Every finding on record at Kiowa Hills Rehabilitation and Nursing, LLC

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision for one (#13) of three residents reviewed for accidents out of 15 sample residents.Specifically, the facility failed to ensure Resident #13 was provided safe transportation in the facility's van.Findings include:Observations, record review, and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 7/14/26 to 7/22/26, resulting in the deficiency being cited as past non-compliance with a correction date of 6/10/26. I. Van incident involving Resident #13 on 6/2/26On 6/2/26 Resident #13 was assisted into the van after an appointment by van driver #1. Resident #13 was not secured properly in the van by van driver #1. When the van braked, Resident #13 slid from his wheelchair and fell onto the floor of the van. Van driver #1 assisted Resident #13 to his wheelchair and returned to the facility. On 6/8/26, Resident #13 reported the 6/2/26 van incident to the nursing home administrator (NHA). Resident #13 complained of swelling and pain in his lower left extremity and embarrassment after falling from his seat in the facility van. An X-ray was ordered of Resident #13's lower extremities and revealed no injuries. The facility's failure to ensure van driver #1 secured Resident #13's wheelchair in the facility's van when he was being transported to and from her appointment placed the resident at serious risk of harm, serious impairment, or death. Resident #13 complained of swelling and pain in his lower left extremity and embarrassment after falling from his seat in the facility van. II. Facility plan of correctionThe corrective action plan the facility implemented in response to the van incident on 6/2/26 involving Resident #13 was provided by the NHA on 7/20/26 at 12:57 p.m. The correction plan revealed the following:A. Immediate actionOn 6/8/26, after Resident #13 reported the 6/2/26 van incident to the NHA, Resident #13 was assessed by the facility nurse. The nurse identified no injuries, but Resident #13 complained of lower left leg pain and swelling. On 6/8/26, the physician was contacted and gave an order for a left lower extremity Xray. The Xray was completed and revealed no injuries were present.Van driver #1 was suspended from the facility on 6/8/26, pending an investigation. On 6/8/26, the NHA initiated an investigation that included a root cause analysis and corrective action plan. An inspection of the van, seatbelts, and wheelchair restraints was completed on 6/8/26 by the maintenance supervisor and no defective equipment was identified.B. Identification of others affectedOn 6/8/26, the facility determined the deficient practice had the potential to affect all residents who used wheelchairs in the facility. A review of other residents was completed to determine if vehicle safety belts were properly applied, and no residents were identified as being improperly restrained in the facility van.C. Systemic changesThe facility provided documentation that all staff who could transport residents had completed wheelchair securement training by 6/10/26. The training included correct procedures for securing wheelchairs in vehicles, the use of appropriate restraints and securing devices, how to inspect and ensure all safety equipment was functioning properly before transport, and procedures to follow in case of an emergency or equipment malfunction. D. MonitoringThe facility would complete daily monitoring of progress notes and incident reports to identify any concerns with resident safety during transportation in the facility van. The 6/10/26 quality assurance and performance improvement (QAPI) committee reviewed the results of the corrective action plan for staff education and daily monitoring. The QAPI committee determined all staff involved in transporting residents completed the mandatory education and residents were properly restrained in the facility van before operating the vehicle.III. Facility policy and procedureThe Transporting a Resident, Facility Van policy, revised 6/8/26, was provided by the NHA on 7/21/26 at 10:56 a.m. It read in pertinent part, It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and other trips the facility deems necessary. The van will be well-maintained and equipped with safety features. Each resident will be secured by a seatbelt while in a seat or in their wheelchair. All wheelchairs will be secured with wheelchair tie-downs.IV. Facility's investigation of Resident #13's fall on 6/2/26Resident #13's fall investigation was provided by the NHA on 7/20/26 at 12:57 p.m. The investigation documented the following:The 6/8/26 incident report documented that Resident #13 was returning to the facility in the transport van. The investigation report documented that van driver #1 secured Resident #13's wheelchair in the facility van. When van driver #1 attempted to apply the vehicle passenger-restraint seat belt, Resident #13 refused and told van driver #1 he did not like the way van driver #1 applied the seat belt. The report read that during the drive back to the facility, van driver #1 applied the van brakes and Resident #13 slid from his wheelchair to the floor in the van. Resident #13 reported the incident to the NHA on 6/8/26. A nurse assessed Resident #13, and no injuries were revealed. On 6/8/26, Resident #13 complained of pain and swelling in his lower left extremity. The physician ordered an Xray of the resident's left leg on 6/8/26 and no injuries were identified. On 6/8/26, the investigation documented the facility provided education and training for applying the five-point vehicular passenger restraints in the facility van. The education included completing a transportation safety checklist and that no transportation would occur if a resident refused to wear the vehicle restraint belt. The educated instructed staff to immediately report any accidents that occurred during the transportation of residents.The facility investigation documented that proper education and demonstrations of how to secure wheelchair residents in the van were not completed prior to the incident. The facility trained all drivers, including a return demonstration, and educated the drivers that all passengers must use a seat belt restraint prior to moving the van. The facility identified the root cause of the incident as gaps in transportation safety, including inconsistent application of passenger restraint belts, and a lack of a standardized process for managing resident refusals to use the passenger seat belt restraint system.The facility investigation identified there was no evidence of facility staff neglect, and van driver #1 was reinstated to his position. V. Resident #13A. Resident statusResident #13, age less than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included end-stage kidney disease, kidney dialysis, right and left below-knee amputations, depression, and anxiety.The 5/29/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #13 used a wheelchair and required set-up, supervision, or touching assistance from staff for repositioning, transferring, toilet hygiene, and dressing. He required supervision or touching assistance for showering and wheelchair mobility. B. Resident interview and observationResident #13 was interviewed on 7/22/26 at 8:40 a.m. Resident #13 was sitting in a wheelchair outside the facility in the outdoor patio area. Resident #13 said he remembered the incident on 6/2/26 in the facility van. Resident #13 said he was very weak from his kidney dialysis when he was loaded into the wheelchair van by van driver #1. Resident #13 said he noticed that van driver #1 secured his wheelchair in the van but did not correctly apply his passenger-restraint seat belt. Resident #13 said van driver #1 appeared unsure of what belts to use for the passenger seat belt restraint system. Resident #13 said van driver #1 tried to use the restraint belt for the seat next to him, instead of the restraint belt for where he was sitting, which created a tangled mess and did not properly reach across his body. Resident #13 said he asked van driver #1 to use the correct belt, and van driver #1 would not listen to him. Resident #13 said he did not have the energy to continue discussing his concern with van driver #1 and trusted that van driver #1 eventually used the correct seat belt restraint. Resident #13 said van driver #1 began driving back to the facility, and along the route, van driver #1 had to brake suddenly, and he (Resident #13) fell forward from his wheelchair and landed on the van floor. Resident #13 said he and van driver #1 were able to reposition him in his wheelchair, and van driver #1 resumed driving to the facility. Resident #13 said when the van returned to the facility, he was upset from the fall and said he was in a hurry to return to his room after the kidney dialysis treatment and waited to report his leg pain because he did not feel well. Resident #13 said van driver #1 asked that he not report the incident to the facility, and Resident #13 said he was okay with that, but said he asked van driver #1 to watch a video or learn somewhere how to use passenger seat belt restraints properly. Resident #13 said when he went for his next dialysis treatment on 6/8/26, he observed van driver #1 appeared to again not understand what seat belts should be used for the passengers in the van. Resident #13 said when he returned to the facility on 6/8/26, he reported the 6/2/26 van incident to the NHA because the van driver had not improved in applying passenger restraint seat belts. Resident #13 said after he reported his concerns to the NHA on 6/8/26, van driver #1 began using the passenger restraint belts properly for himself and other wheelchair passengers on the facility van. Resident #13 said he was unaware the facility developed a behavior care plan that identified that he refused to wear his passenger restraint seat belt (see record review and interviews below). Resident #13 said that made him upset because he always wanted to wear his seat belt and had had years of experience using passenger restraints in transportation vans. Resident #13 said when he did not feel well, he should be able to trust the facility staff to ensure he was properly restrained in the van.Resident #13 said he had pain and swelling in his lower left leg after the fall on 6/2/26. Resident #13 said the facility completed an Xray of his left leg after he reported the van incident and the pain was slowly improving. C. Record reviewResident #13's behavior care plan, initiated 7/8/26, revealed the resident had a tendency to refuse to wear a seat belt in the facility van. Interventions included educating Resident #13 on the necessity of care offered, ensuring the safety of Resident #13, establishing boundaries and limits with Resident #13, monitoring for cognitive factors, emotional, environmental factors with the new behavior, monitoring for signs and/or symptoms of infection, notifying family of new onset finding, proving emotional support regarding new onset of disruptive behavior, providing emotional support regarding new onset of repetitive behaviors, providing verbal feedback regarding behaviors, and using diversion techniques as needed (initiated 7/8/26).A nurse progress note, dated 6/8/26, documented the physician ordered an Xray of Resident #13's left lower extremity. A behavioral health provider progress note, dated 6/11/26 at 8:30 a.m., documented Resident #13 reported the 6/2/26 transportation incident. The progress note revealed Resident #13 did not report the incident to the facility at the time of the incident, and the facility became aware of the incident on 6/8/26. The progress note revealed a nurse assessed Resident #13, and there were no acute changes or injuries noted. The provider documented Resident #13 complained of discomfort in his left lower leg; an Xray was obtained and revealed no acute findings. The provider documented Resident #13 was educated to report safety concerns, incidents, or injuries to facility staff as soon as possible to allow for timely staff assessments and interventions. The IDT progress note, dated 6/11/26 at 9:36 a.m., documented Resident #13 reported that during his transportation to dialysis on 6/2/26, his wheelchair was not secured appropriately in the facility van. The progress note documented Resident #13 did not report the incident to the facility at the time of the event, and the facility became aware of the incident on 6/8/26. The progress note documented Resident #13 was assessed by a nurse on 6/8/26, and no changes or injuries were noted. The progress note revealed Resident #13 complained of discomfort in his lower left extremity, below the knee amputation, and the facility obtained an Xray that revealed no acute findings. The progress note revealed the attending physician was notified of the incident and gave no new orders, except for the leg Xray. VI. Staff interviewsThe NHA and the clinical resource nurse were interviewed together on 7/22/26 at 1:25 p.m. The NHA said that on 6/2/26 van driver #1 transported Resident #13 from his kidney dialysis treatment back to the facility. The NHA said Resident #13 refused to wear the van's passenger restraint seat belt. The NHA said when van driver #1 was interviewed, van driver #1 said that he educated Resident #13 about wearing a restraint seat belt, but Resident #13 continued to decline to wear the passenger restraint belt. The NHA said van driver #1 proceeded to travel back to the facility, and when he applied the van brakes, Resident #13 slid forward and fell from his wheelchair. The NHA said Resident #13 was not assessed on 6/2/26, the day of the incident, because Resident #13 did not report the incident or the pain he experienced in his leg until 6/8/26. The NHA said van driver #1 had received education and training in April 2026 on operating/driving the facility van and how to use the passenger seat belt restraint system. The NHA said van driver #1 should have contacted the facility prior to driving with an unrestrained passenger, and van driver #1 should have reported the incident immediately upon his return to the facility. The NHA said when the facility became aware of the incident on 6/8/26, van driver #1 was suspended from working while the facility conducted an incident investigation. The NHA said van driver #1 was re-educated on applying the passenger seat belt restraint system and performed a return demonstration. He said van driver #1 was approved to return to his position as a facility van driver. The clinical resource nurse said during the investigation of the van incident involving Resident #13, the facility identified that Resident #13 refused to wear the van's passenger seat belt restraint and he had previously demonstrated behaviors of releasing his seat belt early, before the van was fully stopped, when the van returned to the facility. The clinical resource nurse said safety education was provided to Resident #13, following the 6/2/26 incident, on the importance of using the passenger seat belt restraint system, and there had been no further concerns. The clinical resource nurse said the facility completed a corrective action plan that included daily monitoring of documentation or incident reports for concerns regarding residents' van transportation. The clinical resource nurse said the facility had had no additional concerns of resident safety during van transportation.

Based on observations, record review and interviews, the facility failed to ensure three (#15, #9, and #11) of five residents were free from abuse out of 15 sample residents.Specifically, the facility failed to:-Protect Resident #15 from sexual abuse by Resident #5;-Protect Resident #9 from sexual abuse by Resident #14; and,-Protect Resident #11 from physical abuse by Resident #12.Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy, revised 7/16/26, was provided by the nursing home administrator (NHA) on 7/21/26 at 10:56 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. Employees will be educated on abuse during initial orientation and throughout the year during in-service training and as needed. The facility will establish a safe environment that supports a resident's consensual sexual relationship and establish policies and protocols for preventing sexual abuse.II. Incident of sexual abuse of Resident #15 by Resident #5 on 2/23/26A. Facility investigationThe facility's investigation of the incident of sexual abuse of Resident #15 by Resident #5 on 2/23/26 was provided by the NHA on 7/20/26 at 12:57 p.m. The investigation documented that on 2/27/26, Resident #15 reported to a staff member that two to three days prior, a resident (Resident #5) lying in his wheelchair near the bird cage beckoned her to come to him. When she did, Resident #5 grabbed her breast. The facility investigation documented that Resident #15 said she told Resident #5 she was aware of his behavior and he should stop. Resident #15 reported Resident #5 had grabbed her breast, on approximately 2/23/26 and said she was not afraid of Resident #5 because he was in a wheelchair and could not move without assistance. The investigation revealed Resident #15 had no previous behavior incidents at the facility. Resident #5 was identified as an alleged assailant in two previous incidents at the facility on 8/15/25 and 10/13/25 and was placed on one-to-one care for supervision and behavior monitoring.The investigation indicated the facility substantiated the sexual abuse.B. Resident #15 (victim)A. Resident status Resident #15, age greater than 65, was admitted to the facility on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included diabetes mellitus, difficulty walking, anxiety, and depression.The 7/14/26 minimum data set (MDS) assessment revealed Resident #15 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision/touching assistance from staff for shower transfers and walking, and set up assistance for bed mobility. The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others.2. Resident interviewResident #15 was interviewed on 7/16/26 at 2:15 p.m. Resident #15 said she remembered the incident with Resident #5 on 2/23/26. Resident #15 said Resident #5 reached out and grabbed her breast. Resident #15 said she was unsure if anyone witnessed the incident and said she did not initially report the incident because she was not afraid of Resident #5. Resident #15 said she had seen Resident #5 in the facility occasionally, and on the day Resident #5 grabbed her breast (2/23/26), staff had not intervened to direct her away from him. Resident #15 said she was not upset after the incident and she was not afraid of Resident #5 or any other resident in the facility. Resident #15 said she would report any future concerns for herself or other residents to the nurse.3. Record reviewA physicians progress note, dated 2/24/26, revealed Resident #15 was evaluated after the sexual abuse was reported and no concerns were identified. -The record review revealed Resident #15 had no care plan focus for the potential for sexual abuse. C. Resident #5 (assailant)1. Resident statusResident #5, age greater than 65, was admitted to the facility on [DATE]. According to the July 2026 CPO, diagnoses included stroke with left-sided paralysis, cognitive communication deficit, history of traumatic brain injury, anxiety, depression, and personality and behavioral disorders. The 3/10/26 MDS assessment revealed Resident #5 was moderately cognitively impaired with a BIMS score of 12 out of 15. Resident #5 used a wheelchair for mobility and was dependent on staff assistance for his activities of daily living (ADL).The MDS assessment indicated the resident had physical behavioral symptoms directed at others for one to three days during the assessment look-back period. 2. Record reviewThe behavior care plan, revised 6/29/25, revealed Resident #5 had inappropriate physical contact with female staff and/or female residents. Pertinent interventions included administering medications as ordered, monitoring medications for effectiveness, monitoring with one-to-one supervision for 72 hours after incidents until the interdisciplinary team (IDT) determined if behavior was appropriate to discontinue one-to-one monitoring, anticipating and meeting Resident #5's needs, discussing inappropriate behavior with Resident #5, intervening as necessary to protect others for inappropriate touching, positioning Resident #5 with his right side towards the wall so that he could not reach others, and educating staff on appropriate placement of Resident #5 when he was in the common areas (initiated 6/29/25). -There were no revisions made to Resident #5's behavior care plan after the 2/23/26 sexual abuse incident with Resident #15.An IDT progress note, dated 2/27/26, documented Resident #5 was placed on one-to-one supervision while out of bed for an incident of sexual abuse. The IDT documented a referral was made to transfer Resident #5 to another facility.A physician's progress note, dated 2/28/26, documented Resident #5 was evaluated as a follow-up after an incident of sexually inappropriate behavior toward another resident. The progress note revealed Resident #5 had resided at another facility until 6/24/25, when he was transferred for inappropriate sexual behavior toward another resident. The physician documented Resident #5 was scheduled for a facility-initiated discharge to protect other residents. -However, Resident #5's responsible party appealed the discharge plan and Resident #5 remained at the facility. III. Incident of sexual abuse of Resident #9 by Resident #14 on 3/29/26A. Facility investigationThe facility's investigation of the incident of sexual abuse of Resident #9 by Resident #14 on 3/29/26 was provided by the NHA on 7/20/26 at 12:57 p.m. The investigation documented that on 3/29/26 at 6:47 p.m. Resident #9 reported to a staff nurse that she was kissed by Resident #14. When the staff nurse asked Resident #14 about the incident, Resident #14 told the nurse he kissed Resident #9. He said that he would do it again and proceeded to kiss Resident #9 a second time. The facility investigation documented that Resident #14 was not redirectable and was placed on one-to-one for monitoring. After the incident, Resident #9 was assisted to her room by a staff member and was assessed by the nurse. The assessment revealed no concerns. The physician evaluated Resident #9, and no immediate concerns were identified. The facility initiated a referral for a psychosocial evaluation for Resident #9 and began monitoring Resident #9 for post-incident changes in mood or behavior. The facility's investigation revealed Resident #9 had a history of verbal aggression, attention-seeking behaviors, manipulation, making false allegations, and poor impulse control. The investigation revealed Resident #9 had family and power of attorney for a consensual romantic relationship that included hand holding, touching, and kissing, with another resident in the facility (not Resident #14). The investigation documented that Resident #9 told a staff member that she was not getting enough attention from her boyfriend and smiled after Resident #14 kissed her.The investigation revealed Resident #14 had cognitive impairment and had no history of behaviors at the facility. Resident #14 admitted to kissing Resident #9, told a staff member he would kiss her again and proceeded to kiss Resident #9 in front of the staff member. The investigation documented Resident #14 was interviewed by a staff member on 4/1/26, and he did not entirely recall the incident. The facility's investigation included interviews with staff members and other residents, and there were no concerns identified about feeling unsafe from unwanted sexual behaviors. The facility's investigation concluded sexual abuse was not substantiated and that this was an isolated incident due to Resident #9's history of attention-seeking behavior and Resident #14's cognitive impairment, poor impulse control, and diagnosis of dementia.-However, sexual abuse did occur as Resident #9 said that she felt unsafe from Resident #14 and said she did not like Resident #14 kissing her. B. Resident #9 (victim)1. Resident statusResident #9, age less than 65, was admitted to the facility on [DATE], discharged on 9/7/25, and readmitted on [DATE]. According to the July 2026 CPO, diagnoses included cerebral palsy, quadriplegia, irritability, and anger. The 5/12/26 MDS assessment revealed Resident #9 had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident was dependent on staff for all ADLs. The MDS assessment indicated Resident #9 had verbal behavioral symptoms directed toward others for one to three days during the assessment look-back period. 2. Resident interviewResident #9 was interviewed on 7/22/26 at 8:55 a.m. Resident #9 said she remembered when Resident #14 approached her and kissed her on her lips (on 3/29/26). Resident #9 said she did not ask Resident #14 to kiss her and she was upset that he kissed her a second time on the same day. Resident #9 said she was afraid that Resident #14 was going to try to kiss her, but she had told only her boyfriend (a resident at the facility) about her concerns. Resident #9 said she loved her boyfriend and enjoyed spending time with him. 3. Record reviewResident #9's consensual boyfriend care plan, dated 4/8/24, revealed the resident had a boyfriend relationship with another resident who resided in the facility. Resident #9's family and power of attorney agreed and consented to the relationship that included holding hands, touching, and kissing. Interventions included encouraging Resident #9 to express any feelings of discomfort or areas of concern she may have in her consensual boyfriend relationship (initiated 4/8/24).The potential for emotional distress/trauma care plan, dated 3/30/26, identified that Resident #9 may present with behavioral or physical changes after she was kissed by another resident who was not her boyfriend. Interventions included redirecting the triggering resident away from Resident #9 to prevent further contact, educating all staff that Resident #9 had increased vulnerability for unwanted touching from other residents, monitoring non-verbal indicators for emotional distress, and providing activities in a calm, structured environment with trusted staff members nearby (initiated 3/30/26). C. Resident #14 (assailant)1. Resident statusResident #14, age greater than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included dementia, depression, unsteady on feet, difficulty walking, and post-traumatic stress disorder. The 7/3/26 MDS assessment revealed Resident #14 had severe cognitive impairment with a BIMS score of six out of 15. Resident #14 used a walker for ambulation. He was independent for all ADLs. The MDS assessment indicated the resident had wandering behavior on one to three days during the assessment look-back period. 2. Record reviewA nurse practitioner's progress note, dated 3/30/26, revealed Resident #14 was evaluated after he was seen kissing another resident (Resident #9) twice and he had a history of similar behaviors. The progress note revealed Resident #14 was placed on one-to-one care for monitoring, and referrals were made to transfer Resident #14 to a facility with a memory care unit and for a behavioral health evaluation.The 3/30/26 social services progress note revealed the IDT noticed Resident #14 had a significant cognitive decline and felt Resident #14 would benefit from being transferred to a memory care unit. A behavior health progress note, dated 3/31/26, documented Resident #14 admitted to kissing Resident #9 previously (approximately one month previously) but denied kissing her on 3/30/26. The progress note revealed Resident #14 would benefit from placement on a secure unit; however, Resident #14's responsible party declined a transfer to another facility. IV. Incident of physical abuse of Resident #11 by Resident #12 on 6/12/26A. Facility investigationThe facility's investigation of the incident of physical abuse of Resident #11 by Resident #12 on 6/12/26 was provided by the NHA on 7/20/26 at 12:57 p.m. The facility's investigation, dated 6/12/26, documented that Resident #12 ran over Resident #11's feet with his wheelchair when they were both outside a staff member's office. The investigation documented Resident #12 told Resident #11 that he would run over his feet if he did not stop talking. The investigation documented Resident #11 stated he was talking to a staff member and Resident #12 rolled over his feet with his wheelchair. The investigation documented Resident #12 said he was rolling forward and not looking where he was going. Resident #12 said that he did not run over Resident #11's toe but had bumped it. Resident #12 said if he had tried to run over Resident #11's feet, he would have yelled. The facility investigation included a witness statement that documented he observed Resident #11 and Resident #12 arguing in front of an office at the facility. The witness said he heard Resident #12 tell Resident #11 to shut up. The witness said at the same time Resident #11 asked Resident #12 to scoot his wheelchair forward so that he did not bump into him. The witness reported he heard Resident #12 tell Resident #11 to shut up or he would run over his feet. The witness reported he then observed Resident #12 intentionally run over Resident #11's feet. The witness reported Resident #11 responded by raising his fist towards Resident #12. The investigation documented the residents were separated at the time of the incident and staff monitored both residents per facility policy.The investigation documented the facility unsubstantiated the incident of physical abuse because both residents had a behavioral response towards each other.-However, physical abuse did occur when Resident #12 intentionally ran over Resident #11's toes.B. Resident #11 (victim)1. Resident statusResident #11, age less than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included congestive heart failure, malnutrition, dementia, high blood pressure, and cognitive communication deficit. The 7/6/26 MDS assessment revealed Resident #11 had moderate cognitive impairment with a BIMS score of 12 out of 15. Resident #11 required supervision or touching assistance for transfers and showers, and setup assistance for dressing and bed mobility. Resident #11 used a manual wheelchair for mobility.The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms during the assessment look-back period.2. Resident interviewResident #11 was interviewed on 7/21/26 at 11:15 a.m. Resident #11 said he remembered the altercation he had with Resident #12 on 6/12/26). Resident #11 said Resident #12 yelled at him and told him he was going to run over him with his wheelchair because he was in his way. Resident #11 said he did not provoke or understand why Resident #12 thought it was all right to run over his feet. Resident #11 said Resident #12 was a large person and he had pain in his left foot after the incident. Resident #11 said the facility completed an Xray of his left foot and there was nothing wrong with his left foot. However, Resident #11 said that he continued to have pain in his left foot. Resident #11 said staff separated Resident #12 from him, and he had not had any additional altercations or fear of Resident #12. 3. Record reviewA physician's assistant progress note, dated 6/15/26, documented Resident #11 was evaluated for injury to his first and second toes on his left foot, following a resident-to-resident altercation. The progress note documented Xrays were obtained of the left toes and revealed there were no acute fractures. C. Resident #12 (assailant)1. Resident statusResident #12, age less than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included chronic obstructive lung disease, alcoholic liver disease, morbid obesity, difficulty walking, and lack of coordination. The 5/20/26 MDS assessment revealed Resident #12 was cognitively intact with a BIMS score of 15 out of 15. Resident #12 required substantial to maximum assistance from staff for dressing and transfers. Resident #12 used a manual wheelchair for mobility. The MDS assessment indicated Resident #12 had verbal behavioral symptoms directed toward others for one to three days during the assessment look-back period. 2. Record reviewThe IDT progress note, dated 6/16/26, revealed Resident #12 had poor situational awareness and poor impulse control. The progress note documented the altercation with Resident #11 was witnessed by a staff member and the staff member was unable to intervene to prevent the altercation. The progress note documented the staff member immediately separated the residents and they were assessed by the nurse. Resident #12 had no injuries. A physician's assistant progress note, dated 6/17/26, documented Resident #12 was evaluated for a recent altercation with another resident. The physician documented Resident #12 said he did not intentionally run over Resident #11's feet. The physician's assistant made no recommendations to change Resident #12's behavior care plan.Resident #12's behavior care plan, initiated 12/3/25, revealed Resident #12 had the potential to be verbally and physically aggressive. Pertinent interventions included administering medications as ordered, monitoring for side effects and effectiveness of medications, identifying behavior triggers and effective de-escalation interventions, anticipating and meeting Resident #12's needs, monitoring Resident #12 for signs of Resident #12 posing a danger to himself or to others, assisting Resident #12 with appropriate methods of coping and interacting with others, and discussing inappropriate behaviors (initiated 5/12/26).-There were no revisions made to Resident #12's behavior care plan after the 6/12/26 physical abuse incident with Resident #11.V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 7/14/26 at 8:17 a.m. LPN #1 said Resident #9 had a boyfriend who sat with her in the common area, and Resident #9 enjoyed holding his hand and spending time with him. LPN #1 said she was aware of the incident of Resident #14 kissing Resident #9. LPN #1 said Resident #14 had recent falls and increased weakness and was not strong enough to wander in the hallways. She said she monitored Resident #9 when she was in the common area and had no observations of Resident #14 approaching Resident #9.Registered nurse (RN) #1 was interviewed on 7/22/26 at 12:35 p.m. RN #1 said he provided care for Resident #15 and had not noticed a change in her mood or behavior after Resident #5 had kissed her. The NHA and the clinical resource nurse were interviewed together on 7/22/26 at 1:25 p.m. The NHA said the incident of sexual abuse between Resident #15 and Resident #5 was not witnessed by a staff member. The NHA said the facility was aware Resident #5 had a history of sexually inappropriate behavior prior to his admission. The NHA said the intervention of positioning Resident #5 out of reach of others was the intervention in place to protect others from Resident #5 grabbing others. The NHA said the facility would review Resident #5's care plan for appropriate and effective interventions.The clinical resource nurse said Resident #9 had a history of attention seeking behavior and calling out to other residents to approach her. The clinical resource nurse said staff were aware that Resident #9 liked to sit in the common area and was dependent on staff to position her. The clinical resource nurse said staff kept Resident #9 in their line of sight whenever possible. The clinical resource nurse said Resident #14 had made no additional attempts to approach and kiss Resident #9. The clinical resource nurse said Resident #14 was experiencing a change in condition with increased weakness and was unable to ambulate independently. The clinical resource nurse said Resident #14 was evaluated for transfer to a locked memory care unit and his responsible party declined. The clinical resource nurse said the facility would continue to monitor Resident #14 to ensure he did not attempt to kiss any female residents.The NHA said Resident #11 and Resident #12 each had a history of behaviors towards others. The NHA said the facility did not substantiate the occurrence between the two residents on 6/12/26 because after Resident #12 ran over Resident #11's feet, Resident #11 swung at Resident #12's head. The NHA said after the incident, the residents spoke to each other and said they were sorry for the altercation. The NHA said Resident #11 and Resident #12 did not reside on the same hallway and staff were educated to keep the residents apart from each other. RN #1 said he was familiar with Resident #14 and said Resident #14 was unable to propel his wheelchair independently. RN #1 said Resident #14 enjoyed socializing with other residents and staff assisted him to common areas. RN #1 said staff positioned Resident #14 so that he was not physically able to reach out and touch other residents, due to his paralyzed left side.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents with limited range of motion receive appropriate treatment and services out of seven sample residents.Specifically, the facility failed to ensure Resident #1 received restorative services according to the physical therapy recommendations. Findings include:I. Resident #1A. Resident statusResident #1, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2025 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis affecting the left side, major depressive disorder and type two diabetes mellitus. The 8/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required substantial to maximum assistance with toileting, personal hygiene and transfers and partial to moderate assistance with bathing and dressing. B. Resident and resident representative interviewResident #1 and her representative were interviewed together on 10/30/25 at 1:20 pm. Resident #1 said she did not receive therapy consistently. She said she felt she would not be able to maintain her current abilities if the facility staff did not provide restorative therapy consistently. She said she was frustrated and felt the facility did not listen to her concerns. C. Record reviewThe 9/25/25 physical therapy discharge notes documented a recommendation of a restorative ambulation program with ambulation five times per week for six weeks with a hemi-walker with contact guard assistance (CGA) and a wheelchair in tow while on even surfaces to maintain the resident's current level of function.It documented the resident had an excellent prognosis to maintain her current level of function with consistent staff support.The October 2025 restorative nursing notes documented Resident #1 received restorative therapy on 13 occasions out of 22 opportunities.II. Staff interviewsRestorative nursing aide (RNA) #1 was interviewed on 10/30/25 at 2:13 p.m. He said he had worked at the facility for six years and provided restorative services for residents. RNA #1 said the therapy department developed the restorative therapy program for each resident and then he was responsible to execute the program.RNA #1 said Resident #1 enjoyed her restorative therapy program. He said Resident #1 was on a program to receive ambulation five days per week. He said he was not able to provide restorative therapy services to the resident according to the resident's plan. He said he got pulled from providing restorative therapy to go with other residents to outside therapy appointments and to work the floor. He said it was difficult to provide restorative services because of those reasons. He said Resident #1 had not been given restorative services according to the plan because he was not always available to provide the treatment.The director of nursing (DON) was interviewed on 10/30/25 at 3:20 p.m. The DON said the therapy department developed each restorative program and provided it to the RNA to execute. She said RNA #1 was pulled to the floor, to other outside appointments and worked the floor as needed.The DON said she was not aware Resident #1's restorative program was scheduled for five days per week. She said Resident #1 should receive the restorative program five days per week, which was the recommended program by the physical therapy department.The DON said it was important to complete the restorative program to maintain the resident's current level of function.

