and got a new rag. She grabbed the spray bottle from the sink counter and sprayed the rag with the disinfectant and wiped off the call light that had fallen to the floor. She doffed gloves, performed hand hygiene, donned new gloves and got a clean rag. She sprayed the rag and wiped off the bedside table. She did not clean other surfaces in the room like the horizontal surfaces like door handles and dresser tops. She used gloved hands to get the keys that were sitting on top of the clean rags to unlock the cart and store the spray bottle which was not cleaned before storing. HSK #2 doffed gloves, performed hand hygiene, donned gloves, then swept the bathroom and then the bedroom. She mopped the bathroom, got a new mop head and mopped the bedroom and then out of the room. She replaced the mop handles, broom, dustpan on the cart without cleaning between room uses. C. Staff interviews The infection preventionist (IP)/assistant director of nursing (ADON), nursing home administrator (NHA), housekeeping services director (HSD), regional consultant (RC), and director of nursing (DON) were interviewed on 7/21/21 at 11:26 a.m. The HSD said that the process and direction the room was to be cleaned included working from clean to dirty which meant the housekeepers began cleaning in the bedrooms and cleaned the bathroom last. She said she did not hear HSK #1 say that he started cleaning in the bathroom (see observation above), she thought he said he cleaned the bathroom. She said she would provide more training with the housekeepers in clockwise or counter clockwise direction to capture high touch and horizontal surfaces working clean to dirty, ensuring the bathroom was done last. The HSD said the housekeeping cart was set up so that the clean items like rags were on top of the cart, the top shelving in the locked section of the cart contained the spray bottles. The shelf below held the toilet brush container which was on the shelf without other items like spray bottles. She said the housekeeping carts were cleaned once a week because the residue from the cleaners dripped onto the surfaces and left a film. She said she would include the cleaning of the spray bottles, toilet brush container, mop, broom and dustpan handles, before storing them on the cart and using them from room to room, in the training program moving forward. The IP said the spray bottles and toilet container should be cleaned before storing and used in another room. The spray bottles should not be set on clean surfaces especially after being placed on the floor. The IP said gloves should not be worn reaching into pockets and when using keys. She said she would provide training based on the missed opportunities for glove changing and hand hygiene before handling the keys. The NHA said they would find a different place for HSK #2 to store keys since they should not be stored on or in with clean rags. II. Catheter care A. Facility policy and procedure A copy of The Indwelling Urinary Catheter Management policy, revised 5/6/21, was provided by the nursing home administrator (NHA) via email on 7/22/21. It read in pertinent part, Implementing evidence-based infection prevention practices during both the insertion and maintenance of indwelling urinary catheters has been shown to prevent the occurrence of catheter-associated urinary tract infections (CAUTIs). B. Professional reference Memorial [NAME] [NAME] Cancer Center (revised on 1/7/2020) Caring for Your Urinary (name brand) Catheter, retrieved from https://www.mskcc.org/cancer-care/patient-education/caring-your-urinary-foley-catheter (retrieved on 7/29/21). It read in pertinent part, the process for catheter cleaning included the following steps: - Wash hands with soap and water, don gloves - Using mild soap and water, clean genital area, including the urethra. Clean from the entry site of catheter downward away from body. - Rinse the area well and dry it gently The process for changing the drainage bag included the following steps: - Wash hands with soap and water, don gloves - Empty urine from the drainage bag into toilet or emptying container - Pinch off the catheter with your fingers and disconnect the used bag. - Wipe the end of the catheter with alcohol pad - Wipe the connector on the new bag with a second alcohol pad - Connect the clean bag to the catheter and release finger pinch. - Check all connections, straighten any kinks or twists in the tubing. C. Resident #26 1. Resident status Resident #26, around the age of 90, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/19/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #26 required limited assistance of one person with toileting and personal hygiene. The resident had an indwelling catheter. 2. Resident interview Resident #26 was interviewed on 7/19/21 at 9:59 a.m. He stated that staff changed his bag daily between a leg bag and a straight drainage bag. He stated that they emptied the urine, however only cleansed the insertion site of the catheter around his urethra during showers. 3. Observation On 7/21/21 at 5:00 p.m. certified nurse aide (CNA) #2 was observed performing catheter care for Resident #26. There was no hand hygiene performed after emptying the urine bag, and gloves were not changed. CNA #2 used the same aloe infused wipe to clean the connection between tubing and bag and then from the urethra down the catheter tubing. 4. Record review The computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, initiated on 2/24/21 and revised on 5/14/21, documented that catheter care was to be performed every shift. The 7/20/21 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The indwelling catheter was changed and he was started on intravenous (IV) antibiotics for UTI and [CONDITION(S)]. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Staff interviews CNA #2 was interviewed on 7/21/21 at 8:16 a.m. She stated that she had already performed catheter care that day. She described the catheter care process as starting by emptying the urine from the bag, using the aloe infused wipes to clean tubing and connectors, then changing from a straight drainage bag to a leg bag. She said that she cleansed the insertion site around the urethra with the aloe infused wipes. CNA #2 said catheter care was performed daily on every shift. She stated the facility did provide training on catheter care upon hire. The nursing home administration (NHA), director of nursing (DON), regional consultant (RC), and infection preventionist/assistant director of nursing (IP/ADON) were interviewed on 7/21/21 at 5:11 p.m. The IP/ADON stated that the connector port on the catheter bag tubing that was inserted into the indwelling catheter was to be cleansed with alcohol and not an aloe infused wipe. The IP/ADON said the process for cleaning around the urethra during catheter care included starting at the urethra and wiping down the tubing away from the urethral opening. She said it was on every shift. She said the resident had not had a urinary tract infection for many months. The DON confirmed with the manufacturer of the aloe infused wipes that they could be used for catheter care around the urethra, it would not be harmful, however they were not ideal and soap-infused wipes were recommended and would be sent to them that day. The DON said they would implement the soap-infused wipes immediately and provide training to the staff on the use during catheter care. E. Facility follow-up The nursing home administration (NHA), director of nursing (DON), regional consultant (RC), and infection preventionist/assistant director of nursing (IP/ADON) were interviewed on 7/22/21 at 8:40 a.m. The IP/ADON stated that CNA #2 was observed performing catheter care for Resident #26 and that it was performed incorrectly. CNA #2 did not perform hand hygiene after emptying the urine from the collection bag before cleansing the tubing. CNA #2 used the aloe infused wipe for cleansing the connector port rather than alcohol. She said that training was provided to CNA #2 on when to perform hand hygiene, and that alcohol should be used for connectors. The IP/ADON reported that CNA #2 was observed a second time performing catheter care after education was provided and she performed catheter care appropriately.

