Every finding on record at Fowler Health Care

Based on observations and interviews, the facility failed to store, distribute, and serve food in a sanitary manner in two of two kitchen refrigerators.Specifically, the facility failed to ensure nutritional beverages were labeled and dated when opened in the kitchen nourishment refrigerator and the walk-in refrigerator. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/22/26 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 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. (Chapter 3-29).II. Facility policy and procedureThe Food Receiving and Storage policy and procedure, revised November 2022, was provided by the nursing home administrator (NHA) on 4/15/26 at 12:16 p.m. It read in pertinent part, All food stored in the refrigerators or freezers shall be covered, labeled and dated with used by date. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Beverages are dated when opened and discarded after twenty-four hours. III. ObservationsOn 4/13/26 at 8:50 a.m. the following was observed at the main kitchen nourishment fridge and the walk-in refrigerator during the initial kitchen tour and the follow-up observation.In the nourishment refrigerator the following was observed:One opened container of thickened apple juice that was not dated;One container of thickened orange juice that was not dated;One opened container of lemon-flavored thickened water that was not labeled;-One opened container of tomato juice that was not dated; and,-One opened container of unsweetened black tea that had a use-by date of 8/21/25.In the walk-in refrigerator, there was one opened sweet baby barbecue container that was undated.On 4/14/26 at 1:00 p.m. the following was observed at the main kitchen nourishment fridge and the walk-in refrigerator during the initial kitchen tour and the follow-up observation.In the nourishment refrigerator the following was observed:One opened container of thickened apple juice that was not dated;One container of thickened orange juice that was not dated;One opened container of lemon-flavored thickened water that was not labeled;-One opened container of tomato juice that was not dated; and,-One opened container of unsweetened black tea that had a use-by date of 8/21/25.In the walk-in refrigerator, there was one opened sweet baby barbecue container that was undated.On 4/15/26 at 12:21 p.m. the following was observed in the main dining room during lunch observation.During the lunch service, there was a container full of ice that had a gallon of milk, tomato juice and apple juice. The staff were serving these drinks to residents. The beverage containers were opened, but were undated.III. Staff interviewsDietary aide (DA) #2 was interviewed on 4/15/26 at 1:10 p.m. DA #2 said all opened beverages should be dated and labeled, however did not know why they should be dated and labeled. She said she looks for the expiration date on the carton.The dietary manager (DM) was interviewed on 4/15/26 at 1:30 p.m. The DM said the kitchen staff should have all opened juice cartons dated and labeled to be aware of how long it has been opened to avoid distributing contaminated beverages to any resident. She said all kitchen staff and dietary aides were trained to understand the importance of labeling. She said the staff might have forgotten to label those beverages in the nourishment refrigerators. The DM said she would immediately provide education to the kitchen staff and dietary aides to ensure open beverages were labeled and dated properly.

Based on observations, record reviews and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for four (#4, #7, #22 and #2) of six residents reviewed for respiratory care out of 29 sample residents.Specifically, the facility failed to ensure that Resident #4, Resident #7, Resident #22 and Resident #2 received oxygen therapy in accordance with their physician's orders.Findings include: I. Professional reference According to Nursing Skills, Open Resources for Nursing (Open RN), Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 11/11/21, accessed on 4/20/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/, Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11) Devices such as high flow oximetry masks, CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), or mechanical ventilation may be initiated by the respiratory therapist or provider to deliver higher amounts of inspired oxygen. (Chapter 11) Manage oxygen therapy and equipment: If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and properly connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment. II. Facility policy and procedure The Oxygen Administration policy, revised October 2010, was provided by the nursing home administrator (NHA) on 4/15/26 at 11:41 a.m. It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. The general guidelines require verifying that there is a physician's order, reviewing the physician's orders, or the facility protocol for oxygen administration. Preparing appropriate equipment, ensuring safety by removing flammable items and posting warning signs, selecting and applying the correct oxygen delivery device, monitoring the resident for tolerance and complications, documenting all relevant details, and educating the resident and others about oxygen safety precautions. III. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included interstitial pulmonary disease (disorders causing progressive inflammation and irreversible scarring of the lung tissue), muscle weakness, depressive episodes, acute cystitis without hematuria (inflammation of the bladder), and hypo-osmolality (a condition characterized by an abnormal low concentration of solutes in the blood or other body fluid) and hyponatremia (a condition characterized by low sodium levels in the blood). The 1/20/26 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required maximum assistance with transfers, set-up assistance with eating and moderate assistance with personal hygiene and toileting. The assessment revealed the resident was receiving oxygen therapy. B. Observation and resident interview On 4/13/26 at 3:28 p.m. was in her room. There was a nasal cannula (a tubing device that delivers oxygen through the nose) in her nose and connected to a room oxygen concentrator. The oxygen concentrator was set to 2 liters per minute (LPM) of oxygen. Resident #4 said she used oxygen at all times during the day and at night. She said the staff members set the oxygen liter flow. Resident #4 said the staff switched her to the portable oxygen tank when she left her room and put her back on the oxygen concentrator when she returned to her room. On 4/14/26 at 11:04 a.m. Resident #4 was lying down on her bed with a nasal cannula in her nose. The nasal cannula was connected to the oxygen concentrator, which was set at 2 LPM. On 4/15/26 at 9:15 a.m. Resident #4 was sitting in her recliner in her room with a nasal cannula in her nose. The nasal cannula was connected to the oxygen concentrator, which was set at 2 LPM. Resident #4 said she did not know how many liters of oxygen she was receiving. She said a staff member assisted her into her recliner and applied the nasal cannula to her nose. C. Record review The respiratory/oxygen care plan, initiated 4/29/24 and revised 4/8/26, revealed that Resident #4 was at risk for respiratory distress related to interstitial lung disease. Interventions included administering oxygen per the medical director's (MP) order. A review of Resident #4's April 2026 CPO revealed the following physician's order: Oxygen via nasal cannula at 1 LPM at bedtime, ordered 4/9/25. -However, observations on 4/13/26, 4/14/26 and 4/15/26 revealed Resident #4 was receiving 2 LPM of oxygen during the day, not 1 LPM at night as ordered by the physician (see observation above). D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 4/15/26 at 9:15 a.m. CNA #4 said she was able to verify the residents' oxygen orders in the residents' electronic medical records (EMR) and adjust their oxygen flow rates per the physician's orders. CNA #4 said she did not verify the physician's order for Resident #4's oxygen at the beginning of her shift. She said Resident #4 was receiving 2 LPM of oxygen -However, the physician's order for Resident #4 indicated the resident should be on 1 LPM of oxygen at night (see physician's order above). Registered nurse (RN) #2 was interviewed on 4/15/26 at 9:20 a.m. RN #2 said Resident #4 was on continuous oxygen related to a respiratory illness. He said Resident #4 received oxygen at all times. RN #2 said it was necessary to follow the physician's order because oxygen was considered a medication. RN #2 said several medical complications, such as hypoxia (low blood oxygen levels) and hyperoxia (too much oxygen levels), could develop when residents' oxygen orders were not followed accurately as prescribed. RN #2 said he did not know why Resident #4's physician's order for oxygen indicated the resident only wore oxygen at bedtime because the resident had been on continuous oxygen for a long time. RN #2 said he would call the physician to clarify the resident's oxygen order. IV. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included anemia, chronic systolic congestive heart failure, chronic atrial fibrillation, chronic obstructive pulmonary disease (COPD), and muscle weakness. The 2/17/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision and assistance with eating, personal hygiene and transfers and set-up assistance with toileting. The assessment indicated the resident required oxygen therapy B. Observations and resident interview Resident #7 was interviewed on 4/13/26 at 1:38 p.m. Resident #7 said she always used oxygen continuously. Resident #7 said the facility staff regulated her oxygen liter flow rate and she believed she had a physician's order for 2 LPM. Observation of the oxygen concentrator connected to Resident #7's nasal cannula revealed the oxygen concentrator was set at a flow rate of 3 LPM. On 4/14/26 at 9:28 a.m. Resident #7's oxygen concentrator was set at a flow rate of 3 LPM. On 4/15/26 at 9:25 a.m. the resident's oxygen concentrator was set at a flow rate of 2 LPM. C. Record review The respiratory care plan, initiated 5/31/24 and revised 10/23/25, revealed that Resident #7 required oxygen therapy at night related to chronic respiratory failure with hypoxia. Interventions included administering oxygen and medications as ordered by the physician, observing oxygen precautions and reporting any abnormalities to the physician. A review of Resident #7's April 2026 CPO revealed the following physician's order: Oxygen at 1 LPM at bedtime via nasal cannula, ordered 4/9/25. -However, observations on 4/13/26, 4/14/26 and 4/15/26 revealed Resident #7 was receiving 3 LPM and 2 LPM of oxygen continuously, not 1 LPM at bedtime as ordered by the physician. D. Staff interviews RN #2 was interviewed a second time on 4/15/26 at 9:34 a.m. RN #2 said Resident #7 was receiving continuous oxygen and confirmed that the resident's room concentrator was set to 2 LPM. RN #2 verified the physician's order and confirmed that the order read 1 LPM of oxygen at bedtime. RN #2 said he would immediately clarify the resident's oxygen orders with the physician. RN #2 said he did not verify the oxygen liter flow rate that Resident #7 was receiving at the beginning of his shift. The director of nursing (DON) and the chief nursing officer were interviewed together on 4/15/26 at 9:50 a.m. The DON said residents had their initials written on a label that was attached to their portable oxygen tanks with an indication of how many LPM of oxygen each resident was on. The DON said staff were required to check the residents' oxygen liter flow rates at the beginning of their shift. The DON said CNAs were not trained to alter or change the oxygen liter flow rates. The DON said nurses were able to change the liter flow rates of oxygen orders when necessary, document the changes and inform the physician if a change was needed. The DON said she did not know why Resident #4 and Resident #7's oxygen orders indicated they were only on oxygen at bedtime because they were receiving continuous supplementary oxygen. The DON said insufficient or excessive oxygenation could result in medical complications for residents with respiratory diseases. The chief nursing officer said oxygen was a form of medication and required a physician's order to administer. She said the facility would conduct a full-house audit of all residents receiving supplementary oxygen and ensure they were receiving the correct oxygen liter flow rates. V. Resident #22 A. Resident status Resident #22, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included heart disease, kidney failure, diabetes and asthma. -The MDS assessment had not been completed at the time of the survey. B. Observation and resident interview On 4/15/26 at 8:29 a.m. Resident #22 was sitting in her room wearing a nasal cannula attached to a portable oxygen tank. The portable oxygen tank was observed with RN #2 and was set to an oxygen flow rate of 4 LPM. Resident #22 was interviewed on 4/15/26 at 8:46 a.m. Resident #22 said she had been receiving 4 LPM of oxygen continuously since she was admitted to the facility from the hospital two weeks prior. C. Record review A review of Resident #22's comprehensive care plan, initiated 4/7/26, revealed no care plan related to the resident's use of oxygen. A review of Resident #22's April 2026 CPO revealed the following physician's order: Oxygen 2 liters per nasal cannula, continuous day/night, ordered 4/1/26. D. Staff interviews RN #3 was interviewed on 4/15/26 at 9:15 a.m. RN #3 said there was no need to check Resident #22's oxygen setting every shift if her oxygen saturation level (amount of oxygen in the blood) was normal. RN #3 said Resident #22's physician's order was for 2 LPM of oxygen. RN #3 said Resident #22 might have changed the oxygen setting on her portable oxygen tank herself. RN #3 said she was going to contact the physician to confirm the correct order for the resident's oxygen flow rate. RN #3 was interviewed a second time on 4/15/26 at 9:25 a.m. RN #3 said she contacted the physician regarding Resident #22's oxygen flow rate. She said the physician's order for 2 LPM of oxygen was correct. The DON and the chief nursing officer were interviewed together on 4/15/26 at 9:50 a.m. The chief nursing officer said the nurses should check the residents' oxygen settings each shift to ensure the oxygen flow rates matched the physician's orders. The DON said the nurses should document in the residents' progress notes if there was a discrepancy. The DON said it was important to follow the physician's order for oxygen administration as too much oxygen administration could be harmful to the resident. The DON said Resident #22 had a previous oxygen order for 4 LPM and the primary physician had changed the order to 2 LPM when she was readmitted to the facility on [DATE]. The DON said there should have been a care plan for Resident #22's oxygen administration. The DON said if Resident #22 had changed the settings for oxygen administration, this should have been addressed in the resident's care plan. VI. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included hypertension, gastric reflux (acid flows into the esophagus), hypothyroidism (underactive thyroid), peripheral vascular disease (narrowed or blocked blood vessels), sleep apnea (breathing stops and starts during sleep), hyperlipidemia (elevated cholesterol levels in the blood), dementia and diabetes The 3/11/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required maximum assistance with activities of daily living (ADL). The resident required a wheelchair for mobility. The MDS assessment indicated that the resident required oxygen. B. Observations On 4/13/26 at 10:00 a.m. Resident #2 was seated in a recliner in her room. The resident had a nasal cannula in her nose which was attached to an oxygen concentrator. The oxygen concentrator was set to an oxygen flow rate of 3 LPM. On 4/14/26 at 11:00 a.m. Resident #2 was seated in her recliner watching television (TV). The resident had a nasal cannula in her nose which was attached to an oxygen concentrator. The oxygen concentrator was set to an oxygen flow rate of 3 LPM. On 4/15/26 at 9:15 a.m. Resident #2 was in her recliner watching a game show on TV. The resident had a nasal cannula in her nose which was attached to an oxygen concentrator. The oxygen concentrator was set to an oxygen flow rate of 3 LPM. C. Record review A review of Resident #2's April 2026 CPO revealed the following physician's order: Oxygen at 3 LPM via nasal cannula at bedtime, ordered 4/9/25. D. Staff interviews RN #3 was interviewed on 4/15/26 at 4:00 p.m. RN #3 said Resident #2 had a physician's order for oxygen at night for sleep apnea. She said the resident should only be on oxygen at bedtime, per the physician's order. RN #3 said the CNA caring for the resident must have put her oxygen on during the day. RN #3 said she would educate the CNA on what the resident's oxygen needs were. The DON was interviewed on 4/15/26 at 4:15 p.m. The DON said Resident #2 had a physician's order for oxygen at bedtime. The DON said Resident #2 should only have oxygen on at bedtime, per the physician's orders. The DON said it was important for staff to follow the physician's orders. The DON said she would be doing education to the staff regarding following the physician's orders.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#3) of two residents reviewed for hearing out of 29 sample residents.Specifically, the facility failed to follow up on a post-eligibility treatment of income (PETI) request in order to obtain a hearing aid in a timely manner for Resident #3.Findings include:I. Facility policy and procedureThe Audiology and Ancillary Services policy and procedure, undated, was provided by the nursing home administrator (NHA) on 4/15/26 at 12:07 p.m. It read in pertinent part, The purpose of this policy is to provide a process for identifying, arranging, and documenting audiology services for residents who need hearing-related care. The facility will provide or arrange audiology services for residents as needed and as ordered by a physician or other authorized provider, when required. Services may be provided by a licensed audiologist or through a contracted provider. Audiology services may include hearing evaluations, hearing aid recommendations, hearing aid checks, communication recommendations, and follow-up related to hearing concerns. A resident may be referred for audiology services when hearing concerns are identified by nursing, therapy, the provider, the resident, or the resident's representative. A provider order will be obtained when required. The facility will coordinate audiology services based on the resident's needs and provider availability. Audiology recommendations will be shared with the care team and added to the resident's care plan as appropriate. All services, recommendations, and follow-up will be documented in the medical record.II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included unspecified hearing loss, supraventricular tachycardia (a cardiovascular condition characterized by a fast heart rate), muscle wasting and atrophy, unspecified dementia and major depressive disorder.The 1/7/26 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. He was independent with eating and required moderate assistance with toileting and personal hygiene, and maximum assistance with transfers. He used a wheelchair or a walker for locomotion.The MDS assessment documented that he had minimal hearing difficulty.B. Observation and resident interviewResident #3 was interviewed in his room on 4/13/26 at 12:29 p.m.The resident said he developed a hearing deficit upon his admission to the hospital from the facility. He said that after returning to the facility, he reported the issue to the social services director (SSD). Resident #3 said he had been waiting for assistance with obtaining a hearing aid for several months. Resident #3 said he had completed an audiology appointment several months ago, during which a hearing aid was recommended by the audiologist. Resident #3 said he got frustrated and angry when he could not hear. He said it had become difficult to hold a conversation with others unless they spoke louder. Resident #3 said he was not offered any accessories to facilitate better communication with others while he waited for his hearing aid.C. Record reviewThe speech and communication care plan, initiated 10/3/25 and revised 1/9/26, revealed that Resident #3 usually understood but may miss some parts or the intent of a message due to significant hearing loss in the left ear. Interventions included speaking distinctly and rephrasing or simplifying language, repeating information or adjusting tones if the resident was not able to understand, providing a quiet, non-hurried environment, free of background noise and distractions and audiology consults and evaluations as needed.The 2/19/26 audiology patient visit note revealed Resident #3's pure-tone testing bilateral (a hearing assessment that measures the softest sounds a person can hear) suggested mild sloping to moderate sensorineural hearing loss (a permanent inner ear damage) and recommended a hearing aid and retesting if concerns changes.-There was no documentation in Resident #3's electronic medical record (EMR) to indicate that the facility had obtained a physician's order for a hearing aid after the 2/19/26 audiology visit.III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 4/14/26 at 2:50 p.m. CNA #5 said Resident #3 had a hearing impairment. CNA #5 said staff had to speak louder for Resident #3 to hear them when they were communicating with him. CNA #5 said Resident #3 often became agitated due to his inability to hear during care.The SSD was interviewed on 4/14/26 at 3:56 p.m. The SSD said Resident #3 attended an audiology appointment on 2/19/26. She said a post-eligibility treatment of income (PETI) cash request was filed on 2/24/26, but the resident had not yet received a formal letter indicating whether the request was approved. The SSD said that if a formal letter was not received within a couple of weeks, the standard procedure was to follow up with the office. However, the SSD said she had not followed up on the request and acknowledged that she should have done so. The director of nursing (DON) was interviewed on 4/15/26 at 10:14 a.m. The DON said Resident #3 had a hearing impairment and had been seen by an audiologist. She said Resident #3 did not have a physician's order for a hearing aid. The DON said staff had to speak clearly and louder for the resident to hear. The DON said Resident #3 had not been provided with any accessories while he waited for a hearing aid.The SSD was interviewed a second time on 4/15/26 at 5:02 p.m. The SSD said she had not documented her action at the time the PETI was filed. The SSD said her understanding of the PETI cash process was that the amount was based on the monthly resident portion and the money must accumulate over time. The SSD said the resident's portion of the cost of the hearing aid was $1,100.00 and estimated that it would take three months for the required funds to be available for Resident #3. The SSD said the delay in the PETI cash funding should not serve as a barrier to the resident obtaining his hearing aid.

