Every finding on record at Lemay Avenue Health and Rehab LLC

Based on record review and interviews, the facility failed to ensure two (#5 and #15) of four residents reviewed for accidents hazards received adequate supervision out of 16 sample residents. Resident #5 was admitted on [DATE]. Resident #5 required partial assistance from staff to transfer from surface to surface. In December 2025 Resident #5 was presenting with increased anxiety; yelling out; requests to use the bathroom and attempting to self transfer herself to get to the bathroom without staff assistance. Resident #5 fell on 2/4/26 while attempting to self transfer to use the bathroom. The facility failed to address the resident's impulsiveness to attempt to self transfer to use the bathroom. On 2/16/26, Resident #5 fell again and hit her head during an attempt to self transfer to use the bathroom. During this fall, the resident sustained a laceration above her left eye and a brain injury. The resident had a significant change in cognitive status following the fall. Resident #15 was admitted on [DATE] with diagnoses of dementia and severe cognitive impairment. On 4/9/26 and 5/20/26 Resident #15 sustained unwitnessed falls. The facility did not review or update the resident's care plan with new person-centered interventions. On 5/26/26, six days after her last fall, Resident #15 had another unwitnessed fall, resulting in a fracture to her right elbow. Specifically the facility failed to:-Prevent repeated falls resulting in significant injuries for Resident #5 and Resident #15; -Develop and implement person-centered fall care plans to prevent falls for Resident #5 and Resident #15; and,-Ensure all nursing staff were fully trained, understood and were following the facility's fall protocols, including following the purposeful rounding program and the resident person-centered fall prevention care plans for Resident #5 and Resident #15.Findings include:I. Facility policy and procedure The Fall Prevention policy, implemented 4/11/25, was provided by the nursing home administrator (NHA) 6/1/26 at 5:27 p.m. It read in pertinent part, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standardized risk assessment for determining a residents fall risk. A fall risk assessment is completed every 90 days and as indicated when the resident's condition changes. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed.The Purposeful Rounding Program document was provided by the NHA on 5/27/26 at 3:55 p.m. It read in pertinent part, Residents placed on the purposeful rounding program may be at higher fall risk, a new admission, have difficulty communicating needs, experiencing a decline, or attempting to anticipate needs. The four P's of the purposeful rounding program include possessions, positioning, personal needs and pain. Staff are to round routinely to meet the resident needs to prevent falls and other injuries by anticipating their needs. II. Resident #5A. Resident statusResident #5 age greater than 85, was admitted on [DATE]. According to the June 2026 computerized physicians orders (CPO), diagnoses included hemiplegia (paralysis) and hemiparesis (partial weakness) following cerebrovascular (stroke) disease affecting the left side, anxiety, overactive bladder, and cognitive communication deficit. According to the 1/28/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed partial to moderate assistance to perform toileting tasks where the staff lifted, held and supported the resident's trunk or limbs. The assessment documented the resident had a history of one fall with injury while residing in the facility.According to the 2/19/26 MDS assessment, the resident had severe cognitive impairments with a BIMS of three out of 15 with disorganized thinking (unclear or illogical flow of ideas). The resident was dependent on staff to perform transfer and toileting tasks. The assessment documented the resident had not sustained any falls while residing in the facility. -However, Resident #5 sustained a fall with major injury on 2/16/26. According to the 5/13/26 MDS assessment, the resident had severe cognitive impairments with a BIMS of two out of 15 with fluctuating disorganized thinking, incoherent rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching from subject to subject. The resident was dependent on staff to perform transfer and toileting tasks. The assessment documented the resident had not sustained any falls while residing in the facility. -However, Resident #5 sustained a fall with major injury on 2/16/26.B. Record review The fall prevention care plan, initiated 11/18/25 and revised 2/3/26, revealed Resident #5 had the potential for falls related to advanced age, disease process, history of a stroke and a history of falls with the goal of minimizing falls through interventions. The care plan documented the resident refused to wear grippy socks. Pertinent interventions included providing a one-to-one sitter provided by family as much as possible (initiated 2/24/26); anticipating and meeting the resident's needs; keeping frequently used items within reach; placing the resident's bed against the wall; placing the resident's bed in low position; placing a bolster sheet to bed; educating, encouraging and assisting the resident to wear appropriate footwear such as non-skid socks or shoes when ambulating and mobilizing; encouraging the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility; encouraging utilization of common areas for supervision; placing a fall mat at bedside when resident was in bed; orienting the resident to call light and keeping the resident's call light within reach and encouraging the resident to use it for assistance as needed. -Review of the resident's fall care plan did not reveal the facility reviewed the resident's care plan after she fell on 2/4/26 to ensure the fall interventions remained appropriate. The nursing note, dated 12/26/25, documented Resident #5 had been calling out more at night for assistance rather than using her call light. The note documented the call light was clipped to the blanket and was within the resident's reach.The nursing note, dated 12/29/25, documented the resident was added to the purposeful rounding protocol related to increased anxiety, calling out and falling out of bed. -However, review of the resident's fall care plan did not include purposeful rounding as an intervention. The nursing note, dated 12/30/25, documented Resident #5 was on follow-up monitoring post-fall. The interdisciplinary team (IDT) note, dated 1/30/26, documented the staff were to monitor the resident for signs and symptoms, such as loud crying and calling out in the hall along with impatience, perseverance and attention seeking behaviors because the resident had continued calling out and tearfulness. The nursing note, dated 2/4/26, documented Resident #5 fell and hit her head on the bedside table. The resident told staff she was trying to get to the bathroom. The IDT note, dated 2/9/26, documented the staff were monitoring the resident for increased anxiety with symptoms, such as loudly crying and calling out in the hall along with impatience, preservation, and attention seeking behaviors. The IDT discussed asking the physician to assess the resident and her medications. The resident also had an increase in urge to use the bathroom this past weekend. The note documented the IDT would continue to monitor for behaviors. The IDT weekly fall note, dated 2/11/26, documented Resident #5 had an unwitnessed fall on 2/4/26 at 5:00 p.m. The resident was observed on the floor under her bedside table. The resident said she was trying to go to the bathroom and said she hit her head during the fall. No injury was noted to her head or body. The resident did not use the call light prior to self transfering to use the bathroom. The IDT weekly fall note documented the interventions included placing the bed against wall to decrease obstacles without limiting mobility and in low locked position; items of frequent use including call light kept within reach; proper footwear encouraged; implementation of the purposeful rounding program; a personalized toileting program, and use of a personal care provider arranged by the family. The resident was not compliant with the latest new interventions, including using the call light for assistance with transfer. The fall note, dated 2/16/26, documented the resident fell due to a self transfer attempt to use the bathroom. The resident sustained a laceration above her left eye. The resident's physician was in the facility and requested the resident be transferred to the hospital emergency room for evaluation. The post-fall investigation, dated 2/16/26, revealed certified nurse aide (CNA) #3 entered Resident #5's room to assist her to get up out of bed so she could eat her breakfast. The resident was not assisted or offered toileting assistance. After assisting the resident into her wheelchair and setting up the meal for the resident, CNA #3 left to assist another resident next door at 8:35 a.m. CNA #3 said she noticed Resident #5's call light on and returned to Resident #5's room approximately 15 minutes after leaving her to eat breakfast. CNA #3 entered the room and observed Resident #5 lying on her left side on the bathroom floor. The resident's head was in the shower area and her feet were next to the toilet. The investigation documented that the nurse assessed the resident and notified the resident's physician of the fall and the assessed injuries. The investigation documented that the resident had a laceration that needed sutures. The resident was sent to the emergency room for evaluation and treatment. The investigation documented that Resident #5 had used her call light to call for staff assistance, but attempted a self transfer to get to the bathroom before staff arrived to assist her with using the bathroom. -CNA #3 failed to assist Resident #5 to the bathroom upon getting her up that morning before transferring the resident into her wheelchair to eat breakfast (see CNA #3's interview below).The hospital documentation included computed tomography (CT - imaging scan) results, dated 2/16/26, which revealed that Resident #5 sustained a new multicompartment intracranial hemorrhage, including subarachnoid (bleeding in multiple spaces within the skull); with hemorrhaging (bleeding) along the bilateral frontal lobes and left frontal lobe of the brain. Additional findings included a hemorrhagic contusion, and intraventricular hemorrhage in the lateral and third ventricles. A right temporal convexity subdural hemorrhage (localized bleeding), measuring up to nine milliliters (mm) in thickness. There was no evidence of acute vascular injury (a tear in the veins of the brain).The fall risk evaluation note, dated 2/18/26, revealed Resident #5 had three or more falls in the past three months while residing in the facility, had intermittent confusion, was chair bound and incontinent. The psychiatric follow up note, dated 4/7/26, documented the resident was alert in bed being cared for by a hospice aide. Staff reported that the resident continued to yell out throughout the day except when receiving Ativan (anti-anxiety medication).C. Staff interviewsCNA #3 was interviewed on 5/28/26 at 2:20 p.m. CNA #3 said she was assigned to care for Resident #5 on 2/16/26, the day she sustained a fall. CNA #3 said on 2/16/26, shortly after 8:00 a.m. she assisted Resident #5 to put on her socks and shoes and transfer from her bed to a chair for breakfast. CNA #3 said Resident #5 was completely alert and oriented at the time and was able to make needs known, so CNA #3 did not offer to assist the resident to the restroom or suggest that she go prior to breakfast. -However, the 2/11/26 IDT progress note documented the resident was on a personalized toileting schedule.CNA #3 said after setting the resident up for the meal, she left the room to assist other residents. She said within 10 minutes of leaving Resident #5's room, CNA #3 noticed Resident #5's call light on and heard Resident #5 yelling for help. CNA #3 responded to the resident's call and found the resident on the floor in the bathroom with her head on the shower floor with visible blood observed. CNA #3 said Resident #5 was known to call a lot to use the bathroom.CNA #3 said she did not know Resident #5 was on a personalized toileting schedule the day that she fell (2/16/26). CNA #3 said she was not familiar with how the purposeful rounding program worked, but defined the program as requiring staff to perform rounds every two hours to check on the residents for unmet needs. CNA #3 said that was the standard level of care for all residents. CNA #3 did not know of any other rounding expectations for Resident #5. CNA #3 said she was provided a resident information sheet at the beginning of each shift that documented the care needs of each resident she was assigned to care for. She said the sheet was not always updated timely when a resident had a change in condition. CNA #3 said she did not know who was responsible for updating the assignment sheetRegistered nurse (RN) #3 was interviewed on 5/28/26 at 9:45a.m. RN #3 said she had never heard of the purposeful rounding program. CNA #4 was interviewed on 6/1/26 at 1:33 p.m. CNA #4 said he had never heard of the purposeful rounding program or a personalized toileting program but the CNAs were expected to conduct rounds checking on residents every two hours. CNA #4 said each resident should be offered toileting assistance when getting them up in the morning and before and after meals and every two hours.Licensed practical nurse (LPN) #2 was interviewed on 6/1/26 at 3:00 p.m. LPN #2 said the purposeful rounding program was an hourly rounding for those residents who were identified as being on the program. She said there was no standard rounding protocol for those who were not on the program. The director of nursing (DON) and the corporate nurse consultant were interviewed together on 6/1/26 at 6:00 p.m. The DON and the corporate nurse consultant said they were unable to describe the personalized toileting program that was initiated for Resident #5 by the IDT. -However, implementation of a personalized toileting program was listed as an intervention in an IDT note dated 2/11/26. III. Resident #15A. Resident statusResident #15 age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included Alzheimer's disease, contracture to her right hand and fingers, history of falls and weakness.According to the 3/30/26 MDS assessment, the resident had poor short and long term memory recall, poor decision making skills and disorganized thinking with incoherent rambling, irrelevant conversation, unclear or illogical flow of ideas per staff assessment. The assessment documented the resident had difficulty focusing attention and was easily distractible. The assessment documented the resident was able to walk at least 150 feet in a corridor with staff supervision and occasional touching assistance and/or verbal cues in order to stabilize herself. The assessment documented the resident did not have any falls in the facility.B. Record reviewThe fall prevention care plan, initiated and revised 11/25/25, revealed Resident #15 had a history of falls. Pertinent interventions included ensuring lighting was adequate; maintaining a clutter free environment; ensuring the call light was within reach and encouraging use; ensuring items were within reach;providing assistive devices as needed; and, reviewing information on past falls and attempting to determine the cause of falls as indicated.A post-fall investigation, dated 4/9/26, documented Resident #15 had an unwitnessed fall in another resident's room. The resident was lying on her back in between the recliner and sink. The note documented the resident said she did not hit her head. The resident was assessed and then lifted into a recliner with the mechanical lift. The note documented that range of motion in both the resident's upper and lower extremities were within normal limits. The resident complained of some tenderness to the right ribs. A post-fall report, dated 5/20/26 at 3:15 p.m., documented Resident #15 was found by a CNA, sitting on the floor next to her bed. The staff asked the resident if she was trying to sit on the edge of the bed and missed and the resident said yes. The note documented vital signs and neurological checks were taken and within normal limits. The report revealed poor lighting, confusion and walking without assistance were determined to be factors of the fall.A post-fall report, dated 5/26/26 at 11:30 a.m., documented a CNA on duty found Resident #15 lying face down on the floor in her room. The resident was last seen walking around her room without an assistive device before falling. After the fall, the resident was observed with one shoe on and the other foot had three socks on. The resident was known to put on and take off multiple clothing items throughout the day. The resident was assessed for injury. The assessment revealed swelling to the right elbow. The resident was experiencing pain and was unable to fully extend the right elbow. The investigation revealed that confusion, wandering, poor safety awareness and improper footwear were determined to be factors of the fall. The resident was sent to the hospital for evaluation and treatment.The nursing note, dated 5/26/26, documented Resident #15 returned to the facility from the emergency room with discharge paperwork that revealed Resident #15 had a closed displaced elbow fracture. The note documented a sling was in place.The IDT note, dated 5/27/26, documented Resident #15 was sent to the emergency department on 5/26/26 for imaging and workup. Resident #15 returned with a diagnosis of a right elbow fracture. The IDT note documented Resident #15 was impulsive and required stand-by assist when not using an assistive device. Resident #15 ambulated frequently and was on the purposeful rounding program since she did not call or use her call light to use the bathroom very often. C. Observations During a continuous observation on 5/27/26, beginning at 11:22 a.m. and ending at approximately 11:40 a.m., the following was observed:Resident #15 was sitting in a chair in the dining room while a volunteer was reading to her. The resident's right arm was splinted and immobilized in a sling. Once that activity was over, Resident #15 stood up from her chair unaccompanied, took a few steps and stopped. She began to slowly bend over at the waist and attempted to pick something up off the floor that was not there. She remained in that position for a few seconds and then slowly straightened back up and began walking herself to her room with a slow shuffling gait. There were staff members present in the dining room.-However, the staff members did not provide touch or verbal cuing assistance for safety as the resident bent over to the floor as was care planned (see care plan above). D. Resident's representative interviewResident #15's representative was interviewed on 5/28/26 at 12:08 p.m. The representative said to her knowledge, there were no changes in care or modifications made to Resident #15's care plan to prevent future falls.E. Staff interviewsRN #5 and RN #4 were interviewed together on 5/27/26 at 2:00 p.m. RN #5 and RN #4 said they were familiar with the purposeful rounding program. RN #5 said Resident #15 fell on 5/26/26 and broke her elbow, but she was not aware that the resident had a fall on 5/20/26. RN #5 said Resident #15 was very mobile and confused, so a fall mat was contraindicated as it would pose a tripping hazard. RN #5 said she was not aware of other interventions other than implementation of the purposeful rounding program for fall prevention for Resident #15. The assistant director of nursing (ADON) was interviewed on 6/1/26 at 6:00 p.m. The ADON said when in place, the purposeful rounding program directed the CNAs to monitor residents on the program every hour. The ADON said the residents who were placed on the purposeful rounding program were highlighted on the resident information sheet.The ADON said Resident #15 was placed on the purposeful rounding program, but even if staff checked on her more frequently, she could still fall in between checks. The ADON said staff checked on Resident #15 more often than every hour and for the most part, staff knew where the resident was throughout the day.