Based on observations and interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen.Specifically, the facility failed to ensure:-Hand hygiene was conducted appropriately;-Food was held at the correct temperature; and,-Room trays were covered during transportation from the kitchen to the residents' room. Findings include:I. Failure to perform hand hygiene appropriatelyA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/4/25. It revealed in pertinent part, Food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single serve and single use articles. During food preparation, as often as necessary to remove soils and contamination and to prevent cross contamination when changing tasks. -When switching between working with raw food and working with ready to eat food. -Before donning gloves to imitate a task that involves working with food. -After engaging in other activities that contaminate the hands. (Chapter 2-301.14)B. ObservationsDuring a continuous observation during the dinner meal on 8/26/25, beginning at 4:00 p.m. and ending at 5:23 p.m., the following was observed:At 4:05 p.m. cook (CK) #1 was preparing banana pudding while wearing gloves. Without changing gloves, CK #1 then pureed four cups of bananas and added them to the pudding. CK #1 placed a lid on the pudding and placed the pudding in the fridge. At 4:10 p.m. CK #1 took a tray of baked Italian sub sandwiches from the hot warmer box and began cutting the sandwiches in half, using the same gloved hands he used to prepare the pudding. CK #1 placed the sandwiches in a big metal container, using the same gloved hands. CK #1 took out another tray of sub sandwiches from the hot warmer box and began cutting them in half placing them in the same big metal container, using the same gloved hands. She covered the sub sandwiches with parchment paper and placed the metal container back into the hot warmer box. CK #1 then took out another tray of sub sandwiches, cut them up, and placed them in another metal container, using the same gloves hands. CK #1 then covered the second container with parchment paper and placed them back in the hot warmer box.At 4:41 p.m. CK #1 changed her gloves and did not wash her hands. CK #1 opened up a package of cheese, reached into the bread and took out two slices of bread. CK #1 placed one slice of cheese on the bread. The dietary manager (DM) retrieved the deli meat from the refrigerator and sat it down on the counter. Without changing gloves, CK #1 reached into the container of deli meat with the same gloves on and placed the meat on the sandwich. CK #1 got a clean plate and placed the sandwich on the plate and then wrapped the plate with saran wrap.At 4:55 p.m. the two unidentified dietary aides (DA) had gloves on and were taking the food out of the hot warmer box and placing the food on the cart.At 4:58 p.m. one unidentified DA with the same glove hands wheeled the cart out of the main kitchen and down the hallway to the elevator. The unidentified DA pushed the button to get on the elevator and when on the elevator pushed the button again to close the door. The unidentified DA wheeled the cart to the satellite kitchen.At 5:15 p.m. the unidentified DA, with the same gloved hands began taking the temperature of the food and touched the meal tickets. The unidentified DA began preparing plates of food for the residents.At 5:23 p.m. the unidentified DA opened a bag of potato chips. She used the same gloved hands to take potato chips out of the bag and place them on a plate. Without changing gloves, the unidentified DA opened hamburger buns up, grabbed two buns out and placed them on the plate. The unidentified DA then grabbed the hamburger patty out of the metal container with the same gloves hands placed the hamburger on the bun. The unidentified DA did not change out her gloves and continued to plate other residents food.On 8/27/25 at 8:45 a.m. the room trays for the 300 hall were passed out. The cart had four room trays. The plate had a dome cover over the food, however, the oatmeal on the trays were not covered as it was transported down the hallway. C. Staff interviewThe DM was interviewed on 8/27/25 at 10:50 a.m. The DM said the staff should change their gloves between tasks. He said if the CK was handling only buns, they would not need to change their gloves. The DM said the unidentified DA should have changed her gloves after putting her hand in the bag of chips. The DM said the unidentified DA should not have used her hand to get the hamburger patty out of the pan. The DM said the unidentified DA should have used tongs. The DM said he would provide education to the staff on hand hygiene. II. Failure to ensure food was held at the correct temperatureA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/4/25. It revealed in pertinent part, Time/Temperature control for safety food, hot and cold holding at 135 degrees F (Fahrenheit) or higher and 41 degrees F and lower. (Chapter 3)B. ObservationsDuring a continuous observation during the dinner meal on 8/26/25, beginning at 5:05 p.m. and ending at 6:00 p.m., the following was observed:At 5:11 p.m. an unidentified DA took the temperature of the potato salad and it was 49 degrees F. The potato salad was stored on a cart and was not on ice during the meal service. C. Staff interviewsThe DM was interviewed on 8/27/25 10:50 a.m. The DM said hot food should be held at 135 degrees F and cold food at 41 degrees F during meal service. The DM said the potato salad should not have been 49 degrees F. The DM said the potato salad should have been placed in smaller pans. The DM said the satellite kitchen did not have a cooling spot to put cold items in. The DM said the potato salad should have been placed on ice, but they did not have enough pans.III. Failure to ensure food was covered during transportation from the kitchen to the residents' roomsA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/4/25. It revealed in pertinent part, Food shall be protected from contamination that may result from a factor or source. (Chapter 3).B. ObservationsOn 8/26/25 at 9:16 a.m. the room trays for the 600 hall were being passed out to the residents. The cart had four room trays. The plate had a dome cover over the food. The oatmeal and apple sauce on the trays were not covered as it was transported down the hallway. C. Staff interviewsThe DM was interviewed on 8/27/25 at 10:50 a.m. The DM said when room trays were delivered, the food on the tray should be covered. The DM said he did not have covers for the bowls and cups. He said he talked to the NHA about not having bowl and cup covers. He said the nursing home administrator (NHA) said they would purchase those items in September 2025. He said he also did not have enough room tray covers. He said there were a lot of residents who ate in their rooms. The NHA was interviewed on 8/27/25 at 1:41 p.m. The NHA said the kitchen should have covers for the bowls and cups. The NHA said he was not aware that the kitchen did not have covers for the bowls and cups. The NHA said bowls and cups should be covered due to sanitization and temperature control. The NHA said he was working with the DM about what was needed in the kitchen.The NHA said he would get them ordered as soon as possible. He said he would talk to the DM and see what needed to be ordered.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and follow up with residents who attended food committee and resident council on the outcomes and resolutions of grievances expressed regarding food. Findings include:I. Facility policy and procedureThe Resident and Family Grievances policy and procedure, dated 4/11/25, was received by the nursing home administrator (NHA) on 8/27/25 at 3:52 p.m. It read in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The grievance officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary. The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance. The grievance officer will take steps to resolve the grievance, and record information about the grievance, and those actions on the grievance form. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the grievance officer. Prompt efforts include acknowledgement of complaint/grievances and actively working toward a resolution of that complaint/grievance. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know. The grievance officer, or designee, will keep the resident appropriate apprised of progress towards resolution of the grievances. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the grievance officer will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum:-The date the grievance was received;-The steps taken to investigate the grievance;-A summary of the pertinent findings or conclusions regarding the resident's concern (s);-A statement as to whether the grievance was confirmed or not confirmed; -Any corrective action taken or to be taken by the facility as a result of the grievance; -The date the written decision was issued; and, The facility will make prompt efforts to resolve grievances.A. Resident group interviewA group interview was conducted on 8/26/25 at 2:32 p.m. with five residents (#6, #7, #9, #10 and #15), who were identified as alert and oriented through facility and assessment.The residents in the group said they had complained about the food being cold, over cooked and bland in taste. The residents said there was no resolution. The residents said the administration acknowledged the concerns however, did not implement a resolution. The residents said the lunch and dinner orders were not being taken prior to the meal and often the menu did not match what was served. B. Record reviewThe 4/17/25 resident council minutes documented the residents voiced a concern that the certified nurse aides (CNA) were not taking lunch and dinner prior to the meal. The minutes documented the residents voiced a concern that the french fries were not being fully cooked. The follow up section on the form documented the CNAs had been educated. The follow up documentation also documented that the cooks were ensuring the fries reached 180 degrees Fahrenheit (F).-However, it was documented next to the NHA's signature that the action was not sufficient and it was not effective. The 5/15/25 resident council meeting minutes documented the residents voiced a concern that they received the wrong food orders. The residents said they did not know if it was a miscommunication with the CNAs and the kitchen staff. The residents said the menu that was posted was not matching the ticket. The residents said the vegetables were over cooked or raw. The residents said the portion sizes were too small, the fries were not fully cooked and hot food was not hot. The residents said there were not enough snacks. The follow up section on the form documented to ensure the food was hitting the correct temperature of 165 degrees F. It documented for the staff to make sure the meal tickets matched the menu. It documented the CNAs were educated to obtain orders timely. The cooks were educated to ensure the fries were full cooked, that the temperature of the vegetables were correct, portion sizes were correct and to ensure there were enough snacks. -However, it was documented next to the NHA's signature that the action was not sufficient and it was not effective.-Cross reference F803: failure to follow the menus. The 6/19/25 resident council meeting notes documented the residents voiced concerns that the fries were not fully cooked, the hot food was not hot and the residents received their orders wrong. It documented the menus were not matching the tickets. The follow up section of the form documented the cooks were to bake the french fries in the oven. This action was signed off as sufficient. The follow up section of the form further documented that the bistro orders would be clearly identified. -However, the form documented the action was not sufficient and it was not effective. It had not been signed off from the NHA.The follow up section of the form further documented the meals tickets were updating faster than the posted menu with latest menu changes. -However, the form documented the action was not sufficient and it was not effective. It had not been signed off from the NHA.The 7/17/25 resident council notes documented the residents voiced concerns that the hot food was not hot, that residents were not receiving snacks in their rooms, the CNAs were not taking orders for lunch and dinner, the posted menu did not match the meal ticket, residents received their orders wrong and the residents were not getting what they had ordered. The follow up section of the form for the menu not matching the ticket, for food not being hot and for the residents receiving the wrong food revealed a new dietary manager was hired.The follow up section of the form that addressed the residents were not getting enough snacks documented the CNAs were educated to pass snacks to everyone. -However, the form was signed as action was not sufficient or effective. The follow up section of the form that addressed the CNAs not taking the lunch and dinner orders documented the action that was taken was to re-educate the CNAs at staff meetings. -However, the form was signed as action was not sufficient or effective. Resident council minutes for 8/21/25 revealed the residents voiced concerns that hot food was not hot, the CNAs were not taking lunch and dinner orders, the CNAs were not notifying the residents when snacks were out -The follow up section of the form had been filled out identifying the concerns identified from the residents' 8/21/25 resident council., however, it had not been received back from the department with a resolution. C. Staff interviewsThe activity director (AD) was interviewed on 8/27/25 at 9:29 a.m. The AD said the resident council meeting was held monthly. She said the food council was also held monthly. The AD said after each council meeting, she wrote out a grievance form for any concerns voiced by the residents. She said she then distributed the form to the appropriate department. She said the department head then wrote a response to the grievance of how it would be resolved. She said the facility has had numerous complaints regarding the food. She said the facility recently hired a new dietary manager. She said the food grievances were not resolved and continued to be an issue. She said the response for a resolution needed to be received within 72 hours. The NHA was interviewed on 8/27/25 at approximately 12:00 p.m. The NHA said he had worked at the facility for the past month. He said he was aware there were food complaints and he had recently hired a new dietary manager with good experience to help improve the dining department. He said grievances should be followed up within 72 hours. He said that he was slowly chipping away at issues brought up from the resident council.

Based on observations, record review and interviews the facility failed to ensure recipes were followed to meet the residents' nutritional needs.Specifically, the facility failed to follow the correct portion sizes to ensure adequate nutrition was provided to the residents. Findings include:I. Facility policy and procedureThe Food Preparation Guidelines policy and procedure, dated 4/11/25, was provided by the nursing home administrator (NHA) on 8/27/25 at 3:52 p.m. It read in pertinent part, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes.II. ObservationsDuring a continuous observation during the dinner meal on 8/26/25, beginning at 4:00 p.m. and ending at 6:00 p.m., the following was observed: At approximately 5:00 p.m. the dietary manager (DM) prepared and served a plate for a resident who was prescribed a pureed diet. The plate consisted of pureed barley soup and a pureed hamburger patty. -However, the menu extensions indicated the residents prescribed a pureed diet should have received pureed Italian grinder sub and pureed potato salad (see menu extensions below).At 5:15 p.m. an unidentified dietary aide (DA) began plating the resident's meals. for dinner. The unidentified DA placed half of the baked Italian sub sandwich on the plate and put a bowl of the barley vegetable soup on the plate. The unidentified (DA) then handed it to the staff and staff began handing out the food to the residents in the dining room.-However, the menu extensions indicated the residents were to receive two half sandwiches (see menu extensions below).III. Record reviewThe menu extensions were provided by the NHA on 8/27/25 at 3:52 p.m. The menu extensions revealed the residents who were prescribed a regular diet should have received two halves of a baked Italian sub sandwich, #8 scoop (half cup) of potato salad, 6 ounces (oz) (two third cup) of soup, 9 oz beverage of choice and a three inch by two inch brownie.-However, observation revealed the residents were served half of the baked Italian sub sandwich, instead two halves as indicated on the menu extensions (see observations above).The menu extension revealed the residents who were prescribed a pureed diet should have received #6 scoop (two third cups) of pureed Italian grinder sub, #8 scoop (half cup) of pureed potato salad with no raw vegetables, #6 scoop (two third cup) of pureed homemade soup of the day, 8 oz beverage of choice and a three inch by two inch pureed brownie.-However, observation revealed the resident was served pureed soup with a pureed hamburger patty. The resident was not provided with the pureed Italian grinder sub or pureed potato salad.IV. Staff interviewsThe dietary manager (DM) was interviewed on 8/27/25 at 10:50 a.m. The DM said he was responsible for posting the menus for the day. The DM said he used the dining manager RD (registered dietitian) to retrieve his menus for the facility. The DM said the dining manager RD was approved by the RD. The DM said he could not find the recipes in the dining manger RD program. The DM said that he had never used a recipe. The DM said he did not follow a recipe to make dinner on 8/26/25. The DM went over the menu extensions from dinner on 8/26/25. The DM said residents should have gotten two halves of the baked Italian sub sandwich last night for dinner (8/26/25). The DM said the DAs needed more training and were not educated that two halves were supposed to be served. The DM said residents should have been served two halves of the sandwich.The DM said only one resident was prescribed a pureed diet. The DM said the baked italian sub sandwich did not puree well. He said the resident was served the pureed barley soup with a pureed beef patty mixed in. The DM said he did not puree the potato salad because the resident did not like raw vegetables. The DM said the resident also received a pureed chocolate chip cookie and ice cream for dessert.-However, the menu extensions indicated residents on a pureed diet should have received a pureed brownie (see menu extensions above).The DM said when he first started at the facility one of the residents requested chicken strips off the alternative menu. The DM said they were out of chicken strips, so he went and talked to the resident and offered them something else. The DM said he had a stock of everything on the alternative menu so that he does not run out again. The DM said he recently made updated changes to the alternative menu known as the bistro menu. He said he added more options for the residents to choose from.The NHA was interviewed on 8/27/25 at 1:41 p.m. The NHA said the DM and cooks should be following recipes when preparing the meals for the residents. The NHA said there were recipes in the dining manager RD. The NHA said not following the recipes could be concerning for allergies, safety concerns and nutritional values. The NHA said he would make sure to educate the DM on where to find and print out the recipes.

Based on observations, record review and interviews the facility failed to ensure residents consistently receive food prepared by methods that conserve nutritive value, palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature. Findings include:I. Facility policy and procedureThe Food Preparation Guidelines, dated 4/11/25, was received by the nursing home administrator (NHA) on 8/26/25 at 3:52 p.m. It read in pertinent part, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Food shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes but is not limited to: Storing food in a manner to minimize exposure to light and air. Preparing foods as directed. Cooking foods in appropriate amount of water (avoid large volumes). Minimizing holding time prior to meal service. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: Providing meals that are varied in color and texture. Using spices or herbs to season food in accordance with recipes. Serving hot foods/drinks hot and cold foods/drinks cold. Addressing resident complaints about foods/drinks. Honoring resident preferences, as possible, regarding foods and drinks.II. Resident interviewsResident #14 was interviewed on 8/25/25 at 1:14 p.m. Resident #14 said her fries were often cold. Resident #14 said the kitchen served a lot of chicken and she was tired of eating it. Resident #14 said there was not alternative meal options. Resident #14 said she was not given another option for her lunch everyday. Resident #14 said you take what you get and eat it or do not eat.Resident #12 was interviewed on 8/25/25 at 4:25 p.m. Resident #12 said his meal was served cold routinely. He said that the bacon was overcooked, the eggs were watery and the food did not have any flavor. Resident #4 was interviewed on 8/26/25 at 1:50 p.m. Resident #4 said the food was always cold. She said her lunch was cold today.Resident #13 was interviewed on 8/26/25 at 5:30 p.m. Resident #13 said the food was not good. He said the food was served cold, not enough at times and was not flavorful. He said the bread on sandwiches was hard. He said the bread on his Italian sandwich served tonight (8/26/25) was hard and there was not enough meat on the sandwich. He said he only received a half of the sandwich and it was not enough to eat. Cross reference F803: Failure to ensure portion sizes were served according to the menu extensions. Resident #2 was interviewed on 8/27/25 at 12:43 p.m. Resident #2 said the food was horrible. Resident #2 said she had never been offered an alternative meal.Resident #17 was interviewed on 8/27/25 at 2:15 p.m. Resident #17 said he had a difficult time cutting his hot dog because it was overcooked and dry. Resident #17 said he typically ate in his room. Resident #17 said staff sometimes would ask him what he would like off the menu but most of the time it was a mystery. Resident #17 grimaced his face when stating the food temperature is always cold. He said it's a hit or miss asking staff to reheat the food because sometimes they will and sometimes they won't. Resident #17 said the food was always cold. III. Resident group interviewA group interview was conducted on 8/26/25 at 2:32 p.m. with six alert and oriented residents (#10, #15, #7, #6 and #9), per facility and assessment.The residents said the food was always cold. The residents said the pancakes were hard and overcooked, so they could not be cut. The residents said the pancakes were served cold. The residents said the oatmeal was the only food that was always hot. The residents said if they ate their meals in their room that the staff would reheat the food. The group said that staff could not reheat it more than once because there was not enough staff to reheat the food. The group said if they wanted warm food they needed to eat in the dining room.The residents said that the food had been over cooked and sometimes undercooked. The residents said that they reported their concerns in the May 2025 and June 2025 resident council meeting and nothing happened.Resident #6 said the hamburgers were dry and the fries were either burnt or soggy. The residents said the fries were not always cooked all the way.IV. Record reviewThe 4/17/25 resident council minutes documented the residents voiced a concern that the certified nurse aides (CNA) were not taking lunch and dinner prior to the meal. The minutes documented the residents voiced a concern that the french fries were not being fully cooked. The follow up section on the form documented the CNAs had been educated. The follow up documentation also documented that the cooks were ensuring the fries reached 180 degrees Fahrenheit (F)The 5/15/25 resident council meeting minutes documented the residents voiced a concern that they received the wrong food orders. The residents said they did not know if it was a miscommunication with the CNA's and the kitchen staff. The residents said the menu that was posted was not matching the ticket. The residents said the vegetables were over cooked or raw. The residents said the portion sizes were too small, the fries were not fully cooked and hot food was not hot. The residents said there were not enough snacks. The follow up section on the form documented to ensure the food was hitting the correct temperature of 165 degrees F. It documented for the staff to make sure the meal tickets matched the menu. It documented the CNAs were educated to obtain orders timely. The cooks were educated to ensure the fries were full cooked, that the temperature of the vegetables were correct, portion sizes were correct and to ensure there were enough snacks. The 6/19/25 resident council meeting notes documented the residents voiced concerns that the fries were not fully cooked, the hot food was not hot and the residents received their orders wrong. It documented the menus were not matching the tickets. The follow up section of the form documented the cooks were to bake the French fries in the oven. This action was signed off as sufficient. The follow up section of the form further documented that the bistro orders would be clearly identified. The 7/17/25 resident council notes documented the residents voiced concerns that the hot food was not hot, that residents were not receiving snacks in their rooms, the CNAs were not taking orders for lunch and dinner, the posted menu did not match the meal ticket, residents received their orders wrong and the residents were not getting what they had ordered. The follow up section of the form for the menu not matching the ticket, for food not being hot and for the residents receiving the wrong food revealed a new dietary manager was hired.The 8/21/25 resident council minutes revealed the residents voiced concerns that hot food was not hot, the CNAs were not taking lunch and dinner orders, the CNAs were not notifying the residents when snacks were out Cross reference F565: failure to resolve grievances of a group timely. V. ObservationsDuring a continuous observation of the dinner meal service on 8/26/25, beginning at 4:55 p.m. and ending at 6:00 p.m., the following was observed:At 4:55 p.m. the unidentified dietary aide (DA) took the food out of the hot warmer box and placed the food on a rolling chart to take to the satellite kitchen for meal service.At 5:11 p.m. the DA took the temperature of the potato salad and it was at 49 degrees Fahrenheit (F). -The potato salad was not placed on ice and remained on the rolling cart.At 5:17 p.m. the unidentified DA began serving the first plate.At 5:55 p.m. the last room tray was plated.At 6:00 p.m. the room trays left the dining room and were delivered to the rooms.During a continuous observation in the dining room on 8/26/25, beginning at 5:24 p.m. and ending at 5:45 p.m., the following were observed:At 5:24 p.m. Resident #1 said the soup was bad and picked the sandwich apart, eating only the two slices of meat. He said the bread was too hard. VI. Test trayA test tray for a regular diet was evaluated by four surveyors immediately after the last resident had been served their room tray for dinner on 8/26/25 at 6:05 p.m.The test tray consisted of half of a six inch Italian sandwich, beef barley soup, dill potato salad and banana pudding for dessert.-The Italian sub was dry and crunchy;-The dill potato salad was 59.8 degrees F; -The barley soup was bland; and,-The banana pudding was 68.7 degrees F. VII. Staff interviewsThe dietary manager (DM) was interviewed on 8/27/25 10:50 a.m. The DM said hot food should be at 135 degrees F and cold food at 41 degrees or below. The DM said his goal was to have the cold food at 36 degrees F. The DM said the potato salad should have been placed in smaller containers and on ice to keep it within the correct temperature range. The DM said the reason why they were not placed in smaller containers was because he did not have enough smaller containers. The DM said he did not have enough pans to put ice under the pan. The DM said he placed an order for supplies with the NHA. The DM said there was not a cooling spot in the satellite kitchen to place cold items in. The DM said the potato salad should not have been so high. The DM said the potato salad was cooling in the refrigerator for over four hours and did not understand why the temperature was high.The NHA was interviewed on 8/27/25 at 1:41 p.m. The NHA said the DM gave him some invoices for things to be ordered. The NHA said he would talk with the DM and see what he needed ordered for the kitchen.