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to: -Ensure staff performed appropriate hand hygiene in the dining room while assisting residents with eating; -Ensure housekeeping staff used appropriate hand hygiene practices while cleaning the residents' rooms; and, -Ensure housekeeping staff cleaned high-touch surfaces in residents' rooms.Findings include: I. Failed to ensure staff performed appropriate hand hygiene while assisting residents in the dining roomA. Facility policy and procedureThe Handwashing policy, revised October 2025, was received from the nursing home administrator (NHA) on 4/15/26 at 4:00 p.m. The policy read, All personnel are trained on the importance of handwashing. Wash your hands after contact with the resident or in the resident's environment. The use of gloves does not replace handwashing or hand hygiene.B. ObservationsOn 4/13/26 at 11:15 a.m. certified nurse aide (CNA) #1 was observed assisting three residents with eating in the dining room.-CNA #1 failed to perform appropriate hand hygiene between any residents.II. Housekeeping failuresA. Facility policy and procedureThe Cleaning And Disinfection Of Environmental Services policy, revised August 2019, was received from the NHA on 4/15/26 at 4:00 p.m. The policy read, Non-critical contaminated areas can be decontaminated where they are used. Housekeeping surfaces such as desk tops will be cleaned regularly. Non-critical surfaces will be disinfected with an Environmental Protection Agency (EPA)-registered intermediate hospital disinfectant with the dwell time as follows on the label.B. ObservationsOn 4/15/26 at 10:00 a.m., the housekeeping director was cleaning room [ROOM NUMBER].The housekeeping director sprayed the bathroom with Virex diversity disinfectant spray and proceeded to clean the resident's bathroom. When the housekeeping director finished cleaning the bathroom, she took off her gloves. Without performing hand hygiene, the housekeeping director began cleaning the resident's room. -The housekeeping director failed to perform hand hygiene after cleaning the bathroom and removing her gloves prior to beginning cleaning in the resident's room.The housekeeping director made the resident's bed, gathered the trash and swept and mopped the floor. The housekeeping director did not perform hand hygiene after exiting room [ROOM NUMBER]. -The housekeeping director failed to clean the high touch surface areas in the room, including the resident's bedside table, the residents' call light, the bed control and the door knobs.-Additionally, the housekeeping director failed to perform appropriate hand hygiene after cleaning the resident's room.III. Staff interviewsCNA #1 was interviewed on 4/13/26 at 2:15 p.m. CNA #1 said she should have washed her hands in between helping each of the three residents she was assisting with eating in the dining room. She said she should have washed her hands before assisting another resident.The housekeeping director was interviewed on 4/15/26 at 10:20 a.m. The housekeeping director said that the CNAs would clean the residents' bedside tables. She said she cleaned the residents' call lights once a week, along with the bed controls. She said she realized that the high contact areas should be cleaned daily. She said she would change her cleaning to include the bedside table, call light, bed controls, and door knobs to a daily disinfection cleaning.The director of nursing (DON) was interviewed on 4/15/26 at 5:04 p.m. She said that the staff assisting residents with eating should regularly perform hand hygiene. The DON said if staff were assisting more than one resident with eating, they should perform hand hygiene in between residents. The DON said the housekeepers should perform hand hygiene after removing gloves and sanitize high-contact areas in residents' rooms daily.The NHA was interviewed on 4/15/26 at 5:15 p.m. The NHA said that the housekeeping staff should disinfect the high-contact surfaces in the residents' rooms on a daily basis.

Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll roll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include: The facility had a change of staff during the first quarter. I. Record review The PBJ stuffing report for quarter one (10/1/23 to 12/31/23) showed the following triggered area: -Failed to Submit Data for the Quarter II. Interview The nursing home administrator (NHA) was interviewed on 3/13/24 at 10:45 a.m. She said during the last quarter there had been a staff change. She said she tried to submit the data, however, it was not submitted correctly. When she went back to the system to correct the errors, she was unable to make the necessary corrections and the data was not accepted. She said she had not had any issues submitting data since the incident. She said it was important to submit the data timely and correctly.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #2 (hired on 6/1/21), CNA #3 (hired on 10/2/21), CNA #4 (hired on 2/11/19) and CNA #5 (hired on 11/2/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Staff interview The nursing home administrator (NHA) was interviewed on 3/12/24 at 1:30 p.m. She said she could not locate the performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure best care was being delivered to the residents.

Based on observations and interviews the facility failed to store, distribute and serve food in a sanitary manner in two of two kitchen nourishment refrigerators. Specifically, the facility failed to ensure nutritional beverages were labeled and dated when opened in the kitchen nourishment refrigerators. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section 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 as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved 3/14/24). II. Observation On 3/11/24 at 9:47 a.m. the following was observed at the main kitchen nourishment refrigerators during the initial kitchen tour: -In the first nourishment refrigerator, there were two opened undated and with no labels of thickened liquid containers. -In the second nourishment refrigerator, there were four cartons of opened juice containers, (one apple juice, one tomato juice, one grape juice and one orange juice) there were no labels and they were not dated. On 3/12/24 at 10:21 a.m. the following was observed at the main kitchen nourishment refrigerators during the follow-up visit to the kitchen: -In the first nourishment refrigerator, there were two opened undated and with no labels of thickened liquid containers. -In the second nourishment refrigerator, there were four cartons of opened juice containers, (one apple juice, one tomato juice, one grape juice and one orange juice) there were no labels and they were not dated. III. Staff interviews The dietary manager (DM) was interviewed on 3/12/24 at 11:30 a.m. The DM said the kitchen staff should have all opened juice cartons dated and labeled to be aware of how long it has been opened to avoid distributing contaminated beverages to any resident. She said the kitchen staff were trained to understand the importance of labeling. She said the staff might have forgotten to label those beverages in the nourishment refrigerators. The DM said she would educate the kitchen staff to ensure open cartons and containers were labeled and dated properly. The regional registered dietitian (RRD) was interviewed on 3/12/24 at 11:51 a.m. The RRD said all opened dairy products and food kept in the refrigerators were to be labeled and dated. She said undated food items and beverages could potentially get someone sick when opened for a long period and had become contaminated. The RRD said she had advised the DM to provide education to all the kitchen staff to ensure all food items and opened beverages were dated when kept in the refrigerator.

Based on record review and interviews, the facility failed to notify the provider according to physician orders for one (#28) of five residents reviewed for unnecessary medications out of 17 sample residents. Specifically, the facility failed to notify and document Resident #28's elevated blood sugar levels to the provider as directed on the physician's order. Findings include: I. Facility policy and procedures The Hypoglycemia or Hyperglycemia policy and guidelines, revised 2011, was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m. The policy read in pertinent part, The facility would ensure medications were administered per established physician's parameters. Staff would document all labs/treatments in nurse's notes and on the medication sheets. II. Resident #28 A. Resident status Resident #28, over 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included type II diabetes mellitus, personal history of traumatic brain injury, unspecified dementia and long-term (current) use of insulin. The 12/24/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required staff assistance for bed mobility, grooming, toileting, and one-person assistance with transfers with a gait belt. The resident had no behaviors. The resident was administered insulin for seven days and injections for seven days. B. Record review The physician's order dated 1/8/24 at 2:15 p.m. revealed to administer Humalog U-100 unit/milliliter insulin (insulin lispro) once in the evening, inject 13 units subcutaneously. Notify physician if blood glucose is less than 60 or greater than 400. (<60 or >400) Order dated 1/8/24 at 2:15 p.m. Administer lantus solostar U-100 insulin 30 units/milliliter subcutaneously at bedtime and notify physician if blood glucose was less than 60 or greater than 400 (<60 or >400). The care plan for diabetes mellitus was revised on 12/28/23. The interventions were for staff to administer Humalog per physician's order and notify physician if blood glucose was (<60 or >400). The January 2024 medications administration record (MAR) revealed on 1/1/24 that Resident #28 blood sugar level was 464 over the parameter set in the physician's order and on 1/20/24 the resident blood glucose level obtained was 504 above the physician's order parameters. The February 2024 MAR revealed on 2/14/24 that Resident #28 blood sugar level was 412 over the parameter set in the physician's order and on 2/29/24 the resident blood glucose level obtained was 407 above the physician's order parameters. -There was no documentation in the nursing progress note indicating that the provider was notified. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/13/24 at 3:30 p.m. The LPN said the four dates on the resident's MARs revealed the resident insulin levels were elevated above the parameters indicated on the physician's order and there should be documentation that the physician was notified. She said nurses should follow physician orders. She said not documenting that the physician was notified indicates that it did not happen. She said insulin parameters were important because the resident might have experienced high blood sugar levels which would require the physician to adjust the amount of insulin to administer. She said not notifying the physician for the proper dose of insulin could cause the resident to experience shock, become comatose or have an increase in symptoms related to her diagnosis. The director of nursing (DON) was interviewed on 3/13/24 at 3:50 p.m. The DON said the four dates on the resident's MARs revealed the resident's blood glucose levels were elevated above the parameters on the physician's order and the staff should have notified the provider and documented in the nursing progress note. The DON said there was no documentation indicating the physician was notified. She said she was not sure why there was no documentation of the physician's notification for those dates that the resident's blood glucose levels were elevated. The DON said if the nurse failed to document it meant the physician was not notified as ordered. She said the facility would provide education to nurses to ensure they follow physician's orders and document their actions.