Based on observations, record review, and interviews, the facility failed to ensure two (#1 and #4) out of five residents reviewed for pressure ulcers of five sampled residents, received treatment and services for pressure ulcers our of 33 sample residents. Specifically, the facility failed to ensure timely incontinence and pressure reducing care provided for Residents #1 and #4, who were dependent upon staff for assistance with care and had moisture associated skin [CONDITION(S)] on a pressure area to the buttocks and peri-area. Findings include: I. Professional reference National Pressure Injury Advisory Panel (2016), Pressure Injury Prevention Points, retrieved from https://npiap.com/page/PreventionPoints (retrieved on 7/29/21) It read in pertinent part, the process for turning and repositioning residents included the following steps: -Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. -Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. -Consider lengthening the turning schedule during the night to allow for uninterrupted sleep. -Turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed. -Avoid positioning the individual on body areas with pressure injury. -Ensure that the heels are free from the bed. -Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. -Continue to reposition an individual when placed on any support surface. -Use a breathable incontinence pad when using microclimate management surfaces. -Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs. -Reposition weak or immobile individuals in chairs hourly. II. Facility policy and procedure: The Peri-Care policy, last revised 6/9/2020, was provided by the infection preventionist/assistant director of nursing (IP/ADON) via email on 7/22/21. It read in pertinent part, Peri-care will be provided to maintain cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Dignity will be maintained during peri-care by exposing only the peri-area. Peri-care will be provided a minimum of daily and after each incontinent episode. CNAs (certified nurse aide) may apply a physician ordered or house stock incontinence barrier to intact skin following peri-care. If a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Resident #1 A. Resident status Resident #1, age 94, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/20/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She was incontinent of bladder and bowel and no toileting program. She required two persons extensive assistance with transfers and bed mobility. She was at risk for pressure ulcers. She had no unhealed pressure or vascular ulcers. Pressure reducing devices for chair and bed. Application of ointments/medications other than to feet. The resident had occasionally severe pain which interfered with sleep, but not day to day activities. She received scheduled and as needed pain medications, she did not receive non pharmacological interventions. No nutritional concerns identified. B. Resident interview Resident #1 was interviewed on 7/19/21 at 10:37 a.m. She reported that she fell three years ago and she had only gotten out of bed on rare occasions since then. She stated that she received bed baths only and had a bedsore for about a month. She revealed that wound care was provided once a day and stated that the staff tried to reposition her every two hours if they were not too busy. Resident #1 stated that she had participated in activities in the past, but was not interested in that anymore and preferred to remain in her bed. C. Observations and interviews Continuous observations on 7/21/21 from 8:16 a.m. to 11:21 a.m. included the following: At 8:16 a.m. certified nurse aide (CNA) #2 was observed in the room with Resident #1. Resident #1 complained of nausea and feeling like she was going to throw up. CNA #2 told the resident that she could try ginger ale and offered a fan and stated the resident had just got the medicine for nausea, and suggested to the resident that they give that time work and see how she felt. -There was no offer to perform incontinence care and pressure reducing preventative measures like shifting of weight. At 8:59 a.m., CNA #1 was observed bringing Resident #1 toast. -There was no offer to perform incontinence care and pressure reducing preventative measures like shifting of weight. At 10:39 a.m. therapy provided treatment, the therapy services director (TSD) stated Resident #1 rarely got out of bed. TSD reported Resident #1 worked with physical therapy three to five times a week where she would sit at the edge of the bed with minimum assistance for trunk control, however required maximum assistance to get to the edge of the bed. The TSD did not perform incontinence care but did provide therapy services. At 11:21 a.m. CNA #1 was observed providing incontinence care for Resident #1. She used foam soap and aloe infused wipes. Resident #1 had a pencil eraser sized open area on her right buttock that was observed as red without drainage, the wound was surface level, and periwound (surrounding area) was clean, dry, and intact (CDI). Her sacral (tailbone) area, as well as left and right buttock, was open and excoriated with a bright red wound bed observed. The wound was surface level with no drainage and irregular edges. The periwound was reddened. Resident #1 did have stool incontinence at time of changing. CNA #1 was observed rubbing the resident's buttocks and sacrum vigorously with a wipe to remove [MEDICATION(S)] cream. The [MEDICATION(S)] cream was an intervention provided to be applied after peri-care, however it is not to be removed with a wipe (see interview below). After peri-care was performed, CNA #1 left the room and returned with registered nurse (RN) #2 who applied a barrier cream to the excoriated area of the residents buttocks and sacral area. -The resident was provided incontinence care approximately three hours after the observation began. Resident #1 stated she was able to feel urination after it had already occurred, but not before. She stated that she was not able to feel when she had a bowel movement (BM) during or after it occurred. She reported that it was very painful when her buttock wounds were cleansed during peri-care because CNA #1 was rubbing the cream off that was intended to provide relief and prevent a barrier for moisture. D. Record review The care plan, initiated 1/4/19 and revised 9/29/21, documented Resident #1 had actual/potential alteration in her skin integrity due to decreased mobility, incontinence, and moisture in skin folds. The care plan documented the resident was not always aware of her toileting needs and she received a diuretic (medication to eliminate excess fluid in the body). It documented Resident #1 should be checked frequently for incontinence and changed as needed. -The care plan did not include the moisture associated skin [CONDITION(S)] (MASD) on the buttocks of the resident. The July 2021 CPO included the following relevant order: -Order date 4/25/21: [MEDICATION(S)] cream to be applied to the area on the left buttock three times a day and as needed until MASD was resolved. The 7/21/21 skin observation form read in part, Resident #1 had a bruise to her right lateral leg that was dark purple in color and an open area to the right abdominal fold related to MASD. MASD to coccyx area. The 7/14/21 skin observation form read in part, Resident #1's skin was warm and dry and there was a bruise to her right lower leg which had resolved. There was mild redness to the buttocks. E. Staff interviews RN #2 was interviewed on 7/21/21 at 11:45 a.m. She confirmed that Resident #1 did not get out of bed per her own choice. She said she applied cream after incontinent episodes. The nursing home administration (NHA), director of nursing (DON), regional consultant (RC), and infection preventionist/assistant director of nursing (IP/ADON) were interviewed on 7/21/21 at 5:11 p.m. The DON and NHA acknowledged the resident did not get out of bed often per her choice however the resident was able to tell the staff when she needed incontinence care. They were not aware the resident was not able to identify incontinence needs. They said they would perform an assessment and update her care needs accordingly. The DON and NHA stated that they were aware that barrier cream should not be removed, but rather another layer applied after urine and stool cleansed from the resident. They said they would provide the training to the staff on the appropriate use of the barrier cream. IV. Resident #4 A. Resident status Resident #4, age 86, was admitted on [DATE]. According to the July 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/16/21 MDS assessment documented Resident #4 had severely impaired cognitive skills for decision making. The resident required extensive assistance of two people for all activities of daily living (ADL), including bed mobility. She was wheelchair bound and unable to ambulate. She was incontinent of bladder and bowel at all times and was not on a toileting program. She was at risk for pressure ulcers. She had no unhealed pressure or vascular ulcers. Pressure reducing devices for chair and bed. Application of ointments/medications other than to feet. She was on a scheduled pain medication regimen, however did not receive as needed medication or non pharmacological pain interventions. She was unable to verbalize her pain scale, but staff assessment of non-verbal pain indicators documented that there were no signs of pain observed. No nutritional concerns identified. B. Observations and interviews Continuous observations on 7/21/21 from 8:00 a.m. to 11:49 a.m. included the following: At 8:00 a.m. Resident #4 was observed in her wheelchair sleeping in the activity room. At 8:33 a.m. CNA #3 was observed transporting the resident to the community room where she continued to sleep in her wheelchair. At 9:24 a.m. CNA #1 and CNA #3 wheeled Resident #4 to her room. Using a Hoyer (mechanical) lift CNA #1 and CNA #3 transferred the resident into her bed. -The resident's brief was not checked for incontinence and no peri-care was performed at that time. At 11:35 a.m. Resident #4 was noted to be sleeping in her room. -No incontinence care had been offered to the resident. At 11:49 a.m. CNA #2 was asked when Resident #4 would be changed and she stated that it would probably be after lunch. CNA #2 was informed that Resident #4 had not been changed in nearly four hours. CNA #2 reported that she would change Resident #4 at that time. CNA #2 was interviewed on 7/21/21 at 11:25 a.m., while providing incontinence care to Resident #4. CNA #2 was asked when the resident would be getting up into her chair again and she stated that she had intended to assist with eating the resident in her room and would not get the resident up out of bed until dinner time. CNA #2 said the resident usually would get up in her wheelchair at 7:00 a.m. and then would not be put back to bed until after dinner. CNA #2 stated that the staff would transfer Resident #4 into her bed with the Hoyer lift to change her, and then would transfer her back into her chair. She said the facility staff would try to complete incontinence care every two hours. CNA #2 performed incontinence care for Resident #4. The resident had redness between her legs, posterior (back side) upper thighs, and sacrum. The CNA did not notify the nurse to apply barrier cream after the incontinence care was provided. C. Record review The care plan, initiated on 5/13/16 and revised on 7/1/21, documented Resident #4 was at risk for skin breakdown due to decreased mobility, incontinence, and fragile skin. She was incontinent of bladder and bowel at all times, and was not aware of her toileting needs due to cognitive impairment. She wore pull up briefs and required frequent assessment of incontinence. The July 2021 CPO included the following relevant physician order: -Order date 9/20/19: [MEDICATION(S)] cream applied to areas on bilateral buttocks and bilateral inner thighs every shift for skin management. The 7/19/21 skin observation form read in part, Resident #4's skin was clean, warm, dry, thin, and fragile. She had a self inflicted skin tear from a scratch to the back of her neck, which showed no signs of infection. Barrier cream was applied to the buttocks. -The skin observation form did not include a description of the condition of her buttocks as indicated in observations (see above). D. Administrative interviews The nursing home administration (NHA), director of nursing (DON), regional consultant (RC), and infection preventionist/assistant director of nursing (IP/ADON) were interviewed on 7/21/21 at 5:11 p.m. The IP/ADON stated that she believed Resident #4 was on a check and change schedule of every two hours. She said when she worked with the resident the schedule was out of bed for meals and in bed between meals to protect the resident's skin from breakdown and provide incontinence care. V. Facility follow-up The NHA, DON, RC, and IP/ADON were interviewed again on 7/22/21 at 8:40 a.m. They reported a situation, background, assessment, recommendation (SBAR) assessment had been started for Resident #1's wound and incontinence needs. Resident #1's skin assessment was updated. Previous assessment was noted that Resident #1 was able to make needs known, they assessed for change in condition. They reported that Resident #4 usually received incontinence care every two hours and was transferred back and forth from her bed to her wheelchair multiple times throughout the day. They recognized the staff working with the resident during the observations were agency staff and they would need to provide ongoing training to the agency staff to ensure the facility met the residents' needs.

