Every finding on record at Gunnison Valley Health Senior Care Center

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity for five (#24, #17, #3, #14 and #28) of 10 residents reviewed for respect and dignity out of 22 sample residents. Specifically, the facility failed to ensure Resident #24, Resident #17, Resident #3, Resident #14 and Resident #28, who required meal assistance were treated with respect and dignity. Findings include:I. Facility policy and procedureThe Resident Dignity and Respect policy, undated, was provided by the nursing home administrator (NHA) on 1/28/26 at 2:53 p.m. According to the policy, its purpose was to Ensure that all residents are treated with dignity, respect, and consideration at all times, in accordance with federal and state long-term care regulations and the facility's commitment to person-centered care. The policy identified how staff should provide dining with social dignity. It read in pertinent part, Residents will be treated respectfully during meals and not rushed. Staff will sit with residents at eye level whenever possible when providing dining assistance or engagement to promote dignity, meaningful interaction, and a homelike environment. Standing over residents, talking across the room, or providing assistance from a position that may feel intimidating or impersonal should be avoided.II. ObservationsDuring a continuous observation of lunch on 1/26/26, beginning at 12:13 p.m. and ending at approximately 1:00 p.m., the following was observed:At 12:19 p.m. certified nurse aide (CNA) #1 served Resident #24 her meal. CNA #1 stood on the right side of Resident #24. CNA #1 provided Resident #24 several bites of food while standing over the resident. At 12:22 p.m. licensed practical nurse (LPN) #1 stood next to Resident #17 and provided Resident #17 a bite of her food. At 12:25 PM CNA #1 knelt next to Resident #24 and continued to provide the resident meal assistance. At 12:28 p.m. CNA #2 stood next to Resident #3 and provided him with two bites of his meal before she retrieved a stool, sat next to him at eye level and continued to assist him with his meal. During a continuous observation of lunch on 1/27/26, beginning at 12:28 p.m. and ending at 12:56 p.m., the following was observed:Beginning at 12:33 p.m. and ending at 12:46 p.m. CNA #1 stood next Resident #14 while she assisted her with her meal and beverage. Beginning at 12:33 p.m. and ending at 12:47 p.m. LPN #1 stood on the left side of Resident #3 and assisted him with his meal and beverage.On 1/28/26 at 12:21 p.m. CNA #1 was observed to provide meal assistance to Resident #17 while she stood next to Resident #17 and registered nurse (RN) #1 provided meal assistance to Resident #28 while standing next to her.At 12:26 p.m. RN #1 sat down next Resident #28 at eye level to continue to provide meal assistance to her. The assistant director of nursing (DON) brought CNA #1 a chair and instructed her to sit down next to Resident #17 while providing meal assistance to the resident. On 1/29/26 beginning at 9:20 a.m. and ending at 9:25 a.m. CNA #3 was observed providing meal assistance to Resident #24 while she stood over Resident #24 on the resident's right side. III. Resident #24A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included vascular dementia and specific severity with other behavioral disturbance, rheumatoid arthritis, gastro-esophageal reflux disease without esophagitis, generalized muscle weakness and stage four chronic kidney disease.The 1/26/26 minimum data set (MDS) assessment revealed Resident #24 had severe cognitive impairment with a staff assessment for mental status. According to the MDS assessment Resident #24 partial to moderate assistance for eating. B. Record reviewThe activities of daily living (ADL) care plan, revised 1/21/26, identified Resident #24 required setup with supervision assistance by one staff member to eat. According to the care plan, Resident #24 was sometimes dependent on staff for dining.IV. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included vascular dementia, severe, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke) and generalized muscle weakness.The 1/15/26 MDS assessment revealed Resident #17 had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. According to the MDS assessment, Resident #17 needed substantial to maximal assistance for eating. B. Record reviewThe ADL care plan, revised 1/14/26, identified Resident #17 needed one to one maximal meal assistance to eat at her best. V. Resident #3A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included vascular dementia, moderate, with mood disturbance, other drug-induced secondary Parkinsonism, gastroesophageal reflux disease without esophagitis, type 2 diabetes mellitus without complications, and nutritional anemia. The 12/9/25 MDS assessment revealed Resident #3 had severe cognitive impairment with a staff assessment for mental status. According to the MDS assessment, Resident #3 was dependent on staff for eating. B. Record reviewThe ADL care plan, revised 12/02/25, identified Resident #3 was dependent on staff assistance for his meals.VI. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the January 2026 CPO, diagnoses included unspecified dementia, unspecified severity with mood disturbance, unspecified protein-calorie malnutrition, and major depressive disorder recurrent in partial remission.The 1/26/26 MDS assessment revealed Resident #14 had severe cognitive impairment with a staff assessment for mental status. According to the MDS assessment, Resident #14 was dependent on staff assistance for eating. B. Record reviewThe ADL care plan, revised 1/21/26, identified Resident #14 often fed herself with cuing help from staff but occasionally she was dependent on staff for eating.VII. Resident #28 A. Resident status Resident #28, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included vascular dementia, moderate, with other behavioral disturbances, heart failure, and generalized muscle weakness. The 11/13/25 MDS assessment revealed Resident #28 had severe cognitive impairment with a brief interview for mental status (BIMS) score of 5 out of 15. According to the MDS assessment, Resident #28 needed partial to moderate staff assistance for eating. B. Record reviewThe ADL care plan, revised 1/27/26, identified Resident #28 was dependent on staff and required on-to-one assistance for meals.The 3/11/25 CPO directed staff to provide Resident #28 was one-to-one assistance for meals to promote intake. VIII. Staff interviewsThe assistant director of nursing (ADON) was interviewed on 1/28/26 at 12:54 p.m. The ADON said she used to teach the CNA training class. She said staff should sit next to a resident when providing the resident meal assistance. She said staff should not hover or stand next to a resident. She said the staff should sit down so they feel more like a companion to the resident during meal assistance. The ADON said she reminded CNA #1 to sit down when she provided meal assistance to Resident #17 on 1/28/26. The ADON was interviewed again on 1/28/26 at 1:03 p.m. The ADON said she spoke to the NHA and was told the facility did not have a policy not to stand when providing meal assistance but it was not recommended because the process could injure a staff member's back and sitting next to a resident would feel like more a companion to the resident.RN #1 was interviewed on 1/28/26 at 1:05 p.m. RN #1 said when providing residents meal assistance, she should have been sitting down next to the resident to make sure that she was making eye contact with the resident and ensure proper swallowing. RN #1 said it would have been better on her back if she was sitting down next to the resident and probably a nicer experience for the resident. CNA #1 was interviewed on 1/28/26 at 1:11 p.m. CNA #1 tried to converse with the residents when she provided meal assistance. She said some residents want to eat in peace but if they wanted to talk, she would kneel or sit next to them while assisting them with their meal. CNA #1 said she sometimes would stand next to a resident when she has to provide meal assistance to more than one resident. She said it was easier if she stood up so she could move between the residents.The NHA and the director of nursing (DON) were interviewed together on 1/29/26 at 12:07 p.m. The NHA said the facility wanted to make sure the dining experience was homelike as if the staff were joining the residents at a family table. The NHA said staff should be sitting down, engaging the resident while making eye contact with them when the staff member was providing meal assistance. The DON said staff should not stand when providing meal assistance, it would not be a homelike environment. She said staff should treat the residents like a family member. She said sitting next to a resident would give the resident and the staff member a better view of each other and allow staff to make sure they were swallowing properly. The NHA said the facility has not had recent training on providing meal assistance with residents. She said the staff received annual training on dignity and resident rights. The DON said the facility would include the topic of dining, dignity and homelike environment in their next all staff inservice. The NHA said she would conduct an in-the moment education with staff to sit during meal assistance today (1/29/26) and send out a reminder email to them. The NHA was interviewed on 1/29/26 at 2:10 p.m. The NHA said the facility was in the process of educating the staff regarding meal assistance expectations. She said the facility did not have a dignity policy in place so she created it today (1/29/26) but staff were trained on dignity and resident rights during their new hire orientations. V. Facility follow up The Resident Dignity and Respect staff education handout, undated, was provided by the NHA on 1/29/26 via email. According to the email, the staff were provided the educational handout on 1/29/26 and DON reviewed the handout with staff working on 1/29/26 (during the survey). The email identified the staff would receive additional education on dignity and respect during the next all staff in-service. The educational handout defined dignity in a long-term care setting and staff expectations, to include dignity with dining. The handout directed staff to sit at eye level with residents when assisting or engaging during meals; avoid standing over residents or talking across the room; promote conversation and engagement to create a homelike dining experience; encourage independence and use adaptive equipment as needed, and handle spills or accidents discreetly and respectfully.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility's medication error rate was 6.25%, with two errors out of 32 opportunities for error. Findings include:I. Facility policy and procedureThe Facility Administration of Medication policy, last revised 3/12/25, was provided by the nursing home administrator (NHA) on 1/30/26 at 8:49 a.m. It read in pertinent part, Qualified, authorized staff members do the following prior to administering medications: Obtain medication orders from a licensed practitioner as permitted by law and regulation. Review all medication orders in a timely manner. Clarify the order with the prescriber, if necessary. Verify the medication information against the order. Review the medication information to become familiar with the effects, dose, rate of administration, contraindications, and side/adverse effects. Confirm the following just prior to administration: right patient, right medication, right dose, right time, right route (include injection site, if applicable), right indication, right documentation.II. Medication administration observationsOn 1/28/26 at 9:21 a.m. licensed practical nurse (LPN) #1 was preparing and administering medications for Resident #35. Resident #35 had physician's orders for the following medications:AirDuo Digihaler Inhalation Aerosol Powder Breath Activated 113-14 micrograms/ actuation (MCG/ACT) (Fluticasone-Salmeterol with sensor) one puff inhale orally two times a day. Please ensure the resident rinses their mouth out well after using AirDuo.-However, LPN #1 did not have Resident #35 rinse her mouth after inhaling the medication.On 1/28/26 at 9:35 a.m. LPN #1 was preparing and administering medications for Resident #30. Resident #30 had physician's orders for the following medications:Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate-Vilanterol) one inhalation inhale orally one time a day; rinse mouth after use.-However, LPN #1 did not have Resident #30 rinse her mouth after inhaling the medication.III. Staff interviewsLPN #1 was interviewed on 01/28/26 at 10:48 a.m. LPN #1 said she was aware a resident should rinse out their mouth after administering an inhaled powder steroid. LPN #1 said the reason for rinsing out their mouth was to prevent a resident from forming oral thrush (a fungal infection causing white patches on the tongue, cheeks or throat). LPN #1 said she forgot to have Resident #35 rinse their mouth after administering the inhaled medication because she could not see the directions to rinse the medication without hovering her mouse over the order on her computer. LPN #1 said she also could not see the additional directions on the order for Resident #30. LPN #1 said she normally asked Resident #30 to rinse their mouth with one of her other medications that was a liquid medication diluted in water. LPN #1 said she forgot to have Resident #30 rinse with the liquid medication because she did not remember to administer Resident #30's inhaled medication until after she already directed Resident #30 to drink the liquid medication. LPN #1 said she planned to have Resident #30 and Resident #35 rinse their mouth immediately. LPN #1 said she planned to replace the orders for Resident #30 and Resident #35 in order to put the directions for rinsing in bold to make the instructions more noticeable in the future. LPN #1 said she also planned to contact the ordering physician to notify him and planned to complete any additional orders if he had any. The director of nursing (DON) and the NHA were interviewed together on 1/29/26 at 2:43 p.m. The DON said LPN #1 informed her of the medication errors on 1/28/26. The DON said residents risk contracting thrush if they do not rinse their mouth after using an inhaled medication containing powdered steroids. The DON said she assisted LPN #1 with updating the orders for Resident #30 and Resident #35, making the directions to rinse appear in bold. The DON said she also planned to complete an audit of the other residents in the facility in order to ensure directions to rinse after administration were in bold. The DON said she sent out written education to all nursing staff directing staff to ensure all residents rinse their mouth after administering medications with inhaled powder steroids. The DON said she planned to complete additional in person education during the next staff meeting.

Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively every day for seven days a week. Specifically, the facility failed to have an RN on duty for eight consecutive hours consistently from 10/1/23 to 4/24/24. Findings include: I. Record review Review of the nursing schedule from 10/1/23 to 4/24/24 revealed the following: -In October 2023, the facility did not have an RN on duty for eight consecutive hours on three days during the month; -In November 2023, the facility did not have an RN on duty for eight consecutive hours on thirteen days during the month; -In December 2023, the facility did not have an RN on duty for eight consecutive hours on three days during the month; and, -In March 2024, the facility did not have an RN on duty for eight consecutive hours for twelve days. II. Staff interviews The nursing home administrator (NHA) was interviewed on 4/24/24 at 8:25 a.m. The NHA said the facility relied heavily on licensed practical nurses (LPN) to provide nursing care/ She said the facility' s location in the rural mountains made recruiting and retaining RNs was difficult. The director of nursing (DON) was interviewed on 4/24/24 at 10:26 a.m. The DON said the facility had a state waiver for the RN staffing requirement in place. She said she was unaware the state waiver did not apply to the federal staffing requirements. She said she would do her best to meet the federal requirement for the safety of the residents.

Based on interviews and record review, the facility failed to ensure one (#1) out of three sample residents were kept free from abuse. The facility failed to provide increased oversight and monitoring to ensure Resident #1, who had severe cognitive impairment and was unable to consent to sexual contact of any type, was protected from sexual abuse by Resident #2, who was cognitively intact. On 2/13/24, Resident #2 was observed watching television in Resident #1's room by two different staff members. At 9:23 p.m., over an hour after the last known observation of the two residents, certified nurse aide (CNA) #1 entered Resident #1's room while doing routine rounds. Resident #1's door had been closed and when CNA #1 entered Resident #1's room, he observed Resident #2, who was nude, lying on top of Resident #1, who was also nude, and having sexual intercourse with her. A nurse was alerted and Resident #2 was removed from Resident #1's room and placed on one-to-one supervision. However, due to the facility's failures to provide increased oversight and monitoring of the residents once Resident #2 was observed in Resident #1's room, Resident #1 sustained sexual abuse by Resident #2. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/1/24-4/2/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/15/24. I. Incident of sexual abuse A. Sexual abuse investigation The 2/13/24 sexual abuse incident investigation documented the following: The nurse was alerted by CNA #1 while he was doing his rounds, he found Resident #1 (female), nude, supine (lying flat on her back) on her bed with Resident #2 (male), nude, lying on top of her having intercourse. The nurse removed Resident #2 from Resident #1's room. This incident occurred at approximately 9:30 p.m. The nurse and CNA #1 assessed Resident #1 for marks and bruising and placed a clean brief onto the resident. They placed the resident in bed, under the covers and left the lights on in the room. The physician, the NHA (nursing home administrator), the DON (director of nursing) and both residents' power of attorneys (POA) were notified. Upon arrival to the facility by the NHA, Resident #1 had no recollection of the incident. Resident #1 was transferred to the hospital, within one hour of the incident. At the hospital, a SANE (sexual assault nurse examiner) exam was completed and the police were notified. Resident #2 was placed on one-to-one supervision immediately following the incident and then transferred to a secured room, with a security guard, at the hospital. Staff were notified of the event, monitoring was put in place for Resident #1. B. Resident #2 interview Resident #2 was interviewed by the NHA and assistant director of nursing (ADON) in the hospital. Resident #2 said he and Resident #1 were having fun, laughing, chatting and watching television in the common area together. He said they went to her room. Once they were in the room, he said Resident #1 started getting flirty and I accepted it. She was being touchy feely, putting her hands on my neck and touching my hair and rubbing my leg. Resident #2 said he then got out of his wheelchair and sat on the edge of her bed. The female resident then got out of her wheelchair (he said he had to help her) and sat next to him on the bed. He said she continued to act interested by fondling him. He said they both helped each other take off their clothes, got onto the bed and began to get intimate. When asked if he asked the female for consent to take her clothes off, he said he did not. When asked if he had any knowledge or understanding about the female resident's cognitive ability to consent to sexual acts, he said it had never crossed his mind. C. Timeline of events based on the camera footage On 2/13/24, the facility determined a timeline of events based on camera footage: -At 5:53 p.m. Resident #2 entered Resident #1's room. Resident #1 was not in her room. -At 5:54 p.m. Resident #2 exited Resident #1's room with her rabbit. He went down the hallway where Resident #1 was and gave her the rabbit. She smiled and hugged the rabbit. -At 5:55 p.m. Resident #1 went into her room alone and came back out at 6:51 p.m. -At 6:54 p.m. Resident #2 went to her room and grabbed her rabbit again and gave it to Resident #1 in the common area. -At 7:14 p.m. both residents started down the hallway toward Resident #1's room. -At 7:14 p.m. and 52 seconds, Resident #2 entered Resident #1's room. Resident #1 stayed out in the hallway. -At 7:18 p.m. CNA #1 spoke with Resident #1 in the hallway. -At 7:19 p.m. Resident #1 entered her room. Resident #2 was still in the room. -At 8:08 p.m. CNA #1 checked on Resident #1 and Resident #2. He reported both residents were sitting in their wheelchairs watching television. -At 8:19 p.m. the nurse entered the room to administer medications. She reported that both residents were sitting in their wheelchairs watching television and talking to one another. -At 9:23 p.m. (over an hour later), CNA #1 entered the room (the door was closed) and then immediately exited the room to get the nurse. Both CNA #1 and the nurse then re-entered the room and removed Resident #2 from the room. II. Facility correction A. Immediate action The NHA, police department, adult protective services, each resident's POA and physicians were notified appropriately. Upon arrival at the facility, the NHA noted that the victim did not have any recollection of the incident and was confused about why she was going to the hospital. Resident #1 was transferred within one hour to the hospital for assessment and a SANE exam. The NHA accompanied Resident #1 to the hospital until the POA arrived. No further interventions were required during the hospital visit. Resident #2 was placed in his room with one-to-one supervision. This continued but was unsustainable at the facility long term. He was considered a risk to other residents' safety and well-being. The POA was notified of the incident. He was transferred to the hospital with one-to-one care within a few hours of the incident. An immediate discharge notice was delivered in person on 2/14/24, which was signed by the resident and POA. Administrative staff at the facility worked with the case management at the hospital to find an appropriate placement for Resident #2. The Risk Management Team from the health system was brought in for guidance. The team included the CEO (chief executive officer), the chief medical officer, the NHA, the assistant NHA, risk management, the quality director, the DON, the ADON and the physician. The incident, including the interventions, were presented at the Quality and Outcomes committee. All interviewees were cooperative with the investigators. Staff interviewed who witnessed the incident. Resident #1 was not able to recall the incident. Resident #2 was interviewed on 2/14/24. Resident #1 returned to the facility within 24 hours of the incident. Staff were notified of events, monitoring to be conducted and new protocols put in place within 36 hours of the incident. B. Interventions put into place A risk management module in the electronic medical record (EMR) was utilized effectively for documentation of communications around the incident. Fifteen minute checks were implemented upon Resident #1's return. This was in an effort to monitor for signs of trauma or psychosocial behaviors that may be attributed to trauma. Repeated assessments of well-being displayed no signs of trauma or behaviors. After five days, the 15 minute checks were discontinued. The care plan for Resident #1 was updated to address behavioral health needs, trauma informed care and potential triggers. Effective immediately new protocol: Residents are allowed to be in each other's rooms, as long as both residents consent. The door must remain open at all times and staff will round on them frequently. If residents do not have the ability to consent, they will not have other residents in their rooms. Notify the NHA for further assessment if questions arise. The administrative team compiled a list of vulnerable residents who may have increased risk for abuse. After a thorough review of this list, it was decided to have all residents have a complete skin assessment to look for possible injury of unknown origin, particularly in the peri-area (private area). This was decided to make sure nothing was missed or overlooked. This was operationalized with the next bath for each resident. Staff were made aware of the situation, what to be watching for in regards to other potential victims and Resident #1's potential behaviors. The NHA had conversations with other senior care agencies and advocates to help with suggestions around protocols or policies that should be considered. Assessments of other residents were completed and abuse training for all staff and training for all residents at resident council: how to feel safe, is the facility addressing safety and facility response to safety timely. Added resident to resident interactions to the weekly risk meeting agenda with the interdisciplinary team (IDT). C. Resident #1 adjustments to the comprehensive care plan The trauma informed care plan, initiated on 10/16/23 and revised on 3/5/24, documented the resident had a history of trauma related to a previous marriage. It indicated the resident had potentially been the victim of a sexual assault, which had potential to cause psychosocial harm. The interventions included being sensitive when providing personal care and contacting behavioral health services and the physician if the resident showed signs and symptoms of distress. -It indicated that the facility had reached out to a therapist about doing a mental health evaluation for the resident following the potential sexual assault incident. The therapist advised against labeling trauma for the resident and that a mental health consult should only be done if the resident expressed fear, grief, regret or trauma about the incident. At this time, the resident did not remember the sexual assault incident, did not speak about the sexual assault incident and had not expressed any of the above emotions. III. Resident #1 A. Resident status Resident #1, age 72, was readmitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and major depressive disorder. The 2/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent with upper and lower body dressing, personal hygiene and substantial assistance with walking. She required partial to moderate assistance with lying to sitting on the side of the bed, sit to stand, chair to bed transfer and toilet transfer. The resident did not exhibit any behavioral symptoms during the assessment period. B. Record review The activities of daily living (ADL) care plan, initiated on 9/28/23 and revised on 10/5/23, documented the resident had self-care needs. It indicated she required partial assistance from staff to turn and reposition in bed and transfers and maximal assistance by staff to dress and for personal hygiene. The communication care plan, initiated on 9/28/23 and revised on 10/5/23, documented the resident had communication impairment related to dementia and had difficulty in word finding. The interventions included anticipating and meeting the resident's needs; asking yes or no questions; encouraging the resident to continue stating thoughts even if the resident was having difficulty focusing on a word or phrase that made sense; gaining attention before talking; and observing facial expressions and body language and attempt to interpret. The cognitive impairment care plan, initiated on 10/16/23, documented the resident had cognitive impairment and impaired thought processes related to dementia. It indicated the resident participated in a cognitive assessment and scored a three out of 15, which indicated severe cognitive impairment. The interventions included asking the resident yes or no questions; cueing, reorienting and supervising as needed; providing the resident with a homelike environment; and reminiscing by using photos of family and friends. IV. Resident #2 A. Resident status Resident #2, age younger than 65, was admitted on [DATE] and discharged to the hospital on 2/13/24. According to the February 2024 CPO, diagnoses included Parkinson's disease with dyskinesia (movement disorder that often appears as uncontrolled shakes, tics or tremors) and major depressive disorder. The 1/22/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He was independent with all ADLs. It indicated the resident did not exhibit any behaviors during the assessment period. B. Record review The cognitive care plan, initiated on 10/27/23, documented the resident participated in a cognitive assessment where he scored 13/15, which indicated he was cognitively intact. The behavioral care plan, initiated on 10/27/23 and revised on 2/19/24, documented the resident had impulsivity issues, had been known to wander, reject care and take items that did not belong to him. He had a reported history of gambling. It indicated the resident's impulsivity was heightened when he felt he was not getting enough attention. The interventions included assisting the resident to develop more appropriate methods of coping and interacting; encouraging him to express his feelings appropriately; providing opportunity for positive interaction, attention; stopping and talking to the resident as you passed by; intervening as necessary to protect the rights and safety of others; approaching and speaking in a calm manner; diverting attention; removing the resident from the situation and taking to an alternate location as needed; praising any indication of the resident's progress/improvement in behavior; and providing a program of activities that was of interest and accommodates the resident's status. The adjustment care plan, initiated on 11/2/23, documented the resident was having difficulty adjusting to his admission affecting his psychosocial well-being. He reported having a hard time accepting the fact that he lived in a nursing home at his young age and he felt lonely. The interventions included encouraging the resident to participate in activities of choice; encouraging the resident to participate in conversations with staff and other residents daily; encouraging ongoing family involvement by inviting the resident's family to attend special events, activities and meals; and introducing the resident to other residents with similar backgrounds, interests and facilitating interactions. V. Staff interviews The NHA, the ADON and the DON were interviewed on 4/1/24 at 5:15 p.m. The DON said Resident #1 and Resident #2 were friendly but not necessarily friends. She said they were more like acquaintances. She said they both participated in group activities and spent a lot of time in the common area. The DON said Resident #2 had sat with Resident #1 and her husband in the common area. The NHA said CNA #1 was aware Resident #1 and Resident #2 were in Resident #1's room. CNA #1 had reported the door must have closed at some point when he was assisting other residents. The NHA said the residents had not been checked on for over an hour. The NHA said CNA #1 entered the room to put Resident #1 to bed and saw both residents nude with Resident #2 on top of Resident #1. She said CNA #1 did not immediately ensure Resident #1's safety but instead went and got the nurse. She said CNA #1 was in shock and apologized for leaving to get the nurse. The NHA said she accompanied Resident #1 to the hospital. She said Resident #1 had no recollection of the incident and was unsure as to why she was going to the hospital. She said Resident #1's POA came and that was when consent was obtained for the SANE exam. The ADON said Resident #1 had not experienced any trauma from the incident. She said Resident #1 had not exhibited any changes in behavior. She said when they referred the resident for a mental health evaluation, the mental health practitioner said she would not complete the evaluation if the resident did not remember nor spoke anything about the incident. She said she would not want to re-traumatize the resident. The ADON said the facility monitored Resident #1 every day with no negative results observed. The NHA and the DON said Resident #1 and Resident #2 should not have been left alone in the room with the door closed for an hour. They said someone should have seen that the door had been closed and checked on both residents. The NHA said Resident #2 was placed under one-to-one supervision and immediately transferred to a room at the hospital with a security guard monitoring. She said Resident #2 was presented with an immediate discharge notice from the facility. She said the facility worked with the hospital discharge planners to find an appropriate facility. The NHA said the facility implemented a policy that any resident who had cognitive impairment was not able to be in a room with a cognitively intact resident with the door closed. She said meetings would be held with the residents' responsible parties to determine if residents could be left alone. The social services director (SSD) and the activity director (AD) were interviewed on 4/2/24 at 9:16 a.m. The AD said Resident #2 was a well-known member of the community. She said he was very outgoing and very social. She said he usually exhibited behaviors after a negative interaction with his spouse. The AD said Resident #2 saw a therapist regularly and had peer support. She said he attended group activities and loved games such as BINGO, cards and baking. The SSD said Resident #1 and Resident #2 ate in the dining room but did not remember seeing them eating at the same table. She said she did not remember them ever really interacting together privately. The SSD said Resident #1's husband would come to the facility every day. She said he would sit in Resident #1's room and watch television. She said they did this almost daily. She said Resident #1 and her husband would hold hands.