Based on observations, record review and interviews, the facility failed to ensure two (#1 and #2) of four residents reviewed for abuse out of 16 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #1 and Resident #2 from physical abuse by Resident #3.Findings include: I. Facility policy and procedure The Abuse Policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 8/26/25 at 11:10 a.m. It read in pertinent part, “It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Responding immediately and after the investigation to include but not limited to, responding to immediately protect the alleged victim and integrity of the investigation. Increased supervision of the alleged victim and residents. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect, such as, aggressive and/or catastrophic reactions of residents, wandering or elopement-type of behaviors. If abuse happens: separate the assailant from the victim, isolate the assailant to protect others, assess and treat the victim, and notify the abuse coordinator.” II. Incident of physical abuse of Resident #1 by Resident #3 on 6/7/25 A. Facility investigation The facility’s investigation, dated 6/8/25 at 6:25 p.m., was provided by the NHA on 8/26/25 at 12:12 p.m. The investigation revealed the following: On 6/7/25 at approximately 6:04 p.m., Resident #3 was observed walking independently down hallway 400. At that time, Resident #1 was positioned at the threshold of her room, standing in the doorway. As Resident #3 approached, Resident #1 began to audibly call out for help. In response, Resident #3 entered Resident #1’s room briefly; however, no physical contact was observed during this initial entry. Shortly thereafter, Resident #3 re-entered Resident #1’s room without staff or permission by Resident #1. At this point, staff observed Resident #3 physically grab Resident #1 by the hair. The altercation escalated rapidly, prompting immediate intervention by registered nurse (RN) #1, who was in close proximity and responded without delay. RN #1 successfully separated the residents and removed Resident #3 from Resident #1’s room to prevent further physical aggression. The facility investigated an allegation of physical abuse involving Residents #1 and Resident #3 and determined the allegation was substantiated. Resident #3 was observed to frequently respond to external stimuli or episodes of confusion by walking about and making physical contact, such as grabbing staff or other residents. In this incident, Resident #1 reported she did not understand why Resident #3 entered her room and pulled her hair. B. Resident #3 (assailant) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included alcohol induced persisting dementia, bipolar disorder with current episodes of psychotic features, schizoaffective disorder, and panic disorder with paroxysmal anxiety. The 6/10/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff for certain activities of daily living (ADL). The MDS assessment documented the resident had physical behaviors directed at others or other behavioral symptoms directed toward others. 2. Record review The mood care plan, revised 6/23/25, revealed Resident #3 was at risk for a mood problem due to her disease process and her diagnoses of depression and dementia with behavioral disturbance. Pertinent interventions included administering medications as ordered, behavioral health consults as needed, assisting the resident with identifying strengths and positive coping skills and providing the resident with a meaningful program of activities. The psychotropic medication care plan, revised 3/12/25, revealed Resident #3 was prescribed antidepressant and antipsychotic medications. The plan outlined interventions requiring staff to monitor and record instances of target behaviors and symptoms, which included compulsive verbal statements such as help me, can you help me, or repeated expressions of hunger, uncooperative behavior, verbal expressions of depression, mood changes, agitation, aggression toward others, insomnia, jitteriness, nervousness and restlessness. C. Resident #1 (victim) 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, anorexia, hypertension with chronic kidney disease, insomnia, cachexia, obsessive-compulsive behavior and inadequate social skills. The 6/10/25 MDS assessment revealed the resident has moderate cognitive impaired with a BIMS score of nine out of 15. The resident was independent for most ADLs with staff assistance needed for redirection at times. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Resident interview Resident #1 was interviewed on 8/26/25 at 9:45 a.m. Resident #1 was calm and cooperative. She said she felt safe in the facility and trusted the staff. Resident #1 said she was unable to recall specific details regarding the incident with Resident #3 because it had occurred a long time ago. She said she was not hurt and Resident #3 did not pull her hair. -However, the facility’s investigation indicated staff witnessed Resident #3 pulling Resident #1’s hair during the incident (see incident investigation above). D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/26/25 at 11:00 a.m. LPN #1 said the facility investigated the incident between Resident #1 and Resident #3 on 6/7/25 and interviewed the staff and the two residents. LPN #1 said she had never experienced any prior incidents involving Resident #3 and Resident #1. She said Resident #3 often reached towards other residents unintentionally, typically mistaking them for staff members. LPN #1 said she was not on duty the night of the reported event, but she said it was highly unusual for Resident #3 to enter another resident’s room, specifically Resident #1’s room, and engage in physical contact, such as pulling her hair. RN #1 was interviewed on 8/26/25 at 6:15 p.m. RN #1 said on 6/7/25 she observed Resident #1 walking by the doorway of her room and Resident #3 walking on the same side of the hallway. She said as the residents approached one another, Resident #1 suddenly began shouting “Help, help!” quite loudly. She said the shouting caught her attention immediately. RN #1 said shortly after Resident #1 began shouting, Resident #3 entered Resident #1’s room and appeared to respond to the shouting by moving toward Resident #1 and grabbing her by the hair. She said Resident #1 had some bruising on her right hand; however, she did not witness any specific action or incident that might have caused the bruising. RN #1 said she stepped in right away to separate Resident #1 and Resident #3 and prevent the situation from escalating further. She said once they were apart, facility staff assessed Resident #1 for any injuries and none were noted. RN #1 said following the incident, Resident #3 was placed on enhanced supervision to ensure safety and monitor her behavior more closely, per facility policies. RN #1 said the incident on 6/7/25 was her first time seeing Resident #3 have an issue with another resident, but she said that Resident #3 had more cognitive and behavioral difficulties than other residents within the facility. RN #1 said the staff calmed Resident #3 down, but the best thing was usually to leave her alone for a period of decompression and observation in her room, due to her cognitive decline, behavioral issues and anxiety. RN #1 said Resident #3 could also be troubled at times, but had not had any conflict with any other residents or staff that she was aware of recently. RN #1 said she immediately informed the assistant director of nursing (ADON), the director of nursing (DON), the NHA, the residents’ physician, local law enforcement, and the residents’ representatives about the incident. The NHA was interviewed on 8/27/25 at 9:53 a.m. The NHA said the facility substantiated abuse for the incident between Resident #3 and Resident #1 for several reasons. The NHA said Resident #3 had external stimuli that she responded to by going into Resident #1’s room. The NHA said the investigative actions included interviewing staff who responded to the incident, reviewing accounts of nearby residents and assessing both Resident #1 and Resident #3. The NHA said there was no willful infliction or verbal aggression and Resident #3 was not engaging other residents prior to the incident. The NHA said this was supported by the nine residents who were interviewed that were were near Resident #3 and Resident #1 at the time of the incident and did not recall any altercation outside of Resident #1’s room. The NHA said the facility’s investigation revealed, through interviews and observations, that Resident #1 confirmed the hair pulling, but reported no injury or on-going psychosocial distress. He said Resident #3 was unable to provide a clear explanation of the incident or occurrence, due to her cognitive impairment. The NHA said that a review of both Resident #1 and Resident #3’s care plans and behavioral histories was conducted and documentation from the incident was evaluated. He said the social services director (SSD) was engaged to monitor and provide support to Resident #1 and monitor any psychosocial effects of the incident. He said during the facility’s interview of Resident #1, she did not report pain or fear during the incident, but appeared focused on discussing the incident repeatedly. He said Resident #1 was cooperative during the interview and expressed appreciation for the staff support. The NHA said there were no noted behavioral changes observed in Resident #1 following the incident. He said she remained calm and continued her usual routine without signs of distress. III. Incident of physical abuse of Resident #2 by Resident #3 on 6/8/25 A. Facility investigation The facility’s investigation, dated 6/8/25 at 5:40 p.m., was provided by the NHA on 8/26/25 at 12:22 p.m. The investigation revealed the following: Resident #3 exited her room and sat near nurses’ station two. Shortly afterward, Resident #3 approached Resident #2 and grabbed her arm. CNA #1 immediately intervened, separating the residents and escorting Resident #3 back to her room to de-escalate the situation. Resident #3 was placed on one-to-one supervision for close behavioral monitoring. A full medical work up was initiated to assess for any underlying causes contributing to Resident #3’s behavior. Staff were notified and increased awareness and supervision measures were reinforced in shared areas to ensure resident safety. Resident #3 and Resident #2 were interviewed, along with the CNA #1, who witnessed the incident. Resident #2 was interviewed and appeared indifferent to the incident, expressing no concerns or distress. Resident #2 said that Resident #3 grabbed her arm. Resident #2 said she was not in pain or fearful of Resident #3. Resident #2 continued with her regular routine without issue. Resident #3 was interviewed and unable to provide a clear or coherent explanation of the incident. Due to her cognitive impairment, her responses were disorganized and did not align with the events reported. It was determined that she was not of sound mind and unable to meaningfully participate in the interview. CNA #1 was interviewed and said she witnessed Resident #3 approach and grab Resident #2’s arm before promptly intervening. The facility concluded the allegation of physical abuse was substantiated due to CNA #1 directly observing Resident #3 grabbing Resident #2’s arm. B. Resident #3 (assailant) 1. Record review The care plan, initiated 6/9/25, revealed Resident #3 was involved in two separate interactions on 6/7/25 and 6/8/255 with Resident #1 and Resident #2 where Resident #3 had noted increased agitation. Pertinent interventions included Resident #3 was to have a medical work-up and she was placed on a one-to-one for reevaluation after 72 hours. C. Resident #2 (victim) 1. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (a stroke resulting in paralysis and weakness to one side of the body), intracranial and intraspinal phlebitis and thrombophlebitis (inflammation of brain or spinal veins and the formation of blood clots within them) and thrombocytopenia (an abnormally low number of platelets in the blood, which leads to increased bleeding and bruising). The 8/5/25 MDS assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The resident was dependent on staff for most ADLs. 2. Resident interview Resident #2 was interviewed on 8/27/25 at 12:43 p.m. Resident #2 recalled the altercation from 6/8/25 with Resident #3 and said she was not afraid of her because she (referring to herself) was a fighter. Resident #2 said she had not had any recent altercations with Resident #3. 3. Record Review Resident #2’s comprehensive care plan, revised 6/9/25, revealed Resident #2 was involved in an incident with Resident #3 on 6/8/25. Interventions (initiated 6/9/25) included social services providing a one-to-one two times a week with Resident #2 to monitor for any psychosocial trauma related to the event. -However, review of Resident #2’s progress notes failed to reveal documentation to indicate the resident was provided with the one-to-one visits from social services two times a week. Psychiatric follow-up progress notes on 7/2/25, 7/14/25, 7/28/25 and 8/11/25 indicated Resident #2 received routine psychological assessments biweekly by the nurse practitioner. D. Staff interview The NHA was interviewed on 8/27/25 at 9:53 a.m. The NHA said Resident #3 and Resident #2 were both interviewed after the incident on 6/8/25. The NHA said the staff were interviewed following the incident, including CNA #1, who confirmed that Resident #3 approached and grabbed Resident #2’s arm. He said other nearby staff did not witness the incident directly, but reported that Resident #3 appeared restless earlier in the day. The NHA said no other facility residents observed the incident. The NHA said the facility’s internal investigation determined that the abuse allegation incident was substantiated. He said CNA #1 directly observed Resident #3 grab Resident #2’s arm. He said no injuries occurred with the incident and skin assessments were performed on Resident #2. He said appropriate interventions, including enhanced supervision and medical work-up were implemented by the facility. The NHA said during the interview with Resident #3, she was unable to provide a clear or coherent explanation of the incident. He said due to her cognitive impairment, her responses were determined by the facility to be disorganized and did not align with the events that occurred. The NHA said the facility determined through the interview with Resident #3 that she was not of sound mind and unable to participate in a meaningful interview. The NHA said the DON met with Resident #3 and Resident #2 on 6/8/25 about the events that occurred. He said Resident #3 was unable to recall any events due to her cognitive impairment. Resident #2 was unable to communicate the events, due to her aphasia and underlying cognitive impairment.

Based on observations, record review and interviews the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for one (#11) of three residents reviewed for ADLs out of 16 sample residents.Specifically, the facility failed to ensure Resident #11 was repositioned and provided with incontinence care in a timely manner.Findings include:I. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), dementia and muscle weakness.The 8/20/25 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 11 out of 15. He required dependent assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene.The assessment documented the resident was always incontinent of bowel and bladder.B. ObservationsDuring a continuous observation on 8/26/25, beginning at 9:23 a.m. and ending at 1:55 p.m., the following was observed:At 9:23 a.m. Resident #11 was lying in bed.At 9:40 a.m. licensed practical nurse (LPN) #1 entered the room and gave Resident #11 his medications.-LPN #1 did not offer to reposition the resident or ask if he needed incontinence care.At 9:58 a.m. certified nurse aide (CNA) #2 entered the room, took Resident #11's breakfast tray and exited the room at 9:59 a.m.-CNA #2 did not offer to reposition the resident or ask if he needed incontinence care.At 11:03 a.m. CNA #2 entered the room and talked to Resident #11 and his roommate and exited the room at 11:04 a.m.-CNA #2 did not offer to reposition the resident or ask if he needed incontinence care.At 12:11 p.m. CNA #2 entered Resident #11's room and was observed talking to the resident saying she would be back with his lunch tray and exited the room at 12:12 p.m.-CNA #2 did not offer to reposition the resident or ask if he needed incontinence care.At 12:41 p.m. CNA #2 delivered Resident #11's lunch tray and exited at 12:42 p.m.-CNA #2 did not offer to reposition the resident or ask if he needed incontinence care.At 1:25 p.m. hospice CNA #1 and hospice CNA #2 entered Resident #11's room. Hospice CNA #1 said they were there to give Resident #11 a bed bath and proceeded to get the resident ready for his bath.At 1:37 p.m. Hospice CNA #1 and hospice CNA #2 cleaned Resident #11's arms and chest with a wash cloth that was rinsed in soapy water and dried him off with towels. Hospice CNA #1 un-taped the resident's dirty brief and cleaned Resident #11's perineal area (area between the genitals) and dried the area, keeping a towel over Resident #11 when they could. Hospice CNA #1 and hospice CNA #2 rolled Resident #11 to the left, tucking the old brief under him and exposing his bottom. Hospice CNA #1 and hospice CNA #2 placed a new brief on him. The old brief was observed to be saggy and bulky.-Resident #11 was not repositioned or asked if he needed incontinence care for a period of over four hours.C. Resident interviewResident #11 was interviewed on 8/26/25 at 1:07 p.m. Resident #11 said he could not remember if staff changed him today. Resident #11 said staff did not change him every two hours. Resident #11 said staff did not provide incontinence care for him after breakfast (on 8/26/25). Resident #11 said he did not know if he was wet and needed to be changed.D. Record reviewThe ADL care plan, revised 8/26/25 (during the survey), documented Resident #11 had an ADL self-care performance deficit related to AFTT (adult failure to thrive), end-stage congestive heart failure, fatigue, shortness of breath, obesity, bedbound and weakness. Resident #11 was able to verbalize his needs when asked. Resident #11 preferred to remain in bed for the majority of the day due to comfort and energy conservation. Interventions included providing total staff assistance with bed mobility and toileting use.The skin care plan, revised 5/28/25, documented Resident #11 had potential for impairment to his skin integrity. Resident #11 had a history of venous stasis ulcers. Resident #11 preferred to be positioned on his back with his feet elevated on pillows. Interventions included assisting Resident #11 to reposition and/or turn at frequent intervals to provide pressure relief, providing a pressure reducing mattress on his bed, providing total assistance from staff to turn/reposition often as needed or requested and providing incontinence care after each incontinence episode, or per an established toileting plan.The bowel and bladder care plan, revised 5/28/25, documented Resident #11 had both bowel and bladder incontinence. Interventions included checking and changing the resident frequently, on request and as required for incontinence, changing clothing as needed after incontinence episodes and providing total assistance from staff.II. Staff interviewsHospice CNA #1 was interviewed on 8/26/25 at 1:25 p.m. Hospice CNA #1 said that the hospice CNAs came to the facility two days a week on Tuesday and Fridays and gave Resident #11 a bed bath. Hospice CNA #1 said that the staff from the facility was responsible for providing incontinence care and repositioning for Resident #11 when the hospice staff were not there.Hospice CNA #1 was interviewed a second time on 8/26/25 at 1:47 p.m. Hospice CNA #1 said when removing Resident #11's brief it was saturated with urine and his skin was wet in the perineal area.LPN #1 was interviewed on 8/26/25 at 1:50 p.m. LPN #1 said residents should be repositioned every two hours. LPN #1 said incontinence care should be provided every two hours. LPN #1 said CNAs should be doing a skin check when providing incontinence care. LPN #1 said Resident #11 was at risk for developing pressure ulcers as he was not mobile. LPN #1 said Resident #11 did not currently have any pressure ulcers.CNA #2 was interviewed on 8/27/25 at 1:19 pm. CNA #2 said residents should be repositioned and provided incontinence care every two hours. CNA #2 said if residents were not repositioned or changed, they could develop a bed sore or pressure ulcers.CNA #2 said she provided repositioning and incontinence care for Resident #11. CNA #2 said she changed Resident #11 on 8/26/25 at 6:00 a.m. She said after Resident #11 ate his breakfast, she asked him if he wanted to be changed and he said no. She said she usually changed Resident #11 between 9:30 a.m. and 9:45 a.m., but because he had refused, no care was provided. She said she had intended to provide incontinence care and repositioning for Resident #11 after lunch but said that the hospice CNAs had already changed Resident #11 and repositioned him so she did not have to. She said she received reeducation on 8/26/25 on providing timely incontinence care and repositioning.

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#4) of three residents reviewed out of 16 sample residents.Specifically, the facility failed to ensure physician's orders were followed for Resident #4's wound care.Findings include:I. Facility policy and procedureThe Skin Care and Pressure Ulcer policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 8/26/25 at 3:32 p.m. It read in pertinent part, After completing a thorough assessment/evaluation, the interdisciplinary team (IDT) shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:-Redistribute pressure (such as repositioning, protecting and/or offloading heels);-Minimize exposure to moisture and keep skin clean, especially of fecal contamination; and-Provide appropriate pressure re-distributing, support surfaces.The goals and preferences of the resident and/or authorized representative will be included in the plan of care.Interventions will be documented in the care plan and communicated to all relevant staff.Compliance with interventions will be documented in the weekly summary charting.II. Resident #4A. Resident statusResident #4, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders, diagnoses included chronic venous hypertension (a condition where the veins in the lower legs become damaged, leading to increased blood pressure in the veins) with ulcers and inflammation of bilateral lower extremities, history of chronic kidney disease (CKD), type 2 diabetes, bilateral peripheral venous insufficiency (a condition where the veins in the legs or arms do not function properly, leading to blood pooling and damage), chronic tobacco and methamphetamine use and homelessness.The 6/26/25 minimum data set (MDS) assessment revealed that Resident #4 had minimal cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required partial/moderate assistance to roll left and right and partial/moderate assistance to move from sitting to standing. The assessment indicated the resident had three venous and/or arterial ulcers (open wounds that develop on the lower legs due to problems with blood circulation) upon admission.B. ObservationsOn 8/26/25 at 10:53 a.m. Resident #4's wound care was observed with licensed practical nurse (LPN) #2. The resident's legs and ankles were lying on the bed flat without a pillow or other form of support to elevate the resident's heels and ankles off of the bed surface.The resident's dorsal side of her right foot was covered with a bordered gauze dressing (an absorptive dressing consisting of three layers). LPN #2 removed the border gauze dressing which revealed a non-woven fluffy/fibrous looking material, approximately four inches by four inches in size.The resident's right dorsal foot wound was an irregular shape about the size of a closed fist and the wound bed was uneven, pink and red. LPN #2 cleansed the right dorsal foot wound, applied skin prep (a topical solution or wipe used to prepare the skin around wounds for the application of dressings or other medical devices), placed xeroform gauze (a petrolatum-impregnated gauze with an added ingredient called bismuth tribromophenate that helps promote healing by keeping wounds moist and non-adherent, thus facilitating easier dressing changes) and covered the wound with a signed and dated bordered gauze dressing.LPN proceeded to perform the wound care for Resident #4's right medial (inner) ankle. The resident's right medial ankle was not covered with a bordered gauze dressing (see physician's orders below). Resident #4's right medial ankle wound had a saturated non-woven dressing material over it which had mostly molded itself to the resident's ankle. LPN #2 sprayed the dressing, which was stuck to the resident's wound, with a wound cleanser multiple times and let it sit to make the material softer. Once the dressing was softer, LPN #2 peeled the dressing off in pieces, due to the dressing becoming more slimy when exposed to the wound cleanser spray. There was no xeroform gauze beneath the adhered dressing removed by LPN #2 (see physician's orders below). LPN #2 cleansed the right medial ankle wound. Once cleansed, the wound bed was pink and red. LPN #2 applied skin prep, placed xeroform gauze and covered the wound with a signed and dated bordered gauze dressing.LPN #2 proceeded to perform the wound care for Resident #4's left medial ankle wound. had a bordered gauze dressing on it that was slightly saturated and yellow in color. When LPN #2 removed the bordered gauze dressing, there was no xeroform gauze beneath the outer dressing (see physician's orders below). The resident's left medial ankle wound bed was pink, rounded and open. LPN #2 cleansed the wound, applied skin prep, placed xeroform gauze and covered the wound with a signed and dated bordered gauze dressing.C. Record reviewReview of Resident #4's skin integrity care plan revealed the resident had impairment to her skin integrity and required enhanced barrier precautions to prevent the spread of infections. Interventions included following facility protocols for treatment of injury and keeping the resident's skin clean and dry.Review of Resident #4's August 2025 CPO revealed the following physician's orders: Right dorsal foot: Cleanse with wound cleanser, skin prep periwound, xeroform and cover with bordered gauze. Change daily and PRN (as needed). Every night shift for vascular wound care, ordered 8/21/25.-However, Resident #4's right dorsal foot wound did not have xeroform gauze on it during the wound care observation (see observations above).Right medial ankle: Cleanse with wound cleanser, skin prep periwound, xeroform and cover with bordered gauze. Change daily and PRN. Every night shift for wound care, ordered 8/21/25.However, Resident #4's right medial ankle wound had calcium alginate covering it instead of xeroform gauze and there was no bordered gauze dressing over the wound during the wound care observation (see interviews below and observations above).Left medial ankle: Cleanse with wound cleanser, skin prep periwound, xeroform and cover with bordered gauze. Change daily and PRN as needed for wound care, ordered 8/21/25.-However, Resident #4's left medial ankle wound did not have xeroform gauze on it during the wound care observation (see observations above).Review of Resident #4's August 2025 treatment administration record (TAR) revealed the following:-The right dorsal foot wound dressing was documented as changed on 8/25/25 at 9:26 p.m.;-The right medial ankle wound dressing was documented as changed on 8/25/25 at 9:26 p.m.; and,-The left medial ankle wound dressing was documented as changed on 8/25/25 at 9:26 p.m.III. Staff interviewsLPN #2 was interviewed on 8/26/25 at 10:53 a.m. LPN #2 said she did not see xeroform gauze underneath Resident #4's dressings when she changed them. She said it was important to check the physician's orders for how to change wound dressings, because Resident #4 usually had new dressing orders each week. She said the blackish brown material on the resident's right medial ankle wound was calcium alginate build up that needed to be sprayed, softened and removed.-However, the 8/21/25 wound care physician's orders did not indicate calcium alginate was to be used on Resident #4's wounds (see physician's orders above).The wound care physician (WCP) was interviewed on 8/27/25 at 11:38 a.m. The WCP said the facility was treating Resident #4's vascular ulcers, which came and went because of the vascular issues in her legs. He said the current treatment for the wounds was to use xeroform gauze. He said the purpose of treating the wounds with xeroform gauze was to keep a moist healing environment for the cells and it was a barrier to protect the wound environment. He said prior to 8/21/25, the resident's wounds were being treated with calcium alginate, which was a fibrous material used to collect exudate. He said the calcium alginate got thicker and a little more soggy when exudate leaked from the wound and got absorbed into the alginate material. He said the alginate helped absorb exudate and honey helped to soften hard tissues, so he changed the physician's order to xeroform gauze. -However, Resident #4 did not have xeroform gauze on her wounds during the wound observation (see observations and LPN #2's interview above).

Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent a fall with major injury for one (#38) of three residents reviewed for accidents/hazards out of 33 sample residents. Resident #38, who was at high risk for falls and had a history of a fall with a fracture, was admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay for repair of a right femur fracture. Per the resident's fall care plan, staff were instructed to anticipate and meet the resident's needs, keep the call light within reach and keep personal items within reach. Resident #38 experienced a witnessed fall on 12/20/24 while trying to walk to her sink to get a drink of water, resulting in a fracture of her right femur. The staff failed to implement new interventions after the resident's fall with major injury. Observations of Resident #38 during the survey revealed staff were not consistently ensuring Resident #38's call light was within reach when she was in her room. Findings include: I. Facility policy and procedure The Safety and Supervision of Residents policy, dated 12/19/16, was provided by the nursing home administrator (NHA) on 1/15/25 at 5:07p.m. It read in pertinent part, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff via the resident's care plan, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented and documenting interventions. Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions. All direct care staff members are responsible to review and follow the resident's individualized care plan for safety and supervision. II. Resident #38 A. Resident status Resident #38, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included fracture of the neck of the right femur, dementia, repeated falls and metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood). The 12/28/24 minimum data set (MDS) assessment revealed Resident #38 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. Resident #38 required supervision or touching assistance with personal hygiene and partial assistance with transfers. She was independent with mobility in a wheelchair. The assessment documented Resident #38 had clear speech and was always able to make herself understood. She was occasionally incontinent of urine and required partial assistance with getting on and off the toilet. B. Observations and interview On 1/12/25 at 5:30 p.m. Resident #38 was lying in bed. The call light button was on the floor under the head of the bed, out of the resident's sight and reach. On 1/13/25 at 9:50 a.m. Resident #38 was lying in bed. The call light was on her pillow above her head, out of her sight. A continuous observation was conducted on 1/13/25, beginning at 2:09 p.m. and ending at 4:09 p.m. The following was observed: At 2:09 p.m. Resident #38 was lying in bed. The call light button was under the pillow above her head, out of sight and reach. At 2:35 p.m. an unknown certified nurse aide (CNA) stopped and looked into Resident #38's room, then continued to walk down the hall. The unidentified CNA did not enter the resident's room to ensure the resident's call light was within her reach. At 2:50 p.m. an unknown CNA delivered ice water to Resident #38's roommate but did not check the call light placement for Resident #38. The call light button was still under the pillow above the resident's head. At 3:42 p.m. the call light button remained under the pillow above her head. At 4:09 p.m. the call light button remained under Resident #38's pillow above her head. On 1/13/25 at 4:32 p.m. registered nurse (RN) #1 observed Resident #38's call light placement. RN #1 said call lights should be placed beside the residents where they could reach them. RN #1 said the cord had a clip so it could be clipped to the resident's shirt. RN #1 moved Resident #38's call light from under the pillow to the top of her comforter. On 1/14/25 at 8:54 a.m. Resident #38 was lying in bed. The call light cord was clipped to the top corner of the sheet above Resident #38's head. The call button was on the floor under the head of the bed, out of sight and reach. CNA #6 was interviewed on 1/14/25 at 9:21 a.m. He said Resident #38's call light should be placed on the bed where she could reach it. He said she could not reach it on the floor where it was currently laying. CNA #6 picked up Resident #38's call light from the floor and placed it on top of the comforter on her chest. CNA #6 said it was important to keep the call lights where the residents could reach them so they could get help when they needed it. On 1/15/25 at 9:16 a.m. Resident #38 was lying in bed. The call bell cord was clipped to the top corner of the sheet above Resident #38's head. The call button was on the floor under the head of the bed, out of sight and reach of the resident. C. Record review The activities of daily living (ADL) care plan, initiated 2/27/24, included an intervention to encourage Resident #38 to use the call bell for assistance. The communication care plan, initiated 2/27/24, included an intervention to keep the call light in reach. Resident #38's fall care plan, initiated 3/13/24, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, keeping the call light within reach and encouraging the resident to use it, ensuring the resident had shoes or non-skid socks on when walking, ensuring the resident's bed was in the low position when in bed, keeping personal items in reach and keeping the floor free of spills and clutter. The 8/16/24 fall risk evaluation documented Resident #38 was a high fall risk related to balance problems while standing and walking, gait problems, use of an assistive device, high risk medications and diagnoses. The 12/20/24 nursing progress note documented Resident #38 was observed trying to walk to her sink to get a drink of water and fell to the floor. The 12/20/24 change in condition hospital transport report documented Resident #38 experienced a witnessed fall with a suspected serious injury related to pain in her right leg and hip and inability to bear weight. The facility's physician ordered x-rays which revealed a fracture. Resident #38 was sent to the hospital where she underwent surgical repair to the right femur and returned to the facility on [DATE]. -Resident #38's fall care plan was not updated with any new interventions after the fall with fracture on 12/20/24. D. Additional staff interviews RN #2 was interviewed on 1/12/25 at 6:04 p.m. RN #2 said Resident #38's call light should be placed within her reach. The director of nursing (DON) was interviewed on 1/15/25 at 6:07 p.m. The DON said resident's call lights should be within the residents' reach, clipped on the pillow or blanket if they were in bed. The DON said the call light being clipped on the top corner of the bed would not be within reach of most residents due to their lack of dexterity and range of motion. The DON said Resident #38 was a high fall risk and was not safe to transfer without staff assistance.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, satellite kitchen, and one of two nourishment refrigerators. Specifically, the facility failed to: -Ensure ready to eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen; -Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators; -Ensure proper hair restraints were worn in the kitchen; -Ensure the kitchen and food service areas were kept clean; and, -Ensure frozen meats were thawed in a safe manner. Findings include: I. Failed to ensure ready-to-eat foods were handled in a sanitary manner A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 1/23/25. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. (3-301.11) B. Facility policy and procedure The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy and procedure, dated 12/19/16, was received from the nursing home administrator (NHA) on 1/26/25 at 2:38 p.m. It read in pertinent part, Gloves are considered single-use items and must be discarded after completing the task for which they are used. C. Observations During a continuous observation of the lunch meal service on 1/15/25, beginning at 9:42 a.m. and ending at 12:46 p.m. the following was observed: At 11:00 a.m. dietary aide (DA) #1 washed her hands, donned gloves and left the kitchen. DA #1 returned to the kitchen with four heads of lettuce and a plastic bag of shredded carrots. With the same gloved hands, DA #1 removed the outer layer of leaves of two lettuce heads, used her gloved hands to touch the faucet head to move it so she could rinse the lettuce and moved the faucet head back. Using the same gloved hands, DA #1 began slicing lettuce for salad. At 11:04 a.m. DA #1 repeated this process for the other two heads of lettuce using the same gloved hands. At 11:25 a.m. DA #1 donned gloves, used her gloved hands to open the refrigerator and retrieved a bag of shredded cheese wrapped in cling film. Using the same gloved hands, DA #1 unwrapped the bag of cheese shreds and opened it. DA #1 then used the same gloved hands to grab three handfuls of cheese and sprinkled it onto the salad she was preparing. From 11:59 a.m. to 12:35 p.m. DA #2 wore a pair of gloves. DA #2 used these gloves to handle meal tickets, serving utensils and meal trays. DA #2, using the same gloved hands, picked up cookies and put them onto plates to be served to the residents throughout lunch service. At 12:22 p.m. DA #3 placed the palm of her gloved hands on the surface of two plates before serving food on them. DA #3 had previously used the same gloved hands to handle serving utensils. DA #3, using the same gloved hands, opened a plastic bag containing hot dog buns, grabbed two buns and separated the halves of the buns using her gloved hands. At 12:25 p.m. DA #3 repeated the process of opening the plastic bag of hot dog buns, selecting two buns and separating the halves of the buns using the same gloved hands. DA #3 repeated this process at 12:35 p.m. with the same gloved hands. D. Staff interview The dietary manager (DM) was interviewed on 1/16/25 at 9:13 a.m. The DM said ready to eat foods should be handled with gloves. The DM said gloves were single use and single task. He said the dietary staff should remove their gloves and wash their hands between tasks. The DM said the dietary aides should have taken off their gloves and put on fresh gloves between tasks during the lunch service observation. II. Failure to safely and appropriately store food items A. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 1/23/25. It revealed in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (F)) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (3-501.17) B. Observations During an initial tour of the kitchen on 1/12/25 at 2:38 p.m., the following items were observed in the refrigerators: -A container of cottage cheese, with an expiration date of 12/27/24; -A container of hot dogs, with a date of 1/4/25; -An opened container of sauerkraut, unlabeled and undated; -A container of fruit salad, unlabeled and undated; -Five individual containers of diced fruits, unlabeled and undated; -A block of cheese slices, unlabeled and undated; and, -Two containers of raw chicken wings, unlabeled and undated. At 2:38 p.m. in the food preparation area, a container of sugar was observed with no lid on it. The sugar had several dark pieces of debris in it. On 1/13/25 at 3:35 p.m. observations of the contents of the Glacier Peak neighborhood nourishment refrigerator revealed the following: -A deli meat sandwich labeled 1/7/25; -A damp cardboard fast food container in a plastic bag dated 12/5/24 with a resident's name; and, -Two unlabeled undated containers of sliced fruit. On 1/15/25 at 9:42 a.m. the lid to the sugar bin in the kitchen was askew and not covering the bin. C. Staff interview The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said the dietary staff went through the refrigerators in the kitchen each day and threw away items that were out of date. The DM said once opened, items in the refrigerator should only be kept for a range of one to seven days, depending on what the item was. He said the sandwiches should only be held for two to three days. The DM said items in the refrigerators should always be labeled and dated. The DM said he did not know the nourishment refrigerators were part of the kitchen's responsibility to maintain. The DM said he checked the nourishment refrigerators in the nurse's stations briefly each day to make sure there were enough snacks in them. The DM said the fast food container in the nourishment refrigerator (see above) was very old and needed to be thrown away. III. Ensure kitchen staff were wearing appropriate hair restraints while preparing and serving food A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 1/23/25. It revealed in pertinent part, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. (2-402.11) B. Facility policy and procedure The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy and procedure, dated 12/19/16, was received from the NHA on 1/26/25 at 2:38 p.m. It read in pertinent part, Hair nets or caps/hats and beard restraints (as indicated) must be worn to keep body hair from contacting exposed food, clean equipment, utensils and linens. C. Observations On 1/15/25 cook (CK) #1 was observed during a continuous observation of the lunch service, beginning at 9:42 a.m. and ending at 12:46 p.m. CK #1 was preparing food for residents throughout the observation period. -CK #1 had a goatee and mustache approximately 1.5 inches long and was not wearing a beard net or other facial hair covering throughout the observation period. D. Staff interview The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said the facility's kitchen did not have any beard nets available. The DM said he was working on getting beard nets for CK #1. IV. Failure to ensure kitchen and food service areas were kept clean A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 1/23/25. It revealed in pertinent part, Floors, floor coverings, walls and wall coverings shall be designed, constructed, and installed so they are smooth and easily cleanable. (6-201.11) Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11) B. Facility policy and procedure The Dietary Sanitization policy and procedure, dated 12/19/16, was received from the NHA on 1/26/25 at 2:38 p.m. It read in pertinent part, All kitchens and kitchen areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. C. Observations and staff interviews An initial tour of the main kitchen was conducted on 1/12/25 at 2:38 p.m. and revealed the following: -The deli meat slicer that was not actively in use had visible debris along the slicer surface; and, -The floors throughout the kitchen were soiled with dirt and crumbs. On 1/13/25 at 3:41 p.m. the floor of the satellite kitchen used for meal service had dirt and debris throughout the room. On 1/15/25 at 9:28 a.m. the tile floor of the main kitchen had several cracked tiles and was missing a large patch of tiles approximately three feet by four feet near the food prep island with crumbs and debris stuck in the cracks of the missing tiles. There was dirt, debris and crumbs throughout the floor in the kitchen. At 11:59 a.m. in the satellite kitchen there was grime, debris and food crumbs throughout the floor. Seven ants were observed near the trash can in the satellite kitchen near a spill. At 12:06 p.m. the DM was alerted about the presence of ants in the satellite kitchen and began using a broom to sweep them up. The DM moved the trash can and revealed approximately ten more ants. DA #2 said the ants liked the crumbs in the kitchen. D. Staff interviews On 1/13/25 at 3:41 p.m. DA #2 said the kitchen and satellite kitchen were deep cleaned once a month and the floors were mopped and swept every night. The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said the facility did not have any issues with pests to his knowledge. The DM said the dietary staff only saw ants in the kitchen when they were not cleaning properly. The DM said the dietary staff should be sweeping and mopping the satellite kitchen after every meal and the main kitchen once a day. The DM said deep cleaning was performed once a month. The DM said the dietary staff sometimes used a deep cleaning checklist but that they did not have one at the moment. The DM said the dietary staff had checklists for cleaning the satellite kitchen but did not use them. The DM said the missing tiles in the kitchen had not been fixed yet because the facility still occasionally had plumbing issues in that area. The DM said the tiles had been missing for several months. The DM said he had brought the issue up with the management team and thought they were making progress in getting the tiles fixed. V. Failure to ensure frozen meats were thawed in a safe manner A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 1/23/25. It revealed in pertinent part: Time/temperature control for safety food shall be thawed completely submerged under running water with sufficient water velocity to agitate and float off loose particles in an overflow. (3-501.13) B. Facility policy and procedure The Food Preparation and Storage policy and procedure, dated 12/16/19, was received from the NHA on 1/16/25 at 2:38 p.m. It read in pertinent part, Thawing procedures include completely submerging the item in cold running water that is running fast enough to agitate and remove loose ice particles. C. Observations During a continuous observation of the lunch meal service on 1/15/25, beginning at 9:42 a.m. and ending at 12:46 p.m. the following was observed: At 10:01 a.m. a container of raw frozen chicken cutlets and a container of raw frozen beef were submerged in water in metal bins in the kitchen sink under two separate streams of running water. Both the chicken and the beef were in their original plastic packaging. There was a section approximately twelve inches by five inches of frozen beef which sat above the water and was not under running water. At 10:26 a.m. the faucet directing water over the frozen chicken was moved to rinse something during food preparation and not replaced until 10:39 a.m. At 11:15 a.m. the DM adjusted the beef in the metal bin so that the previous section sitting above the water was now submerged, but a new section of beef approximately the same size was above the waterline and not exposed to the running water. D. Staff interview The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said frozen raw meat should be thawed under cool running water or in the refrigerator overnight. The DM said the dietary staff tried to keep the frozen raw meat submerged under water during the thawing process as much as possible. The DM said he was aware that the dietary staff needed to remove the frozen meat from the plastic packaging prior to thawing it in the sink, but said they kept the plastic on because it was too difficult to take it off.

Based on record review, observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease. Specifically, the facility failed to: -Wear the appropriate personal protective equipment (PPE) when entering transmission based precaution rooms; -Offer updated COVID-19 vaccinations and document consent or declination for vaccination for Residents #16, #36, #205 and #255; -Ensure staff followed proper hand hygiene practices during meal delivery; -Ensure staff followed proper infection prevention practices during wound care for Resident #37; and, -Ensure resident's glucometers were disinfected after each use. Findings include: I. Failure to wear personal protective equipment A. Professional reference According to the Centers for Disease Control and Prevention (CDC), Infection Control Guidance: SARS-CoV-2, (6/24/24), retrieved on 1/22/25 from https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filters or higher, gown, gloves and eye protection (goggles or a face shield that covers the front and sides of the face). B. Facility policy and procedure The Initiating Transmission Based Precautions policy, revised February 2023, was provided by the regional clinical resource (RCR) on 1/14/25 at 2:19 p.m. It read in pertinent part, When transmission based precautions (TBP) are implemented, the infection preventionist or designee shall ensure that protective equipment (gloves, gowns, masks, etc.) based on the specific type of TBP is maintained near the resident's room so that everyone entering the room can access what they need. C. Observations and staff interviews On 1/12/25 at 2:49 p.m. an unidentified certified nurse aide (CNA) entered room [ROOM NUMBER], which had a sign on the door indicating droplet precautions should be followed including an N95 mask, eye protection, gown and gloves. The unidentified CNA entered the room without wearing eye protection. On 1/13/25 at 11:35 a.m. the isolation cart supplies outside of room [ROOM NUMBER] were observed with licensed practical nurse (LPN) #1. The sign on the door revealed droplet precautions should be followed including eye protection (goggles or face shield) prior to entering the room. There were no eye protection supplies present in the isolation cart outside of the room. LPN #1 said she had been in the resident's room earlier that morning and said she had forgotten to wear eye protection. On 1/13/25 at 11:40 a.m., registered nurse (RN) #1 entered room [ROOM NUMBER] without eye protection. D. Staff interview The assistant director of nursing (ADON) was interviewed on 1/13/25 at 3:00 p.m. The ADON said she acted as the infection preventionist (IP). She said the residents in room [ROOM NUMBER] and room [ROOM NUMBER] were on transmission based precautions and were positive for COVID-19, required droplet precautions and staff should use googles or face shields when they entered the resident's rooms. -However, residents who are positive for COVID-19 require transmission based precautions. The ADON was interviewed a second time on 1/16/25 at 9:20 a.m. The ADON said in-the-moment training was provided to staff when staff were not wearing face shields as required on 1/12/25 and 1/13/25 (during the survey). She said she would continue to provide training to all of the staff. II. Failed to offer updated COVID-19 vaccinations and document consent or declination A. Professional reference According to theCDC, Staying Up to Date with COVID-19 Vaccines, revised 1/7/25, retrieved on 1/23/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html, Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization , and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are ages 65 and older, are at high risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine. B. Facility policy and procedure The COVID-19 Vaccine policy, revised 6/5/23, was provided by the RCR on 1/15/25 at 12:49 p.m. It read in pertinent part, The facility shall encourage all staff and residents to remain up-to-date with COVID-19 vaccines, but residents and staff may refuse the COVID-19 vaccine. The infection preventionist is primarily responsible to securely track and document COVID-19 vaccination status for all staff and residents. C. Record review A review of Resident #16's electronic medical record (EMR) immunization tracking section revealed the resident last received the COVID-19 vaccination on 12/28/23. -The EMR did not include documentation for Resident #16's COVID-19 vaccination status for the 2024-2025 season. A review of Resident #36's EMR immunization tracking section revealed the resident last received the COVID-19 vaccination on 12/28/23. -The EMR did not include documentation for Resident #36's COVID-19 vaccination status for the 2024-2025 season. A review of Resident #205's EMR immunization tracking section revealed the resident last received the COVID-19 vaccination on 1/26/23. -The EMR did not include documentation for Resident #205's COVID-19 vaccination status for the 2024-2025 season. A review of Resident #255's EMR immunization tracking section revealed the resident last received the COVID-19 vaccination on 12/28/23. -The EMR did not include documentation for Resident #255's COVID-19 vaccination status for the 2024-2025 season. D. Staff interviews The ADON and the RCR were interviewed together on 1/16/25 at 10:01 a.m. The ADON said she did not know if the COVID-19 vaccinations were offered to residents during the 2024-2025 season. The ADON said she had not offered COVID-19 to the residents. The RCR said COVID-19 2024-2025 vaccines were available at the facility and should have been offered to residents. The RCR and ADON said the immunization section in the EMR was not up to date for the residents. III. Failed to ensure staff followed proper hand hygiene practices during meal delivery A. Professional reference According to the CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 1/23/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. B. Observations and staff interview On 1/12/25 at 5:45 p.m., CNA #4 was delivering meal trays to residents on the 100 hall CNA #4 delivered a tray to room [ROOM NUMBER]. CNA #4 did not perform hand hygiene, went back to the dining room and poured drinks into cups and placed them on a room tray. She pushed the room tray cart down the hall. Without performing hand hygiene, she took a tray and delivered it to room [ROOM NUMBER]. She came out of the room, got another tray from the cart and delivered it to room [ROOM NUMBER] without performing hand hygiene. CNA #4 got another tray from the cart and delivered it to the other resident in room [ROOM NUMBER] without performing hand hygiene. CNA #4 then washed her hands at the sink and dried them with paper towels. She took another tray from the cart, with the paper towels still in her left hand in her hand (and holding the room tray with both hands), and delivered it to room [ROOM NUMBER]. She delivered another tray to room [ROOM NUMBER], did not perform hand hygiene and still had the paper towels in her left hand. She pushed the room tray cart to the end of the hall and delivered a tray to room [ROOM NUMBER]. She threw the paper towels in the trash can and brought a dirty cup out of room [ROOM NUMBER], then pushed the cart back to the other end of the hall. She did not perform hand hygiene and delivered the last tray to room [ROOM NUMBER]. On 1/14/25 at 12:52 p.m., CNA #5 was delivering meal trays. CNA #5 delivered a room tray to room [ROOM NUMBER] then pushed the meal tray cart down the hall. She did not perform hand hygiene, obtained the next meal tray and delivered it to room [ROOM NUMBER]. CNA #5 was interviewed on 1/14/25 at 12:56 p.m. She said she forgot to use hand hygiene and she should have performed hand hygiene between passing the two room trays. On 1/14/25 at 1:02 p.m., CNA #4 was delivering meal trays on the 600 hall. CNA #4 pushed the meal tray cart down the hallway, then delivered a tray to room [ROOM NUMBER]. CNA #4 pushed the cart further down the hall and delivered a tray to room [ROOM NUMBER]. She did not perform hand hygiene and delivered a third tray to room [ROOM NUMBER]. C. Staff interview The ADON was interviewed on 1/16/25 at 9:20 a.m. The ADON said staff should be using hand hygiene or hand sanitizer before and between each meal delivery and offer hand hygiene to the residents. The ADON said hand hygiene education was provided at least weekly in the dining area by herself and the dining room manager on duty. IV. Failure to ensure proper infection control practices during wound care A. Facility policy and procedure The Wound Care policy, revised 12/19/16, was provided by the RCR on 1/17/25 at 7:13 a.m. It read in pertinent part, -Use disposable barrier to establish clean field on resident's overbed table or other flat surface. -Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. -Wash and dry your hands thoroughly. -Position resident. Place a disposable barrier next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. -Put on exam gloves and any other PPE indicated based on wound type (e.g. gown if resident has enhanced barrier precautions in place). Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. -Loosen tape and remove dressing if indicated. -Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -Put on gloves. -Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers when part of the treatment order. -Pour liquid solutions directly on gauze sponges on their papers. -Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. -Consideration should be given to wearing sterile gloves when performing invasive wound care (packing a tunneling wound) or working with heavily exudating wounds as an infection mitigation measure. -Dress wound in accordance with physician order. [NAME] dressing with initials and date and apply to dressing. Be certain all clean items are on clean field. -Remove the disposable cloth next to the resident and discard into the designated container. -Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. B. Record review Review of Resident #37's January 2025 computerized physician's orders (CPO) revealed the following physician's order for wound care: -Cleanse right perineal wound and pack with wound cleanser saturated gauze twice daily, ordered on 10/3/24 -Clean right buttocks wound with wound cleanser and apply barrier cream to surrounding skin, cover open areas with skin dressing, change weekly and as needed, ordered on 1/3/25. C. Observations RN #1 was performing wound care on Resident #37's wounds on 1/14/25 at 11:18 a.m. RN #1 cleaned the buttocks wound, then removed the soiled packing from the perineal wound and cleaned the perineal wound with gauze and wound cleanser, packed and redressed the perineal wound. -RN #1 did not change gloves after removing the soiled perineal dressing, nor did she change gloves between wound sites. RN #1 did not place a clean barrier under the resident, and left the resident on a visibly soiled disposable pad. RN #1 did not change gloves or perform hand hygiene after cleansing the wounds and before packing the perineal wound. RN #1 applied barrier cream to the surrounding skin wearing the same soiled gloves, squirting it directly from the tube to her soiled gloves. RN #1 applied the new dressing over the perineal wound wearing the same gloves. RN #1 then removed the soiled disposable pad under the resident and replaced it with a clean one. RN #1 removed her gloves and applied clean gloves without performing hand hygiene. D. Staff interview RN #1 was interviewed on 1/14/25 at 11:40 a.m. RN #1 said she did not know that the wounds should be treated separately and that she should change her gloves between treatments. RN #1 said she thought it was important to avoid cross contamination. RN #1 said she should have changed gloves after cleaning each wound, and before packing the perineal wound and applying the clean dressing. She said it would be important to have a clean disposable pad under the wound so it would not contaminate the wound after it was cleaned. The ADON was interviewed on 1/16/25 at 10:01 a.m. The ADON said RN #1 should have performed hand hygiene and changed her gloves between the removal of the soiled dressing and the application of the clean one. The ADON said gloves should be changed between wounds if there were multiple wounds. The ADON said the nursing staff received wound care education upon hire, annually and whenever issues arise. The ADON said she was going to provide education to the nursing staff regarding wound dressing change procedures. V. Failure to disinfect glucometers after use A. Professional reference According to the CDC, Consideration for Blood Glucose Monitoring and Insulin Administration (8/7/24) retrieved on 1/23/25 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, Blood glucose meters are portable devices that measure blood glucose levels and aid in diabetes self-management. Healthcare providers use these types of devices in a variety of clinical settings. Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. Dedicated meters should be cleaned and disinfected per the manufacturer's instructions. B. Observations On 1/12/25 at 5:08 p.m., RN #2 checked Resident #28's blood sugar. RN #2 removed Resident #28's glucometer from the case in the medication cart. RN #2 then used the glucometer for testing Resident #28's blood and then returned the glucometer to the case. -RN #2 did not clean the glucometer after use and prior to returning to the case. On 1/12/25 at 5:20 p.m., RN #2 checked Resident #6's blood sugar. RN #2 removed Resident #6's glucometer from the case in the medication cart. RN #2 then used the glucometer for testing Resident #6's blood and then returned the glucometer to the case. -RN #2 did not clean the glucometer after use and prior to returning to the case. C. Staff interviews RN #2 was interviewed on 1/12/25 at 5:35 p.m. RN #2 said she should have cleaned the glucometers after use and should clean them every time the glucometer was used with sanitizing wipes. RN #2 said each resident had their own glucometer. The ADON was interviewed on 1/13/25 at 3:00 p.m. The ADON said RN #2 should have cleaned the glucometers with sanitizing wipes after each use.

Based on record review and interviews, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for three (#5, #14 and #38) of five residents out of 33 sample residents. Specifically, the facility failed to invite and conduct regular care conferences to review the resident's plan of care with Resident #5, Resident #14 and Resident #38. Findings include: I. Facility policy and procedure The Resident Participation, Assessment/Care Plans policy, dated December 2016, was provided by the nursing home administrator (NHA) on 1/15/25 at 12:22 p.m. It read in pertinent part, The resident and his or her representative is encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The social services director (SSD )or designee is responsible for coordinating care plan meetings or care conferences, with the resident or resident representative, including inviting the resident/representative and for maintaining records of such meetings. Care conference documentation should include: the date and time of the conference, the resident or representative invited to participate and the date he or she was invited, the members of the interdisciplinary team (IDT) who participated, input from the resident or representative if they are not able to attend and refusal of participation, if applicable. II. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder depressive type, obsessive-compulsive personality disorder, anxiety disorder, binge eating disorder, type 2 diabetes mellitus, hypertensive heart failure and chronic obstructive pulmonary disease (COPD). The 12/20/24 minimum data set (MDS) assessment revealed Resident #5 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #5 was independent or required supervision with dressing, toileting and transferring. He was independent with mobility using a wheelchair. B. Record review The 7/22/24 quarterly care conference summary record attendance documented Resident #5 and his representative declined to attend the care conference. The next quarterly care conference summary record was dated 1/2/25 (five months since the previous care conference) and documented the resident representative attended. -There was no documentation in the electronic medical record (EMR) indicating a care conference was held between 7/22/24 and 1/2/25. III. Resident #14 A. Resident status Resident #14, age 76, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included cerebral infarction (stroke) with hemiplegia (paralysis) and hemiparesis (weakness) affecting the left non-dominant side, hypertension (high blood pressure) and type 2 diabetes mellitus. The 10/30/24 MDS assessment revealed Resident #14 had no cognitive impairment with a BIMS score of 15 out of 15. Resident #14 required supervision or touching assistance with personal hygiene, bed mobility and transfers. Resident #25 walked short distances with staff supervision and used a wheelchair for long distance mobility. B. Resident/representative interview Resident #5 and his representative were interviewed together on 1/13/25 at 10:04 a.m. The representative said she had not been invited to or attended a care conference meeting since the initial meeting this past summer (see below). C. Record review The 8/5/24 quarterly care conference summary record attendance page documented the resident and representative were in attendance. -There were no other care conference summary records found in the resident's EMR until 1/15/25 (during the survey). -There was no documentation found in the EMR of care conference meetings held between 8/5/24 and 1/15/25 (a period of five months). IV. Resident #38 A. Resident status Resident #38, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 CPO, diagnoses included fracture of the neck of the right femur, dementia, repeated falls and metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood). The 12/28/24 MDS assessment revealed Resident #38 had moderate cognitive impairment with a BIMS score of eight out of 15. Resident #38 required supervision or touching assistance with personal hygiene and partial assistance with transfers. She was independent with mobility in a wheelchair. B. Resident representative interview Resident #38's representative was interviewed on 1/13/25 at 10:24 a.m. The representative said he had been invited to care conference meetings in the past but it had been several months since the facility had contacted him for another one. C. Record review The 7/24/24 care conference summary record attendance page documented the resident and representative attended. - There were no care conference summary records found in the resident's EMR since 7/24/24. - There was no documentation found in the EMR of care conference meetings held since 7/24/24 (a period of over five months). V. Staff interviews The social services director (SSD) was interviewed on 1/15/25 at 4:12 p.m. The SSD said each resident had a baseline care plan developed on admission and then it was reviewed quarterly during a care conference meeting with the IDT and the resident and/or the resident's family, if they chose to attend. The SSD said Resident #14 was supposed to have a care conference in November 2024. The SSD said when he was hired in November 2024 he was using the wrong care conference schedule and some residents, including Resident #5 and Resident #14, got missed. The SSD said now he was using the MDS assessment schedule for care conferences. The SSD said he invited families to attend care conference meetings by phone or in person if they were in the building. The SSD said he let the residents know about the meetings in advance. The SSD said he documented the care conference meeting in a progress note. He said, in addition, a care conference summary form was created where he documented if the resident was invited to the care conference. The SSD said a care conference meeting was held today (1/15/25) with Resident #14 and his representative. The regional clinical resource (RCR) responded by email on 1/16/25 at 10:49 a.m. that the facility was only able to locate a care conference meeting and notes from 7/24/24 for Resident #38. The RCR said the facility met with the family (during the survey) and were scheduling a care conference for later this month (January 2025). The NHA was interviewed on 1/16/25 at 11:19 a.m. The NHA said care conferences should be held quarterly corresponding with the MDS assessment schedule. The NHA said it was important to have the resident and the resident's family attend care conferences and be involved in the residents' plan of care.

