Every finding on record at Katherine and Charles Hover Green Houses

Based on record review, observations, and interviews, the facility failed to ensure two (#4 and #28) out of three residents received services and assistance to prevent a reduction in range of motion out of 31 sample residents. Resident #4 was admitted to the facility on [DATE]. According to diagnoses on admission, Resident #4 did not admit to the facility with a contracture to her hands, but based on observations and interviews on 1/26/26 to 1/29/26, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her hands. The facility's failure to provide services to maintain the resident's mobility contributed to a decline in the mobility of the resident's left and right hand. Specifically, the facility failed to ensure Resident #4 and Resident #28's contracture prevention devices were consistently in place. Findings include:I. Resident #4A. Resident status Resident #4, age [AGE], was admitted on [DATE]. The resident was admitted to hospice care on 1/23/23. According to the January 2026 computerized physician orders (CPO), diagnoses included fracture to the left femur with surgical intervention, difficulty walking, muscle weakness and a history of falls prior to admission. The 11/15/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. The resident required extensive one-two person physical assistance with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. The resident had functional limitations in range of motion of her upper and lower extremities. She was enrolled in hospice and had not received any therapy or restorative services during the MDS look back period. -No splint or brace assistance were indicated on the MDS. B. Resident representative interview The resident representative was interviewed on 1/29/26 at 1:46 p.m. She said Resident #4 did not have contractures when she was first admitted to the facility. She said Resident #4 developed the contractures in both of her hands while residing at the facility. She said sometimes there was a lack of communication from the therapy staff to the nursing staff. She said because of this lack of communication, the nursing staff were unaware of interventions such as splints needed to be applied to to prevent contractures. She says she had to put large signs on Resident #4's door to remind the nursing staff how to care for Resident #4. She said the contractures have gotten significantly worse over the past few years while Resident #4 resided at the facility.C. ObservationsOn 1/26/26 at 9:56 a.m. Resident #4 was lying in bed, supine, with her arms folded at her chest and covered with a blanket. Resident #4 had contractors to both hands, wrist and fingers with no splints in place. On 1/26/26 at 3:14 p.m. Resident #4 remained lying supine with her arms folded at her chest. Resident #4 had contractures of bilateral hands, wrist and fingers with no splints in place. The fingers on the resident's left and right hand curled in touching the palm of her hand.On 1/29/26 at 1:30 p.m. Resident #4 was lying in her bed on her back with cloth fabric between her fingers and the palm of her hands. Registered nurse (RN) #5 attempted to open the palm of the hands of Resident #4 for a skin check. Resident #4 started to grimace in her face. Resident number four was unable to completely open both of her hands. -There were no palm protectors or hand rolls observed on the resident's hands. RN #5 did not offer palm protectors to the resident before she left the room. D. Record reviewA review of Resident #4's mobility care plan, revised X, revealed the resident had a potential for limited physical mobility due to dementia and had a habit to clasp her hands in tight fists. She was able to grasp cups usually on demand or with assistance. Palm protectors have been offered, but Resident #4 takes them off and preferred not to use them. She had many stuffed animals which she could hold (initiated 12/27/21and revised on 7/25/24). Pertinent interventions included physical therapy and occupational therapy referrals as ordered and as needed, monitoring, documenting and reporting any signs and symptoms of immobility, contractures forming or worsening and skin-breakdown (initiated 12/27/21) and providing gentle range of motion as tolerated with daily care. (initiated 7/25/24).-The care plan did not mention the resident had an actual hand contracture on both hands and was not able to extend her fingers. In addition, no interventions were in place to minimize the contracture. Intervention for gentle range of motion did not mention the location of motion of the area. A review of Residents #4's CPO revealed the following order.Gently apply handgrips to bilateral hands daily. Leave in place unless showering or providing hand hygiene every day shift and every night shift. Ordered 11/12/25-However, observations revealed the facility staff failed to apply the palm protectors to her bilateral hands. -Resident's hand contractures were not monitored for worsening. There was no documentation of progression of the contractures, monitoring or measurements of the contracture to the resident's left and right hand in the most recent OT evaluation or elsewhere in the resident's record. II. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2026 CPO, diagnoses included spastic hemiplegia (a form of cerebral palsy causing one-sided muscle stiffness) affecting the right dominant side, contracture of muscles of right thigh, contractures of the right knee, muscle weakness, contracture of the right elbow and contracture of the right hand. The 1/7/26 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15. The resident required extensive one-two person physical assistance with bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing. The MDS assessment indicated she had functional limitations in range of motion for both the upper extremity and lower extremity on one side. B. Observation On 1/26/26 at 1:44 p.m. Resident #28 was in her bed lying on her back without a splint on her right hand, elbow or right leg. On 1/28/26 at 8:23 a.m. Resident #28 was sitting in her wheelchair in her room receiving medication from licensed practical nurse (LPN) #1. A hand splint, elbow splint and knee braces were in a wooden chair in the corner of her room. -LPN #1 did not apply hand splints or knee braces before she left the room. She did not offer the resident to move to a recliner as recommended in the care plan below for positioning and contracture management. C. Record Review A review of the Resident #28's mobility care plan revealed the resident had limited physical mobility related to contractors and stroke (initiated 4/16/25 and revised on 7/15/25. Pertinent interventions included monitoring, documenting and reporting as needed any signs and symptoms of immobility, contractures forming or worsening and skin-breakdown (initiated 4/16/25) and offer passive range of motion for 60 seconds four times, on each joint with tone inhibition for contracture management during showers and dressing, positioning in recliner with pillow lateral right lower extremity for hip midline and pillow under right heel for knee extension to decrease contracture (initiated 4/16/25).A review of Residents #28's CPO revealed the following order.Resting hand splint up to two times a day up to two hours with checks after 90 minutes every day shift and evening shift. Ordered 1/29/26 at 3:00 p.m. (during the survey).Right elbow splint while up in chair as tolerated every day shift and evening shift. Ordered 1/29/26. -However, observations revealed the facility staff failed to apply the hand and elbow splint and the knee brace. -There was no documentation for monitoring or measurements of the contracture to the resident's right hand and right elbow in the most recent OT evaluation or elsewhere in the resident's record. D. Staff interviews LPN #1 was interviewed on 1/28/26 at 8:30 a.m. LPN #1 said Resident #28 should have her hand and elbow splints on her as much as she could tolerate. LPN #1 said the nursing staff should have applied these blunts after getting Resident #28 up into her wheelchair. CNA #10 was interviewed On 11/28/26 at 11:54 a.m. He said he had worked at the facility for approximately a year. He said the nurses would tell him if a resident needed hand splints to be applied. CNA #10 said information for the need to apply hand splints would be passed verbally from staff to staff during shift reports. He said he was aware Resident #4 and Resident #28 hands were contracted, however, he was unaware Resident #4 and Resident #28 needed hand splints to be applied. CNA #11 was interviewed on 1/28/26 at 12:55 p.m. She said she Resident #28 need total assistance with care. She said the resident needs assistance from the staff to get her out of bed, getting dressed, and partial assistance with meals. She said the resident has contractures on the left side of her body. She said the residents will refuse to wear her hand, arm and knee braces because it will cause her pain. CNA #1 said the braces were to prevent her contractures from getting worse. CNA #1 said nursing staff can apply the braces for as long as the resident can tolerate wearing them. RN #5 was interviewed on 1/29/26 at 1:30 p.m. RN #5 said Resident #4 needed to have a hand splint in her hands in the past at all times because of her contractors in her hands. RN #5 transitioned from a hand splint to a palm guard because her contractures had gotten worse. RN #5 said sometimes the nursing staff forgot to apply the splint to her hand. RN #5 said the nursing staff tried to keep her nails clean and short. RN #5 said Resident #4 developed a pressure wound in her hand due to her contractures but it healed. RN #5 said it was very difficult to open the resident's hands because of her contractures and that's why a thin piece of cloth between resident's fingers and the palm of her hand was used for skin protection. RN #5 said a gentle range of motion could not be done due to how contracted Residents #4 hands were and because she was having pain. RN#5 said Resident #4 uses a thin piece of cloth because she was unable to open her hands. RN #5 said Resident #4 is very weak and was not likely to refuse her palm protector. Occupational therapist (OT) was interviewed on 1/28/26 at 2:56 p.m. He said Resident #4 was not receiving any therapy services at this time. He said the facility did not have restorative staff or a restorative program. The OT said the nursing staff was aware of the availability of the splints to be applied to Resident #28. The OT said he would communicate verbally with the nursing staff regarding how and when to apply the splints to prevent contractures. The director of nursing (DON) and the director of rehabilitation services were interviewed on 1/29/26 at 2:14 p.m. The director of rehabilitation services She said Resident #4 was not receiving occupational therapy because she was on hospice services. The director of rehabilitation services said Resident #28 was currently receiving occupational therapy. She said Resident #28 contractors were monitored by her level of participation in her therapy services. The director of rehabilitation services said there were no measurements for the contractors of Resident #4 and Resident #28. The director of rehabilitation services said there were many ways to measure contractures including the use of a goniometer to quantify the angles of joint restriction. The director of rehabilitation services said the rehabilitation team measured the contractures by the level of pain and the ability to grip items. The director of rehabilitation services said she was unable to find documentation that Resident #4 contractors had been measured while living at the facility. The DON said she was aware of Resident #4 and Resident #28 had contractors but did not know if there were splints ordered for the residents to wear. The DON said the contractures for Resident #4 and Resident #28 had gotten worse. The DON said nursing staff were responsible for applying the splints on the Resident #28.