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19 in three of three resident neighborhoods. Specifically, the facility: -Failed to ensure proper storage of soiled personal protective equipment (PPE); -Failed to ensure proper doffing (removal) of PPE according to facility policy and Centers for Disease Control and Prevention (CDC) guidelines; and -Failed to ensure adequate supply and availability of alcohol based hand sanitizer. Findings include: I. Professional standards A. Personal protective equipment (PPE) According to the CDC's Using Personal Protective Equipment, reviewed 4/3/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html, How to Take Off (Doff) PPE Gear: Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle.* Healthcare personnel may now exit patient room. Perform hand hygiene. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles. Remove and discard respirator (or facemask if used instead of respirator). Do not touch the front of the respirator or facemask.* Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is [MEDICATION NAME] reuse.* B. Hand sanitizer According to the Colorado Department of Public Health and Environment COVID-19 Preparation and Rapid Response Checklist for Long-Term Care Facilities, revised 4/24/2020, in pertinent part: Ensure adequate hand hygiene supplies: Put alcohol-based hand sanitizer with 60-95% alcohol in every resident room (ideally both inside and outside of the room). II. Facility policy and procedure The Droplet Precautions policy, revised 1/27/2020, provided by the director of nursing (DON) on 5/4/2020 at 2:23 p.m. read: droplet precautions shall be used in addition to standard precautions for residents with infections that can be transmitted by droplets. Droplet transmission involves contact with the conjunctiva or mucous membranes of the nose or mouth of a susceptible person with large particle droplets containing microorganisms generated from a person who has clinical disease or who is a carrier of the microorganisms. Droplets may be generated by the residents coughing, sneezing, talking or during performance of procedures, for example, suction of the oral cavity or [MEDICAL CONDITION]. Section C of the policy and procedure for gown use read in part: a gown should be donned prior to entering the room or resident's space, the gown should be removed prior to leaving the resident's room, and after removal of the gown the caregiver should use caution so that clothing does not come into contact with potentially contaminated surfaces or equipment. III. Observations A. PPE Environmental services assistant (EVS) #1 was observed on 5/6/2020 at 11:30 a.m. exiting an isolation resident room on the Van Tuyl resident hallway. The staff member exited the resident room with her gown still on and was standing outside of the resident door with a contaminated gown. She then doffed her gown in the hallway and put the gown in a trash bag tied to her housekeeping cart. Registered nurse (RN) #1was observed exiting an isolation resident room on 5/4/2020 at 12:26 p.m. The RN exited the room and doffed her gown outside of the resident room in the hallway and then carried the gown to a hamper being stored in the hallway. Certified nurse aide (CNA) #2 was observed exiting a resident isolation room on the(NAME)Park resident neighborhood on 5/4/2020 at 1:00 p.m. She exited the room still wearing her isolation gown and doffed the gown outside of the room in the hallway. She disposed of the gown in a hamper located outside of the resident room in the hallway. A tour of the facility of all three resident neighborhoods completed on 5/4/2020 at 11:30 a.m. showed hampers with soiled isolation gowns in the resident hallways. B. Hand sanitizer Observations throughout the facility on 5/4/2020 from approximately 11:00 a.m. to 2:00 p.m. revealed there was no hand sanitizer in resident rooms. III. Staff interviews RN #2 was interviewed on 5/4/2020 at 11:34 a.m. She said the process for doffing gowns was to do it at the doorway inside the room, then roll the gown up and walk it in the hallway to the nearest hamper. She said there was not a hamper for the soiled gowns inside the residents' rooms. EVS #1 was interviewed 5/4/2020 at 11:36 a.m. She said she had received training on PPE procedures which included doffing of gowns. She said it was hard for housekeeping staff to take the gowns off in the room because they had all their stuff (cleaning products and equipment), so she took her gown off in the hallway outside the resident doorway. She said she disposed of her gowns in the garbage bag attached to her cart. CNA #4 was interviewed on 5/4/2020 11:38 a.m. She said the process for staff to remove gowns was for staff to remove them inside the resident room at the doorway, then wrap them up and dispose of them into a linen hamper in the resident hallways for laundering and reuse. CNA #1 was interviewed on 5/4/2020 at 11:41 a.m. She said she had been trained on proper PPE usage including donning and doffing. She said the process was to remove used gowns inside the resident room at the doorway then roll them up and put them inside of the blue linen bags outside of the room in the hallways. RN #1 was interviewed on 5/4/2020 at 11:48 a.m. She said staff were to dispose of the gowns in the hallway inside one of the blue bagged linen hampers. She said only residents who were COVID-19 positive would have the bags inside the room to dispose of the gown inside the room. LPN #1 was interviewed on 5/4/2020 at 11:57 a.m. He said all residents in the facility were considered to be on active transmission based precautions. He said in the past he had alway been trained to remove PPE inside the resident room at the doorway and dispose of it inside the resident room, but he was not sure why gowns were being disposed of in the hallway. CNA #2 was interviewed on 5/4/2020 at 1:00 p.m. She said she had been trained by the DON to remove gowns inside the resident room at the doorway, and that was the proper way to do it. CNA #5 was interviewed on 5/4/2020 at approximately 1:30 p.m. She said when she left resident rooms on the Van Tuyl hall she had to carry her gown and goggles halfway down the hall to dispose of the gown in a linen bin and get a disposable disinfectant wipe to clean her goggles. She pointed to a linen cart midway down the long hallway with disinfectant wipes nearby. She acknowledged she was having to wear two soiled pieces of PPE (gown and goggles) out of each resident room after providing care. She said they did not have disinfectant wipes any closer than that on the Van Tuyl hall. She acknowledged and it was observed that there was no hand sanitizer in the resident rooms. The DON and nursing home administrator (NHA) were interviewed on 5/4/2020 at 2:25 p.m. The DON said all residents in the facility were on contact/droplet isolation precautions. She said because the facility was using fabric gowns they were disposing them outside of the rooms and taking them to the laundry bins in the hallway. She said the gowns were being used only once, single use, and then put in the laundry bins, and staff were not reusing gowns for each episode of entering the resident rooms. The NHA said they would have liked to keep the soiled gowns in the resident room, but they did not have enough laundry bins for each room. She said they had tried to acquire the laundry bins but they did not have enough. She said she had concerns about putting the hospital laundry bags in each resident room for PPE disposal because of concerns with housekeeping and cross contamination as they collected the bags, so she decided against that. The NHA was interviewed on the afternoon of 5/4/2020 and by phone on 5/5/2020 at 1:00 p.m. She acknowledged there was no hand sanitizer in the resident rooms, and that they were unable to get sufficient hand sanitizer to do so. She said the facility was in crisis use for hand sanitizer and disinfecting wipes.

Based on observations, record review and interviews, the facility failed to prevent pressure injuries for one (#25) of two residents reviewed for pressure injuries out of 25 sample residents. The facility failed to assess and implement interventions for a newly placed medical device (knee brace). The facility further failed to regularly assess Resident #25's skin integrity underneath the knee brace after she was deemed to be high risk for pressure ulcer development. These failures led to the development of an unstageable pressure ulcer to the resident's right lower extremity caused by the leg brace. The pressure ulcer caused the resident to experience pain in the wound area as well as to endure painful dressing changes. Findings include: I. Facility policy and procedure The Pressure Injury Prevention-Long Term Care policy, reviewed 6/14/2019, provided by the director of nursing on 3/11/2020 at 4:23 p.m. read, review the residents medical record, including previous medical history, comorbid conditions, medications, and skin conditions, to identify [MEDICATION NAME] and extrinsic risk factors for pressure injuries. Regularly assess and inspect the residents skin, including skin color, temperature, texture or turgor, integrity, and moisture status. Focus on such high risk areas such as bony prominences, areas of [DIAGNOSES REDACTED], and areas under medical devices. II. Resident #25 status Resident #25, age over 70, was admitted on [DATE]. According to the March 2020 computerized physician orders, [DIAGNOSES REDACTED]. According to the most recent minimum data set (MDS) assessment completed 1/7/2020, the resident scored a seven out of 15 on the brief interview for mental status (BIMS) exam, indicating severe cognitive impairment. The resident required extensive physical assistance of two-plus staff for bed mobility, and was totally dependent on staff for transfers. Based on a formal and clinical assessment the resident was at risk for the development of pressure ulcers, but did not have any current or non healing pressure injuries of any stage. III. Record review Progress notes prior to wound development A nursing progress note, dated 1/1/2020 at 8:47 p.m., showed the resident was complaining of right knee pain all day shift per the nurse aide. The resident stated her knee felt better after a cold pack was placed on her knee for 10 minutes and Tylenol was administered. The nurse notified the resident's daughter of the pain. A nursing note on 1/2/2020 at 11:13 a.m. showed the resident was complaining of severe pain that morning. The physician was called and notified, and they increased the resident's Tylenol to 1000 mg three times a day. The daughter was called and requested that something more be done for the resident's pain. A physician progress notes [REDACTED].#25 was complaining of pain in the right ankle joint, and they were unsure of the etiology. There was no rash or evidence of infection or specific evidence of fracture. An orthopedic referral was made and the physician noted to send the resident to the emergency room if the signs or symptoms worsened, returned, changed, or any new symptoms developed. On 1/3/2020 at 11:09 a.m. a nursing progress note showed a licensed practical nurse (LPN) requested the registered nurse (RN) assess the resident as she was not doing well. Upon assessment it was noted the resident complained of pain when the RN moved the resident's right lower leg. The right lower leg was noted to be hot to touch with bruising behind the right knee and old bruising to the right shin. The right leg was slightly larger than the left leg. The RN notified the physician and the power of attorney and the decision was made to transport the resident to the emergency room for evaluation. A nursing progress noted on 1/3/2020 at 9:42 p.m. showed the resident returned to the facility from the ER. The report from the hospital documented the resident had a [MEDICAL CONDITION] tibia and fibula around the old hardware (past surgery) in the knee. A skin assessment was performed with no new areas except for bruising on the right knee. The resident exhibited increased pain and was given PRN [MEDICATION NAME]. A physician progress notes [REDACTED]. The physician had consulted with the orthopedic physician who recommended it was ok to weight bear if able, but not if causing pain; and ok to pivot transfer but not if causing pain; and a brace for comfort, otherwise not necessary. B. Braden scale The resident's quarterly Braden Scale for predicting pressure sore risk, completed 1/2/2020, scored the resident an 11, at high risk for the development of pressure injuries related to very limited sensory perception, occasionally moist, chairfast, completely immobile, probably inadequate nutrition, and a problem with friction and shearing. C. Wound documentation 1. Weekly wound observation assessments A weekly wound observation assessment, dated 1/31/2020, showed the first documentation of the wound acquired in the facility on the posterior right calf. The wound was specified as a device related pressure injury. The measurements were noted to be 34 mm x 15 mm x 0 mm with 25% slough and/or necrotic tissue present. There was no odor, but a moderate amount of serous drainage was noted. A comment on the observation assessment documented the resident was in a brace status [REDACTED]. However, upon removal, a small abrasion was noted. (The order from the physician was for comfort, otherside not needed. There was no order to not remove the brace.) The wound observation note read the wound was new and to request wound care orders and to cover until orders were received (wound care orders were not placed until 2/11/2020, 11 days later). The next weekly wound observation assessment, dated 2/14/2020 (no wound observation for the previous week), documented the wound was still with 25% slough and necrotic tissue with measurements of 32mm x 12 mm x 0 mm. There was moderate serosanguinous drainage and no odors. The weekly wound assessment, dated 2/21/2020, showed the wound was with slough and granulation tissue and no odor. Measurements were 32 mm x 12 mm with 25% necrosis or slough and moderate serosanguinous drainage. The weekly wound assessment, dated 2/28/2020, showed the wound measurements as 37 mm x 2 mm x 0 mm. The wound bed was 75% slough or necrosis with no odor and moderate serous drainage. The weekly wound assessment, dated 3/6/2020, showed the wound was 45mm x 20mm x 2 mm with 75% slough and moderate serous drainage and no odor (see dressing change observation below). 2. Skin observation tool noting areas of concern The skin observation tool to be completed by a licensed nurse showed the following: -12/30/2019: skin clean, dry, and intact, (old) left shin wounds freshly dressed. No other concerns at this time. -1/4/2020: skin in good condition, no bruising or skin tears noted. -1/27/2020: skin dry and intact, bruising noted to left shin and left lower extremity, red area to back of lower left leg. (There were no documented skin observations between 1/4/2020 and 1/27/2020 provided.) -2/3/2020: right heel breaking down with 1 cm in diameter; scab above right heel 2x4 cm. -2/10/2020: scab above back of right ankle, 1 cm x 2 cm -3/2/2020: right heel is dry and pink, purplish red area to side of right foot just below the 5th toe, wound to right calf, redness under left breast. -3/9/2020: skin clean, dry, and intact; redness beneath left breast, will apply as-needed [MEDICATION NAME]. D. Care plan Resident #25's care plan, initiated 6/13/2015 and most recently revised on 3/6/2020, documented the resident was at risk for impaired skin integrity, skin tears, and pressure ulcers related to fragile skin, limited mobility, incontinence, and the resident enjoyed lying in bed for long periods of time. Interventions on the care plan included: -2/11/2020: wound nurse to evaluate right leg injury as ordered; -3/6/2020: treatment as ordered to the right posterior calf. There were no interventions noted on the care plan related to the knee brace. The resident's actual skin breakdown and skin condition were not documented in the care plan. The care plan did not address pain management related to the resident's wound. E. physician's orders [REDACTED].>The physician ordered on [DATE] for the resident to wear a brace for comfort, otherwise not necessary. There were no orders not to remove the brace, or to remove the brace regularly to assess the resident's skin condition. Wound orders dated 2/11/2020 documented, Right posterior calf wound; cleanse with dermal wound cleanser or saline and apply therahoney to wound base. Cover with optimfoam and change on bath days or three times a week (there were no wound orders prior to 2/11/2020). Pain medication ordered for the resident was noted to be [MEDICATION NAME] 5 mg, give 0.5 tablet every 8 hours for pain as needed. The resident was also receiving [MEDICATION NAME] 1000 mg three times a day for pain, regularly scheduled. F. Wound care nurse consult notes and physician note The wound nurse consult note, dated 2/11/2020, showed the resident had a 3.5 cm x 2 cm area of black, dry, adherent eschar to the posterior calf. There was slight periwound [DIAGNOSES REDACTED] and slight induration of about 0.1 cm around the wound. There was no branching [DIAGNOSES REDACTED], odor or drainage noted. From the history it could be determined that this was a medical device related unstageable pressure injury from the knee brace. This was the only documented visit from the consulted wound care nurse; no other visits were noted. A physician progress notes [REDACTED]. The physician noted the pressure ulcer was to the right calf. A physician progress notes [REDACTED]. No new orders were placed. The physician's note referenced the poor healing of the existing wound; it did not say the wound was caused due to poor vascular status. The wound nurse (on 2/11/20) and physician (on 3/4/20) both documented (see above) that the resident's wound was an unstageable pressure injury. IV. Wound observation/resident interview A dressing change was observed with RN #1 and the DON on 3/11/2020 at 11:15 a.m. RN #1 said she attempted to premedicate Resident #25 prior to the dressing change but she had refused (this was not documented in the Medication Administration Record [REDACTED]. RN #1 removed the old dressing from over her wound, and as she removed the dressing, green slough was pulled with the dressing. The resident was complaining of pain and jumping as RN #1 removed the dressing. The wound was over the resident's right Achilles tendon area and leading up to the lower aspect of the posterior calf. RN #1 went to cleanse the wound with a 4x4 gauze soaked in wound cleanser, and the resident was jumping in bed yelling no! repeatedly. RN #1 then applied [MEDICATION NAME] and the new dressing, and the resident was yelling please don't! and kicking and jumping in the bed. RN #1 did not offer pain medication in response to the resident's pain, during or after the dressing change. Resident #25 was interviewed on 3/9/2020 at 2:59 p.m., before the observed dressing change above. She said she had a wound on her right foot that caused her really bad pain, and they gave her Tylenol for the pain. She said the Tylenol helped thank god, cause I wouldn't know what to do without it. Resident #25 was interviewed again on 3/11/2020 at 5:23 p.m., several hours after the dressing change observation. She said the pain was in her right heel and the back of her leg, and the pain was terrible. She said it hurt at a level of 8 or 9 (out of 10) and the Tylenol they gave her helped bring it down to two or three. V. Staff interviews RN #1 was interviewed on 3/11/2020 at 11:25 a.m. She said Resident #25 would complain of pain in the mornings and she would usually take her pain medication. She said the resident would say her heel hurts her but she would touch her heel and the resident would not complain of pain. She said the resident's pain was in the wound area, not the heel. She said the resident complained of pain during dressing changes as well. She said the wound looks pretty yucky but she guessed it was getting better (although per documentation it was larger and deeper). She said the resident had a fracture and then a knee brace which was rubbing and then some necrotic tissue followed. She said the brace was for comfort but was always on when she worked. She said she thought they took it off at night and for her baths and skin assessments. She reiterated the brace was just for comfort. RN #2 was interviewed on 3/10/2020 at 2:48 p.m. She said she thought the wound was from the brace she was wearing after her injury as it was resting on the back of her leg. She said they were doing repositionoing and floating her leg and feet, but they should have been doing skin assessments under the brace. She said she had not been doing those when she worked because she had to cover both hallways when there were only two nurses working and it was not manageable to do all that. She said she did not have the time to do the skin assessments on the resident. She said the brace was always on when she worked and she was unsure if they took it off at night. She said the brace had been discontinued when the wound was discovered. Life enriching care aide/certified nurse aide (LEC) #3 was interviewed on 3/11/2020 at 2:19 p.m. She said they had put a huge brace on Resident #25 after her fracture and it was just rubbing on her leg. She said it had gotten to a point where there was ooze from the wound on the brace. She said the brace was on all the time, and they would only remove it when they got her dressed. She said they would put the brace over her clothes as well. She said the brace would even rub when the resident was in the wheelchair, and they should have been assessing the skin but she was not sure if they were. The physical therapist (PT) was interviewed on 3/12/2020 at 9:19 a.m. She said the resident was in a hinged knee brace that was monitored by nursing, which she believed they threw away after it was soiled. She said she was the staff member who first identified the wound when they were looking at her toes, and she saw the necrotic area. She said it started as friction from the device (knee brace). She said it was acquired in the facility and may have initially started as a deep tissue injury but was currently a decub (decubitus ulcer). She also said she thought it should be stageable at this point. The DON was interviewed on 3/12/2020 at 9:59 a.m. She said Resident #25 had a fracture and initially afterwards was wearing a leg brace at all times (there was no documentation to support the brace to be worn at all times), but the order was later changed for comfort. She said they performed a skin assessment after removing the brace and there was an abrasion; however, the wound care and physician notes reflect differently. She said they needed to keep the brace off at that point. She said the resident was at risk for developing pressure injuries due to her self limiting behaviors. She said Resident #25 suffered from chronic pain and hallucinations, and the resident had apparently eaten oxy ([MEDICATION NAME]) like it was candy prior to her coming to the facility. She said the resident's skin was assessed weekly routinely, with the brace on as well. She said there were no additional assessments for when the brace was put on. She said the wound was just a surface layer friction area that was reddened, similar to a rug burn. She said it was the device (the knee brace) that caused the resident's wound and the wound nurse had concurred. She said no new assessments or interventions were put in place for the knee brace other than the weekly skin checks and ensuring circulation. She said the charge nurse was responsible for assessing residents' skin and on a weekly basis. She said the resident had requested to keep the knee brace on at times. The DON said Resident #25 did complain of pain at the wound site during dressing changes, and that's when she was notified. She said they were treating the resident's pain with [MEDICATION NAME] and it typically was effective. She said the resident had spit out her meds the day of the wound observation.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to prevent the spread of infection in one of three neighborhoods. Specifically, the facility failed to: -Implement appropriate hand hygiene practices and glove use while providing activities of daily (ADL) care to Resident #26; and -Implement appropriate hand hygiene practices during housekeeping cleaning tasks on the(NAME)Park neighborhood. Findings include: I. Professional standard According to the Centers for Disease Control and Prevention's Hand Hygiene in Healthcare Settings, retrieved from https://www.cdc.gov/handhygiene/providers/guideline.html, on 3/16/2020 and dated 1/30/2020, the guidance included the following recommendations: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: ·Immediately before touching a patient ·Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices ·Before moving from work on a soiled body site to a clean body site on the same patient ·After touching a patient or the patient's immediate environment ·After contact with blood, body fluids, or contaminated surfaces ·Immediately after glove removal When using alcohol-based hand sanitizer (ABHS): -Put product on hands and rub hands together -Cover all surfaces until hands feel dry -This should take around 20 seconds When cleaning with soap and water: -When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. -Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. -Avoid using hot water, to prevent drying of skin. -Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. -Either time is acceptable. The focus should be on cleaning your hands at the right times. II. Hand hygiene during ADL care A. Observations On 3/9/2020 at 3:52 p.m., ADL care was observed for Resident #26. Life enriching care/certified nurse aides (LECs) #8 and #7 entered the room, sanitized their hands and donned disposable gloves. They turned the resident onto his left side and he had been incontinent of stool. LEC #8 removed his adult incontinence brief, provided peri care, and then doffed her soiled gloves and placed them in the trash. At 3:55 p.m., LEC #8 reached into her scrub top pocket, retrieved a clean pair of gloves, and without washing or sanitizing her hands, donned the clean pair. She applied barrier cream to the resident's bottom and then placed a clean incontinence brief underneath him. They turned the resident onto his back and provided peri care again, from the front. LEC #8 touched the bed control with her gloved left hand and lowered the head of the bed. The LECs pulled the resident up in bed and then LEC #8 touched the bed control again and raised the head of the bed. LEC #8 placed a pillow under the resident's knees and they positioned him onto his left side, placing a pillow behind his back. Without washing or sanitizing her hands, LEC #8 touched the bed control again with her soiled gloves and raised the resident's head of the bed further. At 3:58 p.m., LEC #8 doffed her gloves and threw them in the trash. The phone in her pocket rang and she silenced it without washing or sanitizing her hands first. She removed the trash liner from the trashcan and carried it into the bathroom. She opened a cupboard to check the supplies and then she left the room without washing her hands. B. Staff interviews LEC #2 was interviewed on 3/12/2020 at 10:26 a.m., and he confirmed he routinely worked with Resident #26. He said when ADL care was provided for residents, staff should remove their gloves after they were dirty, wash or sanitize their hands, and then don clean gloves. He said cross contamination could occur if hands were not washed after soiled gloves were removed and before donning a clean pair. He said he had not received any additional hand hygiene training related to the COVID-19 pandemic other than the basic reminders for handwashing. The director of nurses (DON), who was also the infection control preventionist, was interviewed on 3/12/2020 at 10:32 a.m. She clarified the facility had implemented a new screening process related to the COVID-19 pandemic for all vendors and families who entered the building, and had handwashing stations set up at the front and back doors. She explained staff who simply entered the community had to wash their hands upon entrance now and she had started a tracking log for ill staff's absences. The DON said education on hand washing was typically provided to LECs upon hire, annually, and more frequently if she saw a need. She said a family member had shared a concern recently that a staff member had not washed their hands during peri care or in between changing gloves. She said she provided additional handwashing training on 3/6/2020 that required a return demonstration from staff. She said when staff washed their hands with soap and water they should scrub their hands for a minimum of 20 seconds. The DON said she had worked with LECs in the past regarding Resident #26's peri care, and explained the staff might be kept in the resident's room for long periods of time because he had frequent bowel movements. She explained they would provide peri care and then he might immediately have another bowel movement that would require care. She said LECs should wash or sanitize their hands before donning clean gloves. III. Hand hygiene during housekeeping cleaning procedures A. Observations On 3/11/2020 at 10:03 a.m., environmental services technician (EVST) #1 was observed cleaning the dining room, kitchenette and nurses' station of the(NAME)Park neighborhood. She was wearing gloves and wiped off a dining table. She opened a compartment on top of her housekeeping cart with a dirty gloved hand and touched the clean glove box. Before removing a new glove, she removed her soiled gloves and threw them away, then donned a clean pair of gloves without washing or sanitizing her hands. She began talking to a resident and withdrew a new cleaning wipe from a dispenser. She wiped down the bar eating surfaces, picked up placemats and wiped underneath them, then returned to her cart and threw the cleaning wipe away. At 10:08 a.m., she withdrew a new cleaning wipe and wiped down the surface of a four-top table, as well as the arms and seats of chairs. At 10:09 a.m., she doffed the soiled gloves, pushed her hair away from her face, then donned a new pair of gloves without washing or sanitizing her hands. She pushed the housekeeping cart towards the nurses' station, retrieved another cleaning cloth, and wiped down the counter surfaces. At 10:11 a.m., she returned to the cart and placed the soiled wipe in the trash, and walked to the kitchen sink and washed her hands briefly, for 10 seconds. She returned to the cart and donned clean gloves. At 10:13 a.m., she removed a broom and swept up the floor of the dining area. At 10:16 a.m., she returned to the housekeeping cart and doffed her gloves. She donned a clean pair of gloves without washing or sanitizing her hands, and then wiped down the kitchen counter and nurses' station surfaces. At 10:19 a.m., she returned to her cart, doffed the dirty gloves, and donned clean gloves without washing or sanitizing her hands. She withdrew a clean cleansing wipe and continued wiping off the kitchen counter surfaces. At 10:24 a.m., she returned to her cart, doffed the dirty gloves and donned clean gloves without washing or sanitizing her hands. She withdrew a clean cleansing wipe and wiped down the bar eating surface. At 10:26 a.m., she doffed the dirty gloves, then went back to the kitchen and opened all of the drawers and cupboards underneath and around the sink without washing or sanitizing her hands. She walked to the clean utility room, retrieved a new package of clean paper towels and restocked the towel dispenser with them without washing or sanitizing her hands. At 10:27 a.m., she returned to her housekeeping cart, donned a clean glove on her right hand and kept her left hand bare. She withdrew a clean wipe and wiped down the surface of the kitchen bar, again using her right hand. She threw the dirty glove in the trash and then pushed her housekeeping cart down to the end of the hallway without washing or sanitizing her hands. B. Staff interviews EVST #1 was interviewed on 3/11/2020 at 10:30 a.m. She said she was the floor tech (technician) for the facility that day and she was responsible for cleaning the common areas, hallways, and public restrooms. She said the facility did not always have a floor tech who worked, but there was one at least two or three times each week. She said the environmental services manager (EVSM) required them to wash their hands frequently and change their gloves often. She said each time she removed her gloves she was supposed to wash her hands. She said she did not carry ABHS on her housekeeping cart or on her person because there were so many dispensers located throughout the building. The EVSM was interviewed on the morning of 3/12/2020. She said she had seven years of hotel and hospitality experience in environmental services and had been the facility's director for approximately one year. She said the EVSTs should use hand sanitizer or wash their hands every time they removed a pair of gloves. She clarified if they had touched anything with body fluids or stool, that might require a physical handwashing with soap. Otherwise, they could just use the ABHS and put on a clean pair of gloves. She said she did most of the hand hygiene training with the EVSTs, which included telling them to use the ABHS for 30 seconds or wash their hands with soap and water for 30 seconds. She said she had received an email from CMS (Centers for Medicare and Medicaid Services) the day before that addressed measures they should take related to COVID-19, which she shared with the environmental services staff. It focused on ensuring the high touch surfaces were cleaned and she said she was happy to know it was the same things that they were already doing.