Based on observations, record review and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the dining room. Findings include: I. Facility policy and procedure The Respect and Dignity policy, revised February 2021 was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m., It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. II. Meals served timely A. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:00 a.m. to 9:00 a.m., lunch at 11:00 a.m. to 1:00 p.m. and dinner at 5:00 p.m. to 6:00 p.m. B. Resident observations and interviews On 3/11/24 at 11:05 a.m. Resident #4 arrived at the dining room for lunch. He sat at his dining table waiting patiently for his meal as he watched the other residents eat and leave the dining room. Resident #4 said he usually had to wait for quite a while before he was served. Resident #4 said he thought the staff had forgotten about him as he continued waiting to be served. Resident #22 was observed waiting at the dining table for 35 minutes. The resident said she usually had to wait for a while before she received her meal. C. Additional observations 3/11/24 -At 4:00 p.m. six residents were sitting in the dining room. Four of the residents were sitting in wheelchairs. -At 4:05 p.m. Resident #4 arrived at the dining room in his wheelchair. The resident sat by his dining table waiting to be served. -At 4:15 p.m. there were 10 residents seated by their dining tables. Three of the residents had been served and they were eating dinner. -At 4:20 p.m. some of the staff started passing out drinks and others started taking resident's meal orders. -At 4:30 p.m. Resident #3 arrived at the dining room and sat across the dining table with Resident #4. The two residents stared at each other as they waited for their dinner. -At 4:40 p.m. Resident #3 was served dinner and he started eating as Resident #4 sat across the dining table watching his tablemate eat his dinner. -At 4:44 p.m. Resident #4 received his dinner and started eating. The resident left the dining room shortly after being served and ate only about 20% of his meal. 3/12/24 -At 10:45 a.m. residents started arriving at the dining room. -At 11:00 a.m. 13 residents were waiting in the dining room ready for lunch. -At 11:00 a.m.Resident #22 arrived at the dining room. -At 11:15 a.m. the facility staff were all standing around the dining area counter with none of them interacting with the residents who were seated at the dining room. -At 11:30 a.m. Resident #22 received her lunch 30 minutes after she arrived at the dining room. III. Staff interview The dietary manager (DM) was interviewed on 3/12/24 at 1:05 p.m. The DM said the facility practiced open dining seating and meals were served on a first come first served basis. The DM said staff would take orders as soon as the residents arrived and pass the meal order to the cook. She said the problem with the dining room meal times was the miscommunication between the kitchen and staff assisting in the dining room. The DM said the facility staff should have been in the dining room earlier enough to know which resident arrived first. She said she would educate the staff to ensure residents who were seated at the same dining table received their meals promptly. The regional registered dietitian (RRD) was interviewed on 3/12/24 at 1:12 p.m. She was told of the observations above. The RRD said residents seated at the same dining table should receive their meals in a reasonable amount of time. She said there was dignity concern when resident waited too long after their tablemate already received their plate of food. She said residents should not wait too long at the dining table while they were seated watching their tablemates eat. The RRD said it was a dignity issue that could escalate resulting in behavior issues. She said some of the residents could leave the dining room without eating their meals. The RRD said she would coordinate with the DM to provide education to the facility staff to ensure residents receive their meals within a reasonable period during meal times.

Based on observations and staff interviews, the facility failed to provide adequate ventilation by means of mechanical ventilation for one resident bathroom and two resident shower rooms. Specifically, the facility failed to ensure resident bathroom vents were free from lint and the exhaust fans were functioning. Findings include: I. Facility policy The Exhaust Fan and Ventilation policy, dated 1/25/24, was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m. The policy read in pertinent part, The facility would check all exhaust fans in bathrooms, shower room soiled and clean utility rooms, janitor's closets, kitchen, and sink and laundry areas and oxygen room. The facility would ensure that airflow is sufficient enough to hold a piece of paper to the vent when operating. Clean vents using vacuum and air compressor to remove all dust. II. Observation An observation of the resident environment was completed on 3/12/24 at 12:40 p.m. The exhaust fans in shower room [ROOM NUMBER] had no audible sound and was not functioning. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans did not function properly. The vent in shower room [ROOM NUMBER] had lint and cobwebs around the surface. The bathroom vent in room [ROOM NUMBER] had lint and cobwebs around the surfaces of the vent. III. Staff Interview The environmental tour was conducted with the maintenance director (MTCE) on 3/13/24 at 11:40 a.m. The MTCE said the exhaust fan in one of the resident's main shower rooms was not functioning. The MTCE said he would have to check the motors on all halls to see why the vent in the shower room was not functioning as it should. The MTCE said the ventilation fans in every resident's shower rooms and bathrooms should be in good working condition. He said the vents in the resident's toilet and the resident's shower rooms should be clean.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections including failure to properly prevent and/or contain COVID-19 in one of one unit. Specifically, the facility failed to: -Increase resident monitoring for COVID-19 to three times daily for six (#1, #2, #3, #4, #5 and #6) out six residents reviewed after a facility outbreak on 11/30/2020; -Ensure resident room doors and/or hallway corridors remained closed while in isolation; and, -Ensure that personal protective equipment (PPE) was readily available for staff by having isolation bins with available PPE outside resident rooms. Findings include: I. Failure to increase resident monitoring for COVID-19 to three times daily after a facility outbreak A. Professional reference The Centers for Disease Control and Prevention (CDC), Preparing for COVID-19 in Nursing Homes, (updated 11/20/2020) retrieved on 12/22/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html it read, in pertinent part, .If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance should be implemented immediately once COVID-19 is suspected .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection. B. Record review 1. County positivity rate The county positivity rate (COVID-19 positive cases) for Otero County was 16.5% the week of 12/13/2020. 2. COVID-19 screening Record review conducted 12/16/2020 at 3:15 p.m., revealed that residents #1,#2, #3, #4, #5, and #6 who were all COVID-19 positive and did not have COVID-19 screening or monitoring increased to three times daily. Review of the December 2020 computerized physician orders [REDACTED].#1, #2, #3, #4, #5 and #6 read, COVID Screening isolate for Temp over 100 or any s/sx (signs and symptoms) of respiratory distress twice a day (Day/Night). The December 2020 CPO further read, start day on 4/23/2020 and end date opened ended. C. Staff interview The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 12/16/2020 at 2:23 p.m. They said they monitored residents for COVID-19 twice daily. They acknowledged residents who were ill and or positive for COVID-19 should have been monitored for COVID-19 signs and symptoms three times daily as acute changes warranted further interventions. II. Failure to ensure resident rooms and hallway corridors remained closed while in isolation, and ensure PPE was readily available for staff A. Professional reference The CDC, Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices, (updated [DATE]), retrieved on 12/22/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. It read, in pertinent part, .Personal Protective Equipment (PPE): perform and maintain an inventory of PPE in the facility. Make necessary PPE available in areas where resident care is provided. Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles). Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room. The Centers for Disease Control and Prevention (CDC), Precautions to Prevent Transmission of Infectious Agents, (Reviewed 7/22/19) retrieved on 12/23/2020 from: https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html read, in pertinent part, Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., [MEDICAL CONDITION] ([DIAGNOSES REDACTED]), [MEDICATION NAME] virus (chickenpox), M. [MEDICAL CONDITION], and possibly [DIAGNOSES REDACTED]-CoV) as described in I.B.3.c and Appendix A. The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR). In settings where Airborne Precautions cannot be implemented due to limited engineering resources (e.g., physician offices), masking the patient, placing the patient in a private room (e.g., office examination room) with the door closed. B. Facility policy and procedure The Coronavirus Disease 2019 (COVID-19) policy, undated, was provided by the nursing home administrator (NHA), on 12/16/2020 at 12:23 p.m. It read, in pertinent part, This facility has established appropriate guidelines pursuant to recommendations from the Colorado Department of Public Health and Environment (CDPHE) and the Federal Centers for Disease Control (CDC). The Policy addresses staff and visitor behavior and responsibilities to try to prevent the transmission of communicable diseases. Healthcare personnel (HCP) are on the front lines of caring for patients with confirmed or possible infection with Coronavirus Diseases 2019 (COVID-19) and therefore have an increased risk of exposure to [MEDICAL CONDITION]. HCP's can minimize their risk of exposure when caring for confirmed or possible COVID-19 patients by following CDC infection prevention and control guidelines, including use of recommended personal protective equipment (PPE) .In general, for care of residents with undiagnosed respiratory infection use standard Contact and Droplet Precautions with eye protection unless suspected [DIAGNOSES REDACTED].g. [MEDICAL CONDITION]) .If there is transmission of COVID-19 activity in the community, in addition to implementing the precautions described above for residents with acute respiratory infection, the facility shall also consult with public health authorities for additional guidance .Make PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room when it's determined PPE is needed for the resident. C. Observations On 12/16/2020 at 11:49 a.m., observation on initial walk-through of halls A, B and C (North, East and West) revealed all resident doors were open, and there was no PPE outside of resident rooms or in the hallways. There was one isolation bin with PPE located on the unit at the entrance to the dining room. III. Interviews Licensed practical nurse (LPN) #1 and certified nurse aide (CNA) #1 were interviewed on 12/16/2020 at 11:55 a.m. They said when they checked in for their shift they would obtain a gown from the clean isolation bin located at the dining entrance where they checked in for their shift. They said they completed their daily screen in morning would get a new gown and wear it for their entire shift and if their gown was soiled and they needed a new one they would have to get it from the isolation bin located at the dining room entrance. They said they discarded their gowns in the biohazard room trash or bag in bio hazard room. They said they removed their gown when they went on break, and would place it in an isolation cart at the nurses station and then would re-don the gown prior to working the unit. The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 12/16/2020 at 2:23 p.m. The NHA said they were on contingency status for PPE and had adequate supplies. The NHA said transmission based precautions were started on 11/30/2020 with full PPE with use of N95 respirator, gowns, gloves and eye protection and resident doors remained shut when lab test results confirmed two resident positive COVID-19 cases. The NHA said they should have provided isolation bins with PPE outside each resident room. The NHA and DON said initially when the outbreak occurred they had residents placed on the east hallway with the corridors shut and each room had an isolation bin stocked with supplies. The NHA and DON said they did not know where the breaks in infection control originated which caused the entire resident population to become positive with COVID-19 and did not conduct a root cause analysis to establish the cause; however, they planned to provide education to their staff, put out isolation bins outside each room, increase resident monitoring for COVID-19 to three times daily and ensure resident rooms remained closed as much as possible. IV. Facility COVID-19 status An interview was conducted with the NHA on 12/16/2020 at 11:49 a.m. She said the facility census was 33. She said all residents had been confirmed COVID -19 positive, their staff outbreak started on 11/18/2020 and resident outbreak started on 11/27/2020 and confirmed lab test result was on 11/30/2020. She said there were 46 out 63 staff that were positive for COVID-19 and 16 of the 46 staff had not cleared to return to work.