Based on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one of one (#2) residents reviewed out of 31 sample residents. Resident #2, who was at risk for falls and had a history of falls, experienced eleven falls since her date of admission of 12/2/25. The interdisciplinary team (IDT) determined Resident #2 had poor safety awareness and was impulsive. On 12/12/25 Resident #2 self-propelled herself outside, where her wheelchair tipped off of the sidewalk. Resident #3 was sent to the hospital and was diagnosed with three rib fractures. On 12/17/25 Resident #2 sustained an unwitnessed fall and was bleeding from her head and was running down her neck. She was sent to the hospital.On 12/20/25 the facility implemented a one-to-one caregiver for Resident #2 from 7:00 a.m. until 7:00 p.m. due to Resident #2 having most of her falls during the day. However, Resident #2 had five falls after the one-to-one was implemented; three of the five falls were after 7:00 p.m. and two happened while the one-to-one was present. On 12/30/25 at 6:30 p.m. Resident #2 experienced an additional unwitnessed fall which resulted in her hitting her head and an abrasion on her left pinky and was sent to the emergency department (ED). The resident was supposed to have a one-to-one caregiver, but sustained an unwitnessed fall.Specifically, the facility failed to:-Review the resident's fall to determine if the fall interventions were appropriate; and, -Ensure the fall interventions were consistently in place. Findings include:I. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included Parkinson's disease (neurodegenerative disease of the central nervous system that affects movement), history of falling, dementia and long-term use of anticoagulants (blood thinners). The 12/29/25 minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The assessment revealed Resident #2 needed partial to moderate assistance with most of her activities of daily living (ADL) and needed substantial to maximal assistance with her mobility. The MDS assessment indicated Resident #2 had more than two falls not resulting in injury since admission and one with an injury. B. ObservationsOn 1/27/26 at 3:32 p.m. observations of Resident #2's room revealed her bed could not be seen from the doorway of her bedroom. Resident #2's bed and entry to her bathroom could only be seen by entering her room completely. Resident #2's bed was in the lowest position and had fall mats on either side of the bed. Her bed did not have a weighted blanket on it. On 1/28/26 at 9:05 a.m. Resident #2 was sitting on the couch in the common area. An unidentified staff member was standing a few feet away from the couch, slightly behind and to the side of the couch. The unidentified staff member was looking at his cell phone. On 1/28/25 at 12:44 p.m. Resident #2 was sitting at the dining room table for lunch. The unidentified staff member was going back and forth from the dining room to the kitchen, leaving Resident #2 at the dining room table. -The unidentified staff member was assigned to be the one-to-one caregiver for Resident #2. C. Resident interviewResident #2 was interviewed on 1/26/26 at 4:02 p.m. She said she was admitted to the facility in December 2025. She said she was falling all the time at home. She said she did have some falls at the facility, which was why she had a certified nurse aide (CNA) with her all the time. She said she had fallen in the bathroom, the living room, outside, almost everywhere in the facility. She said she remembered going to the hospital after a fall when she hit her head. She said she was working with physical therapy (PT) and occupational therapy (OT). She said she had Parkinson's which caused her to be unsteady. D. Record reviewThe falls with injury care plan, initiated 12/3/25 and revised 12/10/25, revealed Resident #2 had the potential for falls due to confusion, deconditioning, history of falls, impaired balance, Parkinson's disease, and was on psychoactive and anticoagulant medications. Pertinent interventions included anticipating and meeting her needs, clipping the call light to Resident #2 when she was in bed, placing the bed in the lowest position, offering a weighted blanket for comfort when resting, ensuring the bedside mats were in place as needed for safety, encouraging and assisting Resident #2 to participate in activities that promote exercise, ensuring Resident #2 was wearing appropriate footwear, having commonly used articles within reach, offering activities to minimize potential for falls but to use caution to not over stimulate Resident #2 which can cause anxiety, offering books on tape and word searches, having OT and PT to evaluate and treat as needed, offering the restroom throughout shift, keeping Resident #2 in line of sight as much as possible when she is out of her room and offering to rest in her recliner in the common area. -The care plan did not indicate the resident was to with a one-to-one caregiver from 7:00 a.m to 7:00 p.m. (see below).Review of Resident #2's electronic medical record (EMR) revealed Resident #2 had eleven falls since admitting on 12/2/25. 1. Fall on 12/2/25 at 6:00 p.m. - unwitnessedThe 12/2/25 fall report documented Resident #2 was in her room and was unable to give an account of what happened. The report documented Resident #2 was agitated and flailing her arms. It documented she possibly hit her right elbow on furniture, which caused a skin tear. -Review of Resident #2's EMR did not reveal the facility reviewed the resident's fall to determine if new fall interventions were needed.2. Fall on 12/8/25 at 3:30 p.m. - unwitnessedThe 12/8/25 fall report documented Resident #2 was found on the floor in the visitor's restroom. Resident #2's wheelchair was in the living room. The report documented Resident #2 stated she walked over to use the restroom. The note documented no injury was reported. The 12/9/25 IDT note documented the root cause was Resident #2 had to use the bathroom and chose to walk to the closest bathroom. She then lost her balance and fell. The interventions that were implemented were offering to assist her to the bathroom and to keep in line of sight as possible. 3. Fall on 12/12/25 at 9:21 a.m. - unwitnessed. The 12/12/25 fall report documented Resident #2 had an unwitnessed fall on the sidewalk at 9:21 a.m. The report documented Resident #2 hit her head and was bleeding and was sent to the ED. The report documented the resident said she was going out for a walk and fell. The 12/12/25 IDT note documented the root cause of her fall was the wheels of her wheelchair went off the edge of the sidewalk and her wheelchair tipped and she fell. The fall resulted in minor injuries. (However, the hospital discharge summary documented the resident sustained a fracture of three ribs). It was also reported by staff that Resident #2's wheelchair had been pulling to the right when in use. Interventions implemented after the fall were encouraging the resident to go for walks with staff and have maintenance check her wheelchair function. The 12/14/25 hospital discharge summary revealed Resident #2 was admitted on [DATE] due to a fall. She was discharged on 12/14/25 with diagnoses of a closed fracture of three ribs on the left side and a scalp laceration on the back of her head. 4. Fall on 12/14/25 at 3:15 p.m. - unwitnessedThe 12/14/25 fall report documented Resident #2 was found in the dining room, lying on her back next to the dining room table and her wheelchair was near. The report documented the fall was unwitnessed. Resident #2 sustained a skin tear to her right elbow and was unable to state what happened. The 12/15/25 IDT note documented the root cause was the resident continued to transfer and ambulate without assistance, poor safety awareness and impulsivity. New interventions implemented were continuing to work with therapy and offering to ambulate with the resident. 5. Fall on 12/17/25 at 6:20 a.m. - unwitnessedThe 12/17/25 fall report documented Resident #2 was found on the floor mat next to her bed, sitting upright on both of her knees. Blood was noted on the carpet and floor mat. Resident #2 was noted to have blood dripping from her head running down her neck and onto her night gown. The nurse was unable to determine the exact location of the injury. The report documented Resident #2 was not having any pain and was sent to the ED. The 12/17/25 IDT note documented the IDT reviewed falls from 12/8/25, 12/12/25, 12/14/25 and 12/17/25. The note documented interventions upon admission were low bed with mats, educating the resident on the call system, having the resident in a room that was off the common area, and the resident was evaluated by therapy. The interventions listed post falls were keeping in line of sight as possible, offering assistance to bathroom frequently, medication review with increased pain medication, and offering to ambulate Resident #2 so she has help. The note documented that the interventions were for mitigating injuries rather than preventing falls. 6. Fall on 12/19/25 at 1:35 p.m. - unwitnessed. The 12/19/25 fall report documented Resident #2 had an unwitnessed fall from her chair to the floor. The report documented Resident #2 could not say what happened or why she was on the floor. The report documented no injuries were noted. The 12/22/25 IDT note documented the fall on 12/19/25 did not result in injury. They determined the root cause was Resident #2 had Parkinson's and did not know her limits. The note documented she had poor safety awareness. Resident #2 stood up and attempted to ambulate without assistance and fell. New interventions were to move her recliner to the common area and to keep her in line of sight as much as possible. The 12/24/24 IDT note documented the team reviewed Resident #2's falls from 12/17/25 and 12/19/25. The team initiated a one-to-one on 12/20/25 during daylight hours. The team determined she only fell during the day. The root cause was determined to be Resident #2 had no safety awareness, was confused, her cognition fluctuated, and she was impulsive. -However, the one-to-one intervention was not added to her care plan (see care plan above) and the one-on-one caregiver was not consistently with the resident (see observations above).7. Fall on 12/30/25 at 6:30 p.m. - unwitnessedThe 12/30/25 fall report documented the CNA that was assigned to provide one-on-one care for Resident #2, left the resident sitting at the dining room table and went to assist another resident in a room. She then heard a loud crash and came out to dining room. The CNA found Resident #2 on the floor and had hit her head on the ground. The registered nurse (RN) assessed Resident #2 and noted the area on the back of her as feeling soft and a small abrasion on her left pinky finger. Resident #2 was sent to the ED. The 12/31/25 IDT note documented the 12/30/25 fall resulted in an abrasion on Resident #2's left pinky finger and an injury to the back of her head. The note documented the root cause was Resident #2 had no safety awareness and was impulsive due to her diagnosis of Parkinson's disease. Interventions were to continue the one-to-one caregiver and have the medical doctor do a medication review. -However, the one-to-one caregiver left the resident assisted on 12/30/25, when the resident sustained an unwitnessed fall and hit her head.8. Fall on 1/1/26 at 9:00 p.m. - unwitnessedThe 1/1/26 fall report documented Resident #2 was found on her floor mat next to her bed. The bed was in the lowest position. The report documented Resident #2 was unable to describe what happened and no new injuries were found. The 1/2/26 IDT note documented the root cause was Resident #2 was confused and did not call for assistance when needed. No new interventions were implemented. The 1/7/26 IDT note documented the team reviewed the fall that occurred on 1/1/26. The root cause was Resident #2 did not have safety awareness and did not know her limitations. The note documented the one-to-one was from 7:00 a.m. to 7:00 p.m. and the team was considering expanding the one-to-one to around the clock.9. Fall on 1/12/26 at 10:49 a.m. - witnessedThe 1/12/26 fall report documented the resident sustained a witnessed fall in the television room. The report documented the CNA said I was right there with her when she fell. Resident #2 was on the floor next to her chair. Resident #2 obtained a skin tear to her left forearm. The 1/13/26 IDT note documented the root cause was Resident #2 had no safety awareness, was impulsive, had a shuffling gait, poor balance and jerky turns. There were no new interventions put in place. 10. Fall on 1/12/26 at 9:00 p.m. - unwitnessedThe 1/12/26 fall report documented Resident #2 was found on the floor mat between her bed and the window. Resident #2 was unable to say what happened. No injuries were noted. The 1/13/26 IDT note documented the root cause was Resident #2 rolled from her low bed to the fall mat. New interventions implemented clip call cord to Resident #2's clothing while she esd in bed. -However, review of the care plan revealed this intervention was already implemented on 12/3/25. The 1/14/26 IDT documented the two falls on 1/12/26 were reviewed. The note documented new interventions were one-to-one supervision, and in line of sight and to explore providing weighted blanket when she was in bed. -However, the one-to-one was implemented on 12/20/25 and the weighted blanket was originally implemented on 12/3/25.11. Fall on 1/14/26 at 7:55 p.m. - unwitnessedThe 1/14/26 fall report documented Resident #2 was found on her bedside fall mat perpendicular to her low bed. The report documented Resident #2 stated I was adjusting my blanket and fell. There were no injuries documented. The 1/15/26 IDT note documented the root cause for the 1/14/26 fall was Resident #2 was adjusting her blankets and rolled off the low bed onto the fall mat. The new intervention was to offer a trial weighted blanket. The 1/21/26 IDT note documented the team reviewed Resident #2's 1/14/26 fall. The team determined she rolled off her bed while adjusting her blankets. The intervention was to ask the family to bring a weighted blanket. The note documented the blanket is pending. -However, the weighted blanket was originally implemented on 12/3/25.II. Staff interviewsCNA #5 was interviewed on 1/27/26 at 3:22 p.m. She said Resident #2 was on a one-to-one caregiver because she frequently fell while she was by herself. She said she was unsure of how long she had been on the one-to-one caregiver. CNA #6 was interviewed on 1/27/26 at 3:32 p.m. She said Resident #2 was on a one-to-one caregiver because she had frequent falls due to her dementia. She said Resident #2 had a one-to-one caregiver seven days a week from 7:00 a.m. to 7:00 p.m.Licensed practical nurse (LPN) #1 was interviewed on 1/28/26 at 9:15 a.m. She said Resident #2 was a high fall risk. She said she had fallen and sustained sutures and staples in her scalp. She said she had also sustained skin tears from falling. She said she thought her one-to-one caregiver started the beginning of January 2026.CNA #7 was interviewed on 1/28/26 at 9:51 a.m. She said Resident #2 was impulsive, she would be fine one minute and then the next she would not. She said not having a one-to-one caregiver with Resident #2 was not an option for her. She said Resident #2 has been on the one-to-one caregiver since about the time she was admitted to the facility. She said she would have to go over the one-to-one expectations with the agency staff that was there that day. She said she expected the agency to engage with her and to be next to her and to keep her occupied (see observations above). CNA #8 was interviewed on 1/28/26 at 11:29 a.m. She said Resident #2 had been on the one-to-one caregiver for over a month. She said she was on the one-to-one caregiver because of her frequent falls. She said staff always tried to keep a close eye on Resident #2 and talk to her. She said staff would constantly check on her. She said staff could find interventions in the Kardex (a reference guide that has important information on residents). She said there was also a communication book for reporting any changes or updates that CNAs need to know. She said anyone could write in the communication book, but it was information that needed to be passed on to CNAs. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 1/29/26 at 10:30 a.m. They said Resident #2 was admitted to the facility as a high fall risk. They said when she was living at her previous place of residence, she had fallen and broken bones. They said she was here for therapy and was planning on going back to her assisted living facility. They said they thought she would do better in a memory care facility. They said Resident #2's family would need to hire a 24/7 one-to-one caregiver for Resident #2 since she would no longer be on therapy services starting on 1/30/26. They said Resident #2 did not realize she could not walk alone. They said she did not not realize her gait and balance were impaired due to her diagnosis of Parkinson's disease. They said she had a short attention span. They said the resident could be distracted by eating and walking. They said the interventions that were implemented upon admission included placing her bed in a low position, ensuring the fall mats were in place, having the resident reside in a room close to the common area and clipping the call light to her while in bed. They said the interventions that were added were medication review, pain medication review, keeping her in line of sight, frequent toileting and a weighted blanket. They said they were still waiting for the family to bring in the weighted blanket. They said she was officially put on the one-to-one on 12/20/26 from 7:00 a.m. to 7:00 p.m. They said they implemented the 7:00 a.m. to 7:00 p.m. because she was falling during the day. They said she recently started falling in the evening. They said they have not had the ability to officially put her on a one-to-one 24 hours because of staffing. They said they had been completing frequent checks after 7:00 p.m. and if they noticed she was restless they would offer her to go to the common area. They said if they felt she needed to be on a one-to-one caregiver then they would pull the float CNA. They said they felt like they had put every intervention in place to prevent falls and injuries. III. Facility follow-upThe facility sent additional information on 1/30/26 provided by the NHA documenting that Resident #2's falls were clinically unavoidable due to her diagnosis of Parkinson's and her being educated to not stand without assistance but she continued to do so. -However, observations revealed the facility failed to consistently implement the one-to-one caregiver as recommended (see observations above).