Based on record review and interviews, the facility failed to ensure one (#20) of five residents reviewed for unnecessary medications out of 25 sample residents was free from unnecessary drugs. Specifically, the facility failed to ensure [MEDICAL CONDITION] medications included evidence that informed consent was provided for and by the resident; which included evidence of education, targeted behaviors, potential side effects and correct dosage. Findings include: I. Facility policy and procedures The Initiation of a [MEDICAL CONDITION] Drug policy, reviewed January 2020, provided by the nursing home administrator (NHA) on 3/12/2020 at 11:00 a.m., documented that the resident's family was to be notified and a consent from the resident's power of attorney (POA) or responsible party must be completed. The consent should be obtained prior to the initiation of the new medication. II. Facility census and conditions The facility's resident census and conditions form, dated 3/10/20 and provided by the NHA, documented 19 residents in the facility were being prescribed antidepressant medications. III. Resident status Resident #20, age 89, was admitted on [DATE]. According to the March 2020 computerized physician orders [REDACTED]. The 1/2/2020 minimum data set (MDS) assessment revealed no brief interview for mental status (BIMS) score, but documented the resident had both short-term and long-term memory deficits. Per staff assessment, the MDS documented the resident showed little interest or pleasure in doing things, felt depressed and hopeless, displayed both appetite and sleep disturbances, had little energy, said she felt bad about herself, had trouble concentrating and was restless nearly every day during the 14-day lookback period. It documented the resident felt life was not worth living on most days of the lookback period. The resident scored 26/30 on the total severity mood scale. The MDS documented the resident was not having hallucinations or delusions. It revealed the resident was having daily behavioral symptoms not directed towards others, such as itching and picking at her skin. The resident wandered on four to six days during the seven day lookback period. The resident received an anti-depressant medication on three days during the seven day lookback period. IV. Record review A. Care plans The care plan dated 1/3/2020 documented due to Resident #20's poor short term memory, the resident could become anxious, nervous, tearful and tended to wander throughout the Blue Mesa memory care community. An intervention was to administer medications as ordered. Although the facility developed a specific care plan in relation to the use of anti-anxiety medications, the facility failed to create a specific care plan in relation to the use of antidepressant medications. B. March 2020 CPO The CPO included the following pertinent medication orders [REDACTED] -[MEDICATION NAME] (an antidepressant medication), 12.5 mg every day for anxiety disorder. This medication was ordered on [DATE]. -[MEDICATION NAME] ([MEDICATION NAME], an antianxiety medication), 0.5 mg every 10 hours for anxiety. This medication was ordered on [DATE]. (However, see below, an incomplete consent form was documented several months earlier on 10/29/19.) C. Consents for [MEDICAL CONDITION] medications The consent for [MEDICATION NAME] was signed by the resident's responsible party on 3/11/2020. The possible side effects listed on the form included drowsiness, dry mouth and fatigue. No specific target behaviors related to anxiety (per physician order) were included on the form. The incorrect dosage of 50 mg one time day was documented on the form, although the resident was currently prescribed 12.5 mg per day (see CPO above). The consent for [MEDICATION NAME], 0.5 mg Q 12 (every) hours PRN (as needed) for agitation and [MEDICAL CONDITION] was signed by the resident's responsible party on 10/29/19. No potential side effects were listed on this form. No specific target behaviors related to anxiety (per physician order) were included on the form. D. Interdisciplinary progress notes The pharmacy note documented by the director of nursing (DON) on 1/24/2020 documented Resident #20 was receiving [MEDICATION NAME], 25 mg for [MEDICAL CONDITION]. E. Staff interviews The NHA was interviewed on 3/11/2020 at 10:04 a.m. and said she did not think the facility has been requiring consents for the use of antidepressants. She said the facility had been monitoring behaviors for the use of those drugs, but she did not think they were asking for the consents. The traveling minimum data set (MDS) coordinator was interviewed on 3/11/2020 at 10:59 a.m. and said it was usually the responsibility of the social services director (SSD) or the MDS coordinator to obtain consents for [MEDICAL CONDITION] medications. She was asked if the facility had a consent for the use of [MEDICATION NAME] for Resident #20 before the resident began receiving the medication. She said the facility only requested the consent earlier that morning. She said the facility should have been requesting a consent for any [MEDICAL CONDITION] medication in use, regardless of the class of medications. She said antidepressant medications should have informed consents completed for every drug prescribed. The social services director (SSD) was interviewed on 3/11/2020 at 11:14 a.m. She said the nursing staff completed the informed consent forms for [MEDICAL CONDITION] medications. She said there should have been a consent completed for this resident for the use of [MEDICATION NAME]. The NHA was interviewed on 3/11/2020 at 11:17 a.m. She said the facility completed a consent from Resident #20's son that morning. She said she had spoken with various nurses earlier that morning and learned that the facility nurses were aware that they should be completing the informed consent form for the use of antidepressant medications. The NHA was interviewed a final time on 3/12/2020 at 10:06 a.m. She said the facility did have an action plan in place related to informed consents for [MEDICAL CONDITION] medications, but the plan was possibly lost in the background with the addition of the new DON a few months prior. She said the ongoing plan to ensure the completion of consents for medications would be a triple check on the electronic computer dashboard. She said she or the DON needed to begin monitoring the charts for new prescriptions on a daily basis. She said the second checks would be for the MDS coordinator to check when completing the admission MDS and the SSD to check when completing the PASRR (pre-admission screen/resident review) information. She said the third check would be when the facility met with their pharmacist on a monthly basis to review residents' medications.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#26 and #19) of five residents reviewed for immunizations out of 25 sample residents. Specifically, the facility failed to offer and provide the pneumococcal 23-valent [MEDICATION NAME] vaccine (PPSV23) to the residents. Findings include: I. Professional standard According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2020, retrieved from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (3/2020), the routine pneumococcal vaccination for adults aged [AGE] years or older and were immunocompetent, one dose of PPSV23 should be administered. II. Record review A. Resident #26 Resident #26, age 82, was admitted [DATE] and readmitted [DATE]. According to the March 2020 computerized physician orders [REDACTED]. The medical record for Resident #26 showed he received the pneumococcal conjugate vaccine (PCV13) on 10/11/18, but had not been offered or given the PPSV23. The 1/1/2020 minimum data set (MDS) assessment documented the resident's pneumococcal vaccine was up to date. B. Resident #19 Resident #19, age 67, was admitted on ,[DATE]. According to the March 2020 CPO, [DIAGNOSES REDACTED]. The medical record for Resident #19 showed he refused the PCV13 on 3/13/18. There was no documentation to show the resident was offered, given, or refused the PPSV23. The 12/30/19 MDS assessment documented the resident's pneumococcal vaccination was not up to date because the pneumococcal vaccination was offered and he declined. However, he was not offered the PPSV23. III. Staff interviews The minimum data set coordinator (MDSC) was interviewed on 3/12/2020 at 11:11 a.m. She said the 1/1/20 MDS assessment for Resident #26 showed his pneumococcal vaccinations were up to date and confirmed he had received the PCV13 in the past. However, she was unable to find documentation he had been offered or given the PPSV23. She said she would have to refer to the MDS requirements for the documentation and could modify and fix it if needed. The MDSC confirmed the 12/30/19 MDS for Resident #19 documented his pneumococcal vaccinations were not up to date, and had no documentation that he had been offered, given, or refused the PPSV23. The director of nurses (DON) was interviewed on 3/12/2020 at 10:32 a.m. She said residents or their representatives were asked about their immunization histories upon admission, and if they were unsure about them, the facility would ask local physicians to provide the records. She said they provided the residents with the latest vaccine information, had them sign a consent to receive them, and then provided them with the vaccine unless it was contraindicated. She said the facility had a computerized tracking sheet for the residents for the pneumococcal vaccinations and confirmed they followed the CDC's Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2020. The DON said she did not have acceptance or declination information for Resident #26's PPSV23, and confirmed he would have been eligible to receive it in November 2019. She said she became the facility's DON in mid-October 2019 and the responsibility for the pneumococcal vaccines became her responsibility when the previous MDSC left. She said it was her understanding that the PPSV23 and PCV13 needed to be administered five years apart. The DON said she did not have any documentation that Resident #19 was offered, administered, or refused the PPSV23.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and the spread of food-borne illness. The following sanitation concerns were found in two of three kitchens: -Hand washing was not performed appropriately; -Maintain the appropriate sanitation levels for kitchen cleaning solutions; -Ensure dishware was stored in a sanitary manner after washed; -Maintain cleanliness in the kitchen; and, -ensured spoiled food was disposed of timely. Findings include: I. Hand washing A. Professional standards According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended (MONTH) 15 (YEAR), effective (MONTH) 1, 2019) page 47, Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles and: After touching bare human body parts other than clean hands and clean, exposed portions of arms. B. Observations On 2/6/19 at 11:50 a.m., Cook #3 was observed while making pureed food. She touched her neck with her right gloved pinky finger and returned to making the puree without removing her gloves and performing hand washing. Cook #3 then touched above her left eye with her right gloved hand. She removed the soiled gloves and donned clean gloves without washing or sanitizing her hands. At 12:48 on 2/6/19, Cook #3 was observed leaving the steam table pantry while removing her gloves and donning new gloves without hand washing. Then she opened the freezer and touched shelves inside and removed a container of ice cream. She then served that ice cream to a resident. On 2/6/19 at 12:15 p.m., Certified nurse aide (CNA) #5 was observed assisting with serving lunch meals to residents. The CNA washed her hands in the steam table room sink then donned a hairnet while touching her hair and face. The CNA did not wash her hands after donning the hairnet and continued to serve lunch meals to residents. The CNA changed gloves at 12:27 p.m. without washing or sanitizing her hands. II. Dish storage A. Professional standard According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended (MONTH) 15 (YEAR), effective (MONTH) 1, 2019) pages 148-49 (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single use articles shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 B. Observations On 2/4/19 at 11:30 a.m., six rows of six high stacked plastic cups used to serve resident ' s water were observed to be stored on a clean utensil rack with visible moisture condensation in between the cups. On 2/6/19 at 5:20 p.m., three stacks of six high stacked cups were on the clean utensil storage rack. One row of the six was observed to have wet condensation inside the cups. On 2/7/19 at 5:20 p.m., two stacks of cups stacked six high used to serve resident ' s water were observed on the clean utensil rack. One of the two stacks were observed to be holding wet condensation on the inside of the cups. III. Spoiled foods According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended (MONTH) 15 (YEAR), effective (MONTH) 1, 2019) page 53 food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. A. Observations -On 2/4/19 at 11:28 a.m. approximately 10 spoiled limes were observed in a box on a shelf inside the walk in refrigerator. The limes were browning with fuzzy growth on them. Also observed was a box with two butternut squash that were withered and had mold growing on them. IV. Cleanliness A. Professional standard According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended (MONTH) 15 (YEAR), effective (MONTH) 1, 2019) page 139 . (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. B. Observations 1. An initial kitchen tour was conducted on 2/4/19 at 11:30 a.m. and the following was observed: -Visible debris was noted on top of the dishwashing/sanitizing machine. -Dust was observed on top of the coffee machine. -A white dried substance was crusted and caked on top of the mixer. -Two large unopened cans of chocolate pudding were on the floor being utilized as door stops to keep the dry pantry door open. -Grease runoff was observed below the stove on the floor. 2. A follow up kitchen tour was conducted on 2/6/19 at 5:20 p.m. and the following was observed: -Visible debris was noted on top of the dishwashing/sanitizing machine. -Dust was observed on top of the coffee machine. -A white dried substance was crusted and caked on top of the mixer. -A 20 liter bucket was stored on the clean dish rack with visible debris and dust in the bottom. V. Inadequate sanitizing A. Professional standard 1. According to the Colorado Retail Food Establishment Rules and Regulations, effective (MONTH) 1, 2019, p. 73; food contact and non-food contact surfaces shall be clean to sight and touch and kept free of dust, dirt, food residue and other debris. In addition, details for cleaning and sanitizing specific to equipment and chemicals used by the facility included the following (pp. 135-143): -Effective cleaning of equipment and utensils shall utilize manual or mechanical means with the use of appropriate detergents and wetting agents. -Quaternary ammonium compound (QAC) chemicals used for sanitizing shall be at a minimum temperature of 75 degrees F and be used in accordance with the manufacturer ' s instructions and the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. 2. According to the product information sheet for Oasis 146 multi-quat sanitizer, retrieved from https://www.ecolab.com on 1/26/19, the recommended dilution levels for a solution in a sanitizer pail was 150-400 parts per million (ppm). B. Observations Upon the initial kitchen tour on 2/4/19 at 11:30 a.m., the red sanitizer bucket was checked by Cook #4. The dilution level read 100 ppm, and the cook said the levels should have been between 50 to 100 ppm. -At 5:25 p.m. on 2/4/19, the sanitizer bucket was checked by the dietary manager (DM) and the level was observed to be 50 ppm. The DM said that the level should be close to 50 ppm. On 2/6/19 at 11:22 a.m., the sanitizer solution was checked by Cook #6 which read between 100 and 200 ppm. The Cook was unsure of the proper sanitizer concentration and said she had never been asked to check it before. On 2/6/19 at 5:20 p.m., the DM said the sanitizer bucket was cold and had been sitting for quite awhile and nobody would use it if it were cold. She poured a fresh bucket of sanitizer solution and tested the solution which read 150 ppm. The DM was unaware of the proper dilution level but thought it should be around 50 ppm. VI. Dietary manager interview The DM was interviewed on 2/7/19 at 12:54 p.m. The DM stated the sanitizer bucket was used to sanitize table tops and other kitchen items after they had been cleaned. She said she was unsure of the proper dilution level of the sanitizer used in the bucket. She stated she thought it was between 50 to 100 ppm, but the night prior she checked the manufacturer's instructions and found it to be 150 to 400. She said when it came out of the dispenser and was hot it is safe to use and would expect it to be at the correct level. The DM stated that the staff required training due to the dilution level being observed several times below the recommended levels. The DM said after dishes and cups were removed from the dish washing machine they should be placed and stored in an area that would allow them to be air dried. Cups would go through the dish machine in single layers and wouldn ' t be stacked until they were dry. The DM said that staff would need training to ensure cups were not being stored with wet condensation still in them. The DM said that food was labeled and dated anytime anything was opened. She acknowledge that spoiled limes were in the walk in fridge and said that they had been disposed. The DM was unaware of the spoiled squash in the refrigerator, but said that anytime spoiled food was found it should have been disposed of. The DM said that she did walk throughs to ensure that the kitchen was being cleaned and sanitized appropriately. She also said they currently did not have a cleaning schedule she was aware of, and that she would be working on creating one in the coming weeks. The DM said she would be putting together a plan and having a meeting with kitchen staff to figure out which cleaning tasks or area should be assigned to staff and when they should be completed. The DM stated the meeting and interim audits should help to ensure things like the top of the washer and the mixer were being cleaned appropriately. The DM said kitchen staff should be washing hands upon entering the kitchen. Any time something different was done that contaminated gloves, staff should take off their gloves, wash hands, and put on new gloves. The DM said that most of the staff were trained prior to her acquiring her interim dietary manager position, but that she believed staff required new or more training on hand washing. The DM said the facility had a deficit on facility specific policies and procedures for hand washing and kitchen sanitation. A hand washing policy was provided; however, the policy was for the hospital and clinically based and not specific to meal preparation or kitchen sanitation. The DM stated that the facility needed to revamp their kitchen policies due to them being very old.