Based on record review and interviews, the facility failed to provide medications as ordered for one (#1) of three residents of 16 sampled residents.Specifically, the facility failed to have a physician's ordered medications available at the facility to administer to Resident #1.Findings include:I. Professional referenceAccording to the National Library of Medicine, Medline Plus, Valacyclovir, dated 2026, retrieved on [DATE] from https://medlineplus.gov/druginfo/meds/a695010.html Valacyclovir is used to treat certain viral infections including varicella infections including herpes zoster (shingles) and chicken pox. It is in a class of medications called antivirals. It works by stopping the spread of the herpes virus in the body.According to Skinlight, Shingles (Zoster), last revised [DATE], retrieved on [DATE] from https://skinsight.com/skin-conditions/zoster-shingles/?Imiw9cApl=1 Oral antiviral medication such as valacyclovir may help if given within 72 hours after shingles lesions first appear. These medicines do not cure shingles, but they can decrease the amount of time you have pain and a rash. Antiviral medications may also decrease your chance of getting posherpetic neuralgia and may decrease your risk of developing visual problems if you have shingles on the face.According to the Centers for Disease Control and Prevention (CDC), Pink Eye is Treatable, dated [DATE], retrieved on [DATE] from https://www.cdc.gov/conjunctivitis/treatment/index.html Epidemic Keratoconjunctivitis (EKC) is caused by adenoviruses and is highly contagious. EKC can spread by direct contact with an infected person and has been associated with equipment used during eye exams. EKG causes severe inflammation of the conjunctiva and cornea and can result in vision loss. A doctor can prescribe antiviral medication to treat more serious forms of pink eye (like infection caused by herpes simplex virus or varicella-zoster virus). Antibiotics will not improve viral pink eye; these drugs are not effective against viruses.II. Facility policy and procedure The Pharmacy policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 6:33 p.m. It read in pertinent part, It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.III. Resident #1 A. Resident statusResident #1, age greater than age [AGE], was admitted on [DATE] and expired on [DATE]. According to the computerized physician orders (CPO) diagnosis included impaired visual function, diabetes, hypertension and heart failure.According to the minimum data set (MDS) assessment, dated [DATE], the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required minimal assistance with activities of daily living. The resident's vision was impaired and he had corrective lenses.B. Record reviewReview of the [DATE] CPO revealed the following physician's order: Valacyclovir HCL oral tablet 500 milligrams (mg). Give one tablet by mouth three times a day for exposure to keratoconjunctivitis (a highly contagious viral infection that causes severe inflammation and sometimes vision-threatening corneal scarring), ordered [DATE].Review of the resident's electronic medical record (EMR) and progress notes revealed the prescribed valacyclovir antiviral medication was not administered because the pharmacy would not supply the medication due to no insurance coverage.The eye care visit note, dated [DATE], documented the assessment revealed keratoconjunctivitis to both eyes and keratitis (inflammation of the cornea) in both eyes. The note documented valacyclovir 500 mg capsule by mouth three times a day, doxycycline (antibiotic medication) 100 mg by mouth two times a day, moxifloxacin 0.5% eye drops, instill one drop in both eyes four times a day and tobramycin 0.3% eye drops, instill one drop in both eyes four times a day were ordered. The note documented to replace the bandage contact lens (a specialized, high-oxygen-transmissible contact lens placed over the cornea to protect the eye, relieve severe pain from exposed nerve endings, to accelerate the healing of the corneal surface), and replace once a month for long-term care therapy to provide comfort measures for hospice status.The nursing progress note, dated [DATE], documented the resident returned from an eye physician appointment with orders for doxycycline 100 mg twice per day and valacyclovir 500 mg three times a day for exposure to keratoconjunctivitis to the right eye. The note documented the nurse would follow up with the eye doctor tomorrow for an end date. The nursing progress note, dated [DATE], documented the hospice provider called back and said hospice did not cover the cost of the resident's prescribed eye medications. The nursing note, dated [DATE], documented the facility called the physician again as eye medication and valacyclovir were ordered and did not have a stop date. -Review of Resident #1's electronic medical record (EMR) did not reveal documentation indicating the eye doctor was informed that the resident was not receiving valacyclovir. On [DATE] a fax was sent to the eye doctor which documented all orders above were open ended. The fax documented if hospice did not cover the medications, the doctor needed to discontinue the medications.-There was no documentation that the facility made attempts to consult with the facility's medical director or the resident's primary care physician for alternative medication treatment when they could not get ahold of the resident's eye doctor.IV. Staff interviewsThe assistant director of nursing (ADON) and the chief nursing officer were interviewed on [DATE] at 6:40 p.m. The chief nurse office said they had issues with their pharmacy due to poor communication and they had to change pharmacy providers as a result of the communication issues. The ADON said Resident #1's community eye doctor had prescribed a series of medications to treat his eye infection and the resident's insurance would not cover the medication nor would the hospice provider. The ADON said they tried to get the resident's wife to pay for the medications after discovery of non coverage. The ADON said the wife agreed to the pay for the medications after several conversations.The ADON said the resident was started on all of the medications ordered by the eye doctor except for the valacyclovir. The ADON said the family had provided the other medications ordered by the eye doctor. The ADON said the valacyclovir was not covered by insurance and did not have an end date. The ADON said the main reason why the facility did not get the medication started was because it did not have an end date on the prescription.The ADON said nursing staff tried to contact the resident's eye doctor for other options for covered medication, but did not get a call back. The ADON said they did not consult with the facility's medical director for an alternative covered medication or make any attempts to have the facility purchase the medication so the resident could begin treatment for his diagnosed eye infection.The chief nursing officer said they took this issue to the quality assurance performance improvement (QAPI) committee. The chief nursing officer said the outcome was to change pharmacy providers, have the new pharmacy provide an increase in the amount of the types of medication available in the emergency back up mediation kit. The chief nursing officer said the new pharmacy assisted to train the nursing staff on the emergency back up medicine kit.V. Facility QAPI action planThe QAPI action plan, dated [DATE], documented the following:Identified concern: prescribed medications not available for administration over several doses, timed administration. Medication error: mediation not available from the pharmacy due to pharmacy transition, hospice policy and poor communication.Corrective actions taken on [DATE]: The facility DON or staff development coordinator (SDC) was to verify that the pharmacy received the mediation orders.Pharmacy to communicate availability of the prescribed medications. Audit the compliance of the administration records to ensure compliance with pharmacy services in relation to timely medication administration. Identify all affected residents and correct. Re-educate nursing staff on pharmacy and medication administration. Nursing leadership to audit medication administration practices for three months -The QAPI action plan failed to address management of how the facility will ensure timely administration of prescribed medications. as ordered, when the resident insurance did not cover the cost of the resident medication and how to proceed when the physician ordered medicine with no date. -The QAPI action plan failed to address how to proceed with timely medication administration when there were questions about the ordered medication and the prescribing physician failed to respond to facility communication attempts. There was no plan on how the medical director or other designated physician would get involved particularly in cases where the diagnosed condition was indicative of a need to start medications sooner than later for the best success in treatment outcome.

Based on record review and interviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTI) for one (#16) of four residents out of 16 sample residents.Specifically, the facility failed to prevent recurring UTIs for Resident #16.Findings include:I. Facility policy and procedureThe Incontinence policy, revised 12/1/25, was provided by the regional vice president of operations on 6/1/26 at 6:00 p.m. It read in pertinent part, Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.The Infection Prevention and Control Program policy, revised 12/1/25, was provided by the regional vice president of operations on 6/1/26 at 6:00 p.m. It read in pertinent part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.II. Resident #16A. Resident statusResident #16, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), the diagnoses included urinary tract infection (UTI), sepsis due to Escherichia coli (E. coli), hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non-dominant side and type 2 diabetes mellitus.The 3/11/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. The 4/4/26 MDS assessment revealed the resident required substantial/maximal assistance with showering and dressing, and required partial/moderate assistance with toileting, personal hygiene and ambulating. The assessment documented the resident had an active diagnosis of a UTI in the seven day assessment period and in the past 30 days. The resident was taking antibiotics with indication (diagnosis of an infection).B. Resident interviewResident #16 was interviewed on 5/27/26 at 10:30 a.m. Resident #16 said she had been having frequent UTIs, but she did not know why. She said there had been times when she was incontinent and had to wait for nursing staff to change her, and she said it made her feel bad to sit in wet clothes.C. Resident #16's representative interviewResident #16's representative was interviewed on 5/26/26 at 12:30 p.m. The representative said the resident complained of UTI symptoms for two weeks without receiving treatment before it turned into sepsis. He said he told nursing staff about her complaints, but all they did was encourage the resident to drink extra fluids. The representative said the staff were not regularly checking the resident for incontinent care needs, and there was a time the staff pushed his mother in her wheelchair to him with feces running up her back. He said he could smell the feces as soon as the resident got close and he had to tell the staff that she needed to be cleaned up and changed. Resident #16's representative was interviewed again on 5/28/26 at 10:30 a.m. The representative said the resident has had recurring UTIs since October 2025 while residing in the facility, but she had not had recurring UTIs previous to that time.D. Record reviewReview of Resident #16's May 2026 CPO revealed the following physician's orders:Macrodantin (nitrofurantoin macrocrystal) oral capsule 50 milligram (mg). Give 50 milligram (mg) by mouth four times a day for UTI for three days, ordered 4/3/26 and discontinued 4/6/26.Sepsis screening every shift. If two or more of the following are true, notify the provider: 1) Temperature greater than 100 degrees fahrenheit (F); 2) Pulse greater than 100 beats per minute (bpm); 3) Systolic blood pressure less than 100 millimeters of mercury (mmHg) or greater than 40 mmHg from baseline; 4) Respiration rate greater than 20 or oxygen saturation (SpO2) greater than 90 percent (%); or, 5) Altered Mental Status. Every shift encourage fluids and monitor for nausea and vomiting, ordered 4/4/26.May obtain urinalysis (UA) (and culture if indicated) as needed for dysuria (painful urination) and/or fever, ordered 4/10/26.Review of Resident #16's progress notes revealed the following documentation:On 4/1/26 at 12:48 p.m. a nurse's note documented the resident's representative visited that morning. The representative voiced concerns of Resident #16 complaining of abdominal discomfort and requesting for a UA. Alert charting was opened to monitor for signs/symptoms of UTI, the physician was notified and the physician planned to see the resident on this date.On 4/2/26 at 6:50 a.m. a nurse's note documented the resident's representative visited on 4/1/26 in the morning with an additional follow-up phone call in the afternoon. The family representative had concerns related to a possible UTI and the resident's toileting schedule. All concerns were addressed, the physician was notified and orders were in place to obtain a UA.On 4/4/26 at 6:53 p.m. a nurse's note documented an UA was obtained via clean catch on 4/2/26. The urine culture revealed 80,000 E. Coli and 80,000 Aerococcus urinae (A. urinae). The resident was currently on Macrobid 50 mg four times a day for three days for UTI. The resident was currently on contact isolation related to vomiting. The resident was started on the sepsis protocol on this date. The note documented the resident's vital signs were stable. The resident continued to report dysuria (pain when urinating).On 4/4/26 at 6:50 p.m. a nurse's note documented the resident's representative was at the nursing desk voicing concern of the resident having a UTI and vomiting. The representative requested the resident be sent to the hospital for further evaluation and treatment.Resident #16's 4/7/26 urine culture result revealed 10,000 to 50,000 colonies/milliliter (ml) of E. coli and greater 100,000 colony-forming units per milliliter (cfu/ml) of A. urinae.Resident #16's 4/10/26 hospital discharge summary said the resident was treated for severe sepsis due to a UTI with extended-spectrum beta-lactamases (ESBL - a strain of bacteria resistant to most common antibiotics) and E. coli.Review of Resident #16's bowel and bladder care plan, initiated 3/16/26, revealed the resident was at risk for complications related to bowel and bladder incontinence. Pertinent interventions, initiated 3/16/26, included to clean the perineal (groin) area with each incontinence episode; encourage fluids during the day to promote prompted voiding responses; ensure the resident had an unobstructed path to the bathroom; incontinence products per resident information sheet (RIS); limit fluids two to three hours prior to bedtime; monitor and document intake and output as per facility policy; monitor fluid intake to determine if natural diuretics such as coffee, tea, or cola were contributing to increased urination and incontinence; monitor/document for signs/symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating pattern; and, monitor/document/report as needed any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke and/or medication side effects.-However, the facility failed to identify person-centered interventions to prevent recurring UTIs.Review of Resident #16's grievances, provided by the regional vice president of operations on 5/28/26 at 8:30 a.m., revealed that on 3/25/26 the resident's family representative filed a grievance which stated he had concerns that Resident #16's every two hour checking and changing toileting program was not being followed. On 4/3/26 the resident's family representative filed a grievance, which stated Resident #16 had been in the activity room before she was assisted in her wheelchair to the dining room sitting in urine and fecal matter. The grievance form indicated the family representative was concerned that nursing staff were unaware of the two hour checks, and he wanted the two hour checks in place due to the resident's history of frequent UTIs. The grievance form documented the following resolution: Two hour checks/purposeful rounding program was on Resident #16's resident information sheet at the time of the concern.-However, the facility failed to make sure that all nursing staff were all aware of the purposeful rounding program protocol (see interviews below).Review of 4/8/26 care conference meeting notes revealed the resident had a history of UTIs and the family was concerned regarding the two hour checks. The notes indicated that cranberry supplement was removed from the formulary several months ago.The 5/11/26 purposeful rounding program documentation revealed nine nursing staff members received the following education: Risks and red flags: UTIs have increased over the last month, with many residents growing E. coli in urine cultures. This is often due to issues with perineal care. UTIs can be fatal for residents, and it is the staff's responsibility to prevent them whenever possible: assist with fluid intake - goal is 1200 milliliter (ml) minimum daily; toilet often and assist with thoroughly good hygiene - wipe front to back; assist with thorough perineal care as needed - ensure the resident and linens were completely clean; change briefs as soon as possible when wet or soiled - follow toileting program; and, cleanse the catheter tubing at least twice daily, preferably once per shift minimum unless the resident had requested to not be disturbed at night and with each bowel movement of incontinent episode. Teaching and training: Proper perineal care can prevent skin breakdown of perineal area, itching, burning, odor and infections. Perineal care was to be done after each incontinent episode and with each episode of toileting. Always follow the one swipe per wipe rule. Wipe front to back or away from the meatus. If your gloves become contaminated during perineal care, change gloves. One of the most important aspects of perineal care was checking for signs of infection, rash or skin breakdown. Observe the area as you clean it and report any skin abnormalities to the nurse.III. Staff interviewsThe corporate nurse consultant was interviewed on 5/27/26 at 10:25 a.m. She said the facility utilized the McGeer criteria for UTI determination.Licensed practical nurse (LPN) #1 was interviewed on 5/27/26 at 1:50 p.m. LPN #1 said residents received incontinence care at least every two hours by the certified nurse aide (CNA). She said staff knew when a resident required incontinence care because the resident would be restless, there would be an odor or if they were capable the resident would let the staff know they needed to be changed. LPN #1 said incontinence care was documented in the facility's documentation system, and it was important to provide timely incontinence care to prevent sores and mitigate falls. She said signs and symptoms of a UTI included confusion, possible redness and pain. LPN #1 said if she noticed a change of condition, such as a UTI, she would notify the charge nurse and they would initiate alert charting on UTI symptoms every shift. LPN #1 said Resident #16 had a history of UTIs and she believed the resident was just treated for a UTI three to four weeks ago.CNA #1 was interviewed on 5/27/26 at 2:45 p.m. CNA #1 said incontinence care was provided at least every two hours, but she said a few of the residents were on special precautions that indicated the resident should be checked and changed more frequently. CNA #1 said if the resident was unable to hit the call light to notify nursing staff about toileting, then staff should perform more frequent rounding for incontinence care. She said staff knew which residents required increased rounding because they were discussed in shift to shift report. CNA #1 said incontinence care was documented in the facility's documentation system, and it was important to perform timely incontinence care to prevent pressure wounds and skin breakdown. CNA #1 said signs and symptoms of UTI included irritability, pain in the bladder or a difference in urine color. She said if she noticed signs/symptoms of a UTI, or a change of condition, in one of her residents she would notify her nurse right away. CNA #1 said Resident #16 was currently on alert monitoring for UTI.Resident #16's physician was interviewed on 5/28/26 at 1:48 p.m. The physician said Resident #16 has had three UTIs over the last 12 months. She said what was so concerning about Resident #16's most recent UTI was that the resident was fairly asymptomatic when she was hospitalized , although she was very ill and definitely met criteria for sepsis. The physician said if the staff were documenting that they were changing and checking Resident #16 every two hours during awake periods there were many reasons the resident might have been having recurring UTIs, such as an anatomical reason that would require a urology evaluation. She said some women were more prone to UTIs even under the best of care.The physician said as a result of Resident #16's recurring UTIs, she had discussed unnecessary antibiotic therapy, antibiotic resistance and the increasing risk of multidrug-resistant organisms (MDROs). She said she used McGeer's criteria, and when Resident #16 had urinary symptoms she would check a UA and start antibiotic therapy. The physician said if the urine culture resulted negative, then she would stop the antibiotics. She said when the interdisciplinary team was in the period of figuring out if Resident #16 had a UTI they would place her on the sepsis protocol and check her vital signs at least every shift to ensure she was not declining.CNA #2 was interviewed on 5/28/26 at 3:05 p.m. CNA #2 said if she noticed a resident appeared differently than they did at the start of her shift, such as a UTI, she would go talk to the nurse about it then measure the resident's vital signs. She said the potential negative outcome of not recognizing a change of condition such as a UTI was that the resident could decline faster.Registered nurse (RN) #2 was interviewed on 5/28/26 at 3:10 p.m. RN #2 said if she noticed a resident appeared differently than they did at the start of her shift, such as a UTI, she would perform an assessment then call the charge nurse. She said if the resident was on hospice, she would notify the hospice physician of the change. RN #2 said the potential negative outcome of not recognizing a change of condition in a resident with a UTI was that they could become septic.The assistant director of nursing (ADON) was interviewed on 5/28/26 at 3:35 p.m. The ADON said she also served as the facility's infection preventionist. The ADON said the facility has had an increase in UTIs - she said the facility typically averaged two to four UTIs per month, but this month they had seven. She said through her infection tracking process she determined the facility was seeing a trend in E. coli infections, as well klebsiella infections. The ADON said E. coli was typically found in bowel movements, or feces, but she did not think it was caused by poor incontinence care because the facility had consistent CNAs. She said she performed a weekly huddle with the CNA and nurses the week of 5/11/26 and educated the staff on the importance of proper incontinence care. The ADON said she had not noticed any concerns with incontinence care; however, she said she did not audit incontinence care.The ADON said the facility did not have residents with recurring UTIs very often, but Resident #16 did have recurring UTIs. She said she had discussed Resident #16 and her recurring UTIs in the daily stand-up meetings. The ADON said Resident #16 was septic from a UTI in early April 2026 and the facility had since initiated a toileting program involving checking and changing the resident every two hours. She said the facility had also initiated the sepsis protocol on Resident #16 to be hyperaware that she was not going septic again. The ADON said the facility used the McGeer's criteria but were quicker to order antibiotic therapy for concerns of UTI for Resident #16 due to her history of sepsis.