Based on record review and interviews, the facility failed to maintain complete resident records for residents involved with community resources for two (#51 and #26) out of 33 sample residents. Specifically, the facility failed to: -Have the physician signed medical orders for scope of treatment (MOST) form on file for Resident #51; and, -Ensure urology consults were in Resident #26's records. Findings include: I. Facility policy and procedure The Documentation policy, updated 1/13/19, was received from the nursing home administrator (NHA) on 7/22/21 at 1:00 p.m. It read in pertinent part: The medical record must be complete, accurately documented, readily accessible and systematically organized. II. Resident #51 A. Resident status Resident #51, age 93, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/2/21 minimum data set (MDS) revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) assessment of eight of 15. The resident required extensive one-person assistance with bed mobility, bathing, and personal hygiene, extensive two-person physical assistance with transfers and dressing, limited one-person physical assistance with locomotion on unit and toileting, and supervision and one-person physical assistance with walking and eating. The resident required the use of a wheelchair. B. Record review The MOST form was reviewed on 7/21/21. The MOST form revealed a signature from the resident representative on 7/8/21. No physician signature was included on the MOST form and a note at the top of the form documented DNR per outside community clinic. The signed MOST form was not present in the building at the time of the survey. When informed the facility contacted the outside community clinic and a copy of the physician signed MOST form, dated 11/8/11, was faxed to the facility during survey on 7/21/21 at 3:00 p.m. C. Staff interview Registered nurse #1 was interviewed on 7/21/21 at 2:30 p.m. She said the nurse reviews the advanced directives with the resident/representative and flags the MOST form in the chart for the physician to review and sign. After the MOST form is signed by the physician the nurse can input the orders into the resident's profile. She said the physicians will usually sign the MOST form and not reference a form that was not in the facility or on file. She said requests for the Resident #51 MOST form had been made but they had not received the form from the outside community care clinic the resident received physician services from. The director of nursing (DON) was interviewed at 3:00 p.m. She said she had been trying to get a copy of the physician signed MOST form since the residents' admission. She said she had called multiple people and made multiple attempts to get the signed MOST form from the outside community clinic and no one returned her calls or forwarded the MOST form. III. Resident #26 A. Resident status Resident #26, around the age of 90, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/19/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had an indwelling catheter. B. Record review The resident's medical record was reviewed on 7/21/21, however the referenced urology notes were not available in the electronic health record for the following visits: 5/19/21 and 6/23/21. When informed, the facility contacted the managing company and a copy of the notes were faxed to the facility during the survey on 7/22/21 at 3:00 p.m. C. Staff interviews The nursing home administration (NHA) and director of nursing (DON) were interviewed on 7/21/21 at 5:11 p.m. They acknowledged that they did not have the above documentation in the facility available for review when it was requested. They said they would work with the management company to ensure health records were available in Resident #26's medical record at the facility.

Based on observations, resident interviews and staff interviews, the facility failed to maintain an infection control program designed to prevent possible spread of the Corona disease (COVID-19). Specifically, the facility failed to ensure: -Residents wore a face mask or covering when out of their rooms; -Ice coolers and linens were secure from communal use; -Community rooms where residents used computers and phones were cleaned and disinfected after each resident's use; -Beverage carts were cleaned and disinfected before going from one resident's room to another to prevent the spread of infection. Findings include: I. Facility policy and procedure The policy COVID-19 Management, revised April 2, 2020, was provided by the director of nursing (DON) on 4/15/2020 at 12:00 p.m. It read in pertinent part, COVID-19 management (policy) will help prevent the spread of [MEDICAL CONDITION] which is believed to spread through direct person-to-person contact, inhalation of an [MEDICAL CONDITION], and contact with surfaces contaminated by [MEDICAL CONDITION]. Cleaning of contaminated hands, using appropriate PPE (personal protective equipment) and cleaning and disinfecting the environment will be used to help prevent the spread of microorganisms. Our community will use COVID-19 management practices to protect our residents, visitors, and staff from infection. II. Facility failures A. Observations Observations were conducted on 4/15/2020 from 11:00 a.m. to 1:00 p.m. -At 11:00 a.m. Upon entering the facility, none of the four residents in the entry communal area were wearing masks. Upon entering the facility, there were four residents sitting at the entry communal area. There were no masks or face coverings on the residents to prevent the spread of infection. Further observations throughout the facility revealed residents had no masks or face coverings while out of their rooms. -At 11:20 a.m., the ice cooler and scoop were observed in the hallway of the south unit. -At 11:40 a.m., the ice cooler and scoop were observed in the hallway of the north unit. Both ice coolers were accessible to anyone in the facility including residents which could potentially be a risk for the spread of infection. During observations, both ice coolers were not monitored by staff to prevent the spread of infection. -At 11:30 a.m., the south hall linen closet was observed. There were towels, sheets, wash cloths and blankets in the closet. There was a curtain in front of the closet. It was located in front of a resident's door. It was accessible to anyone in the facility including the residents. During observation, it was not monitored by staff to prevent the spread of infection. -At 11:10 a.m., one resident was observed on the phone in the main hallway area between the administrative offices. The phone was available for use by all residents. After the resident was done with the phone, he hung up and left the area. The phone was not cleaned or disinfected by staff after the resident had completed his phone call. -At 11:59 a.m., the southern community room was observed. In the room was a computer, phone and a television. The room was accessible to all residents who wanted to use the computer or phone. Resident #2 was observed playing card games on the computer (communal computer). -At 11:40 a.m. three staff were observed distributing drinks to resident rooms from a cart. The drinks were on top and covered with plastic, the cups were stacked on the bottom of the cart and were not covered. They pushed both carts into one resident's room, came out and pushed both beverage carts into another resident's room. The ready to use cups were uncovered. The staff did not clean or disinfect the cart prior to pushing it into another resident's room. B. Resident interviews Resident #1 was interviewed on 4/15/2020 at 11:25 a.m. He said the facility had not offered him a face mask or covering. Resident #2 was interviewed on 4/15/2020 at 12:00 p.m. He was observed in the community room. He was playing a card game on the computer. He said the community room was not monitored by staff. He said it was used by any residents who wanted to use it. He said he had not seen staff clean and disinfect the computer or phones after each resident use. He said the housekeeper would do the regular cleaning of the room, but was not sure if they cleaned and disinfected the computer or phone after it was used by a resident. He said he was aware of COVID-19 but he was not offered or told to wear a mask or face covering. He said masks were only worn by staff. C. Staff interviews Housekeeper (HK) #1 was interviewed on 4/15/2020 at 12:00 p.m. She said each HK was responsible for a hall, including communal areas. She said all areas of the facility were cleaned twice a day. She said all communal areas and electronics should be wiped down and disinfected after resident use (during observations the phone and computer were not cleaned and disinfected after they were used by the residents). Dietary aide (DA) #1 was interviewed on 4/15/2020 at 12:55 p.m. He said he brought the carts into the residents' rooms because there were no lids for the beverages. He said the carts were brought into the rooms so that nothing could get into the drinks. He said all drinks and ice were delivered to the residents' rooms before mealtimes and should be covered with plastic. He said drink carts would sometimes be left in the hallway if the residents liked to touch the carts or the things on the cart. He said he did not know how COVID-19 was transmitted. The social services director (SSD) was interviewed on 4/15/20 at 12:55 p.m. She said she assisted with serving beverages to the residents. She said to take the entire cart into the resident's room was not the usual practice at the facility and she was not sure why it was done this way. The ADON, who was also the infection preventionist, was interviewed on 4/15/2020 at 1:26 p.m. She said masks were not provided to the residents due to a shortage of masks. She said masks were only given to residents who were potentially symptomatic. She said she was not aware that all residents were to be wearing face masks or coverings. She said masks were given to residents who had symptoms. She said the ice coolers and linen closets were monitored by staff. She said if the residents needed ice or linen, they would ask the staff. (However, during observation the ice coolers and the linen closets were not monitored by staff and were accessible to anybody. She said she had not put a plan in place regarding the community room. She acknowledged that if the computer or phone was used by a resident in the community room and was not clean or disinfected after use, it could potentially spread infection. She said she would put a plan in place for staff to monitor the room and clean/disinfect after each resident's use to prevent the spread of infection. She also said DA #1 should not have taken the entire cart into the resident's room. She said the cart should have remained in the hall in front of the resident's door. She said taking the cart from one resident's room to the other could spread infection. She said she would provide education to the staff.