Based on observations, record review, and interviews, the facility failed to ensure one (#37) of one resident reviewed for positioning of 29 sample residents received the care and services necessary to attain or maintain their highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive plan of care. Specifically, the facility failed to ensure proper wheelchair positioning and positioning at the dining table for Resident #37. Findings include: I. Professional standard According to Perry, Potter, and Ostendorf (copyright 2014), Clinical Nursing Skills and Techniques (eighth edition), page 210: Correctly positioning patients is crucial for maintaining body alignment and comfort; preventing injury to the musculoskeletal and integumentary systems; and providing sensory, motor, and cognitive stimulation. The term body alignment refers to the condition of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures. Without this balance the center of gravity is displaced, which increases the force of gravity and predisposes a person to falls and injuries. II. Resident #37 status Resident #37, age 94, was admitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/15/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, had no [MEDICAL CONDITIONS], or rejection of care. She had a weight loss of five percent or more in the last month or a loss of 10 percent or more in the last six months that was not physician prescribed. Her nutritional approaches included a mechanically altered and therapeutic diet. A. Observations On 2/4/19 at 12:18 p.m., Resident #37 was sitting in her wheelchair at a table in the dining room, leaning and slouched over to the right side with her right shoulder and cheek touching the bolster of the wheelchair. Her lunch was served to her at 12:30 p.m., and she lifted a cup with a straw independently and took a drink, while she remained slouched over. The resident was offered bites of food from staff seated at the table, but refused to eat and continued to drink the beverage. -At 12:55 p.m., licensed practical nurse (LPN) #2, sat down next to the resident and encouraged her to eat her lunch. The LPN did not attempt to reposition Resident #37 into an upright position and fed her bites of meat loaf while she was leaning over and slumped down to the right. On 2/6/19 at 12:39 p.m., Resident #37 was sitting in her wheelchair at a table in the dining room, reclined backwards slightly and leaning to the right side with her right cheek touching the bolster of the wheelchair. Her lunch had not been served yet, and she was holding a beverage in her hands, taking sips from the straw independently. -At 12:49 p.m., Resident #37 was served her meal and LPN #1 administered her medications and assisted her to eat while she remained in the reclined and leaning position. She ate approximately 25 percent of her lunch. On 2/7/19 at 12:48 p.m., Resident #37 was sitting in her wheelchair at a table in the dining room eating her lunch independently. She was leaning significantly to the right side of her chair and was slouched forward. Certified nurse aide (CNA) #7 was seated on the opposite side of the table between two other residents, assisting them with their meals. Resident #37 was not encouraged or assisted to sit upright in her wheelchair for the meal. B. Record review The care plan, initiated 12/11/15 and revised 1/2/19, identified an activities of daily living (ADL) self-care performance deficit related to poor eyesight, activity intolerance, weakness, and cognitive impairment. Approaches included providing extensive assistance with meals and she rarely ate independently. She was to sit at the table for assistive dining, enjoyed sweets, and was able to make her preferences known. The care plans were reviewed in their entirety and did not include an intervention or approach that addressed her wheelchair positioning. The Multidisciplinary Care Conference note dated 1/21/19, documented the resident required extensive assistance with eating and personal hygiene. Her appetite was fair, she received a pureed diet. She had a recent weight loss of 12 percent in the past 30 days, which was being addressed with the use of protein shakes and oral nutritional supplements in addition to her meals. The most recent quarterly therapy screening, dated 1/9/19, identified the resident was at her baseline level of function and no skilled therapy needs were identified at that time. The sections on the form titled, Wheelchair Mobility and Positioning were void of documentation. C. Staff interviews LPN # 1 was interviewed on 2/7/19 at 12:19 p.m., and she confirmed she routinely worked with Resident #37. She said when residents were seated at a dining table for meals, They should definitely be upright and close enough to the table to reach their food items. She said Resident #37 was so hard to keep upright, and said she did not know why. She said the resident was unable to feed herself and needed assistance with meals. CNAs #7 and #8 were interviewed on 2/7/19 at 1:50 p.m., and both confirmed they routinely worked with Resident #37 and knew her well. They said all residents should be seated upright at the dining tables for meals. CNA #8 said Resident #37 tended to lean to the right and her wheelchair had pillows built into each side of it to hold her upright and stated, And if that didn't work well enough, we can put pillows behind her back and on her sides. On 2/7/19 at 12:25 p.m., a request was made to speak to the facility's occupational therapist. The nursing home administrator (NHA) said the physical therapist (PT) who was routinely in the building five days each week, was currently out on vacation, but a PT from the local hospital was covering for her. The PT was interviewed via phone call on 2/7/19 at 2:56 p.m., and she confirmed residents should be sitting as upright as possible in their chairs at mealtimes, optimally at a 90-degree angle. She said she would be able to go to the facility to evaluate Resident #37 for positioning, and did not recall a positioning issue with her in the past. The PT was at the facility at 3:15 p.m., and Resident #37 was in the therapy gym with a restorative aide who was getting ready to work with her. They had positioned the resident in an upright position with good alignment in the wheelchair. The director of nurses (DON) was interviewed on 2/7/19 at 3:30 p.m. She said residents should be upright in their wheelchairs for meals, and close enough to the table so their food was within reach. She said Resident #37 had problems with leaning and had received therapy screens in the past, but staff should ensure she was in an upright position during meals.

Based on observations, record review and interviews, the facility failed to ensure it was free of medication error rates of five percent or greater. Specifically, the medication pass observation error rate was 6.45%, or two errors out of 31 opportunities for error. The findings include I. Professional standard According to Clinical Nursing Skills & Techniques, by Perry, Potter & Ostendorf, 8th Edition (copyright 2014), page 480-489: Safe Medication Administration: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation -Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication . -Follow agency policies and protocols during medication administration: do not take shortcuts. II. Facility policy and procedure The Medication Administration and General Guidelines policy, no date of inception noted, was provided by the nursing home administrator (NHA) on 2/05/19 at 10:00 a.m., and included if it was safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube fed using the following guidelines: -Long-acting or [MEDICATION NAME] coated dosage forms should generally not be crushed. Refer to the manufacturer guidelines. III. Medication errors A. Licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #242 on 2/6/19 at 8:30 a.m. The resident ' s order was for [MEDICATION NAME] Extended Release 12 hour tablet, give 600 mg by mouth two times a day for excess mucus production. The manufacturer guidelines for [MEDICATION NAME] extended release 600 mg tablets was provided by the NHA on 2/7/19 at 10:00 a.m., and included the directions do not crush, chew, or break tablet LPN #1 was observed crushing the [MEDICATION NAME] extended release tablet then administering the medication to the resident along with his other medications. The LPN was unsure if extended release [MEDICATION NAME] was a crushable medication and she had to look it up on her portable device. The LPN then said that the medication was not supposed to be crushed and she should not have crushed the medication prior to administration. B. LPN #2 was observed preparing and administering medications to Resident #15 on 2/6/19 at 3:45 p.m. The resident ' s order stated to apply [MEDICATION NAME] cream 0.5% to the resident ' s head and left ankle topically two times a day for a rash. The LPN was observed to read out loud the order for the cream and confirm the locations prior to administration. The LPN removed the resident ' sock and applied the cream to the resident ' s right ankle, then replaced the sock back onto the foot. After the medication was administered, the LPN confirmed the order again and stated that she had applied the cream to the wrong ankle and it should have been applied to the resident ' s left ankle. IV. Interviews Registered nurse (RN) # 2 was interviewed on 2/7/19 at 8:26 a.m. during medication pass. The RN said extended release or [MEDICATION NAME] coated medications should never be crushed. The director of nursing (DON) and NHA were interviewed on 2/7/19 at 10:45 a.m. The DON said to ensure medications were given as ordered, she hoped the nurses were reading the electronic medical record (EMR) and comparing it to the medications while following the Rights of Medication Administration. The DON said [MEDICATION NAME] extended release should not be crushed prior to administration, and she also said applying a topical cream to the wrong site is a true medication error.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions in one of two kitchens. Specifically, the facility failed to: -Maintain cleanliness in the kitchen; -Ensure refrigerated foods were sealed appropriately, labeled, and dated when opened; -Ensure kitchen equipment was kept in safe working order; and -Store chemicals away from food preparation areas. The findings included: I. Kitchen Sanitation A. Expectations According to the Food Code 2013, U.S. Department of Health and Human Services, page 139, Non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13), pg. 55, Nonfood-contact surfaces shall be constructed of approved materials, in good repair, and be easily maintained in a clean and sanitary conditions. B. Observations On 9/11/17 at 11:15 a.m., during the initial tour of the facility, the following was observed: -The rack in the dry storage area had dust and debris accumulation on the shelves that held utensils, plate covers, and equipment. Steam table covers were stored upside down and contained several thickener packets and discarded paper. The shelves also held the base for a blender, two coffee pots and several plate covers. -A freestanding popcorn maker was observed to have oily smudges on the inside of the glass and popcorn kernels were present in the lower portion of the machine, which needed to be cleaned. This was observed throughout the survey on 9/12/17, 9/13/17 and 9/14/17. On 9/13/17 at 12:00 noon, the dietary manager said he had cleaned out the popcorn machine. However, oily smudges and unpopped popcorn kernels remained in the lower portion of the machine. -The walk-in refrigerator contained the following items stored directly on the floor: an uncovered box of seven whole pineapples, a box of hardwood smoked bacon, whipped light cream, a box that contained four whole cabbages, a box of yogurt, and one tomato. -The ceiling in the walk-in refrigerator had dust and dirt buildup directly over the shelves where food was stored, and needed to be cleaned. Additional Observations: On 9/12/17 at 4:00 p.m., the meat slicer was stored on a lower shelf and the electric cord was wrapped around the base, and the plug was resting directly on the meat platform. On 9/12/17 at 4:00 p.m., the main kitchen area was observed to have a large trash can with a broken foot pedal. In order for staff to open the trash can, they had to manually lift the lid and contaminate their hands. On 9/12/17 at approximately 4:00 p.m., a plastic three-slotted shelving unit was sitting directly on the floor. The bottom shelf contained three glass beverage containers and their lids. The floor beneath this bottom shelf was visibly dirty with black colored dirt and grime. On 9/13/17 at 10:50 a.m., the mixer was uncovered and observed to have dried red and white food splatter on the base that needed to be cleaned. The wall behind the mixer in the food prep area had a fire extinguisher mounted on it and it was splattered with food and liquids. On 9/13/17 at 11:55 a.m., the walk-in refrigerator was observed to have a box of ground beef on a lower shelf and the box was soiled with a pool of brownish liquid. The source of the liquid was unknown. On 9/13/17 at 12:00 noon, the vent above the fryer and oven in the kitchen was observed to be rusted and appeared dirty. II. Unlabeled/Undated/Expired Food Items A. Expectations According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13), pages 26, 49 and 50: Food shall be in sound condition, free from spoilage or contamination and shall be safe for human consumption .Ready-to-eat, potentially hazardous food (time/temperature control for safety food) served in facilities providing food to highly susceptible populations shall adhere to the following date marking requirements .The day the original container is opened in the food establishment shall be counted as Day 1; and the day or date marked by the food establishment may not exceed a manufacturer's use by date if the manufacturer determined the use-by-date based on food safety .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 . B. Observations On 9/11/17 at 11:15 a.m., during the initial tour of the kitchen, the following was observed: -The reach-in refrigerator had an opened five-pound container of sour cream that was undated as to when it was first opened. -The reach-in refrigerator had an opened one-gallon container of mayonnaise that was undated as to when it was first opened. -A reach-in freezer located in the back room of the kitchen had hamburger patties in an opened, unsealed bag which was unlabeled and undated when it was first opened. There was noticeable freezer burn on a package of chopped ham, and the thermometer was covered with frost and ice buildup had to be removed from it in order to read the temperature. -The walk-in freezer had a box of beef patties on a shelf that were open to air and undated when they were first opened. III. Kitchen Equipment Not Maintained in Safe Working Order A. Expectations According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13), section 4-201: All equipment, utensils and single-service articles shall be fabricated with safe materials .Fabricated for durability under conditions of normal use; and resistant to denting, buckling, pitting . Food Contact Surfaces: Multi-use food contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, pits, and similar imperfections. B. Observations On 9/11/17 at 11:15 a.m., the handwashing sink inside the entrance to the kitchen had a soap dispenser that fell forward off the wall each time was soap was dispensed. This occurred each time the kitchen was inspected on 9/12/17, 9/13/17, and 9/14/17. The dietary staff were observed to interrupt their hand-washing process each time to restore the dispenser to its upright position, contaminating their hands. On 9/11/17 at 11:20 a.m., a reach-in freezer located in the dry storage area was heavily frosted. A thermometer located inside the back of the freezer was covered with frost and ice and was not visible. The dietary manager scraped the ice off and said the freezer was going to be defrosted and cleaned the next day. On 9/11/17 at 11:30 a.m., the walk-in refrigerator was inspected and was located outside of the building, directly behind the kitchen. The door appeared to be lopsided in the door frame and did not seal or close properly, and left a gap above the concrete threshold of approximately one-quarter inch. The temperatures inside the refrigerator were adequate. -The outside door of the walk-in refrigerator had a metal latch secured to the outer door frame that could fold over across the door, which could be padlocked closed. On 9/12/17 at 4:30 p.m., the dietary manager was observed to use a blender with a jagged chip out of the lip that was approximately one inch wide, to make the pureed food items for three residents. On 9/13/17 at 10:50 a.m., the dietary manager was again observed to use the same chipped blender to make the pureed food items for three residents. The chipped blender was not a smooth surface and chips or shards could have contaminated the food. IV. Unsafe Chemical Storage A. Expectation According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13), section 7-1: Containers of poisonous or toxic materials and personal care items shall bear a legible manufacturer's label .Working containers used for storing poisonous or toxic material, such as cleaners and sanitizers taken from bulk supplies, shall be clearly and individually identified with at least the name of the material. Separation: Poisonous or toxic materials shall be stored so they do not contaminate food, equipment utensils, linens, or single-service and single-use articles by: A. Separating the poisonous or toxic materials by spacing or partitioning; and B. Locating the poisonous or toxic materials in an area that is not above food, equipment, utensils, linens, and single-service or single-use articles. Except that equipment and utensil cleaners and sanitizers may be stored in warewashing areas for availability and convenience if such materials are stored to prevent contamination of food, equipment, utensils . B. Observations On 9/11/17 at 11:15 a.m., two spray bottles were observed beneath the prep sink. One was labeled Sanitizer and the other Degreaser. The labels were hand-written on the spray bottles and the print was faded and difficult to read. The color of each solution was a similar tan color. On 9/12/17 at approximately 4:30 p.m., the area where pureed foods were being made was inspected. To the right of the counter was a food prep sink, and below the sink, the following items were observed: Two large steel wool scrubbers, four clean blue cloths, and two white cloths. The two white cloths were heavily soiled, and one was wet and the other dry. There were also four spray bottles, one with degreaser written on it, and the other with sanitizer written on it. There was also a spray bottle of No Work Plus oven cleaner and a bottle of Industrial Strength Glass Cleaner. C. Record Review The Material Safety Data Sheet (MSDS) for the oven cleaner, last revised 4/18/11, was reviewed and included: Hazards Identification .Corrosive liquid. Harmful if swallowed. Can cause [MEDICAL CONDITION] eyes, skin, respiratory tract, and/or digestive tract upon direct contact .May cause kidney, liver, and/or CNS (central nervous system) damage with prolonged, repeated exposures. The MSDS for the glass cleaner, last revised 1/2/15, was reviewed and included: Warning: Combustible liquid .Avoid breathing dust/fume/gas/mist/vapors/spray. Wash skin thoroughly after handling .Store in a well-ventilated place. Keep cool. Store locked up .If swallowed: Rinse mouth. Get medical attention if symptoms occur. V. Staff Interview The dietary manager and orienting nursing home administrator were interviewed on 9/13/17 at 4:35 p.m. The dietary manager said they had a cleaning schedule in the kitchen that included a daily and weekly checklist they followed. He said the daily cleaning included wiping down the countertops and underneath the counters, cleaning the microwaves, wiping down the hood and all surfaces in the kitchen. He stated, There is a lot on that list. -The dietary manager explained each dietary aide had cleaning tasks each shift and he checked it off after they completed the tasks. He said he would either make a check mark if an item was cleaned properly or circle it if it wasn't done. He said he hadn't had to circle many tasks lately because the cleaning was being completed. He said deep cleans were also done routinely, for kitchen equipment like the hood, dish machine, and reach-in freezer. -The dietary manager was informed of the observations of the dried food splatter, and debris accumulation on the ceiling in the walk-in refrigerator. He said they tried to clean those things every other day. -The dietary manager said the dry storage non-food area where the shelves were dusty was equipment storage and stated, The majority of that doesn't get used and is a backup. If we do need it, we will throw it through the dish machine. -The dietary manager was informed of the crooked walk-in refrigerator/freezer door that did not seal. He explained there was an incident in the recent past when he was inside the refrigerator and the wind caused the outside door latch to cross over the refrigerator door and he was trapped inside. He stated, I kicked the door down, in order to get out of the refrigerator and he thought that was what caused the door to be ajar and lopsided in the door frame. He said he did not feel the opening at the lower portion of the door was large enough for rodents to enter, but said insects and other small pests might be able to. -He said he expected the kitchen staff to date food items when they were first opened, and to label items if the entire content was not used. He confirmed food containers and packaging should be closed and sealed up for storage, rather than be left open to air. -The dietary manager agreed cleaning chemicals should be stored separate from work prep areas and stated, We are a pretty small kitchen.