Based on record review, observation and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice for two (#3 and #14) of four residents reviewed of 16 sample residents. Specifically, the facility failed to ensure Resident #3 and Resident #14 received oxygen therapy in accordance with the physician's orders.Findings include:I. Professional referenceAccording to National Library of Medicine, National Center for Biotechnology Information, dated 2026, retrieved on 6/10/26 fromhttps://urldefense.proofpoint.com/v2/url?u=https-3A__www.ncbi.nlm.nih.gov_books_NBK551617_&d=DwICAg&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=F6R-BWIUxqh9IqzzEaBXT9YWHUnChmp6u0hLTAxMezU&m=fR9UKZ2WivqmKsbBTslFP3UR6BBqsRa-mqc7zWWU79ugNfcxTb6JkaXk8jtat7ys&s=NyHFcX8Cm3wLDxzgAoz-uZPKFS5061mqlh5eL6zCOm4&e= Oxygen therapy is a critical medical intervention designed to ensure adequate oxygen delivery to the body's cells, supporting essential functions and preventing life-threatening conditions. The absence of sufficient oxygen, or hypoxia, can result in severe complications such as organ dysfunction, brain damage, and cardiac arrest.According to the [NAME] Stroller Patient operating instructions, undated, retrieved on 6/10/26 from https://documentcloud.adobe.com/gsuiteijk0-ntegration/index.html?state=%7B%22ids%22%3A%5B%221zWBXdsf66fFzelboIRcDg9KKYbx8UUqs%22%5D%2C%22action%22%3A%22open%22%2C%22userId%22%3A%22115130554584976839904%22%2C%22resourceKeys%22%3A% It read in pertinent To verify the level of liquid oxygen in the unit with the electronic liquid level gauge: Depress the push button (liquid level switch) on top of the unit for two seconds minimum. Read across the top of the light bar to indicate contents level and read the arc of LEDs, which indicates content level. Caution: The Stroller/Sprint (oxygen tank) is empty if only the last segment of the light bar is lit.II. Facility policy and procedureThe Oxygen Administration policy and procedure, revised 12/1/25, was provided by the nursing home administrator (NHA) on 6/1/26 2:37 p.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Oxygen is administered under the orders of a physician, except in the case of an emergency. In such a case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. The residents' care plan shall identify the interventions for oxygen therapy, based upon the residents assessment and orders.III. Resident #3A. Resident statusResident #3 age [AGE], admitted to facility 4/4/23 and discharged [DATE]. According June 2026 computerized physicians orders (CPO) diagnoses include congestive heart failure, chronic respiratory failure with hypoxia and primary hypertension. According to the minimum data (MDS) assessment, dated 5/15/26, the resident had no memory deficits, she was independent with decision making and no inattention, disorganized thinking and no alterations in levels of consciousness per staff assessment. The assessment revealed the resident had shortness of breath while laying flat. The assessment did not document that the resident was receiving oxygen therapy. -However, the physician's order revealed the resident had been on oxygen therapy since November of 2025.B. Resident representative interview:Resident #3's representative was interviewed on 6/1/26 at 3:22 p.m. The representative said she found Resident #3's portable oxygen tank was empty several times, so she made it a habit of checking the tank every time she visited to make sure it was full. The representative said on 4/1/26 she visited Resident #3 and found her portable tank was empty. She said she placed her on the stationary oxygen concentrator that was kept in the resident's room. She said at that time, Resident #3 told her she was on four liters of oxygen and asked the representative if she still needed to be on that increased amount of oxygen. The representative said she had not been informed of the resident's change of condition or what prompted her to need an increase in liter flow of oxygen. The representative spoke with the nurse on duty and was told that Resident #3 had been off her oxygen and was found to have a desaturated oxygen level of 50% (normal oxygen saturation in a person should be between 95 and 100 percent). The representative said this led to the physician increasing the resident's oxygen liter flow to four liters per minute to stabilize the resident. C. Record reviewReview of the June 2026 CPO revealed the following physician's order:Continuous Oxygen at two liters per minute by nasal cannula. Do not wake the resident at night to check oxygen saturation levels but check the resident every two hours to ensure the resident is receiving the oxygen therapy per the order. Verify that the resident is wearing oxygen, and that the tank was full and the liter flow is correct, ordered on 11/20/25. Resident #3's oxygen care plan last revised 11/24/25 documented the resident had chronic respiratory failure and was at risk for complications related to poor oxygen absorption. The resident was on oxygen therapy. Interventions included administering medication/puffers as ordered, monitoring for effectiveness and side effects, monitoring for signs and symptoms of respiratory distress, reporting signs and symptoms ot the physician and providing oxygen at two liters of oxygen via nasal cannula continuously.A facility grievance/concern resolution form, dated 4/21/26, revealed that a certified nurse aide (CNA) had transferred the resident from her oxygen contractor unit to her portable unit and the resident was without oxygen long enough to cause her oxygen saturation level to drop significantly to 50%. The CNA thought the resident had only been off her oxygen for a couple of minutes. The form documented that the resident recovered quickly.-However, there was no documentation that the resident was titrated back to her prescribed oxygen rate of liter flow. IV. Resident #14A. Resident status Resident #14 age greater than 85 admitted to facility 5/20/26. According to the June 2026 CPO, diagnoses include chronic respiratory failure with hypoxia and dementia with agitation.According to the MDS assessment, dated 6/5/26, the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of five out of 15. The assessment documented the resident was not receiving oxygen, -However, the resident was receiving oxygen therapy (see record review below).B. Record reviewThe June 2026 CPO revealed the following physician's order:Provide oxygen four liters continuously, ordered on 5/21/26.-However, the physician's order did not provide instructions for the delivery method or duration of use. The oxygen care plan, initiated 5/20/26, documented the resident had altered respiratory status and difficulty breathing. The focus documented the resident was on oxygen therapy. Pertinent interventions included monitoring for symptoms of respiratory distress and oxygen. -However, the oxygen intervention was incomplete and did not provide the oxygen setting liter flow, delivery method, duration or if humidification was needed. B. Observation and interviewsOn 6/1/26 at 10:47 a.m. Resident #14 was in the common area wearing oxygen via a nasal cannula. The oxygen portable tank's fill light indicator showed only one red light was illuminated, which indicated that it was empty (see the Stroller users manual above). CNA #4 was informed of the fill light indicator being on the last red light indicator and he checked the device immediately. CNA #4 was interviewed on 6/1/26 at 10:47 a.m. After being alerted Resident #14's tank needed to be filled, he checked the fill gauge. He said he would refill the oxygen as soon as he was able. CNA #4 said he could not leave the unit to fill her tank at that immediate time and had to wait until the other CNA returned from break to take over monitoring the residents on the unit.CNA #4 said that the portable oxygen tanks were supposed to be filled by the night shift staff. Morning shift staff were supposed to check the portable oxygen tank before transferring the resident from their in room concentrator to the portable tank for the day. CNA #4 said normally a full tank can last a few days. CNA #4 said he did not start his shift with the morning staff and had not arrived until approximately 10:47 p.m. and he was not aware that Resident #14's oxygen tank fill indicator was on the last red light indicator. CNA #5 was interviewed on 6/1/26 at 1:06 p.m. CNA #5 said the last red indicator light on the resident's portable oxygen tank meant the tank was empty.V. Additional staff interviewsThe assistant director of nursing (ADON) and director of nursing (DON) were interviewed on 6/1/26 at 6:08 p.m. The ADON said when the portable oxygen tank had at least one light lit the tank still had oxygen in the tank and would continue to supply the resident with the needed oxygen. She said she was not sure how the tank alerted when it was empty but would contact the oxygen provider for more information. -However the manufactures manual documented that the tank was empty when the fill indicator had only one light indicator lit (see above).

Based on observations, record review and interviews, the facility failed to ensure residents who were diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practical physical, mental, and psychological well-being an prevevent re for two (#6 and #12) of five residents out of 16 sample residents. Specifically, the facility failed to develop individualized interventions related to Resident #6 and Resident #12 behavioral symptomatology for becoming aggressive towards other individuals (resident and visitors) when they did not like what was going on in their environment/surroundings; to prevent each of them from initiating an aggressive altercation directed towards other individuals.Findings include:I. Facility policy and procedureThe Dementia Care policy and procedure, revised 12/1/25, was provided by the nursing home administrator (NHA) on 6/1/26 at 5:27 p.m. It read in pertinent part, This facility will provide dementia treatment and services which may include, but is not limited to, ensuring adequate medical care, diagnosis, and supports based on diagnosis, ensuring the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choices, and safety and utilizing individualized, non-pharmacological approaches to care.Residents who display or are diagnosed with dementia will receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.Identify, address, and/or obtain necessary services for the dementia care needs of the residents.Develop and implement person-centered care plans that include and support the dementia care needs identified in the comprehensive assessment.Develop individualized interventions related to the resident's symptomology and rate of progression.Review and revise care plans that have not been effective and/or when the resident has a change in condition.Modify the environment to accommodate resident care needs and achieve expected improvements or maintain the expected stable rate of decline.II. Resident #6A. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnosis included Parkinson's disease, dementia, severe, with frontal lobe, cognitive communication deficit , executive function deficit and a history of aggressive behavior.The 3/18/26 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 MDS assessment indicated the resident did not have behaviors directed towards others. B. Record reviewA facility investigation, dated 11/25/25, documented staff observed Resident #6 and Resident #13 having a tug of war over a kleenex box. Resident #13 brought a box of tissues from her room to the dining room table and when Resident #6 saw the box on the table he thought it was his and proceeded to take possession of it. Resident #13 tried to stop Resident #6 from taking the box and he became upset.The investigation revealed that Resident #6 was confused and becoming increasingly upset when he was stopped by Resident #13 from taking her box of kleenex. In the struggle over the box Resident #6 reached out to grasping at Resident #13 and scratched Resident #13 causing her fragile skin to tear open. The investigation documented the staff responded to the interaction between Resident #6 and Resident #13 and separated both residents to ensure safety. The investigation documented Resident #6 was referred to a behavioral health provider.A facility investigation, dated 1/3/26, documented the activities director observed Resident #6 grabbed Resident #8's wheelchair and shaking it out of frustration to get Resident #8 to move out of his way.The investigation documented the staff responded to the interaction between Resident #6 and Resident #8 by separating the residents to ensure safety. Resident #6 was asked to speak to residents if he wanted them to move or if he wanted something from them; Resident #6 said he would try.A facility investigation, dated 4/12/26, documented another resident reports that Redient #6 was acting strange in the dining room. He witnessed Resident approached Resident #7 and his wife who were visiting in the dining room and started kicking their chairs and telling them they were talking too much. Resident #6 was getting more agitated Resident #6's aggressive behavior was making Resident #7 upset and making his wife feel fearful.A nursing staff was seated at the nurses station and heard Resident #6 yelling at Resident #7 and his wife. And just observed to see how things went. The CNA did not respond to intervene immediately. Until the resident witness went to report the incident to staff and get staff to deescalate the incident. The investigation documented Resident #6's care plan was reviewed. It indicated Resident #6 was seen by an in-house provider on 4/14/26, and the social services director (SSD) placed a request for behavioral health services to see the resident. Resident #6's behavior care plan, initiated 4/13/24 and revised 3/25/26, revealed the resident had a history of verbal aggression towards others, yelling at others, taunting, and non-verbal body language towards others, physical aggression including pushing, and has kicked others' wheelchairs. Pertinent interventions included redirecting the resident to an independent activity if he was showing behaviors in group settings.-Review of the care plan did not reveal the facility implemented effective person-centered dementia care interventions to prevent Resident #6's ongoing aggressive behavior directed towards others. C. Observations and interviewsResident #7 was interviewed on 5/27/26 at 11:50 a.m. Resident #7 said he remembered when Resident #6 came to their table on 4/12/26. He said Resident #6 made his wife uncomfortable.Resident #13 was interviewed on 5/27/26 at 3:23 p.m. Resident #13 said she got a scratch on her arm when Resident #6 grabbed her Kleenex box from the dining room table they were sharingResident #6 was interviewed on 5/27/26 at 3:32 p.m. Resident #6 was able to recall events in the past with some clarity. Resident #6 said his wife was recently admitted to the facility for short term rehabilitation, and he was spending his time with his wife on a different floor of the facility.Resident #8 was interviewed on 5/28/26 at 10:52 a.m. Resident #8 said Resident #6's grabbed his wheelchair started shaking it after Resident #6 got upset about watching what was on the television on 1/3/26. Resident #8 said he used to play card games with Resident #6. He said Resident #6 became upset if the other residents did not follow his rules.III. Resident #12A. Resident statusResident #12, over age [AGE], was admitted on [DATE]. According to the June2026 CPO, diagnosis included cognitive communication deficit, severe dementia with anxiety, and need for assistance with personal care.The 4/13/26 MDS assessment revealed the resident was severely cognitively impaired, with a BIMS score of zero out of 15. She required supervision or touch assistance with toileting and personal hygiene and eating.The MDS assessment revealed the resident wandered daily and exhibited physical behavioral symptoms, such as hitting, kicking, scratching, grabbing, pushing, and sexually abusive behavior toward others.B. Record reviewA facility investigation, dated 4/21/26, documented the staff observed Resident #12 grab a blanket from Resident #9 and hit her on the arm three times.The investigation documented the staff responded to the interaction between Resident #12 and #9. The certified nurse aides (CNA) intervened immediately and separated both residents to ensure safety. The investigation documented Resident #12 was assessed and had no no pain, discomfort, injury, and did not show any signs of fearfulness.The investigation documented Resident #12 was moved to her room while Resident #9 showed little to no reaction to the incident.The investigation documented Resident #12's care plan was seen by behavioral health services (BHS) and adjustments made in the times medications were administered. And Resident #12 will remain in a frequent rounding program.C. Observations and interviewsDuring a continuous observation of the secure memory care unit on 5/26/26, beginning at 11:45 a.m. and ending at 1:05 p.m., the following was observed:Resident #12 was screaming at the staff who were assisting her with bathing. The unidentified staff members said staff said Resident #12's yelling was normal for him. On 5/28/26 at 4:41 p.m. Resident #12 was going into other residents' rooms.The staff present on the unit did not intervene or provide Resident #12 with a person-centered activity to meet her dementia care needs.On 6/1/26 at 3:40 p.m. Resident #12 was going into other residents' rooms.The staff present on the unit did not intervene or provide Resident #12 with a person-centered activity to meet her dementia care needs.Resident #12's behavior care plan, initiated 1/5/26 and revised 4/20/26, revealed the resident was at risk for wandering and elopement due to his diagnosis of unspecified dementia. The care plan documented Resident #12 often asked to go home and would usually attempt to follow a staff and visitors off the unit and attempt to open doors on the unit. The care plan revealed the resident had a history of being aggressive towards people in her surrounding area. The care plan documented the resident had a history of sitting at doorways and kicking/reaching out towards people when agitated. The care plan documented redirection was not generally effective and the staff should attempt to keep residents separate from others. Pertinent interventions included intervening as necessary to protect the rights and safety of others, approaching and speaking to the resident in a calm manner removing the resident from the situation, taking the resident to an alternate location as needed, praising the resident for any indication of the resident's progress/improvement in behavior and providing a program of activities that was of interest and accommodates residents' status. -However, the staff failed to monitor and engage Resident #12 in meaningful activities to minimize his wandering behaviors (see observations above).IV. Staff interviewsThe activities director (AD) was interviewed on 5/27/26 at 3:04 p.m. The AD said Resident #6 was unpredictable. The AD said one moment he would be fine, the next moment he could be mad. The AD said he especially got mad during movies or if he was interrupted.CNA #6 was interviewed on 5/28/26 at 2:43 p.m. CNA #6 said Resident #12 wandered and sometimes became verbally aggressive. CNA #6 said at times it was difficult to keep her separated from other residents. She said there had been some recent staff change over in the secured units resulting in more resident to resident altercations.CNA #6 said Resident #12 had a history of becoming agitated, reaching out towards others, kicking others or flailing at them.Licensed practical nurse (LPN) #3 was interviewed on 5/28/26 at 4:15 p.m. LPN #3 said Resident #12 provoked other residents in the secured unit.LPN #3 was interviewed again on 5/28/26 at 4:41 p.m. LPN #3 said Resident #12 has made behavioral improvements with the addition of Ativan (antianxiety medication). LPN #3 said Resident #12 continued to have aggressive behaviors, and it was hard to tell if it was because of a change in medication or something else.LPN #3 said the secured unit at the facility would benefit from more planned activities by decreasing the ratio of staff to residents.