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19 in four of four halls. Specifically, the facility: -Failed to cancel communal dining. Findings include: I. CDC recommended guidelines The Center for Disease Control (CDC), Key Strategies to Prepare for COVID-19 in Long-termCare Facilities (LTCFs) (4/30/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html, Prevent spread of COVID-19: Actions to take now: -Cancel all group activities and communal dining. -Enforce social distancing among residents. -Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments. -Ensure all HCP wear a facemask or cloth face covering for source control while in the facility. Cloth face coverings are not considered personal protective equipment (PPE) because their capability to protect healthcare personnel (HCP) is unknown. Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required. II. Observations and interviews On 5/6/2020 at 8:45 a.m. 12 residents were observed sitting in the dining room finishing breakfast. III. Staff interviews Dietary aide (DA) #1 was interviewed on 5/6/2020 at 10:00 a.m. She said the facility had communal dining. She said the facility assigned one resident per table. The nursing home administrator (NHA) was interviewed on 5/6/2020 at 10:15 a.m. She said she had separated the dining room tables by six feet, but did not know communal dining had been stopped by the CDC. She said she would provide education to the dietary staff and the residents on the changes.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and -The freezer temperature was below zero degrees Fahrenheit. Findings include: I. Improper hand hygiene [NAME] Professional references According to the Food and Drug Administration (FDA) Food Code (2017), pp. 48-50, foodservice staff shall use the following handwashing procedures: -Rinse under clean, running warm water; -Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; -Rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails and creating friction on the surfaces of the hands and arms fingertips, and areas between the fingers; -Thoroughly rinse under clean, running warm water; and -Immediately follow the cleaning procedure with thorough drying using individual disposable towels, a continuous towel system that supplies the user with a clean towel, or a heated-air hand drying device. The FDA Food Code (2017) pp. 49-50, detailed the following instances when foodservice staff should wash their hands: -Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service articles; -After touching bare human body parts other than clean hands and clean, exposed portions of arms; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and -After engaging in other activities that contaminate the hands. B. Observations Observation of meal preparation was conducted on 12/17/19 from 10:45 a.m. to 12:30 p.m. Observations in the primary production kitchen included: Dietary aide (DA) #2 was serving lunch, wearing a glove on his right hand. He grabbed a plate and spatula and removed a ham and cheese sandwich from the stove top. He placed the sandwich on the cutting board next to the serving line. He cut the sandwich in half with a knife. He picked the sandwich up with his gloved hand and placed the sandwich on the plate. He wiped his gloved hand on the side of his apron. He reached over and grabbed a bowl and placed a ladle of soup into the bowl. He placed the bowl on the plate and grabbed a handful of crackers with his gloved hand and placed them onto the plate. He returned to the serving line and proceeded to serve meals. He repeated this process four more times, each time he returned to the serving line. He then placed a slice of pizza onto a plate, reached over and grabbed several pieces of fried mushrooms with his gloved hand, and placed them onto the plate. He received an order for [REDACTED]. He returned to the food preparation area with a bag of hamburger patties. He cut the plastic wrap on the raw hamburger and removed a single hamburger patty with his gloved hand. He placed the hamburger patty into a small frying pan and placed it on the stove top. He turned the burner on with his gloved hand and returned to the preparation area. He resealed the plastic bag which the other hamburger patties were in. He reached into his pocket and removed a pen. He wrote the date on the plastic bag and placed the pen back into his pocket. He left the food area and walked over to the walk-in refrigerator, reached for the door handle and entered the walk-in. He exited the walk-in and returned to the serving line. He proceeded to serve residents' meals. He received a special order for a cold cut sandwich. He left the serving area and walked toward the walk-in refrigerator. He reached for the door hand of the walk-in refrigerator with his gloved hand. He exited the walk-in refrigerator with a large container of mayonnaise under his arm and a package of cold cuts. He proceeded to make a sandwich. He removed two slices of bread from the bag with his gloved hand. He opened the package of cold cut and placed two slices of meat onto the bread. He walked over to the serving line and grabbed a slice of cheese with his gloved hand and walked to the preparation area and placed the sliced cheese onto the bread. He then spread some mayonnaise onto the meat and bread and completed making the sandwich. He reached for a knife, cut the sandwich in half and placed it onto the plate with his gloved hand. He proceeded to grab a soup bowl and place a ladle of soup into the bowl. He then reached over and grabbed a handful of crackers with his gloved hand and placed them on the plate. He returned to the preparation area and sealed the cold cuts and mayonnaise and returned then into the walk-in refrigerator. He returned to the serving line and proceeded to serve the meals. He did not wash, change gloves, or sanitize his hands during this process. C. Staff interview The dietary manager (DM) was interviewed on 12/17/19 at 1:24 p.m. She said all kitchen staff needed to wash their hands between every task. She said all staff must wash their hands before handling or serving food. Staff should also wash their hands when they left the kitchen area. The DM was told of the observations of staff during meal observation. The DM said staff should be washing their hands every time they changed their gloves. The DM said it was his expectation all dietary staff would have been washing their hands between tasks to avoid cross contamination. II. Proper freezer temperatures [NAME] Professional reference According to the Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR _RFFC_EffJan2019.pdf, in pertinent part: Stored frozen food shall be maintained frozen. B. Observations An observation of the kitchen was conducted on 12/15/19 at 9:32 a.m. The temperature of the walk-in freezer was measured at 10 degrees Fahrenheit (F), according to the appliance thermometer. The facility's thermometer inside the freezer measured 19 degrees F. An observation of the kitchen was conducted on 12/16/19 at 8:17 a.m. The temperature of the freezer was measured at 10 degrees F, according to the appliance thermometer. The facility's thermometer inside the freezer measured 19 degrees F. On 12/17/19 at 10:45 a.m., DA #5 was asked to observe the temperatures in the walk-in freezer. Thermometers recorded temperatures of 14.8 degrees F. C. Record review The (MONTH) 2019 temperature log documented in part: -12/1/19, temperature log (TL) documented no temperature taken -12/2/19, TL documented 10 degrees F -12/3/19, TL documented 10 degrees F -12/4/19, TL documented 12 degrees F -12/5/19, TL documented 12 degrees F -12/6/19, TL documented 11 degrees F -12/7/19, TL documented 11 degrees F -12/8/19, 12 degrees F -12/9/19, 11 degrees F -12/10/19, 10 degrees F -12/11/19, 10 degrees F -12/12/19, 12 degrees F -12/13/19, 11degrees F -12/14/19, 10 degrees F -12/15/19, 10 degrees F -12/16/19, 12 degrees F D. Staff interview On 12/17/19 at 1:24 p.m., the DM said the repair service that replaced the compressor was coming in to check the compressor. The DM said she was checking the food in the freezer and what was soft would be thrown out.

Based on record review and interviews, the facility failed to ensure staff had current abuse and dementia care training. Specifically, the facility failed to: -Ensure one of two registered nurses (RNs) reviewed received abuse prevention training and two of two received dementia training; -Ensure one of two licensed practical nurses (LPNs) reviewed received dementia training; and -Ensure two of six certified nurse aides (CNAs) reviewed received dementia management training, and one of six received abuse prevention training. Findings include: I. Training review The (MONTH) 2019 staffing schedule was provided on 12/15/19 by the nursing home administrator (NHA). A sample of two RNs, two LPNs and six CNAs included on the schedule were reviewed for compliance with training requirements. Training records revealed: -RN #1 did not have dementia management training and RN #2 did not have current abuse prevention training or dementia training. -LPN #2 did not have dementia management training. -CNAs #3 did not have dementia management training oe abuse prevention training, and CNA #5 did not have dementia management training. II. Interviews CNA #4 was interviewed on 12/17/19 at 1:45 p.m. She said she had taken the computer training courses during orientation. She said she had just completed (computer) training approximately two to three months ago but did not clarify what the training entailed. CNA #2 was interviewed on 12/17/19 at 2:00 p.m. She said she had completed the computer training when she was hired. She said she had not had any further training on dementia management since she was hired. She said she had worked at the facility for a couple of years. Licensed practical nurse (LPN) #1 was interviewed on 12/17/19 2:14 p.m. She said she would receive educational memos on training and had recently completed training on natural disasters. She said she could not recall the last time she received training on dementia management. The NHA was interviewed on 12/18/19 at 1:00 p.m. She said it was important to ensure all staff were current with their training to provide the most current and up to date care for all the residents in the facility. She said she would monitor the training more closely to verify all staff training was up to date.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience, and the least restrictive alternatives were used, for one (#6) of two residents reviewed for assistive devices out of 16 sample residents. Specifically, the facility failed to: -Re-evaluate the ongoing use of a personal restraint; and -Develop a comprehensive care plan addressing the use of the restraint. Findings include: I. Facility policy and procedure The Restraint policy, revised (MONTH) (YEAR), provided by the director of nursing (DON) on 12/17/19 at 2:33 p.m., included: restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been unsuccessful. Restraints shall only be used to treat the resident's medical symptoms and never for the discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least resistive alternative will be used for the least amount of time necessary, and the ongoing reevaluation for the need for restraints will be documented. II. Resident status Resident #6, age 87, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 10/16/15 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The resident's cognitive skills for daily decision making were moderately impaired. The resident had minimal depression, scoring three of 27 on the patient health questionnaire (PHQ-9). The resident had physical behaviors directed toward others and refusal of care. The resident had a chair alarm. III. Observations The resident was observed spending most of her time sitting in her wheelchair with a clip-on chair alarm. She did not sit in the chair in an unsafe manner, she did not attempt to stand up or move while sitting. The resident did not display unsafe behaviors during the following observations. On 12/15/19 at 12:29 p.m., the resident was sitting in her wheelchair with the alarm attached to the back of her blouse and chair. She was sitting in front of the south nursing station. On 12/16/19 2:33 p.m., the resident was in her wheelchair sitting next to the nursing station with the alarm attached to the back of her blouse. On 12/17/19 at 8:47 a.m., the resident was in his wheelchair in front of the nursing station. She was facing toward the nursing station with her hands on her lap. She was not attempting to stand up. The alarm was attached to the back of her blouse. The resident was not moving independently. She did not attempt to move or stand up from the wheelchair, during the above observations. The resident remained sitting in her wheelchair. IV. Record review The care plan, initiated 9/26/19 and revised 11/10/19, identified the resident was at risk for falling related to dementia. Interventions included assure the floor was free of glare, liquids, foreign objects. Avoid use of restraint. Encourage to assume standing position slowly. Fall risk observation quarterly and as needed (PRN). Give verbal reminders not to ambulate/transfer without assistance. Keep personal items and frequently used items within reach and provide well maintained foot wear. The care plan did not include directives to staff when to check the alarm, when to release the alarm or when to complete assessments. The safety device observation, dated 9/23/19 at 12:52 p.m., revealed the wheelchair under seat alarm was to reduce risk/number of falls. The fall assessment, dated 9/23/19 at 12:44 p.m., revealed the resident was at high risk for falls. The (MONTH) 2019 CPO revealed the resident's physician ordered the resident to have safety devices PRN, on 6/26/18. There was no evidence of any attempts to use less restrictive alternative measures. V. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 12/17/19 at 1:45 p.m. She said alarms were used to ensure the residents were safe from falling. She said the alarm sounded when the resident moved, and tried to stand up. She said the clip detached from the back of the resident's blouse when a resident stood up and the alarm sounded. She said the alarm alerted staff when they were not in the area and staff would get to the resident as quickly as possible to try to have the resident sit down in their wheelchair. She said the resident had not had a fall in a while and she had not made any attempts of standing up for approximately two months. CNA #2 was interviewed on 12/17/19 at 2:00 p.m. She said the resident's chair alarm alerted them when she was trying to stand. When the alarm goes off we run to make sure she sits down right away. She said, The resident has not attempted to stand up for a long time. Licensed practical nurse (LPN) #1 was interviewed on 12/17/19 2:14 p.m. She said the chair alarm was used to alert staff if a resident was trying to get out of their wheelchair. LPN #2 said the alarms were placed after a resident had a fall or when the staff noticed the residents were trying to get out of their wheelchair. She said the alarms were used to prevent a resident from falling and for notifying the staff when a resident was not in their wheelchair. She said the staff attended to the resident when the alarm sounded and it was a prevention for the resident not to fall. She said when Resident #6 first came into the facility she would attempt to get out of her chair but now she was compliant with sitting in her wheelchair and does not try to get up anymore. The director of nursing (DON) was interviewed on 12/17/19 at 2:12 p.m. The DON said the resident had several falls and the alarms were used to ensure the resident was safe from falls. She said the resident had not had any falls since 6/24/19 and we should have reassessed the chair alarm to see if it was still an effective intervention.

Based on observations, record review and interviews, the facility failed to ensure as needed (PRN) orders for [MEDICAL CONDITION] drugs are limited to 14 days for one (#33) of five residents reviewed for unnecessary medications out of 16 sample residents. Specifically, the facility failed to discontinue a PRN psychoactive medication after 14 days without a physician's rationale for Resident #33. Findings include I. Resident #33 status Resident #33, age 53, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 11/16/19 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident had no mood symptoms. The resident had behaviors directed towards others and refused care. II. Record review The care plan, initiated 3/4/05 and revised 11/16/19, identified the resident would be prescribed the lowest effective dose of medication. Interventions included administering [MEDICATION NAME] per medical doctor (MD) order. Notify MD of adverse effects. Administer as needed (PRN) [MEDICATION NAME] before leaving for transport if needed. Attempt a gradual dose reduction per pharmacy recommendations. Attempt non pharmacological interventions. Observe residents for mood and response to medication. Pharmacy consultant review quarterly and PRN. The (MONTH) 2019 CPO included: -[MEDICATION NAME] 0.5 mg, give one tablet by mouth one hour before leaving for transport. Ordered 12/16/08. The (MONTH) 2019 Medication Administration Record [REDACTED] III. Staff interviews The director of nursing (DON) was interviewed on 12/17/19 at 2:12 p.m. She said she was not familiar with the new regulation specific to 14-day PRN psychoactive medication orders. She said it was only used when the resident was being transported to a doctor's appointment and that was why it had an open end date. She said she would get with the resident's provider and make changes to the PRN medications immediately.