Based on observation, record review and interviews, the facility failed to ensure nursing standards of quality were provided during medication administration and wound care for five of (#3, #6, #26, #42, and #46) of 29 sample residents. Specifically, the facility failed to: -Ensure proper glove use during wound dressing change for resident #46; -Ensure the medication [MEDICATION NAME] was administered timely according to professional standards for resident #26; -Ensure medications were disposed of properly for resident #3; -Ensure eye medications were administered according to professional standards for residents #6 and #42; and -Ensure medications were timely ordered and available for resident #42. The findings included: I. Failure to ensure proper glove use during wound care. A. Professional References According to The Lippincott Manual of Nursing Practice 10th Edition 2014, pages 125, 126, 1084, in pertinent part: Gloves are worn to provide a protective barrier and prevent gross contamination of the hands of health care workers; if used properly they reduce the transmission of microorganisms and help prevent cross-contamination within a patient. Change gloves after contact with infective material, such as feces and wound drainage. Gloves also must be changed between procedures on the same patient. B. Facility Expectation The Dressings Dry/Clean policy and procedure, provided by the orienting administrator on 9/14/17 at 11:15 a.m., included: Put on clean gloves. Loosen tape and remove soiled dressing. Pull glove over dressing and discard into plastic or biohazard bag. Wash and dry your hands thoroughly. Open dry, clean dressings. Using clean technique, open other products. Pour prescribed cleansing solution over the dry, clean gauze into clean basin section of tray. Put on clean gloves. Assess the wound Cleanse the wound .Apply the ordered dressing and secure with tape. C. Resident #46 Resident #46, age 94, was admitted on [DATE]. According to the resident information sheet, [DIAGNOSES REDACTED]. According to the 7/16/17 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident required extensive assistance with toileting and limited assistance with bed mobility, dressing and personal hygiene. She was always incontinent of bowel and frequently incontinent of bladder. The care plan, revised 9/7/17, identified the resident had a stage 2 pressure injury to the right gluteus and was receiving end of life care. Interventions included wound monitoring and dressing changes as ordered. A physician order, dated 9/11/17, included wound orders as follows: Cleanse open area at right glute with wound cleanser, apply hydrogel to wound bed, skin prep to periwound and cover with [MEDICATION NAME] dressing. Change on bath days and PRN (as needed). Observation/Interview Registered nurse (RN) #20 provided a wound dressing change on 9/13/17 beginning at 2:50 p.m. RN #20 reviewed the above wound orders, cleared and sanitized a bedside table. After applying a chux over the table she laid out the dressing materials and cleaned a scissors with an alcohol prep pad. She washed her hands and applied a pair of gloves and removed the old wound dressing and dropped it into a biohazard bag. Without removing her gloves and washing her hands she sprayed wound cleanser on a 4 x 4 gauze and cleaned the wound. She used a paper measuring tape to measure the wound and stated it was one centimeter by one centimeter. She did not comment on depth. Without changing her gloves and washing her hands she cut out a small piece of hydrogel and applied it to the wound bed. She opened a small packet of skin prep and swabbed the periwound. She pulled a pen out of her pocket and dated the [MEDICATION NAME] dressing and applied it over the hydrogel. She removed her gloves and assisted nursing assistant #7 with applying a new incontinence brief to one side of the resident. She put on a pair of clean gloves, provided peri-care and finished positioning the clean incontinence brief on the resident. She removed her gloves and put away the wound dressing materials. At 3:15 p.m. RN #20 was asked about glove use. She said, I know I should have done that (changed gloves/washed hands) or at least used hand sanitizer. The director of nurses (DON) was interviewed on 9/14/17 at 1:10 p.m. about the wound dressing observation. She said she would have expected RN #20 to remove her gloves, wash her hands and apply new gloves, after she had removed the soiled dressing. II. Failure to administer [MEDICATION NAME] according to professional standards A. Professional Reference According to Mosby's 2017 Nursing Drug Reference manual page 198, [MEDICATION NAME] - administration/handling - space doses evenly over waking hours. B. Resident #26 Resident #26, age 79, was admitted to the facility on [DATE]. According to the resident information sheet, [DIAGNOSES REDACTED]. According to the 4/22/17 MDS assessment, he had a BIMS score of nine out of 15, which indicated moderate cognitive impairment. He required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and bathing. He required extensive assistance of one person with personal hygiene. He had no behavioral symptoms or rejection of care. On 9/11/17 at 2:37 p.m. the resident's power of attorney (POA) said the resident's [MEDICATION NAME] medication was not being administered properly. She said, They give it too close together at times. Initial physician orders, dated 4/6/16, included an order for [REDACTED]. Review of the August and September 2017 medication administration records (MARs) revealed instruction to administer the medication Upon (rising), Mid D(ay), PM and HS (hour of sleep). Specific instructions included Give 1.5 tablet by mouth four times a day for [MEDICAL CONDITION]. Administer one hour before or after having protein. The facility's medication administration times were provided by the administrator, on 9/14/17 at 11:30 a.m. The document revealed the following ranges for administration times: Upon Rising - 7:00 a.m. to 10:00 a.m.; Mid Day 10:00 a.m. to 2:00 p.m.; and PM - 3:00 p.m. to 7:00 p.m. The orienting administrator provided detailed administration times for August and September 2017. The documentation revealed [MEDICATION NAME] was administered as close as one hour apart (the morning administration at 12:05 p.m. and midday at 1:05 p.m. on 9/13/17) and as long as five hours and 48 minutes apart (morning administration at 7:06 a.m. and midday at 12:54 p.m. on 9/9/17). C. Staff Interviews Licensed practical nurse (LPN) #15 said, on 9/13/17 at 12:01 p.m., We can give it before or after meals. I like to give it at 7 (a.m.) and before lunch, but if he is like 'I am going to lunch right now,' I give it after he eats. RN #22 said, on 9/14/17 at 12:55 p.m., she did not work at the facility very often and could not state when she usually administered the [MEDICATION NAME]. The DON was interviewed on 9/14/17 at 1:13 p.m. She said the restrictive instruction had been put on the MARs by the pharmacy and she would have to go to the consulting pharmacy and get less restrictive instruction on there. III. Medication disposal A. Professional reference According to the United States Food & Drug Administration (FDA), How to dispose of Unused Medicines, 2017, https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm 3.htm (September 2017), in pertinent part: -Drug disposal guidelines were developed to ensure proper disposal of medicines and help reduce harm from accidental exposure or intentional misuse. -Transfer unused medicines to collectors registered with the Drug Enforcement Administration (DEA). -The FDA did not want to add drug residues into water systems unnecessarily. B. Resident status Resident #3, age 67, was admitted on [DATE] and readmitted on [DATE]. According to the September 2017 computerized physician orders [REDACTED]. According to the 8/16/17 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview mental status (BIMS) score of six out of 15. He required total assistance for transfers and extensive assistance of one person for toileting and eating. The care plan, initiated on 6/24/15 and revised on 11/16/15, identified he was at risk for constipation related to decreased mobility and MS. Interventions included administer [MEDICATION NAME] per physician orders. C. Observation/Interview A medication pass observation, made on 9/13/17 at 9:03 a.m., revealed licensed practical nurse (LPN) #15 poured resident #3's remaining [MEDICATION NAME] (which was mixed in grape juice) into a sink located in the dining room. LPN #15 said resident #3 did not consume all of his [MEDICATION NAME] and she would document it in a progress note. D. Record review According to the 9/13/17 nurse progress note by LPN #15: -17 grams of [MEDICATION NAME] were to be given one time a day to resident #3 for constipation -she mixed 17 grams (g) of [MEDICATION NAME] in 120 milliliters (ml.) of grape juice -resident #3 took one drink and refused to drink the remaining [MEDICATION NAME] in grape juice mixture According to the September 2017 Medication Administration Record [REDACTED].) ounces of liquid one time a day for constipation. LPN #15 documented in the MAR indicated [REDACTED]. E. Staff interviews LPN #15 was interviewed on 9/13/17 at 9:37 a.m. She said the facility had medication destruction bins located in the medication room. Registered nurse (RN) #22 was interviewed on 9/14/17 at 10:40 a.m. She said nurses were to dispose of all liquid medications in the sink in the medication room. The director of nursing (DON) was interviewed on 9/13/17 at 10:57 a.m. She said nurses were to dispose of all liquid medications using one of the appropriate medication destruction bins in the medication room. She said liquid medications were not to be poured in the trash or in any sink. IV. Eye drop administration A. Professional reference According to the Joint Commission on Allied Health Personnel in Opthalmology (JCAHPO), Best Practices Procedure for Instillation of Eye Drops, 2013 http://documents.jcahpo.org/EyeLights/0413/EyeDrop_Ointment_Checklist.pdf (September 2017), in pertinent part: -Have the patient look up as the lower lid is gently pulled down and squeeze the dropper to release one drop into the inferior cul-de-sac. B. Facility Policy The instillation of eye drops policy, provided by the DON on 9/13/17, reflected eye drops were to be instilled in the mid lower eyelid. C. Observation A medication pass observation, made on 9/13/17 at 9:25 a.m., revealed LPN #15 attempted to administer eye drops in the inner corner of resident #6's eyes. The eye drop fell out of the inner corner of his left eye and the eye drop fell on resident #6's face (not on the inner corner of his right eye) when she attempted to administer it into the inner corner of his right eye. A medication pass observation, made on 9/13/17 at 8:36 a.m., revealed LPN #15 attempted to administer resident #42's eye drops in the inner corner of his eye and told him he was out of his eye drops (no eye drops came out when she repeatedly squeezed the bottle). D. Resident #6 Resident #6, age 84, was admitted on [DATE]. According to the September 2017 CPOs, [DIAGNOSES REDACTED]. According to the 7/4/17 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. He required limited assistance for transfers, extensive assistance for toileting, and was independent and required set up for eating. Record review According to the September 2017 CPOs, the resident had an order for [REDACTED]. According to the September 2017 MAR, LPN #15 documented she administered resident #6's refresh tears solution 0.5 % (eye drops) at 8:00 a.m. E. Resident #42 Resident #42, age 93, was admitted on [DATE]. According to the September 2017 CPOs, [DIAGNOSES REDACTED]. According to the 7/20/17 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. He required extensive assistance of one person for transfers and toileting, and was independent and required set up for eating. Record review The care plan, initiated and revised on 10/15/15, identified he had impaired visual function related to [MEDICAL CONDITION] as evidenced by [MEDICAL CONDITION] to his left eye and impairment to his right eye. According to the September 2017 CPOs, the resident had an order for [REDACTED]. F. Staff interviews LPN #15 was interviewed on 9/13/17 at 9:37 a.m. She said eye drops were instilled by pulling down the resident's lower eyelids and instilling them into the inner corners of their lower eyelids. She said the entire eye drops did not go into resident #6's eyes. She said the eye drop could have fallen on his cheek. RN #22 was interviewed on 9/14/17 at 10:42 a.m. She said eye drops were instilled in the inner corners of resident's lower eyelids. The DON was interviewed on 9/14/17 at 12:15 p.m. She said she wanted her nursing staff to follow the facility policy and procedure when instilling eye drops to residents. She said she would educate the nursing staff on the facility's policy to instill eye drops in the center of resident's lower eyelids. V. Medication unavailable for two doses A. Professional references According to the RxList, [MEDICATION NAME], 2017 http://www.rxlist.com/[MEDICATION NAME]-drug.htm (September 2017), in pertinent part: -The recommended dose is one drop of [MEDICATION NAME]® in the affected eye(s) twice daily approximately 12 hours apart. According to Potter & Perry, Fundamentals of Nursing, Eighth Edition, Mosby, St. Louis Missouri, 2013, p. 570: in pertinent part: -To maintain a therapeutic plateau the patient must receive regular fixed doses. -Safe drug administration involves adherence to prescribed doses and dosage schedules. B. Observation A medication pass observation, made on 9/13/17 at 8:36 a.m., revealed LPN #15 attempted to administer resident #42's eye drops and told him he was out of his eye drops. No eye drops came out when she repeatedly squeezed the bottle. C. Resident status Resident #42, age 93, was admitted on [DATE]. According to the September 2017 CPOs, [DIAGNOSES REDACTED]. According to the 7/20/17 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. He required extensive assistance of one person for transfers and toileting was independent and required set up for eating. D. Record review The care plan, initiated and revised on 10/15/15, identified he had impaired visual function related to [MEDICAL CONDITION] as evidenced by [MEDICAL CONDITION] to his left eye and impairment to his right eye. According to the September 2017 CPOs, the resident had an order for [REDACTED]. According to the September 2017 MAR, LPN #15 documented on the morning of 9/13/17 that resident #42's ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] Solution 0.2-0.5 % (eye drops) were not administered and to see the progress notes. According to the nurse progress notes, on 9/13/17 at 8:42 a.m., LPN #15 documented ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] Solution 0.2-0.5 % (eye drops) one drop to be instilled in both eyes, two times a day for [MEDICAL CONDITION], was not available to administer and the pharmacy would be notified. There was no documentation LPN #15 notified the physician or pharmacy that resident #42's eye drops were not administered and not available. E. Staff interview/record review LPN #15 was interviewed on 9/13/17 at 8:36 a.m. She said nurses were to order medications before they ran out. She said night nurses were to go through the medication carts to determine what needed to be ordered. She said resident #42's ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] Solution 0.2-0.5 % (eye drops) must not have been reordered. She said she would notify the physician for a stat order and fill out an order for [REDACTED]. An observation, made on 9/13/17 at 8:53 a.m., LPN #15 had reviewed the prior drug reorder forms, and confirmed a back up ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] Solution 0.2-0.5 % (eye drops) was ordered by the night nurse. She wrote his eye drops on the refill order form, said she would fax it to the pharmacy by lunchtime, and continued passing medications. She did not notify the physician nor the DON. According to the facility's refill order only form, provided by LPN #15 on 9/13/17 at 8:53 a.m., LPN #15 documented a refill order request for resident #42's ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] Solution 0.2-0.5 % (one eye drop to be instilled in both eyes, two times a day). F. Staff follow-up interviews RN #22 was interviewed on 9/14/17 at 10:42 a.m. She said nurses were to immediately notify (via phone and/or fax) the physician and the pharmacy when a medication was not available to be administered to residents. She said nurses were responsible to ensure medications were available for administration. She said she could not administer resident #42's ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] Solution 0.2-0.5 % (eye drops) because they were not available. She said he was upset about it and kept asking when he would receive his eye drops. She said his eye drops were on hold until they arrived from the pharmacy. The DON was interviewed on 9/13/17 at 10:57 a.m. She said the moment when medications were unavailable to administer to residents nurses were to order them from the pharmacy. She said night nurses were to ensure medications were available for administration. She said they were to check medication carts to see what medications (such as eye drops) needed to be reordered, and were to then order them from the pharmacy. The DON was interviewed a second time on 9/13/17 at 12:20 p.m. She said LPN #15 should have faxed/notified the physician and the pharmacy when resident #42 was not administered his eye drops, and also because his eye drops were not available to administer. She said she had LPN #15 notify the physician of the need for resident #42's ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] Solution 0.2-0.5 % (eye drops) and had her document in the progress notes as well. G. Facility follow up Review of nurses' notes, faxes to the physician and MAR, the resident's eye drops were received and administered during the day shift on 9/14/17.

Based on record review and interviews, the facility failed to ensure one (#26) of three residents reviewed for activities of daily living (ADLs) out of 29 sample residents, received such assistance. The findings included: 1. Facility Standards A certified nurse aide (CNA) job description, provided by the orienting administrator on 9/14/17 at 11:15 a.m. included: Assist residents with bathing/bowel functions/morning routines such as brushing teeth, washing face, dressing etc. On 9/14/17 at 11:15 a.m., the orienting administrator said the facility did not have a policy and procedure for ADLs. 2. Resident Status Resident #26, age 79, was admitted on [DATE]. According to the resident information sheet, [DIAGNOSES REDACTED]. According to the 4/22/17 minimum data set (MDS) assessment, he had a brief interview for mental status (BIMS) score of nine out of 15, which indicated he was moderately cognitively impaired. He required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and bathing. He required extensive assistance of one person with personal hygiene. He was always incontinent of bowel and bladder. He had no behavioral symptoms or rejection of care. 3. Interviews The power of attorney (POA) was interviewed on 9/11/17 at 2:16 p.m. She said the facility did not always provide activities of daily living for resident #26. Specifically, she said the resident did not always receive three baths per week, oral care twice daily, toileting assistance and medications administered properly. (Cross refer tag F281). She said during a visit the previous Sunday (9/10/17) the staff on duty said they did not have time to bathe the resident as scheduled and hoped he could be bathed the following day. She said she would bring up ADL concerns at care conferences and it would get better for awhile and then problems resume. The POA said she or a privately hired caregiver, spent extensive amounts of time with resident #26. She said they did not provide personal care to resident #26, outside of occasional face cleansing or hair combing. The private caregiver was present on 9/12/17 at 3:49 p.m. She said she had arrived at 12:20 p.m. and no staff member had been in to check on the resident, including providing incontinence care. The caregiver said she came in three or four days per week, for four to six hours per visit, to provide companionship, but not personal or ADL care, for the resident. The caregiver said she had concerns the resident was not always provided with ADL assistance. 4. Record Review The care plan, revised on 4/14/16, identified resident #26 required extensive assistance with toileting. He refuses to use BR (bathroom) often and needs encouragement to use the toilet (every) 2 hours and PRN (as needed). He needs assistance with cleansing self after elimination, changing soiled briefs, and transferring on and off the toilet. Bath schedules, toileting, oral care and bathing records were reviewed from 8/1/17 through 1:42 p.m. on 9/13/17. Bathing records revealed baths were scheduled for Sunday, Tuesday and Friday. He had been provided three baths per week, with the exception of the current week. Resident #26 had not received his scheduled bath on Sunday 9/10 and Tuesday 9/12/17. Toileting records revealed the resident was toileted 72 times in August and 26 times during the 11 days he was present in the facility in September, an average of twice per day. On 9/11/17 staff documented resident #26 was toileted at 11:37 p.m. and not again until 9/12/17 at 1:25 p.m.; however, on 9/12/17, the private caregiver had been continually present with the resident since 12:20 p.m. and said no one had provided toileting assistance. 5. Staff Interviews CNA #2 was interviewed on 9/13/17 at 10:19 a.m. She said she was a bath aide for the first time that day. She said baths were always documented when they were performed. CNA #5 was interviewed on 9/13/17 at 10:28 a.m. She said resident #26 was completely dependent on staff for ADLs. He was incontinent and staff checked and changed his incontinence brief every two hours. Nursing assistant (NA) #7 was interviewed on 9/13/17 at 10:43 a.m. He said the resident required total care for all ADLs, and did not resist care. CNA #4 was interviewed on 9/13/17 at 10:49 a.m. CNA #4 said the resident needed extensive two person assist for all ADLs, and required check and change every two hours. CNA #3 was interviewed on 9/13/17 at 3:26 p.m. CNA #3 said resident #26 was mostly incontinent . He is a check and change and never refused cares. NA #8 was interviewed on 9/13/17 at 3:31 p.m., She said the resident was incontinent and was on a two hour changing schedule. She said he did not refuse cares. The director of nurses (DON) was interviewed on 9/14/17 at 1:21 p.m. She said care staff worked eight hour shifts. She did not know why resident #26 had not received his bath the previous Sunday or Tuesday. She said if he had refused, it should have been documented. She said the staff could document each time they provided toileting assistance; however, it was the facility's practice to document once per shift. She said if staff had a spell they might document in the middle of their shift; however, they usually sat down and documented at the end of each shift. She said if there was an average of only two toiletings documented per day, one shift was just not documenting. She felt staff were continually toileting the residents.

Based on observation, interviews and record review, the facility failed to ensure that a resident with a limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for one (#40) of three residents reviewed for ROM of 29 sample residents. Specifically, the facility failed to ensure the resident's restorative program for ROM was consistently administered. The findings included: 1. Facility policy and procedure The facility's Rehabilitative Nursing Care policy and procedure, revised April 2017, was provided by the orienting administrator on 9/14/17 at 11:15 a.m. The policy and procedure included: Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes but is not limited to: . Assisting residents with their routine range of motion exercises. 2. Facility Expectations Job descriptions for restorative certified nurse aides (RCNAs) and CNAs, provided by the orienting administrator on 9/14/17 at 11:15 a.m., included: the restorative CNA provides direct rehabilitation/restorative care as taught in CNA school and supervised by nurse or as delegated and taught by therapy and/or nursing. Assists with improving range of motion for residents. Documents program completion every day and narrative progress notes as required by facility policy. Reports unusual problems regarding resident care to nursing staff immediately (i.e. pain, refusals, falls, etc). The CNA essential functions included: Provide daily indwelling catheter care, perineal care, range of motion exercises, physical and respiratory therapy, diabetic urine testing etc. 3. Resident Status Resident #40, age 73, was admitted on [DATE]. According to the resident information sheet, [DIAGNOSES REDACTED]. According to the 6/4/17 minimum data set (MDS) assessment, a brief interview for mental status (BIMS) was unable to be conducted. He required extensive assistance of two persons for bed mobility, transfers, dressing and toileting. He last received occupational therapy (OT) on 8/3/16 and physical therapy (PT) on 7/13/16. He received restorative therapy in the form of active range of motion (AROM) for three of seven days reviewed and passive range of motion (PROM), two of seven days reviewed. 4. Record Review The care plan, developed by the physical therapist on 4/7/15 and revised by her on 8/2/17, indicated the resident was to receive restorative PROM. Staff were to assist the resident with PROM to the left and right upper extremities while sitting in a chair and ankle circles and knee extension to the right lower extremity. The program included soft tissue mobilization wrist to shoulder, forearm supination, wrist and finger extension of the right upper extremity. The stated goal was to reduce pain sensitivity to the right upper extremity and left extremity and increase ROM for dressing, grooming and sitting/positioning. A physician order, dated 1/27/16, discontinued a wrist splint due to resident refusal. The MDS coordinator wrote a care plan note, dated 6/14/17, that included AROM to upper and lower extremities in all ranges for ten repetitions of each motion, one time per day. The July, August and September 2017 restorative documentation completed by the RCNA and CNAs, from 7/1/17 through 9/13/17, revealed the resident participated in ROM 14 of 31 days in July, five of 31 days in August and three of the first 13 days in September. For the period reviewed, staff documented a total of nine refusals, 32 not applicable and 12 days of no documentation at all. 5. Observations Resident #40 was observed on 9/11/17 at 1:42 p.m. resting in bed. His right hand and fingers were contracted. Resident #40 could respond yes and no to questions. When asked if he wore a splint on his hand, he pointed to a chair in his room where a black sling was. He responded no when asked if staff performed any exercises on his arms or legs. 6. Staff Interviews Staff interviews conducted on 9/12/17 revealed CNA staff were not providing restorative services. Registered nurse (RN) #29 said, on 9/11/17 at 3:45 p.m., resident #40 had a contracture of the right hand. She said the resident had a splint; however, refused to wear it. She was not sure if the resident received ROM. She said a student PT (physical therapist) is coming over (from a local college) but I'm not sure if they are working with him. The director of nurses (DON), said on 9/13/17 at 9:51 a.m., I am in charge of restorative. We have a restorative meeting monthly and a binder (with restorative information) that is updated periodically with who is on. She said there were probably 12 residents currently receiving restorative services. She said PT #28 screened residents and wrote the restorative modalities. She said a restorative CNA attended the meetings and the facility recently went into a contract with a local college for their grad students in exercise physiology to come over and do the modalities. She said resident #40 was currently on restorative and had refused to wear a splint on his right hand. When asked the frequency of the restorative services for resident #40, as they were not indicated on the care plan, the DON said, it should be done daily. A restorative aide (#30) (graduate student with the local college) joined the DON's interview on 9/13/17 at 10:04 a.m. She said she worked with residents on Monday, Wednesday and Friday. She said, I have 20 plus patients and I am only here four hours a day, so I can't get to everyone every day. CNA #5 said, on 9/13/17 at 10:31 a.m., resident #40 was dependent on staff for daily living activities. She said an arm sling was applied prior to the resident's transfers. He did not have a splint for his hand and did not receive any exercises that she was aware of. CNA #7 said, on 9/13/17 at 10:40 a.m., resident #40 received ROM services from restorative aide (#30). His restorative documentation of not applicable was reviewed with him and he said he documented that because restorative aide #30 does the restorative program. CNA #4 said, on 9/13/17 at 10:51 a.m., resident #40 wore an arm sling during transfers so it stays in place. She said, He does have a restorative ROM program and any one of the CNAs can do that; it is on day shift I think. She said it was for both upper and lower extremities; however, she was not sure what exercises were performed. CNA #3 said, on 9/13/17 at 3:28 p.m., resident #40 was on a restorative program, but she was not sure what it was. It is done by a restorative aide; that is a day shift thing. Nursing assistant (NA) #8 said, on 9/13/17 at 3:34 p.m., resident #40 did not receive any ROM from the evening staff. She said, There is a restorative aide during the day that does it. The DON was interviewed again on 9/14/17 at 1:06 p.m. She said PT #28 was contract staff and came to the facility two or three times a week. She would review the restorative program with the restorative CNA and she attended the monthly restorative meetings. The DON said, We actually go over each person's restorative program and comment whether we are going to continue, change or put (services) on hold if there is an acute change, or discontinue (services). In response to the lack of restorative services for resident #40, as evidenced by record review and interviews, she said she thought there was confusion by the new CNAs. She said they had been inserviced to provide all of the care modalities, including restorative, except on the days the restorative CNA was present. It is on the schedule for them to do it.

Based on observations and staff interviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the expiration date when applicable in one of two medication carts. The findings included: 1. Professional Reference According to Perry, Potter & Ostendorf, Clinical Nursing Skills & Techniques, 8th Edition (copyright 2014), page 544: A multi-dose vial contains several doses of a medication and thus can be used several times, although only for a single patient. When using a multi-dose vial, write the date that the vial is opened on the vial label . Properly discard the multi-dose vial when the allowed time for being open has expired. 2. Main medication cart observation On [DATE] at 1:46 p.m., the main medication cart was inspected with registered nurse (RN) #20, and the following observations were made: -An opened bottle of 20 milligrams (mg)/ milliliter (ml) morphine sulfate had no date written on the bottle to indicate when it was first opened, and used. -An opened bottle of travatan eye drops, which had a broken seal, had no date written on the bottle to indicate when it was first opened, and used. -An opened tube of sodium eye ointment had no date written on the tube to indicate when it was first opened, and used. 3. Staff interviews RN #20 was interviewed on [DATE] at 1:46 p.m. She said when medications were first opened, nurses were to immediately date the bottles/vials/tubes (not the boxes or bags they came in) when all medications were first opened. RN #22 was interviewed on [DATE] at 10:42 a.m. She said nurses were to, immediately upon opening, write the date opened directly on the bottles of medications, and not the boxes or bags they came in. She said nurses were to do this because the packaging could be lost. The director of nursing (DON) was interviewed on [DATE] at 2:46 p.m. She said nurses needed to mark medication bottles directly, with the date they were opened, at the time they were opened.