Based on 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 development and transmission of diseases and infection on two of eight units.Specifically, the facility failed to:-Ensure the vital signs machine was disinfected after being used in a COVID-19 positive room;-Ensure the vital signs machine was disinfected between each resident's use on the secure unit; and,-Ensure housekeeping staff doffed (took off) their personal protective equipment (PPE) and closed the trash bags before exiting a COVID-19 positive room.Findings include:I. Failed to ensure the vital signs machine was disinfected after being utilized in a COVID-19 positive roomA. Professional referenceAccording to the Centers for Disease Control And Prevention's (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, updated June 2024, retrieved from https://www.cdc.gov/infection-control/hcp/disinfection-and-sterilization/index.html on 9/15/25, Medical equipment surfaces blood pressure cuffs, stethoscopes, hemodialysis machines, and Xray machines) can become contaminated with infectious agents and contribute to the spread of healthcare-associated infections. For this reason, non-critical medical equipment surfaces should be disinfected with an EPA-registered low-level or intermediate-level disinfectant.B. Facility policy and procedureThe Infection Prevention policy and procedure, revised March 2025, was provided by the nursing home administrator (NHA) on 9/12/25 at 2:25 p.m. it read in pertinent part, When a resident is placed on transmission-based precautions, the staff should implement the following: Clearly identify the type of precautions and the appropriate personal protective equipment (PPE) to be used, make PPE readily available near the entrance to the resident's room; use disposable or dedicated noncritical resident-care equipment (blood pressure cuff, bedside commode). If noncritical equipment is shared between residents, it will be cleaned and disinfected with an environmental protection agency (EPA)-registered disinfectant after use. C. ObservationsOn 9/8/2025 at approximately 3:06 p.m. certified nurse aide (CNA) #1 entered a COVID-19 positive room with the vital signs machine. The vital signs machine did not have disinfectant wipes available on the vital signs machine cart.On 9/8/2025 at 3:10 pm CNA #1 exited the COVID-19 positive room but did not disinfect the machine. CNA #1 proceeded to enter another resident's room (the resident did not have COVID-19) with the same vital signs machine. III. Failed to disinfect the vital signs machine after each resident's use on the secure unitA. ObservationsOn 9/9/25 at 4:02 p.m. an unidentified female CNA took four different residents' vital signs in the secure unit dining room without disinfecting the vital signs machine in between each resident's use. The vital signs machine did not have disinfectant wipes available on the machine.IV. Failed to ensure housekeeping staff doffed their PPE and sealed the trash bags inside the COVID-19 positive room A. Professional referenceAccording to the CDC's Summary of Recommendations of the Guidelines for Isolation Precautions, updated September 2024, retrieved on 9/15/25 from https://www.cdc.gov/infection-control/hcp/isolation-precautions/summary-recommendations.htmll, Before leaving the patient's room or cubicle, remove and discard PPE. B. Facility policy and procedureThe Infection Prevention policy and procedure, revised March 2025, was provided by the nursing home administrator (NHA) on 9/12/25 at 2:25 p.m. it read in pertinent part, Remove all PPE before exiting the resident's room except a respirator, if worn. Remove the respirator after leaving the room.C. ObservationsOn 9/8/25 at 2:48 p.m. an unidentified housekeeper exited a COVID-19 positive room (room [ROOM NUMBER]) still wearing her full PPE, which included a face shield, mask, gloves and a gown. The housekeeper was carrying an open bag of used PPE and trash from the resident's room. The housekeeper proceeded to doff her PPE and put her used PPE in the open bag of trash in the hallway. She then proceeded to tie the trash bag closed in the hallway.IV. Staff interviewsThe infection preventionist (IP) and the assistant director or nursing (ADON) were interviewed together on 9/10/25 at 3:43 p.m. The IP said the vital signs machine should be wiped down with disinfectant after each use. She said all of the vital signs machine carts should contain disinfecting wipes. She said COVID-19 positive rooms or isolation rooms had carts that were placed outside of each room that should contain all of the necessary PPE to use in the room. She said the carts also contained plastic containers which housed vital signs equipment specifically for that isolation room alone. She said the staff should not be taking the vital signs machines used for residents who were not on isolation into the isolation rooms. The IP said if a vital signs machine was taken into an isolation room, then it should be wiped down thoroughly with the disinfecting wipes. The IP said the housekeeper should not have doffed her PPE in the hallway. She said the housekeepers should not be closing the trash bags in the hallways. She said housekeepers should be doffing their PPE and closing the trash bags inside the isolation rooms. CNA #1 was interviewed on 9/11/25 at 12:15 p.m. CNA #1 said staff should be disinfecting the vital signs machine after each use. He said that staff should be using the designated vital signs equipment that was in the isolation carts for the COVID-19 positive rooms. He said if there was a piece of vital signs equipment missing from the bin outside the resident's room, then he would press the call light and ask another staff member to get him what he needed. He said he did not remember taking the vital signs machine into the COVID-19 positive room. He said he should have disinfected the vital signs machine completely before using it on another resident.

Based on record review and interviews, the facility failed to ensure three (#13, #11 and #12) of three residents out of 11 sample residents had their grievances resolved promptly by the facility. Specifically, the facility did not promptly respond to Resident #13, Resident #11 and Resident #12's grievances of long call light times. Findings include: I. Facility policy and procedure The Grievance Procedure policy, revised on 10/31/24, was provided by the nursing home administrator (NHA) on 2/19/25 at 6:10 p.m. The policy revealed the purpose of the policy was to protect resident rights and ensure prompt resolution of grievances. If at any time, a resident or representative had a grievance, it was their responsibility to express it orally or in writing to the nursing home administrator (NHA) or designee. Each resident had the right to voice grievances without discrimination, reprisal, or retribution. The facility had a Grievance Committee, which consisted of the NHA or their designee, a resident selected by the facility's residents and a third person agreed upon by the NHA and the facility's resident representative. The NHA or designee was responsible for overseeing the process to the conclusion, maintaining confidentiality, issuing written decisions and coordinating with regulatory agencies as necessary. A review of the grievance would be completed within three (3) calendar days of receiving the grievance and a written explanation of the findings with proposed remedies would be provided. If dissatisfied with the findings and remedies, the aggrieved party might appeal to the Grievance Committee within ten (10) calendar days of receiving the written explanation. The committee would confer with the person involved, within ten (10) calendar days of the date of the appeal and would provide a written explanation of the findings and the proposed remedies. II. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included unsteadiness on feet, history of falling, muscle weakness, lack of coordination, urine retention, atherosclerotic heart disease of native coronary artery without angina pectoris, and abnormalities of gait/mobility. According to the 1/6/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required partial/moderate assistance with the staff, provided less than half of the effort with the staff lifting or holding the resident's trunk/limbs and provided less than half of the effort for toileting. B. Resident interview Resident #13 was interviewed on 2/19/25 at 1:53 p.m. Resident #13 said he had waited up to 40 minutes for staff to answer his call light. He said he had defecated in his pants waiting on staff to answer the call light. He said this made him feel terrible and degraded. He said there had been times when he put his call light on and had to ambulate, using his wheelchair, down to the nurse's station from his room at the end of the hall to go ask them why they were not answering the call lights. He said the staff did not give him a sufficient answer to this question. He said at times, staff came into his room, turned the call light off and did not come back. He said he had to turn the call light on again to get the staff to come back to his room and the staff told him that they forgot about him. Resident #13 said sometimes his catheter bag became full and spilled over into the privacy bag because he was waiting on staff to answer the call light. He said this made him angry as well. C. Resident grievances Resident #13's initial concern report, dated 12/10/24, documented the resident and his daughter reported intermittent long call light times. The resident complained of call light time issues with his catheter. -The report did not contain documentation to indicate if the resident was satisfied with the findings or remedies for long call light times. -The report did not provide information on how the resident would initiate the appeal process to the Grievance Committee. Resident #13's initial concern report, dated 1/22/25, documented the resident complained of long call limes. -The report did not contain documentation to indicate if the resident was satisfied with the findings or remedies for long call light times. -The report did not provide information on how the resident would initiate the appeal process to the Grievance Committee. D. Staff interviews The NHA, the social services director (SSD) and the assistant social services director (ASSD) were interviewed together on 2/19/25 at 3:41 p.m. The ASSD said she completed Resident #13's initial concern reports dated 12/10/24 and 1/22/25. The ASSD agreed the forms did not reveal if the resident was satisfied with the findings or remedies for long call light times. The NHA, the SSD and the ASSD agreed a call light should remain on until the resident's needs were addressed. The NHA, the SSD and the ASSD agreed staff should not turn the call light off and not come back. III. Resident #11 A. Resident status Resident #11, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included atrial fibrillation, retention of urine, presence of other cardiac implants and grafts-[NAME] implant, heart failure, abnormalities of gait/mobility, lack of coordination, muscle weakness, unsteadiness on feet, difficulty in walking and type 2 diabetes mellitus with other skin complications-with necrotizing fasciitis. According to the 1/27/25 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required substantial/maximal assistance with the staff, provided more than half of the effort with the staff lifting or holding the resident's trunk/limbs and provided more than half of the effort for toileting. B. Resident interview Resident #11 was interviewed on 2/19/25 at 10:55 a.m. Resident #11 said she had to wait up to one hour and 40 minutes at times for staff to answer her call light. She said it made her feel that she did not count as a person when she had to wait on the staff so long. She said staff would come into the room, turn the call light off and did not come back to help her. She said she urinated on herself at times while she waited on staff to answer the call light. Resident #11 said she was frustrated that the staff took a long time to answer the call light because she could not care for herself and had to wait on the staff. C. Resident grievance Resident #11's initial concern report, dated 11/4/24, revealed the resident complained of long call light times. -The report did not contain documentation to indicate if the resident was satisfied with the findings or remedies for long call light times. -The report did not provide information on how the resident would initiate the appeal process to the Grievance Committee. D. Staff interviews The NHA, the SSD and the ASSD were interviewed together on 2/19/25 at 3:27 p.m. The ASSD said she filled out Resident #11's initial concern report dated 11/4/24. The ASSD agreed the form did not reveal if the resident was satisfied with the findings or remedies for long call light times. She said the report did not provide information on how the resident would initiate the appeal process to the Grievance Committee. The NHA, the SSD and the ASSD agreed an acceptable call response time average was ten minutes or less. VI. Resident #12 A. Resident status Resident #12, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included multiple sclerosis, retention of urine, muscle weakness, lack of coordination, unsteadiness of gait and the need for assistance with personal care. According to the 12/18/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required partial/moderate assistance with the staff, provided less than half of the effort with the staff lifting or holding the resident's trunk/limbs and provided less than half of the effort for toileting. B. Resident interview Resident #12 was interviewed on 2/19/25 at 12:50 p.m. Resident #12 said he had waited up to one and one half hours for staff to answer the call light. He said during this long wait (one and one half hours), he needed to pick something up off the floor and when he reached for the item, he said he fell to the floor, with no injuries. He said he should have waited for the staff, but it took a long time. Resident #12 said it was very common for staff to come into the room, turn the call light off and never come back. C. Resident grievance Resident #12's initial concern report, dated 1/28/25, revealed the resident reported that he pressed the call light at 3:50 p.m. and called his wife, who worked at the facility, at 5:25 p.m. to tell her how long he had been waiting on staff to answer his call light. A certified nurse aide (CNA) came into the room at approximately the same time the resident called his wife. D. Staff interviews The NHA, the SSD and the ASSD were interviewed together on 2/19/25 at 3:49 p.m. The ASSD said she filled out Resident #12's initial concern report dated 1/28/25. The ASSD agreed the form did not reveal if the resident was satisfied with the findings or remedies for long call light times. She said the report did not provide information on how the resident would initiate the appeal process to the Grievance Committee. The NHA said the root cause of Resident #12's fall was his arm got in the way of the wheel chair remote. CNA #2 was interviewed on 2/19/25 at 1:20 p.m. CNA #2 said a few residents had complained about long call light waits occasionally. CNA #2 said she had heard residents say a couple of times that nursing staff shut off the call light and did not return to the room. She said a reasonable wait for a call light response was less than 10 minutes. CNA #3 was interviewed on 2/19/25 at 1:33 p.m. CNA #3 said she answered call lights in less than five to 10 minutes and an ideal amount of time for residents to wait for their call lights to be answered was five minutes or less.