Based on observations, record review and interviews, the facility failed to ensure an infection prevention and control program was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four units. Specifically, the facility failed to: -Implement an effective water management plan to monitor for Legionella-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care and transfers for Resident #14 and Resident #24, who was on enhanced barrier precautions (EBP) for wounds; and,-Ensure hand hygiene was performed appropriately in the dining areas. Findings include: I. Water management failures A. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, retrieved on 1/27/26 from https://ww.cdc.gov/contro.-legionella.php/toolkit/potable-water-systems-module.html Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140 degrees F ( fahrenheit) or 60 degrees C (celsius). Ensure hot water in circulation does not fall below 120 degrees F (49 degrees C). Recirculate hot water continuously, if possible. Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 degrees F, 25-45 degrees C). Legionella may grow at temperatures as low as 68 degrees F (20 degrees C). Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Ensure disinfectant residual is detectable throughout the potable water system. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. Consider testing for Legionella in accordance with the routine testing module of this toolkit. B. Record review A request for the facility's water management plan was made on 1/28/26 at 11:00 a.m The NHA said the facility did not have a water management plant (see interview below). C. Staff interviews The NHA was interviewed on 1/29/26 at 12:33 p.m. The NHA said she was unable to locate the facility water management plan . She said the facility should have a water management plan. The water management plan prevents the introduction and spread of Legionella in the facility water system. The plant operations director was interviewed on 1/29/26 at 12:43 p.m. He said the facility had tankless hot water heaters. He said these heaters did not have standing water, so he did not need to have a water management plan. II. EBP failures A. Facility policy and procedure The Infection Control policy, undated, was received from the nursing home administrator (NHA) on 1/28/26 at 5:36 a.m. The policy read in pertinent part, The enhanced barrier precautions refers to infection prevention and control interventions designed to reduce the transmission of multi drug resistant organisms (MDRO) during high contact resident care activities. Enhanced barrier precautions are applied when a resident is infected or colonized with a MDRO or if a resident has a wound or indwelling medical device during high contact activities. Examples of high contact resident care activities requiring the use of gown and gloves include dressing, bathing and showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing Linens, prolonged High contact activity with internal medical devices, and wound care. B. Observations On 1/27/26 at 9:36 a.m. licensed practical nurse (LPN) #1 completed wound care for Resident #14. She completed hand hygiene and donned (put on) gloves. There was a sign on Resident #14's door that indicated she was on EBP. -LPN #1 failed to put on a gown prior to completing wound care for Resident #14, who was on EBP. On 1/27/26 at 2:12 p.m. certified nurse aide (CNA) #3 and CNA #4 were assisting Resident #24 transfer from her wheelchair to her bed using a mechanical lift. Both CNA #3 and CNA #4 completed hand hygiene and donned gloves and a mask prior to assisting the resident. CNA #3 and CNA #4 provided incontinence care forResident #24 during the transfer. There was a sign on Resident #24's door that indicated she was on EBP because of her pressure wounds. -CNA #3 and CNA #4 failed to put on a gown prior to completing cares for Resident #24, who was on EBP. On 1/27/26 at 2:32 p.m.LPN #1 completed wound care for Resident #24LPN #1 completed hand hygiene and donned gloves. There was a sign on Resident #24's door that indicated she was on EBP. -LPN #1 failed to put on a gown prior to completing wound care for Resident #24, who was on EBP. C.Staff interviews CNA #3 and CNA #4 were interviewed together on 1/27/26 at 2:55 p.m. CNA #3 said she only wore gloves when providing care to Resident #24 because she was helping with toileting hygiene. She said the only staff that wore gowns were the nurses when they were changing the resident's wound dressing. She said she did not know she was required to wear a gown when providing incontinent care. CNA #4 said she did not know Resident #24 was on precaution for any reason. She said she always wore gloves when assisting a resident to prevent the resident from getting an infection. She said she did not remember receiving training on infection control from the facility. LPN #1 was interviewed on 1/28/26 at 2:00 p.m. She said she was supposed to wear a gown with gloves when doing wound care for Resident #14 and Resident #24. She said she did not wear a gown, because they were too small. She said she received training on EBP from the facility when she was hired. She said the reason for a resident to have EBP was to prevent the resident from getting contaminated with bacteria and possible infection. The director of nursing (DON) was interviewed on 1/28/26 at 3:12 p.m. The DON said she had completed the CDC in infection prevention training. The DON said she would provide nursing staff with education regarding infection control protocol. The DON said she would have the nursing staff provide a return demonstration of standards of care for PPE donning. The DON said EBP and contact precautions were very different. She said if a resident were on contact precautions, the nursing staff would be required to wear gowns, gloves, mask with goggles before entering their room. The DON said gloves and gowns were required for all nursing staff engaged high-contact resident care activities if a resident was on EBP. She said all nursing staff were expected to follow all of the requirements for EBP. The DON said the nurses were trained upon hire, annually and as needed. The DON said she did infection control audits on facility staff for transmission based precautions earlier this month. The DON and the infection preventionist (IP) were interviewed together on 1/29/26 10:29 a.m. The IP said she would do training for all nursing staff on EBP beginning today. The IP said she would watch all of the nursing staff to ensure they were wearing the correct PPE. She said it was important for the nursing staff to understand the importance of adhering to EBP to protect the resident and to protect the staff as well. She said infections could spread very quickly so the key was to follow professional standards of care. III. Hand hygiene failures A. Observations Observations of Catalpa house on 1/26/26 at 11:23 a.m. CNA #1 touched the rims of six glasses with her fingers as she placed them on the table. She was not observed to wash or sanitize her hands prior to touching the rims of the six glasses. Observations of Catalpa house on 1/28/26 at 11:00 a.m. revealed CNA #1 was setting the table with eight place mats, cloth napkins and silverware. CNA #1 was not observed to wash or sanitize her hands prior to pre-setting the table for the lunch meal. At 12:16 p.m. Resident #30 ambulated herself with the use of her right hand, to propel to the dining table. Her right hand touched the push rim of the right wheel. Also at this time, Resident #18, with the use of a front wheeled walker, ambulated herself to the dining table. Her hands gripped the hands on the walker during ambulation. Neither resident was offered or assisted with hand sanitization at the table. B. Staff interviews CNA #2 was interviewed on 1/28/26 at 12:33 p.m. CNA #2 said she was not in the dining room when Residents #18 and #30 came to the dining table. CNA #2 said residents' hands should be sanitized at the dining table before a meal service. The registered dietitian (RD) and the dietary manager (DM)were interviewed on 1/29/26 at 7:25 a.m. They said the staff should not be touching the rims of glasses when serving. They said the staff should encourage and help residents sanitize their hands at meal times. The RD said these observations were infection control concerns. The RD said the lack of infection control procedures might result in the spread of germs and a possible outcome might be a resident becoming sick. The RD said staff were educated on infection control procedures upon hire and during yearly in-services.

Based on observations, record review and interviews the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, the facility failed to ensure all staff that were responsible for preparing and cooking meals for the residents were fully educated on proper food handling and food preparation. Findings include:I. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 2/4/26. It read in pertinent part, Employees are properly trained in food safety, including food allergy awareness, as it relates to their assigned duties. Food allergy awareness includes describing food identified as major food allergens and the symptoms that a major food allergen could cause in a sensitive individual who has an allergic reaction. (Chapter 2-103.11)II. Facility policy and procedureThe Food Preparation and Service policy, dated 2001, was provided by the nursing home administrator (NHA) on 1/29/26 at 4:39 p.m. It read in pertinent part, Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to elders. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. III. ObservationsOn 1/27/26 at 3:15 p.m. certified nurse aide (CNA) #5 (who was an agency staff member) began putting silverware away. She did not wash her hands before putting the silverware away. On 1/28/26 at 12:15 p.m. an unidentified agency CNA put on gloves to pass out cucumber salad. The unidentified CNA did not wash his hands before donning (putting on) the gloves. On 1/28/26 at 12:44 p.m. an unidentified agency CNA put on a pair of gloves. He did not wash or sanitize his hands before putting on a new pair of gloves. He began serving plates of pizza and bowls of cucumber salad. He then went into the kitchen and grabbed a piece of pizza with his gloved hand and placed the pizza on a plate. He microwaved the pizza, did not take the temperature of the pizza and served it to a resident. IV. Resident representative interview and resident interviewResident #41's representative was interviewed on 1/26/26 at 11:15 a.m. He said the facility was having the CNAs cook and they did not have adequate training. He said some of the CNAs were good at cooking and some were not. He said the facility used to have homemakers and they would do the cooking and cleaning. The representative said now the CNAs did all of the cooking and cleaning. Resident #5 was interviewed on 1/27/26 at 9:23 a.m. He said the food varied based on who cooked the food. He said when agency staff cooked the food was usually bad. V. Staff interviewsCNA #5 was interviewed on 1/27/26 at 3:27 p.m. She said she was an agency staff member. She said she cooked for the residents from time to time. She said she did not get any training for working in the kitchen. CNA #6 was interviewed on 1/27/26 at 3:36 p.m. She said she was an agency staff member. She said she did not get any training before working in the kitchen. She said there were binders that had recipes and that there were temperature sheets in the kitchen. She said it was very difficult to cook for this population. CNA #7 was interviewed on 1/28/26 at 9:47 a.m. She said she had been working at the facility for almost two years. She said she got some training on temperatures and testing the sanitizer water during her orientation. CNA #8 was interviewed on 1/28/26 at 11:38 a.m. She said she was not trained on how to cook but was trained on temperatures and to follow the recipes. The dietary manager (DM) and the registered dietitian (RD) were interviewed together on 1/29/26 at 1:00 p.m. They said the only person who was ServSafe certified (food safety certificate) was the RD. The RD said she was also certified as a food safety instructor. They said they planned on getting all of the staff ServSafe certified this year. They said the DM did the training on food handling at orientation and then yearly. They said they would do one-on-one training with staff but they did not document those trainings. They said when a resident complained about a meal, it was usually when an agency staff member did the cooking. They said if it were one of the facility's staff members, they had a meeting with the staff member so coaching could be provided. They said the facility staff members should be supporting the agency staff members when they were cooking. They said if a unit only had agency staff working, there were binders that had recipes and lists on what to do in the kitchen. The NHA was interviewed on 1/29/26 at 2:15 p.m. She said the facility staff should be conducting the kitchen duties, such as cooking. The NHA said the facility staff should be supporting and guiding the agency staff while they were in the kitchen. She said the facility did not give agency staff any formal training for working in the kitchen.

Based on record review and interviews, the facility failed to notify the one (#41) of six residents or their representative orally and in writing of a charge for an item out of 31 sample residents. Specifically, the facility failed to provide Resident #41 and his representative notification of an accidental charge for Narcan (medication used for reversal of opioid overdose) and how to get reimbursed for the accidental charge in a timely manner. Findings include: I. Resident #41A. Resident statusResident #41, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included cerebrovascular disease (conditions affecting the brain's blood vessels and supply), dementia, history of transient ischemic attack (stroke), anxiety disorder and muscle weakness. According to the 11/5/25 minimum data set (MDS) assessment Resident #41 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment indicated Resident #41 needed partial to moderate assistance with most of her activities of daily living (ADL). The MDS assessment indicated Resident #41 did have a scheduled abd as needed pain medications.B. Resident representative interviewResident #41's representative was interviewed on 1/26/26 at 12:10 p.m. He said Resident #41 was prescribed tramadol (a narcotic pain reliever) for pain as needed. He said the facility did not talk to him about the fact that Resident #41 was going to need Narcan and the facility charged him for it. Resident #41's representative was interviewed a second time on 1/29/26 at approximately 11:30 a.m. He said he wanted to know what steps he needed to take to get reimbursed for the Narcan. C. Record reviewThe January 2026 CPO revealed the following physician's orders: Tramadol 50 milligrams (mg) every six hours as needed for pain, ordered 8/5/25. Narcan nasal liquid four mg/.1 milliliter (ml) as needed for opioid overdose, ordered 11/26/25. II. Staff interviewsThe director of nursing (DON) was interviewed on 1/27/26 at 3:10 p.m. She said she thought there was a new requirement to have the medication Narcan available for each resident in the facility. She said she misinterpreted the requirement incorrectly. She said the mistake had been fixed. The DON was interviewed again on 1/29/26 at 12:30 p.m. She said Resident #41's representative should not have been billed for the Narcan. She said if the representative brought tin the bill, the facility would reimburse him. The DON was interviewed again on 1/29/26 at 12:46 p.m. She said she was unsure if Resident #41's representative was notified about bringing in the bill for the Narcan to get reimbursed. She said she had talked to him about the Narcan before she realized she had made a mistake. She said only one other family had come and talked to her about the Narcan charge. She said that family had been reimbursed. She said she was only talking to families that came and talked to her about it. She said she did not send out a notification of the mistake to all the families. She said she would talk to the nursing home administrator (NHA) about sending out a letter or email. The DON was interviewed again on 1/29/26 at 1:01 p.m. The DON said she had called Resident #41's representative and told him to bring in the bill for the Narcan. She said she notified the representative that he would be reimbursed.