Based on observations and interviews; the facility failed to store and serve food in accordance with professional standards for food service in one of two dining rooms and one of two nursing stations. Specifically, the facility failed to ensure staff handled food properly and ensure food was stored at the proper temperature at the nursing station. Findings include: I. Facility policy and procedure The Use of Plastic Gloves policy, dated 2005, was provided by the director of culinary services (DCS) on 7/10/19 at 3:23 p.m., revealed Plastic gloves are to be worn whenever handling the food directly with hands when: handling ready-to-eat foods. The Storing Temperature Controlled for Safety (TCS) Food Safety guidelines, undated, was provided by the DCS on 7/10/19 at 3:18 p.m.,, revealed Store cold TCS food at an internal temperature of 41 degrees Fahrenheit (F) or lower. II. Observations The residents were eating lunch in the main dining room on 7/8/19 at 12:07 p.m. Certified nurse aide (CNA) #4 placed her bare hand down on the top of the table. She proceeded to cut a sandwich for one of the residents. She touched the sandwich with her bare right hand while she cut the crust off of the sandwich after touching the table. A container of snack foods was observed at the ' Peaceful nursing station on 7/10/19 at 8:37 a.m. This container was accessible to the residents. The container was full of package sealed cookies, peanut butter crackers and handmade sandwiches such as peanut butter and meat and cheese. The meat and cheese sandwich was dated 7/9/19. Registered nurse (RN) #2 said the snack foods were there when she got to the facility at 6:00 a.m. She removed it at 8:40 a.m. after being informed. The snack foods were observed out at room temperature from 6:00 a.m to 8:30 a.m. within reach of the residents. The RN said she did not know how long the food was out at room temperature. The meat and cheese sandwich was warm to the touch. The cheese was slightly melted. The residents were eating lunch in the main dining room on 7/10/19 at 12:02 p.m. CNA #3 was assisting a resident with his meal. She placed her bare left hand on the top hamburger bun and then placed it to the side. At 12:08 p.m., the same CNA picked up some potato chips with her bare right hand and fed them to the resident. During the above observations no hand hygiene, donning of gloves occurred before using utensils to handle ready-to-eat foods. III. Staff interviews The director of nurses (DON) and the licensed practical nurse (LPN) were interviewed on 7/10/19 at 1:00 p.m. They said they were in charge of all of the trainings. Infection control was in charge of the food handling training. Agency staff had their own trainings. The staff was just trained on proper food handling. The DCS and the culinary supervisor (CS) were interviewed on 7/10/19 at 1:35 p.m. They said nursing staff completed trainings for the CNAs assisting in the dining room. They said they participated in the trainings during orientation. The DCS said snacks were sent to the floor from 6:30 to 7:00 p.m. He said the food items needed to be refrigerated. Everything left from the night before was thrown out the next day. The DON and the LPN were interviewed on 7/10/19 at 1:41 p.m. They confirmed staff should not touch ready-to-eat food with their bare hands. They also confirmed food needed to be stored at the proper temperature. The DON said that staff was always doing that.

Based on observations, record review and interviews; the facility failed to ensure residents with new bruises were investigated for one (#54) of two residents reviewed for skin conditions of 23 sample residents. Specifically, the facility failed to ensure a bruise for Resident #54 was investigated after identification. Findings include: I. Facility policy and procedure The Bruise Investigation and Management policy, revised 10/12/12, provided by the nursing home administrator (NHA) on 7/10/19 at 10:57 a.m. revealed, in part, When a bruise or potential injury of unknown origin is identified, the direct care nurse will immediately be informed. Evaluation and treatment will be initiated. Evaluation includes inspection, description, and measurement of the area(s), and if necessary, first aid. The responsible party and physician will be notified, and appropriate treatment orders obtained. Evaluation of potential causes and prevention interventions will be initiated by the direct caregivers. Direct care staff and interdisciplinary team members will evaluate potential injuries of unknown origin using the .incident investigation format. II. Resident #54 status Resident #54, age 86, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician order [REDACTED]. The 6/10/19 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score five of 15. No bruises were marked. Findings include: III. Resident observations and interviews The resident was observed on 7/8/19 at 12:32 p.m. She had a visible blue-purple bruised area (discoloration) on her left hand. The bruise covered the top of her hand, extending over her knuckles and fingers. The resident was in the living area in her wheelchair on 7/9/19 at 3:11 p.m. She had the same visible blue-purple bruised area (discoloration)on her left hand. The nursing home administrator (NHA) and corporate consultant were interviewed on 7/9/19 at 3:55 p.m. They stated there was no incident report for this resident ' s bruise so an investigation was never completed. They started an investigation after being informed. They said the resident did not know where she got the bruise. The resident was in the dining room at 7/10/19 at 8:00 a.m. She was eating breakfast by herself. The bruise on her left hand was blue with some streaks of purple throughout. The bruise was located across the top of her left hand, extending along her knuckles and fingers. The resident also had a smaller bruise on the top of her right hand. The resident was interviewed at 8:35 a.m. She said she did not remember where she got the bruise. When asked if the bruise hurt, she said sometimes. IV. Record review The care plan, revised 7/10/19, revealed At risk for skin breakdown, skin tears and bruising due to decreased mobility, incontinence, poor nutritional intakes and fragile skin. Interventions included: weekly skin assessment (last revised 1/28/16); Encourage me to put on my gardening gloves with the fingers cut out to help protect my hands (initiated 7/10/19). Review of the skin observation tool, dated 7/10/19, revealed the following: -Right hand (back) bruising: length: 3 centimeters (cm) and width: 2.5 cm. -Left hand (back) bruising: length: 7.8 cm and width: 3.5 cm. Review of the progress notes revealed no documentation of bruising from 7/6/19 at 8:52 p.m. through 7/9/19 at 3:51 p.m. There was documentation of bruising to the left hand on 7/9/19 at 3:52 p.m. and there was documentation of bruising to the right hand on 7/10/19 at 11:41 a.m. V. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 7/10/19 at 8:43 a.m. She said she was unsure how the resident got her bruise. She said the bruise was not there on Saturday (7/6/19). The NHA and the director of nurses (DON) were interviewed on 7/10/19 at 8:54 a.m. They said a CNA had identified and reported the bruise to the nurse on Monday 7/8/19 at 10:45 a.m. The nurse said it was an old bruise so no investigation was completed. The DON said that was not the standard of care and that was not the proper process. She said the nurse should have completed an investigation. They confirmed the bruise occurred sometime between Sunday (7/7/19) at 6:00 p.m. and Monday (7/8/19) at 10:45 a.m. CNA #1 was interviewed on 7/10/19 at 9:39 a.m. She said this resident did not have a bruise on Saturday. She said she came back to work the day before (Tuesday) and she had a bruise. She said when they identified a bruise, they needed to report it to the nurse so they can evaluate, investigate and educate. The Licensed practical nurse (LPN) was interviewed on 7/10/19 at 10:33 a.m. She confirmed the nurse did not complete an investigation for the bruise on the left hand. She said she was not aware of the residents bruise on her right hand. She confirmed the last skin assessment dated [DATE] was clear of any bruising. Registered nurse (RN) #2 was interviewed on 7/10/19 at 11:39 a.m. She said she was not aware of any bruising until it was reported on Tuesday. She said the LPN talked to the resident and the resident said she bumped it on the table. The director of rehabilitation (DR) was interviewed on 7/10/19 at 12:33 p.m. She said they implemented an intervention which included the resident wear gloves to help protect from further bumps.