Based on observations, record review and interview, the facility failed to ensure residents who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (#86) of four residents reviewed for oxygen therapy out of 14 sample residents. Specifically, the facility: -Failed to have complete and comprehensive oxygen orders for Resident #86, and -Failed to have a baseline care plan addressing the use of oxygen for Resident #86 who was receiving oxygen therapy. Findings include I. Professional references Potter/Perry, Fundamentals of Nursing, ninth edition, Elsevier, Canada, (YEAR), p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Resident #86 A. Resident status Resident #86, age 84, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders (CPO), [DIAGNOSES REDACTED]. The incomplete 12/14/18 minimum data set (MDS) assessment identified the resident utilized oxygen therapy. B. Record review and failures The (MONTH) (YEAR) CPO did not include a comprehensive order for oxygen. The baseline care plan did not include the use of oxygen. The (MONTH) Medication Administration Record [REDACTED]. The progress notes (PNs) were reviewed from date of admission and included the following: -The PN dated 12/7/18 at 9:44 p.m. identified the resident was on 3 liters (L) per minute (pm). -The PN dated 12/8/18 at 9:51 a.m. identified the resident was on 3L pm. -The PN dated 12/9/18 at 7:01 a.m. identified the resident was on 2L pm. -The PN dated 12/10/18 at 9:20 a.m. identified the resident was on 3L pm. -The PN dated 12/11/18 at 3:14 p.m. identified the resident was on 3L pm. -The PN dated 12/12/18 at 8:15 a.m. identified the resident was on 3L pm. -The PN dated 12/13/18 at 2:39 p.m. identified the resident was on 3L pm. -The PN dated 12/14/18 at 12:17 p.m. identified the resident was on 3L pm. -The PN dated 12/15/18 at 4:24 a.m. identified the resident was on 2L pm. -The PN dated 12/16/18 at 4:41 a.m. identified the resident was on 2L pm. -The PN dated 12/16/18 at 9:41 a.m. identified the resident was on 2.5L pm. -The PN dated 12/16/18 at 3:34 p.m. identified the resident was on 2.5L pm. -The PN dated 12/17/18 at 4:49 a.m. identified the resident was on 2L pm. -The PN dated 12/17/18 at 8:20 a.m. identified the resident was on 3L pm. -The PN dated 12/18/18 at 6:30 a.m. identified the resident was on 3L pm. The above documentation revealed the resident was not on a consitent oxygen liter flow with no documentation of why the liters of oxygen changed. There were no physician orders or care plan in place to follow. C. Observations The concentrator in the residents room was set at 3Lpm through a nasal cannula on 12/17/18 at 1:47 p.m. The concentrator in the residents room was set at 3Lpm through a nasal cannula on 12/18/18 at 2:13 p.m. D. Interviews The resident was interviewed on 12/17/18 at 1:47 p.m. She said she had used oxygen for a long time and always at 3L. Certified nurse aide (CNA) #1 was interviewed on 12/19/18 at 9:54 a.m. She said the resident was at 3L of oxygen. She said the resident received oxygen by a nasal cannula (NC). She said she knew how much oxygen the resident received because of the setting on the concentrator. Licensed practical nurse (LPN) #2 was interviewed on 12/19/18 at 9:57 a.m. She said the resident was on 2L, delivered by NC, and if needed the nurses would tirtate if the O2 saturation was too high. This contradicted what the concentrator was actually set to. LPN #1 was interviewed on 12/19/18 at 9:59 a.m. She said she could not find a physician's order for the oxygen. She said the resident was receiving 3L oxygen by NC from the concentrator in her room. She said oxygen was a medication and the resident needed a comprehensive physician's order for the oxygen. The director of nursing (DON) was interviewed on 12/19/18 at 10:05 a.m. He said he could not find an order for [REDACTED]. He said, he was in charge of ensuring the baseline care plans were done and he should have identified the use of oxygen.

Based on record review, observation and interviews, the facility failed to ensure menus were followed to meet the needs of residents. Specifically, the facility: - Failed to ensure portion sizes included on menus approved by the registered dietitian were followed; and, - Failed to ensure all items included in each meal were provided to residents requiring a pureed diet. The findings included: 1. Portion Sizes A. Record Review The menu for 6/15/17 included: supreme pizza, breadsticks, garden salad, Italian mixed vegetables and a brownie. The alternate meal was buffalo chicken wings and French fries. The serving size, according to the extension sheet, for the buffalo chicken wings was 3 oz. B. Observation The lunch meal service was observed on 6/15/17 from 10:45 a.m. to 1:05 p.m. Dietary aide (DA) #2 was observed serving ten residents buffalo chicken wings, each resident received three chicken wings. DA #2 also served two facility staff members five and six buffalo chicken wings. Following the meal service, DA #2, in the presence of the dietary manager (DM), measured the weight of three buffalo chicken wings, off the bone, at 1.3 oz. C. Interviews DA #2 was interviewed on 6/15/17 at 12:48 p.m. The DA said she thought three buffalo chicken wings was a 3 oz. serving. DA #2 said she did not realize she was giving the staff more food than was given to the residents. She said she was picking them up with the tongs and thought it was all the same. The DM was interviewed on 6/15/17 at 12:50 p.m. The DM said he was not aware the weight was meat only, off the bone. He said he would have to make changes to the menu because it was the summer menu cycle. He said residents were not receiving the recommended serving and could contribute to weight loss and residents not getting full. The registered dietician (RD) was interviewed on 6/21/17 at 11:42 a.m. She said the residents should have been served the recommended 3 oz. of meat on 6/15/17. The staff should have measured the weight of the chicken wings off of the bone. The RD said the risk to the residents was not having enough calories or protein to fulfill the needs. 2. Pureed Menu Items A. Record Review The menu for 6/15/17 included: supreme pizza, breadsticks, garden salad, Italian mixed vegetables and a brownie. The alternate meal was buffalo chicken wings and French fries. The extension sheet revealed the supreme pizza and buffalo chicken wings were served pureed and mashed potatoes were substituted for French fries. The menu for 6/20/17 included: Ranch chicken breast, mashed potatoes with gravy of the day, dinner roll, spinach salad, orangey beets, and caramel apple squares. The alternate meal was a roast beef sandwich with mixed vegetables. The extension sheet revealed all items were supposed to be served to residents with pureed diets. B. Observation Dietary aide (DA) #3 was observed on 6/15/17 from 10:45 a.m. until 11:38 a.m. She was preparing pureed pizza and Italian vegetables for six residents. Other items were not pureed. The lunch meal was observed on 6/20/17 from 11:00 a.m. to 1:00 p.m. Residents were served pureed chicken with gravy, orangey beets, mashed potatoes and gravy and caramel apple oat square. C. Interviews DA #3 was interviewed on 6/15/27 at 11:38 a.m. She said the only items she was supposed to puree were the pizza and vegetables. DA #3 said chocolate pudding was served instead of the brownie and indicated the other menu items could not be pureed. The DM was interviewed on 6/21/17 at 10:45 a.m. He said he did not know he had to follow the extensions and provide all items to residents who required mechanically altered pureed meals. The DM said he never served pureed bread items or salads, because you can't puree lettuce and fresh vegetables, the brownie, or chicken wings. The RD was interviewed on 6/21/17 at 11:42 a.m. She said she approved the menus to ensure there was enough proteins, well balanced and not repetitive. She said the items listed for both days were included when calculating the nutritive value of each meal. The RD said the residents who required a pureed diet should have received all items, except the bread because they could not puree the dinner roll or bread sticks. She said it was not imperative because the residents were served mashed potatoes and other carbohydrates.