Findings include:I. Facility policy and procedureThe Required Training policy, reviewed on 1/9/26 was provided by the nursing home administrator (NHA) on 1/29/26 at 2:02 p.m. The policy revealed the facility would comply with State and Federal regulations and requirements as they pertain to training. Every employee was also required to complete an annual training curriculum through Care Academy (and/other sources) that would be assigned according to their job responsibilities. It was the responsibility of the employee to complete the required training to maintain employment status. The policy did not address that nursing staff were to demonstrate competency in skills and techniques necessary to care for residents on an annual basis.II. Record reviewOn 1/29/26 at 7:52 a.m. an email request was made to the NHA for the facility's annual competency assessment for CNA #1, CNA #2 and CNA #12.-The facility was unable to provide documentation to show that the three selected CNAs had the specific skill sets necessary to provide competent care for residents' needs as demonstrated in an annual skills assessment.III. Staff interviewsThe NHA was interviewed on 1/29/26 at 12:40 p.m. The NHA said she was unable to locate the annual skills competencies assessments for CNA #1, CNA #2 and CNA #12. The NHA said she called the former assistant director of nursing (ADON) and was told the facility had assessed all of the CNAs for skilled competencies and those assessments had been placed in a binder. The NHA said she was unable to locate this binder. The NHA said all CNAs should receive annual skill set competencies assessments. The NHA said the annual skill competencies assessments were necessary to ensure CNAs maintain their skills to provide adequate care of the elders. The NHA said if a CNA was lacking in their competencies, a resident might not receive the care that they required. The director of nursing (DON) was interviewed on 1/29/26 at 1:01 p.m. The DON said the facility was unable to find the nursing staff competency assessments binder. The DON said the competency assessments of CNAs was necessary to check the skills to ensure they know the basic skills of a CNA. The DON also said the assessment would help identify and allow correction of any lack in the basic skills for resident care. The DON said a lack of basic skills might diminish the quality of care for a resident.

Based on record review and interviews, the facility failed to notify the provider when a resident had a significant change in condition requiring a need to alter treatment for two (#12 and #22) out of five residents out of 20 sample residents. Specifically, the facility failed to inform Resident #12 and Resident #22's provider when medications were not administered according to the physician's orders. Findings include: I. Facility policy The Medication and Administration of Medications policy, revised 2/6/24, was provided by the director of nursing (DON) on 2/6/24 at 2:09 p.m. It read in pertinent part,Medication technicians administering medications must use the medication list to identify and monitor for possible ineffective drug therapy and shall promptly report problems to the physician, including residents who are refusing medications. The resident's power of attorney shall also be immediately notified. II. Resident #12 A. Resident status Resident #12, age 84, was admitted on [DATE], discharged to the hospital 12/31/23, readmitted [DATE], discharged to the hospital on 1/16/24 and readmitted on [DATE]. According to the February 2024 computerized physician order (CPO), the diagnoses include traumatic subarachnoid hemorrhage (brain injury), hypertensive heart, chronic kidney disease, muscle spasms, hydronephrosis (a kidney swollen due to a build up of urine), pain syndrome, history of falling and a history of urinary tract infections. The 1/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental score (BIMS) of 15 out of 15. He required set up assistance with eating and oral hygiene. He required partial assistance with bathing and required substantial assistance with dressing and with transfers. B. Resident representative interview The resident representative was interviewed on 2/6/24 at 1:18 p.m. She said she saw the resident three to four times a week. She said he did not bounce back after his two hospitalization s. She wanted the facility to hold all medications except his blood pressure medication and depression medication because she thought he took too many medications. She wanted him to only take the medication that he really needed to stabilize him back to his baseline. She wanted the facility to crush and mix his medications in yogurt to see if that would help his medication compliance. C. Record review The February 2024 CPO revealed: -Lorazepam 2mg/ml. Give 0.5 ml by mouth at bedtime for anxiety. May hold for sedation, start on 1/31/24. -Lorazepam 2mg/ml. Give 0.5 ml by mouth every eight hours as needed for anxiety for 14 days, start on 1/31/24. -Sertraline 50mg. Give one tablet by mouth in the morning for depression and anxiety, start on 1/25/24. The January and February 2024 medication administration (MAR) showed the following medications were not administered per physician orders: -Lorazepam 2mg/ml was refused on 2/1/24 through 2/3/24. -Sertraline 50mg was refused on 1/25/24 through 1/30/24. The interdisciplinary team met on 1/24/24. The progress note revealed the resident had a recent decline in overall health with two hospitalization s affecting his mood. He started Sertraline for signs and symptoms of depression. Staff would monitor side effects and effectiveness of medication to support his unmet needs manifested in repetitive statements. Progress notes from the nursing staff revealed the resident was anxious on the following dates: 1/24/24, 1/25/24, 1/27/24, 1/29/24 and 2/3/24. Progress notes included that the resident was very anxious and had the following behaviors: having a blanket over face, repeated things like not wanting to be poked and shaking. The 1/27/24 progress note revealed the resident refused medications. The representative would not like the resident to take any medication except his blood pressure medication. The 2/5/24 provider progress note (after being identified on the survey) revealed to discontinue several medications to decrease pill burden. -There was no documentation the provider was notified that the resident refused his medication. D. Staff interview Certified nursing aide with medication authority (CNA/MA) #1 was interviewed on 2/5/24 at 1:42 p.m. She said Resident #12 went through a lot of changes. She said the resident's representative told her she only wanted the resident on blood pressure medications. She relayed that to the nurse to follow up. She said he was on a lot of medications and it was hard for him to swallow. She thought he was scared he would choke on the medication. She said the resident was anxious lately because of his stroke and his recent hospitalization s. She said that it might have helped if the medications were crushed and in a yogurt but there was not an order to crush medications. Registered nurse (RN) #2 was interviewed on 2/6/24 at 10:47 a.m. She said Resident #12 went through a lot of changes. He went to the hospital and had a horrible experience. His dementia was worse when he returned and he had one set back after another. She said if she was the nurse on duty when the resident representative requested to hold all medications except his blood pressure medications, she would call the provider the same day as the request. The DON was interviewed on 2/5/24 at 2:27 p.m. She was not aware that Resident #12 refused his medications and that the family's representative requested to hold all medications except his blood pressure medications. III. Resident #22 A. Resident status Resident #12, age 87, was admitted on [DATE]. According to the February 20204 CPO, the diagnoses include Alzheimer's disease, type II diabetes, hypertension, dysphagia (difficulty swallowing), hyperlipidemia (high cholesterol), palliative care and muscle weakness. The 12/13/23 MDS) assessment revealed the resident was cognitively impaired with a BIMS of two out of 15. She required total assistance with transfer, dressing, toileting and personal hygiene. The resident was on hospice care. B. Record review The February 2024 CPO revealed: -Seroquel 25 mg, give one tablet two times a day for dementia with behavioral disturbance, start date 6/16/23. -Tramadol 50 mg, give one tablet three times a day for pain per hospice, start date 9/12/23. The December 2023 and January 2024 MAR showed the following medications were not administered per physician orders: -Seroquel 25 mg was refused in the afternoon on 12/6/23, 12/8/23, 1/14/24 and 1/28/24. It was refused in the afternoon and in the evening on 1/21/24. -Seroquel 25 mg was not administered because the resident was sleeping for the afternoon dose on 1/10/24 and 1/30/24 -Tramadol was refused in the afternoon 12/6/23, 12/8/23, 1/14/24 and 1/28/24. It was refused in the afternoon and in the evening on 1/21/24 and on 1/31/24. -Tramadol 50mg was not administered because the resident was sleeping for the afternoon dose on 12/10/23 and for the evening dose on 12/17/23, 12/21/23, 12/31/23, 1/9/24 and 1/30/24. -There was no documentation the physician or the hospice provider were notified that the resident refused her medication or the medication was not administered because she was sleeping. C. Staff interviews CNA/MA #1 was interviewed on 2/5/24 at 1:42 p.m. She said Resident #22 never refused her medication. She said sometimes it was hard to administer the medication because the resident would bite down on her teeth really hard. It took some time to have the resident take the medication. She said the resident was sleeping more recently and had good and bad days. She said some days were hard to administer medications but she was able to give the medications as ordered on most days. RN #2 was interviewed on 2/6/24 at 10:47 a.m. She said if Resident #22 refused medication, she would tell the CNA/MA #1 to try again. She was aware that she was sleeping more and she took a lot of medications. If she was sleeping and comfortable, she would hold the medication until the afternoon dose. She would not notify the hospice provider if the resident refused or slept for one day but if it was two days or more, she would call the hospice provider. The DON was interviewed on 2/5/24 at 2:27 p.m. She was not aware that Resident #22 refused medication and medication was not administered because the resident was sleeping. CNA/MA #1 interview was shared about Resident #22 biting down on her teeth which made it hard to administer the medication. CNA/MA #1 was able to administer the medication after she reattempted. The DON said it sounded like medication technicians and nurses needed training on how to administer medication when residents bite down on their teeth. IV. Additional interviews CNA/MA #1 was interviewed on 2/5/24 at 1:42 p.m. She said if a resident refused medication, she would let them refuse and then she would go back a little bit later to see if the resident wanted the medication at that time. If a resident was sleeping, she would go back an hour later to see if the resident was awake. If the resident still refused or if the resident was still asleep, she would notify the nurse. If hospice staff were in the building, she would notify them. RN #2 was interviewed on 2/6/24 at 10:47 a.m. She said if a resident refused a medication, she would document the refusal and then she would go back in an hour to try again. If a certified nursing aide with medication authority informed her that a resident refused medication, she would tell them to try again. If they still refused, she would call the provider and document in a progress note. If a resident was sleeping, she would wait until the resident was awake. If the resident was still sleeping, and there was an afternoon dose, she would hold the medication. The DON was interviewed on 2/5/24 at 2:27 p.m. She said if a resident refused a medication, the medication technician or nurse should document the refusal and notify the DON or assistant director of nursing (ADON). The DON tracked and trended refusals. She said on the first refusal, she wanted to know why. If there was a second refusal, she would learn more and notify the doctor. She said the staff should notify the family at the same time they notified the provider. If a resident was sleeping, she said the staff should come back an hour later to see if the resident was asleep. When a resident representative requests to hold a medication, the nurse should contact the provider to hold the medication. She said the nurse should notify the provider within the same day the request to hold a medication was made.

Based on record review and interviews, the facility failed to implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for six of 60 employee files reviewed. Specifically, the facility failed to complete criminal background checks for six employees prior to the employees working with residents. Findings include: I. Facility policy and procedures The Abuse Prevention Program policy, revised December 2016, was provided by the nursing home administrator (NHA) on 11/8/23 at 2:21 p.m. It read in pertinent part, Our elders have the right to be free from abuse, neglect, misappropriation of elder property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the eider's symptoms. As part of the elder abuse prevention, the administration will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, has had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of elders or misappropriation of their property or has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of elders or misappropriation of elder property. II. Employee file review Review of certified nurse aide (CNA) #5's employee file revealed she was hired on 5/11/23. Review of the October 2023 and November 2023 CNA schedules confirmed she was working with residents. -There was no documentation in CNA #5's employee file that a criminal background check had been completed prior to her working with residents. Review of CNA #9's employee file revealed she was hired on 6/9/23. Review of the October 2023 and November 2023 CNA schedules confirmed she was working with residents. -A criminal background check was not completed until 7/28/23, over one month after CNA #9 was hired. Review of CNA #10's employee file revealed she was hired on 5/10/23. Review of the October 2023 CNA schedule revealed she was working with residents. -There was no documentation CNA #10's employee file that a criminal background check had been completed prior to her working with residents. Review of CNA #11's employee file revealed she was hired on 7/20/23. Review of the October 2023 and November 2023 CNA schedules confirmed she was working with residents. -There was no documentation CNA #11's employee file that a criminal background check had been completed prior to her working with residents. Review of registered nurse (RN) #1's employee file revealed she was hired on 6/9/23. Review of the October 2023 and November 2023 nurse schedules confirmed she was working with residents. -There was no documentation in RN #1's employee file that a criminal background check had been completed prior to her working with residents. Review of the director of nursing's (DON) employee file revealed she was hired on 10/2/23. -A criminal background check was not completed until 11/7/23, over one month after the DON was hired. III. Staff interviews The human resources director (HRD) was interviewed on 11/7/23 at 2:25 p.m. The HRD said she started working at the facility in May 2023. She said when she started she had an assistant that was working with her, however, she said the assistant quit shortly after she started. The HRD said she was still learning the role when the assistant quit and some of the criminal background checks for new employees had been requested late or they had not been requested at all. She said the missed background checks were an oversight during her initial learning process, however, she said the process had improved since then. She said going forward the facility would have a more integrated and streamlined process to ensure all staff had the appropriate background checks completed prior to beginning work. The DON was interviewed on 11/8/23 at 1:10 p.m. The DON said criminal background checks should be completed on all employees prior to hire. She said none of the staff should be working with residents until all of the background check information was requested and received by the facility. The nursing home administrator (NHA) was interviewed on 11/8/23 at 1:43 p.m. The NHA said criminal background checks on all employees should all be requested and received by the facility prior to any prospective employees starting orientation. She said it was important to have the criminal background checks completed before the employees started working with residents to ensure the safety of residents. The HRD was interviewed on 11/8/23 at 2:15 p.m. The HRD said she had requested and received the DON's criminal background check prior to the DON starting work at the facility on 10/2/23, however, she said she could not locate the original criminal background check. The HRD said she had the DON's criminal background check completed again on 11/7/23, during the survey.