Based on observations and interviews, the facility failed to ensure residents were provided services that meet professional standards for five (#1, #205, #255, #46 and #4) of nine residents out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and Resident #205 received medications in a timely manner according to the physician's orders; and, -Ensure lancets were used instead of a syringe with a needle to check blood sugar levels for Resident #205, Resident #255, Resident #46 and Resident #4. Findings include: I. Failed to ensure Resident #1 and Resident #205 received medications in a timely manner according to the physician's orders A. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. B. Resident #1 1. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral palsy (a disorder that affect a person's movement, balance, and posture), quadriplegia (paralysis of all four limbs), neuropathy (nerve pain) and contractures to the right elbow, left hand, left elbow, left shoulder, and left wrist. According to the 12/26/24 minimum data (MDS) assessment, the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment indicated the resident was on a scheduled pain medication regimen. 2. Record review The chronic pain care plan, revised 6/21/24, revealed Resident #1 had chronic pain due to neuropathy. Pertinent interventions included evaluating the effectiveness of pain interventions and reviewing for compliance, alleviation of symptoms and dosing schedules for pain medications. The January 2025 CPO revealed Resident #1 was prescribed the following medications: -Gabapentin 100 milligram (mg) capsule. Give one capsule by mouth three times a day for neuropathy, ordered 10/13/24; and, -Baclofen 5 mg oral tablet. Give one tablet by mouth three times a day for muscle spasms, ordered 10/13/24. Review of Resident #1's progress notes revealed the following: -Gabapentin was not given on 11/20/24, 11/21/24, 11/22/24, 11/23/24, 11/25/24, 11/26/24 and 11/29/24 due to the medication being on order; and, -Baclofen was not given on 11/22/24, 11/23/24, 11/25/24 and 11/26/24 due to the medication being on order. A progress note, dated 11/24/24 at 4:43 p.m., revealed the last gabapentin capsules had been taken out of the emergency medication supply for Resident #1's dose that morning (11/24/24) so the medication was not available. -The progress notes from 11/20/24 through 11/29/24 did not reveal any note of Resident #1's provider being contacted for the missed medication doses. The November 2024 medication administration record (MAR) revealed Resident #1 was scheduled to receive the gabapentin and baclofen at 8:00 a.m., 4:00 p.m. and 8:00 p.m. each day. The November 2024 MAR revealed Resident #1 did not receive the following doses of gabapentin as prescribed: -At 8:00 p.m. on 11/20/24; -At 8:00 p.m. on 11/21/24; -At 8:00 a.m., 4:00 p.m., and 8:00 p.m. on 11/22/24; -At 8:00 a.m. and 4:00 p.m. on 11/23/24; -At 4:00 p.m. on 11/24/24; -At 8:00 a.m. and 4:00 p.m. on 11/25/24; -At 8:00 a.m. and 4:00 p.m. on 11/26/24; and, -At 4:00 p.m. on 11/29/24. The November 2024 MAR revealed Resident #1 did not receive the following doses of baclofen as prescribed: -At 8:00 a.m. and 4:00 p.m. on 11/22/24; -At 8:00 a.m. and 4:00 p.m. on 11/23/24; -At 8:00 a.m. and 4:00 p.m. on 11/25/24; and, -At 8:00 a.m. on 11/26/24. 3. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 1/15/25 at 2:58 p.m. LPN #2 said the facility should not run out of medications. LPN #2 said every shift she worked she checked the medication cart to ensure medications were stocked. LPN #2 said if a medication did run out, she would alert the pharmacy so they could send the medication with their next delivery. LPN #2 said she would also alert the provider that the resident was out of the medication and get orders for what to do in the meantime. Registered nurse (RN) #2 was interviewed on 1/15/25 at 3:10 p.m. RN #2 said most medication sheets had a reorder point indicated on the sheet seven days prior to running out of the medication. RN #2 said once that reorder point was reached, the nurse could go into the MAR and reorder the medication. RN #2 said the facility just started using a brand new pharmacy that automatically ordered medications when they were close to running out. RN #2 said if she did run out of a medication, she would call the pharmacy to ensure it was reordered and see when it would arrive. RN #2 said she would then contact the resident's provider and let them know the resident was out of the medication in question and see what the provider wanted them to do in the meantime. RN #2 said this information would be charted in the resident's progress notes. RN #2 said there were issues with the pharmacy they had been using, as there was a cutoff time in which they needed to have the medication ordered and they had transitioned to a new pharmacy. RN #2 said there were also newer staff members and potentially some issues with their training for medication ordering. The director of nursing (DON) was interviewed on 1/16/25 at 10:25 a.m. The DON said the facility just transitioned to using a new pharmacy. The DON said they had previously had issues with medications taking a long time to be delivered, so the pharmacy would send the prescriptions to a local pharmacy to be filled instead of shipping them directly. The DON said if the facility ran out of a medication, the nurse should check the emergency medication supply The DON said if the medication was not in the emergency medication supply, the nurse would call the pharmacy to let them know the resident was out. The DON said if a resident missed a dose of medication, the nurse should contact their provider. The DON evaluated Resident #1's November 2024 MAR and verified each of the missed doses of gabapentin and baclofen (see record review above). The DON said Resident #1 received gabapentin for nerve pain and baclofen as a muscle relaxant for her muscle spasms, as she had contractures (a permanent tightening of muscles, tendons, ligaments, or skin that limits movement). After looking at Resident #1's progress notes, the DON said she did not see any documentation to indicate that the provider was notified about the missed doses of medication. The DON said Resident #1 missed quite a few doses of medication. The DON said she was not sure how Resident #1's medications were administered or marked as administered between 11/20/24 and 11/29/24 if the medications were not available. The DON said it was not okay to start and stop gabapentin because if it was not given consistently, it did not achieve the same effect. The DON said the same was true for the baclofen. The DON said if baclofen was not given as scheduled, it did not prevent muscle spasms. The DON said the baclofen was very helpful for Resident #1. The DON said she would have expected the nursing staff to contact the Resident #1's provider when the resident missed the doses of the medications. C. Resident #205 1. Resident status Resident #205, age less than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included chronic respiratory failure, anxiety disorder and depressive episodes. The 11/25/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The resident was mostly dependent and required supervision and assistance with most activities of daily living. 2. Record review The oxygen therapy care plan, revised 10/9/24, revealed Resident #205 received oxygen therapy due to his chronic pulmonary disease and was at risk for shortness of breath. Pertinent interventions included giving medications as ordered by the physician. The anti-anxiety care plan, revised 2/27/24, revealed Resident #205 received an anti-anxiety medication to treat his anxiety. Pertinent interventions include administering anti-anxiety medications as ordered by the physician. The January 2025 CPO revealed Resident #205 was prescribed the following medications: -Advair diskus aerosol powder. Inhale one puff orally two times a day for maintenance related to chronic respiratory failure, ordered 10/17/24; and, -Buspirone HCl 5 mg oral tablets. Give one tablet by mouth three times a day for anxiety, ordered 10/8/24. Review of Resident #205's progress notes revealed the following: -Buspirone was not given on 11/24/24 and 11/25/24 due to the medication being on order; and, -Advair was not given on 12/25/24, 12/26/24 and 12/27/24 due to the medication being on order. A progress note, dated 12/26/24 at 11:25 a.m., revealed the Advair was not available. The nurse called the pharmacy and the order had not been seen on their end. The pharmacy entered the order and said the medication would be delivered to the facility the following day. A progress note, dated 12/26/24 at 8:54 p.m., revealed the Advair was not available and the day shift nurse had notified the pharmacy. -However, the progress notes from 11/24/24 through 11/25/24 and 12/25/24 through 12/27/24 did not reveal any note of Resident #205's provider being contacted for the missed medication doses. The November 2024 MAR revealed Resident #205 was scheduled to receive buspirone at 8:00 a.m., 4:00 p.m. and 8:00 p.m. each day. Review of the November 2024 MAR revealed Resident #205 did not receive the following doses of buspirone as prescribed: -At 8:00 a.m. and 4:00 p.m. on 11/24/24; and, -At 8:00 a.m. on 11/25/24. The December 2024 MAR revealed Resident #205 was scheduled to receive Advair at 8:00 a.m. and 8:00 p.m. each day. Review of the December 2024 MAR revealed Resident #205 did not receive the following doses of Advair as prescribed: -At 8:00 a.m. on 12/25/24; -At 8:00 a.m. and 8:00 p.m. on 12/26/24; and, -At 8:00 a.m. and 8:00 p.m. on 12/27/24. 3. Staff interviews LPN #3 was interviewed on 1/15/25 at 5:33 p.m. LPN #3 verified that Resident #205's December 2024 MAR indicated he missed doses of his Advair on 12/25/24 through 12/27/24. LPN #3 said she could not find any progress notes indicating why those doses were missed. RN #2 was interviewed on 1/16/25 at 10:16 a.m. RN #2 verified Resident #205 missed doses of his Advair from 12/25/24 to 12/27/24 due to the medication being on order. RN #2 said she was not sure how or why the evening dose on 12/25/24 was marked as administered if Resident #205 was out of the medication. The DON was interviewed on 1/16/25 at 10:25 a.m. The DON verified the missed doses of medication in Resident #205's November 2024 and December 2024 MARs. The DON said she knew the nurses on duty notified the provider for Resident #205's missed medication doses, but she said she did not see that they had documented it. The DON said it did not make sense to her that Resident #205 missed a dose the morning of 12/25/24 but was administered or marked as administered a dose on the evening of 12/25/24. The DON verified Resident #205's buspirone dose was missed the morning of 11/24/24 but marked as given on the evening of 11/24/24. The DON said it was very confusing to her and she thought maybe the nurses were not paying attention to what they were documenting. The DON said the buspirone was to treat anxiety and the Advair was an inhaler for Resident #205's shortness of breath. The DON said Resident #205 frequently went to the hospital because he was short of breath and he had pneumonia and lots of respiratory issues. 48458 II. Failed to ensure lancets were used instead of a syringe with a needle to check blood sugar levels for Resident #205, Resident #255, Resident #46 and Resident #4 A. Professional reference According to the Centers for Disease Control and Prevention (CDC), Considerations for Blood Glucose Monitoring and Insulin Administration, (8/7/24), retrieved on 1/21/25, from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, Fingerstick devices, also called lancing devices, prick the skin to obtain drops of blood for testing. Single-use, auto-disabling fingerstick devices are disposable and prevent reuse through an auto-disabling feature. These should be used in settings where you perform assisted blood glucose monitoring. B. Observations and interview On 1/12/25 at 5:40 p.m. registered nurse (RN) #2 performed a fingerstick using a disposable lancet and obtained a blood sample from Resident #28 for blood glucose testing. RN #2 said the facility ran out of the lancets for a few days in December 2024 and the nursing staff used insulin syringes with needles attached to prick the finger for blood glucose testing of residents. RN #2 said a facility staff member obtained additional lancets from a pharmacy, but that supply ran out before the new supply of lancets arrived, so the nurses continued to use the insulin syringes with needles for testing. The medication storage room was observed on 1/12/25 at 5:40 p.m. Seven boxes of disposable lancets (100 per box) were on a shelf. RN #2 said the facility had staff who kept track of the supplies in the medication room, but the staff left the facility prior to the depletion of the lancet supply. RN #2 said the assistant director of nursing (ADON) had taken over the ordering of supplies, including lancets, at that time. C. Resident interviews Resident #255 was interviewed on 1/13/25 at 2:30 p.m. Resident #255 said the facility ran out of lancets a few weeks ago. He said the facility used syringes with needles attached to obtain blood for glucose testing. Resident #255 said the syringe needle hurt more than the lancets that the facility usually used. Resident #255 said the facility was using the needle method to test his blood for approximately three days. He said the facility did not have anyone in the supply room to order supplies. Resident #205 was interviewed on 1/15/25 at 1:44 p.m. Resident #205 said the facility ran out of lancets for a few days and used a syringe with a needle on the end to obtain his blood. Resident #46 was interviewed on 1/15/25 at 1:56 p.m. Resident #46 said the facility ran out of lancets a few weeks ago and for a few days the nurses used the needles they used to give insulin to prick her finger and check blood sugars. Resident #46 said this was done at least two to three times and it hurt her more than the lancet that was usually used to test her blood. Resident #4 was interviewed on 1/15/25 at 5:00 p.m. Resident #4 said the facility ran out of lancets for blood sugar checks. She said the nurses used a needle on the end of a syringe to obtain blood from her finger. Resident #4 said the needle hurt more than the lancets did. She said her blood was tested in this manner for two days (about six times per Resident #4). D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/13/25 at 2:50 p.m. LPN #1 said a few weeks ago the facility was low on their supply of lancets. LPN #1 said she had enough in her medication cart to use and she reported the low supply to management (she was unable to identify the specific manager notified). LPN #1 said she did not return to work for several days and did not know if the facility ran out of the lancet supply. The ADON and the director of nursing (DON) were interviewed together on 1/13/25 at 3:07 p.m. The ADON said the facility ran out of lancets in December 2024. The ADON said a staff member went to a pharmacy to obtain additional lancets but returned to the facility with the wrong devices. The ADON said she assumed the responsibility for ordering supplies after the previous central supply personnel left the facility in November 2024. The ADON said she placed an order for lancets when she learned the supply had been exhausted. The ADON said she directed nurses to use a tuberculin/insulin syringe with the needle attached to obtain blood from residents for glucose testing. The ADON said this method was used for testing until a lancet supply was obtained from a sister facility, which was later the same day. The ADON said the borrowed lancets from the sister facility also ran out a day before the ordered supply of lancets arrived so the nursing staff used the insulin syringes with needles again for blood glucose testing. The DON said it was not appropriate to check residents' blood sugars with an insulin syringe and a needle. The DON said the facility did not have same day service to order lancets from their pharmacy when the supply of lancets was exhausted, however, the pharmacy was now able to provide same day supplies. The DON said she thought it would be more painful for residents if nurses used insulin syringes with needles for testing, as it was not possible to control the depth of the needle.The DON said she did not know why it took so long to obtain lancets from the sister facility. The ADON said the order for lancets was placed as an overnight order, however, it took three days for the supplies to arrive. The ADON said the facility now kept 10 boxes on hand and she checked supplies two to three times weekly. The DON and the regional clinical resource (RCR) were interviewed together on 1/15/25 at 6:15 p.m. The DON said the ADON should not have directed staff to use an insulin syringe with a needle attached to obtain blood for glucose testing from residents. The RCR said the ADON should not have directed staff to use insulin syringes with needles attached to obtain residents' blood for glucose testing under any circumstances. The medical director (MD) was interviewed on 1/16/25 at 9:02 a.m. The MD said it would cause more pain to residents to use a syringe with a needle for glucose testing than a lancet. He said lancets were usually a higher gauge device (needle was smaller) and the needle would be a smaller gauge (the needle was larger with a smaller gauge). The MD said he had never seen a syringe with a needle attached used before to obtain blood for glucose testing. The MD said he would never think about using anything other than the lancet to obtain blood for glucose testing, and other than causing more discomfort, he did not think there would be any long term consequences of using the needle.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts and one of one medication storage room. Specifically, the facility failed to: -Ensure expired medications were removed from the medication carts and medication storage room; and, -Ensure over the counter medications intended for use by a single resident were labeled with the resident's name. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 1/22/25 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Manufacturer's recommendations The manufacturer's recommendations for latanaprost eye drops were retrieved on 1/22/25 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf. It read in pertinent part, Latanaprost sterile ophthalmic solution is indicated for the reduction of intraocular pressure in patients with open angle glaucoma. Once a bottle is open for use it may be stored at room temperature for six weeks. III. Observations On 1/14/25 at 1:17 p.m. the medication storage room was observed with the director of nursing (DON). The following items were found: -Seven tubes of activon medical grade honey (a wound treatment) with an expiration date of December 2024; and, -One box of phos-nak dietary supplement 100 count with an expiration date of April 2024. On 1/14/25 at 9:25 a.m. the medication cart on the 100 hallway was observed with registered nurse (RN) #1. The following item was found: -One bottle of cetirizine (allergy medication) 10 milligrams (mg) with an expiration date of December 2024. On 1/14/25 at 2:06 p.m. the medication cart on the 100 hallway was observed again with RN #1. The following items were found: -One bottle of latanaprost eye drops opened 10/1/24; -One bottle of buproprion (antidepressant medication) ER 150 mg with an expiration date of 9/17/24; -One bottle of amlodipine (medication used to treat high blood pressure) 10 mg with an expiration date of 10/12/24; and, -One bottle of citalapram (antidepressant medication) 20 mg with an expiration date of 11/30/24. On 1/15/25 at 10:56 a.m. the medication cart on the 600 hallway was observed with the DON. The following items were found: -One box of Genteal tears containing two tubes of ointment, opened 1/9/25, with no pharmacy label or resident name on either tube or the box; and, -One bottle of saline nasal spray opened 1/13/25 with no pharmacy label or resident name on the bottle. IV. Staff interviews RN #1 was interviewed on 1/14/25 2:15 p.m. RN #1 said she would dispose of the expired medications in the drug buster (a drug disposal system that breaks down unwanted medications into a non-toxic liquid that can be safely disposed of in the trash). RN #1 said she was not sure how long latanaprost should be used after opening. RN #1 said the risks of giving medication that was expired were unexpected side effects or decreased effectiveness of the medications. The DON was interviewed on 1/15/25 at 3:25 p.m. The DON said the medication carts and medication storage room should be examined every week by the assistant director of nursing (ADON) or the DON. The DON said she did not know why the bottles of expired medications were left in the medication cart. The DON said it was not advisable to use expired medications because their potency could be reduced.

Based on record review and interviews, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) (2025), retrieved on 1/22/25 from https://www.nccap.org/assets/docs/F-TAG%20680%20QUALIFICATION%20OF%20ACTIVITY%20DIRECTOR.pdf, The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist, or an activities professional who is licensed or registered if applicable by the state in which practicing; and, Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or, Has two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program; or, Is a qualified occupational therapist or occupational therapy assistant; or, Has completed a training course approved by the State. An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes completion of the activities component of the comprehensive assessment, contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities and interests/preferences of each resident. II. Resident interview Resident #16 was interviewed on 1/12/25 at 4:26 p.m. Resident #16 said he had been sitting in his chair all day with nothing to do. He said the programming on television (TV) was very limited and repetitive. Resident #16 said the facility had very few activities. He said activities mainly consisted of Bingo and there were very few other activities provided to the residents. Cross-reference F679 for failure to ensure activities meet the interest/needs of each resident. III. Record review The job description for the activities director (AD) was provided by the regional clinical resource (RCR) on 1/16/25 at 1:32 p.m. The job description read in pertinent part, The activities director will collaborate with an activities consultant regarding resident and department issues and implement any recommended changes, including development of monthly activity calendars and development and revision of activity care plans. Complete all activities related documentation in each residents' medical record, including assessments, progress notes, care plans and activity attendance records. The initial January 2025 activity calendar (posted prior to 1/14/25) and revised January 2025 activity calendar (posted on 1/14/25) were provided by the nursing home administrator (NHA) on 1/16/25 at 3:00 p.m. The initial activities calendar contained a daily 9:30 a.m. coffee and news activity which represented 50% of the activities for the month, or 31 of 62 scheduled activities. The revised activities calendar had additional activities scheduled and changes to the initially scheduled activities from the initial calendar. IV. Staff interviews The AD was interviewed on 1/15/25 at 9:40 a.m. The AD said the administrator in training (AIT) was her supervisor. The AD said she did not have anyone providing activities director training to her and she had no previous experience or qualifications for the activities director position prior to assuming the role on 1/6/25. The AD said she asked her supervisor if certification was required for her role and was told the facility would get back to her. The AD said she was told she would have a mentor for her position but had not been provided with the mentor's name or phone number. The AD said she was not aware what the experience or education requirements were for an AD in a nursing facility. The AD said the previous January 2025 activities calendar was removed and replaced with a calendar she created on 1/14/25. The AD said she did not know who had posted the previous January 2025 calendar. The AD said it was the first activities calendar she had created. The AD said she used an example calendar which was left on her desk to create the January 2025 calendar. The AD said she did not know if Resident #16 had enough or appropriate activities. The AD said the previous AD had worked in the facility's maintenance department prior to working in the AD role. She said the previous AD was in the role from September 2024 to December 2024. The AIT and the nursing home administrator (NHA) were interviewed together on 1/15/25 at 10:25 a.m. The AIT said the AD misunderstood and the AIT was not her supervisor. The NHA said the previous AD who was in the role from September 2024 to December 2024 was not a certified AD. The NHA said the facility had a contract with a certified AD who was a consultant. The NHA said the consultant was the direct supervisor for the previous AD and the current AD. The NHA said the consultant met with the previous AD on 12/18/24. The NHA said the consultant was at the facility once a month for eight hours and as needed. The NHA said monthly supervision was not sufficient for an AD who did not have experience and needed to learn the role. The AIT said he would ensure the AD had contact information for her mentor (the consultant). The NHA said the AD did not know what the residents' needs were based on their conditions because she had not had training in the role. The NHA said he did not know if anyone had informed the AD of the requirements for her role. The NHA said the consultant likely was not aware there was a new AD because the consultant would have contacted the AD to arrange training if the consultant was aware the new AD was hired.