Based on observations, record review and staff interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Demonstrate proper hand hygiene while assisting a residents with their meals; -Ensure control measures for monitoring and preventing Legionella and waterborne pathogens growth were included in the facility's water management plan; and, -Pass medications in a sanitary manner. Findings include: I. Proper hand hygiene A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 11/20/23 from https://cdphe.colorado.gov/environment/food-regulations revealed in pertinent part, Cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip-contact surfaces is prevented. B. Facility policy and procedure The Standard Precautions policy and procedure, revised November 2023, was provided by the nursing home administrator (NHA) on 11/16/23 at 2:00 p.m. It revealed in pertinent part, Health care workers must perform hand hygiene (even if gloves are used): Before and after direct contact with a resident, before performing an aseptic (minimizing contamination) task, after contact with inanimate objects in the residents room especially those in the immediate vicinity of the resident and before and after meals. C. Observations Staff were observed touching the mouthpiece of residents ' drink glasses during meal service after using frequently touched items at the drink station such as drink pitchers and a pump container of thickening agent. The staff failed to perform hand hygiene before touching the mouthpiece of drink glasses and carried glasses and cups using the handle or base of the glass. The staff also failed to perform hand hygiene before utilizing a resident's silverware to assist in cutting her food. Dining room observations were made on 11/13/23 from 11:40 a.m. to 12:30 p.m. At 11:57 a.m. certified nurse aide (CNA) #2 picked up a pitcher from a drink station and filled two drink glasses. CNA #2 then used her hand to pump a gel thickener into each glass and used a spoon to stir the drinks. CNA #2 then carried the two full drink glasses with her bare hands around the mouthpiece of the glass and sat them in front of a resident at a dining table. At 11:59 a.m. CNA #2 poured a can of soda into a drink glass and then used her hand to pump a gel thickener into the glass. CNA #2 held the mouthpiece of the glass with one hand and used a spoon to stir the drink with her other hand. CNA #2 then carried the drink glass and set the drink on the table in front of a resident who then took a drink from the glass. At 12:03 p.m. CNA #2 placed two drinking glasses on the counter. CNA #2 then grabbed a drink pitcher and poured a red colored beverage into one glass, grabbed a second pitcher and poured water into the second glass. CNA #2 then carried the two drink glasses to the dining room with a finger around the mouthpiece of the glasses and placed the glass of water at one table and then glass of red drink at another table. At 12:05 p.m. CNA #2 pushed her hair behind her ear with her fingers, then stirred a drink on the table with a spoon, removed a straw from the wrapper, put the straw in the glass she just stirred and offered a resident a drink from the same glass. The resident took a drink. -CNA #2 failed to perform hand hygiene after touching her hair and then stirring a resident's beverage and placing a straw inside the glass. At 12:11 p.m. CNA #2 poured hot water from a pitcher into a coffee cup and placed a tea bag in the hot water. CNA #2 carried the coffee cup to a dining table with her hand around the mouthpiece of the coffee cup, and set the cup in front of a resident. The resident drank from the coffee cup during the meal. At 12:12 p.m. CNA #2 placed a drinking glass on the counter, picked up a water pitcher and filled the glass with water while her fingers held the mouthpiece of the glass. CNA #2 then carried the drinking glass while still touching the mouthpiece and set it in front of a resident at a dining table. Dining room observations were made on 11/15/23 from 12:00 p.m. to 12:40 p.m. At 12:12 p.m. an unidentified staff member poured coffee from a pitcher into a coffee cup, then carried the coffee cup with his fingers around the mouthpiece of the cup and set the cup on a dining table in front of a resident. The resident drank from the coffee cup. At 12:13 p.m. CNA #2 placed two glasses on the counter and filled the first glass with water from a pitcher. CNA #2 then opened a can of soda and filled the second glass. CNA #2 then brought both drinks to a resident at a dining table. At 12:15 p.m. CNA #2 offered a resident sitting at a table to heat up his cup of coffee. CNA #2 took the coffee cup and walked to the microwave, opened the microwave and placed the coffee cup inside the microwave to heat up the coffee. CNA #2 then removed the coffee cup from the microwave and returned to the resident's table carrying his coffee cup with her fingers around the mouthpiece. CNA #2 then set the coffee cup on the table in front of the resident. The resident then drank out of the coffee cup. At 12:19 p.m. CNA #2 carried a coffee cup to the table by the handle and set it down on the table. CNA #2 then removed her hand from the handle of the coffee cup and grabbed the mouthpiece of the coffee cup to turn the cup so the resident was able to reach the handle of the coffee cup. At 12:37 p.m. an unidentified staff member delivered a meal tray to a resident's table and set the tray on the table. The unidentified staff member then removed the resident's meal plate from the tray and set the plate in front of the resident. The staff member did not perform hand hygiene, then unrolled the resident's silverware from the clean linen napkin and used the resident's silverware to cut the residence food and then handed the silverware to the resident. -The meal trays used to deliver meals were not sanitized in between each meal delivery and staff set the meal trays on the residents ' dining tables during meal times. After a meal was dropped off at a resident's table, the tray was returned to the bottom of a stack of trays to be used for additional meal deliveries during the same meal service. D. Staff interviews The assistant director of nursing was interviewed (ADON) on 11/16/23 at 10:00 a.m. The ADON said she had concerns about handwashing, and handwashing was something the facility always continued to improve on and the facility did hand washing audits monthly. The facility completed the hand washing audits observing staff in resident rooms and in the dining rooms. The infection preventionist (IP) was interviewed on 11/16/23 at 10:00 a.m. The IP and ADON said handling of the cups in the dining room would be observed more going forward. The ADON was interviewed on 11/16/23 at 12:40 p.m. The ADON said she provided facility staff with training to not touch the mouthpiece of the drinking glasses. The ADON said staff stated to her during the training the mouthpiece of the drinking cups were touched in the dining room. The ADON was interviewed on 11/16/23 at 2:05 p.m. The ADON said when she provide education to CNA #2 about hand hygiene in the dining room, CNA #2 acknowledged that she did carry resident beverage cups and glasses by the mouthpiece. E. Facility follow up The ADON provided follow up education presented to CNA #2 on 11/16/23 at 2:05 p.m. The topics the CNA was educated on included: not touching the top of resident cups while serving beverages, using handles on mugs to deliver and education on hand sanitizing before cutting up resident food to prevent cross contamination. The ADON provided a Sanitary Serving in-service documentation on 11/16/23 at 2:05 p.m. The inservice was given on 11/16/23 and previously in April 2023 to facility staff members. Pertinent information in the inservice included: Never pick up drinking glasses from the rim, always pick them up from the bottom, hand hygiene should be performed after touching dirty dishes and between each tray passed. II. Monitoring legionella A. Professional reference The Center for Disease Control and Prevention (CDC) recommendations for Legionella, last reviewed on 3/25/21, was retrieved on 11/20//23 at https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html under Healthcare Water Management read in pertinent part: Healthcare facilities, such as hospitals and nursing homes, usually serve the populations at highest risk for Legionnaires' disease. These include older people and those who have certain risk factors, such as being a current or former smoker, having a chronic disease, or having a weakened immune system. Also, healthcare facilities can have large complex water systems that promote Legionella (the bacterium that causes legionnaires' disease) growth if not properly maintained. For these reasons, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) consider it essential that hospitals and nursing homes have a water management program that is effective in limiting legionella and other opportunistic pathogens of premise plumbing (waterborne pathogens, for short) from growing and spreading in their facility. Water management programs identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key activities are routinely performed in a Legionella water management program: Establish a water management program team; describe the building water systems using flow diagrams and a written description; identify areas where Legionella could grow and spread; decide where control measures should be applied and how to monitor them; establish ways to intervene when control limits are not met; make sure the program is running as designed (verification) and is effective (validation); document and communicate all the activities. Members of a building water management program team work together to: Identify ways to minimize growth and spread of legionella and other waterborne pathogens, conduct routine checks of control measures to monitor areas at risk, and take corrective action if a problem is found. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions. Programs should include predetermined responses to correct hazardous conditions if the team detects them. B. Facility policy and procedure The Legionella policy and procedure, revised December 2022, was provided by the assistant director of nursing (ADON) on 11/14/23 at 10:42 p.m. It revealed in pertinent part, In man made settings, Legionella can grow if water is not properly maintained and then small drops of water that contain the bacteria get into the air and people breath them in. Those at highest risk for Legionnaires' disease are persons with weakened immune systems, chronic lung diseases and certain comorbidities. The most likely sources of infection include water used for showering, cooling towers used in large air cooling systems, hot water tanks and heaters, large plumbing systems, decorative fountains and hot tubs. C. Record review The Water Management Plan, dated April 2023, was provided by the NHA on 11/14/23 at 3:00 p.m. The Water Management Plan documented protocols for vacant or unoccupied rooms and staff responsible for the protocol were housekeeping staff. Protocols revealed the maximum number of days a room was allowed to be vacant without action was three days. Protocols for rooms recently vacated were to open every plumbing fixture in the room on maximum hot setting for approximately one minute, open every plumbing fixture in the room on cold setting for approximately one minute, flush the toilet one time, and clean and disinfect the room. Protocols for rooms vacant more than three days were to open every plumbing fixture in the room on maximum hot setting for one minute and open every plumbing fixture in the room on maximum cold setting for one minute and flush the toilet. The potable system monitoring frequency revealed empty rooms were to be flushed daily. The Water Management Plan revealed internal measures and corrective actions were put in place for areas that had potential for Legionella colonization and growth or other organizations in the facility ice machines. The ice machines were to be cleaned according to the manufacturer's instructions. -The facility was unable to provide documentation of monitoring or control measures for recently vacated rooms, rooms vacant more than three days or facility ice machines as required by the facility Water Management Plan. D. Staff interviews The NHA was interviewed on 11/16/23 at 12:30 p.m. The NHA said housekeeping staff cleaned resident rooms daily when the rooms were empty. The housekeeping department kept track of empty resident rooms and room turnover. The NHA said the facility changed that the housekeeping will monitor the vacant room flushes in the future. The NHA said she was unable to find the ice machine cleaning records because the records were previously electronic records and not saved, and the facility did not have any additional written records of the ice machine cleaning. 37166 III. Failure to follow infection control practices during medication pass A. Observations RN #3 was observed on 11/14/23 at 11:54 a.m. during medication administration. On three occasions she was observed passing medication to the residents in the dining room. RN #3 she disposed of the plastic medication cups into the trash by pushing the trash lid with the side of her hand. -She did not sanitize her hands prior to passing medications to the next resident. B. Staff interview The assistant ADON was interviewed on 11/16/23 at 4:30 p.m. She said all staff were expected to clean or sanitize their hands after touching the lid on the trash. She said the plan was to educate the staff on proper hand hygiene and to replace the trash bin with a different one where the lid was operated by the foot pedal.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of four sample residents received adequate supervision and services to prevent an accident/hazard. Resident #1 had diagnoses of dementia, bilateral knee contractures and chronic pain. She required extensive assistance with a mechanical lift to transfer. The facility had mechanical ceiling lifts in resident rooms and tub rooms. Resident #1 had a brain injury due to a fall from a ceiling lift on 5/27/23 at approximately 11:00 a.m. According to the facility investigation, Resident #1 had fractures of the right and left femur (thigh bone), C1 and C2 fractures (neck), right clavicle fracture and a subdural hematoma (bleeding in head between brain and outermost covering) due to the fall. She passed away at the hospital. The facility investigation documented the resident was a two person transfer with a ceiling lift, and the nurse aide was transferring the resident with the ceiling lift by herself. The investigation revealed one of the sling loops came off the lift hook causing the resident to fall. Findings include: I. Facility policy and procedure The Transferring, Lifting, Repositioning policy, revised 5/31/23, was received from the director of nursing (DON) on 7/13/23 at 12:07 p.m. The policy documented in pertinent part, Upon admission or change of condition, residents will be evaluated for their ability to transfer safely. Mechanical lift transfers may be completed by one or two staff in accordance with facility protocol. No staff member is to use a mechanical lift device until properly educated on its use. Utilize the Mechanical Lift (sling) for: Anyone requiring maximum assistance of one person for lifting or transfers; Anyone requiring 2 people to transfer or lift; Anyone unable to bear weight for at least 4 seconds (so they can't safely stand/pivot); Anyone who is unpredictable with the amount of assistance they require (if their knees tend to 'give out' , if they resist when trying to transfer or lift, or if they are uncooperative at times); Any situation where it is unclear if the resident can be transferred safely with the assistance of one person; or anytime a resident is on the floor and needs to be lifted to a chair or bed. Residents will be re-evaluated throughout their stay for any possible changes to their transfer status, which will be communicated to nursing and therapy staff. See sling color chart for (lift manufacturer) slings. II. Resident status Resident #1, over [AGE] years old, was admitted on [DATE] and readmitted on [DATE] and discharged to the hospital 5/27/23. According to the July 2023 computerized physician orders (CPO) diagnoses included right and left knee contractures, dorsalgia (back pain) and osteoarthritis. The 5/19/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and unable to complete a brief interview for mental status score (BIMS). She had short term memory loss and moderate difficulty making daily life decisions. She required extensive two person assistance with transfers, and extensive one person assistance with bed mobility, toileting, dressing, and personal hygiene. She had not had any falls since her last assessment. III. Facility investigation The facility investigation was received on 7/12/23 at 12:10 p.m. from the nursing home administrator (NHA). The investigation documented: A form titled Occurrence summary, dated 5/27/23, in the investigation file documented Resident #1 was being transferred from bed to wheelchair with the ceiling lift by nurse aide (NA) #1 who was working as the bath aide. The resident sustained a fall to the floor with neurological changes and complaints of left leg pain.The resident landed on the floor mat with her upper body on the floor. The resident was sent to the hospital and diagnosed with fractures to both femurs, C1 and C2 vertebrae of the neck, right clavicle fracture and subdural hematoma. NA #1 reported that she had been using two hands to operate the ceiling lift remote, as it was not functioning properly. A loop on the sling slipped off the lift and the resident fell out of the sling. The investigation documented the NA transferred the resident without two people using the ceiling lift, and the resident's care plan said she was a two person transfer. The charge nurse, registered nurse (RN) #2, contacted the on-call nurse manager, the staff development coordinator (SDC). The SDC came into the facility at 11:53 a.m. and began interviewing the staff involved. The investigation documented the director of nursing (DON) and nursing home administrator (NHA) were notified on 5/27/23, and the SDC finished the investigation on 5/27/23 at 5:00 p.m. Interviews in the investigation file documented the following: Nurse aide (NA) #1 documented she had just finished Resident #1's bath. She said in the tub room she had to hold the wire at the base of the remote for the ceiling lift to work. She took the resident to her room. She used the ceiling lift in the resident's room to transfer the resident. NA #1 said she had to hold the cord at the base of the remote in a certain way for the buttons to function on the ceiling lift. She connected the loops of the sling to the bar of the lift. She began to lift the resident but the right lower loop was not connected. She lowered the resident back down and reconnected the right lower loop. The NA said after reconnecting the loop she started the lift again and stated she started struggling with the remote control. She said the cord appeared to be not connected to the remote. The NA said she was focused on holding the remote correctly at the top so the buttons would work on the lift's remote. She said both hands were on the remote in order for the lift to work correctly. Resident #1 was suspended over the floor mat which was still in place adjacent to her bed. NA #1 said it appeared the right lower loop on the sling disconnected again from the lift hook. The resident fell , landing on her bedside mat diagonally, with her head on the floor, both legs were under the bed and the right knee hit the vertical post under the bed and the left leg followed. She said she did not have her resident information sheet (RIS). She knelt next to the resident, held the resident's head and tried to find a pulse. She began yelling for help and pushed the call light. Two certified nurse aides (CNAs) came within two minutes and ran for the nurse. She said RN #3 and RN #1 responded within five minutes. RN #1 documented a CNA came and told her she needed a nurse. RN #1 said she and RN #3 ran to the room and observed Resident #1 lying diagonally on the floor mat. NA #1 was holding the resident's head. NA #1 told RN #1 that she was transferring the resident when one of the loops came off. The NA said she tried to protect the resident's head as she fell . RN #1 said she could only hear a faint heartbeat at her chest. She said RN #3 obtained a pulse in the 50s on the resident's wrist (normal pulse for this resident was 54 to 72 beats per minute). RN #1 said she did not see any lumps or bumps on the resident's head but the resident's pupils were sluggish to react and unequal. She was unsure if this was the resident's normal baseline. RN #1 said she called for the charge nurse. The charge nurse, RN #2, arrived at the room. RN #1 documented she focused on stabilizing the cervical (neck) spine while RN #2 inspected the resident's lower extremities for passive range of motion. RN #1 said Resident #1 was not initially responsive to verbal or tactile stimulation, but her eyes were open. Resident #1 became more alert with the exam of her lower extremities. RN #2 left the room to call the family. RN #2 returned and said the family wanted to discuss with each other whether to send the resident to the hospital. RN #1 said that RN #2 observed the resident's left foot was rotated inward. The right leg appeared normal. RN #2 left the room again to inform the family of a possible fracture to the left leg. RN #1 said the resident's power of attorney (POA) arrived and asked the resident how she was doing, the resident responded she was not doing well. The resident said her left leg hurt. RN #1 said emergency medical services (EMS) arrived a few minutes later and the resident was transferred to the hospital. RN #3 documented at approximately 10:50 a.m. she heard a CNA yelling down the hall they needed a nurse. She said she and RN #1 ran to Resident #1's room. The resident was lying on the floor on her fall mat on her right side. Her legs were hitting the bottom of the bed. The bath aide (NA) #1 was with the resident. NA #1 said she was transferring the resident with the