Based on record review and interviews, the facility failed to ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity which included proper licensure or certification for one of seven licensed practical nurses (LPN). Specifically, the facility failed to ensure LPN #1 had an active license in the State registration system to ensure the licensure was aligned with the requirement of the State. Findings include: I. LPN job description The LPN job description, which was undated, was provided by the nursing home administrator (NHA) on [DATE] at 1:28 p.m. It read in pertinent part, Must possess a current, unencumbered, active license to practice as a practical nurse in the state of Colorado. II. Record review On [DATE] at 12:23 p.m. LPN #1's license was checked utilizing the Colorado Department of Regulatory Agencies ([NAME]) Division of Professions and Occupations online license verification system. -According to [NAME], LPN #1's license expired effective [DATE]. Review of LPN #1's payroll time cards from [DATE] through [DATE] revealed the following: [DATE]: -LPN #1 worked seven days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -LPN #1 worked 11 days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -LPN #1 worked eight days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. III. Staff interviews The director of nursing (DON) was interviewed on [DATE] at 1:52 p.m. The DON said she had been working at the facility since [DATE]. She said the previous assistant director of nursing (ADON) had been responsible for ensuring nursing staff had active licenses. She said the previous process for keeping active employee records was not effective or thorough. She said the facility was currently in the process of identifying which of their employees were currently active employees and possessed appropriate active licensure. The DON said she had spoken to LPN #1 regarding her expired license. She said LPN #1 told her she had not renewed her license at the time it was due for renewal and was aware that she was practicing on an expired license. The DON said the facility was terminating LPN #1's employment with the facility and was reporting her to the Colorado Board of Nursing for practicing with an expired license. The human resources director (HRD) was interviewed on [DATE] at 2:25 p.m. The HRD said going forward the facility would have a more integrated and streamlined process to ensure all staff had the appropriate background checks and licensure verifications completed prior to beginning work. The NHA was interviewed on [DATE] at 1:43 p.m. The NHA said nursing licensures and certifications should be verified prior to a nurse or certified nurse aide beginning work. She said the facility needed to have a better process in place to ensure nursing staff held an active license or certification and that the licenses and certifications were not expired. IV. Facility follow-up On [DATE] at 1:15 p.m., the DON provided a copy of a notice from the Colorado Board of Nursing dated [DATE]. The notice documented the facility's complaint regarding LPN #1 working on an expired license had been received and would be investigated.

Based on record review and interviews, the facility failed to ensure each nurse aide had registry verification and had met competency evaluation requirements to provide nursing and nursing related services for five of 42 certified nurse aides (CNA). Specifically, the facility failed to ensure five CNAs (CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5) who were providing resident care were certified in the State registration system. Findings include: I. Homemaker job description The Homemaker job description was provided by the NHA on [DATE] at 12:50 p.m. It read in pertinent part, Responsibilities of the homemaker include meal preparation and housekeeping. -The job description did not include resident care as part of the homemaker's responsibilities and a CNA license was not required. II. CNA job description The CNA job description was provided by the nursing home administrator (NHA) was provided on [DATE] at 2:20 p.m. It read in pertinent part, Responsibilities of the CNA include resident care and care of the residents' environment including cooking, laundry and housekeeping. Qualifications include a CNA license. III. Record review On [DATE] at 12:23 p.m. certifications were checked for all 42 CNAs employed by the facility utilizing the Colorado Department of Regulatory Agencies ([NAME]) Division of Professions and Occupations online license verification system. -According to [NAME], CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5 did not hold an active CNA certification. Review of CNA #1's payroll time cards from [DATE] through [DATE] revealed the following: [DATE]: -CNA #1 worked 19 days: [DATE], ,d+[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -CNA #1 worked 17 days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -CNA #1 worked 14 days: [DATE], [DATE], [DATE], ,d+[DATE], 23, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the [DATE] CNA schedule for [DATE] and [DATE] revealed the following: -CNA #1 worked [DATE]. Review of CNA #2's payroll time cards from [DATE] through [DATE] revealed the following: [DATE]: -CNA #2 worked 17 days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -CNA #2 worked 14 days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -CNA #2 worked ten days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the [DATE] CNA schedule for [DATE] and [DATE] revealed the following: -CNA #2 worked [DATE] and [DATE]. Review of CNA #3's payroll time cards from [DATE] through [DATE] revealed the following: [DATE]: -CNA #3 worked two days: [DATE] and [DATE]. [DATE]: -CNA #3 worked 12 days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the [DATE] CNA schedule for [DATE] and [DATE] revealed the following: -CNA #3 did not work on either date. Review of CNA #4's payroll time cards from [DATE] through [DATE] revealed the following: [DATE]: -CNA #4 worked four days: [DATE], [DATE], [DATE] and [DATE]. [DATE]: -CNA #4 worked three days: [DATE], [DATE], and [DATE]. [DATE]: -CNA #4 worked 13 days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the [DATE] CNA schedule for [DATE] and [DATE] revealed the following: -CNA #4 worked [DATE] and [DATE]. Review of CNA #5's payroll time cards from [DATE] through [DATE] revealed the following: [DATE] -CNA #5 worked 10 days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -CNA #5 worked seven days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: -CNA #5 worked seven days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the [DATE] CNA schedule for [DATE] and [DATE] revealed the following: -CNA #5 did not work on either date. IV. Staff Interviews The director of nursing (DON) was interviewed on [DATE] at 1:52 p.m. The DON said she had been working at the facility since [DATE]. She said the previous assistant director of nursing (ADON) had been responsible for ensuring nursing staff had active licenses. She said the previous process for keeping active employee records was not effective or thorough. She said the facility was currently in the process of identifying which of their employees were currently active employees and possessed appropriate active licensure. The DON said she had spoken to CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5 about their lack of certification. She said the CNAs would work as homemakers (see job description above) and not provide resident care until they had been certified through the State licensing board. She said the CNAs told her the previous administration had said they could work as CNAs despite the fact that they did not hold an active CNA certification. The human resources director (HRD) was interviewed on [DATE] at 2:25 p.m. The HRD said going forward the facility would have a more integrated and streamlined process to ensure all staff had the appropriate licensure verifications completed prior to beginning work. CNA #2 was interviewed on [DATE] at 11:15 a.m. CNA #2 said she had taken the CNA class and passed the written test for certification. She said she still needed to take the CNA skills demonstration test in order to become a certified CNA. She said the previous administration had told her she was allowed to work as a CNA and perform resident care even though she was not certified. She said she had been performing resident care for several months. CNA #2 said the DON had spoken to her on [DATE] and informed her she was no longer able to perform resident care until she obtained her CNA certification. She said she was to work as a homemaker doing only cooking, laundry and housekeeping until she was certified. CNA #1 was interviewed on [DATE] at 11:45 a.m. CNA #1 said she was not certified as a CNA. She said she had taken her written test in February 2023 and failed it. She said she was rescheduled to take the written test in [DATE]. She said she had not scheduled her skills demonstration test for certification yet. CNA #1 said she had been working on the floor as a CNA and had not told anyone she did not pass her written test for certification. CNA #1 said the DON told her she could no longer do clinical care with the residents until she was certified. CNA #3 was interviewed on [DATE] at 12:05 p.m. CNA #3 said she had taken the CNA classes, but had not taken her written test or her skills demonstration test yet. She said she had been working as a CNA on the floor because the previous administration had told her she was allowed to do that since she had completed the CNA classes. CNA #3 said she had just been told by the new DON that she was only to work as a homemaker and not provide resident care until she received her CNA certification. The NHA was interviewed on [DATE] at 1:43 p.m. The NHA said nursing licensures and certifications should be verified prior to a nurse or certified nurse aide beginning work. She said the facility needed to have a better process in place to ensure nursing staff held an active license or certification and that the licenses and certifications were not expired.

Based on record review and interview, the facility failed to provide training to their staff that at a minimum educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically the facility failed to: -Provide effective initial hire orientation for abuse identification and prevention training or dementia management training for six of eight certified nurse aides (CNA) reviewed; and, -Provide annual abuse identification and prevention training or dementia management training for the five of eight CNAs. Findings include: I. Facility policy and procedures The Abuse Prevention Program policy, revised December 2016, was provided by the nursing home administrator (NHA) on 11/8/23 at 2:21 p.m. It read in pertinent part, Our elders have the right to be free from abuse, neglect, misappropriation of elder property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the eider's symptoms. As part of elder abuse prevention, the administration will develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our elders and require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive elder behavior. -The facility did not have a dementia management policy at the time of the survey. II. Record review Review of CNA #1's employee file revealed she was hired on 7/20/22. -There was no documentation in CNA #1's employee file that she had completed abuse identification and prevention training or dementia management training during her initial hire orientation. -There was no documentation in CNA #1's employee file that she had completed abuse identification and prevention training or dementia management training annually since her date of hire. Review of CNA #2's employee file revealed she was hired on 8/24/22. -There was no documentation in CNA #2's employee file that she had completed abuse identification and prevention training or dementia management training during her initial hire orientation. -There was no documentation in CNA #2's employee file that she had completed abuse identification and prevention training or dementia management training annually since her date of hire. Review of CNA #6's employee file revealed she was hired on 9/23/21. -There was no documentation in CNA #6's employee file that she had completed abuse identification and prevention training or dementia management training during her initial hire orientation. -There was no documentation in CNA #6's employee file that she had completed abuse identification and prevention training or dementia management training annually since her date of hire. Review of CNA #7's employee file revealed she was hired on 10/1/2020. -There was no documentation in CNA #7's employee file that she had completed abuse identification and prevention training or dementia management training during her initial hire orientation. -There was no documentation in CNA #7's employee file that she had completed abuse identification and prevention training or dementia management training annually since her date of hire. Review of CNA #8's employee file revealed she was hired on 8/27/2020. -There was no documentation in CNA #8's employee file that she had completed abuse identification and prevention training or dementia management training during her initial hire orientation. -There was no documentation in CNA #8's employee file that she had completed abuse identification and prevention training or dementia management training annually since her date of hire. Review of CNA #12's employee file revealed she was hired on 9/7/23. -There was no documentation in CNA #1's employee file that she had completed abuse identification and prevention training or dementia management training during her initial hire orientation. III. Staff interviews The social services director (SSD) was interviewed on 11/6/23 at 1:38 p.m. The SSD said she conducted abuse training during new hire orientation. She said she gave all new employees a packet which talked about mandatory reporting and the different types of abuse. She said she and the new hires read the packet out loud during orientation. She said the packet did not include who the abuse coordinator for the facility was or the timeframe for reporting abuse to the proper authorities. She said she told the new hire employees the information, however it was not in the abuse packet. The SSD said she did not provide a specific in-depth training related to dementia during new hire orientation. She said it was briefly mentioned in the abuse packet. She said the staff did not sign anything to indicate they had received abuse training. The SSD was not aware of annual abuse and dementia training was provided to the staff after they were hired. CNA #2 was interviewed on 11/8/23 at 11:15 a.m. CNA #2 said she had a short introduction of abuse training in orientation when she was hired in August 2022. She said she did not remember any dementia training from orientation. CNA #2 said she had not received any training on abuse or dementia since she was hired. CNA #7 was interviewed on 11/8/23 at 11:22 a.m. CNA #7 said she thought she received abuse and dementia training when she was hired, however, she could not recall for sure. She could not remember if she had received abuse and dementia training since she was hired. CNA #7 did not know who the abuse coordinator for the facility was. She said she would report abuse to the nurse on duty or the social worker. She said she was aware there was a timeframe for reporting abuse, however, she did not know what the timeframe was. CNA #8 was interviewed on 11/8/23 at 11:31 a.m. CNA #8 said she might have received abuse and dementia training when she was hired. She said did not work very often and therefore she had not received abuse and dementia training since she was hired. CNA #8 said she did not know who she was supposed to report abuse to. She said she would probably report it to human resources. CNA #6 was interviewed on 11/8/23 at 11:39 a.m. CNA #6 said she did not receive abuse and dementia training when she was hired. She said she had received some abuse and dementia training since she was hired, however, she said she did not receive it annually. CNA #6 said she did not know who the abuse coordinator was for the facility. She said she would report abuse to the SSD. CNA #1 was interviewed on 11/8/23 at 11:45 a.m. CNA #1 said she did not remember getting abuse or dementia training in orientation. She said she had some training on abuse and dementia one time, however, she did not remember when she received the training. CNA #1 said she did not know who the abuse coordinator was for the facility. She said she would report abuse to the SSD. CNA #12 was interviewed on 11/8/23 at 1:00 p.m. CNA #12 said she did not recall getting any training on abuse or dementia in orientation. She said she had not received any abuse or dementia training since she was hired. CNA #12 did not know who the abuse coordinator was for the facility. She said she would report it to the director of nursing (DON). The DON was interviewed on 11/8/23 at 1:10 p.m. The DON said abuse and dementia training should be provided during new hire orientation and annually thereafter. She said abuse training should include definitions of abuse, mandatory reporting, who to report abuse to and the timeframe for reporting abuse. The DON said it was important to ensure staff had as much knowledge as possible regarding abuse and when and who to report abuse to because all staff had an obligation to protect residents from abuse. She said dementia training was important because staff needed to be provided with techniques and tools to utilize when working with residents with dementia in order to provide the residents with the best possible quality of life. The NHA was interviewed on 11/8/23 at 1:43 p.m. The NHA said she was the abuse coordinator for the facility. She said abuse and dementia training should be in depth and include a quiz to ensure staff is retaining the information presented to them. She said abuse training was important to ensure that residents were protected and staff understood that even something as innocent as putting an arm around a resident could be seen as unwanted touching. The NHA said dementia training was important because a lot of the facility's population was residents with dementia and staff needed to be comfortable working with the residents. She said staff needed to be provided the tools to give the residents the best care possible. The NHA said dementia was not a one size fits all kind of population and required creativity when working with them to provide a good quality of life. She said abuse and dementia training should be provided during new hire orientation and annually thereafter.