Based on observation, record review and resident and staff interview, the facility failed to assist one (#89) of 42 sample residents in obtaining routine and 24-hour emergency dental care. Specifically: The facility failed to ensure the resident was seen by the dentist in a timely manner. The resident entered the facility on 7/4/12 with dental pain, complained of pain almost daily and was medicated for mouth pain almost daily. As of survey exit 9/27/12, the resident had not seen a dentist. The findings include: A. Professional Reference According to Perry & Potter, Fundamentals of Nursing, 7th Edition, 2009, page 207, "Dental problems with natural teeth and dentures are common in older adults. Dental caries, gingivitis, broken or missing teeth, and ill fitting or missing dentures affect nutritional adequacy, cause pain and lead to infection." B. Resident #89 Resident #89, age 57, was admitted to the facility on [DATE]. According to the admission face sheet, printed 9/24/12, [DIAGNOSES REDACTED]. According to the 7/10/12 Admission Minimum Data Set (MDS), the resident was cognitively intact. She was able to communicate her needs and understand the communication of others. She required limited assistance, or supervision for most activities of daily living, including personal hygiene. She was independent with bed mobility and eating. She was continent of bowel and bladder. She was coded to have abnormal mouth tissue (ulcers, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn), inflamed or bleeding gums or loose natural teeth, and mouth or facial pain, discomfort or difficulty with chewing. Review of the 7/17/12 care plan for pain, reviewed 7/3/12, identified the problem as "I have a tooth abcess (sic) to my left side of my mouth. I have done antibiotic (ABX) therapy and I am working with Social services to address my dental work. I am able to eat and when it hurts I ask for my pain meds." -The goal was the resident's pain would be managed to an acceptable level. The resident's pain was ten out of ten at its worst, and an acceptable level was zero to four out of ten. -Approaches included pain assessments each shift and as needed, medications (meds) as ordered, non-pharmacological interventions, and a 9/26/12 entry the resident was scheduled for a dentist appointment on 10/5/12. (This was three months after facility admission.) Observations and Resident Interview: Observation on 9/20/12 at approximately 11:20 a.m. and 9/26/12 at 10:20 a.m., revealed a broken molar on the right lower side of the resident's mouth. The tooth was broken off at the gum line, with remaining tooth visible in the gum. The resident was interviewed, on 9/20/12 at approximately 11:20 a.m. The resident said her teeth were painful. She said oral pain medication helped relieve the pain. She said she requested the pain medication every four hours. She said the kitchen ground up her meat so she did not have to chew as much, which helped decrease her dental pain. She said she was on a gluten-free diet, so her choices for some food items were limited. She said a cookie she was often given for dessert was so hard she stopped eating it, as she had trouble chewing. She said the kitchen was out of a gluten-free brownie mix, so until more was delivered, the only dessert she got was the cookie that was too hard to chew, or a popscicle. She said she had a dental problem, and was advised she could not get dental work until her Medicaid was in effect. In an interview on 9/26/12 at approximately 10:20 a.m., the resident said she chewed on the left side. She said she had an abscess on the left lower side of her mouth when she first got to the facility. She said there was still pain on the left lower side, but it was less intense than on the right side at the present time. She said there are two dental abscesses on the right lower side at this time. She said she wanted all of her teeth removed, under anesthesia so she would not be awake. Record Review: (1) Pain Medications Review of the 9/12 computerized physician orders [REDACTED]. (2) Medication Administration Records (MARs): MARs were reviewed from the facility admitted , 7/4/12 through the afternoon of 9/25/12: -7/4/12 through 7/31/12, the resident was given 63 doses of [MEDICATION NAME], or an average of 2.2 tablets per day. Daily administration of this drug ranged from zero to five doses a day. Sixty-one of the 63 doses (or 97%) were given for a complaint of oral, mouth, or tooth pain. -8/1/12 through 8/31/12, the resident was given 84 doses of [MEDICATION NAME], or an average of 2.7 tablets per day. Daily administration of this drug ranged from zero to five doses a day. Fifty-eight out of the 84 doses (or 69%) given were attributed to oral, mouth, or tooth pain. -9/1/12 through the afternoon of 9/25/12, the resident was given 67 doses of [MEDICATION NAME], or an average of 2.7 tablets per day. Daily administration of this medication ranged from one to four doses a day. Twenty-eight of the 67 doses (or 42%) were attributed to oral, mouth, or tooth pain. Review of the MARs from admission through 9/25/12 revealed the following: Pain Assessments, ordered every shift, scheduled morning (AM), afternoon (PM) and "Late Bedtime," for July 2012, ranged from 0 (no pain) to 9 out of 10 (worst pain), August 2012 ranged from 0 to 8 out of 10, and September 2012 (through 9/25/12) ranged from 0 to 9 out of 10. (3) Nurse's Notes Review of the Nurse's Notes from admission (7/4/12) through 9/26/12 revealed: -7/4/12 at 1400 (2:00 p.m.) "I also have some pain to my mouth from tooth abscess need extraction." -7/5/12 at 1045 (10:45 a.m.) "I may not even use the [MEDICAL CONDITION] (continuous positive air pressure machine for treatment of [REDACTED]." -7/5/12 at 1600 (4:00 p.m.) "Resident continues to complain of tooth/jaw pain medicated (med) x1 with relief. Spoke with social worker about dental appointment as soon as possible." -7/5/12 at 2100 (9:00 p.m.) "Med for general pain" -7/7/12 at 0411"Pain management in progress. C/O (complains of) pain to inside of mouth earlier at bedtime given prn (as-needed) [MEDICATION NAME] and [MEDICATION NAME] one tablet 5/325 (milligrams) with good effect." -7/8/12 at 0500 (5:00 a.m.) "Resident requested prn [MEDICATION NAME] for tooth pain at 2330 (11:30 p.m.) and 0200 (2:00 a.m.) with positive results." -7/8/12 at 1830 (6:30 p.m.) "Med x2 this shift with [MEDICATION NAME] for mouth pain Reports 5/10 (pain level) with good relief from pain meds." -7/9/12 at 0500 "Requested prn [MEDICATION NAME] at 2100 (9:00 p.m.) for tooth pain, effective results." -7/19/12 at 1600 (4:00 p.m.) "C/O tooth pain x2 today with good relief." -8/1/12 at 1700 (5:00 p.m.) "Resident c/o of tooth pain requested (up arrow) pain med. Dr. gave order for [MEDICATION NAME] (an anti-[MEDICAL CONDITION]) 200 mg po qid (four times a day), prn." -8/28/12 at 2000 (8:00 p.m.) "Resident was medicated with one [MEDICATION NAME] orally as ordered prn for pain, will monitor." (This was after a fall, with injury to her leg) -8/29/12 at 1140 (11:40 a.m.) "Resident c/o of 6/10 pain to left lower extremity and mouth. Prn pain med given with tolerable results." -9/6/12 at 0500 (5:00 a.m.) "She c/o leg and mouth (pain). Given pain pills with good effect." -9/7/12 at 2:00 a.m. "C/O shoulder pain/mouth/legs. Resident stated the pill helps." -9/8/12 at 0915 (9:15 a.m.) "Reports left leg pain 7/10, oral pain 6/10, and left shoulder soreness/tenderness tolerable discomfort 1/10 for which medicated with [MEDICATION NAME]." -9/8/12 at 10:15 a.m. "Verbalizes relief from pain." -9/9/12 at 1345 (1:45 p.m.) "Resident continues with mouth pain and leg pain. PRN given with positive effectiveness." -9/9/12 at 2200 (10:00 p.m.) "Resident c/o 7/10 pain to mouth, shoulder and leg. PRN given with positive effectiveness." -9/18/12 at 0012 (12:12 a.m.) "Resident showed nurse a small piece of decayed tooth; resident showed nurse where tooth had come out. This nurse noted that resident has a decayed tooth on bottom left (other notes refer to right lower jaw, see below) jaw. No redness, drainage or swelling noted." -9/18/12 at 2200 (10:00 p.m.) "Area to right lower jaw without redness, swelling. Medicated for pain with positive effectiveness." -9/19/12 at 0022 (12:22 a.m.) "C/O tooth, left shoulder and left lower leg pain. Resident medicated per request. No facial swelling, drainage from broken tooth site. Taking oral fluids and food without difficulty." -9/19/12 at 2245 (10:45 p.m.) "Medicated for pain to mouth related to broken tooth, positive effectiveness." -9/20/12 at 0500 (5:00 a.m.) "On charting for losing a piece of her tooth. She continued with [MEDICATION NAME] with good effect all through the shift." -9/20/12 at 1600 (4:00 p.m.) "Resident c/o of 6/10 pain to mouth one time this shift. PRN pain med given with positive effectiveness. No redness to gum to right bottom jaw. No signs or symptoms (S/S) of infection noted." -9/20/12 at 2350 (11:50 p.m.) "Medicated for mouth pain with positive effectiveness. No redness to gum and right bottom jaw, no S/S of infection, remaining afebrile." -9/21/12 at 3:00 a.m. "Medicated as needed for c/o mouth and left leg pain." -9/21/12 at 12:05 p.m. "Resident c/o of 6/10 (pain) to mouth. PRN pain med given with positive effects. No S/S of infection to gum to bottom right side." -9/22/12 at 4:00 a.m. "Medicated prn for c/o mouth pain, left leg pain. "It helps." Now resting quietly." -9/23/12 at 0256 (2:56 a.m.) "C/O teeth, left shoulder and leg pain. PRN medication effective." -9/24/12 at 1355 (1:55 p.m.) "Resident c/o 6/10 pain to mouth. PRN pain medication given with positive effectiveness. Gum to right lower jaw pink. No swelling or S/S of infection." -9/24/12 at 2345 (11:45 p.m.) "Medicated for gum pain with positive effectiveness, no redness to gum and bottom right mouth." -9/25/12 at 0220 (2:20 a.m.) "C/O tooth, left shoulder and left lower leg pain. Medicated per order. Medication effective. Will continue to monitor. Took fluids and food without problem." -9/25/12 at 1515 (3:15 p.m.) "End charting for missing tooth on right lower jaw. Will continue monitor in pain in (illegible word). Has referral to Social Services for follow dentist." (4) Review of the 7/4/12 Nursing History and Physical Assessment showed the resident had pain from a tooth abscess in the left lower jaw. She needed a [MEDICAL CONDITION] at night, but would not use it until the tooth was fixed. (5) Review of the 7/26/12 Resident Summary (monthly) showed the resident experienced moderate pain in her mouth daily. This was relieved with [MEDICATION NAME]. Staff Interviews: In an interview on 9/25/12 at 4:30 p.m., the assistant Social Worker (SW) confirmed this resident was one of the residents she managed for the facility. She said the resident got a Medicaid card, but the facility had not gotten notification of resident's status from the state agency managing that program. She said the lead SW managed Medicaid status for all facility residents. In an interview on 9/27/12 at 8:10 a.m., the assistant SW said she made the 10/5/12 dental appointment for the resident. This was immediately after the resident broke her tooth. In an interview on 9/26/12 at 9:10 a.m., the lead SW said the facility just got the confirmation letter from the State Medicaid office, confirming the resident had coverage. She said the resident already got her cards, and the confirmation from the State Medicaid office was the last piece of information to ensure the resident had coverage. The lead SW said dental care should be "out of pocket." She said this meant the facility should pick up the costs of needed dental care while awaiting the decision of the State Medicaid application process. She agreed waiting since 7/4/12 for dental care was too long. She said when a resident had immediate dental needs, she usually arranged for a dental evaluation to determine how to proceed. She said she was not aware the resident had unmet dental needs.