Based on observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on four of five neighborhoods. Specifically, the facility failed to maintain a comfortable air temperature range on four out of five neighborhoods. Findings include: I. Facility policy and procedure The Quality of Life-Homelike Environment policy, dated 12/19/16, was provided by the nursing home administrator (NHA) on 1/16/25 at 2:38 p.m. It read in pertinent part, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable and safe temperatures of 71 to 81 degrees fahrenheit (F). II. Group interview Residents who frequently attended monthly resident council meetings and the resident council president were interviewed on 1/14/25 at 10:38 a.m. The four residents (#1, #50, #205 and #23) who attended the meeting said the facility was not warm enough. Resident #205 said he talked to the maintenance supervisor (MS) regarding the cold temperatures in the facility but the MS was too busy to address the concern. Resident #205 said the heaters worked periodically at the facility. Resident #23 said the dining room was cold. She said she thought it was difficult to keep the dining room warm enough since it had a lot of windows. III. Resident and representative interviews Resident #37 was interviewed on 1/12/25 at 4:01 p.m. Resident #37 said her room was cold. She said the furnace in her room was barely warm. She said she was told the facility was having a repair person come in the following day to fix it and that the staff gave her extra blankets in the meantime. Resident #38's representative was interviewed on 1/13/25 at 10:24 a.m. Resident #38's representative said Resident #38 told him the heat register in her room had not been working for about thirty days. Resident #38's representative said Resident #38 complained to him about being cold at night. Resident #37 was interviewed a second time on 1/14/25 at 12:55 p.m. Resident #37 said it was still cold in her room. Resident #37 said the facility had told her they would have someone out to look at the furnace but no one had come. Resident #37 said she told the MS and one of her nurses that it was cold in her room. Resident #37 said it was colder at night and early in the morning in her room. Resident #48 was interviewed on 1/14/25 at 1:29 p.m. Resident #48 said it was cold in her room. Resident #25 was interviewed on 1/14/25 at 2:40 p.m. Resident #25 said her heater was broken. Resident #25 touched the radiator in her room and said it did not feel warm. Resident #25 said the radiator had not been working all winter as far as she knew. Resident #37 was interviewed a third time on 1/14/25 at 2:44 p.m. Resident #37 said it was still cold in her room. Resident #37 was visibly shivering. IV. Observations On 1/14/25 at 2:28 p.m. ambient temperatures were taken throughout the facility. The following temperatures were observed: -At 2:28 p.m. the 300 hallway was 62.9 degrees F; -At 2:30 p.m. the 100 hallway was 70.1 degrees F; -At 3:32 p.m. the dining room was 68.9 degrees F; -At 2:34 p.m. the 600 hallway was 68.9 degrees F; and, -At 2:35 p.m. the 500 hallway was 67.4 degrees F. From 3:48 p.m. to 4:00 p.m. additional ambient temperatures were assessed by the administrator in training (AIT) and the MS which revealed the following: -The nurse's station measured 69.1 degrees F; -The 600 hallway measured 70.2 degrees F; -The 400 hallway measured 66.7 degrees F at one end of the hallway and 68.7 degrees F partway down the hallway; -The 100 hallway measured 71.4 degrees F; -The 300 hallway measured 63.5 degrees F at one end of the hallway and 65.1 degrees F part way down the hallway; and, -The dining room measured 67.1 degrees F. V. Staff interviews The MS was interviewed on 1/14/25 at 3:34 p.m. The MS said there was a mechanical service company working on the heaters at the time of the interview. The MS said he had confiscated several space heaters from employees and made them take them home. He said the company that previously owned the facility would not give him the funds to fix the heaters in the facility. The MS said residents complained to him about being cold, so he did everything he could to help, including bleeding the radiators and setting the thermostats as high as they could go. The MS said the thermostats throughout the whole facility were set to 90 degrees F. The MS said he monitored the facility's temperatures daily and measured the temperatures throughout the facility every morning and again after lunch. The MS said the temperatures in the facility typically ranged between 68 and 72 degrees F. The MS said they were supposed to maintain temperatures between 71 and 81 degrees F in resident areas, and that below 70 degrees F was too cold and above 82 degrees F was too hot. The AIT and the MS were interviewed together on 1/14/25 at 3:48 p.m. The AIT said the facility temperatures should be between 71 and 81 degrees F. The AIT said the doors where residents went out to smoke were open all the time and let cold air into the building. The MS said the 300 hallway was like a wind tunnel because the handicap accessible door kept the door open for the smoking patio. The MS said the facility had been having issues with its heating system since before September 2024. The MS said he had been working on getting quotes and getting the heaters serviced since then. VI. Additional information Heater service invoices were provided by the NHA on 1/15/25 at 8:46 a.m. The invoices revealed the following: On 10/23/24 cleaning and flushing of supply lines was performed on the facility's boiler. The boiler was tested and its operation was verified. On 11/13/24 the maintenance company responded to the facility to address a reported issue of no heating. The maintenance company discovered several sensors for the heating system were not set correctly and adjusted them accordingly. The maintenance company tested the functionality of the heating system afterward and the issue had been resolved. On 11/22/24 the maintenance company responded to the facility to address a reported issue of no heating. The company found the 400 hallway thermostat was working intermittently and recommended a replacement. The company also determined there was a blockage in the heating pipes in the 300 hallway which needed to be repaired. On 12/3/24 a quote was provided by the maintenance company to supply and install baseboard covers for several rooms in the 500 hallway, two rooms in the 400 hallway, one room in the 100 hallway, and three rooms in the 600 hallway. The quote also involved servicing the facility's hydronic (radiant heat) system. -However, no quotes were provided for the thermostat replacement in the 400 hallway nor the repair work in the 300 hallway that was recommended on 11/22/24. On 1/15/25 at 8:56 a.m. the NHA said via email that the services provided on 1/14/25 involved replacing the baseboard heater covers in the 300 hallway but that the facility had not yet received an invoice for those repairs.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#5) of three residents reviewed out of 33 sample residents. Specifically, the facility failed to: -Ensure Resident #5 was provided beverages of his choice when requested; and, -Ensure Resident #5 was provided clothing when he requested to get dressed and was not dressed in a hospital gown. Findings include: I. Facility policy and procedure The Resident Rights policy, dated 5/1/17, was provided by the nursing home administrator (NHA) on 1/16/25 at 2:38 p.m. It read in pertinent part, Employees should treat all residents with kindness, respect and dignity, and honor each resident's rights. These rights include the resident's rights for a dignified existence, to be treated with respect, kindness and dignity, self-determination and to be supported by the facility in exercising his or her rights. II. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder depressive type, obsessive-compulsive personality disorder, anxiety disorder, binge eating disorder, type 2 diabetes mellitus, hypertensive heart failure and chronic obstructive pulmonary disease (COPD). The 12/20/24 minimum data set (MDS) assessment revealed Resident #5 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #5 was independent or required supervision with dressing, toileting and transferring. He was independent with mobility using a wheelchair. B. Resident interview and observations Resident #5 was interviewed on 1/14/25 at 8:59 a.m. Resident #5 said he was going through some unfair treatment at the facility. Resident #5 was observed asking an unknown staff person for a cup of coffee and the staff told him the dining room was closed. -The staff person did not offer Resident #5 an alternate beverage. Resident #5 said he was going to find the social services director (SSD) so he could get a coke. Resident #5 asked the nurse working on the other hallway if she knew where the SSD was. The nurse told Resident #5 the SSD was in a meeting and he would have to wait. -The nurse did not offer to assist Resident #5 or find another staff person who could assist him. On 1/16/25 at 9:39 a.m. Resident #5 was sitting in his wheelchair in the doorway to his room wearing only an incontinent brief. Resident #5 asked housekeeper (HK) #1 for a cup of coffee. HK #1 told the resident she would have to ask his nurse first and then said Resident #5 was on a fluid restriction. -However, review of Resident #5's electronic medical record (EMR) did not reveal the resident was on a physician-ordered fluid restriction (see record review below). On 1/16/25 at 9:40 a.m. registered nurse (RN) #2 approached Resident #5 and asked if he wanted to get dressed. Resident #5 told RN #2 he did not have any clothes in his room. RN #2 offered the resident a hospital gown and assisted him to put it on. RN #2 was interviewed on 1/16/25 9:41 a.m. RN #2 said Resident #5 had clothes and kept them in his room but he constantly soiled them with urine and they were probably all in the laundry. She said she would check with the laundry staff and try to find some clothes for him. C. Record review The January 2025 CPO documented Resident #5 was on a regular diet with no fluid restrictions. The psychosocial needs care plan, initiated 2/27/24, documented Resident #5 would remain at the facility for ongoing psychosocial and care needs. Interventions included the following, per the resident's representative: Resident #5 would be given two Mountain Dew sodas per day until he was able to utilize the bathroom in his room and keep his room clean. The bladder incontinence care plan, initiated 2/27/24, documented Resident #5 voided in inappropriate places such as his bed, the trash can and the floor. Interventions included staff reminding him to use the toilet or urinal frequently, encouraging him to change soiled clothing and encouraging him to limit fluid intake two to three hours before bedtime as he would allow. -Review of Resident #5's EMR indicated Resident #5's family member was the resident's medical and financial power of attorney (POA), however, there was no documentation supporting this in the EMR or on file at the facility. The behavioral health clinical treatment plan of care, reviewed 11/19/24, documented Resident #5 indicated staff at the facility did not like him because he had urinary accidents throughout the day and night. D. Other resident interviews Resident #255, who had a BIMS score of 15 out of 15, was interviewed on 1/16/25 at 9:36 a.m. Resident #255 said he had heard the staff tell Resident #5 he could not have coffee when he asked for it because he kept peeing on the floor. E. Additional staff interviews The SSD was interviewed on 1/16/25 at 9:20 a.m. The SSD said Resident #5 had signed his own consents and was very intelligent. The SSD said Resident #5 could make daily decisions regarding his routine. The SSD said he did not have a copy of the POA paperwork for Resident #5. The SSD was interviewed again on 1/16/25 9:48 a.m. The SSD said Resident #5's care plan needed to be updated because he had his own stock of pop at the facility. The SSD said resident #5 was allowed to choose when to drink soda or coffee. The SSD said the care plan should have been updated at his last care conference meeting on 1/2/25. The SSD said when clothing was sent to the laundry, it was a two-day turnaround time for the clothes to be returned to the residents. The SSD said if Resident #5 was running out of clothing he would contact his representative to bring more in. The SSD said there was some donated clothing downstairs and he would look for some clothing for Resident #5 to wear until he got more clothes. The SSD said if the resident wanted to get dressed, he should not have to wear a hospital gown. The NHA was interviewed on 1/16/25 at 11:19 a.m. The NHA said if a resident wanted to get dressed they should have clothing to wear and they should not have to wear a hospital gown. The NHA said if a resident had a POA, they should still be able to make daily decisions and make simple choices. The NHA said a POA should not be restricting a resident's choices. The NHA said the care plan for Resident #5 should not include statements that the resident had to keep his room clean or use the bathroom appropriately in order to receive soda. He said the care plan would be updated.

Based on record review and interviews, the facility failed to honor resident choices for one (#46) of two residents out of 33 sample residents. Specifically, the facility failed to honor Resident #46's preference for assistance with bathing from female shower aides. Findings include: I. Facility policy and procedure The Accommodation of Needs and Preferences policy and procedure, dated 12/19/16, was provided by the nursing home administrator (NHA) on 1/16/25 at 2:38 p.m. It read in pertinent part, The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. II. Resident #46 A. Resident status Resident #46, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (a type of stroke that occurs when brain tissue dies due to a lack of blood flow), hemiplegia and hemiparesis (a neurological condition that causes paralysis or weakness on one side of the body). The 12/12/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was dependent on staff for bathing. B. Resident interview Resident #46 was interviewed on 1/15/25 at 1:41 p.m. Resident #46 said she did not receive showers often enough. She said she preferred to shower every other day. Resident #46 said she preferred female shower aides and would not allow male shower aides to provide her assistance. She said she would refuse when the male shower aides tried to give her a shower, which led to either the facility getting a female shower aide or she would not receive a shower that day. Resident #46 said she told several staff members about her preference of having a female shower aide, but had not received any resolution to the issue. Resident #46 said she missed one or two showers as a result of the issue. C. Record review The activities of daily living (ADL) care plan, revised 9/17/24, revealed Resident #46 had an ADL performance deficit due to left-sided weakness/hemiplegia. Pertinent interventions revealed Resident #46 required assistance with bathing and preferred showers on Mondays, Wednesdays, and Fridays on evening or day shifts. -The care plan did not include any information regarding Resident #46's shower aide preferences. The trauma informed care care plan, initiated 8/30/24, revealed Resident #46 had a history of sexual assault and trauma that resulted in difficulty connecting with and trusting others. The care plan specified Resident #46 did not have a preference for male or female caregivers due to her trauma experience. -However, the resident's preference sheet, dated 8/30/24, documented Resident #46 preferred to receive care from female employees. Resident #46's representative filed a grievance with the facility on 12/5/24 which revealed Resident #46 would only like to be bathed by female staff members. The facility resolution, enacted 12/5/24, revealed the social services director (SSD) notified the nursing staff and made it known that only female staff would bathe Resident #46 from that point forward. Resident #46 signed the grievance form and indicated she was satisfied with the resolution. -However, Resident #46's care plan was not updated to reflect this preference, nor was this preference documented in the resident's electronic medical record (EMR) or on the Kardex (a tool utilized by staff to provide consistent resident care. Bathing records from 12/16/24 to 1/13/25 revealed a male aide assisted Resident #46 with her shower on 1/4/25 at 9:59 p.m. A resident preference sheet, undated, was uploaded to Resident #46's EMR effective 8/30/24. The preference sheet revealed Resident #46 preferred to receive showers on Tuesday and Friday evenings. Resident #46 indicated she preferred to receive care from female employees. A bathing preference sheet, dated 10/24/24, revealed Resident #46 preferred to have a shower on Monday, Wednesday, and Friday but did not have a preference for time of day. The preference sheet did not include any areas in which the resident could indicate a shower aide preference. The shower book, which was kept at the nurse's station, was reviewed on 1/15/24 at 2:06 p.m. The shower book revealed each resident's preference for time and day of week for their showers, but did not indicate any preferences regarding shower aides. D. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 1/15/25 at 2:06 p.m. CNA #6 said each resident's shower preferences were updated periodically and those updates were recorded in the shower book kept at the nurse's station. CNA #6 said he had not provided showers to Resident #46 so he was not aware of her preferences. CNA #6 said shower aide preferences were not documented in the shower book. He said the nursing staff knew that information from working with the residents. CNA #7 was interviewed on 1/15/25 at 2:17 p.m. CNA #7 said Resident #46 received showers on Monday, Wednesday, and Friday evenings and preferred a female aide to assist her. CNA #7 said resident preferences were assessed when the resident first admitted and given to the nurse who then updated the resident's EMR. CNA #7 said the facility CNAs were told about resident preferences when they were initially trained but preferences were not recorded. Registered nurse (RN) #2 was interviewed on 1/15/25 at 3:10 p.m. RN #2 said resident preferences for showers were identified on admission then recorded in their Kardex and the shower book. RN #2 said preferences were also passed along between nursing staff at shift changes during the handoff report. The SSD was interviewed on 1/15/25 at 3:25 p.m. The SSD said he updated Resident #46's care plan to indicate Resident #46 preferred female bath aides. He said Resident #46 did not want to be touched by men due to her history of trauma. -However, a review of Resident #46's care plan revealed Resident #46 did not have a preference for male or female staff for bathing. Licensed practical nurse (LPN) #3 was interviewed on 1/15/25 at 5:33 p.m. LPN #3 reviewed Resident #46's Kardex but did not find any notes indicating her preference of shower aide. LPN #3 reviewed Resident #46's care plan and said it documented Resident #46 did not have a preference of male or female staff. The director of nursing (DON) was interviewed on 1/16/25 at 11:34 a.m. The DON said residents' bathing preferences were assessed upon admission and added to their baseline care plans. The DON said the facility staff identified if the resident preferred a bath or shower, time of day and the days of the week. The DON said the shower preference sheet did not ask about male or female aide preference. She said male or female preferences were determined by the staff and then should be documented on the bathing task in the EMR system. The DON said she was not aware of any specific shower aide preferences for Resident #46. The DON reviewed Resident #46's bathing task, care plan and Kardex and said she was unable to find any information regarding Resident #46's shower aide preferences.

Based on record review and interviews, the facility failed to ensure two (#1 and #2) of four residents reviewed for abuse out of nine sample residents were protected from abuse. Resident #2, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was in Resident #1's room doorway on 10/12/22 when she was pushed by Resident #1 out of his room. Resident #1 had verbal and physical behaviors directed towards others. Due to the facility's failures of not appropriately addressing Resident #2's wandering behaviors, they failed to protect her from abuse which resulted in her sustaining a traumatic subdural hemorrhage (brain bleed) as a result of being pushed by Resident #1. Findings include: I. Facility policy and procedure The Abuse policy, modified October 2022, was received from the nursing home administrator (NHA) on 12/13/22 at 9:06 a.m. It read in pertinent part: It is the policy to empower and enable any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, volunteers, and others ( 'Associates' ) currently or potentially working for the Facility to make reports to the relevant authorities pursuant to the provision of the Elder Justice Act ( 'EJA' ) and Center for Medicare and Medicaid (CMS) regulations. The Facility will not retaliate against any Associate in response to lawful acts done by the Associate pursuant to the EJA. II. Resident to resident physical altercation between Resident #1 and #2 A. Facility investigation Incident 10/12/22 Resident #2 was standing in doorway and Resident #1 got upset and pushed Resident #2. Resident #1 was immediately placed on one-to-one (staff supervision) and Resident #2 was sent to the emergency room . -The facility substantiated the abuse investigation. B. Resident #2 (victim) 1. Resident status Resident #2, age 70, was admitted on [DATE], readmitted on [DATE] and discharged [DATE]. According to the December 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 11/18/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had no behaviors. She required supervision for bed mobility, transfers, grooming and toilet use. 2. Record review The care plan, initiated 3/20/2020 and revised 10/25/22, identified the resident had the potential to be physically aggressive related to Alzheimer's. Intervention included analyzing times of day, places, circumstances, triggers and what de-escalates behaviors and document behaviors. Provide physical and verbal cues to alleviate anxiety. Give positive feedback and assist verbalization of sources of agitation. Guide away from the source of distress and engage calmly in conversation. The care plan, initiated 3/20/2020 and revised 10/25/22, identified the resident frequently wandering around the facility un-purposely. I do not attempt to leave the facility. Interventions include distract me from wandering/pacing by offering pleasant diversions, structured activities, food, conversation. I prefer: reading romance, suspense, mysteries and the bible, listening to country/western music, and watching boxing on TV (television). Nurse note dated 10/12/22 at 5:20 p.m. this writer heard another nurse calling out resident's name and noted resident lying on the floor of 600 hallway on her left side. This incident was witnessed by the assistant director of nursing (ADON). Resident was lingering outside another resident's doorway. The resident in the room became enraged, striking the resident in the chest, causing her to fall to the floor hitting her head. Resident was unresponsive initially and then slow to respond to verbal stimulations. During this writer's physical assessment of the resident, noted moaning when touching her left temporal area and left pelvic area. No shortening or rotation of her bilateral legs noted. The resident was able to grip bilateral hands equally. Pupils are equal and reactive to light. No swelling/bleeding noted on the resident's head. Vital signs taken. Advised by the director of nursing (DON) to send to the emergency room (ER) immediately for further evaluation. Ambulance called and transported to the hospital emergency room . Attempted to notify emergency medical contact but the phone number listed was incorrect. DON and nursing home administrator (NHA) also notified of transfer to ER. Social service note dated 11/16/22 at 1:42 p.m., social service spoke with the resident's son about transferring the resident into a secured unit. He stated he was fine with the transfer but he would like her to stay within the sister facility (within the corporation) if possible. Referral sent to sister facility for transfer. C. Resident #1 (assailant) 1. Resident status Resident #1, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 11/7/22 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The resident had verbal and physical behaviors directed at others. He required extensive assistance for bed mobility, transfers, grooming and toilet use. 2. Record review The care plan, initiated 11/7/22 and revised 11/13/22, identified the resident was dependent on staff for meeting my emotional, intellectual, physical, and social needs related to brain tumor, fractured vertebra. Cognitive deficits, immobility, physical limitations. Family members have expressed preferences or wishes for, comfortable tactile stimulation, companionship, touch and a variety of sensory stimulation. Interventions include providing me with materials for individual activities as desired. The resident preferred independent activities. -Resident #1 did not have a person-centered care plan or interventions to evaluate the effectiveness of the interventions to prevent further physical abuse. Interdisciplinary team (IDT) note dated 10/18/22 at 8:34 a.m. IDT review for physical aggression towards another resident. IDT reviewed the incident from 10/12/22. This resident struck another resident in her chest, resulting in a fall to the floor with head injury. The resident was placed on one-to-one (staff supervision) immediately following the incident and continues with one-to-one at this time. Resident has exhibited no aggression towards another peer or staff member. Resident trigger specific Resident #2. Resident care plan was reviewed, and reviewed by my medical doctor. IDT will continue with one-to-ones and refer to psychologists. III. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 12/12/22 at 2:55 p.m. He said Resident #1 did not have any behaviors directed towards others. He said Resident #1 was very territorial of his space and would get agitated if you would get in his space. He said Resident #1 did not have any other altercations or problems with any other residents in the facility. Certified nurse aide (CNA) #1 was interviewed on 12/12/22 at 3:00 p.m. He said Resident #1 was not comfortable with staff he was not familiar with and would get agitated if he was not familiar with staff providing care. Speech therapist (ST) #1 was interviewed on 12/12/22 at 3:17 p.m. She said she Resident #1 had receptive deficits and was having struggles to understand and process messages and information he received from others. She said his behaviors were not so much aggression but more frustration as he cannot express himself. She said he gets down on himself when he cannot complete or understand a task. She said she had heard about the resident to resident altercation. She said it could have been confusing for both parties as he did not know how to express himself and he did not have the ability to do so. The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 12/12/22 at 4:22 p.m. The NHA said, I am the abuse coordinator and the incident was substantiated as there were injuries. The DON said Resident #1 did not have a history of physical behaviors directed toward others. She said Resident #1 did have an issue with Resident #2 and staff could not understand what the issue was. She said Resident #1 was on one-to-one staff supervision while transfer for Resident #2 was in the process. The NHA said Resident #1 had not had any other outburst towards anyone other residents or staff since the transfers of Resident #2. She said during the investigation, staff could not figure out what it was about the interaction with Resident #2 which agitated him. She said they continued to monitor Resident #1 and have found no other triggers with residents or staff. She said the resident had a decline in physical health and had a recent fall which may be due to the disease process. She said physical therapy was working with him as Resident #1 had right side weakness. The social service director (SSD) was interviewed on 12/13/22 at 9:01 a.m. She said the residents did have a resident to resident altercation. She said Resident #2 was standing in Resident 1's doorway. She said Resident #1 pushed Resident #2 in the chest area and she fell back hitting her head. She said Resident #2 was immediately sent out to the emergency room (ER). She said Resident #1 was on one-to-one after the incident and was on one-to-one till Resident #2 was transferred out of the facility. She said Resident #1 had not had any other altercations or behaviors. She said Resident #1 was still being monitored. The SSD said she updated the residents' care plan after an altercation to address behaviors and or added interventions. The SSD said she did not update Resident #1's care plan after the altercation. She said a negative outcome would be staff would not know what behaviors to observe.