Based on observations, interviews, record review, and policy review, the facility failed to ensure proper provision of urinary catheter care. Specifically, the facility failed to ensure 1 (Resident #24) of 2 residents' indwelling urinary catheter urine collection bag and tubing were maintained below the level of the resident's bladder to help prevent urinary tract infections. Findings included: A review of the facility's policy titled, Catheter Care, Urinary, revised 09/2014, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy further indicated, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. A review of Resident #24's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #24's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderately impaired cognition. The MDS indicated the resident had an indwelling urinary catheter and required setup help and supervision to manage the catheter. A review of Resident #24's Care Plan, revised 09/28/2022, revealed the resident had an indwelling urinary catheter due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 10/24/2022 at 2:15 PM revealed Resident #24 sat in a chair with the catheter bag and tubing resting on top of the handlebars of the resident's walker, above the level of the resident's bladder. At 2:16 PM the Administrator spoke to Resident #24 and, at 2:25 PM, a certified nursing assistant (CNA) spoke to Resident #24; however, there was no change made in the location of the resident's catheter bag or tubing during the encounters. At 2:38 PM, the resident sat in a chair in a hall with the urinary catheter bag and tubing still above the level of the resident's bladder. During an observation on 10/25/2022 at 3:31 PM, Resident #24 walked through the kitchen with their urinary catheter bag and tubing over the handlebars of their front-wheeled walker and above the level of the resident's bladder. Resident #24 then sat in a chair; however, the resident's urinary catheter bag and tubing remained over the handlebars of the front-wheeled walker. During an observation on 10/26/2022 at 2:59 PM, Resident #24 sat in a chair in a living room area. The resident's urinary catheter bag and tubing were observed resting over the handlebars of the resident's walker and above the level of Resident's #24's bladder. Regarding the location of the urinary catheter bag and tubing being situated above the level of the resident's bladder, Resident #24 stated to the surveyor, What's wrong with it? The urine is still going down into the bag. Resident #24 noted they had positioned the urinary catheter bag and tubing over their walker since living in the facility, that everyone in the facility had seen it, and that nobody had talked with the resident about how the catheter bag and tubing should be positioned. During an interview on 10/26/2022 at 3:03 PM, CNA #1 stated Resident #24 placed the urinary catheter bag and tubing on the handlebars of the walker and noted she was unaware if the tubing should be at such a level. During an interview on 10/26/2022 at 3:08 PM, CNA #2 stated Resident #24 was very independent and hung their urinary catheter bag and tubing over the handlebars of their walker. CNA #2 voiced, That's okay for [the resident] to do, to put it there. During an interview on 10/26/2022 at 3:13 PM, CNA #3 stated the catheter tubing position should not be on the handlebars of the walker due to contamination. During an interview on 10/26/2022 at 3:16 PM, Registered Nurse (RN) #2 stated that, when Resident #24 first arrived to the facility, the resident did not want to take direction from staff, but noted the resident now listened to staff direction. RN #2 stated the resident hung the urinary catheter bag and tubing high on the walker, noting he had addressed this issue with the resident quite often. RN #2 stated the risk of placing the urinary catheter bag and tubing above the level of the bladder included the backflow of urine. RN #2 stated he did not know if he documented any education with the resident about the position of the catheter bag and tubing. During an interview on 10/26/2022 at 3:38 PM, the Director of Nursing (DON) stated she expected staff to remind the resident about the proper placement of the urinary catheter bag and tubing or to ask if staff could move the urinary catheter bag and tubing themselves. The DON stated the risk of placing the urinary catheter bag and tubing above the level of the bladder was the backflow of urine, which could cause a urinary tract infection. During an interview on 10/26/2022 at 3:51 PM, the Administrator stated she expected the CNAs to be safe with the resident's urinary catheter bag and tubing so there was no backflow to help prevent infection. The Administrator stated she expected staff to address any issues with a resident by educating the resident.

Based on interviews and document review, the facility failed to ensure Payroll-Based Journal (PBJ; an electronic report that contained the number of hours every direct care staff member worked for each day of the quarter) data was reported quarterly to the Centers for Medicaid & Medicare Services (CMS) as required. This deficient practice had the potential to affect staffing information posted on consumer websites and data used in quality rating systems to help consumers understand the level and differences of staffing in nursing homes and, ultimately, had the potential to impact the quality of care delivered to residents who currently resided in the facility. Findings included: A review of a facility Staffing Summary Report, also referred to as a PBJ Report, for the period 10/01/2021 through 12/31/2021 revealed no data was reported to CMS. A review of a facility Staffing Summary Report for the period 01/01/2022 through 03/31/2022 revealed no data was reported to CMS. A review of a facility Staffing Summary Report for the period 04/01/2022 through 06/30/2022 revealed no data was reported to CMS. A review of a facility Staffing Summary Report for the period 07/01/2022 through 09/30/2022 revealed no data was reported to CMS. During an interview on 10/25/2022 at 2:26 PM, the Minimum Data Set (MDS) Coordinator stated she was not aware of the PBJ process and had never been responsible for reporting PBJ data. The MDS Coordinator stated she used to have access to an associated dashboard and remembered seeing a link to PBJ information, but noted she no longer had access to the dashboard or PBJ data. According to the MDS Coordinator, an Accounting Manager at the facility who handled the reporting of PBJ data recently passed away unexpectedly. The MDS Coordinator explained that, after this unexpected passing, she assisted the Business Office Manager (BOM) with itemizing work tasks, during which it was discovered that PBJ reporting was not being done. During an interview on 10/25/2022 at 2:34 PM, the BOM stated she did not have a role in the PBJ data reporting or access to the program. According to the BOM, after the facility's former Accounting Manager passed away, she and the MDS Coordinator reviewed work tasks and discovered that PBJ data reporting was not being done. The BOM stated she would be the person responsible for PBJ data reporting going forward, but she had not started reporting yet because she was still in the process of getting access to the program and training on the reporting process. During an interview on 10/25/2022 at 2:40 PM, the Administrator stated she was unaware until recently that the facility's former Accounting Manager was not reporting PBJ data quarterly. The Administrator stated she was aware that quarterly PBJ data reporting was a requirement, but she was not sure how to go about getting access to the correct program to ensure quarterly PBJ data was reported. According to the Administrator, she had contacted an individual to obtain guidance regarding the process and noted the BOM would be the staff member responsible for reporting PBJ data going forward. The Administrator also stated she was waiting to hear back from someone regarding if PBJ data could be retroactively reported for the prior four quarters that were missed. During a follow-up interview on 10/27/2022 at 8:56 AM, the Administrator stated the facility did not currently have a policy for the reporting of PBJ data, but was in the process of developing a policy.