ceiling lift from the bed to the wheelchair, had trouble with the remote and one of the straps on the sling came undone from the lift. RN #3 said Resident #1 appeared to be having a hard time breathing and was not responding, just staring off into space. RN #3 said she did not know if the resident hit her head on the floor or the fall mat next to her bed. She said she ran to get the vital sign equipment, RN #1 stayed with the resident and RN #2 went to call the family. RN #3 said Resident #1's blood pressure and respiratory rate were elevated. She said RN #1 listened to the resident's chest, but had a hard time hearing her heartbeat. RN #3 said she was able to locate a pulse on the resident's wrist and it was in the 50s. RN #3 said RN #2 arrived. RN #3 said she turned the resident's oxygen up from one liter per minute (LPM) to four liters per minute to keep the resident's oxygen saturation above 90%. She said RN #2 assessed the resident's eyes and said her pupils were sluggish and the right more dilated than the left. RN #3 said the resident continued to appear to have difficulty breathing. She said RN #2 left to call the family and she monitored the vital signs while RN #1 stabilized the resident's neck. RN #3 said the resident became more alert and started to answer questions but not at her baseline. She said the resident was still staring off in space. RN #3 said RN #2 had spoken to the family and they would discuss what they wanted to do. RN #3 said she, RN #2, RN #1 and NA #1 transferred the resident to the bed to be more comfortable. RN #3 said the resident was more comfortable in bed and appeared to be breathing easier and began to answer questions. RN #3 said the distal end of the left thigh area appeared deformed. RN #2 left to call the family again. RN #3 said the family arrived and the resident told them she was not doing well and had pain in her left leg. The resident was transported to the hospital via EMS per the family's request. RN #2 documented the resident had fallen from the ceiling lift. She was lying diagonally on the floor mat with her legs under the bed. She had a pillow under her head. RN #2 said Resident #1 was diaphoretic (sweating heavily). She was less alert than her baseline. RN #2 said her oxygen saturation level was low and it had been difficult to obtain vital signs. She said her legs appeared bent, without obvious injuries. She said her right pupil was larger than the left and she had a change in cognition. RN #2 said she had no bumps on her head. RN #2 said Resident #1 said ouch a few times during the assessment but could not state the location of her pain. RN #2 said she left to call the family due to the advance directive medical orders for scope of treatment (MOST) form documenting comfort care was desired. She said the family would discuss what they wanted to do. RN #2 said upon further assessment of Resident #1, the left thigh area had a bump and was visibly deformed. She left to call the family again. RN #2 said the family came to the facility. The resident was sent to the hospital. The investigation documented the resident passed away on 5/28/23 at 1:40 a.m. in the hospital. It further documented the hospital records listed the immediate cause of death was heart block; other significant conditions which contributed to the death included C1 and C2 fracture, right and left femur fractures. The facility findings in the investigation documented: The resident fell while using a mechanical lift and sustained an injury. Safety interventions and facility's policies and procedures were not followed. The fall was due to human error but may be secondarily due to equipment malfunction. Resident #1 required two people to transfer with the lift due to pain. The resident was transferred with one person and the nurse aide did not have a RIS with her to indicate how the resident transferred. NA #1 was working as the bath aide that day and the bath sheet did not contain the resident's transfer status. The facility documented they changed the policy after this to print out an RIS for the bath aide each day for all the halls. The maintenance department was notified of the issue with the ceiling lift in Resident #1's room and in the tub room. NA #1 was suspended on 5/27/23 and the facility terminated her employment on 6/1/23. The facility documented NA #1 had not followed facility policy, she did not have a second person with her for a ceiling transfer, and the resident was not secured properly in the lift. NA #1 reported that she had trouble with the lift remote, however this had not been reported to the charge nurse or maintenance. The termination further documented the NA had transferred the resident three previous times without seeking assistance. The SDC documented she tested the ceiling lift in the tub room and in Resident #1's room that morning and the lifts only worked intermittently. The lift in the resident's room appeared to have a connection issue at the cord and remote which was what NA #1 had described. The lift in the tub room and the buttons on the controls failed intermittently with weight to the sling. She documented the ceiling lift belt that extended down to the bar which held the sling was observed to be frayed. The facility documented their plan was to provide education both verbal and written to NA #1. The NA was suspended and sent home pending the investigation. It documented the NA did not follow proper transfer techniques and did not tag out faulty equipment. The facility documented it intended to conduct education for all staff on ceiling lifts and education on maintenance. The investigation documented immediate transfer training was started 5/27/23, with education on not using equipment that was not functioning properly and notifying the maintenance department. On 5/27/23 the education, titled Transfer Safety Education, was based on the previous facility policy that allowed ceiling lift transfers to be done by one or two people. The education included steps for a safe transfer with a one or two person assist, including proper sling placement and ensuring the sling straps were secured properly and evenly. The education documented to never use a piece of equipment that was not functioning properly. Notify the maintenance department via a maintenance request that a repair was required as soon as possible. Always transfer resident as indicated on the RIS. The RIS should be carried by all CNAs each shift. On 5/28/23, the education titled Transfer Safety Education was revised. It documented two people were needed to assist a resident with a ceiling lift transfer. The first person would operate the lift controls and assist with resident positioning. The second person would manage the resident's extremities for safety, manage oxygen or catheter tubing as needed and assist with positioning. On 5/30/23 a Transfer Training inservice reviewed safety and the current lift transfer policy. Nurse managers would complete routine audits to observe staff transfer residents with ceiling for lifts, daily for two weeks, weekly for four weeks, monthly for three months and quarterly for four quarters. The investigation documented the evening charge nurse on 5/28/23 completed an audit of the facility ceiling lifts. The investigation documented the maintenance department assessed the lift in the affected resident's room on 5/30/23. The only issue noted was an issue with the battery that did not interfere with safety. A ceiling audit lift done by maintenance on 5/31/23 indicated the lift in Resident #1's room was no longer in use. Additionally, 56 other lifts were removed or tagged out to not use due to, for example, issues with the emergency stop switches, hand controls or remotes not working properly, cracks in chassis (load bearing portion of lift) and wheels, worn straps and battery issues (see below). -Although 56 lifts were removed or tagged, six residents who required the ceiling lifts were changed to a mechanical hoyer lift. The facility investigation documented they had updated their Transfer and Lift policy on 5/28/23, from one to two person assist with lifts based on the resident status to two person assist with all lifts. The facility charge nurses and nurse managers completed random audits of staff transferring residents with a mechanical lift. The random audits by the nurse managers and charge nurses were reviewed. The facility had completed 47 random observations of lift transfers with the nursing staff since the fall on 5/27/23. One person required more education, which was immediately completed. The facility investigation concluded the cause of the fall from the lift was due to the NA not having second person with her for the transfer, not carrying the resident information sheet with her, verifying placement of the sling loops on the ceiling lift, the ceiling lift remote not functioning and the ceiling lift not being tagged and removed from service when the NA first noticed the issue with the remote. IV. Observations and interviews CNAs #1 and #3 were interviewed on 7/12/23 at 10:40 a.m. during an observation of transferring Resident #2 with a ceiling lift. CNA #1 said she heard Resident #1 fell during a ceiling lift transfer due to the sling not being properly connected and the remote was not working correctly. CNA #1 and CNA #3 said in the past the CNAs could use the ceiling lift with one or two people to transfer. They said after the resident had the fall from the lift, the staff had to use two people. CNA #3 said they were in-serviced about a month ago to use two people for the lifts. The two CNAs began to roll Resident #2 and place a sling under Resident #2 to transfer him with the ceiling lift. The resident was then lifted by the ceiling lift with CNA #1 controlling the lift and CNA #3 guiding the resident from the bed to the wheelchair. CNA #1 said a resident's transfer status was listed on the RIS (resident information sheet) the CNAs carried in their pockets. She said the charge nurse updated them with a new admission or change in condition for a resident. CNA #1 said the RIS was a list of basic things the resident needed like how they transferred, whether to use a lift and how many staff were needed to assist the resident. CNA #2 was interviewed with CNA #3 on 7/12/23 at 10:51 a.m. while transferring Resident #3 with the ceiling lift from bed to wheelchair. CNA #4 entered the room after a few minutes and introduced herself as the CNA team lead. CNA #2 controlled the lift and CNA #3 guided the resident to the wheelchair. CNA #2 said she had training on the lifts about two months ago due to a resident who fell out of a sling from a lift. She said the training consisted of a demonstration of the lift and placement of sling loops. She said she did not have to demonstrate how to use the lift and there was no quiz or other follow up from the inservice. She said the staff were educated that all residents who used a lift required two staff members to assist. CNA #2 said in the past, some residents could be transferred with the lift and one staff member to assist. CNA #2 said the RIS sheet told the staff how to transfer the resident. She said each resident had their own sling in their room. CNA #2 said she checked the lifts to make sure there was no red warning light on. She said some of the other lifts had red lights on but those had not been used since Resident #1 fell . Resident rooms on the second floor were observed on 7/12/23 at 3:59 p.m. Rooms 2109, 2209, 2217, 2509 and 2409 had signs on the ceiling lift to not use them. Resident #1's room, the ceiling lift was removed. V. Record review and interviews The NHA was interviewed on 7/12/23 at 12:10 p.m. She said the maintenance supervisor (MS) was new and had started on 6/1/23. She said the regional maintenance director (RMD) had completed an audit of all ceiling lifts for any malfunctioning or repairs needed on 5/31/23.The NHA provided a copy of the maintenance audit of the ceiling lifts and personnel file for NA #1 on 7/12/23 at 3:43 p.m. The NHA said the maintenance audit was done on 5/31/23 by the RMD. She said the facility was built in 2007 and many of the ceiling lifts in resident rooms and tub rooms were installed at that time. She said some were installed later according to the audit done by the RMD and dates on the lifts. The untitled, undated, unsigned resident room ceiling lift audit completed on 5/31/23 by the RMD according to the NHA, revealed the following information: Twenty-nine rooms listed as room [ROOM NUMBER]. The lifts were dated 2004, 2005 and 2007. Repairs needed included one or more of the following for each lift: emergency stop switch issue, maintenance light was on, see damage report, cracked chassis, batteries and hand control issues, new strap needed on lift, new strap switch plate needed, new switch board and chassis needed. It was unclear where these lifts were located. Twenty-five rooms, with specific room numbers listed, dated 2004 and 2007, documented emergency stop switch issues, hand control issues, battery concerns, cracked chassis and maintenance lights that were on. Six of these rooms were highlighted in the audit. The audit did not indicate what the highlighting meant. These six rooms were observed during the survey with signs on the lifts to not use them (see above). The residents in these six rooms required a lift, and the hoyer lift was used. Resident #1's room number was not listed on the audit (the lift may have had one of the lifts listed as room [ROOM NUMBER].) Resident #2 and Resident #3's rooms were listed on the audit as no repairs needed. The RMD was interviewed with the NHA on 7/13/23 at 10:48 a.m. The RMD said he could not locate any previous maintenance records for the ceiling lifts. He said he had been in contact with the manufacturer and had signed a contract to have the manufacturer come out and inspect the lifts. He said it would be next month in August but he did not have a date yet. The NHA said the staff knew to let the maintenance supervisor know if there were any issues with the lifts. She said the facility had started a new process for maintenance requests. The NHA said she did not remember when, she thought maybe in June 2023. The new process involved having a maintenance book on each floor where the staff could write their concerns and the maintenance supervisor would review when he was in and sign off the request. The RMD said the rooms listed as 0 on the 5/31/23 ceiling lift audit were lifts he removed from rooms. He said he did not keep track of which ones were removed from which rooms. He said the highlighted rooms on the audit that had maintenance issues were six rooms where the resident needed a lift and the staff should use a portable mechanical lift and not the ceiling lift. He said a sign had been placed on the ceiling lift to prevent use. The RMD said the rest of the resident rooms with ceiling lift issues were residents who did not use the lifts. The NHA or RMD did not have a process to track if a resident's transfer status in those rooms changed and they needed to use the lift to ensure the staff did not use the ceiling lifts. The RMD said he had checked the lifts with his assistant on 5/31/23 for maintenance lights, issues with the switches for the emergency stops, cracked chassis housing, worn straps, hand control issues and battery issues. He said the lifts would be inspected again by him next quarter. The RMD said he assessed the four tub lifts on 5/31/23 and the lifts were working appropriately. The maintenance supervisor (MS) was interviewed with the NHA on 7/13/23 at 11:57 a.m. The MS said he had the position at the facility on 6/1/23. He was the only maintenance person for the facility but he could call the regional maintenance director (RMD) if he needed to. The MS said if the staff had a maintenance issue, they logged in a maintenance book on each floor. He said he checked the maintenance books when he came in each day. The MS said the staff had sometimes left him sticky notes on his door, sent him an email or called him if there was a maintenance issue rather than writing it in the maintenance book. He did not have a preferred method for the staff to communicate with him. The NHA said the facility had started the new process of writing maintenance requests in books on each floor a month or two ago, but she could not remember. She said she was unhappy with an outside company who the facility used for maintenance tracking and the facility had switched to this new process. The facility general orientation sheet documented NA #1 had been given information and facility's policies about resident handling, transfers and body mechanics. On 7/26/23 at 3:40 p.m., during the survey, the nurse consultant (NC) provided a computer printout that documented NA #1 had nursing orientation on 3/18/23 that included a skills assessment on mechanical lifts. The staff development coordinator (SDC) was interviewed on 7/13/23 at 11:40 a.m. She said she was the nurse manager on call on 5/27/23 and had come into the facility to investigate what happened on 5/27/23. She said the event with Resident #1 was an accident. She said she had spoken to the staff on 5/27/23 about being more intentional with their work by paying more attention to what they were doing. She said it was not the process of the transfer that failed but it was a safety issue. She said she called and spoke to the DON on 5/27/23 about changing the facility's policy on one to two person assistance with the lifts to always having two people to help avoid further risks of errors with transfers. The SDC said she began to inservice the staff at the facility on 5/27/23 on transfer safety education. She said she thought maintenance did some audits of the lifts on 5/28/23. The SDC said she posted on 5/28/23 mandatory transfer training scheduled for 5/30/23, 5/31/23 and 6/1/23 in 30 minute blocks. The SDC said it was not that NA #1 did not know how to transfer the resident. She was trained before she went on the floor. She said the staff all know how to transfer the residents with the lifts. She said they just needed to be more mindful and purposeful with their work. The SDC said on 5/30/23 the facility changed their policy to always having two people to transfer a resident using a lift. She said during a transfer with ceiling lift, the second person's job was to guide the resident's legs and body while the first person operated the remote and lift. The SDC said the education on 5/30/23 through 6/1/23 consisted of a demonstration on the ceiling lift and portable hoyer lift. The SDC said all staff were trained when hired on tagging equipment and removing it from use if it was malfunctioning. The SDC said she did not know if all nursing staff had been through the education yet. She said she thought it was about 98% of the nurses and 83% of the CNAs. The SDC said she thought the business office was tracking the staff that still needed to be educated. The SDC said it was not a training issue, it was human error. The DON was interviewed with the NHA on 7/13/23 at 2:35 p.m. She said the facility had begun immediate training with the nursing staff on 5/27/23 regarding lift safety. She said additional education was provided again when the facility changed their policy to having two persons assist with all lifts 5/30/23. Additionally, in person demonstration of lift training was done over the next few days and the charge nurses began random audits of lift transfers and were still doing random transfers according to the facility's follow up plan (see above). The DON said when a resident was admitted the admitting nurse got a report from the hospital. The admitting nurse updated the RIS with the resident's needs including how they transferred. If the transfer status was unknown the resident was transferred with two people until they were assessed by the therapy department. She said the staff would use the mechanical lift if the resident could not bear 50 percent of the weight. The RMD was interviewed again on 7/26/23 at 1:55 p.m. He said some of the lifts were left in resident rooms even though they had maintenance issues after his audit on 5/31/23. He said those lifts were stuck and he could not remove them. The RMD said those rooms had a tag placed on them that indicated not to use them. The RMD was interviewed again on 7/26/23 at 3:40 p.m. He said the ceiling lift manufacturer would be coming to the facility on [DATE] to assess all the ceiling lifts for any further issues or parts needed. CNA #1 was interviewed again on 7/26/23 at 2:05 p.m. She said she did not recall any concerns with the lift for Resident #1 prior to the fall. CNA #1 said the staff used to type the maintenance concern on a tablet for the maintenance person. She said last month the facility transitioned to a maintenance request book on each nurses station. CNA #4 as interviewed on 7/26/23 at 2:07 p.m. She said she did not remember any concerns with the lift in Resident #1's room. LPN #1 was interviewed on 7/26/23 at 2:17 p.m. She said she did not remember any issues with Resident #1's lift prior to her fall. The DON was interviewed on 7/26/23 at 2:30 p.m. She said she did not think there were any other resident falls from using the lifts. She said she had been at the facility since it opened in 2007. RN #4 was interviewed on 7/26/23 at 2:50 p.m. She said she was not here the day Resident #1 fell from the lift. She said she heard the fall was due to user error. She said she heard the clip on the lift hook was not closed allowing the sling loop to slip out. She said if there was a concern with a lift, she would put a sign on it to not use it and use a different lift. RN #4 said a request for the maintenance department to look at the lift should be written in the maintenance request book. The DON was interviewed again on 7/26/23 at 3:40 p.m. She said the facility currently had 26 residents that required a mechanical lift. She said 46 of the facility ceiling lifts were functioning properly, 34 lifts had been removed from resident rooms due to maintenance issues, 15 rooms still had lifts in them that did not work and were tagged not to use and four lifts in the tub rooms were working properly. The DON said seven residents were using a Hoyer lift (floor lift) due to the ceiling lift in their room not functioning properly.