Based on observations, record review and interviews, the facility failed to provide timely and effective interventions to prevent accidents for four (#25, #36, #18 and #4) of 31 sample residents. Specifically, the facility failed to initiate timely and effective interventions for resident #25 to prevent nine falls within five months. These failures contributed to the resident suffering a fall with hip fracture within two days of admission, eight falls after the fracture, and an overall decline in mobility. The facility further failed to investigate root causes and implement timely and effective interventions to prevent falls with injury for residents #36 and #18, and failed to ensure safe transfers for resident #4. The findings included: I. Expectations A. Facility Standards According to the facility policy and procedure on falls dated ,[DATE], provided by the director of nursing (DON) the morning of [DATE]: -The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. -The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. -For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. -If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been indentified) and will re-evaluate the continued relevance of current interventions. B. Professional Reference According to HCPro Inc. Long Term Care Nursing Library, Neurological checks for head injuries, [DATE], <http://www.hcpro.com> (,[DATE]), in part: 1. Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours. 2. Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions; confusion; memory loss; difficulty speaking; gait or balance problems; pupils of unequal size or reactions; headache; vomiting; visual disturbances; or periods of coherence alternating with periods of confusion or lethargy. Monitoring must continue for a minimum of 72 hours (or until the resident is asymptomatic for a specified period of time). 3. Perform frequent neurologic assessments every: § 15 minutes for two hours § 30 minutes for two hours § 60 minutes for four hours § Eight hours for 16 hours § Eight hours until at least 72 hours have elapsed and resident is stable 4. Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. Completing the Glasgow Coma Scale immediately, then once each shift following a head injury, helps keep findings objective. II. Resident #25 Resident #25, age 97, was admitted on [DATE]. According to the ,[DATE] computerized physician orders [REDACTED]. According to the [DATE] minimum data set (MDS) assessment, the resident had disorganized thinking and moderate cognitive impairment, with a brief interview for mental status (BIMS) score of eight out of 15. No mood or behavior symptoms were noted. She required extensive assistance of two for bed mobility and toileting, and limited assistance of one for transfers and ambulation in her room. She was frequently incontinent of bladder and occasionally incontinent of bowel, and was on a toileting program. Care Plans The resident's care plans, initiated [DATE] and revised [DATE], identified the following in part: Activities of daily living (ADL) self-care performance deficits related to confusion and left hip fracture. Interventions included: -Toilet use: requires extensive assistance by two staff members for toileting and peri-care. -Toilet every two hours and use a commode as needed. -Transfer: requires extensive assist from two staff members for transferring surface to surface. Stand pivot transfers using gait belt, remind her to stay off left leg and use only right leg to bear weight. High risk for falls related to poor safety awareness and limited mobility as evidenced by a history of frequent falls and having falls since admission. Interventions included: -Anticipate and meet needs during purposeful rounding and as needed -Call light within reach, has pendant light also -Toilet every two hours and as needed and check on regularly at night. She does not like to be wet and lay in it; therefore she will try and get up unassisted (initiated [DATE]) -Appropriate footwear -Safe environment with bed in low position at night. The use of a fall mat was not included on the care plan, although documentation review (see falls below) revealed a fall mat was in place at various times. Impaired cognitive function thought processes related to dementia as evidenced by periods of confusion and disorientation, history of sun downing. She is able to make some of her needs and wants known to staff but staff does anticipate her needs too. Interventions included: -Communication: As many times per day, when in room, remind her not to get up on her own. Remind her that her bone is still healing and if she gets up on her own she could break her bone again. Show her again where the call light is (initiated [DATE]). A. Resident status on admission - failure to assess, identify and care plan resident safety needs According to the [DATE] admission summary, the resident was admitted to the facility from a hospital after a fall resulting in three rib fractures. She was ambulating with a front wheeled walker and stand-by assist. According to a [DATE] physician progress notes [REDACTED]. She was previously healthy for age 96 with minimal medical issues, now with broken hip and being treated conservatively at the facility by therapies. According to the [DATE] physical therapy (PT) initial examination, the resident suffered from decreased functional activities and transfers, secondary to her left femur fracture as well as her prior injuries, and poor safety awareness and sequencing due to dementia. She was unable to be tested for strength related to confusion. No recommendations were made for fall safety at that time by PT. According to a [DATE] PT daily note, resident with a change in status secondary to left femoral neck fracture with decreased mobility, difficulty with transfers, difficulty with bed mobility. No recommendations were made for fall safety during this visit. According to the [DATE] Morse fall scale, the resident's score was 75, indicating high risk for falls. Her [DATE] score was also 75. Assessment instructions were to complete on admission, quarterly, at change of condition and after a fall. Scoring: ,[DATE] low risk, ,[DATE] moderate risk, 45 and higher is high risk. -Although the resident had a history of [REDACTED]. Two fall risk assessments had been completed, on ,[DATE] and [DATE], not according to instructions to complete on admission and after each fall. Medical record review revealed the resident was admitted to the facility's open unit. She was moved to the secure unit related to wandering and restlessness at night, then moved back to the open unit after she broke her hip. There was no evidence of an individualized acute care plan to assess fall risk and identify fall prevention measures, such as the resident's daily routines, room layout to meet her needs, or her ability to use her call light. There was no evidence of an interdisciplinary team meeting, or interventions put in place, upon admission to plan how to prevent further falls with injuries. B. Failure to assess root causes, identify and implement measures to prevent further falls and injury 1. Fall with injury on [DATE] According to an incident report, dated [DATE] at 7:15 a.m. and revised [DATE] at 12:49 p.m., the resident was found on the floor of her bedroom in front of her bathroom door. She had impaired movement to her left lower extremity that was rotated slightly externally. Her power of attorney (POA) was notified on [DATE] at 11:15 a.m. The physician was notified on [DATE] at 11:40 a.m. According to progress notes: -Late entry [DATE] at 12:49 p.m., the resident was found on the floor of her bedroom in front of her bathroom door at 7:15 a.m. She was assisted into a recliner. - [DATE] at 9:00 a.m. the resident had complained of left hip pain but declined pain meds stating pain was tolerable. - [DATE] at 11:10 a.m. the resident slept for an hour and half. Upon waking she requested to use the bathroom. She was unable to bear weight on left lower extremity with transfer, denied pain. Her left hip was inflamed/deformed, externally rotated. Physician telephoned and updated, order received to send to emergency room (ER) for evaluation. -[DATE] 11:15 a.m. Emergency medical services (EMS) were phoned and updated; first POA telephoned and message left. Second POA called and updated. Paperwork prepared for EMS. -[DATE] 11:50 a.m. EMS at facility, transported resident to ER. Report called to ER. - [DATE] 6:18 p.m. Resident returned from ER with [DIAGNOSES REDACTED]. Family chose not to have surgery due to the risk. Orders were received for non-weight bearing status for four to six weeks then have physical therapy (PT) and occupational therapy (OT) evaluate. New orders received for Tramadol 25mg every 6 hours as needed for pain. Resident lethargic and responded to verbal stimuli upon arrival. Hypertensive in ER with blood pressure of ,[DATE]. At facility blood pressure was ,[DATE] and heart rate 103. Has large hematoma noted to left hip. Ice applied. Neurological assessment ,[DATE]-[DATE] was done but not complete. (On [DATE] day shift, the level of consciousness, pupil response, motor functions, and pain response were blank. On [DATE] no assessment or vital signs were documented for evening shift.) Care plan was initiated on [DATE]. 2. Fall on [DATE] According to a progress noted dated [DATE] at 11:15 p.m., the resident was found on the floor on her floor mat at 11:10 p.m. She stated she needed to void. No incident report was completed. A neurological assessment was done but not complete. (On [DATE] at 4 and 5 a.m. no level of consciousness, pupil response, motor functions or pain response were documented. This also occurred on [DATE] for evening shift.) No injuries were documented. The care plan was updated on [DATE] to include: as many times per day, when in room, remind her not to get up on her own. Remind her that her bone is still healing and if she gets up on her own she could break her bone again. Show her again where the call light is. Care plan updated [DATE] to include: toilet every two hours and as needed and check in regularly at night. She does not like to be wet and lay in it; therefore she will try and get up unassisted. The fall investigation did not document when the resident had last been toileted or checked on, or if she had been incontinent when found on the floor. Documentation review revealed no evidence the resident was being checked on regularly in keeping with the plans above. There was no evidence of therapy involvement for fall prevention recommendations. 3. Fall on [DATE] According to the incident report dated [DATE] at 8:01 p.m. and revised [DATE] at 8:23 p.m., the resident was observed kneeling on the fall mat with arms on the bed and bare feet. She stated, I had to go to the bathroom and my legs won't work. No injuries documented. POA was notified [DATE] 8:10 p.m. Physician was not notified. According to a progress note dated [DATE] at 8:18 p.m., the certified nurse aide (CNA) found the resident on the floor. She was observed kneeling on the fall mat with arms on the bed and bare feet. Resident had stated that she had to go to the bathroom and her legs wouldn't work. Neurological assessment was done but not complete. (On [DATE] at 1:45 and 2:45 a.m. no level of consciousness, pupil response, motor function or pain response were documented. This also occurred on [DATE] day shift. No assessment or vital signs were documented on [DATE] night shift.) Care plan was revised on [DATE] - see above. There was no documentation of when the resident was last toileted or checked on, and whether or not she had been incontinent when she was found on the fall mat. Although a fall mat was in place, there was no evidence of assessment for appropriateness versus safety risk for the resident. The fall mat was not included in the care plan. According to a multidisciplinary care conference note dated [DATE], the resident had one fall this last quarter (this was inaccurate - see above three falls). Maintaining her functional status with ADLs and had a decline with mobility since left hip fracture received at the facility. Although the care plan was updated on this date, there was insufficient evidence of detailed fall investigations, assessment or root cause analysis. The care plan was not updated. 4. Fall on [DATE] According to incident report [DATE] 5:30 a.m. revised [DATE] 7:36 a.m. Resident was found on her knees on the fall pad facing the bed found by CNA. Resident stated, I was trying to sit up on my own. I felt like I could do it on my own. No injuries documented. POA was notified [DATE] 7:15 a.m. Physician was not notified. According to progress noted [DATE] 7:31 a.m. resident was found on her knees on the fall pad facing the bed found by CNA. She was instructed to use her call light or pendant to call for help when she wants to get up. Neurological assessment was done but not complete. (On [DATE] at 1015 a.m. and [DATE] night shift no assessment or vital signs were documented. On [DATE] day shift no vital signs were documented.) There was no documentation of when she had last been toileted, whether or not she had been incontinent when found on the fall mat, or assessment/care planning regarding appropriateness of the fall mat. No new interventions were put into place. The care plan was not updated. 5. Fall on [DATE] According to the incident report dated [DATE] at 12:06 a.m. and revised [DATE] at 12:23 a.m., the resident was found on the floor by a CNA. Resident denied pain or injury. Assessment was completed by RN and no injury found. Resident was attempting to ambulate to the restroom. No notifications were made. According to a progress note dated [DATE] at 12:23 a.m., the resident was found on the floor by a CNA. Resident denied pain or injury. Assessment completed by RN and no injury found. 72 hour fall monitoring initiated. Neurological assessment was done but not complete. (On [DATE] at 1:00 a.m. no level of consciousness, pupil response, motor function or pain response was documented. On [DATE] at 6:00 a.m. no assessment or vital signs were documented. On [DATE] evening shift no vital signs were documented.) There was no documentation of when the resident had last been toileted or checked on by staff. No further interventions were put in to place. The care plan was not updated. 6. Fall on [DATE] According to the incident report dated [DATE] at 2:24 a.m. and revised [DATE] at 2:46 a.m., the resident was found on the floor in the bathroom. She said she needed to go to the restroom and didn't want to wait for assistance. No injuries observed. No notifications were made. According to progress note on [DATE] at 2:40 a.m., the CNA notified the RN that he had found the resident on the floor in the bathroom. Resident denied any injury or pain. Assessment completed and no injuries found at that time. 72 hour fall monitoring initiated and teaching completed on the proper use of call light. Neurological assessment was done but not complete. (On [DATE] evening shift and [DATE] day shift no assessment or vital signs were documented.) No new interventions put into place. Care plan was not updated. There was no documentation of when the resident was last toileted or checked on, or if she had been incontinent. 7. Fall on [DATE] According to an incident report dated [DATE] at 8:28 p.m. and revised [DATE] at 10:01 p.m., the resident was observed sitting on the floor leaning against the CNA. No shoe on left foot. Fall mat beside the bed. Oxygen was not on. CNA found resident lying on the floor on her back with head on the floor. Brief only on right leg. Temperature 99.1 pulse 111 Resident stated, I thought I could scoot across the floor to get to the toilet. Did complain of pain to left lower extremity. Pain assessment done. POA notified ,[DATE] at 8:33 p.m. Physician was not notified. According to progress note [DATE] 8:33 a.m. at 8:15 p.m. staff reported resident was on the floor. Resident stated I needed to go to the toilet and thought I could just scoot myself on the floor and get there. POA notified. Neurological assessment was done but incomplete. (On [DATE] evening, [DATE] night shift, and [DATE] evening shift no assessment or vital signs were documented.) No new interventions were put into place. The care plan not updated. The time the resident was last toileted or checked on was not documented. Although the fall mat was in place, there was no assessment of whether or not it contributed to the resident's fall. 8. Fall on [DATE] According to the incident report dated [DATE] at 4:51 a.m. and revised [DATE] at 3:07 p.m., the resident rolled out of bed onto the floor mat, and hit right side of forehead. Resident stated she was attempting to go to the rest room. No notifications were made. According to the progress note dated [DATE] at 4:56 a.m., the resident rolled out of bed, laying on right side on fall mat next to bed. Resident stated she was attempting to go to the rest room. According to a progress note dated [DATE] at 12:27 p.m., a small bruise developed at the right corner of her eye. Neurological assessment done but not complete. (On [DATE] at 5:00 a.m., 5:15 a.m., 5:30 a.m., 5:45 a.m., and 6:15 a.m. no level of consciousness, pupil response, motor function, or pain response were documented. On [DATE] at 6:45 a.m., 7:15 a.m. and 9:45 a.m. no vital signs were documented. On [DATE] evening shift no assessment or vital signs were documented. On [DATE] evening shift no level of consciousness, pupil response, motor functions, or pain response were documented.) There was no documentation of what she hit her head on, causing the bruise. No new interventions were put into place. The care plan not updated. There was no documentation when the resident was last toileted or checked, or if she had been incontinent. (According to toileting documentation for [DATE], the resident was last toileted at 4:03 a.m., but did not void. However, this information was not included in the progress notes or incident report.) 9. Fall on [DATE] According to the incident report dated [DATE] at 3:45 p.m. and revised [DATE] at 10:08 p.m., the resident was observed sitting on the floor, leaning against the bed. No shoes. No injury. No complaints of pain. Assisted by two staff from floor into wheelchair. Taken to toilet, per resident request. Did not use call light. Fall mat was not on the floor. POA notified 4:27 p.m. Physician was not notified. According to a progress note dated [DATE] at 4:27 p.m., at 3:45 p.m. staff called the nurse to the resident's room, advising the resident was found on the floor. Able to bear weight in bathroom for transfer. Neurological assessment done but not complete. (On [DATE] at 6:30 p.m., 9:30 p.m., and 10:30p.m. no assessment or vital signs were documented. On [DATE] day and evening shift, no assessment or vital signs were documented.) No new interventions were put into place. The care plan not updated. There was no documentation in progress notes or incident report. C. Toileting Documentation Review -The facility failed to track and trend the resident's falls with her expressed needs to use the toilet. According to ,[DATE] toileting documentation, reviewed from ,[DATE] through [DATE], the resident did not receive toileting assistance every two hours as care planned, or in keeping with a toileting program as noted on the MDS. Documentation revealed that, on a daily basis, the resident waited from four hours to seven and a half hours between toileting assistance times. -On [DATE] (the resident was found on the floor at 4:51 a.m.) the resident had been toileted at 2:08 a.m. (four and a half hours after previous time), at 8:02 a.m., at 12:03 p.m. (four hours later) and then not again until 6:48 p.m. (six and a half hours later). -On [DATE] (date of last fall) the resident was toileted at 12:48 p.m., 4:57 p.m., and not again until 9:57 p.m. The fall was documented at 3:45 p.m. There was no evidence the facility reviewed the toileting documentation, reassessed the resident's voiding schedule, and implemented measures to help her to the bathroom timely, although most of her falls occurred around needing the bathroom per the resident's statements. D. Observations On [DATE] at 9:21 a.m. the resident was lying in bed. No fall mat was in place and the bed was not in low position. On [DATE] at 10:12 a.m. the resident was lying in bed. No fall mat and bed not in low position. On [DATE] at 2:25 p.m. the resident was lying in bed. No fall mat and bed not in low position. On [DATE] at 8:01 a.m. the resident was lying in bed with fall mat next to bed, bed not in low position. Interview attempts revealed the resident was confused and non-interviewable. E. Staff interviews The physical therapist (PT) #20 was interviewed on [DATE] at 9:54 a.m. She stated interventions for residents included reminders to use the call light and ask for assistance during rounding. She was not aware the resident had fallen nine times since admission in February. She said they reviewed falls in IDT weekly but admitted the facility did not have a system for finding out the root cause of falls. She said the resident's therapy was discontinued on [DATE]. The CNA coordinator (#10) was interviewed on [DATE] at 10:50 a.m. She said the resident was impulsive and does not use her call light. Interventions to prevent the resident from falling were two hour rounding and frequent reminders. The IDT team reviews who fell on weekday mornings and the MDS coordinator documents it in the care plan. The occupational therapist (OT) communicates interventions in the communication book. Nurse aide (NA) #14 was interviewed on [DATE] at 11:08 a.m. She said interventions to prevent the resident from falling were to keep the door open and rounds with reminders. She said she looks in the computer to see what kind of care the resident requires and was not aware that she was on a toileting program. CNA #8 was interviewed on [DATE] at 11:21 a.m. She said the resident did fall a couple weeks ago but didn't get injured. She is forgetful and needs frequent reminders but the call light is always in reach and also has a pendant call light that she uses. She has a fall mat next to her bed and she is also supposed to be toileted every two hours and as needed. She required limited assist of one for toileting. She stated that she finds information on the resident in the computer. RN #15 was interviewed on [DATE] at 1:45 p.m. She said the resident's last fall was [DATE] at 4:27 p.m. where she was found on the floor with no injuries. She said interventions were to assist with transfers, frequent rounding and checks with reminders and call light within reach. She stated that a copy of the incident was put in the rounds book for the physician to review every Wednesday, and that the family was involved in decisions about interventions during the care conference quarterly. The DON was interviewed on [DATE] at 3:00 p.m. She stated, The times on the bowel and bladder sheets are just the times that the CNAs documented the task. It should be every two hours. If you are seeing five to six hours in between, then that is something that is absolutely a problem. They should be documenting as close to when they are doing the task as possible. They are probably sitting down and documenting it all at the same time. The documentation is a continuous problem. -She stated that the physician and POA should be notified immediately and was not aware that this was not being done. She said the family should be involved in decisions made about interventions put into place after a fall but they probably were not. She agreed that the incident reports did not have much information about the falls documented and they are not filled out to the best practice standards. She agreed that the care plan should be updated after every fall. She was aware the resident had nine falls, but was not aware that no new interventions were being placed on the care plans. III. Resident #36 Resident #36, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the ,[DATE] medication review report, the resident's [DIAGNOSES REDACTED]. According to the [DATE] quarterly minimum data sheet (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The care plan, initiated [DATE] and revised [DATE], identified high risk for falls related to dementia, psychoactive drug use, unsteady gait and balance when not using walker, and poor safety awareness as evidenced by history multiple falls. Interventions included: Anticipate needs . Be sure resident's call light within reach and encourage the resident to use it for assistance as needed . Follow facility fall protocol . Physical therapy evaluate and treat as ordered or as needed . Review information on past falls an attempt to determine cause of falls. Record the possible root causes . The care plan was not updated after the resident's fall on [DATE] (see below). A. Observations On [DATE] at 11:38 a.m., the resident was observed sitting in a recliner chair in the living room area, sleeping. On [DATE] at 4:20 p.m., the resident was observed sitting in a recliner chair, awake. B. Record Review Fall on [DATE]: According to the incident report, dated [DATE], the resident was found by an RN on floor next to bed. RN call for certified nurse aide (CNA) for assistance was completed. Floor mat was in place and resident was assessed for injuries. Resident denied injury or pain. RN found scrape on resident right lateral buttock and resident was returned to bed. Vital signs (VS) were all within normal limits (WNL). -Immediate action taken: 72 hour fall monitoring initiated and assessment was completed. Resident taken to hospital? No. -Injuries observed: no injuries observed -Level of consciousness: alert -Mental status: (blank) -Injuries post incident: no injuries observed -Mental status: (blank) -Predisposing environmental factors: poor lighting -Predisposing physiological factors: confused, gait balance -Predisposing situation factors: ambulating with assist -Witnesses: No witnesses found -Agencies/people notified: No notifications found. No new interventions were addressed. According to the progress notes for [DATE]: -[DATE]: Resident was found by RN on floor next to bed. RN called for CNA for assistance to return resident to bed after assessment was completed. Floor mat was in place and resident was assessed for injuries. Resident denies injury or pain. RN found scrape on resident lateral buttock and resident was returned to bed. VS were all WNL. Neuro assessment was negative. 72 hour fall monitoring initiated and assessment was completed. According to the Morse fall scale, dated [DATE], the score was 65, high risk for falling. According to the physical therapy (PT) screen, dated [DATE], Screen performed secondary to reports of recent decline in gait. Patient is ambulating well. CNAs report that his decline in gait is volitional. Patient would not benefit from therapy at this time. There was no evidence a new therapy screen was requested following the resident's fall. C. Family Interview A family member for resident #36 was interviewed on [DATE] at 3:30 p.m. When asked about this resident's fall, she said that they would usually call her if there was a fall. I would be the one. She said nobody had called her. The last fall she knew about was approximately six months ago. D. Staff interviews CNA #9 was interviewed on [DATE] at 8:45 a.m. She said she did not know the last time this resident had a fall. She said he had gotten better since he was admitted into the secure unit. The RN #15 was interviewed on [DATE] at 9:45 a.m. She said she was not there when this resident had fallen. Interventions included: supervision, room checks, rounding and ensuring there were no hazards in the way. The PT #20 was interviewed on [DATE] at 10:00 a.m. She said they did a screen on him because there was a decline in ambulation. He was not interested. He had a restorative goal of encouraging him to walk. The CNA coordinator #10 was interviewed on [DATE] at 10:40 a.m. When asked about fall interventions, she said they had two hour rounding, really more than every two hours. They would check to see if the resident was safe or if they needed to use the bathroom. The DON was interviewed on [DATE] at 1:40 p.m. She said the incident reports she provided were not completed to her standards. She said the care plans should have been updated with changes and other falls. She confirmed that the fall interventions were not documented. She said it should have been documented in the electronic medical record. She also said they should have notified the power of attorney (POA) right away after a fall. IV. Resident #18 Resident #18, age 90, was admitted on [DATE] and readmitted on [DATE]. According to the ,[DATE] medication review report, the resident's [DIAGNOSES REDACTED]. According to the [DATE] quarterly MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The care plan, initiated [DATE] and revised [DATE], identified the problem Resident is high risk for falls related to poor safety awareness and unsteady gait/balance. Interventions included: Be sure resident's call light is within reach when in room and encourage him to use it . Follow facility protocol . Anticipate and meet resident's needs . Ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The care plan was not updated after the resident's falls (see below). A. Observations On [DATE] at 11:38 a.m., the resident was observed in the secure unit dining room waiting for lunch meal. On [DATE] at 1:05 p.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in two of two kitchens. The facility failed to ensure: -Cleanliness in the kitchen; -Expired foods were disposed of; -Foods were dated/ sealed; and -Hairnets were used. The findings included: I. Cleanliness in the kitchen A. Expectations According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13) page 55, Nonfood-contact surfaces shall be constructed of approved materials, in good repair, and be easily maintained in a clean and sanitary condition. B. Observations The main kitchen was observed on 7/25/16 at 11:00 a.m. with the following: -Food spatter along the outside of the trash can, next to the sandwich station. -Food spatter along the back side of the sandwich station. -The hood was covered with lint along the top edge. -The walk-in freezer was observed with a liquid spill/trash along the flooring underneath the shelving on the right. -The flooring outside the dry storage area was observed with deep stains. -The tall freezer was observed with liquid food stains on the outside. -The outside of the robot coupe was observed with food spatter. -The outside of the blender was observed with food spatter. -The microwave was observed dirty along the inside and outside. -The shelving underneath the food prep area was observed as dirty. -The knobs along the outside of the steam table were observed as dirty. The main kitchen was observed again on 7/27/16 at 9:10 a.m. with the following: -The hand washing sink and the wall behind the sink were observed as dirty. -The microwave was observed dirty along the inside and outside. -Three spatulas were hanging as clean, observed with dried on food particles. The main kitchen was observed on 7/27/16 at 11:32 a.m. with the following: -The ceiling above the oven was observed with lint. The secure unit kitchen was observed on 7/27/16 at 12:10 p.m. with the following: -Four out of five white mugs were observed with deep stains along the inside of the mugs. -The microwave was observed as dirty along the inside and outside. II. Expired Foods A. Expectations According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations, page 26, Food shall be in sound condition, free from spoilage or contamination and shall be safe for human consumption. B. Observations The main kitchen was observed on 7/25/16 at 11:00 a.m. with the following: -Two full cases and eight cans of [MEDICATION NAME] 1.5 were observed with a use by date of 7/1/16. The main kitchen was observed again on 7/27/16 at 9:20 a.m. with the following: -The lower refrigerated portion of the sandwich station was observed with a container of 2% milk dated with a best by date of 7/24/16. III. Dating/Sealing of Foods A. Expectations According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations, page 49, Refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. B. Observations The main kitchen was observed on 7/25/16 at 11:00 a.m. with the following: -The tall freezer contained 2 bowls of ice cream, uncovered and undated. -The tall freezer contained a large clear bag of onion rings, unsealed. -In the dry storage area, a large clear container of breading mix was observed, undated and unlabeled. -In the dry storage area, a large clear container of granulated sugar was observed, undated and unlabeled. -The upper refrigerated portion of the sandwich station contained one stack of American cheese slices and one stack of white cheese slices, undated. -The lower refrigerated portion of the sandwich station contained three stacks of American cheese, undated. The main kitchen was observed again on 7/27/16 at 9:20 a.m. with the following: -The tall refrigerator contained a loaf of rye bread and a clear bag of bagels, undated. -The upper refrigerated portion of the sandwich station contained two stacks of white cheese slices, undated. -The lower refrigerated portion of the sandwich station contained two stacks of American cheese, undated. -The tall freezer contained a clear bag of a breaded food item, undated and unlabeled. -In the dry storage area, a large clear container of breading mix was observed, undated and unlabeled. -In the dry storage area, a large clear container of granulated sugar was observed, undated and unlabeled. -Below the food prep table, a box of bran flakes was observed, unsealed. IV. Hairnets A. Expectations According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations, page 25, Food employees engaged in food preparation shall wear hair restraints, such as hats, hair coverings, hair or beard nets, or other effective means, to effectively keep hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service or single-use articles. B. Facility Standards According to the hair restraint policy provided by the dietary manager on 7/28/16 at 1:21 p.m., dated 7/28/16, All culinary staff members must wear a hat that covers and restrains all exposed hair on the head. C. Observations The main kitchen was observed on 7/25/16 at 11:00 a.m. with the following: -The cook #25 was observed to have walked in and out of the kitchen throughout meal service without a beard net. The main kitchen was observed on 7/27/16 at 9:10 a.m. with the following: -The culinary aide #2 was observed during food production wearing a cap with hair out the back and sides, uncovered. -The dishwasher was observed wearing a cap with hair out the back and sides, uncovered. -The culinary aide #2 was observed during food production wearing a cap with hair out the back and sides, uncovered. He was dishing out sherbet into individual bowls. The secure unit kitchen was observed on 7/27/16 at 12:10 p.m. The certified nurse aide (CNA) #9 was observed in food production with shoulder length blonde hair, uncovered. She was preparing a peanut butter, banana, honey sandwich with whipped topping and chocolate syrup. V. Staff Interview The dietary manager (DM) was interviewed on 7/28/16 at 9:15 a.m. When asked about the hood, he said they had been having problems with that. He said they completed deep cleaning once per month. They tried to clean sooner when needed. He said it may not have been getting done every day. They were getting ready to put up some plastic for the area behind the hand washing sink. They had plans to redo the flooring with housekeeping. When asked about the expired [MEDICATION NAME] 1.5, he said he didn't know where that stock had come from. He said that he along with the cook were in charge of disposing of expired foods. He was aware that foods needed labels and dates. He said they would be taking care of the issues in dietary. The registered dietitian (RD) was interviewed on 7/28/16 at 12:53 p.m. When asked about the kitchen sanitation inspections, she said she did not have time to do those. She said that the kitchen was short staffed, more recently.