Based on observations, interviews and record review, the facility failed to ensure two (#19 and #23) of five residents reviewed for activities of 23 sample residents received an ongoing program of activities designed to meet the needs and interests of the residents and promote physical, medical and psychosocial well-being. Specifically, the facility failed to provide meaningful activities based on the resident's preferences for Resident #19 and #23. Findings include: I. Facility policy and procedure The Activities Evaluation policy and program, last revised June 2018, provided by the nursing home administrator (NHA) on 7/27/21 at 8:30 a.m. revealed in pertinent part, In order to promote the physical, mental and psychosocial well-being of elders, an activity evaluation is conducted and maintained for each elder at least quarterly and with any change of condition that could affect his or her participation in planned activities. An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the elder (also referred to as resident). The elder's activity evaluation was conducted by activity department personnel, in conjunction with other staff who evaluate related factors such as functional level, cognition and medical conditions that may affect activities participation. The activities director is responsible for completing, directing and or delegating the completion of the activities component of the comprehensive assessment. The elder's lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences are included in the evaluation. The activity evaluation is used to develop an individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the elder to participate in activities of his or her choice and interest. Each elder's activities care plan relates to his or her comprehensive assessment and reflects his or her individual needs. Through the interdisciplinary process, the activity evaluation and activities care plan identify if an elder is capable of pursuing activities independently, or if supervision and assistance are needed. The completed activity evaluation is part of the elder's medical record and is updated as necessary, but at least quarterly. The Activity Attendance policy, last revised June 2018, provided by the nursing home administrator (NHA) on 7/27/21 at 8:30 a.m.revealed in pertinent part, Attendance and participation was recorded for every elder in group and individual activities on a daily basis. records are reviewed on a regular basis, and at least quarterly, to determine any changes in elder participation that might indicate a change in condition and lead to reassessment and care plan review. Attendance records are maintained and secured for a minimum of three years. Attendance records are used when completing elders' progress notes to determine their participation as it relates to their activity plan. II. Facility activity schedule for July 2021 The July 2021 facility activity calendar, provided by the NHA on 7/27/21, revealed the following activities scheduled for the week of 7/19/21 to 7/25/21: -Giant Crossword at 10:00 a.m. on Monday July 19th. -Non-denominational Bible Study with Deacon at 11:00 a.m. on Tuesday July 20th. -Trivia at 10:00 a.m. on Wednesday July 21st. -House council at 11:00 a.m. on Thursday July 22nd with a line crossed out the 11:00 a.m. and handwritten 3:00 p.m. was there. -Bingo at 10:00 a.m. on Friday July 23rd. -Board games on Saturday the 24th with no time. -Morning devotionals and to ask the aide for the daily bread or online streaming of church services on Sunday the 25th with no time and movie matinee on Netflix with no time. The July 2021 facility activity calendar, provided by the NHA on 7/27/21, revealed the following activities scheduled for house #2 for the week of 7/26/21 to 8/1/21: -Giant Crossword at 2:00 p.m. on Monday July 26th. -Non-denominational Bible Study with Deacon at 11:00 a.m. and Armchair travel at 2:00 p.m. on Tuesday July 27th. -Hangman at 2:00 p.m. on Wednesday July 28th. -Make suncatcher activity at 2:00 p.m. on Thursday July 29th. -Bingo at 2:00 p.m. on Friday July 30th. -Board games on Saturday the 31st with no time. -Morning devotionals and to ask the aide for the daily bread or online streaming of church services on Sunday August 1st with no time and movie matinee on Netflix with no time. III. Resident 19 A. Resident status Resident #19, age 74, was admitted on [DATE]. According to the July 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/19/21 minimum data set (MDS) assessment revealed the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) of three out of 15. The resident required limited assistance of one person for bed mobility, toileting and hygiene. He was supervised for transfers and independent for dressing and eating. The 5/19/21 MDS interview for activity preferences revealed it was somewhat important to the resident to have books, newspapers and magazines to read and to listen to music he liked and to do his favorite activities. He said it was not very important to go outside to get fresh air or to participate in religious services. Other areas were not important at all to the resident, including being around animals and doing things with groups of people. B. Resident interview and observations Resident #19 was observed on 7/21/21 at 2:30 p.m., laying on his bed in his room alone and he was awake. He had no books or reading materials in his room. There was no television and no radio on in the room. He said he wanted to know if it was dinner time. He pointed to the photo on his bedside table and reminisced about the memory. He said he did not attend activities. On 7/22/21, continuous observations for Resident #19 were made from 1:20 p.m. until 3:15 p.m. Resident #19, was in his room, he layed in bed with no television on and no radio on. No staff interaction was observed during this time and no activities were in the common area. On 7/26/21 at 10:30 a.m. Resident #19 was observed in the common area, staff assisted to give the resident orange juice and a plate of food. Resident sat at the table alone and ate his meal. There was no other interaction between staff and the resident. C. Record review The combined activity care plan with discharge planning, mood, behavioral and cognition for Resident #19, initiated 11/23/2020, revealed Resident #19 needed cues and reminders about the fun things that he enjoyed to get him out of his room. His goal was to get out of his room and socialize daily. Interventions were to assist the resident with operating the television, to watch war movies and detective shows. Encourage fresh air, sunshine, socialization and music. Encourage friendships among housemates. He likes to talk about what was in the photos. Assist with via chats with his friend. Offer opportunities for exercise. His interests also included jazz, model trains and detective movies. This care plan was revised on 7/24/21 (during survey). The 11/7/2020 initial activities review revealed Resident #19 wished to participate in walking outdoors, watching detective movies and he enjoyed model trains. Resident #19 answered yes to all the questions; Does the elder wish to participate in activities while in the home, Does the elder wish to participate in group activities, Does the elder wish to go on outings, Does the elder wish 1:1 (one-on-one)with staff, and Do the elder like independent activities? Limitation and special needs for Resident #19 activities revealed the resident needed modification to accommodate activities for vision and assistance to attend. He would benefit from reminders and cues to fully participate. The 2/21/21 activities quarterly or annual participation review revealed the Resident #19 preferred 1:1 (one on one) activities and did not participate often in group activities. The May 2021 activity participation log for Resident #19 revealed the resident attended 10 activities out of the 31 days reviewed. The June 2021 activity participation log for Resident #19 revealed the resident attended five activities out of the 30 days reviewed. The July 2021 activity participation log for Resident #19 revealed the resident attended eight activities out of the 27 days reviewed. IV. Resident #23 A. Resident status Resident #23, age 78, was admitted on [DATE]. According to the July 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/12/21 MDS assessment revealed the resident had modified independence with daily decision making.The resident required extensive total assistance of one to two people for all her ADLs. According to the 6/12/21 MDS assessment, the interview for activity preferences revealed it was not very important to the resident to have books, newspapers and magazines to read. Somewhat important to go outside to get fresh air when the weather is good. It was very important to do her favorite activities. Other areas were not important at all to the resident, including being around animals and doing things with groups of people. B. Observations On 7/21/21 at 12:30 p.m. Resident #23 was observed in her bed eating lunch. She had a stuffed animal next to her and her television was on. She said lunch tasted good and she did not attend activities. She said she liked to paint. On 7/22/21 at 1:30 a.m. Resident #23 was observed in her bed. She was lying on her left side and had a stuffed animal in her hand. She did not have any reading materials in her room and the television was turned off. She said she wanted to attend activities when asked and said she liked to paint. She pointed to pictures on the wall and said she painted them. On 7/26/21 at 2:15 p.m. Resident #23 was observed in her bed. She had a stuffed animal in her hand. Her television was off and she was engaged in a conversation with the stuffed animal. C. Record review The combined activity care plan with discharge planning, mood, behavioral cognition for Resident #23, initiated 6/6/2020, revealed Resident #23 needed a lot of encouragement to get out of bed and she wanted to get stronger to do more things with her day. The goal was to get out of bed every day. The interventions were to offer fresh air, exercise, essential oils, socialization with housemates and work with art. Assist the resident to identify strengths, positive coping skills and reinforce these. She enjoyed holding a handmade stuffed pink pig, unicorn and bear. She responded and engaged in games she had on her computer tablet. Encourage the resident to attend socially distanced events in the living room with others to include art and house renovations. She enjoys music and watching jeopardy and home improvement shows. She takes part in art projects. The 5/28/2020 activities initial review revealed Resident #23 was asked the question: Does the elder wish to participate in activities while in the home, and the assessment was marked unknown. The family was interviewed on the assessment date and said the resident will need encouragement to take part in any groups and may sit on the periphery (outside) of the group activity. The 2/27/21 activities quarterly or annual participation review, revealed Resident #23 socialized at meals occasionally and went out to watch television in the common area. She expresses interest in painting again, and she sometimes participates in weekly exercises at zoom meetings. The May 2021 activity participation log for Resident #23 revealed the resident attended no activities. The June 2021 activity participation log for Resident #23 revealed the resident attended one activity of watching television on 6/21/21. The July 2021 activity participation log for Resident #23 revealed the resident attended one activity of watching television on 7/5/21. V. Staff interviews Certified nurse assistant (CNA) #6 was interviewed on 7/22/21 at 1:40 p.m. She said Resident #23 just arrived back from an appointment. She assisted her back into bed. She said the resident stayed in bed a lot and did not want to come out of her room for meals or activities. She said she knew the resident liked to paint but she was not sure when she painted last. CNA #3 was interviewed on 7/22/21 at 1:50 p.m. She said she knew the residents' wishes from the preference sheet on admission. She said Resident #23 loved to paint and hold her stuffed animals. She said she stayed in her room alot to watch her television shows and sometimes came out for meals but not often. She said Resident #19 came out for meals and he liked to read the newspaper at the table. She said activities depended on the residents and their likes. She said the activity director was there daily to do different things with the residents. She said they celebrated international day for a few days with temporary tattoos. She said there was no calendar of events, just a paper that suggested a crossword puzzle or something like that. She said there was no activity planned for today. She said it would be a good idea to have a calendar so she could help the residents with an activity. She said most of the residents in the house slept. CNA #7 was interviewed on 7/22/21 at 2:00 p.m. She said residents in House #2 sleeps alot and did not really attend any activities. She said the residents watched the Olympics and television in their rooms. She said the task check off box in the computer system was checked when the resident had full participation on being engaged with all care during the day. She said the House Council meeting was one time a week and the residents completed crossword puzzles and read the newspaper daily. Resident #35 was interviewed on 7/26/21 at 10:30 a.m. She resided in House #2 and she said House #2 had regular meetings with staff to discuss issues in the house. She said a few months ago the residents complained they had little activities in the house so the corporation hired an activity director. She said the activity was a crossword puzzle on some days but most residents stayed in their rooms. She said she wanted more activities and had suggestions often but was told the residents did not want to attend. She said she signed herself up to go to an outside program to get some stimulation daily. The life enrichment coordinator (LEC) was interviewed on 7/27/21 at 12:15 p.m. She said her role was to assist the residents with activities. She met with each residential house separately in a House Council meeting weekly to discuss the activities for the next week. She gave each house a calendar to follow and then it was up to the certified nurse aides (CNA) in each house to assist the residents with those activities. She said she staggered the events because she could not be in all areas at one time. She said House #2 had reading material, games and puzzles available for residents at all times. She said the residents chose what they would like to attend. The CNAs documented in the computer the participation of each resident. She said Resident #23 did not have alot of engagement with activities and refused often. She said Resident #19 came out to the common area as he liked to be around others but he did not have a high level of integration at times. She said she offered to have one on one visits with both residents but they often refuse. She said refusals to attend activities or be involved in daily events were documented on the computer. She assisted the social service director (SSD) with care planning for activities. The social service director (SSD) was interviewed on 7/27/21 at 12:30 p.m. She said she assisted with the development of the care plan in combination with the psychosocial wellbeing of each resident. She said she spoke with the residents and their families to find out what their preferences were to help guide the daily activities. She said this started when the facility lost the prior activities person. The facility then hired a new life enrichment coordinator a few months ago. She said Resident #23 liked to do crafts and watch jeopardy on television. She said Resident #19 liked crime shows and liked to listen to music. She said each house had one activity per day and a lot of little individual ones with each resident. She said the CNAs assisted the residents with their activities of daily living. The CNAs coordinated any changes with her and the LEC. She said the documentation did not always capture what activities were being completed because the activities were individualized. She said the resident quarterly assessments were completed and the resident care plan was updated when needed.