Based on physician, resident, and staff interviews and record review, the facility failed to ensure the resident environment on the North Unit of the facility remained as free of accident hazards as possible and that one of 33 sample residents (#38) received adequate supervision and assistive devices to prevent accidents. Specifically: 1. The facility failed to ensure that resident #38 was secured adequately in her wheelchair with the required seat belts and straps. This failure contributed to resident #38 sustaining injuries from a fall while being transported in the facility van. The resident sustained [REDACTED]. 2. The facility failed to lock the housekeeping closet, leaving hazardous materials within the residents reach on the North unit in the facility. The findings include: 1. INADEQUATE SAFETY PRECAUTIONS Resident #38, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/6/11 annual Minimum Data Set (MDS) assessment documented resident #38 was cognitively intact, independent with eating and locomotion in her wheelchair, needed extensive assistance with bed mobility, dressing, and personal hygiene, was totally dependent on the staff for transfers and toileting, was incontinent of bowel and had an indwelling catheter. The MDS also reported that the resident had not had any recent falls. Record review revealed the resident was assessed 5/1/11, to be at high risk for falls with a fall risk score of 10. (A score of 10 or greater indicated the resident was at high risk for potential falls.) Per the assessment, the resident was alert and oriented, had no falls in the past three months, was chair bound, had no visual deficits, was unable to walk, had no drop in systolic blood pressure, took three to four medications that increased the resident's fall risk, and the resident had one to two predisposing diseases that could also make her a fall risk. a. Fall with fractures 6/1/11 A nurses note in the chart written on 6/1/11 at 6:00 p.m. documented, "Res fell out of her chair during transport in van. C/o right leg pain. The doctor, at 4:00 p.m. in facility, ordered stat (immediate) right fib/tib x-ray. Medicated PRN (as needed) for pain. No other problems noted." The resident's vital signs at the time of the note were: temperature 98.6?, pulse 78, respiratory rate 20, blood pressure 128/64, and 90% pulse oximeter. Another nursing note on 6/1/11 written at 6:15 p.m. documented, "At approximately 12:00 p.m. staffer pulled into parking lot, alerted staff that resident slid out of w/c when she was cut off in traffic. Seat belt noted around her. Staffer states she was leaning forward messing with her bag (foley) prior to falling. She did not hit head. When asked by staffer if she was hurt several times she stated no. She was placed back in the chair. MD in building - c/o's (R) leg pain. X-ray ordered." The 6/1/11 nurses note, written at 10:00 p.m. documented, "Received x-ray results at approximately 8:10. ... MD called, order received to send to ER for eval & treat. The ambulance was called at approx 10:30 p.m., DON (director of nursing) notified. The ambulance here at approx 11:30 p.m. & transported the resident to the hospital for eval and treatment ..." The 6/3/11 nurses note, written at 11:30 a.m. by the DON documented, "Late entry for 6/1/11 @ 12:30 p.m. This nurse was alerted by the CNA/van driver to come help resident who had fallen in van during transportation. Resident was observed to be sitting on van floor in front of w/c. CNA & resident stated someone pulled out in front of van & the driver was forced to stop van abruptly. Resident was asked if we could call 911. Resident refused 911 call. Assessed resident, no evidence of head trauma. Resident states, "I did not hit my head." Legs showed no evidence of displacement or dislocation. Resident is unable to move legs as her baseline of dx (diagnosis) of paraparesis. She denied pain upon assessment. Resident was lifted using a draw sheet by five staff members & returned to w/c per her request. LPN (licensed practical nurse) notified. Vital signs & blood sugar obtained & WNL (within normal limits). The 6/3/11 nurses note, written at 2:38 p.m. documented, "Late entry for 6/1/11. At approximately 12:00 a.m. this nurse manager was outside with DON and other nurse manager. Staffer pulls into parking lot with new van and states that resident had slid out of w/c when she was cut off in traffic. Upon entering van, resident was seated on the bus floor on butt with legs in front of her with seatbelt across her. She states "Get me up." I asked, "What happened?" "I slid under my seat belt." "Do you want 911?" "No." "Are you hurting?" "Just get me up ... I feel like my BS (blood sugar) is low." I alerted the CNA to get 2 glasses of OJ (orange juice). Called the resident's charge nurse to check BS - (BS 296). She drank one glass of OJ. CNA attempted to get vital signs - she wanted to get up. She denied hitting head. BUE (bilateral upper extremity) ROM (range of motion) WNL. BLE (bilateral lower extremity) ROM with paraparesis - no abnormality noted. She was then assisted into w/c with 5 staff & draw sheet. She was taken into facility and reported to charge nurse." The 6/3/11 nurses note, written at 3:00 p.m. documented, "Late entry for 6/1/11. At approx 12:45 p.m. I was notified that res had fallen in van on transport from wound clinic. Res was brought into facility by staff. Upon speaking to res at 3:00 p.m., res denied hitting head. Was alert & O (oriented) x 3. Denied any pain to lower extremities after fall. Stated, "I feel nauseated." Res requested to hold medications until a little later. Also inquired if res would like to lay down, res refused. Res cont to stay sitting in w/c. At 3:30 p.m. res propelled self down to smoke. At 4:00 p.m. she took her meds." The Emergency After Care Instructions form given to the resident after her visit to theER on [DATE] documented that the resident was seen by the ER doctor for a right femur/tibial plateau fracture. b. Pain - discovery of additional fractures - facility response Nursing Notes: The 6/2/11 nurses note, written at 6:55 a.m. documented, "Res returned to facility transported by an ambulance company and accompanied by 2 paramedics on stretcher at 4:30 a.m. Res c/o 9/10 (R) leg pain. Scheduled med pain given. Pain level now 7/10. Res has (R) femur fracture & (R) tibial plateau fracture. Order for knee immobilizer at all times, CMS (circulation, motion, sensation) checks q shift & no transfers noted. Follow-up with ortho in 1 week to be scheduled by day nurse." The 6/2/11 nurses note, written at 7:55 a.m. documented, " ... Per report from the RN (registered nurse) at the hospital fractures non operable." The 6/3/11 nurses note, written at 5:30 a.m. documented, " ... Resident requested pain meds at bedtime for c/o right hip and BLLE (bilateral lower leg extremity) (pain) at 7/10 rate. Given scheduled Methadone and requested Dilaudid PRN with good effect. Observed right hip and right lower extremities, no bruising from previous fall ... Can feel sensation to toes when touched and checked ..." The 6/3/11 nurses note, written at 6:30 a.m. documented, "TO (telephone order) for pain patches, nasal spray, vitamins D3 + calcium." Nurses' notes 6 /4/11 - 6/9/11, continued to document pain and swelling of the resident's right foot (6/6/11, 6/8/11) interspersed with documentation of no specific pain (6/4/11, 6/8/11). The resident's monthly nursing summary, completed on 6/9/11 documented that the resident had experienced pain in the seven days prior to the assessment being completed. The summary documented that the resident felt pain almost constantly, that it was sharp aching pain, and 8/10 at its most severe. Per the summary, the resident's pain at its best was 3/10. Nurse Practitioner (NP) and Physician Documentation: The 6/2/11 monthly note from the resident's NP documented that, "Nursing reports resident slid out of w/c (wheelchair) en route to the facility after wound clinic appointment at the hospital on [DATE]. C/O (complains of) pain to the right leg, x-ray was done. Result showed acute mild impacted fracture of right medial tibial plateau with minimal (dis)placement. She was later sent to the hospital ER for evaluation and treatment. Resident returned back to the facility earlier this am." -Under the Review of Symptoms section, it was documented that the resident's pain rating was severe. The location of the pain was in the resident's right leg and the resident described the pain as a "sharp, ache." The resident's pain was being treated with medication and the resident was on opioid use for pain. -Under the Physical Exam section, it was documented that the resident was alert and oriented to person, place, and time. The resident was complaining of pain to the right leg and was able to verbalize her needs well. The resident had 1-2+ edema at the time of the exam. The resident was able to wiggle her right toes during the assessment. -Under the [DIAGNOSES REDACTED]. The resident was on Methadone 10 mg tab, Lyrica 100 mg cap, and Hydromorphone 2 mg tab for pain. -The treatment plan was to keep the resident's pain under control. At the time of the assessment, the resident stated that her pain was 9/10 and her worse pain was 10/10. She stated that 2-3/10 was what was acceptable to her. The resident had been taking Dilaudid at the time of the assessment approximately every four hours, which was taking her pain down to 6-7/10. -The NP documented, " ...Pain is aggravated since fractures. She points to pain localized to right knee and right anterior tibia. Pain currently is uncontrolled. Given pattern of Dilaudid use since fracture to right tibia/femur, will add Duragesic 50 mcg every 72 hours and keep Dilaudid for breakthrough pain. At risk for decreased mobility with decline with increased pain. Monitor and make changes to POC (plan of care) as needed." -The resident was also coded as having a closed fracture of the upper end of the tibia and a closed supracondylar fracture of the femur. -Per the treatment plan, the NP documented, "Evaluated and treated at the hospital ER for right medial and lateral tibial plateau fracture with intra-articular extension supracondylar femur fracture. ... Considered prospect of using Lovenox for DVT (deep vein thrombosis) prophylaxis. ... This was discussed with the MD (medical doctor) and came to the conclusion that the risk outweighed the benefit and we will not pursue Lovenox. ... Given fracture, will start Calcium 600 mg po (by mouth) BID (two times a day) and increase Vitamin