Based on record review, observations and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including the novel Coronavirus (COVID-19). The failure affected all residents present in the facility, which placed the facility in an immediate jeopardy situation. Specifically, the facility failed to update and follow their Infection Control Plan submitted to the State Agency and last updated on 4/27/2020 which failed to prevent the spread of the COVID-19 virus by ensuring staff who were exhibiting signs and symptoms of the COVID-19 virus were sent home and did not continue to work. A unit manager indicated on the screening forms she was experiencing signs and symptoms (s/s) of COVID-19 on 11/29/2020. She indicated on the screening forms she continued with s/s of COVID-19 on 12/1/2020 to 12/5/2020, while working. The facility COVID-19 tracking indicated the unit manager had a positive COVID-19 test result on 12/5/2020. The nursing home administrator (NHA) experienced symptoms on the night of 11/20/2020, 11/21/2020, 11/23/2020 and 11/24/2020. He continued to work at the facility on 11/23/2020 and 11/24/2020. On 11/24/2020, he was not feeling well and sent himself home. Later that day he received a positive COVID-19 test result. The above failures in infection control practices created an immediate jeopardy situation with the likelihood of serious harm due to potential of further transmission of the highly infectious COVID-19 virus to residents throughout the facility, staff and others, if not corrected immediately. Additionally, the facility failed to ensure staff donned full PPE when entering COVID-19 positive resident rooms and ensure Resident #3, who was positive with COVID-19, wore a mask when walking with a CNA down the hallway. Findings include: I. Facility status COVID-19 positive staff and residents The facility COVID-19 line listing documented 25 positive staff members since 11/19/2020. The last positive staff person was identified on 12/7/2020. Results from the facility's COVID-19 testing performed identified 44 positive results for residents. The facility had 44 residents on isolation precautions as of 12/7/2020 for having positive COVID-19 tests. The facility had 25 positive staff members and 44 positive residents as of 12/7/2020. II. Immediate Jeopardy A. Findings of Immediate Jeopardy Record review conducted on 12/7/2020 of the facility employee and essential healthcare personnel screening logs from 11/17/2020 to 12/7/2020, revealed the unit manager, who was responsible for supervising every nursing unit in the facility, began showing signs and symptoms of COVID-19 on 11/29/2020. The unit manager continued to work at the facility while showing signs and symptoms of COVID-19 from 11/29/2020 to 12/5/2020. On 12/4/2020, the unit manager conducted facility wide COVID-19 testing of every resident and staff member of the facility, while she was experiencing signs and symptoms of COVID-19. On 12/5/2020, while working, she was notified she had a positive COVID-19 test result and was sent home. The unit manager was positive for COVID-19 and was experiencing signs and symptoms of COVID-19 while coming in direct contact with every resident and staff member of the facility on 12/4/2020. Additionally, the NHA experienced signs and symptoms of COVID-19 starting on 11/20/2020. The symptoms persisted into the weekend and on Monday developed a cough. The NHA did not identify on the facility screening forms that he had experienced signs and symptoms of COVID-19. The NHA continued to come to work and on Tuesday, 11/24/2020, he indicated he felt sick and sent himself home. He received his positive COVID-19 test result later that day. These failures created the likelihood for serious harm to all facility residents and staff due to potential transmission of the highly infectious COVID-19 virus. B. Facility notice of Immediate Jeopardy On 12/7/2020 at 4:55 p.m. the nursing home administrator (NHA) was notified that the failures above under F880 created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). C. Facility plan to remove immediate jeopardy On 12/8/2020 at 12:05 p.m., the NHA submitted a plan to remove the immediate jeopardy. The plan read: 1. Employees currently on shift were immediately assessed for signs or symptoms of COVID-19 by a registered nurse using our screening tool. No staff were found to have symptoms (December 11, 2020). 2. The screening log for 12/7/2020 was immediately reviewed by the director of nursing (DON) for any documented symptomatic staff and no discrepancies identified. Additionally, 30 days of screening immediately prior to today was audited (December 11, 2020). 3. The Administrator and the unit manager were re-educated by the District Director of Clinical Services on the active screening process for COVID-19 including sending employees home who present with symptoms of COVID-19 (December 11, 2020). 4. All staff will be re-educated by the Director of Nursing, Infection Preventionist or designee, on the symptoms of COVID-19, not coming to work with symptoms of COVID-19, and reporting any symptoms of COVID-19 that are developed during their shift immediately to their manager/Supervisor (December 11, 2020 or prior to their shift). 5. All staff will be in-serviced on the severity of COVID-19, the significance of positive test results, ramification of positive exposure to a vulnerable population, and reporting possible symptoms while not at work as well (December 11, 2020 or prior to their shift). 6. Licensed Staff will be re-educated on the active screening process including signs and symptoms of COVID-19 and sending staff members home who exhibit or report signs or symptoms of COVID-19 (December 8, 2020). Education to staff will include whether the licensed staff notes any symptoms they are to immediately send that staff member home and the Director of Nursing, or designee, will contact the staff member within 24 hours to determine if symptoms warrant COVID-19 testing or if alternate [DIAGNOSES REDACTED]. 7. Beginning immediately the Director of Nursing, Infection Preventionist, or designee will audit the screening logs after the beginning of each shift to validate that no employees reported or were found to have symptoms of COVID-19 were allowed to work. This will be reviewed by the manager on duty on the weekends. 8. Infection prevention plan will be reviewed, updated, and implemented on the CDPHE website to reflect a new plan by the end of day, December 8, 2020. The plan will be updated as needed and uploaded to the website. Staff will be educated on any changes to the plan and it will be readily available for review at each nurse's station. D. Removal of immediate jeopardy On 12/8/2020 at 12:05 p. m. the NHA was informed the immediate jeopardy was removed based on the facility's implementation of the above plan. However, deficient practice remained at a F level, potential for more than minimal harm that was widespread. III. Systemic failure to maintain an effective infection prevention and control program A. Failure to prevent the spread of the COVID-19 virus by ensuring staff were sent home when experiencing signs and symptoms of COVID-19. 1. Professional references According to the Centers for Disease Control (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 12/10/2020), As part of routine practice, ask HCP (healthcare professional) to regularly monitor themselves for fever and symptoms consistent with COVID-19. Remind HCP to stay home when they are ill. If HCP develop a fever or symptoms consistent with COVID-19 while at work, they should inform their supervisor and leave the workplace. Have a plan for how to respond to HCP with COVID-19 who worked while ill (e.g., identifying and performing a risk assessment for exposed residents and co-workers). Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their facemask on and leave the workplace. 2. Record review a. Personnel screening logs The employee and essential healthcare personnel screening logs were reviewed from 11/17/2020 to 12/7/2020. The following information was documented: -The unit manager documented she experienced symptoms of the COVID-19 virus on 11/29/2020, 12/1/2020, 12/2/2020, 12/3/2020, and 12/5/2020. It did not indicate the type of symptoms the unit manager experienced. It did indicate she was actively screened by another staff member. The NHA documented he did not experience any signs and symptoms of the COVID-19 virus on 11/23/2020 and 11/24/2020. b. COVID-19 location tracking form The confirmed COVID-19 location tracking form documented the unit manager had a COVID-19 test conducted on 12/1/2020 and she was placed on isolation due to a positive COVID-19 test on 12/5/2020. It indicated the unit manager conducted facility wide testing for both residents and staff on 12/4/2020, therefore exposing every staff member and resident at the facility. The NHA confirmed COVID-19 location and tracking form documented the NHA had a COVID-19 test completed on 11/23/2020 and had an onset of COVID-19 symptoms on 11/20/2020. It indicated he was placed under isolation on 11/24/2020. c. Line listing The facility COVID-19 tracking line listing revealed the facility had 44 residents and 25 staff members with confirmed COVID-19 test results beginning on 11/23/2020 to 12/7/2020. 3. Staff interviews The NHA and DON were interviewed on 12/7/2020 at 12:12 p.m. The NHA said on Friday, 11/20/2020, at night, he started experiencing symptoms of COVID-19. He said the symptoms persisted on Saturday. He said he did not experience symptoms on Sunday, 11/22/2020. He said he went to work at the facility on 11/23/2020 and 11/24/2020. He said on Monday, 11/23/2020, he coughed a few times throughout the day. He said on 11/24/2020, after he arrived at work, he was not feeling well and decided to go home. He said he received his positive COVID-19 test result later that day. He confirmed he documented on the screening form he was not experiencing symptoms. He said his symptoms were mild and he did not think he should stay home from work. He confirmed he tested positive for COVID-19 after the symptoms began to manifest. The DON was interviewed on 12/7/2020 at 1:00 p.m. She said she was not at the facility for the previous two weeks because she had confirmed COVID-19. She said that day was her first day back in the facility. She said if she had known the NHA had experienced symptoms of COVID-19 she would have instructed him to stay home and quarantine until his test results returned. She said no staff should enter the facility if they were experiencing symptoms. CNA #1 and restorative nurse aide (RNA) #1 were interviewed on 12/7/2020 at 2:50 p.m. RNA #1 said each staff member was required to be screened by the on duty nurse prior to entering the facility. She said if staff were experiencing signs and symptoms of COVID-19, they should call their supervisor before coming to the facility. She said staff were not allowed to enter the facility and work if they were experiencing signs and symptoms of COVID-19. She said it was the on duty nurse who decided if the staff were allowed into the facility following the screening. She said if staff experienced symptoms, they should stay home for 10 days following the start of the symptoms. The DON was interviewed on 12/7/2020 at 2:30 p.m. The said active screening was to be completed for anyone who entered the facility. She said the nurse on duty was assigned to perform the screening. She said if a staff member or visitor indicated they were experiencing symptoms, the nurse should obtain information about the specific symptoms, the date of onset and then send them home. She said any staff member or visitor who was experiencing symptoms of COVID-19 should not be permitted to enter the facility. She said they should not return to the facility until 10 days following the onset of signs and symptoms of COVID-19. She said the unit manager provided oversight for the entire facility. She said if there was a nursing call off, then the unit manager would provide direct care to staff. She said the unit manager conducted facility wide COVID-19 testing for both residents and staff on 12/4/2020. She said she was not aware the unit manager had indicated she was having signs and symptoms of COVID-19 from 11/29/2020 to 12/5/2020. She said she would not have permitted the unit manager to enter the facility or work while experiencing symptoms of COVID-19. She confirmed the unit manager exposed all staff and all residents in the facility when she conducted the testing while experiencing symptoms. She said she was unable to find any documentation to indicate the nurse who screened the unit manager had determined what symptoms the unit manager was exhibiting. She said the facility did not have a system in place that documented staff symptoms and any follow-up made by nursing management. B. Failure to ensure staff wore proper PPE when entering resident rooms when they were positive with COVID-19 and ensure a resident who was positive with COVID-19 wore a mask when in the hallway 1. Professional references According to the Centers for Disease Control (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 12/10/2020), Health care professional (HCP) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE (personal protective equipment), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. .enter the room of a patient with known or suspected COVID-19 should adhere to standard precautions and use of respirator, gown, gloves and eye protection. When available, respirators should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring airborne precautions. The PPE recommended when caring for a patient with known or suspected COVID-19 includes: Put on an N95 respirator (or higher level of respirator) or facemask (if a respirator is not available) before entry into the patient room or care area. Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19). Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others enter their room. 2. Observations During observations conducted on 12/7/2020 starting at 11:30 a.m. until 12:15 p.m. the following was observed: -At 11:47 a.m. a certified nurse aide (CNA) was observed walking down the hallway pushing a cart of lunch meal trays. She entered room [ROOM NUMBER] to take the resident their lunch tray. She was wearing a facial mask and a face shield. She did not don further PPE prior to entering the resident's room. Outside the room, an isolation cart was observed with a notice outside the room which indicated the residents who resided in that room were under droplet isolation precautions. Upon exiting the room, she did not perform hand hygiene. - The CNA immediately went to the meal cart and grabbed another lunch meal tray and entered room [ROOM NUMBER]. She did not don PPE prior to entering the resident's room. Outside the room, an isolation cart was observed with a notice indicating the residents in the room were under droplet isolation precautions. She did not use hand hygiene when she exited the resident room. -She observed a family member of a resident at the door and waved to them. She then entered the resident's room of the family at the front door of the facility. She did not don PPE prior to entering the resident's room. The room was observed with an isolation cart outside and a notice on the door indicating the residents were under droplet isolation precautions. The CNA exited the resident room with Resident #3 using a four wheel walker. He walked with the CNA toward the door at the front of the facility. He spoke to his family for a few minutes through the door, and then walked with the CNA back to his room. Resident #3 was not wearing a mask. 3. Resident #3 a. Resident status Resident #3, age 91, was admitted on [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 11/17/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of ten out of 15. He required limited assistance of one person with dressing and personal hygiene. He was independent with bed mobility, transfers, toileting and eating. b. Record review The COVID-19 virus infection care plan revealed the resident had a confirmed nasopharyngeal swab test for the COVID-19 virus. The interventions included to implement and encourage social distancing, monitoring any signs and symptoms every shift of [MEDICAL CONDITION], initiate transmission based precautions, and if the resident must be transported from his room, use a mask to cover his mouth and nose. The 12/1/2020 nursing progress note documented the resident's family was notified the resident had a confirmed positive COVID-19 test result. It indicated the resident was keeping to his room per facility protocol. 4. Staff interviews CNA #1 and RNA #1 were interviewed on 12/7/2020 at 2:50 p.m. The CNA said any resident who had a confirmed positive COVID-19 test result had a notice on the outside of the room to indicate they were under droplet precaution isolation and an isolation cart. She said prior to entering the room, staff should don a gown, gloves, N95 mask and a face shield. She said upon exiting the room, the PPE should be doffed and hand hygiene completed. She said each staff member had a bottle of hand sanitizer in their pocket to ensure hand hygiene was done often. The NHA and DON were interviewed on 12/7/2020 at 12:12 p.m. The DON said the facility had 44 residents with confirmed COVID-19. She said for residents with confirmed COVID-19, there was an isolation cart with PPE at the outside of the door and a pink sign indicating the resident was placed on droplet precaution isolation. She said all residents with confirmed COVID-19 should stay in their rooms to help prevent the spread of [MEDICAL CONDITION]. She said if they must come out of their rooms, the resident was required to wear a mask. She said hand hygiene should be performed every time a staff member leaves a resident room. She confirmed Resident #3 had active COVID-19. She said the CNA should have instructed the resident to wear a mask before bringing him into the hallway, where he could expose others to [MEDICAL CONDITION]. She confirmed the CNA should have donned a gown and gloves prior to entering each of the COVID-19 positive rooms.

Based on observations, staff interviews, and record review, the facility failed to ensure one (#59) of two residents observed with a [MEDICAL CONDITION], out of 41 total residents sampled, received proper respiratory treatment and care. Specifically: Resident #59 had a [MEDICAL CONDITION] to maintain her airway. She had a recent history of aspiration pneumonia requiring hospitalization . Interview with four licensed staff caring for resident #59 revealed they had not received education on [MEDICAL CONDITION] care, suctioning, and assessment, including how to respond to the emergent situation of a spontaneous decannulation of a [MEDICAL CONDITION]. Two of these staff, LPN #4 and LPN #6, were scheduled as the only licensed staff for the overnight shift four times in September 2015. Review of staffing schedules for June - August revealed other overnight shifts covered only be staff untrained in respiratory care. The facility's failure to ensure staff on duty was qualified and educated to care for a resident with a [MEDICAL CONDITION], including the emergent situation created by a spontaneous decannulation, created a situation of immediate jeopardy for serious harm. Cross Reference: F282, F490, and F520 The findings include: I. Imposition of Immediate Jeopardy On 9/10/15 at 11:19 a.m., the nursing home administrator (NHA) was informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to ensure staff on duty was qualified and educated to care for a resident with a [MEDICAL CONDITION], including responding to the emergent situation of a spontaneous decannulation, created a situation of immediate jeopardy for serious harm. II. Facility Response and Removal of Immediate Jeopardy On 9/10/15 at 4:45 p.m., the following plan (draft #2) was submitted by the facility to CDPHE to remove the immediate jeopardy situation. The plan read: Cedar Wood HealthCare Center respectfully submits this plan to abate the allegations of immediate jeopardy identified on September 10, 2015. All residents who have a respiratory [DIAGNOSES REDACTED]. Effective immediately the Director of Nursing and Division Director of Clinical Services educated licensed and registered nurses at the facility currently regarding [MEDICAL CONDITION] care, specifically on the indications that [MEDICAL CONDITION] care is needed, the type of equipment needed to perform the care, preparation, implementation, special considerations, recannulation complications and documentation. At the conclusion of the training the nurses are qualified to perform recannulation. Staff were also trained that if the situation is or becomes an emergent situation they are to call 911. Licensed nurses not currently scheduled will be educated prior to working their next shift before they are permitted to resume their responsibilities. Respiratory therapist (RT) was in on 9/915 and assessed the resident respiratory status and current treatment plan and found it to be appropriate for the resident. The same RT will be in on 9/11/15 to do follow up training and observations of care to validate treatment plan and understanding of what to do in the case of an emergency. An RN will be in the facility 24 hours a day starting today 9/10/15 and ongoing to provide clinical supervision, as needed. Residents with tracheotomies will be assessed prior to admission by the Director of Nursing or designee to ensure the facility can meet the needs of the resident. The resident will then be assessed on admission, quarterly, and with significant change of condition. Care plans will be implemented and kept updated specifying interventions for [MEDICAL CONDITION] care. The nursing staff will be educated on each [MEDICAL CONDITION] resident in regards to their specific care needs, including what to do in the case of an emergency. The Director of Nursing and a contracted Respiratory Therapist (RT) will review assessments and assure thorough observational competencies that licensed nursing staff is competent to carry out [MEDICAL CONDITION] care in accordance with resident plan of care. The results of these reviews will be brought to the Quality Assurance Performance Improvement Committee meeting weekly for one month and then monthly thereafter. The facility provided a sign in sheet dated 9/10/15 that listed the licensed and registered nurses who had been trained on [MEDICAL CONDITION] care and management. The facility was instructed to continue to provide CDPHE with in service documentation daily until all licensed nursing staff was trained and on 9 /12/15, 9/13/15, and 9/14/15, CDPHE received additional sign in sheets of licensed staff trained on [MEDICAL CONDITION] care and treatment on which concluded training for all licensed nursing staff. On 9/10/15 at 5:10 p.m. the NHA was notified that the immediate jeopardy had been removed based on staff interview and review of the facility's in-service documentation. However, based on interviews and record review, deficient practice remained at a D level, the potential for more than minimal harm that is isolated. III. Resident #59 A. Resident Status Resident #59, a [AGE] year old female, was admitted to the facility 7/2/13, discharged to the hospital on [DATE] for aspiration pneumonia and re-admitted to the facility on [DATE]. The facility face sheet on readmission revealed the resident had [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION] in place at the time of her original admission in order to maintain her airway. The quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was in a persistent vegetative state with no discernible consciousness. She required total assistance of two persons with bed mobility, dressing, toilet use, and personal hygiene. She required total assistance of one person with eating and she was non-ambulatory. She received oxygen therapy, suctioning, and [MEDICAL CONDITION] care. 2. Orders and Care Plan a. Physician Orders The facility order recap report revealed the following active physician orders [REDACTED]. - 7/2/15, Clean [MEDICAL CONDITION] site and change dressing every shift and as needed for preventative care. - 7/2/15, Change inner cannula every shift and as needed with a size 6.0 millimeter (mm) [MEDICATION NAME] for preventative care. - 7/2/15, Change [MEDICAL CONDITION] ties twice per week and as needed for preventative care. - 7/7/15, Suction [MEDICAL CONDITION] every shift and as needed for preventative care and every hour as needed for preventative care. - 7/27/15, monitor for signs and symptoms of infection every shift (increased temperature, [MEDICAL CONDITION], etc.) for preventative care and notify the physician if symptoms present. - 3/2/15, Change oxygen tubing every Sunday There were no orders regarding oxygen administration. b. Care Plans The resident's [MEDICAL CONDITION] care plan, dated 7/31/15, read the resident had a [MEDICAL CONDITION] related to impaired breathing mechanics, [MEDICAL CONDITION], aspiration pneumonia, and [MEDICAL CONDITION]. -The goal was that potential for signs and symptoms of infection would be minimized with interventions, she would have clear and equal breath sounds bilaterally, her white blood cell count would remain within normal limits, she would remain afebrile, and no abnormal drainage would be observed around the [MEDICAL CONDITION] site. -Interventions included to change the [MEDICAL CONDITION] ties and ensure secured at all times, and observe and document her respiratory rate, depth, and quality. Ensure the oxygen settings were administered as ordered, and suction her as necessary. B. Failure to ensure staff on duty was qualified and educated to respond to the emergent situation involving resident #59's [MEDICAL CONDITION]. 1. Facility Expectations The facility policy on [MEDICAL CONDITION] Management, with a revised dated of 12/05, read that there will be a licensed nurse with additional training on [MEDICAL CONDITION] care and management, or a respiratory therapist on the schedule at all times. Staff with direct care responsibilities will have undergone training in [MEDICAL CONDITION] care and management of the resident with a [MEDICAL CONDITION]. The facility policy on Spontaneous Decannulation: Reinsertion of [MEDICAL CONDITION], with a revision date of 6/08, read that decannulation is an emergency situation. The [MEDICAL CONDITION] must be reinserted quickly in order to maintain a patent airway. Staff was to activate the EMS (emergency medical system) and begin medical emergency procedures and notify the physician. Included on the resident's [MEDICAL CONDITION] care plan (see above) was a procedure for decannulation ([MEDICAL CONDITION] out of the trachea) which read to keep an extra [MEDICAL CONDITION] and obrurator (device used to assist in placement of the [MEDICAL CONDITION]) at her bedside. It further read: If the ([MEDICAL CONDITION]) tube would be coughed out, open the stoma with a hemostat. If the tube could not be reinserted, observe and document for signs of respiratory distress. If able to breathe spontaneously, elevate the HOB 45 degrees and stay with the resident. Obtain medical help immediately. 2. Facility record review a. Review of the facility's in-service records for the last six months revealed six out of 14 licensed staff scheduled in September had received in-service education on [MEDICAL CONDITION] care, suctioning, and assessment. -A 6/4/15 respiratory in-service sign in sheet that showed eight staff members were in-serviced on [MEDICAL CONDITION] care, suctioning, and assessment. Of the staff in-serviced, four were certified nurse aides (CNAs) and the others were no longer working at the facility. There was no evidence from the in-service outline that staff were in-serviced regarding the potential complications for a resident with a [MEDICAL CONDITION] or the procedure for responding to spontaneous decannulation. -A 4/8/15 respiratory in-service sign in sheet revealed 11 staff members were educated on [MEDICAL CONDITION] care, suctioning, and patient assessment. Of the 11 staff members at the in-service, seven continued to work for the facility. Four were Licensed Practical Nurses (LPNs), two were RNs, and one was a CNA. Review of the sign in sheet revealed LPN #4, #6, #3, and #5 (see interviews below) had not received the [MEDICAL CONDITION] in-service. Moreover, no evidence from the in-service outline that staff were in-serviced regarding the potential complications for a resident with a [MEDICAL CONDITION] or the procedure for responding to spontaneous decannulation. b. Further review of staff records 6/15 - 9/15 (to date) revealed that, contrary to facility policy (see above), staff not trained in [MEDICAL CONDITION] care had worked the night shift alone without RN support on the following dates: In June - 6/17, 6/18, 6/22, 6/23, 6/24, 6/28/, and 6/30/15; in July - 7/22, 7/23, 7/26, 7/27, and 7/30/15; in August - 8/5, 8/10, 8/11, 8/15, 8/16, and 8/31/15; and September - 9/1, 9/2, 9/9 and 9/10/15. Staff on the 9/15 shifts were LPN #4 and #6. 2. Staff interviews Interviews revealed licensed staff that cared for resident #59 was unaware of the procedure to be implemented if resident #59 [MEDICAL CONDITION] came out. (See procedures above) On 9/10/15 at 4:50 a.m. LPN #4 reported she had worked at the facility for one month. She stated she was assigned to care for resident #59 on this night; her shift began at 10:00 p.m. on 9/9 and continued until 9/10/15 at 6:00 a.m. and the only other licensed staff on this shift was LPN #6. She stated she and LPN #6 had worked together as the sole licensed staff on several occasions. She reported if resident #59 had spontaneous decannulation, she would clean the stoma site with normal saline and call the physician to get an order to send the resident to the emergency room . She stated she did not know if there was another [MEDICAL CONDITION] in the building; she stated there might be one in the store room. She stated she did not know how she would keep the resident's stoma patent. She reported she had not had any specialized [MEDICAL CONDITION] training and the facility had not provided her with any [MEDICAL CONDITION] training. On 9/10/15 at 6:00 a.m. LPN #6 who was working the overnight shift with LPN #4 stated, I do not know what to do if the resident's [MEDICAL CONDITION] came out. She stated she was not sure if putting a new [MEDICAL CONDITION] in would be within her scope of practice. She reported the facility had not provided her with any training regarding [MEDICAL CONDITION] care. She indicated she and LPN #4 occasionally worked as the sole licensed staff on the overnight shift. On 9/10/15 at 6:35 a.m. LPN #3 who was working the day shift stated she would apply a wet to dry dressing over the stoma and call her physician. She stated she did not know what she would do to keep the stoma patent. She reported the facility had not provided her any training regarding [MEDICAL CONDITION] care. On 9/10/15 at 7:00 a.m. LPN #5 who was working the day shift stated she would get the Registered Nurse (RN) if the resident's [MEDICAL CONDITION] came out. She reported that if a RN was not available, she would call the respiratory company and make sure the oxygen was on. She reported she would try to put a new [MEDICAL CONDITION] in, but was not sure if the [MEDICAL CONDITION] would be found in the supply room or the medication room. She reported she had training regarding [MEDICAL CONDITION] care approximately a year ago. Although she stated she did not care for resident #59 often, the potential was there for her to float on occasion which would require her to care for the resident. On 9/10/15 at 7:30 a.m. the Director of Nursing (DON) stated an extra [MEDICAL CONDITION] was kept at resident #59's bedside in case of decannulation. She stated she did expect the nursing staff to be trained and comfortable with [MEDICAL CONDITION] care and decannulation. She reported that since she started on 8/24/15, she had been working on the floor as a staff nurse and had not been able to provide the staff with any training or education. She was not aware LPN #4 and LPN #6 were untrained in [MEDICAL CONDITION] care. She stated she had not worked on the schedule since she started and reported the NHA had been making the schedule. C. Failure to provide treatment and cares as ordered and expected 1. Facility expectations [MEDICAL CONDITION] Cannula and Stoma Care, provided by the facility and printed off of the Lippincontt procedures online website on 9/9/15 by the vice president of clinical operations read, in part, that the goal of [MEDICAL CONDITION] care is to ensure airway patency by keeping the tube free from mucous buildup, to maintain mucous membrane and skin integrity, and to prevent infection. It set forth the following steps for cleaning of the stoma and outer cannula: - Perform hand hygiene - Put on clean gloves - With the dominant hand, moisten a sterile gauze pad with the sterile normal saline solution or sterile water. Squeeze out the excess liquid to prevent accidental aspiration. Then wipe the resident's neck under the [MEDICAL CONDITION] flanges and [MEDICATION NAME] tapes. - Assess the stoma site and surrounding skin for redness, swelling, and drainage, which may indicate infection. - Use a sterile, cotton-tipped applicator and a sterile gauze pad to clean the stoma site and the tube's flanges. Wipe only once with each applicator or gauze pad and then discard it to prevent contamination of a clean area with a soiled applicator or pad. - Rinse debris with one or more sterile 4 x 4 pad, apply a skin barrier, as needed. - Apply a new sterile [MEDICAL CONDITION] dressing. Resident #59's care plan, in addition to the interventions on the [MEDICAL CONDITION] care plan (see above), directed staff in the resident's potential for infection care plan to assess her breath sounds as ordered and as needed and to notify the physician of any abnormalities, to observe for signs of increased infection, such as redness, warmth, drainage, increased pain, and fever and to administer oxygen as ordered and provide site care to [MEDICAL CONDITION] and surrounding tissues as ordered. See also physician orders [REDACTED]. 2. Failures in managing resident #59's respiratory treatment and care a. Observations -On 9/9/15 at 9:00 a.m. CNA #9 was observed while providing care to the resident. She lowered the resident's head of the bed (HOB) flat, and proceeded to change the resident's bedding and provide her incontinent care. The resident did not appear to be in acute distress but audible gurgling was heard throughout the procedure and saliva was observed running down the side of her face. CNA #9 reported she always cared for the resident alone, stating, it's routine. She elevated the resident's HOB upon completion of the task and the audible gurgling improved, but was still present. The CNA left resident #59's room and moved on to provide another resident morning cares. The CNA was not observed to alert the nurse to the audible gurgling sounds heard during cares. No follow up assessment by the nurse was completed to assess her oxygenation or the need for suctioning. The oxygen tubing and drain bag was observed lying on the floor, partially under the resident's bed. -On 9/10/15 at 5:00 a.m. the resident was in bed with the HOB elevated to 45 degrees. The oxygen tubing and drain bag were observed lying on the floor. -On 9/9/15 at 10:00 a.m., LPN #1 performed [MEDICAL CONDITION] care and suctioning. She used sterile technique throughout the procedure, but she did not assess or clean around [MEDICAL CONDITION] stoma prior to applying a new dressing. -On 9/14/15 at 1:05 p.m. LPN #6 performed [MEDICAL CONDITION] care. She did use sterile technique throughout the procedure but she did not assess or clean around the [MEDICAL CONDITION] stoma prior to applying a new dressing. b. Record Review Review of resident #59's medication administration records (MAR) and treatment administration records (TAR), nurses' notes (NN) and respiratory therapy notes from 4/15 to 9/15, revealed a lack of documentation to show [MEDICAL CONDITION] care was being provided, oxygen orders were obtained and followed and the resident's respiratory status consistently assessed and monitored. April: -The 4/15 MAR and TAR did not reveal any orders in relation to the care of the [MEDICAL CONDITION]. -The 4/15 NNs revealed one note dated 4/24/15 indicating the resident's [MEDICAL CONDITION] had been suctioned. There was no documentation that [MEDICAL CONDITION] care had been provided. -On 4/28/15, a respiratory care progress note read the [MEDICAL CONDITION] was changed. Oxygen was at five liters and her lung sounds were clear but diminished bilaterally. White, semi-thick secretions were suctioned and removed. May: -The 5/15 MAR and TAR revealed changing the dressing around the [MEDICAL CONDITION] site every shift was not started until 5/15/15. - There was no documentation on the MAR or TAR to show the facility had suctioned the [MEDICAL CONDITION], changed the inner cannula, or administered oxygen. -On 5/1/15, 5:52 p.m. a NN read the resident had a fever of 101.1degrees Fahrenheit with adventitious lung sounds but baseline for the resident. She was sent to the hospital for evaluation and she was admitted with the [DIAGNOSES REDACTED]. -On 5/7/15, 1:44 p.m. a NN read the resident had returned to the facility. She was on oxygen at seven liters per minute. -The 5/15 NNs revealed documentation related to suctioning of the [MEDICAL CONDITION] but no documentation was found regarding an assessment of the [MEDICAL CONDITION] site or changing of the inner cannula. -On 5/28/15, a respiratory care progress note read the resident's [MEDICAL CONDITION] was changed. Oxygen was at five liters via [MEDICAL CONDITION] mask. Abnormal lung sounds (rhonchi) were noted in her bilateral upper lobes. [MEDICAL CONDITION] care was provided and the stoma was cleaned. June: -The 6/15 MAR and TAR revealed the [MEDICAL CONDITION] site was not cleaned and dressing change was not completed three out of 90 times from 6/1/15 to 6/30/15. There was no documentation on the MAR or TAR that staff suctioned the [MEDICAL CONDITION], changed the inner cannula, or the administered oxygen. -The 6/15 NNs revealed documentation related to suctioning of the [MEDICAL CONDITION] but no documentation was found regarding an assessment of the [MEDICAL CONDITION] site or changing of the inner cannula. -The 6/30/15 respiratory care progress note read the resident's [MEDICAL CONDITION] was changed. Oxygen was at five liters via [MEDICAL CONDITION] mask and her lung sounds were diminished in all lobes. July: The 7/15 MAR and TAR revealed the oxygen tubing was not changed one time out of four from 7/1/15 to 7/31/15, the inner cannula was not changed 11 out of 88 times from 7/2/15 to 7/31/15, suctioning of the [MEDICAL CONDITION] was not completed 11 out of 74 times from 7/7/15 to 7/31/15, and the [MEDICAL CONDITION] site was not cleaned and the dressing change was not completed 14 out of 88 times from 7/2/15 to 7/31/15. - There was no documentation was found to indicate the facility had administered oxygen. -The 7/6/15, 5:59 a.m. NN revealed resident #59 was suctioned eight times over 45 minutes. Her lung sounds were diminished and wet. She was diaphoretic and drooling. She was sent to the emergency room for an evaluation and returned to the facility on the same day. A chest x-ray revealed she had a right middle lobe infiltrate and she was placed on antibiotic therapy. -The 7/15 NN's revealed the resident had oxygen administered on multiple days at three liters rather than five as indicated in the respiratory care progress notes (see above). -The 7/22/15 microbiology report revealed a culture of the resident's trachea was completed. The culture revealed heavy growth of [DIAGNOSES REDACTED] pneumonia and positive for extended spectrum B-Lactamases (ESBL's) which was resistant to all cephalosporins and [MEDICATION NAME]. The physician was contacted on 7/26/15 and a new order was obtained to monitor for fever or [MEDICAL CONDITION]. No treatment was to be administered unless the resident became symptomatic. -The 7/28/15 respiratory care progress note read the resident's [MEDICAL CONDITION] had been changed. Abnormal lung sounds (rhonchi) were noted in her bilateral upper lobes. She was on five liters of oxygen via [MEDICAL CONDITION] mask. One to two milliliters (ml) of white, thick secretions was suctioned and removed. August: The 8/15 MAR and TAR revealed monitoring for signs and symptoms of infection was not completed four shifts out of 93 total shifts from 8/1/15 to 8/31/15, the inner cannula was not changed five out of 93 times from 8/1/15 to 8/31/15, suctioning of the [MEDICAL CONDITION] was not completed eight out of 93 times from 8/1/15 to 8/31/15, and the [MEDICAL CONDITION] site was not cleaned and dressing change was not completed five out of 93 times from 8/1/15 to 8/31/15. In addition, there was no order to administer oxygen. September: The 9/15 MAR and TAR did not indicate the facility had administered oxygen. c. Staff Interviews On 9/9/15 at 11:40 a.m. the Respiratory Therapist (RT) stated the oxygen tubing and drain bag should not have been lying on the floor as this could increase the resident's risk for infection even though it was a closed system making the risk unlikely. He stated he had educated the staff to shorten the tubing as it was 12 feet long and could be shortened to prevent the excess from lying on the floor. On 9/14/15 at 7:39 a.m. LPN #6 stated [MEDICAL CONDITION] care included cleaning the [MEDICAL CONDITION] stoma with sterile kits in the resident's room. She was not sure what was in the kit but thought it was hydrogen peroxide. She stated it was a sterile procedure to change the inner cannula which was to be completed every shift. She stated she was now aware (see interview above on 9/10/15) that there was an extra cannula on the wall in the resident's room and she would re-insert the cannula and call EMS if the [MEDICAL CONDITION] came out. She said an order would be required for the administration of oxygen.