Based on record review and interview, the facility failed to identify issues with respect to which quality assessment and assurance (QA) activities were necessary and develop and implement appropriate plans of action to correct identified quality deficiencies affecting facility residents. Cross-reference: F241 (E), F248 (D), F281 (E), F309 (D), F323 (G), F 327 (D), F329 (D), F356 (E), F365 (D), F371 (F), F431 (E), F441 (E), and F468 (E). The findings included: Failures to maintain compliance in the areas of quality of life and quality of care, and failures to prevent repeat deficiencies. The facility was cited with 15 deficiencies during the recertification survey exiting 7/28/16: F241 (E), F248 (D), F 281 (E), F309 (D), F323 (G), F327 (D), F329 (D), F356 (E), F365 (D), F371 (F), F431( E), F 441 (E), F468 (E), and F520 (F). Review of the facility's regulatory record revealed it failed to operate a QA program in such a manner as to prevent repeat deficiencies. During the recertification survey dated 7/28/16, the facility was cited with four repeated deficiencies, which had also been cited during the 9/23/15 recertification survey: -F248 Activities to Meet Individual Resident Needs; -F309 Highest Practicable Resident Well-Being regarding Dining Positioning; -F329 Unnecessary Medications; and -F371 Kitchen Sanitation regarding Kitchen Cleanliness and Hairnet Use. The nursing home administrator (NHA) was interviewed on 7/28/16 at approximately 2:15 p.m. He said the facility had a monthly meeting related to quality assurance (QA). He said all the managers and consultant pharmacist and the medical director meet when it is possible but sometimes the medical director or pharmacist might not be able to make it. He said he had talked to a consultant about the facility QA process and they were working towards a new process called quality assurance performance improvement (QAPI). Review of the 7/28/16 survey findings, including repeated deficiencies from the 9/23/15 recertification survey, revealed the facility did not operate an effective quality assurance committee. The committee failed to develop and implement action plans that achieved sustained compliance with federal and state regulations that insured quality of life and quality of care for the facility's residents.

Based on record review, observation, and interview, the facility failed to ensure measures to prevent development and worsening of a pressure ulcer for one (#37) out of one resident reviewed for pressure ulcers, from a sample of 24 residents. Specifically, the facility failed to: -Provide timely, accurate and consistent skin and wound assessments; -Ensure early interventions were in place to prevent pressure ulcer development and worsening of a pressure ulcer; -Ensure a registered dietitian assessed and evaluated the resident timely after the development or worsening of a pressure ulcer; and -Ensure that facility staff consistently provided turning and repositioning every two hours as care planned. These failures contributed to the development of a pressure area that worsened to a stage III and progressed to an unstageable pressure ulcer. -Facility documentation reflected that an area on the resident's left ischial started on 4/30/14 as a red warm area, and then on 5/4/14 a blister that opened. The pressure ulcer was documented as a stage III on 5/18/14, and progressed to an unstageable pressure ulcer on 7/20/14 which remained unstageable as of observation on 11/6/14. -The facility failed to consistently document wound and skin assessments. Wound documentation was scattered throughout the resident's medical record, and some of the documentation could not be found. Weekly assessments, when documented, were often incomplete. -Pressure relieving interventions were delayed, and turning and repositioning were not consistently documented as provided. The findings included: Non-interviewable resident #37, age 88, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident Status: According to the minimum data set ((MDS) dated [DATE], the resident did not have a pressure ulcer. -According to the MDS dated [DATE], the resident had one unstageable pressure ulcer that measured 2.0 cm length x 2.0 cm width x 0.1 cm depth. -According to the most current MDS dated [DATE], the resident had one unstageable pressure ulcer that measured 3.5 cm length x 3.3 cm width x 0.3 cm depth. In addition, the resident was coded as severely impaired with making decisions regarding tasks of daily living. She required extensive assistance with bed mobility, transfers, dressing, and toileting. She required extensive assistance of one person with eating. The resident was incontinent of bowel and bladder. The care plan, initiated 4/26/14, identified "actual impairment to skin integrity related to low Body Mass Index (BMI), incontinence, non- ambulatory due to [MEDICAL CONDITION], and senile dementia." On 5/16/14, a care plan update documented the resident had a "left ischial spine, unstageable ulcer." -The goal was for the pressure ulcer to heal over the next 90 days, and to maintain clean, intact skin. -Interventions included: Encourage good nutrition and hydration, provide diet and nutritional supplements as ordered, pressure redistribution mattress on the bed, avoid doughnut type devices, provide turning and repositioning every two hours when in bed, and shift weight changes when up in wheelchair or chair. -Gel overlay on bed. Staff will not position the resident on her left side and will position her on her back and her right side. Use pillows or foam wedges to keep boney prominences from direct contact. -Nurse wound consultant to assist in care of the pressure ulcer. Provide weekly skin assessments and treatment with documentation to include measurement of the wound width, length, depth, type of tissue, exudates, and any changes. Keep the physician advised of the wound condition. According to the MDS Coordinator, interviewed on the evening of 11/5/14, the pressure redistribution mattress was an air mattress. Observations: On the evening of 11/3/14 during observation of the resident's room, the bed was observed to have an air mattress. The resident was observed in the dining room sitting in a Broda wheelchair with a gel cushion pad and a pad behind her back. The staff was observed to provide assistance to feed the resident. Observations were made on 11/3/14 during the evening at the dinner meal and at lunch time on 11/4/14, and 11/5/14. The resident was observed in bed on her air mattress positioned with pillows to keep pressure off the left ischium between meals after breakfast and after lunch on 11/4/14 and 11/5/14 and again after breakfast on 11/6/14. The resident was only up for meals, she was on bed rest for the remaining time. Record Review: a. Skin Assessment of Pressure Sore Risk -The Braden Scale for Predicting Pressure Sore Risk, dated 4/16/14, documented a score of 14 indicating the resident was at moderate risk for skin breakdown. The 5/18/14 Braden Scale documented the resident's score was 12, indicating high risk for skin breakdown. -According to the nurse's note dated 5/4/14, the resident had a blister that had opened, indicating the resident already had a skin issue at the time of the 5/18/14 assessment for predicting pressure sore risks. b. Treatment Administration Records Treatment Records, in part documented: -On 5/3/14 apply Nutrashield to red area on buttocks. -On 5/4/14 Calazine to open blister on left ischial area daily until healed and as needed, cover with [MEDICATION NAME]. -On 5/14/14 Apply hydrogel gauze in wound bed after cleaning with wound cleaner, cover with bordered [MEDICATION NAME] every day to left ischial area. In June 2014 the order of 5/14/14 continued. In July 2014 the order from 5/14/14 continued through 7/11/14. -On 7/10/14 new orders read: cleanse left buttocks wound with wound cleanser, apply skin prep to peri-wound, apply Santyl to wound bed and follow with [MEDICATION NAME] powder, cover with [MEDICATION NAME]. -On 7/20/14 new orders read: cleanse pressure ulcer to left buttocks with wound cleanser, pat dry, apply skin prep to peri-wound, apply Santyl to wound bed, cover with border foam, and change daily. -On 8/13/14, new orders read: while sitting in chair - tilt for 10-15 minutes every one hour to unweight left ischial. -On 8/26/14, new orders read: cleanse pressure ulcer to left buttocks with wound cleanser, pat dry, apply Santyl to wound, cover with hydrogel gauze, cover with [MEDICATION NAME], and apply skin prep. -On 9/23/14, new orders read: [MEDICATION NAME] powder apply daily to ischial decubitus with stop date of 10/17/14. -On 10/28/14, new orders read: [DIAGNOSES REDACTED]. Please consult with general surgeon. -On 10/28/14, per the general surgeon: Left ischial decubitus since 5/4/14. Agreed with current plan of treatment. Performed sharp debridement of the wound. Wound is healing. c. Occupational Therapy Notes The Occupational Therapy Evaluation dated 5/20/14 in part documented the resident was provided with a new wheelchair cushion that was less firm, and the staff were to refer back to Occupational Therapist (OT) if the new cushion did not satisfy the resident's needs. The resident was also evaluated by OT on 8/1/14 and was to continue with the gel cushion. On 9/25/14 the OT provided a memory foam cushion with gel overlay with instructions that the gel cushion must always be on top for maximal pressure relief. d. Turning and Repositioning The facility used paper documentation until the start of the electronic records system beginning on 10/26/14 for the "Turn and Reposition every 2 hours" order. Review of the paper and electronic documentation revealed that both had multiple instances of missing documentation to indicate the resident had not consistently been turned and repositioned every two hours. Specifically: -During the first five days of November 2014, the resident should have been turned or repositioned a total of 60 times. Review of the documentation revealed the resident was only turned or repositioned 35 out of the 60 times scheduled. -In October during each 24 hour period the resident should have been turned 12 times, with 31 days in the month of October, the resident should have been turned or repositioned in the wheelchair a total of 372 times. Review of the resident's scheduled turning forms revealed that the resident had been turned or repositioned only 172 of the 372 times scheduled. e. Wound and Skin Assessment Records (1) Wound consultant notes Records purportedly written by the wound consultant were dated 5/18, 7/20, 8/25, and 9/21/14. These reports were not signed by the wound consultant. Review of these records revealed the wound (full thickness) was located on the resident's left ischium and it was facility acquired. It was documented as a Stage III ulcer 5/18, and as "unstageable" 7/20, 8/25 and 9/21/14. The wound decreased in size from 2.9 x 3.0 on 5/18, to 2.0 x 2.0 on 7/20 but increased to 2.6 x 2.1 on 8/25 and to 3.2 x 3.2 on 9/21/14. (2) Wound Skin Condition Reports/Weekly Pressure Ulcer Reports On 11/6/14, the Wound Skin Condition Reports/ Weekly Pressure Ulcer Reports completed by facility nurses, were reviewed, beginning with reports dated 9/2/14. On 11/6/14, the Wound Skin Condition Reports/Weekly Pressure Ulcer Reports were requested beginning with the first observation of the left ischial wound, which was approximately 4/30/14. As of survey exit, no the Wound Skin reports had been provided from 4/30/14 through August 2014. The forms provided were void of the location of the wound and the stage of the wound. -9/2/14 - The wound was measured by size in centimeters, length x width x depth, 3.0cm x 2.1 cm x 0.2cm; color 10% red, 75% yellow, 15% black; drainage was serosanguinous; no odor; progress declined; treatment - not effective; no signs or symptoms of infection. Nurse comment: resident had a stage III pressure ulcer. -9/5/14 - Measurements: 3.7 cm x 3.0 cm x 0.2 cm; Color 10% red, 70% yellow, 20% black; Drainage: serosanguinous; no odor; progress declined; treatment not effective; no sign or symptoms of infection. -9/9/14 - Measurements: 3.3 cm x 2.8 cm x 0.2 cm; Color: 15% red, 85% yellow, 0% black; No drainage; No odor; progress improved; treatment effective; no sign or symptoms of infection. -9/12/14 - Measurements: 3.3 cm x 2.7 cm x 0.2 cm; Color, 10% red, 90%yellow; Drainage serosanguinous; no odor; progress improved; treatment effective; no sign or symptoms of infection. -9/15/14 - Measurements: 3.5 cm x 2.1 cm x 0.3 cm; Color 10% red, 88% yellow, 2% black; no drainage; no odor; progress declined; no signs or symptoms of infection. -9/19/14 - Measurements: 3.5 cm x 2.3 cm x 0.3 cm; Color 10% red, 90% yellow; drainage (void of documentation); no odor; progress declined; no sign or symptoms of infection. -9/26/14 - Measurements; 3.2 cm x 3.4 c x 0.3 cm; Color 10% red, 90% yellow; Drainage purulent; no odor; progress no change; no signs or symptoms of infection. -9/30/14 - Measurements; 3.5 cm x 2.6 cm x 0.3 cm; Color 10% red, 90% yellow; no drainage; no odor; progress improved; treatment effective, no signs or symptoms of infection. -10/3/14 - Measurements; 3.3 cm x 3.0 cm x 0.3 cm; Color 15% red, 85% yellow; drainage serosanguinous; no odor; progress (void of documentation); no signs or symptoms of infection. -10/14/14 - Measurements; 3.4 cm x 3.0 cm x 0.3 cm; Color 30% red, 70% yellow; drainage serous; no odor; progress (void of documentation); treatment effective; no signs or symptoms of infection. -10/17/14 - Measurements; 3.5 cm x 3.3 cm x 0.3 cm; Color 60% red, 40% yellow; drainage serosanguinous; no odor; progress (void of documentation); treatment effective; no signs or symptoms of infection -10/21/14 - Measurements; 3.5 cm x 2.7 cm x 0.5 cm; Color 20% red, 80% yellow; drainage none; odor none; progress (void of documentation); treatment effective; no signs or symptoms of infection. Nurse comment: pressure ulcer deepening, wound consultant notified. -10/24/14 - Measurements; 3.0 cm x 3.5 cm x 1.5 cm; Color (void of documentation); drainage none; no odor; progress declined; treatment not effective; no signs or symptoms of infection. -10/28/14 - Measurements; 2.6 cm x 3.2 cm x 0.4 cm; Color 40% red, 60% yellow; drainage none; no odor; progress improved. -10/31/14 - Measurements; 3.3 cm x 3.4 cm x 0.9 cm; Color (void of documentation); drainage (void of documentation); odor (void of documentation); progress (void of documentation). -11/4/14 - Measurements; 3.2 cm x 3.6 cm x 0.6 cm; Color 50% red, 50 % yellow; no drainage; no odor; progress improved. f. Nurses' Notes The Nurse's Note dated 4/30/14 documented the resident had a "raised red lump on her left ischial area. The area was warm to touch with skin intact and very tender to touch. The resident continues on antibiotic medication for urinary tract infection." -On 5/2/14 the Nurse's Note read: "Small hard red area in center of a 5cm red area on the resident's left buttocks." -On 5/4/14 at 7:40 p.m., the nurse documented the resident had a "red area to left ischial that remained to be a firm lump with a 1cm diameter fluid filled blister in the center of the firm red area." She documented that nutrashield was applied and the blister opened. -On 9/26/14 the nurse documented in the electronic record that the pressure ulcer of the left ischial area measured 3.2 cm x 3.4 cm x 0.3 cm deep, the wound bed had 100% yellow slough, wound borders had red granulation, the peri wound area was pink and blanchable. -On 10/8/14 the nurse documented she had spoken with the wound consultant related to having the bed mattress switched to an air mattress. She documented the current bed mattress would be changed in the morning with the air mattress while the resident was up for breakfast. -The nurse's noted dated 10/8/14 indicated the resident was not using an air mattress prior to 10/9/14. (However, the wound consultant notes 8/25 and 9/21/14 (see above) referenced the resident was on an air mattress.) g. Observation On the afternoon of 11/6/14 the resident's wound was observed with the nurse RN. The wound was located on the resident's left ischium. The RN measured the length and width to be 3.0 cm x 2.8 cm with 100% yellow slough in the wound bed. The nurse said the wound was unstageable due to the yellow slough. h. Dietary Records Review of dietary notes revealed the registered dietitian (RD) had made a quarterly assessment on 4/26/14 and documented the resident was currently on 240 ml of nutritional supplement every day at lunch time. -The next documented dietary note was dated 7/23/14, three months later. The assessment documented the RD increased the nutritional supplement to three times per day and added a high calorie, high protein shake between meals twice per day for wound healing. -The dietary note dated 10/27/14 recommend continue current nutritional interventions. Staff Interviews: (1) On 11/6/14 at approximately 1:30 p.m. the Director of Nurses (DON) was interviewed and informed of missing records related to wound assessments 5/14 - 8/14. The DON said the facility had started moving information over to the new electronic system and some information was on paper and some might be electronic. The DON said she would provide what she could find. (2) On 11/6/14 at approximately 11:50 a.m. the RD was interviewed about the pressure ulcer and dietary assessments. The RD said she evaluates in the beginning according to physician orders, then she does a quarterly assessment. She said she does not receive notice to reevaluate every time the pressure ulcer changes. She said the resident was now on two different supplements that provide the nutrition and vitamins to help heal the pressure ulcer. (3) On 11/11/14 at 1:50 p.m., the DON was interviewed again by phone. The DON said she had looked for the missing pressure ulcer documentation in the resident's paper copies and/or electronic records. She said that when the facility started the new electronic system in October 2014 there were concerns that some information could get misplaced. The DON said she believed the resident's wound had not gotten worse since discovery in 5/14. She said the ulcer had first started as an unstageable ulcer and had remained an unstageable ulcer. (But see wound documentation above). She said the wound consultant looked at the ulcer weekly and each month documented a report on the ulcer; however, she also stated the wound consultant did not come to the facility weekly. Rather, the consultant, who was not close by, came to the facility about once a month to observe the wound. She said the wound consultant made recommendations for changes in treatment or devices to consider, and the physician then would review and sign orders accordingly. The DON, after reviewing the wound consultant reports 5/14, 7/20, 8/25 and 9/21/14, agreed she did not see the signature of the wound consultant. She said that the wound consultant should sign the assessments and recommendations made. The DON said the physician had done some debridement of the ulcer. She reiterated that she thought the ulcer had improved. The DON was asked to provide a written documented timeline of events related to the pressure ulcer, and the DON said she would. However, no new information was provided as of 11/13/14.