D3 50,000 units to q (every) week instead of q month. Also start Miacalcin nasal spray, 1 spray daily x4 weeks ..." The Physician's Progress note, dated 6/3/11, documented that the resident had fractures of the femur and the tibia. The injuries occurred when the resident, "slid out of w/c on bus, twisting leg/knee ("I caught my leg on the footrest") - x-ray here positive for a tib plateau fx (fracture). Sent to the ER and found med condyle fx femur also (nondisp) - pt denies any HI (head injury)." The doctor's assessment was, "Pt (patient), by her hx (history) and disc (discussion) with staff about removal from van (pt refused 911), injury clearly was result of sliding out of w/c, catching leg on leg rest, and "twisting around it" (per pt report)." For the tibia and femur fracture, the doctor discussed with the staff placement and monitoring of the resident's knee immobilizer and recommended that the resident have a follow-up with the orthopedic doctor. A follow-up note from the NP, dated 6/14/11, documented that the resident's last day of PT/OT (physical/occupational therapy) was that day. The resident had started therapy due to her right tibial/femur fracture and was being discharged from therapy for a lack of participation. The resident was seen by orthopedics on 6/10/11, and that doctor discontinued the right knee immobilizer for the resident. Care plans: The 6/1/11 Acute Temporary Care Plan, written on 6/1/11 documented, "I fell on my Rt (right) leg in the van. I have a fracture to my (R) (right) medial tibial plateau." There was no goal included in the care plan. The approaches included: Notify MD, Rt fib/tib x-ray, Monitor pain level and Send to ER (emergency room ) for eval and treatment. The Acute Temporary Care Plan, written on 6/2/11 documented, "I have a fractured (R) femur and (R) tibial fracture." There was no goal included for the care plan. The approaches were: -Staff to check right lower extremity every shift -Monitor for increased swelling -Knee immobilizer on at all times -Pain meds as ordered and PRN (as needed) -Follow-up with ortho one week -Call NP (nurse practitioner) or MD for increased pain or swelling, numbness, tingling, purple/blue toes, or cold toes. The Acute Temporary Care Plan, written on 6/3/11 documented, "I have potential for skin breakdown R/T (related to) knee immobilizer." The goal was that the resident would not have skin breakdown. The approaches included were: -Check skin under immobilizer in the morning and at night -To follow up with the medical doctor regarding any skin issues -To educate the resident on the importance of checking her skin Orders: Chronological review of the physician's telephone orders revealed the following in pertinent part: -6/1/11 5:00 p.m., "X-ray 2 view Rt. fib/tib Dx (diagnosis) pain post fall" -6/1/11 (no time), "Send to ER. Eval and treat." -6/2/11 (no time), "CMS (circulation, motion, sensation) checks to RLE (right, lower extremity) Q (every) shift, knee immobilizer on at all time, no transfers." -6/2/11 11:00 a.m., "PT to Eval for transfers" -6/2/11(no time) "OT (Occupational Therapy) eval & tx (therapy). OT clarification skilled tx 5 x wk X 2 wks ..." -6/2/11 (no time), "Monitor VS (vital signs), pulse ox (oximeter) q shift through 6/7/11, CMS checks RLE q shift through 6/7/11. Non-weight bear(ing) RLE. Call NP/MD for increased pain, swelling, numbness, tingling, purple/blue toes, or cold toes (R)." -6/2/11(no time), "Duragesic patch 50 mcg #10. Apply q 72 hours for pain. Miacalcin Nasal Spray - 1 spray, alternating nostrils X 4 weeks - fracture and pain. Calcium 600 mg PO BID (by mouth two times a day)" -6/2/11 (no time), "D/C Vitamin D3 q month, Vitamin D3 50,000 PO week. (Vitamin D def/fracture ...") -6/2/11 (no time), "D/C no transfers" -6/3/11 (no time), "Discontinue Duragesic patch 50 mcg Dx for pain ..." -6/5/11 (no time), " ...Lovenox 80 mg sub q bid DVT (deep vein thrombosis) prophylaxis ..." -6/7/11(no time), "Decrease skilled OT services 3X wk X 30 days..." -6/7/11 (no time), "PT Clarification: PT will decrease 3X wk X 30 days ..." Hospital and Radiology Reports: The Emergency Department Report, dated 6/2/11, for the resident's visit on 6/1/11 documented that the resident's x-rays had shown an acute fracture of the proximal, lateral tibia. The CT (computed tomography scan) showed a medial, lateral tibial plateau fracture with intra-articular (joint) extension supracondylar femur fracture. Per the progress notes, orthopedics saw the patient and determined that the resident's pain was well managed. The discharge impression from the doctor was that the resident had a tibial plateau fracture and a femur fracture. The Radiology department section documented, "Antero lateral & medial tibial plateau depression fx (fracture) without clear extension intra-articularly. Also left distal medial femur fx without displacement or intra-articular extension. Marked osteopenia." The [DIAGNOSES REDACTED]. The Orthopedic History & Physical form from the hospital, completed at 11:40 p.m. on 6/1/11 documented, "57 yo F with MMP (multiple medical problems), wheel-chair bound. BI (brought in) from SNF (skilled nursing facility) after fell out of wheel-chair ~ (at approximately) 9:30 this AM onto knees. Initially denied pain but c/o subsequent pain throughout day." The radiology consultation report transcribed on 6/2/11 at 2:34 a.m. reported that the resident had "Intra-articular (joint) medial and lateral tibial plateau fractures, with medial femoral condyle fracture and fibular head fracture. Per the x-ray completed at the facility, dated 6/1/11 at 7:07 p.m., the resident only had an "an acute mild impacted fracture of the right, medial tibial plateau with minimal displacement." c. Facility Report of Incident The incident report, completed on 6/1/11 at 12:00 p.m., documented that the resident was coming back from a doctor's appointment when a car cut the van off and the driver had to slam on the brakes. When that happened, the resident yelled and was on the ground. The staff member asked her if she was in pain and she stated that she was not in pain, that she just wanted to go home. The staff member asked the resident if she wanted her to call 911 and the resident stated that she did not want her to call 911, she wanted the driver to get her back to the facility and have four strong men get her back into her wheelchair. Per the incident report, the resident was assessed on the van by a licensed practical nurse (LPN) when it arrived back at the facility. On 6/15/11 at 3:08 p.m., during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), they stated that they started the investigation into the fall immediately after the fall occurred and the investigation showed that there may have been an issue with the seat belt system. Per the NHA, "The issue through return demonstration with the driver demonstrated that it seat belt was not right. It did not look right. Independent of the driver, the maintenance director demonstrated the same system error. Not being an engineer, I determined that it was not mechanically possible to secure the seat belt as intended. Once that was determined, we immediately put a stand down on both vans for residents that were wheelchair bound. The van dealer was out here on the 9th to see what the problem was and we took the van into the shop on the 13th. To the best of my knowledge, I cannot say with certitude when this issue may or may not have arisen. Prior to the accident on 6/1/11, I was not notified of any issues with the seat belts on the van." d. Failure to protect the resident from an accident and injuries in the van. Resident #38 was interviewed on 6/7/11 at 9:48 a.m., on 6/14/11 at 2:58 p.m. and again on 6/15/11 at 10:00 a.m. Interviews revealed the resident was not secured in her wheelchair on 6/1/11, and staff responded improperly after the resident fell . The resident reported her fractures caused her an unacceptable level of pain. In an interview with the resident on 6/7/11 at 9:48 a.m., she stated that her leg had been fractured a week earlier. She stated "We were in the van and the person in front of us slammed on their brakes and we had to slam on our brakes. When that happened, I was holding on to the railing and a bracket on the van in my wheelchair, and when they slammed on the brakes, I lost my grip. I did have a seatbelt on across me and when I fell , I was on the floor with the seatbelt on me. It stretched all the way out with me in it. The wheelchair was secure but I was on the floor, I slipped out of the wheelchair. When I was on the floor, the driver was trying to comfort me and took the seatbelt off ... When we got back to the facility is when they helped get me off the floor into my chair and then I was taken back to my room. They came to take an x-ray of my leg and we found the broken leg later in the afternoon..." When the resident was interviewed again on 6/14/11 at 2:58 p.m., she stated that she had been in the van four times prior to the accident and that she had been secured in the van the same way each time she was on it. -She stated, "Yes. That seat belt ain't worth a diddly squat. That is why I fell out of my wheelchair. I was not secure. I fell down with the seatbelt connected to me onto the floor. I broke my leg from that... It will take one to two months to heal. I am in a lot of pain everyday because of it, especially when I am in bed, when I have to be moved to my right and to my left side. It is also painful sitting in the chair. When I have to go down to smoke it is painful ..." -She stated, in response to a question about how it felt when she fell out of her wheelchair onto the van floor, the resident replied, "Oh my word. Now this is happening to me. Not only have I had paralysis and edema, now I have a broken leg . . . I was in shock, I was totally in shock, I could not think straight . . . She (the van driver) should have called 911, not let me sit on the floor . . . Yes, it hurt right away. The front of the leg, the knee, was where most of the pain was but my whole leg and whole body hurt. When I fell , my leg was angled to the side and when the driver came back, she straightened it out so it was straight on the floor . . . I was not surprised to find that my leg was fractured because it was "hurting like crazy . . . My pain level (at the time of the fall)? . . . (On a scale of 1 to 10) it was a 20." -She related, "I was going to the left and to the right (on the ride back to the facility) I was holding on to the left side onto a metal railing and then