Based on record review and interviews, the facility failed to ensure each resident received, and the facility provided, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (#11) of two residents reviewed for non-pressure related skin conditions of 25 sample residents. Specifically, the facility failed to consistently monitor wounds for resident #11. The findings included: A. Resident Status Resident #11, age 75, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 computerized physician orders [REDACTED]. According to the 5/17/17 minimum data set (MDS) assessment, the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behavior symptoms were noted. He did reject cares four to six days out of the past seven. He required extensive assistance for transfers, grooming and toilet use. B. Record Review Care Plans The care plan, initiated 5/15/17 and revised on 6/20/17, identified the resident impaired skin integrity on the second left toe due to a trauma from the podiatrist. Interventions included encourage resident to off-load/reposition at least every hour and as needed (PRN) and (follow) wound care per orders. The care plan, initiated 5/15/17 and revised 6/20/17, identified impaired skin integrity due to infected hair follicles to the back of neck. Interventions included encourage resident to off-load/reposition PRN and (follow) wound care per orders. The care plan, initiated 5/15/17 and revised on 6/20/17, identified impaired skin integrity due to dehisced surgical wound to donor site (right thigh). Interventions included: (resident) continues to refuse to see the wound clinic, encourage resident to off-load/reposition at least every hour and PRN and (follow) wound care orders. The care plan, initiated 2/12/17 and revised on 6/20/17, identified impaired skin integrity due to dehiscence of knee surgical site. Interventions included encourage resident to off-load/reposition at least every hour and as needed (PRN) and (follow) wound care per orders. The care plan, initiated 5/24/17, identified resistance to care and negative statements about staff due to depression diagnosis. Interventions included encourage him to get out of bed once each day while bed is changed; if refuses care, leave alone for several minutes and re-attempt later; and, maintain a therapeutic relationship through frequent, brief contacts and accepting attitude The acute care plan dated 3/23/17 identified a blister to right knee. The intervention was to clean with normal saline and apply skin prep every day until healed. The acute cate plan dated 4/12/17 identified wound care to left foot and right thigh. Interventions included left foot second toe cleanse with wound cleanser, pat dry, apply medi-honey sheet to area and then an extra absorbent foam every day; and, right thigh donor site clean with wound cleanser, pat dry, apply medi-honey sheet and cover with extra absorbent foam every day. The acute care plan dated 5/7/17 identified wound care to the right knee. Interventions were to cleanse with wound cleanser, pat dry; apply medi-honey to wound bed; and, cover with [MEDICATION NAME] and wrap with [MEDICATION NAME] every shift. The acute care plan dated 5/10/17 identified wound care to the right knee. Interventions were to cleanse with wound cleanser, pat dry; apply medi-honey to wound bed; and, cover with [MEDICATION NAME] and wrap with [MEDICATION NAME]. The acute care plan dated 6/3/17 identified wound care to the right thigh donor site. Interventions were to clean wound with cleanser, pat dry; apply skin prep to peri-wound; and, apply medi-honey sheet and cover with extra absorbent foam every other day. The acute care plan dated 6/20/17 identified wounds to the back of the neck and the right knee. Interventions included back of neck cleanse with wound cleanser, pat dry; apply skin prep to peri-wound; apply collagen powder to wound bed; cover with calcium alginate dressing every day; rght knee clean with wound cleanser, pat dry; apply skin prep to peri-wound; apply collagen powder to wound bed; and, cover with foam dressing every day. Physician Orders The June 2017 CPO included orders to: -Cleanse area to left foot second toe with wound cleanser, pat dry. Apply medi-honey sheet to area and then extra absorbent foam. Once a day. -Back of neck wound cleanse with wound cleanser, pat dry. Apply skin prep to peri-wound. Apply collagen powder to wound bed, cover with calcium alginate and cover with dressing daily. -Clean right knee wound with wound cleanser, pat dry. Apply skin prep to peri-wound, apply collagen powder to wound bed and cover with foam dressing daily. -Right lateral thigh donor site clean with wound cleanser, pat dry. Apply skin prep to peri-wound. Apply medi-honey sheet and cover with extra absorbent foam every other day Nurses' Notes The progress note dated 3/28/17 at 4:22 p.m. included. Dressing changed per order. Measurements taken by this nurse. Lateral aspect of knee measures 1.4x0.4x<0.2 with no drainage noted, no redness or warmth noted, 100% granulation noted. Anterior knee measures 4x1.9x>0.2 moderate drainage noted, 100% granulation no s/sx of infection noted. Right lateral thigh measures 10.5x15.5x0.3 with an area lateral area measures 7x5.8x0.3 moderate amount of drainage noted. No odor noted, red granulation tissue noted. Edges are smooth except for right anterior part of wound .Continue to educate resident on importance of turning and getting out of bed. Resident continues to refuse to get up for meals . The progress note dated 4/10/17 at 5:13 p.m. included, Dressing changed per orders. This nurse measured all wounds: Right lateral thigh measures in the middle of wound 15x17.5x0.2 and the top part of wound measures 20x17.5x0.2. Wound has 100% granulation tissue with moderate serosanguinous drainage noted to entire wound. No odor or s/sx of infection noted, Left lateral knee is healed, kneecap measures 4x2.5x>0.2. Wound bed has 100% red granulation tissue, min to no drainage noted. No odor or s/sx of infection noted. Resident left toe has large amount of bloody drainage noted. Red granulation tissue noted to top of toe. 20% slough noted to edges of toe. All dressings changed per MD order.Resident continues to refuse to be repositioned in bed becomes angry with staff and will not redirect. Resident continues on an air mattress for prevention but continues to refuse any further intervention .Resident and power of attorney (POA) also refuse to see any wound clinic as resident does not wish to be transported anywhere as he stated, 'It is not gonna to help.' Staff to continue to educate resident. The progress note dated 4/12/17 at 1:05 p.m. included, This nurse and certified wound ostomy nurse consultant (wound nurse consultant) in facility and measured all wounds. Right lateral knee surgical wound measures 4.3x2.0x0.2 with 100% granulation tissue, wound bed is beefy red and clean, Right lateral surgical donor site measures 22.5x18.5x0.3 with moderate serosanguinous drainage noted. Wound bed has 100% beefy red granulation tissue with [MEDICATION NAME] islands scattered throughout. Left second toe measures 4.5x2.6x0.2 with 70% granulation tissue and 30% slough noted. Peri wound intact. Continue with current treatment orders. Resident continues to be resistive to care and resistive to be turned or sit in wheel chair. Educated resident on importance of getting out of bed and resident becomes angry and resistive to getting up. Resident refuses to see outside wound clinic. Resident and POA are both in agreement to not see a wound clinic for wound . The progress note dated 4/17/17 at 1:17 p.m. included, .This nurse explained to medical director (MD) resident's refusal to seek outside medical wound help. MD in to do wound rounds. MD educated resident on importance of seeing a wound clinic. Resident continues to refuse . The progress note dated 4/21/17 at 3:58 p.m. included, Returned from primary care provider (PCP)'s office with orders to go to Saint Mary Corwin wound care clinic. The progress note dated 5/2/17 at 9:35 p.m. included, Resident returned from (hospital) wound clinic via facility van and one staff member. No new orders .Resident in good spirits smiling. Stated 'I am glad to be back here.' Notified POA of resident's return. The progress note dated 5/7/17 at 2:03 p.m. included, Old surgical area opened up measures 0.7 x 0.6 cm. Cleanse with wound cleanser, apply medi-honey, cover with [MEDICATION NAME] and wrap with kerlix. POA and physician were notified. The facility failed to identify the specific surgical area. The progress note dated 5/10/17 at 1:49 p.m. included, This nurse in to do wound round with nursing staff. Resident is in a pleasant mood at this time. Right knee measures 4.5x3x0.2 with moderate drainage noted no odor. Free from odor or redness, no s/sx of infection, wound bed is 100% granulation tissue. Lateral part of right knee that has an old surgical scar has opened and measures 0.5x0.5x0.2. Area has opened up prior to skin graft as when anterior knee heals pulls on lateral part of scar causing it to open. Left toe measures 5x3.5x0.2 with purulent drainage noted. 80% of granulation tissue with 20% slough Peri-wound intact. No odor or s/sx of infection at this time. Right later thigh (donor site) measures 26x24x0.3 100% beefy red granulation tissue. Wound bed continues to have [MEDICATION NAME] islands throughout wound bed. Serosanguinous drainage noted. Posterior neck measures 2.9x3.7x0.3 with moderate amount of drainage noted. No s/sx of infection or odor noted .Resident continues on air mattress. The progress note dated 5/16/17 at 1:23 p.m. included, This nurse and (wound nurse consultant) in facility for wound rounds. Right knee measures (Surgical wound) 3.9x3.1x0.2, wound has moderate serosanguinous drainage. Anterior part of knee has 100% granulation tissue and the old surgical wound to lateral knee has reopened and measures 1.9x1.4x0.2 with 100% granulation tissue. Left 2nd Toe measures 4.5x2.6x0.2 with moderate purulent drainage noted, wound bed has 90% granulation tissue with 10% slough peri-wound intact. Lateral thigh donor surgical site measures 25x23x0.3 with serosanguinous drainage noted. Wound bed is 100% beefy red granulation tissue with [MEDICATION NAME] islands throughout wound. Islands are increasing in healing of wound. Pressure ulcer to posterior neck measures 2.8x3.5x03 with serosanguinous drainage noted 90% red granulation tissue with 10% slough. Peri wound is intact. Resident continues to refuse to get out of bed or sit in wheel chair even with education. Resident is resistive to care. Resident refuses to help with turning and repositioning. Continues on air mattress. POA is aware of concerns and educated on importance of repositioning and stated That is just how my uncle has always been. It's okay. Continue to encourage to get resident up in wheel chair to help with repositioning and resident continues to refuse any further intervention (other) than the air mattress. The facility failed to identify the date of the discovery of the wound on the neck. The progress note dated 5/24/17 at 11:27 a.m. included, Resident current weight is 120 lbs., stable since last month. He continues with wound care to right knee and left toe. Continues on fortified diet with Liquid Protein supplement. His recorded intakes are 75-100%. Resident does not complain of N/V/D and says his appetite is fine. Will continue to monitor. Written by the registered dietician (RD). The progress note dated 5/26/17 at 11:39 a.m. included, .This nurse received a call from resident's POA stating that she was on her way to visit resident. She said that resident will not go back to (hospital) wound clinic, but would be willing to try (a second hospital) wound clinic. POA had made an appointment for June 2nd at 10:45. This nurse stated that she will call clinic and get appropriate paper work and look at transport schedule for availability. POA was happy and will be in facility to visit sometime today. The progress note dated 5/26/17 at 3:42 p.m. included, POA was in facility and came into this nurses office and stated that she talked to resident about (second hospital) wound clinic and he said he 'would like to think about it over the long weekend before agreeing to go.' The progress note dated 5/31/17 at 1:03 p.m. included, Donor site continues to improve with healing as [MEDICATION NAME] islands are improving over donor site. Donor site is covered with medi-honey and medi-honey can be left in place for up to 7 days. Due to resident being uncomfortable with donor site dressing change. PCP ordered to change dressing every other day. Resident is aware and is happy with new order. The progress note dated 6/7/17 at 11:39 a.m. included, Wound rounds done on resident for wound care .Measurements are as followed: Right knee cap measures 4x5.6x0.2 cm. Knee is 100% granulation tissue, peri-wound shows acute remolding, no s/x of redness or odor noted. Dressing did have serosanguinous drainage noted, and later knee measures 47.9x2.6x0.2 cm with serosanguinous drainage, no s/sx of infection or redness noted. No odor noted. Continue with medi-honey gel and cover with dressing, Back of neck wound measures 3.7x4.4. Small amount of drainage noted. Wound bed is 100% granulation tissue, no s/sx of infection or odor noted. Wound bed is clean. Peri-wound intact. Left second Toe measures 3.7x3x0.2, purulent drainage noted. No odor, redness or s/sx of infection noted at this time. Continue with current treatment orders. Left lateral thigh measures 28.8x25x0.3. Moderate Serosanguinous drainage noted. Wound bed has 100% beefy red granulation tissue with [MEDICATION NAME] island and grown skin scattered throughout. Wound has good blood supply noted to wound. Continue with current treatment plan. Resident continues to refuse to get out of bed for further intervention. Resident refuses to sit in w/c even with redirection and education. No changes at this time to plan of care. The progress note dated 6/15/17 at 9:59 a.m. included, Wound rounds done on 6/14/2017 with (wound nurse consultant) and this nurse and charge nurse. Right thigh donor site measures 30x28.5x0.3 with 100% granulation tissue with 30% of wound with intact skin and 15% of wound has [MEDICATION NAME] islands scattered throughout. Wound edges are now smooth, moderate amount of serosanguinous drainage noted. No s/sx of infection or redness noted. Continue with current plan of treatment as wound in improving. Second left toe that was caused by trauma measures 4.2x3.1x0.2. Toe now has 100% granulation tissue, no slough noted at this time. No odor or redness noted. Toe has beefy red granulation tissue. Surgical wound to knee measures 9.2x6.5x0.2. Both anterior and lateral knee measured together instead of separate at surgical wound has opened both areas and almost meet. Both wounds have 100% granulation tissue, serosanguinous drainage noted. No odor or redness noted. Back of neck right side measures 3.5x4.4x0.3 healing well. Wound has 100% red granulation tissue. Continue to monitor for any ingrown hair follicles. Scant amount of serosanguinous drainage noted. No odor or redness noted. Peri-wound intact. Left side of neck has a small area noted that measures 0.9x1x>0.2 95% of red granulation tissue noted and 5% slough noted. Same treatment started per PCP for collagen powder to help with slough. No drainage noted. Staff to continue to encourage resident to reposition and get out of bed for meals. Resident continues to be resistive to repositioning and getting out of bed even after education and encouragement. POA is aware of resistive to care and has no concerns .Resident continues to on an air mattress for pressure reduction but refuses any further interventions I.E wound clinic as he stated 'they don't know me they don't do anything more then you.' Explained to resident that wound clinic specializes in wound and can give a second opinion. Resident and POA continue to decline any further intervention. Will continue to encourage and educate resident. The facility failed to consistently measure the wounds at least weekly. Wound Nurse Notes The first wound nurse consultant note dated 4/12/17 identified a wound on the right knee as a surgical wound. She identified the wound acquisition was surgical. The second wound nurse consultant note dated 4/12/17 identified a wound on the right lateral thigh (donor site) as a surgical wound. She identified the wound acquisition was surgical. The third wound nurse consultant note dated 4/12/17 identified a wound on the left second toe as a non-pressure wound. She identified the wound acquisition was a trauma tissue injury. The first wound nurse consultant note dated 6/16/17 identified a wound on the right knee as a surgical wound. She identified the wound acquisition was surgical. The second wound nurse consultant note dated 6/16/17 identified a wound on the right lateral thigh (donor site) as a surgical wound. She identified the wound acquisition was surgical. The third wound nurse consultant note dated 6/16/17 identified a wound on the left second toe as a non-pressure wound. She identified the wound acquisition was a trauma tissue injury. The fourth wound nurse consultant note dated 6/16/17 identified a wound on the left posterior neck as a non-pressure wound. She identified the wound acquisition was a trauma tissue injury. C. Interviews LPN #1 was interviewed on 6/20/17 at 12:55 p.m. She said she was familiar with and had worked with all the residents in the facility. She said resident #11 has his wounds measured weekly by the DON and wound nurse consultant. The LPN said she can perform the treatments, but if she discovered any changes in the wound she immediately notified the DON for her to complete an assessment. She said the wound nurse consultant would make recommendations for the wound care and the facility relays the recommendations to the provider who usually agrees and orders the changes in treatment. The DON was interviewed on 6/20/17 at 1:05 p.m. She said the resident was extremely resistive to cares. She said the facility and PCP tried wound care for the resident at a wound care clinic. When the resident refused to go to a wound care clinic, she asked the MD to talk to the resident. He agreed after talking to the MD, but then refused after going. She said he refused to off-load and reposition, but she still continued to educate the resident on the importance of pressure relief. She said all wounds should have been monitored and measured at least weekly to determine improvement or deterioration of the wounds.

Based on observations, record review and resident and staff interviews, the facility failed to provide assistance to each dependent resident for activities of daily living (ADLs) for one (#29) of two residents reviewed for continence decline out of 25 sample residents. Specifically, the facility failed to provide timely incontinence care to a dependent resident. The findings included: A. Resident Status Resident #29, age 84, was admitted on [DATE] and readmitted on [DATE]. According to the June 2017 computerized physician orders [REDACTED]. According to the 5/26/17 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. She required extensive assistance from one person for bed mobility, dressing and personal hygiene. The resident required extensive assistance from two people for toilet use and transfers. The resident was always incontinent of urine and frequently incontinent of bowel. B. Observations The resident was observed continuously on 6/15/17 between 1:38 p.m. and 3:45 p.m. She was taken from the dining room to her room and assisted to her recliner chair. A certified nurse aide (CNA) entered the room and quickly exited at 2:44 p.m. CNA #1 delivered a beverage to the resident at 3:01 p.m. The resident's husband and family visited at 3:13 p.m. CNA #1 entered the room at 3:36 p.m. and another CNA entered at 3:39 p.m. to transfer the resident from the recliner into the wheelchair. The resident was not checked for incontinence during the observation. The resident was observed continuously on 6/20/17 from 9:28 a.m. to 12:32 p.m. The resident was sitting in her recliner watching television. CNA #2 entered the room and provided a cup of juice to the resident at 10:28 a.m. and then exited. CNAs #1and #3 entered the room to transfer the resident from her recliner to her wheelchair at 10:48 a.m. The resident was taken to the dining room at 11:20 a.m. and remained there until CNA #1 took her to her room at 11:43 a.m. The resident was transferred to her recliner at 11:51 a.m. CNA #1 and #2 entered the room at 12:29 and exited 12:32 p.m. carrying an adult brief in a clear plastic bag. C. Resident Interview The resident was interviewed on 6/15/17 at 3:45 p.m. She said the CNAs moved her from the recliner to her wheelchair earlier but did not check her for incontinence. The resident said she used an adult brief to eliminate and did not receive toileting assistance. D. Record Review Care Plan The care plan initiated 3/31/17 identified the resident was at risk for bowel and bladder incontinence related to staff assistance for toileting. The interventions included, toilet the resident every two hours and as needed and use attends at all times. The care plan initiated 3/31/17 identified the resident was at risk for constipation related to narcotic use and decreased mobility. The interventions included: determine presence of awareness of need to defecate; observe for signs of constipation; position the resident upright on a toilet or bedside commode; and teach the resident the importance of responding to rather than delaying the urge to defecate. Activity of Daily Living Flow Sheets A review of ADL flow sheets completed between 4/1/17 and 6/20/17 revealed the facility failed to check the resident, and provide incontinence care when needed, every two hours as care planned. The flow sheets revealed the resident often received continence care three times between 6 a.m. and 10 p.m. and once between 10 p.m. and 6 a.m. D. Interviews CNA #1 was interviewed on 6/20/17 at 12:32 p.m. She said the resident was incontinent when she was checked (see observation above) and her brief had a small amount of urine. The CNA said the resident will let staff know when she was wet. CNA #4 was interviewed on 6/21/17 at 10:33 a.m. She said dependent residents were checked every two hours, sometimes every hour, depended on the resident. The CNA said staff document on the tracking sheet every time a resident is checked and indicate whether the resident was wet or had a bowel movement. CNA #4 said the resident was checked every two hours because she was unable to go by herself and was incontinent of bladder and bowel. She said the resident could tell them sometimes when she had to go to the bathroom. CNA #4 said she documented each time she checked on her. The director of nursing (DON) was interviewed on 6/21/17 at 9:38 a.m. She said dependent residents were checked at least every two hours, before and after meals, before and after activities and as needed. She reviewed the flow sheet for toileting for resident #29. The DON said it did not look like the resident was checked or changed as often as she was supposed to be. She said there were four hours, five hours, nine and a half hours, ten hours and 11 hours in between toileting. The DON said it was, .Not okay, to not check and change the resident for long periods of time. She said the resident wore adult briefs because she was incontinent and a toileting schedule was not successful since her return from the hospital in the middle of May. The plan was to get her back to using the commode every two hours and as needed. The DON said the resident was at risk for urinary tract infections, skin breakdown, and impaired skin integrity.