Based on observations, record review and interviews the facility failed to ensure one resident (#43) of two reviewed for anticoagulant therapy use received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of 23 sample residents. Specifically, the facility failed to: -Monitor Resident #43 for side effects related to anticoagulant therapy; and, -Ensure skin assessment were timely and accurate for Resident #43. Findings include: I. Facility policy The Anticoagulant Clinical Protocol policy, revised November 2018, was provided by the nursing home administrator (NHA) via email on 7/26/21 at 11:43 a.m. It read in pertinent part, As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example those with a recent history of [CONDITION(S)] (DVT), or heart valve replacement, [CONDITION(S)] or those who have had recent joint replacement surgery. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. The physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated. II. Resident #43 A. Resident status Resident #43, age 83, admitted to the facility on [DATE]. According to the July computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 7/7/21 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required limited assistance from one staff member to perform activities of daily living (ADLs). The assessment indicated that the resident had received anticoagulant medication zero out of seven days during the assessment period. B. Resident interview and observation Resident #43 was interviewed on 7/20/21 at 10:20 a.m. She was observed to have two light purple bruises on her right cheek/jawline and a cluster of bruises on her chest; one larger deeper purple bruise and a cluster of lighter purple bruises around it. The resident said she was unsure of how or when she got the bruises, but she said she was harmed by residents or staff. She said that she would bruise easily and she was not sure if she had any other bruises. C. Record review A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2021 medication administration record (MAR) revealed the resident had been administered [MEDICATION(S)] twice daily from 7/1/21 to 7/22/21. The resident care plan did not include that the resident received anticoagulant medication therapy. An pre-admission skin assessment, dated 6/25/21, was completed by the discharging nursing facility; it documented the resident had old bruising on her left upper chest and bilateral upper extremities. Open areas to coccyx and bilateral buttocks were observed. The resident had scattered bruising on abdomen, a black intact blister on her left heel and bilateral groin rash. An initial skin assessment was not completed when the resident was admitted on [DATE]. The facility completed a risk management document on 7/8/21 after it was identified that the resident had not been assessed when she was admitted , which was nine days after her admission. The risk management document identified that the resident's skin was not intact and that she was admitted to the facility with a pressure ulcer on her coccyx and healing blister on her left heel. A skin assessment completed on 7/9/21. However, the skin assessment did not identify the bruising indicated in the observation above. A skin assessment was completed on 7/16/21. However, the skin assessment did not identify the bruising indicated in the observation above. -The resident electronic medical record revealed no documentation of the resident's bruising or monitoring for side effects of anticoagulant therapy. III. Staff interviews Registered nurse (RN) #1 was interviewed on 7/22/21 at 9:51 a.m. She said Resident #43 was on anticoagulant therapy. She said that she had first noticed that the resident had bruising earlier that morning between 7:30 a.m. to 8:00 a.m. when she had gone into the resident's room to administer medication. She said that some of the resident's bruises appeared to be older but the bruising to her face and chest was new. She said she had not worked in a few days and the last time that she worked the resident did not have bruising (review of the staff schedule indicated RN #1 had last worked on 7/18/21). She said that all of the nursing staff would monitor for bruising and document in the resident record if there were any new bruises or concerns of potential side effects of medications. She said that if a resident had new bruising, the staff would use a marker to draw around the area on the resident's skin to determine if it was getting larger. She said that side effects of anticoagulant therapy use were typically monitored and documented on the medication administration record (MAR) and was included on the resident care plan. She reviewed Resident #43's electronic medical record and said that she did not see that monitoring for side effects of anticoagulant therapy had been completed on the MAR and she said that it was not included in the resident's care plan. She said that on the resident's last skin assessment on 7/16/21, there was no documentation of bruising. CNA #8 was interviewed on 7/22/21 at 10:18 a.m. She said that the resident was admitted with bruising and she was aware the resident had older bruises. CNA #10 was interviewed on 7/22/21 at 10:21 a.m. She said that the resident had been admitted with bruising. IV. Facility follow up A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident care plan was updated on 7/22/21 to include that the resident is at risk for bleeding and bruising due to the use of anticoagulant therapy. Interventions include to administer anticoagulant therapy per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) A skin assessment was completed on 7/22/21 documented that the resident had bruising to right cheek and right cheek by ear. The resident had bruising to left lower leg, dark skin/scarring to bilateral lower arms, a deep tissue injury to left heel, bruising on her chest, moisture associated skin damage (MASD) on her bottom and brown spots on the front of right lower leg. The general note on the assessment read Elder (resident) has multiple bruising, she is on anticoagulant therapy. Elder has no DVT ([CONDITION(S)]). She stated she has always had fragile skin. Area on elder right arm is from a scar she stated she fell when living in Florida on concrete. Elder open area on heel followed by wound team. A social services note was entered on 7/24/21 which read in part, this writer followed up with (the resident) regarding reported bruising. An investigation was started as (the resident) was unable to state how she became bruised. The resident was adamant that she bruised easily, was not hurt by anyone, was not afraid of anyone and was not aware of the bruises. The director of nursing (DON) and NHA were interviewed on 7/26/21 at 2:03 p.m. The NHA said that the resident's record had minimal documentation regarding bruising. She said that she had completed a report on the state reporting system for the bruising as an injury of unknown origin. She said that, based on the facility's investigation, the bruising was likely caused by the resident scratching herself. The DON said, based on interviews with staff and the resident; the bruising was likely caused by the resident rubbing or scratching herself. She said that the bruising to the resident's cheek and sternum were new. She said when a resident is on anticoagulant therapy, the nursing staff should monitor every shift for signs of bleeding or bruising. She said that monitoring for side effects was typically documented on the treatment administration record (TAR). She said that the facility completed individualized pre-admission packets for each resident describing care needs and put them in the nurses station for the CNAs and nurses to read when they had time. She said that she and another nurse supervisor would review and enter orders into the resident electronic medical record. She said that nurse education was completed on 6/15/21 regarding completion of accuracy of skin assessments, however, the resident admitted on [DATE] and an initial skin assessment was not completed until 7/9/21 (see record review above). She said there had been an oversight when entering orders for Resident #43. She said that the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that the facility planned to provide reeducation to nursing staff that worked in the resident's home.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#24) out of one resident reviewed for accidents hazards out of 23 sample residents. Specifically, the facility failed to ensure staff utilized safe practices when assisting Resident #24 with ambulation and transfer. Findings include: I. Facility policy The Safe Lifting and Movement of Elders Policy, revised July 2019, was provided by the nursing home administrator (NHA) via email on 7/27/21 at 9:14 a.m. It read in pertinent part, In order to protect the safety and well-being of staff and elders, and to promote quality care, this community uses appropriate techniques and devices to lift and move elders. Elder safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of elders. Manual lifting of elders shall be eliminated when feasible. Nurses and shahbazim in conjunction with the rehabilitation staff, shall assess individual elders ' needs for transfer assistance on an ongoing basis. Staff will document elder transferring and lifting needs in the care plan. Such assessment shall include: Elder's preferences for assistance, elder's mobility (degree of dependency); elder's size, weight-bearing ability; cognitive status, whether the elder is usually cooperative with staff; and the elder's goals for rehabilitation, including restoring or maintaining functional abilities. II. Resident #24 A. Resident status Resident #24, age 60, was admitted on [DATE]. According to the July 2021 computerized physician orders diagnosis included [CONDITION(S)], cognitive communication disorder, weakness, difficulty in walking, repeated falls, hammer toe, polyneuropathy, restless leg syndrome and dementia. According to the 6/2/21 minimum data set (MDS) assessment, the resident had severe impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident required extensive assistance from staff to perform transfers, walk in room and corridor, walk in room and bed mobility. The resident was totally dependent on the assistance of stuff for toileting, dressing, personal hygiene and locomotion on and off the unit. B. Observation On 7/26/21 at 4:20 p.m., Resident #24 was observed sitting in her wheelchair at the dining room playing a card game with certified nurse aide (CNA) #5 and other residents. The resident had her right hand on the side of the table and was sitting with legs crossed to the right side of her wheelchair and was bouncing her legs. CNA #5 said to another staff member she was going to get the resident up to walk. She said to the other residents at the table she was going to need to take a break from playing cards to assist Resident #24 to walk. At 4:22 p.m. CNA #5 stood and placed her left arm under the resident's right armpit and reached her right arm around the resident's waist. Once the resident was standing, CNA #5 standing behind the resident facing forward with her arms around her torso. The resident struggled to gain her footing and was able to take a few steps before leaning to the left, with CNA #5 supporting most of her weight. CNA#5 asked where the resident's walker was and another staff member said another resident had her walker. CNA #5 held onto Resident #24 by the waist and walked with her to get a walker approximately 10 feet away. CNA #5 then asked where the resident's gait belt was and another staff member responded she thought it was in her room. Resident #24 was unsteady and lifting the walker up with her as she attempted to walk, with CNA #5 holding on to her from behind, forward-facing as she provided reminders to the resident to stay forward facing. CNA #5 said, you are not doing this safely, let's go get your gait belt. CNA #5 held onto Resident #24 and walked with the living room area down the hall to the resident's room. The resident would not go into her room once they reached the door. They turned around and walked back down the hallway. Resident #24 lifted her leg and was leaning to her left side with the walker fully off the ground. CNA #5 said we are not being safe right now, you are walking sideways while supporting the resident as she was holding the walker off the ground. CNA #5 walked approximately 10 feet with the resident and got her to a chair located in the hallway near the living room. CNA #5 held the resident steady in the chair. The resident's gait belt was retrieved from her room and she was transferred back to her wheelchair. C. Record review The resident care plan, revised 7/7/21, instructed that the resident has had actual falls with minimal or no injury. Elder (resident) is at risk for continued falls due to [CONDITION(S)], poor balance, secondary to [CONDITION(S)], poor communication/ comprehension secondary to dementia and attention deficit disorder, psychoactive drug use, unsteady gait, restless leg syndrome, incontinence and polyneuropathy. The resident utilized a wheelchair most of the time, which she was unable to self propel. The resident was able to walk supervised with the use of a walker. Interventions included having commonly used articles and equipment within the resident's reach. The resident required the assistance of staff to move between surfaces as necessary. A physical therapy progress note dated 6/21/21 documented remaining functional deficits/impairments, patient continues to have impaired alignment, balance, attention to right, impaired safety with mobility, transfers and ambulation with limited distance and abnormal pattern. Patient shows improved ability to walk and move with therapy staff. A physical therapy progress note dated 6/28/21 documented patient makes attempts at standing from wheelchair at minimum to moderate assistance from one (staff member). Patient shows increased leaning to the left and inability to correct, requiring assistance back into her wheelchair. Patient requiring hand placement assistance to walker bars and able to come to standing with minimum assistance and take six steps with a front wheeled walker. Patient shows increased crossing requiring halt in bout for safety. A physical therapy assessment note dated 7/21/21 documented the analysis of function/ clinical impression of the resident; she could be as little as standby assistance for mobility depending on attention and tone. It read (the resident) has very poor problem solving and safety awareness requires supervision at all times for safety. Patient can walk with staff and do standing activities when in a good state. A restorative care note dated 7/21/21 recommended the resident ambulate with staff with or without a walker and with a gait belt three times per week. III.Staff interviews CNA #5 was interviewed on 7/26/21 at 4:34 p.m. She said part of the resident's plan for safety was to keep her in line of sight of staff at all times due to falls. She said when the staff get her up to walk, a gait belt and walker should be used. She said she would provide reminders to the resident to stay forward facing. She said the staff would walk with her when she was feeling like she needed to get up from her wheelchair. She said she should have her walker and gait belt in place before walking and assisting the resident to square up. She said she attempted to bring the resident to her room to go get her gait belt but the resident would not go into her room so she brought her back down the hallway to sit down. The physician assistant (PA) was interviewed on 7/26/21 at 4:42 p.m. He said the resident had fairly significant [CONDITION(S)]. He said the resident had significant rigidity. He said recent medication adjustments and being seen by a neurologist had been beneficial to the resident to be more calm, as she would try to get out of her chair at times. He said the resident received therapy. He said the resident gets up in a hurry and she was a fall risk no matter what. He said I had seen her stand up without a walker, he said I don't imagine it would be safe for her to walk without a walker, a gait belt and someone being right there. CNA #2 was interviewed on 7/26/21 at 4:49 p.m. She said the resident walks with staff using a gait belt or walker or both. She said therapy instructed the resident shouldn ' t wear shoes when ambulating, just socks with grips on the bottom. She said she had walked with the resident earlier that day using her walker, but could not find her gait belt. She said would typically use a gait belt with the resident and a walker as a stabilizer. She said she would stand on the residents side when walking with her so she could guide the walker with one hand and hold onto the gait belt at the same time. The director of nursing (DON) and NHA were interviewed on 7/27/21 at 12:28 p.m. The DON said the residents were assessed by nursing to determine the type assistance the resident required to complete mobility and transfers. She said the resident had a tendency to get up quickly and there were times when staff did not have the time or ability to put a gait belt on her. She said she had observed the resident to get up and walk on her own at times, however, she would expect a gait belt to be used when the staff were anticipating to assist the resident with walking. She said the amount of assistance staff needed to provide the resident was dependent on her mood and abilities at the time which fluctuated. The NHA said she had observed the resident to get up and walk on her own at times due to impulsivity. She said safe practices should be followed when staff were anticipating to assist the resident with walking. The minimum data set coordinator (MDSC) was interviewed on 7/27/21 at 12:54 p.m. She said during the assessment period (seven days) the level of assistance needed to perform transfers and mobility was driven by nursing documentation of the assistance provided. She said if a resident was determined to require extensive assistance from one staff person, it meant in order to perform the task, the staff would be carrying approximately 75 percent of the weight load required. She said she would also observe residents performing tasks to help determine the level of assistance needed. She said, per facility policy, when it is safe and feasible a gait belt should be utilized with residents who required extensive assistance with walking, mobility and transfers. She said if the staff were assisting the resident to get up a gait belt should be utilized.

Based on observations, interviews and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as Coronavirus disease (COVID-19). Specifically, the facility failed to: -Ensure staff had all updated training and information about COVID-19 prior to caring for residents; -Ensure all staff were properly screened prior to entering the facility to care for residents; and -Ensure the facility's COVID-19 policy was up to date with the most recent CDC recommendations. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (retrieved 5/29/2020), Ensure that healthcare providers (HCP) are educated, trained and have practiced the appropriate use of personal protective equipment (PPE) prior to care for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin and the environment during the process of removing such equipment. Educate them about new policies for source control while in the facility. Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of shortness of breath, new or change in cough, sore throat, and muscle aches, nausea, vomiting, diarrhea, abdominal pain, headache, runny nose, fatigue. According to the Colorado Department of Public Health and Environment (CDPHE), Communicable Disease Branch, COVID-19 Preparation and Rapid Response: Checklist for Long Term Care Facilities, 4/24/2020, All staff should be screened at the beginning of their shift for fever (take temperature) or symptoms (cough, shortness of breath, difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new olfactory (smell) and taste disorder; consider also rhinorrhea, diarrhea, nausea or vomiting). According to the Centers for Disease Control and Prevention (CDC) website, Return to Work Criteria, https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fhcp-return-work.html, retrieved 5/29/2020, Symptomatic healthcare personnel (HCP) with suspected or confirmed COVID-19 should be exclude from work until: -At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medication and improvement in respiratory symptoms -At least 10 days have passed since symptoms first appeared. II. Failure to ensure current education and training A. Record review Review of the facility's training records for COVID-19 revealed five of the 11 staff members providing care or scheduled to provide care to the residents on 5/6/2020 had not received the most current/updated information for COVID-19 provided by the facility. B. Staff interview The DON was interviewed on 5/6/2020 at 1:30 p.m. She said all staff should be educated with any updated information prior to working their shift. III. Failure to ensure proper screening of staff A. Record review On 5/18/2020 review of the employee screening forms from 3/14/2020 to 5/6/2020 revealed the following: -On 4/15/2020 at 2:17 p.m. a staff member answered yes to being exposed to someone with documented or suspected COVID-19. No follow-up was documented. -On 4/24, 4/25, 4/26, 5/4 and 5/5/2020, no screening was documented for several staff members; -On 4/24/2020 at 10:00 a.m. a staff member answered yes to coughing/sneezing. The staff members screen themselves and there was no documented follow up. The staff screening log for temperatures and respiratory symptoms was reviewed on 5/18/2020 and revealed the following: -On 3/12/2020 temperatures were being logged in as low as 88 degrees Fahrenheit (F) and 93.4 degrees (F). -On 4/9/2020 at 6:00 a.m. a staff member logged in with no temperature being recorded. -On 5/1/2020 at 6:42 a.m. a staff member logged in with no temperature being recorded. -Between the dates of 5/5/2020 and 5/6/2020, a temperature was logged in, however the name of the person the temperature was obtained from, date and time, were not recorded. B. Staff interview The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 5/6/2020 at 1:30 p.m. They said the staff are screening themselves for symptoms and they notify the nurse in the house they are assigned to work. The nurse is to contact the DON so the staff member can be interviewed and directed to leave the premises and seek medical attention. They said the sheets were being monitored daily. They said the staff member that answered yes to coughing/sneezing was tested for COVID-19 and had been off the schedule since. IV. Updating policy A. Record review The facility's Coronavirus (COVID 19) policy and procedure, last revised August 2014, reviewed on 5/6/2020, revealed the policy was not updated with the most current recommendations from the CDC. The recommendations for how long a healthcare worker should be excluded from work was only 24 hours after they no longer had a fever and seven days from symptom onset instead of the recommended 72 hours and 10 days. B. Staff interviews The NHA and DON were interviewed on 5/6/2020 at 1:30 p.m. They said they were trying to keep up with all the recommendations from the CDC and health department and agreed their policy needed to be updated with the most recent recommendations.