Based on observation, review of the facility's policy, and interviews, it was determined the facility failed to ensure one (Hall 2500) of four medication carts were locked while not in use and unattended. Findings included: A review of the facility's policy titled, Medication Receiving, Storage, and Destruction revised 06/23/2022 revealed, A. Only those individuals who are assisting in receiving, storage, destruction or administration of medications will be allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access to protect each resident's medications from use by other residents, visitors, and staff. During an observation on 08/18/2022 at 8:00 AM, the medication cart on Hall 2500 was observed at the end of residential Hall 2500. The medication cart was unattended and unlocked. At 8:09 AM, Registered Nurse (RN) #6 exited a resident's room. The resident's room (#2506) was two rooms away and approximately twenty-five feet from the medication cart. The door to the resident's room had been closed while the RN was in the room with the resident. The RN returned to the medication cart, placed a stethoscope on top of the medication cart, and walked back down the hallway toward the nurses' station. At 8:12 AM, the RN returned to the medication cart and opened the medication cart drawer, and at that point she appeared to realize the medication cart was unlocked. When RN #6 was asked if the medication cart had been left unlocked, she stated it was. RN #6 was asked what the facility's policy was for securing the medication carts and she stated the medication carts were to be always locked. During the observation, no residents, staff members, and/or visitors walked on the hallway while the cart was unattended and unlocked. On 08/18/2022 at 5:06 PM, the Director of Nursing (DON) stated it had been reported to her that the medication cart had been left unlocked. The DON stated the RN did not usually leave the cart unlocked. The DON added that the carts were to be always locked, and the medication carts should not be left unattended while unlocked. The Administrator was also present during the interview.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain infection control practices during wound care for one (Resident #62) of one resident observed for wound care. Findings included: Review of the facility policy, Skilled Nursing Facility Wound Management, dated 08/18/2022, revealed, G. Infection control practices, including the use of standard precautions, is observed during wound care. A review of the facility's Dressing Change Guidelines, dated 2017, revealed the guideline was prepared and provided for educational and information purposes and to promote the safe and effective use of the products provided. Treatment Procedure 10. Place at designated bedside table which has already been cleaned/prepped for use. Clean field should be arranged per facility policy, and it is suggested to arrange items on field in order of use. Obtain appropriate trash receptacle or red biohazard bag for discarded dressings and used supplies. Wash hands, don gloves and open dressing packs and leave on bottom half of wrapper if possible. Write date, time and initials on cover dressing or pre-cut tape. Marking pen should not run or bleed into dressing. Hang labeled tape pieces on edge of bedside table. 12. Remove gloves, wash hands and scissors. 13. Don gloves, remove soiled dressings. 14. Remove gloves, wash hands, swab scissors with alcohol wipe if used. 15. Don gloves, utilizing aseptic (clean) technique. Continued review revealed, 19. Remove gloves and discard in appropriate receptacle, wash hands. 20. Don gloves for topical/dressing application utilizing aseptic technique. 21. If more than one wound is being treated, the gloves should be removed, hands washed, and fresh gloves applied for each wound. Further review revealed, 26. Wash hands and scissors with anti-bacterial soap. Dry and wipe scissors again with alcohol. Wash hands again thoroughly and dry. A review of Resident #62's electronic health record (EHR) and verified by the Wound Care Nurse (WCN) revealed the resident had four diabetic wounds on the left foot and three pressure ulcers: one on the left ischium, one on the right ischium, and one on the sacrum. During wound care observation for Resident #62 on 08/15/2022 at 12:00 PM, the WCN set up supplies, cut off the gauze bandage roll wrap on the resident's left foot, and placed the scissors on a barrier on the bed. The WCN cleaned and measured the wounds on the left foot. The WCN did not clean her hands or change gloves, and at 12:12 PM, she removed the dressing on the right ischium and the sacrum, changed gloves without cleaning her hands, and then cut two portions of clean wound treatment material to pack the wounds without first cleaning the soiled scissors that had been used to cut the bandage off the left foot. The WCN then cleaned and measured the wounds without cleaning hands or changing gloves between wounds. The WCN then sanitized her hands, changed gloves, repositioned the resident, removed the resident's soiled brief and removed the soiled dressing from the left ischium. While wearing the soiled gloves, the WCN cleaned the wound and measured the wounds without sanitizing her hands or changing her gloves. The WCN then proceeded to dress the foot wounds. During an interview on 08/15/2022 at 12:39 PM, the WCN stated she did not usually clean the scissors, but it made sense to do it. She further stated she should have used hand sanitizer and changed gloves between the wounds and between cleaning and dressing the wounds, and should have cleaned the scissors. She acknowledged not doing those things could be a source of cross contamination and infection risk between wounds. During an interview on 08/18/2022 at 11:33 AM, the Infection Control Preventionist (ICP) stated she expected staff to clean hands, don gloves, remove a soiled dressing, and then clean hands and put on clean gloves before cleaning the wounds. Per the ICP, nurses should don clean gloves to apply any treatments and the dressing. The ICP stated whenever gloves were changed, hands should be cleaned, and the scissors should be cleaned between uses for wound care to prevent the risk of cross contamination of wounds. During an interview on 08/18/2022 at 11:45 AM, the Director of Nursing (DON) stated the nurse should have cleaned the scissors and should have cleaned her hands and changed gloves after removing the soiled dressing and before cleaning the wound and applying the clean dressing. During an interview on 08/18/2022 at 11:49 AM, the Administrator stated she expected the scissors to be cleaned and staff should clean their hands when moving from dirty to clean parts of the dressing change, and between wounds. She stated there could be a risk of infection from cross contamination between wounds

Based on observation, interviews, record review, facility policy review, and facility document review, it was determined that the facility failed to prevent a resident (Resident #36), who was severely cognitively impaired with known wandering and exit-seeking behaviors, from exiting the facility unsupervised on 06/09/2022. This affected one (Resident #36) of three residents reviewed for wandering behaviors. Findings included: A review of the facility's Elopement Prevention and Missing Resident policy, dated 12/15/2004 and revised on 08/15/2022, revealed, The facility provides a safe environment for each resident with avoidance of occurrences that would place a resident in danger. Every effort will be made to prevent an elopement episode while maintaining the least restrictive environment for residents who remain at risk. Interventions will be implemented immediately and will be based upon the individual resident's condition. All departments will be alerted to the wandering/exit seeking actions and asked to watch for the resident near exits and in areas not usually available to residents. A review of the Resident Face Sheet revealed the facility admitted Resident #36 with diagnoses of Alzheimer's disease, dementia with behavioral disturbance, depression, [CONDITION(S)] due to a known physiological condition - sundowning, and a history of falling. A review of Resident #36's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Further review revealed a wandering behavior occurring daily. Resident #36 required supervision of one person for ambulation on and off the unit. A review of Resident #36's care plan revealed a problem of wandering without regard to personal safety and would be at risk of leaving an unsecured environment, started on 07/29/2021 and edited on 06/15/2022. Resident #36 resided on a secure unit with a WanderGuard (a device worn by the resident that would sound an alarm if the resident attempted to exit doors equipped with the WanderGuard door alarm system) started on 06/09/2022. A review of Resident #36's Elopement Assessment, dated 05/25/2022, revealed Resident #36 was at risk for elopement. A review of Resident #36's Elopement Event, dated 06/09/2022, revealed Resident #36 was observed in the facility parking lot by staff and was redirected back into the facility and onto the secure unit without difficulty; no injuries were noted. A review of an incident report, dated 06/09/2022, revealed Resident #36 eloped from the secure unit around 3:25 PM. Registered Nurse (RN) #3 observed Resident #36 walking in the back parking lot from her second-floor office window. RN #3 redirected Resident #36 back into the building and into the secure unit. Using security footage, it was determined Resident #36 exited the facility through the front entrance and was outside alone for approximately six minutes. The Maintenance Director (MD) assessed the secure unit doors and found the doors to be functioning properly. Nursing placed a WanderGuard to Resident #36's right wrist following the incident. A review of Resident #36's August Medication Administration Record (MAR) revealed an order for a WanderGuard to the right wrist and to monitor placement every shift (QS) started on 06/09/2022. During an interview on 08/16/2022 at 1:00 PM, the Director of Nursing (DON) stated RN #3 observed Resident #36 outside in the parking lot from her office window. Resident #36 was not supposed to be outside on their own, so RN #3 went out and redirected Resident #36 back into the building and notified management. The DON was unsure how Resident #36 exited the secure unit, but using security footage, determined Resident #36 exited the building by walking out the front entrance. Resident #36 had no injuries and was outside on their own for about six minutes before RN #3 noticed them. The DON further stated that following the elopement, the Maintenance Director confirmed the secure unit doors locking mechanism was working properly and nursing placed a WanderGuard on Resident #36 to protect against exiting the building unassisted moving forward. Observation on 08/17/2022 at 1:20 PM revealed Resident #36 walking up and down the hallway of the secure unit with a Wanderguard in place on the right wrist. Further observation revealed Resident #36 pushed on the secure unit exit doors which were locked. During an interview on 08/18/2022 at 10:58 AM, RN #3 stated she observed Resident #36 in the parking lot on their own on 06/09/2022. RN #3 stated she knew Resident #36 should not be outside unassisted, so she ran outside to redirect Resident #36 back into the facility and notified management. During an interview on 08/19/2022 at 8:50 AM, the DON stated she expected increased monitoring on the secure units because the residents resided there due to their increased risk for elopement. The DON further stated nursing placed a WanderGuard on Resident #36 following the elopement on 06/09/2022, and no further incidents had occurred. During an interview on 08/19/2022 at 9:10 AM, the Administrator stated she expected residents to have adequate supervision throughout the day on the units where they resided.