with my right hand I was not able to hold on to anything at all... I did not have any secure device holding me; I was bouncing around back there. There were no straps to create a makeshift seatbelt with to hold me. When I was on the floor driving back, I felt unsecure. I hope nothing else happens to me again." -With regards to managing her knee pain, resident #38 stated that she took pain medication to numb the pain down. "Right now, I got my pain meds at 11:30 a.m.; right now it is a 5 out of 10 at my knee. I did not have any pain in my knee prior to my fracture . . . The pain gets worse in the morning when I get up and it can get up to 7 or 8 out of 10. When I get pain medication it goes down to a 5 which is not acceptable. No pain is acceptable. After I am done talking to you, I am going to go ask my nurse for pain meds because it is going to go up to an 8." -She stated that she had gone to a follow-up doctor's appointment on 6/13/11 and she was "scared" to ride in the van (a different van than the one in which she fell ). "I was holding on for dear life. When I get back in the white van (the van in which she fell ) it is going to be scary. I never feel really secure on the vans, I still move around an awful lot." On 6/15/11 at 10:00 a.m., the resident stated that her pain when she had awakened was 7 out of 10. She said that she had received pain meds at 6:00 a.m. and the pain was down to a 5 out of 10 but it was heading toward 6/10, which she identified was not acceptable to her. She said was going to let the nurse know that she would like two Dilaudid to help get her pain lower than 5/10. e. Staff Interviews: Staff interviews revealed conflicting accounts of the events on 6/1/11, and staff training on transporting wheelchair residents in the van. Interviews further indicated staff had prior knowledge of problems with the van seat belt. During an interview with the van driver on 6/14/11 at 1:17 p.m., she stated that she was a CNA (Certified Nursing Aide) and she confirmed that she was the driver of the van on the day of the fall. She stated that she had been working in the facility for [AGE] years and had been driving the vans on and off for about eight months. According to the CNA, the activities staff, maintenance director, and another CNA were also drivers. -She stated that the van drivers were trained by a video and then they were shown how to secure the wheelchair bound residents in safety classes. She said she remembered that it was the van dealer that trained them on securing the residents in the van when it was first purchased. She recalled that the van drivers had completed the vehicle training earlier in the year, possibly in January or February. She stated that "now" in case of an emergency; she was supposed to call her supervisor and then call 911. -She then explained how she secured residents in the van, "There are straps down on the floor, I put their brakes on, and follow every procedure that I was trained to follow. Once I put their brakes on, I ask them if they are okay and comfortable. I explain everything that I am doing to them while I work. I ask them if they are okay various times and ask if they have any temperature related problems. I then start securing the residents, starting from the back of the wheelchair to the front. I take the straps from the floor and secure them to the frame of the wheelchair. Then I follow the same procedure in the front. Once I finish, I make sure that the wheels are locked. Then I take the seat belt strap from the van; put it through the wheelchair handles, across the resident's torso, to the back of the wheelchair, where it then attaches to a strap on the floor, which is attached to the van floor." -She then recounted the events of 6/1/11 as follows. "We were coming back from the appointment around 12:30 or 1:00 p.m., and I was going down the ramp on I-25 and a person in front of me cut us off. I slammed on my brakes and heard the resident fall forward and say "Ow!" I did not see the resident fall..." She confirmed that there were two belts for the resident, one that went across the resident's chest and one that went across the resident's abdomen. She stated that when she went back to see how the resident was, both belts were still attached to the van; and were on the floor with the resident. The resident had been sitting between the foot rests and she took them off when she got to the resident. She said, "When I went back to check on the resident, she was on the floor with her right leg bent beneath her and her left leg straight out ... She told me that she did not want me to call 911 and that she just wanted to get back to the facility and get 4 strong men to lift her up." -She said she had attempted to secure the resident on the ride back to the facility. She got a seat belt from the floor and a seat belt from the van, and made a shift seat belt. "On the drive back, I kept asking her if she was okay or sliding. She said she was fine and had a little bit of pain. I was nervous on the drive back because the resident's leg was bent beneath her and every time that I picked up the phone to make a call, she told me not to call 911. I called the maintenance director first when I arrived at the facility to let him know that we were here and that I needed help. At the time the fall happened, I did not call anyone." She said she did not recall how the resident's leg was when they arrived back at the facility. She stated that when they returned to the facility, the resident complained of having a desire to throw up. During a follow-up interview with the driver on 6/16/11 at 11:46 a.m., she stated that she did not recall the exact time of the incident but that it occurred sometime between 12:00 and 12:30 p.m. She stated that the maintenance director got help and the DON and one of the unit managers were part of the recruited assistance. She recalled the DON assessing the resident when she saw the resident. The DON checked the resident for any open areas and for complaints of pain. The resident denied having pain at the time ... After the assessment, four staff members got the resident back into her wheelchair. They got some blankets, put them under her, and did a body lift. "I do not recall if the resident complained of pain when they were getting her up. She asked for OJ to drink because she was feeling nauseous. The staff got her OJ and a CNA did her vital signs... The resident was then taken back to her room." -She stated that she remembered being trained on securing residents in the van in January or February. "To my knowledge, it was never determined that my training was insufficient." When she did the demonstration of how to correctly secure a resident for the van dealer (after the resident's fall 6/1/11), he had confirmed that she had completed the wheelchair securing correctly. "He verified that the procedure that was being followed was the correct one that he taught us. He then stated that something was not correct with the seatbelt and that something was loose with the chest belt as well as the attachment from the floor. She said the van dealer explained to us that he was going to work on it and get back to us. He did not like the way the belts were fastening. He took it for repairs and told us not to drive it ... If I had it to do over, I would not do anything differently, that is how I was trained to do it." -She stated that since the accident, the policy and procedures were changed. The new procedure if an accident occurred was to stop the vehicle, stay where they were, and call 911. She had been told that if something did not feel right with the van, then they should not take it out. Per the driver, "The new policy and procedure is much better. It gives me more guidance and overrides the desire to do everything for the resident and follow the resident's explicit instructions." -She said that she felt that the mechanism from the seat belt on the bus was not working properly. The seatbelt from the van came out with the resident when she fell instead of catching like it should have. "It was maintenance that realized that there was a problem with the seat belts and straps on the van. That is why we do not have the van; it was sent in for maintenance. We did not use the van again after the incident happened. We called the place that sold us the van and the guy stated that there was something not right with the seatbelt." During an interview with the maintenance director (MD) on 6/15/11 at 1:59 p.m., he stated that it was his responsibility to maintenance the van. It also was his responsibility to train the staff on safety in the van, driving, procedures, and in loading and off-loading of residents. "We have a CD (compact disc) and a book that the staff signs off on when they complete the required training. Basically, the CD and the book are the same. Most of what is in the book does not really cover the safety procedures - it covers the van operation (e.g. how to use the van, using the lift, etc). -The MD said, "Pretty much I am the one that does the training on securing the residents in the van. It is also covered in the book. I was trained from the book, on-line material, and we contacted the insurance company that provided information for training. They provided hand-outs with descriptions and pictures. We also received information from Colorado.gov. When they delivered the van, the delivery man did a very quick demonstration, most of which were things I was already aware of." -The MD said, "When I am training a new driver, the first thing I do is hand them the book and ask them to review that thoroughly. They do not sign off on it until I go out to the van with them and do a demonstration with them. The staff must demonstrate how to secure a wheelchair in the vehicle and that they are able to drive the vehicle, etc. Prior to doing that, the background check and license check is completed. I trained both the staffing coordinator and the activities staff on the wheelchair securing procedures. We are constantly ensuring that people are doing things correctly. That is part of our safety committee procedures. Pretty much every time that they go anywhere I am checking that they are doing correctly because they need my help. If I am not here, then they must do it alone because they are the only ones that know how to do it correctly. -The MD said, "Since the fall, we now have formal observations monthly. We did not have formal observations since January because we have not been using the van that much, we have been seeing how it wor