Based on observations, record review, resident and staff interviews, it was determined that the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for four (#14, #42, #19, #24 ) of 28 sample residents. Specifically: For resident #14, the facility failed to consistently and accurately assess the resident's mouth pain as indicated by the facility policy. The facility failed to timely obtain and administer mouth pain medication for a resident who could not eat sufficient amounts of her food due to mouth pain. The facility failed to timely initiate all physician orders [REDACTED]. These failures contributed to the resident experiencing mouth pain which she consistently described to surveyors, as ,[DATE] and ,[DATE] on a scale of 1 to10, with 10 being the highest level of pain. In addition: --Resident #42 was not assessed timely for shoulder pain. --Resident #19 failed to have diabetic parameters and the facility lacked a systematic plan to address competing health needs in regard to fluid intake. --The facility failed to promptly assess or treat Resident #24's complaints of itching/discomfort. Findings include: I. Expectations for Pain Management A. Professional Reference: "Clearly, for many years clinicians have been placed in a challenging situation...they had no standards for assessment and treatment (of pain)...Critical to correcting this is establishing a standard for assessing the existence and intensity...if caregivers do not agree on a standard for assessing pain intensity, each is likely to assess pain differently...the care of a single patient can vary from one caregiver to another, very likely resulting in unrelieved pain... Many studies have shown that either lack of pain assessment or the existence of differences between the clinicians' pain ratings and those of patients is a major cause of inadequate pain management. Source: McCaffery, Margo and Pasero, Chris, "Pain: Clinical Manual," 2nd edition, Mosby, St. Louis, 1999, pp. 5 and 36. P. 732 in McCaffery M, Pasero C: Pain: Clinical Manual, Copyright 1999, Mosby, Inc. Standards for Pain, Assessment, Treatment, and Documentation, in pertinent part, states: " -Patients will be promised attentive [MEDICATION NAME] care by being informed verbally and in writing at the time of their initial interview that effective pain relief is an important part of their treatment that their report of unrelieved pain is essential, and that staff will respond quickly to their reports. -Patients will be taught to use a pain rating scale. When patients are taught to use the pain rating scale, they will be asked to set a comfort (pain relief) goal. Patients will be told that pain rated above the goal ...will trigger an [MEDICATION NAME] dose increase, additional [MEDICATION NAME], other pain relief intervention. -Pain ratings that are persistently above the comfort goal will trigger interdisciplinary review of the pain management plan and a modification in treatment. " B. Facility Pain Management Policy: The facility pain management policy was requested from the Nursing Home Administration (NHA) and was provided on [DATE]. The policy read in pertinent part, " Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimum management of the resident experiencing pain enhances healing and promoted both physical and psychosocial wellness. It is beneficial for the resident and his or family...as appropriate, to be involved in all aspects of ...care, including pain management...If the screening assessment reveals pain is present in the resident, it is the responsibility of staff to conduct a clinical assessment of the pain ...and periodic assessments of the patient for determination of pain and relief from pain, including the intensity and quality (i.e., character, frequency, location and duration of pain) and response to treatment ...If resident is in pain ...or discomfort nursing staff will assess pain and after ordered pain medication administration, resident is to be reassessed for pain relief. If resident is still in pain reassess resident, contact PCP (primary care Physician) and alter your plan of care ...Condition charting shall be implemented with new onset or increase of pain and PCP notified ...Pain Assessment is performed by the MDS coordinator on all new admissions and quarterly ....CHOOSE A NUMBER FROM 0 TO 10 THAT BEST DESCRIBES YOUR PAIN ...No pain..(0) ...Distressing pain 5 ...Unbearable pain ...10. " The policy further indicated in pertinent part ... (0) No Hurt ...6 ...Hurts Even More ....8 Hurts Whole Lot ...10 ...Hurts Worst. " On [DATE] at 6:11 p.m., the Assistant Director of Nursing (ADON) was interviewed for clarification on pain management documentation policy. In that interview the ADON clarified the policy and stated in pertinent part, "If there is a change of condition in pain, we chart for a minimum of 72 hours, to monitor the effectiveness of pain management ...We document every eight hours a day every shift for 72 (hours) . "During that interview the DON clarified the shifts as 6:00 a.m. to 2:30 p.m., 2:00 p.m. to 10:30 p.m., and 10:00 p.m. to 6:30 p.m. The ADON further stated in pertinent part, "For change of condition of pain or pain medication changes I expect nursing documentation three times a day." Resident #14, [AGE] years old, was initially admitted to the facility on [DATE], and readmitted to facility on [DATE]. The resident died at the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. 1. Resident Status The resident's Minimum Data Set ((MDS) dated [DATE], was reviewed and revealed the following: -The resident scored 15 on her brief interview for mental status (BIMS), indication of no cognitive deficits. The resident had no short-term or long-term memory impairments. The resident usually understood others and was usually understood by others and her speech was clear. The resident had no behavioral symptoms. - The MDS indicated that the resident was independent with bed mobility, transfer, and toilet use and eating. The resident needed limited assistance of one staff for dressing, locomotion out of her room and bathing. The resident used a wheelchair for mobility. The MDS indicated that the resident had pain. The MDS further indicated that the resident received scheduled pain and as needed (PRN) pain medication regiment. The MDS indicated that the resident verbally rated her pain intensity level at ,[DATE]. The MDS indicated that that pain level did not interfere with her activity level. 2. Pain Management Care Plans: The resident's pain care plan with an initial date of [DATE] and an update on [DATE] was reviewed and indicated that the resident had a problem of generalized pain. The goal for the care plan read in pertinent part, "will verbalize reduction of pain." The goal target date was [DATE]. The approaches to the care plan read in pertinent parts; "Approach Start Date: [DATE] Administer [MEDICATION NAME] per MD (physician) order. Notify MD of adverse effects." The care plan further read in pertinent parts, " Administer Tylenol per MD orders ...Observe for any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors ...Observe for any non-verbal signs of pain: (e.g., guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc). " On [DATE], the care plan was further updated with the following problems in pertinent part, "Pain ...thrush ....Pain/anxiety. " The goals on that date read in pertinent part, " Resident will have ... (Decreased) pain ....all s/s (signs and symptoms) of thrush will resolve ... (Decreased) s/sx. " The approaches to that care plan read in pertinent part, " DC (discontinue) [MEDICATION NAME] ,[DATE] mg ...PRN ...(initiate) [MEDICATION NAME] IR 5 mg QID (four times a day) [MEDICATION NAME] 4 ml, swish & swallow QID X 7 days. " The care plan did not indicate that Tylenol was to be held when routine [MEDICATION NAME] was administered the resident. Pain medications: [REDACTED] Review of computerized physician orders [REDACTED]. "Diet: Regular with thin liquids." 1."Tylenol 325 mg ...2 Tabs (tablets) ...oral ...Pain ...Twice a day; AM PM. " That order was initiated on [DATE]. 2. " [MEDICATION NAME] - 5 mg ...1 TAB ...oral ...Four Times a Day; AM, NOON, PM, HS (bedtime). " That order was initiated on [DATE]. 3. [MEDICATION NAME] suspension; 100,000 unit/ml; amount 4 ml; oral ...SWISH AND SWALLOW. TAKE FOR 7 DAYS ...Dx ([DIAGNOSES REDACTED]. " That order was initiated on [DATE], although the Physician order [REDACTED]. None was given till [DATE] after 5:00 a.m. 4. "[MEDICATION NAME]-[MEDICATION NAME] ..XXX,[DATE] mg amt: 1 TAB ...oral ...Dx ...pain ...Every 6 Hours PRN. " That order was initiated on [DATE] and discontinued on [DATE]. 5. "Monitor for s/s (signs and symptoms) of pain or discomfort. Have resident rate if able. " That order was initiated on [DATE]. Nurses Notes and Medication Administration review: Nurses ' notes dated [DATE] at 1:14 a.m., read in pertinent part, "Resident complaint of her mouth being sore. Noted several white patches with some redness. Also resident c/o (complain of) right leg pain ,[DATE]. Note: R (right) leg ...L (left) leg. Has been having 3+ to 4+ weeping [MEDICAL CONDITION] to L.E.'s (lower extremities) recently, but R leg > (greater than) L leg in size. Negative Homans. Unable to palpate pedal pulses due to [MEDICAL CONDITION]. Both feet feel cool to touch. (Physician name) will be in on rounds today and will inform day nurse for follow up. " Although, the last dose of [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg, 1 TAB orally PRN for pain was last administered on [DATE] at 3:36 p.m., a period of over nine hours in between, there was no indication that the resident was offered pain medications on [DATE] at 1:14 a.m. Further review of the resident's MARs and PRN pain management flow sheet dated [DATE] through [DATE] revealed that again, on [DATE] at 3:33 a.m., over two hour later, the resident complained of increased pain which she rated at ,[DATE]. The flow sheets/MARs indicated that on [DATE] at 3:33 a.m., the resident received [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg 1 TAB orally PRN for c/o pain. The results (after administration of PRN medication read in pertinent parts " SE (somewhat effective), " In an interview with the DON on [DATE] at 2:39 p.m., she clarified that "SE" above indicated that the resident ' s pain medication administered was "Somewhat Effective," which was indication that the resident's pain was not relieved with that administration. Further review of the MARs and nurses notes dated [DATE], revealed no documentation of further pain assessment to include the location, duration, quantity, quality or lack of alleviation of the resident ' s pain after the resident received no pain relief from PRN medication administration at 3:33 a.m. (above), that day, as indicated by the facility policy and care plan. There was no indication that the resident's physician was notified of the lack of pain relief for further instructions, when the resident received ineffective pain relief above, as indicated in the care plan. Initial observations: On [DATE] at 10:16 a.m., during the initial resident interview, the resident was asked if she had any discomfort at the time of the interview or if she had been having discomfort such as pain, heaviness, burning, or hurting with no relief ?" The resident answered in pertinent part, "My mouth hurts ...I got sores in it ...The nurse knows about it, " as indicated in nurses notes above at 1:14 a.m. The resident was asked how her breakfast was and stated in pertinent parts, "I can't eat ...my mouth hurts." The resident was asked to rate her pain on a scale of 1 to 10 (as described above). The resident stated, "About 8." The resident further stated that they were not giving her specific medications for her mouth sores. During that same interview the resident was asked if the food tasted good and if the food was appetizing. The resident answered in pertinent part, "My mouth hurts ....they do not give me anything for my mouth (mouth pain)...It hurts...I can't eat." The resident was asked if she had dental problems with her gums, including mouth sores and stated in pertinent parts, " My mouth hurts. " During that same interview the resident further stated that staff was aware that resident #14 was unable to eat secondary to mouth pain. Without being prompted, the resident opened her mouth and the resident's mouth was observed with redness on the edges of her mouth and white matter in her mouth. On [DATE] at about 10:20 a.m., the Nurse Practitioner (NP) came into the resident's room and introduced himself to the resident and surveyor at that time. The NP then stated that he was following up on the resident's [MEDICAL CONDITION] to her lower extremities. During the visit, the resident was overheard as she stated to the NP that she had mouth sores and they hurt. The NP was overheard as he assessed the resident ' s mouth and confirmed that the resident's mouth had sores. Again, the ,[DATE] MARs/flow sheets indicated that on [DATE] at 10:47 a.m., the resident received [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg, 1 TAB orally PRN for pain at that time the resident's pain level was documented at ,[DATE]. The pain relief results of that medication administration again, read in pertinent part "SE," indication of somewhat effective but no effective pain relief was experienced by the resident after [MEDICATION NAME]-[MEDICATION NAME] PRN was administered. Again, nurse's notes were void of further documentation for inclusion of the lack of pain relief, quality and quantity of pain, after the PRN medication was administered without relief, as indicated by the facility policy and care plan. Although the resident received no relief and the NP ordered new medications, when he assessed the resident on [DATE] at about 11:30 a.m., specifically, "[MEDICATION NAME] - 5 mg ...1 TAB ...oral ...Four Times a Day; AM, NOON, PM, HS (bedtime), " there was no documentation that indicated that the resident was administered the medication until after 4 p.m., (PM dose), for a resident who voiced " SE, " or no relief from her PRN medication which had been administered at 10:47 a.m., that morning. There was no documentation that the physician was consulted as to why the scheduled noon dose of [MEDICATION NAME] was not administered the resident as ordered on [DATE], for a resident who had no relief from her discontinued pain medication that morning. On [DATE] at 12:56 p.m., nurses' notes documented physician orders [REDACTED]. Those nurses notes read in pertinent parts, " ORDERS ...FNP (Family NP) in facility today and saw resident. Following orders received: 1) ACE wraps to bilateral LE, on in AM off at HS2) DC (discontinue) [MEDICATION NAME] ,[DATE]mg, 1 PO (by mouth) Q6 (every) hours PRN pain3) [MEDICATION NAME] IR, 5mg, 1 Tab, PO, QID for pain4) Daily wt x 7 days5) [MEDICATION NAME], 4mL, swish & swallow QID x 7 daysPOA (Power of Attorney) notified of above orders. Again on [DATE] at 4:15 p.m., nurses notes read in pertinent part, " SKIN: Resident continues to have multiple excoriations to body r/t scratching and c/o itchy skin. " Again the resident ' s pain level was not assessed at the time, although the resident was ordered new pain medications. There was no documentation of pain relief or lack of, as indicated in the facility policy and resident's care plan. Although new pain medication