Based on observation, record review and staff interview, the facility failed to ensure one (#24) of 12 sample residents received care and treatment for [REDACTED].#24's respiratory needs to ensure the resident received proper assistance to maintain her oxygen level above 88% at all times, per physician order. The facility failed to respond promptly to the resident's consistently declining oxygen saturation level. The resident became hypoxic, confused, and delirious and was emergently transported to the hospital. The findings include: A. Professional Reference According to "Medical Surgical Nursing," by Lewis & Collier, 3rd Edition , pages 445 and 814: "The SaO2 is expressed as a percentage. For example, if the SaO2 is 90%, then 90% of the hemoglobin attachments for oxygen have oxygen attached to them." Refer to the following table: "SaO2 (%) Considerations a. >94 Adequate unless client is hemodynamically (refers to the monitoring of blood flow and pressure within the cardiovascular system) unstable. b. 90 Adequate in almost all clients. c. 88 Adequate for clients with chronic hypoxemia (refers to a blood oxygen level that is lower than normal) if no cardiac problems occur. d. <75 Inadequate: Tissue [MEDICAL CONDITION] (refers to a deficiency in tissue oxygenation and is associated with symptoms that reflect inadequate oxygen delivery to vital organs, such as the heart and brain) and cardiac [MEDICAL CONDITION] (irregular heart beat) can be expected." B. Resident #24 Resident #24 originally was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record Review: Record review for resident #24, revealed that the resident was documented as requiring oxygen respiratory care and to maintain oxygen levels of at least 88% at all times. Record review revealed the resident had a fall on 11/25/11 at 7:35 pm. Record review indicated the resident stated "I fell on my butt and hit my head on the wall. I think I broke a rib." Nurse notes for 11/25/11 at 9:10 p.m., revealed the physician requested the facility observe for shortness of breath "which may indicate a perforated lung." Physician order [REDACTED]. Nurse notes revealed the resident was documented as having oxygen saturation of 72% on 3 liters of oxygen during 11/25/11, 11:00 p.m. transport to the ER. Nurse notes revealed the resident returned to the facility on [DATE] at 12:35 a.m., with no documented fractures. The resident's oxygen level was documented as being 63% on 3 liters on 11/26/11 at 1:00 a.m. Further documentation revealed that the resident's oxygen level was documented at 84% on 3 liters on 11/26/11 at 12:45 p.m., 65% on 3 liters of oxygen on 11/27/11 at 12:30 a.m., and 72% on 4 liters of oxygen saturation on 11/27/11 at 2:30 a.m. Resident stated she couldn't take a deep breath per nurse notes on 11/27/11 at 4:00 p.m., and was documented as having oxygen saturation of 77% on 3 liters. Resident did not wish to have more aggressive oxygen respiratory care provided, but the physician was not documented as being notified to the resident's consistent oxygen saturation levels below the ordered 88%. The nurse notes continued to reveal 70% oxygen saturation on 3 liters on 11/28/11 at 12:10 a.m. There were no further nurses' notes after 12:10 a.m., about the resident's respiratory status. On 11/29/11 at 10:00 a.m., the physician assessed the resident. Review of physician progress notes [REDACTED]." and "Today is significantly hypoxic (79). Needed rebreather. Also very delirous and confused." Interview: An interview with a registered nurse (RN) on 11/30/11 at 3:00 p.m., confirmed that the resident's oxygen saturation levels had been consistently falling since her fall on 11/25/11. The RN confirmed that "we should have contacted the doctor sooner. Yes, she was supposed to be above 88%." The RN confirmed that the resident had been resistant to respiratory care, but that the physician had only been notified of the resident's rib pain. The RN stated they had not provided any information to the physician after the resident's return on 11/26/11, related to the low oxygen saturation levels from the resident or her resistance to oyxgen care following her fall. The RN stated that the resident was now at the hospital on aggressive respiratory therapy and pain medications.

Based on observations, interviews and record review, the facility failed to ensure that residents, including five (#32, #16, #53, #35, and #52) of 35 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically: The facility failed to provide adequate supervision and assistive devices for residents #32 and #52. Resident #32 resided on the secure unit (SCU) and had a history of [REDACTED]. The resident fell and sustained a hip fracture. The findings include: A. SCU 1. SCU - General Observations Observations of the SCU, revealed 11 residents resided on the unit. Nine residents on the SCU were wheelchair-bound. All nine had tab alarms on their wheelchairs. Observations in the SCU on 10/18/11 at 3:23 p.m., revealed five or six residents remained on the SCU while the activities aide took the others on an outing. Two certified nurse aides (CNAs) were the only staff on the SCU at that time. Both CNAs were in room #306 assisting a resident who required a two-person transfer. -Two female residents were observed at this time, in wheelchairs in room #305 (directly adjacent to room #306). This was not the room of either of the two residents. One resident (#16) was attempting to propel her wheelchair into the bathroom. The second resident (#53) entered the room behind her and attempted to push resident #16's wheelchair from behind. Resident #53 grabbed the oxygen canister on the back of resident #16's wheelchair and tugged on it. -Resident #53 then began propelling around the room, while resident #16 was able to self-propel into the bathroom. Resident #16 placed her left hand on the grab bar next to the commode and made several unsuccessful attempts to pull herself up into a standing position. She did not have a seatbelt on and no alarm sounded, although she had a tab alarm on her wheelchair. -At approximately 3:28 p.m., one of the CNAs emerged from room #306. She walked by room #305 without taking note of the two residents. The CNA was informed that resident #16 was attempting to stand in the bathroom. The CNA then went to assist that resident to her room for toileting. Observations in the SCU on 10/19/11 at 2:30 p.m., revealed one activities assistant was with several residents at a table in the commons area of the SCU. One CNA was in a resident room, and the second CNA was at the nurse's station. -Resident #35 self-propelled his wheelchair, so it was parallel to a large easy chair, located near the table with the activities assistant. He was in full view of the nurse's station. Over the course of ten minutes, he made multiple unsuccessful attempts to rise from his wheelchair and transfer to the easy chair. He had not released his self-releasing seatbelt. The tab alarm on his wheelchair did not sound. -At 2:40 p.m., the CNA at the nurse's station was asked if resident #35 could safely transfer independently. She stated he could not, and she and the other CNA went to assist him. 2. Resident #32 Resident #32, an [AGE] year-old female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She resided on the secure unit (SCU). a. Observations Observations of the SCU during the four days of survey (10/17-10/20/11), revealed resident #32 was in a Brody wheelchair with both a self-releasing seatbelt and a tab alarm on the chair. She had a brace on her right leg to limit movement, due to her recent surgery for [REDACTED]. b. Record Review Minimum Data Set (MDS) Assessment: A significant change MDS assessment completed on 6/6/11, identified resident #32 as having a BIMS (brief interview for mental status) score of 7. Her BIMS score on a quarterly MDS completed on 8/20/11 was 5. A BIMS score of 0 to 7 was indicative of severe cognitive impairment. Fall Risk Assessment: A fall risk assessment completed on 7/21/11, resulted in a total score of 22, with a score of ten or above indicative of a high risk for falls. Care plan: Resident #32's care plan was most recently reviewed on 10/6/11. The care plan for fall risk, included interventions such as self-releasing seat belt for her wheelchair; tab alarms for wheelchair and bed; low bed; fall mat beside bed; "noodle" placed on bed to define perimeter. The care plan did not address the resident's supervision needs. Documentation of Restraint-free Trial and Falls: A restraint-free trial was initiated on 6/1/11. The resident was selected for this trial because she wanted to walk more on her own. Physical and occupational therapists (PT, OT) assessed the resident and determined she understood the brakes on her walker and their use and that she was able to ambulate safely with a walker. Prior to the trial, the resident had been using a wheelchair with a self-releasing seatbelt. The trial began on 6/1/11 and ended on 6/29/11. The methods and environmental modifications for the trial were: -Resident will use walker w/(with) brakes. Her walker does have a seat. Watch carefully & remind of setting brakes. -Initial gait assessment 6/1/11 -PT/OT with RN (registered nurse) An evaluation of the first 24 hours of the trial stated, "Hasn't fallen, but forgets walker constantly." The 72-hour evaluation stated, "Doing well, but still forgetting walker when going potty." The one week evaluation stated, "No falls, new degree of independence, now resident to get up in AM and resident to join group for lunch..." The 4th week evaluation stated, "Staying in w/c (wheelchair), still gets up to walk from recliner or bed without using walker, undoes tabs, high fall risk." On 6/5/11, the resident fell in her bedroom. She was not using her walker. (found at 4:00 p.m.) On 6/14/11, the resident again fell in her bedroom. She sustained a cut requiring stitches over her eye. (found at 6:40 p.m.) As a result of this trial, the resident returned to using a wheelchair with a self-releasing seatbelt and a tab alarm. Nurses Notes - Additional Falls: -6/26/11, 2:45 p.m. CNA responded to the resident tab alarm and found resident lying on the floor of her room. The resident stated, "I was reaching for a flower and fell on my butt." -6/30/11, IDT (interdisciplinary team) review of fall of 6/26/11. "Was in w/c; bent over to pick up flower, forget to ask for assistance. Tab alarmed staff. (Staff) could not get there fast enough. Staff will attempt to keep her out of (her) room in common area with encouragement, or when in room check on her frequently." -7/18/11, 4:30 p.m. Aide went to resident's bathroom after hearing her call out "help me." Res was sitting with knees pulled up to chest on floor of bathroom. -7/21/11, IDT review of fall of 7/18/11. "Resident self-released her Velcro seat belt to transfer to toilet. Alarm did not sound and discovered a wire had been pulled. Repaired, checked for functioning. Also placed tab on w/c back (illegible)." -8/16/11, 8:10 p.m. "On entering res(ident's) room I found her on the bathroom floor on her back & sitting up, then lying back again. She had voided in toilet, gotten up, threw pj (pajama) bottoms in trash can and evidently turned and fell . She was in sock feet. She'd disconnected her tabs and gotten out of bed without setting alarm off. Noodle on side of bed in place. When we checked bed alarm it was functioning." -8/18/11, IDT review of fall of 8/16/11. "Took tab off while in bed to go to (bathroom). Will change clip-on tab to mattress sensor. On dementia unit with confusion, no safety awareness." -9/14/11, 4:15 p.m. "SCU staff found resident sitting on the floor of the common area next to her w/c. Was leaning against the legs of another SCU resident. Denies hitting her head. No redness or bruise found. Does c/o (complain of) pain in right knee. No edema or redness noted. (Complained of) pain with ROM (range of motion) to both knees. Is anxious and yelling at staff. .. Gave Tylenol Arthritis with other dinner meds. Daughter notified." (A nurse's noted dated 9/15/11, stated the resident was seen by her physician on this date.) -9/15/11, IDT review of fall of 9/14/11 "Does self-release seatbelt. Evidently released & alarm did not go off. Will check for function, assure alarm system is operating." - 9/16/11, "Resident has c/o increased pain this a.m. 'I hurt so bad I can hardly stand it.' Decreased mobility, unable to bear weight, favoring right lower extremity ...new orders to send for x-ray." A subsequent entry that day stated, "This RN notified by (resident's physician) that as evident by x-ray done this a.m., she does have a right hip fracture." The IDT reviews of the falls sustained between 6/5/11 and 9/14/11, did not address the times the falls occurred. All the falls occurred between 2:45 p.m. and 8:10 p.m., with three falls occurring between 4:00 p.m. and 4:30 p.m. There was no evidence that lack of supervision had been considered as a contributor to the falls. Incident Report: An incident report dated 9/14/11, stated the resident was admitted to the hospital for treatment of [REDACTED]. The report read, in pertinent part: -The resident was interviewed by staff after her fall on 9/14/11 and stated, "I reached for it and no one is helping me. My knee hurts." -A certified nurse aide (CNA) found the resident sitting on the floor of the commons area of SCU next to her wheelchair. Her legs were extended in front of her, and she was leaning on (male resident's) legs. She denied hitting her head and complained of right knee pain. Her leg was in good alignment. Tab alarm was not alarming, "not connected to resident?" Mental status (was) confused, anxious, noncooperative. -The nurse's conclusion: Resident fell from w/c while reaching for something. No injury found except for c/o knee pain - improved with scheduled Tylenol arthritis and ibuprofen, ace wrap & ice. -Interventions placed: Tabs on while in wheelchair. Make sure resident's tabs is on & working. -9/16/11 c/o pain in hip, sent to ER for eval X-ray found r hip fx Staff Interviews: The director of nursing (DON) was interviewed on 10/20/11, 12:30 p.m. She stated resident #32 was in the common area on the SCU when she fell on [DATE]. -The DON said, "I know the tab alarm was not sounding." The DON stated she had identified issues with tab alarms on SCU. She had set up a fall room with multiple choices of interventions available to staff. She stated she had empowered the staff to make changes when something, such as a tab alarm, is not working for a resident. For example, when a resident removes tab alarm, staff were to go and get an alarming mattress pad. -The DON stated, "If the alarms are not working, if the resident is taking off the tab alarm, I would expect that staff would go to the fall room to find an alternative." A nurse who periodically provided care for residents on the SCU, was interviewed on 10/20/11 at 9:20 a.m. -The nurse said, staffing on the SCU was as follows: two CNAs on day and evening shifts and one CNA on night shift. An activities assistant was usually on the unit during the day. A charge nurse was assigned part-time to the SCU. -The nurse stated she believed that there should be an additional person on the SCU to assist the two CNAs on day and evening shifts, and that there should be two CNAs assigned to the SCU on the night shift. -The nurse stated that while there were currently only 11 residents on the SCU, nine required two-person assistance with transfers and ambulation. And, several residents on the SCU had behaviors that required frequent monitoring. See general observations on the SCU above. B. Non SCU Resident #52 Resident #52, an [AGE] year-old male, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to his 10/4/11 MDS, resident #52 had a BIMS score of 10, no behavioral issues, was tired and had no energy, needed limited one-person assistance with activities of daily living, used a walker and wheelchair, and had a suprapubic catheter. He had a urinary tract infection (UTI) within the last 30 days. His gait and balance were unsteady, and he had experienced falls with injuries. Review of physician orders, revealed the resident received, among other medications, Cymbalta (antidepressant), Restoril (hypnotic), Lasix (diuretic), Atenolol (antihypertensive); a. Record Review Fall Risk Assessment: The resident's most recent fall risk assessment, dated 8/16/11, scored him at 18. A score of ten or more signifies high risk. Care Plan: The resident's care plan, dated 2/18/10 and revised on 9/1/11, identified risk for falls and injury due to unsteady gait, history of falls with injury, and iron deficiency. Approaches were: - Remind resident not to stand without assist or use of front wheeled walker. - Assess for safety alternative. Tab alarm in bed to alert staff he is getting up without supervision. - Resident uses front wheeled walker when ambulating. Restorative nursing program for ambulation, ROM (range of motion), dressing, grooming. - Resident has a light touch call light that staff encourage him to use when he is in his room. Make sure path is free of obstacles and staff remind him frequently, whenever they lay him down, to use the call light to call for help with transfers, etc. to avoid another fall. b. Staff Interview The charge nurse on duty, was interviewed on 10/17/11 at 3 p.m. When asked if the resident had any falls within the last 30 days, she said he fell on [DATE] and 9/23/11. On 9/4/11, he had a skin tear to his left upper arm, which was now healed over. On 9/23/11, there were no injuries. c. Resident observations The resident was observed using a wheelchair for ambulation during the survey conducted 10/17-10/20/11. He spent most of his time in bed sleeping or in his wheelchair. - On 10/17/11 during lunch, he was observed sleeping at the dining room table, sitting in his wheelchair. - On 10/17/11 at 4:30 p.m., he was sitting in his wheelchair in the doorway of his room. - On 10/18/11 at 11:55 a.m., he was observed sitting in the dining room, with bruising to the top of his left hand, and a lap belt strapped loosely across his waist. - On 10/19/11 at 9 a.m., he was in an exercise activity, but was not participating. At 9:40 a.m., he was sleeping in his wheelchair at the back of the activity circle. His daughter was sitting next to him. - On 10/19/11 at 10:50 a.m., he was in an activity with his head resting on the table, sleeping. - On 10/19/11 at 11:42 a.m., he was walking to the dining room with two staff, one following with a wheelchair. At 11:50 a.m., he was sitting at the dining room table waiting for lunch. He said he was tired and a little hungry. He said it felt good to stretch his legs. - On 10/20/11 at 8:45 a.m., he was sleeping in his bed, his legs and blankets hanging over the edge and almost resting on the floor. A nurse was alerted and entered his room to assist him. The resident was observed to have a TAB alarm and self-release alarming seat belt when up in his wheelchair, and a TAB alarm when in his bed. d. Failure to ensure the resident received adequate supervision and assistive devices to prevent accidents. (1) Interview The resident's daughter was interviewed on 10/19/11 at 9:50 a.m. She said, "Morning is the time he's usually awake. He had a bad week last week. He seems to be sleeping more, he's a little combative. He had a fall about a month ago. Sometimes I think the alarms aren't on because he has a bed alarm and a pull tab. They said the pull tab was still on him and the alarm didn't go off. I know a lot of times they have a lot of new people and it's hard for them to remember every step." - "They wanted to add a medication for anxiety a couple of months ago and I refused to sign for that. He's sleepy enough already. I didn't want to sign for the Restoril (hypnotic). They assure me they never give it to him past 1 a.m., and only when he needs it. He often refuses it. Often he'll go to bed at 6 p.m., and wake up at 10 p.m., very restless. When he sleeps so much he's got to have some awake time. They shouldn't give him a sleeping pill just because he's awake at night." - "He was walking a lot until he fell in December and fractured his vertebra ... Now he's in a wheelchair versus a walker." - "In December the CNA (certified nurse aide) found him on the floor and was trying to get him up although he'd fallen and the CNA didn't know it. The CNAs that come in on the staggered shift at 3 and 4 p.m., don't get the shift report. ...They need better communication." (2) Record Review Care Plan: See above; the resident's care plan was not updated when the resident experienced recent falls, that he used a wheelchair now, not a walker. There was no approach regarding resident history of removing his TAB alarm (see below), and no mention that the resident also had a sensor alarm on his bed (per family and staff interviews below). - Although the resident had urinary tract infections (see nurses' notes below), which caused intermittent confusion; and took multiple medications, which could have added to his fall risk, including Cymbalta (antidepressant), Restoril (hypnotic), Lasix (diuretic), Atenolol (antihypertensive); these items were not identified on his care plan as potential fall risks. Nurses' Notes and Fall Investigations: Review of nurses' notes and fall investigation reports, revealed resident #52 was assessed at high risk for falls, but was not adequately supervised to prevent falls and accidents. (a) The resident fell on [DATE] at 7:10 a.m. He was found sitting up with his back against the bed and a CNA at his side. The nurse noted a moderate amount of blood on the floor and on the bed frame from the resident's arms. He had skin tears to his left elbow, left forearm, right elbow and left upper lateral rib area. He had an abrasion to his back 5 x 4 cm from his fall against the bed. The resident was noted to have "no safety awareness," was on antibiotics for a urinary tract infection, and his mattress sensor was "not plugged in - pt knows how to take off tabs slip also." The resident was sent to the hospital due to back pain (8/10), and diagnosed with [REDACTED]. Per nurses' notes, the resident was taking Cipro for a urinary tract infection starting on 12/10/10 (two days before the fall). There were no notes after 12/10/10, until the fall on 12/12/10, to indicate that the resident was being monitored for safety, given his infection, cognition, and poor intake. The resident's care plan was not updated to state that he removed his alarms. Interventions were staff education, educate resident to use call light, and physical/occupational therapy. (b) On 9/4/11 at 5 a.m., the resident was found in bed with dried blood on his sheet. Exam revealed two skin tears to his left upper arm and a red mark on his face, to his left cheek. The resident was noted to have said, "I fell awhile back." The nurse noted he was "restless all night - set off TABS (alarm) multiple times, but was found sitting on edge of bed each time. No fall witnessed. Resident cannot tell when he fell ." On 9/8/11, the interdisciplinary team (IDT) met to review the resident's 9/4/11 incident and discuss. The notes documented there were no skin tears. Resident did state that he fell , but no evidence of a fall. There was no evidence the IDT took action to prevent recurrence, or that the care plan was updated or staff educated to provide additional monitoring. IDT review was four days after the incident. The tab alarm was noted in use and working; there was no evidence the IDT investigated how the resident, who had been restless all night and found sitting on the edge of the bed, had fallen without staff knowledge. (c) On 9/23/11 at 5:30 a.m., the resident was found sitting on the floor at the head of the bed with his back against the bed. His TABS alarm was attached, but his sensor pad was disconnected. The resident was wearing socks. No injuries were documented. There was no evidence that the resident's care plan was updated. Interventions stated to "make sure & check that sensor pads are connected & working." The use of gripper socks, increased supervision and monitoring, and the trend that the resident was falling in the early morning hours, were not listed as interventions. IDT review of the fall was noted on 9/29/11, six days after the resident's fall. It was documented that the resident got up, disconnected TAB and had socks on, without assist, ended up on floor. They questioned whether hypoxia was the cause, and noted, "Staff will be inserviced on checking on rounds that safety devices are connected & operable. No injury - low bed with tab. All proper entities notified." The resident's care plan was not updated, and there were no specific details on how staff were to anticipate the resident's needs, or how often he should be monitored for safety. (d) Staff interview The charge nurse on duty, was interviewed at 1:30 p.m. on 10/20/11. The charge nurse acknowledged that the care plan was not updated appropriately. -She said, "He does still have both, a tab alarm and a sensor pad. If his tab alarm was going off constantly they should have gotten him up and met whatever the need was." -Upon reviewing the incident report documentation, the charge nurse said, "This is what's happening - he's having a need and it's not being met. They can encourage him to get up, go to the bathroom, get something to eat. We can fix that - they're all falling into that same kind of realm it looks like (early morning, unwitnessed falls or accidents where the resident is experiencing agitation). The charge nurse said, "The restlessness at night was the reason that Restoril was ordered. We should absolutely request the Restoril to be PRN (as needed) at least if not just DC'd (discontinued) if he's refusing it that much." The resident's October 2011 medication administration record, showed he had been given Restoril, 15 mg every evening at bedtime, for insomnia, since 7/25/11. During the month of October, he had refused the Restoril 15 times out of 18 nights. One night was blank. The director of nursing and nursing home administrator (NHA) were interviewed the afternoon of 10/20/11, and the findings above were discussed. They acknowledged the resident's care plan should have been updated, and that monitoring, supervision, and checking that alarms were operational should have been done, but were not regularly scheduled. The NHA said the facility was reconsidering the use of alarms, after current findings suggested alarms increased accidents.