Based on observations, record review and staff interviews, the facility failed to ensure a resident's environment remained as free of accident hazards as was possible and that adequate supervision was provided to prevent accidents for three (#2, #1, and #3) of 11 sampled residents. Specifically: -Resident #2, a resident with dementia assessed as a high fall risk, had a history of [REDACTED]. This fall resulted in a left femur fracture with hospitalization . Staff assessments of the resident's activities of daily living (ADLs) needs were inconsistent, stating the resident was a pivot transfer to needing extensive assistance (see interviews below). -Resident #1 required the use of wheelchair positioning devices to prevent falls which were not in place. -Resident #3 was improperly assessed for falls, and staff assessments of resident's ADL needs were inconsistent. The resident fell on [DATE]. -The facility failed to follow their policy relating to the Falling Star Program. -Cross-referenced with F353 (Staffing). The findings include: I. Facility Policy on Fall Management - review date of 8/2012 Review of the facility's policy in regards to fall management (in pertinent part) revealed: -Each resident was assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluated each resident's fall risks. A Plan of Care was developed and implemented, based on this evaluation, with ongoing review. -Facilities would take a proactive approach for new residents and would consider new admissions at risk for falls until the resident was reviewed by the IDT. -All residents would be assessed for fall risk quarterly, annually, and for significant change using the Fall Risk Assessment. -New admissions would be placed on the Falling Star Program until reviewed by the IDT. -The Falling Star was a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. -Visual identifiers would assist the facility staff as well as family and visitors to identify those residents that were at risk for falls, and to respond accordingly when the resident demonstrated a behavior that may be associated with an impending fall. -Placement on the Falling Star Program: newly admitted residents; residents identified at risk; IDT determination. -If resident was identified for the program, a falling star symbol would be placed on any or all of the locations below: over the bed; on assistive devices (wheelchair, walker); identification band. -When the resident was removed from the program, a nurse would remove the Falling Star Symbols from the resident's room, wheelchair, etc., and the care plan would be revised. 1. Resident #2 Resident #2, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE], indicated a BIMS (Brief Interview for Mental Status) score of 12, moderate cognitive impairment. The MDS noted the resident needed extensive assist of one person for bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS coded the resident as not steady for balance, only able to stabilize with staff assistance for moving from seated to standing position, moving on and off toilet, and surface to surface transfer. The resident was only noted as using a wheelchair for mobility. The resident was not coded as having physical behavioral symptoms directed toward others. Care Plans (in pertinent part): -Initiated 11/5/08 and revised 8/24/09. Non-compliance with safety measures related to transfers, falls, calling for assistance. Approaches: Explain why treatment/care is necessary; Notify family and enlist assistance prn; notify the physician; Offer alternative if appropriate; Encourage to keep call light within reach; is on a restorative program. -Initiated 5/22/08. Potential for injury related to seizure activity. Approach: Administer medications per the MD orders; Protect from injury during seizure episodes; Monitor labs per the MD orders; Encourage to wear soft helmet at all times when up; Educate staff on symptoms of potential seizure activity; Resident chooses to not wear helmet on occasion. -Initiated 9/21/07 and revised 9/15/10. At risk for falls related to mental status, recent fall, history of previous falls, ambulatory, balance problem/standing/walking, utilizes assistive devices (wheelchair), seizures, narcotics in use, psychotropics, resident refuses chair alarm taking and throwing away. Approaches: Falling Star program; Encourage resident to ask for assist; Ensure the resident has proper footwear; IDT referral to PT and OT as needed; Provide assistive devices (wheelchair); Wheelchair (wc) auto lock; Self releasing seat belt; Helmet related to falls/seizures; Landing strip bedside; Staff to assist the resident to the bathroom during rounds at night; Pressure alarm to the bed; Tab monitor to the wc when in wc. -Review of resident's care plans did not reveal any documentation for the use of the resident's walker, as noted in staff interviews below. Hospital History and Physical dated 2/20/15 -status [REDACTED]. Review of the 2/20/15 hospital history and physical indicated the following: -Patient was an [AGE] year old female, with known dementia, who was being transferred with assistance at her nursing facility when she fell and had a deformity of her left leg. She was brought to the emergency room and x-rays were taken which showed a periprosthetic left femur fracture below her prior DHS (Dynamic Hip Screw) fixation. She was unable to provide any history. -Past medical history included medical history of [REDACTED]. -Past surgical history included a significant for open reduction internal fixation of her left intertrochanteric femur fracture and a cervical fracture. -Her x-rays were reviewed and showed a midshaft femur fracture around the base of her long DHS plate with significant displacement. It appeared she has a malunion of a left hip intertrochanteric fracture that was treated with a DHS plate and that does appear healed on the x-ray. She was significantly osteopenic. Hospital Therapy Documentation revealed: 2/22/15: "Pt was reported to be non-ambulatory per her facility." 2/23/15: "Resident who fell with staff and sustained a femur fx (fracture)." physician progress notes [REDACTED]. -On 12/19/14, the resident had a fall in 12/13. The family member "is upset about CNAs at the facility and the way they treat her (resident)." -On 1/21/15, it was documented the resident has a history of convulsions, on Tegretol and Neurontin, with last seizure in 1/15. The resident refuses to wear her protective helmet. Her last fall was 12/13. Resident with continued functional decline related to chronic illnesses/co-morbidities contributing to her poor safety awareness and current health status. Couple this with advancing age and the resident is at risk of weight loss, recurrent falls, and generalized global decline. Assistive devices used: wheelchair. The family member "is upset about CNAs at the facility and the way they treat her (resident)." -On 2/25/15, the resident was readmitted to the facility s/p (status [REDACTED]. Resident suffered a left periprosthetic midshaft femur fracture and underwent left ORIF (open reduction internal fixation). She returned to facility on the evening of 2/24. She has been increasingly lethargic since surgery, minimally participatory in therapy, and was agitated and combative during hospitalization . -On 2/26/15 - Follow up to hospitalization for left femur fracture with ORIF s/p fall. Resident with a fall from standing on 2/20 and was sent to the hospital where she was found to have left periprosthetic midshaft femur fracture and underwent left ORIF. She is toe touch weight bearing, receiving PT at this time, but minimally participatory. Review of the current Physician order [REDACTED]. -5/31/13 Alarm: wheelchair pad alarm every shift. When in wheelchair, underseat wheelchair alarm. -1/20/15 OT (occupational therapy) evaluation and treatment for [REDACTED]. -1/22/15 OT clarification: wheelchair cushion for positioning/comfort/pressure relief. -1/22/15 OT three times a week for therapeutic exercise, neuromuscular reeducation, therapeutic activities, self care management, wheelchair management, manual therapy, group therapy for seizure precautions and lack of coordination. -2/25/15 Dressing change qd (every day) prn (as needed). -2/25/15 OT five times a week for therapeutic exercise, neuromuscular reeducation, therapeutic activities, self care management, wheelchair management, manual therapy. For high fall risk, seizure disorder, ttwb (toe touch weight bearing) to lower left extremity, immobilizer in place. -2/25/15 PT (physical therapy) five times a week for therapeutic exercise, neuromuscular reeducation, therapeutic activities, manual therapy, group therapy for ttwb to lower left extremity, immobilizer in place. The "Resident Transfer Evaluation" was completed on 1/30/15, and showed a score of four (caregiver performs less than 50% of the task, resident performs 51% or greater of the task, gait belt, transfer board). No other evaluation was noted. A "Fall Risk Evaluation" was last completed on 1/30/15, before the most recent fall. The score was 16, indicating the resident was a high risk for falls. Review of the Nurses' Notes revealed: -The 1/26/15 Nursing Daily Skilled Summary read - transfers with one person extensive assist. -The 2/18/15 nurse note read - patient is resistive to care this shift. Refused medications in the morning and at noon. -The 2/24/15 (after the recent fall) Nursing Admission Assessment indicated - Partial weight bearing. Prior level of functioning: limited assist with ADLs with eating. Extensive assist with transfers. -The 2/25/15 Nursing Daily Skilled Summary revealed: noted as extensive two person assist for transfers and bed mobility. The note read, "Total care for all adls x 1." -There was no evidence of any nurses' notes for 2/20/15, the day of the fall. There was no evidence of a late entry documentation was noted for the fall on 2/20/15. Review of the "Incident/Accident Report" for the fall on 2/20/15 revealed the following: Resident attempting to ambulate without assist in her room. fell resulting in fracture left femur. The form was not completed for "Was incident/accident witnessed?" -However, as noted in staff interviews below, staff was present for this fall with injury. Review of the SBAR (Situation, Background, Assessment, Request) Communication Form for 2/20/15 revealed: -Fall with injury. Assessment: deformity to left femur. Resident attempted to ambulate in her room without assist. Fall caused injury to left femur area. Order noted to send to ED (Emergency Department) for evaluation and treatment. Power of attorney informed of fall incident and plan to transfer to ED. -This form again failed to indicate whether staff was present, as was confirmed by staff in the interviews below. Review of the Interdisciplinary Post Fall Review dated 2/20/15 read: -Resident attempted to ambulate without assist, fell causing injury to left femur. -Conditions that may contribute: unsteady gait, history of falls. -At time of fall: socks. -MD and family notified. -Summary of Interdisciplinary Team: Assessment and neuros; Transferred to ER department for evaluation; Revise care plan with evaluation. -This form was left blank (no documentation) for if the fall was witnessed or unwitnessed, the location of resident prior to the fall, and the activity at the time of the fall. This form failed to indicate whether staff was present, as was confirmed by staff in the interviews below. Staff Interviews: The CNA involved in the fall of resident #2 was unavailable for interview during the investigation (3/2 thru 3/4/15). An interview was conducted with the Occupational Therapist (OT) on 3/3/15 at 10:21 a.m. The OT stated she had become aware of the resident's fall and had treated her on 3/2/15, but the hip was "still very painful for her. She isn't as verbal as she was." The OT stated that prior to the fall, the resident had been receiving therapy to improve self-feeding and for wheelchair positioning for safety. The OT stated that prior to the recent fall, the resident needed assistance with most of ADLs. "She was a one person assistance with her ADLs. Currently she is total or maximum assist. I think she is still a one person (assist)." An interview was conducted with the Physical Therapy Director (PTD) on 3/3/15 at 10:42 a.m. The PTD stated the resident had a history of [REDACTED]." The PTD stated due to these concerns, she also had a seat belt she could undo on her wheelchair. The PTD said the resident always needed supervision because of these concerns, and that "she had so many falls, we couldn't risk it. I think I heard she is having more seizures recently. After the fall, she was a Hoyer lift. For therapy, she is a one person extensive assist with bed mobility. Because she won't remember the toe touch, the staff should use the Hoyer anyway." The PTD also stated she was currently using a low bed for safety, and was now less active and not initiating things. "I make sure the staff is aware of what she can do, and they need to keep me informed." The PTD stated they were not sure if the resident would "bounce back yet," but that they were seeing her five times a week for therapy. An interview was conducted with a registered nurse (RN #1) on 3/3/15 at 11:25 a.m. The RN stated she did not work with resident #2 but knew her."I know before the fall she needed help, she can be combative with cares. That is a long history for her. She does have uncontrollable seizures, since she came here really. Before the fall she had fall mats. I'm not sure if she had a personal alarm or not. Since the fall, she was total care." The RN stated as the resident has become less groggy, she has been able to move a little better, and is less lethargic."She has a low bed now, and always has. It's kept in the low position. She hasn't attempted to get out of the bed. She is a Hoyer lift, total lift." The RN confirmed, "I don't think she has a fall mat because she isn't moving. If she started moving around a lot, we would reconsider that. She is more alert and isn't trying to move at all." The RN added therapy was watching the resident currently and she was total assist. "I don't think she would be a fall risk right now." An interview was conducted with RN #2 on 3/3/15 at 6:22 p.m. The RN stated resident #2 used to get around in her wheelchair and was a one person transfer. The RN stated the resident could wheel herself around. The RN added when the resident fell , she (the nurse) was in a different resident's room. The RN confirmed a nurse came and informed her, since she was the charge nurse, that the resident had fallen and broken her leg, and was going to be sent to the hospital. The RN stated the other nurse informed her that he had not been in the resident's room during the fall, but that an aide was present. The RN confirmed this occurred on the evening shift. The RN stated she knew the resident could be combative with care. The RN said she was informed that the aide had been trying to assist the resident to bed when the resident told her she could get into bed by herself. According to the RN, the aide apparently believed the resident. "It didn't go well." The RN stated the aide had worked with the resident before, but did not believe she had put the resident to bed before. The RN said she had educated the aide "about believing what residents say." The RN confirmed the resident would "have needed a pivot transfer with one person. She could stand, but she clearly couldn't do it by herself. " The RN stated the resident used a wheelchair alarm because she did like to stand. The RN also confirmed the aide assisting the resident was new. The RN stated the day shift had aides that had been at the facility awhile, but the evening shift had two new aides. The RN said the new aide had spent six days in orientation, working three days on each hallway, but only in the evenings. However, the RN stated, "Because aides can float from days to evenings, we like to train (them) on both shifts. They still generally train on both shifts, but for some reason she didn't get days." The RN stated the resident has been progressing after the fall, and was starting to ask questions. The RN said for safety precautions, "She (the resident) needs an alarm in her wheelchair, and she has a helmet for her seizures. She should have an alarm on her bed when she starts to move around more. And she is progressing at this point." An interview was conducted with LPN #3 on 3/4/15 at 8:32 a.m. The LPN stated she had heard the resident had broken her femur and had gone to the hospital. The LPN confirmed the resident had been a one person assist to be wheeled to the bathroom, pivot and sit to the toilet. "That would be pivot to the bed too. I don't recall if she was a Falling Star." An interview was conducted with the MDS employee on 3/4/15 at 9:57 a.m. The MDS employee reviewed the resident's records and confirmed on 3/4/15 at 10:23 a.m., a change of condition MDS was in process for the resident. The MDS employee confirmed, "For me, she had a fall and had a significant injury and had to repair her femur. So even though her ADLs haven't changed in the past, it was a change in condition." The MDS employee stated the MDSs were reviewed as an overall team approach with facility departments, gathered during team meetings. The MDS employee confirmed the resident "has been an extensive assist" for her ADLs since last August 2014. An interview was conducted with CNA (certified nurse aide) #2 on 3/4/15 at 11:12 a.m. The CNA stated she had worked with the resident before and after her fall. The CNA stated she would use a walker with assistance, but with ambulation she would always need help. "For the bed, we would assist her walker or push the wheelchair to the bed. Not great on her feet. We would stand her up using the gait belt and pivot to bed. She was always a pivot. The aides should know she needs to be pivoting. If an aide was new, when they come in for shift change, they should be educated. If an aide is new, they may not know everything about the residents. Once working the floor by yourself, you are expected to know the ADLs needs." The CNA stated she heard the resident had fallen with a new CNA present. "After the fall, she is in bed and refusing to eat. She is bruised. I can get her to smile. She is declining. ADLs are now extensive. I'd say two people for transferring." The CNA added that room care needs for resident #2 would be with one aide. An interview was conducted with CNA #3 on 3/4/15 at 11:49 a.m. The CNA stated the resident was able to stand with a walker and a gait belt prior to the recent fall. "She had seizures, so you wouldn't allow her to be on her feet." The CNA stated the resident would be in a standing position with the gait belt and then assisted into bed. "She was the only seizure resident I'm aware of, that I was told." An interview was conducted with the ADON on 3/4/15 at 3:46 p.m. The ADON stated the resident had fallen while a staff member was present. The ADON stated the CNA was assisting the resident to get her ready for bed. "She turned or something and the resident stood up and was incontinent and slipped in the urine. And they realized she fractured her leg and sent her to the hospital." The ADON confirmed the aide was new to the facility. The ADON said new staff go through general orientation covering falls, and that they give them two days on each hallway to shadow a staff member. "If they don't feel that it is enough, they need to come talk to me so I know what problems they may be having. I would expect them to know the ADL needs of each of the residents they are working with." The ADON stated the resident could ambulate, was impulsive, and she did not have safety awareness. The ADON added the resident would reach down to grab things, although her balance was off. The ADON stated the resident record should show this information. "She wants to do things by herself but she doesn't have the gait or balance to do (things) by herself. She had a seat belt she could put on or take off by herself. I would expect it to say she needed assistance with her ADLs. I would want in there to have her compulsivity to be on there. And that she can be combative. She would understand risk and benefits short term, but not long term. I don't know why she was a pivot transfer because I've cared for her." In relation to the recent fall, the ADON stated that "I hadn't heard that she had stated she could do it herself." 2. Resident #1, age [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment with short and long term memory impairment. The MDS indicated the resident was not steady, only able to stabilize with staff assistance for moving from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer. Care Plans (in pertinent part) -Initiated on 9/23/11 - Potential for injury. Impaired ability to self-transfer related to mental status, gait/balance, history of falls, dementia. Requires use of gait belt. Needs physical assistance of one with transfers. Approaches: place call light within reach; encourage resident to obtain assistance for transfers; IDT referral for PT, OT, Restorative, and ST as needed. -Initiated 9/23/11 - Requires staff assistance and intervention for completion of ADL needs. Requires supervision, limited assistance, extensive assistance, total care utilizing one staff member. Revised on 12/8/11, resident extensive assist with transfers, bed mobility, toileting, bathing. Approaches: gather and provide needed supplies; allow individual adequate time to complete tasks; provide cueing with tasks as needed; updated on 1/26/15 to include wheelchair positioning-wedge cushion and right lateral support. -Initiated on 9/23/11 - At risk for falls related to new admission, mental status, ambulatory, balance problem/walking, seizures, arthritis, history of fracture, lowers self to floor frequently. Approaches include: Falling Star Program; encourage resident to ask for assist; IDT referral PT and OT; provide assistive devices wheelchair as indicated and accepted; chair alarm; therapy place nonskid mat in wheelchair. A physician progress notes [REDACTED]." Current Physician order [REDACTED]. -Alarm: chair alarm every shift, when up in wheelchair (1/13/12). -Alarm: bed alarm pad every shift, when in bed. (1/13/12). -Floor mat every shift, when in bed (1/13/12). -PT to evaluate and treat for wheelchair positioning (1/5/15). -OT evaluate and treat for wheelchair positioning, dx (diagnosis): fall. DC (discontinue) PT order (1/6/15). Nurse and At Risk Meeting Notes Review of nurses' notes and At Risk Meeting Notes revealed conflicting assessment information: -The Nursing Daily Skilled Summary dated 12/20/14, read the resident was noted as a one person assist for transfers and bed mobility. -The Nursing Daily Skilled Summary dated 12/21/14, read the resident was noted as an extensive assist of one person for bed mobility and transfers. Patient did fall but is not in any pain. -An At Risk Meeting note dated 12/23/14 read the resident's last fall was 12/21/14. No injury noted. Resident was reported by staff nurse to be playing around in his room. Safety precautions were in place. No recent med changes noted. -An At Risk Meeting note dated 1/6/15 read, No more falls since 12/21/14. Continues with fall precautions. OT to evaluate and treat per 1/5/15 order. -An At Risk Meeting note dated 1/13/15. No more falls since 12/21/14. Continues with fall precautions. OT in place for wheelchair positioning. The last Fall Risk Evaluation was completed on 12/19/14, two days prior to the resident's last fall. The resident was documented as a high fall risk. An interdisciplinary post fall review dated 12/21/14, revealed the resident had a fall at 9:30 a.m. "Pt (patient) was playing around in his room. Pt was on the floor. Pt had slid out of his chair because he was playing with something on the dresser. Pt was dry and not wet. Chair alarm was in place." No Fall Risk Assessment was found in resident's chart before or after the fall on 12/21/14. The incident report for the 12/21/14 fall read, the patient was on the floor next to his wheelchair by the bed. Patient alarm was working - was alarming. Patient did not seem to be in any pain. Patient was dry and clean. Family and doctor notified. Occupational Therapy Assessment Notes: -On 1/6/15 - "Patient referred for OT evaluation and treatment for [REDACTED]. -Missing side panel to wheelchair and no cushion on superhemi/pediatric wheelchair. Will order special cushion for chair and add lateral support for fall prevention. Patient tends to sit on very edge of wheelchair seat which may lead to fall." Observations: On 3/2/15 at 4:50 p.m., the lateral cushion for the resident's wheelchair was observed lying across a bedroom chair. The lateral cushion was not found in the resident's wheelchair as per physician's orders [REDACTED]. On 3/3/15 at 8:40 a.m., the resident was observed sitting in his wheelchair in the common area on the West hallway. The bottom cushion in the resident's wheelchair was observed in place. The lateral cushion was not in the wheelchair. The lateral cushion was found in the resident's room. On 3/4/15 at 8:10 a.m., the resident was observed again sitting in his wheelchair on the West hall common area. The bottom cushion was observed in the resident's wheelchair, but the lateral support cushion was not. On 3/4/15 at 12:50 p.m., the lateral support cushion was observed in the resident's wheelchair. Staff Interviews An interview was conducted with the OT on 3/3/15 at 10:21 a.m. The OT stated the resident was recently seen for wheelchair positioning. The OT stated they had ended up "getting a wedge cushion because he ends up sitting on the edge of the chair, even when they try to talk to him." The OT said they wanted to keep the resident from sliding out. The OT also confirmed, "We had a lateral side piece where a piece on the side of the wheelchair was missing. We just didn't want him getting his hand caught down the side." The OT stated the resident was observed for two weeks to ensure that "all the pieces are in place." The OT said the resident had shown definite improvement in wheelchair positioning. An interview was conducted with LPN #3 on 3/4/15 at 8:32 a.m. The LPN stated the resident needed one person full assist for all of his ADLs. "He can stand but he needs help. He has poor gait." The LPN confirmed the resident had a tab alarm on his wheelchair and he also had an alarm on his bed. An interview was conducted with CNA #2 on 3/4/15 at 11:12 a.m. The CNA stated the ADLs for the resident were "extensive assist for everything, dressing, transferring, eating. He uses a walker for restorative services and I get him to use it for changing. He can stand for that." The CNA stated the resident had an alarm on his wheelchair, a floor mat, and believed he had a side cushion in his wheelchair, and another one to sit on. "I think the lateral support is on the right side and it should just stay in his wheelchair. I think it has been taken out. They take it out at night for cleaning. I would expect them to both be in there during the day." An interview was conducted on 3/4/15 at 12:05 p.m. with a restorative (CNA #4). The CNA stated the resident wiggled a lot in his wheelchair, and would get agitated. "We have an alarm. It will go off when he stands up a lot. Sometimes he will use the walker." The CNA said the resident would scoot forward and backwards in the wheelchair and that a cushion had been placed in the wheelchair for him to sit on. The CNA stated that she was not sure about the resident's lateral support, but knew that it had been tight when placed into the wheelchair. "I don't know who took it out. It's not good. I thought I heard someone mention it to therapy and I think that is why they took it out. I would expect them to fix it. There is an opening on the right side of his arm chair." An interview was conducted with the ADON on 3/4/15 at 3:46 p.m. The ADON stated the resident used a wheelchair alarm, a bed alarm, and a low bed. The ADON said the resident was able to ambulate and restorative assisted the resident to ambulate with a walker. The ADON stated she saw him in his wheelchair, but was not aware of any recent wheelchair issues for the resident. When the ADON was informed about wheelchair cushions for positioning, she stated she was not aware. 3. Resident #3, age [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 14 day MDS completed on 2/4/15, indicated a BIM score of 15 which indicated no cognitive impairment. The resident was noted to need extensive assist of two people for bed mobility. The resident was documented as needing extensive assist of one for transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. For balance, the resident was noted as not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking with assistive device if used, turning around, moving on and off toilet, and surface to surface transfer. The resident was noted to be using a walker for mobility only. Care Plans (in pertinent part): -Initiated on 2/5/15. Potential for injury or complications related to seizure disorder. Interventions: administer medications as ordered; labs as ordered; provide safe environment; PT, OT, Eval and treat prn; encourage to call for assistance with transfer. -Initiated 1/26/15. Resident at risk for falls as evidenced by cognitive impairment. Approaches: encourage resident to ask for assistance of staff; ensure call light is in reach, answer promptly; therapy to eval and treat per orders; anticipate needs, provide prompt assistance; assure lighting is adequate and areas are free of clutter; encourage socialization and activity attendance-as tolerated; Falling Star Program. -Initiated on 1/26/15. Residents ADL functions: Extensive assist for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Approaches: assist with adls as needed; assist with transfer as needed; assist with repositioning as appropriate; wheelchair and four wheel walker for mobility. A 1/16/15 Hospital Referral form noted, "Fall/right hip pain." Referred to Skilled Care. A History and Physical dated 1/14/15, noted a new seizure disorder diagnosed ,[DATE]. "The patient is not able to give much of a history specifically, because of some underlying dementia, but she says he