regiment was ordered by the resident's physician on [DATE], after the resident developed painful mouth sores, the resident's pain level was not assessed as indicated by the facility policy or care plan. On [DATE] at 5:05 p.m., documentation of MARs/flow sheet revealed that the resident received no scheduled Tylenol dose which was scheduled for p.m., that day. Documentation revealed that the Tylenol was held when resident #14 received scheduled [MEDICATION NAME] that p.m. or evening. Review of the medical record revealed no MD orders to hold or discontinue the resident's scheduled Tylenol, when [MEDICATION NAME] was administered to the resident. There was no documentation that indicated that physician notification was initiated for further instructions, as indicated, for a resident who experienced increased pain without relief. Again, there was no documentation regarding the resident ' s pain relief or lack of relief after her medications were changed, as indicated in the facility policy. Further Observations on [DATE]. On [DATE] at 5:13 p.m., the resident was observed as she sat up in wheelchair while at the dining table, her hearing aid was in place to her right (R) ear. At that time, the resident was asked about her mouth pain. At that time, the resident stated that her level of mouth pain was at ,[DATE] at this time and she could not chew her food. On [DATE] at 5:30 p.m. resident #23 (table mate to sample resident #14) was interviewed by another surveyor who was watching meal serving at that time. resident #23 stated that resident #14 had trouble eating because her mouth hurt, and that the facility was going to get her ice cream for that meal. On [DATE] at 5:31 p.m., another surveyor interviewed resident #14 and asked how she was doing. Resident #14 said to that other surveyor that her mouth hurt and that there were sores. During that interview with another surveyor, resident #14 opened her mouth and pulled down her lower lip; the other surveyor observed that the resident had two white patches surrounded by red edge on inside of lower lip and gums. Consequent observations and staff interviews: On [DATE] at 6:01 p.m., the resident was observed by two surveyors during dinner. In the presence of the two surveyors the resident stated in pertinent part, " I can't swallow ...my mouth hurts. " Again, the resident stated that her mouth pain level was at ,[DATE]. At that meal, her food intake of dinner was verified with dining aide #1, who was assisting with serving and recording meal intake for that meal. In an interview with dining aide #1 at that time, she stated in pertinent part, " She (resident #14) ate only less than 25% of dinner ...she ate none of the beef and barley soup (which was served as the main dish served the resident that evening), then ate ,[DATE] of a small bowel of mashed potatoes and a small slice of peaches...she ate less than 25% of the meal. " Again, indication that the resident was unable to eat a significant amount of her food due to mouth pain, as stated by resident #14 and her dining table mate, resident #23, above. On [DATE] at about 6:18 p.m., the resident ' s medical record was reviewed. The medical record revealed that the resident received [MEDICATION NAME] 5 mg one tab, which was scheduled for the PM was administered (no time of administration was recorded). Unit RN#1 interview: On [DATE] at about 6:20 p.m., RN #1 was interviewed about lack of documentation for resident #14 ' s pain and pain management for that day. In that interview the RN confirmed that she had not documented on resident ' s pain since that morning (6:30 a.m. until 6:20 p.m., when the surveyor brought it to her attention). The RN stated that she was very busy that day (from 6:30 a.m., through 6:20 p.m., the time of the interview) and had not documented the resident ' s pain that day. The RN stated that she would document in the resident's chart after that interview. The surveyor then left the RN so the RN would document the resident ' s pain assessment and management for that day shift. On [DATE] at about 6:50 p.m., the surveyor reviewed the resident's chart again. After the surveyor brought it to the RN's attention above, the RN documented in pertinent parts, "[DATE] 06:28 PM PAIN: Resident was on [MEDICATION NAME] ,[DATE]mg for pain but pain was not being effectively controlled ....FNP (Family Nurse practitioner) was consulted and her pain medication was changed to [MEDICATION NAME] 5mg, IR, QID (four times a day). New medication appears to be effective as resident is not c/o any breakthrough pain, and resident has been observed resting quietly between doses with no complaints voiced by resident, " Indication that the RN was unaware of the resident's complaints of mouth sore pain and inability to eat during that evening meal on that date. Although the resident companied of pain of ,[DATE] to surveyors at the dinner meal and was unable to eat adequate amounts of her food, above, the RN documentation for that day was not completed to include complaints of pain or accuracy lack of pain relief for that resident. The RN #1 was interviewed a second time on [DATE] at 6:52 p.m. The RN #1 stated that the resident had a newly scheduled dose of [MEDICATION NAME] which worked well for her pain. The RN #1 stated that the resident was able to rest and sleep during the day and that she had generalized pain when she was last assessed (earlier on [DATE]). She stated that she was unable to state when she was last assessed as the pain level documentation had not been added to the form. The RN #1 confirmed that the resident's pain management medications were changed. The RN #1 then stated that when the pain management orders were changed, nursing staff was to assess pain for the resident. The RN then confirmed the facility policy and stated that the nurse was to ask the resident for the characteristics of their pain and document those findings whenever there was a change in the resident's pain management regiment. The RN #1 stated in pertinent part, "I will rate pain if the resident is on pain medications." In that same interview on [DATE] at 6:52 p.m., the RN #1 was asked for clarification of pain assessment for the resident. The RN stated in pertinent part, "I am not rating her pain ...she started her new pain medication yesterday ([DATE]) and this new pain medication order has not been put in to assess pain." The RN confirmed that she was not assessing the resident's pain as indicated by the facility policy. On [DATE] at 3:00 p.m., the findings were brought to the attention of the DON and ADON. No further comments were provided. No further documentation was faxed shortly after survey as requested by the surveyor. The facility failed to accurately and consistently assess the resident's unrelieved pain. The facility withheld the resident's Tylenol without a physician order [REDACTED]. The resident continued to experience unrelieved pain and was unable to eat significant amounts of her food due to mouth pain. Resident #42 Resident #42, age 84, was initially admitted to the facility on [DATE]. The resident ' s face sheet, dated [DATE] indicated [DIAGNOSES REDACTED]. The most recent minimum data set (MDS), dated [DATE], indicated that she occasionally experienced pain and was on medication for her pain. Observations: On [DATE] at 5:30 p.m., Resident #42 was observed to walk into the dining room with the support of one CNA and her walker. The resident sat down in her seat, which was at the table for residents requiring feeding assistance, directly across from two Paid Feeding Assistants (PFA #1 and PFA #2, ) who were assigned to supervise and assist residents at that table. The resident stated that her shoulder hurt, and held her shoulder continuously for fifteen minutes. The PFAs failed to acknowledge the resident, ask about her shoulder, or notify a nursing staff member to talk to the resident about her shoulder pain. The resident was observed to grimace and clutch her left shoulder a second time at 5:54 p.m., again from 6:00 to 6:02 p.m. and at 6:11 p.m. The PFAs did not ask the resident about her pain during any of these instances. The resident was assisted out of the dining room by a certified nurse aide, CNA # 4 at 6:55 p.m. The PFAs did not mention the resident ' s favoring her shoulder to the CNA. Interviews: On [DATE] at 7:09 p.m., CNA # 4, who was familiar with the resident, was interviewed. The CNA stated that the resident had arthritis in multiple joints, and that she was on pain medication. The CNA stated that she had not been made aware of the resident ' s shoulder pain before helping her out of the dining room that evening. On [DATE] at 7:13 p.m., the charge nurse for the resident ' s hall, RN # 1, was interviewed. The RN stated that the PFAs were hired directly by the facility, and that while their specific job was to supervise dining, they were expected to act as part of a team. The RN stated that the PFAs were expected to communicate with the nurses, because they had direct interaction with the residents during the meal, and as a result may see behaviors or symptoms that she was not able to observe. She stated that she asked PFAs following meal service to list any concerns they had during the meal, and stated that it was the expectation that they report symptoms, even if they were not directly related to meal intake. She confirmed that if a PFA observed a resident who appeared to be in pain, or who was expressing pain, during the meal, they would be expected to inform the RN so that the nursing staff could address the resident ' s pain. She stated that she had standing orders for Tylenol and aspirin that she could use as needed, but agreed that in order for her to administer pain medication, she would first need to know that the resident was in pain. The RN also confirmed that she had not been made aware of Resident #42's shoulder pain by either of the PFAs. On [DATE] at 2:15 p.m., the ADON and DON were interviewed. The DON stated that the facility had used PFAs for about four or five years. She stated that she had been made aware of the situation with Resident 42 ' s shoulder by the nursing staff, and confirmed that it was the facility ' s expectation that the PFAs would inform nursing staff of any and all concerns related to the residents, including pain that was not related to the resident ' s dietary needs. 3. Resident #19 Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's [DATE] quarterly minimum data set (MDS) noted the resident exhibited no rejection of evaluation/care and received insulin injections 7 out of the last 7 days during the assessment period. a. Diabetic management Record Review: The resident's [DATE] plan of care (POC) noted the resident was at risk for unstable blood glucose levels related to diabetes mellitus and directed staff to monitor, record and report blood glucose levels as ordered. Review of ,[DATE] computerized physician orders [REDACTED]. The CPO directed staff to obtain a finger stick blood glucose twice a day starting on [DATE]. The CPO lacked blood glucose parameters to identify what values required physician notification by staff to help guide treatment decisions. Review of finger stick blood glucose levels for [DATE] -[DATE] revealed staff obtained and recorded blood glucose levels twice a day. The blood glucose levels ranged from a low of 74 to a high of 289 milligrams/deciliter (mg/dl). Staff Interview: An interview was conducted with the assistant director of nursing (ADON) on [DATE] at 4:20 p.m. The ADON identified the resident's POC should contain blood glucose parameters between ,[DATE] mg/dl and confirmed that the POC lacked such parameters. The ADON then pulled up the resident's electronic Medication Administration Record [REDACTED]. The ADON then identified that the twice-daily target blood glucose range needed to be more specific and based on the resident ' s usual values, noting she intended to call the physician and obtain parameters so that staff knew when to call the physician for treatment recommendations. An interview was conducted with LPN #2 on [DATE] at 6:50 p.m. LPN #2 identified she had worked with the resident for approximately 6 months and, while she was not responsible for conducting the resident's "p.m." blood glucose check, she could check the blood glucose levels in the system if necessary. She stated she had never known the resident's blood glucose to be out of control, but identified that the resident would occasionally sneak snacks. LPN #2 stated she would call the physician for any blood glucose level below 70 or above 200 and, if the blood glucose was 120 or above, she would first look at the physician orders [REDACTED]. Facility Follow up: The ,[DATE] CPO contained an order added [DATE] that directed staff to obtain finger stick blood glucose levels twice a day and to notify the resident's primary care physician for any blood glucose value less than 60 or higher than 250 mg/dl. b. Fluid restriction management program Record Review: The resident's [DATE] quarterly minimum data set (MDS) coded the resident as independent with eating and drinking and identified the resident as usually able to make his needs known. Review of the resident's [DATE] plan of care (POC) revealed the resident had potential for respiratory distress related to [MEDICAL CONDITION]. The POC directed all staff to encourage fluid intake of 1500 cubic centimeters (cc) per day to liquefy the resident's secretions. Another POC, also dated [DATE], noted the resident was occasionally incontinent of bladder and directed staff to encourage fluids to 1500 cc/day. The resident also had a [DATE] POC regarding his potential for constipation related to decreased mobility and use of narcotic medication which directed staff to encourage fluid intake of 1500 cc/day. Review of a Quarterly Nutrition Assessment completed [DATE] by a registered dietitian (RD) revealed the resident was on a consistent carbohydrate diet with thin liquids and no supplements. The total fluids required to meet the resident's need were listed as 2300 cc/day with the resident's actual oral/nutritional intake noted as ,[DATE] cc/day. Review of ,[DATE] computerized physician orders [REDACTED]. The [DATE] [MEDICATION NAME] order represented a reduction in the resident's previous dose. -According to the [MEDICATION NAME] patient registry website at [MEDICATION NAME].com, [MEDICATION NAME] has potent [MEDICATION NAME] effects and can cause fatal gastrointestinal adverse reactions such as constipation, intestinal obstruction, fecal impaction, and paralytic ileus. Constipation may be treated by ensuring adequate hydration and use of bulk laxatives. The CPO contained a [DATE] dietary order for small portions at meals, but contained no parameters for fluid intake. Observation and Interviews: The resident was observed in the dining room on [DATE] at approximately 12:35 p.m. The resident waved survey staff over and asked for more ice and water. The request was relayed to certified nurse aide CNA #7, who stated the resident couldn't have any more water for now. When this information was relayed to the resident, he grimaced and sighed. Around 12:42 p.m., Registered Nurse (RN) #1 was interviewed at the nurse's station. RN #1 explained they had to restrict the resident's water/fluid intake because the resident would drink ,[DATE] liters/day if allowed and would flus