Based on interviews, observations and record review the facility failed to ensure a safe, sanitary and comfortable environment was maintained. Specifically the facility failed to ensure isolation precautions were followed by staff for residents who were on isolation in seven rooms. The finding included: Facility Protocol 1. The undated facility Protocol: Preventing the Spread of Influenza documented, in pertinent part: - Implement isolation immediately for influenza-like illness. - Ensure needed supplies are in the room: Biohazard linen and trash containers. - CNA: Obtain biohazard trash container and place inside the resident's room. 2. The undated facility Protocol: Preventing the Spread of Gastrointestinal Illness documented, in pertinent part: - Implement isolation immediately for vomiting and/or diarrhea. - Ensure needed supplies are in the room: Biohazard linen and trash containers. - CNA: Obtain biohazard trash container and place inside the resident's room. Interviews/Observations 1. Nursing Home Administrator (NHA) On 5/22/17 at 10:34 a.m., the NHA said the facility had floor-to-floor isolation system. 2. Second Floor On 5/22/17 at 10:37 a.m., licensed practical nurse (LPN) #1 was interviewed. She said she had two residents on isolation, room [ROOM NUMBER] for contact/droplet precautions for a cough, and room [ROOM NUMBER] for loose stools. She said the facility has been on floor to floor isolation since 5/18/17. She said this was in effect so infections were not spread from floor to floor. On 5/22/17 at 10:51 a.m. room [ROOM NUMBER] was observed with a red bag on the floor full of trash and an empty yellow bag hanging on the door handle. The room had an isolation cart outside by the door. On 5/22/17 at 11:51 a.m., certified nurse aide (CNA) #1 was interviewed. She said when someone was on isolation they would dispose of the trash in the red bags and dirty linen in the yellow bags. She said she would wait until the bags were full then carry them down the hall, past the nurses' station and dining room and into the hall where the dirty utility closet was and dispose of them. She confirmed there were not bins in each room to dispose of dirty laundry and trash when a resident was on isolation. On 5/22/17 at 11:55 a.m. room [ROOM NUMBER], where the resident was on isolation, both small trashcans, lined with a red bag, were observed over flowing with trash, which included visible briefs, a gown and wipes. On 5/22/17 at 12:21 p.m. room [ROOM NUMBER], where the resident was on isolation for loose stools, there was no red bag in the trashcan and a red or yellow bag was not visible in the room. On 5/22/17 at 1:11 p.m. room [ROOM NUMBER] was observed to have a red bag in the trashcan full of trash with a dirty brief on top. At 1:15 p.m. registered nurse (RN) #2 was interviewed and observed the trash in room [ROOM NUMBER]. She said once it was full the CNAs would empty the trash or they would do it at the end of their shift, whether the resident was on isolation or not. She said if the red bag in the trashcan was full they would carry it down the hall to the soiled utility room. 3. First Floor On 5/22/17 at 11:08 a.m., CNA #2 was interviewed in front of room [ROOM NUMBER]. He said the resident was recently admitted and was on isolation. He said we would transport the dirty laundry and trash down the hall wearing gloves and dispose of in the soiled utility closet. On 5/22/17 at 11:15 a.m., RN #1 was interviewed. She said she had two residents who were on isolation, in room [ROOM NUMBER] and room [ROOM NUMBER]. 4. Infection Control Nurse (ICN) The infection control nurse was interviewed on 5/22/17 at 12:36 p.m. She said the CNAs would only dispose of trash in an isolation room when the trashcan was full. She said the housekeeping would assist with emptying the trash. She said she had implemented the floor to floor isolation on 5/16/17 because she wanted to ensure infections were not carried from one floor to another. She said she would use her discretion when floor to floor isolation occurred. - The ICN was made aware of the isolation room observations related to overflowing visible trash and confirmed that was not appropriate and the staff should remove the trash. - She said the facility had just a couple of biohazard bins. She said the bins should be kept in each room to contain biohazard linen and trash containers. She agreed it would be ideal to have one of each (biohazard linen and trash container) in every room for residents on isolation, but they are very expensive. She confirmed currently there were no rooms, in which residents were on isolation, and bins were available to dispose of trash (red bags) and linens (yellow bags). - At 12:45 p.m. a tour was conducted with the ICN and resident rooms who were under isolation precautions were observed. She said in room [ROOM NUMBER] where the trash was overflowing with observed briefs and wipes, there was no need to bag the trash until it was emptied as she considered the entire room to be a dirty environment. - At 12:50 p.m., the ICN walked to the soiled utility closet on the second floor. She confirmed that was the area where the CNAs take the trash in the red bag. She said the CNAs will usually keep one hand gloved and one hand will not be gloved to avoid the spread of germs. She demonstrated grabbing the key from the hook on the highest part of the doorframe with her right hand, unlocking the door with her right hand and opening the door with her left hand, which indicated the difficulty staff would have while holding dirty trash with a gloved hand. - The red bin was observed overflowing with red closed trash bags. She said it was housekeeping's responsibility to empty the trash from the soiled utility room. - The ICN pointed to one empty biohazard trash container located in the soiled utility room. She said housekeeping would generally remove it from the soiled utility room and place it in the room for the resident who was on isolation. She said she would make housekeeping aware but had not had the opportunity yet. Record Review The director of nursing (DON) provided the facility event summary report on 5/22/17 at 12:25 p.m. The isolation data documented the following: 1. Facility Event Summary Report (5/16/17 to 5/22/17) a. First Floor: - room [ROOM NUMBER]: Isolation effective 5/18/17 for droplet isolation d/t (due to) RSV (respiratory syncytial virus). - room [ROOM NUMBER]: Isolation effective 5/22/17 for contact isolation r/t emesis - room [ROOM NUMBER]: Isolation effective 5/21/17 for contact isolation r/t emesis b. Second Floor - room [ROOM NUMBER]: Isolation effective 5/17/17 for contact isolation r/t diarrhea - room [ROOM NUMBER]: Isolation effective 5/17/17 for contact isolation r/t diarrhea - room [ROOM NUMBER]: Isolation effective 5/18/17 for Droplet isolation r/t cough, Isolation started at 1015 am. Monitor/document compliance with isolation. - room [ROOM NUMBER]: Isolation effective 5/17/17 for contact plus: liquid stool, temp(erature) 100.9, Closed 5/22/17.

Based on family and staff interviews and record reviews, the facility failed to ensure that one resident (#1) was free of significant medication errors. Specifically, the facility failed to administer the resident his ordered medication. On [DATE] the medical durable power of attorney (MDPOA) of resident #1, who was currently residing in the facility, reported the facility was discharging the resident on [DATE] due to the cost of the resident's medication and as a result, the facility had not administered the resident's ordered medication timely. Record review and interviews revealed the resident's oncologist had ordered three medications for the resident to start on [DATE]. Two of the three medications were started timely; however, the facility refused to obtain and administer the third medication Revlimid, citing cost and safety (waste) concerns as prohibitive factors. Per the oncologist, Revlimid was a medically necessary medication for the resident to receive. As a result of the facility's action, the resident failed to receive the medication from ,[DATE] to [DATE], which jeopardized his health and created a situation of immediate jeopardy for serious harm. The findings included: I. Immediate Jeopardy (IJ) A. Imposition of IJ On [DATE] at 12:44 p.m., the nursing home administrator (NHA) and director of nursing (DON) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures to timely administer medication left facility residents vulnerable and created a situation of immediate jeopardy for serious harm. B. Facility Response to the IJ The abatement plan was accepted on [DATE] at 2:00 p.m. The IJ remains in effect until the resident is discharged from the facility. The abatement plan included: Corrective action accomplished for residents affected by the deficient practice: The facility completed the following: - Facility reiterated to oncologist and family of the facility's inability to safely and effectively manage the administration of the medication and the resident's care after administration. [DATE] - The facility obtained an order from the PCP to hold the administration of the medication until further orders are obtained by oncology. [DATE], 2:00 p.m. - Both the facility Medical Director (FMD) and the resident's PCP have left messages on the cell phone for the oncologist expressing the urgency to return their phone calls and have not heard back as of this time. [DATE] - [DATE] 1:40 The FMD contacted the oncologist's supervising physician, (ONCS), who provided the Medical Director with the following information: - He stated the medication is not an emergency medication and can wait until oncologist is available to make a determination - He did not feel that the patient needed to be admitted to the hospital to receive the medication - He expressed to FMD, that it was his understanding the medication cannot be provided in a skilled nursing setting based on the safety issues with the medication. - Contacted oncology, awaiting reply - Received order from primary care physician to hold Revlimid pending further orders from oncology - [DATE] 11:15 The facility met with the resident's daughter/Medical Proxy and presented the following options: - The resident remains in the facility and does not receive the medication. - Family accepts this option until they receive the medication. - The medication is currently not available to be administrated as it is only manufactured by one pharmacy in the country and is currently scheduled for delivery on [DATE] to the family's home. - [DATE] 8:05 Referred resident to LTAC (long-term acute care) hospital for inpatient service and administration of the medication. - Social Worker called LTAC and they denied services for anyone receiving Revlimid - [DATE] 8:10 Contacted and referred to other Skilled Nursing Facilities in the community to determine their ability to manage a resident taking Revlimid. Social Worker called the following Skilled Nursing Facilities (SNF)- SNF - Agreed to review further for this Resident, were awaiting reply, Director of Clinical Services left an additional message to determine if they could care for the resident. Received phone call from SNF at at 4:25 pm and they may have a facility that can do chemo precautions and will continue to work through the referral process and will be in touch with our facility SNF - left message, awaiting reply SNF - Denied services for anyone receiving Revlimid SNF - Not accepting admissions until after holiday weekend Discharge the resident home with referral to HHC (Home Health Care) that may have the ability to manage a resident on Revlimid for PT, OT, RN, and CNA services. Referral for 24 hour care by non-medical home care for cuing and non¿ medical needs with family providing direct cares. [DATE] 8:45 Social Worker called the following non-skilled home care services HHC - Denied services for anyone receiving Revlimid HHC - Agreed to review further for this Resident. Denied on further review. [DATE] 9:15 Social Worker called the following home health care agencies: HHC- Denied any services for anyone receiving Revlimid HHC - Denied any services for anyone receiving Revlimid HHC - Denied any services for anyone receiving Revlimid HHC - Agreed to review further for this Resident, accepted resident as they would not be administering the medication or dealing with medical waste. The family would need to administer the medication and a non-medical home care or the family would need to manage the waste (incontinence, emesis, or other body fluids) Discharge the resident to the hospital for administration of the medication. ONCS, managing partner of oncology clinic notified Medical Director that Resident is not appropriate for admission to the hospital. [DATE] at 1:40 ONCS stated to the facility Medical Director that the medication was not emergent. [DATE] at 1:40 The hospital also would not have the medication in stock to be able to administer the medication. Director of Social Services and Discharge Planner met with MDPOA at 11:15am on [DATE] to discuss plan of care and goals. Explained that Resident would not be able to receive Revlimid during his stay at LAHR as it is a safety concern to manage hazardous waste. MDPOA expressed that they do wish for Resident to receive this medication as soon as they receive it from their pharmacy on Saturday [DATE]. Reviewed LAHR recommendation for 24hr care, DME, and possible discharge options; such as home with 24hr care, ALF, or alternative SNF. Daughter expressed that she would like Resident to admit to another SNF, only if it is under a Medicare A stay or discharge home with home health care skilled and non-skilled. Daughter expressed that she would consider ALF if skilled home care was not available. Daughter reported that Saturday would be the goal day for discharge, but was not certain and wished to discuss with Resident and family before making a final decision. Daughter plans to meet with Discharge planner after these conversations occur. Daughter gave consent to send referral to any accepting agencies. [DATE] Director of Clinical Services, RN - spoke with all facilities/agencies who agreed to review the Resident further to ensure they can meet Resident's needs. Excepting HHC who stated that they would be closed and would be resuming admissions on [DATE]. How the facility will identify other residents at risk. - Chart audit by night shift nurses to determine if there are any ordered meds not being administered for any reason. [DATE], Night Shift - Systemic changes to ensure deficient practice does not recur. - The designated Nurse Manager will review the service or medication order at the earliest opportunity and inform the resident/responsible party and the ordering physician of any specific complications on the 151 day the order is received, inquire of service or medication alternatives and/or changes in the plan of care, and request a Hold Order for the service or medication while under review. Education provided. [DATE] - If the facility determines that the ordered service or medication cannot be administered in the facility the facility will request that the service or medication be discontinued or that the resident be transferred to such a location where the administration and management of the service or medication can safely be accomplished. How the facility will monitor performance. All medications or services determined by review to not be in facility's ability to provide will be reported to and reviewed by the QA Committee. II. Facility Policies on Medication Administration A. Physician order [REDACTED]. - If the order is not complete or there are any questions regarding the appropriateness of the order for the resident, the appropriate dose, the appropriate frequency or any other questions or concerns, the ordering provider shall be contacted for clarification prior to administration or beginning treatment. - A licensed nurse shall note the order to indicate the order has been processed and necessary steps taken to proceed with the order. The undated documentation policy documented in pertinent part, Documentation - If it wasn't charted, it wasn't done. B. Review of the facility's policies and procedures revealed no policy regarding the administration of [MEDICAL CONDITION] medications, such as how administration would be evaluated and determinations made on administration within the facility. III. Allegation of Facility Refusal to Administer Necessary Medication to Resident #1 A complaint was received by CDPHE alleging resident #1 was being discharged on [DATE] because the facility would not administer the resident a medication, Revlimid, ordered by his oncologist. Record review revealed resident #1, age 79, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the resident's face sheet, he had [DIAGNOSES REDACTED]. IV. Revlimid and Administration of [MEDICAL CONDITION] Drugs A. Professional Reference 1. Revlimid According to Sruti Krishna, The Myeloma Beacon, Study Finds Revlimid-[MEDICATION NAME] Is Effective And Safe For Relapsed/Refractory Myeloma In 'The Real World', [DATE], <http://www.myelomabeacon.com/news/[DATE]/revlimid-lenalidomide-[MEDICATION NAME]-relapsed-refractory-myeloma> ([DATE]), in pertinent part: - Study's findings confirm that Revlimid <http://www.myelomabeacon.com/resources/[DATE]/revlimid/> (lenalidomide) plus ¿¿[MEDICATION NAME] <http://www.myelomabeacon.com/resources/[DATE]/[MEDICATION NAME]/>([MEDICATION NAME]) is effective and safe in day-to-day use among relapsed myeloma patients; - The majority of the patients in the study (77 percent) responded to treat¿ment with Revlimid and Dexa¿metha¿sone, with 20 percent achieving a complete response; and - Revlimid plus Dexa¿metha¿sone is more effective as a treatment for [REDACTED].¿metha¿sone alone, and numer¿ous clinical studies have further studied the efficacy and safety of the combination. 2. Administration of [MEDICAL CONDITION] Drug - Discussion of Risks According to Department of Health and Human Services, Center for Disease Control and Prevention, National Institute for Occupational Safety and Health, NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016, DHHS (NIOSH) Publication No. ,[DATE], Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Cincinnati, OH, 2016, pp. 8 & 32. Pertinent information included: - The actual risk to healthcare workers depends on toxicity of the drugs, how the drugs can enter the body (e.g. dermal, inhalation, or ingestion), and how the drugs are handled; - Dispensing a single tablet to a patient may pose a relatively low risk to the healthcare worker. A single pair of gloves may be adequate; - Intact tablet or capsule, administration from unit-does package, single gloves can be used, no protective gown required, no respiratory protection required and no respiratory protection required; and - Working with hazardous drugs in health settings: drugs and metabolites in body fluids, disposal and cleaning, double chemo-therapy gloves required, protective gown required, eye/face protection required if liquid that could splash, and respiratory protection required if inhalation potential exists. B. Interviews with Oncology Clinic Staff On [DATE] at 9:50 a.m. the Oncology Pharmacy Clinical Coordinator (OPCC) was interviewed. -The OPCC said that [MEDICATION NAME] was a supportive medication for the [MEDICATION NAME] and the Revlimid. She said the [MEDICATION NAME] and the Revlimid were more effective when used together to treat the myeloma. She said that patients live longer when using the combination. She said there was very little effect when a patient was using [MEDICATION NAME] alone. She said the standard is the combination of both [MEDICATION NAME] and Revlimid. She said the Revlimid required a specialty pharmacy to develop the compound and would usually arrive in approximately 48 hours after ordering the medication. -The OPCC provided a copy of the NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016. She said the NIOSH guidelines contained information about manufacturing guidelines for administering and handling Revlimid which was a Table 2. Group 2 drug. She said she was surprised to hear that the facility was not willing to administer the medication and said it was an uncommon response from a facility to not want to administer the medication to one of their residents. She said other similar facilities that she had worked with were willing to administer the same medication to their residents. IV. Facility Failure to Ensure Resident #1 was Free of Significant Medication Error A. Oncology Center Documentation Review of documentation from the oncology center revealed orders were written to restart resident #1's Revlimid on [DATE] and received by the facility on [DATE]. On [DATE], the facility declined to restart the medication which the oncologist felt was medically necessary for the resident to receive at the facility. Although indicating on [DATE] that it would administer the medication, the facility ultimately determined it would not. 1. Medical Records A copy of the resident's concerns was provided on [DATE] at 10:10 a.m. by the Oncology Pharmacy Clinical Coordinator (OPCC). The concerns included, in pertinent part: - [DATE] at 9:34 a.m.: Documented by resident's oncologist's nurse Received message from RN (registered nurse from (facility name). There were concerns for decrease in cognition yesterday [DATE]. According to last note on [DATE] with NP (nurse practitioner) pt (patient) have varying degrees of confusion. As of yesterday he was A&Ox0 (alert and oriented times zero). The RN today has not done her assessments. She will contact me back once her assessment is completed. A copy of the resident's treatment plan was provided on [DATE] at 10:10 a.m. by Director of Oncology Operations (DOO) the treatment plan included, in pertinent part: - [DATE] at 12:55 p.m.: Documented by resident's oncologist to the oncologist's nurse Revlimid restart. - [DATE] at 2:38 p.m.: Documented by oncologist's nurse to financial counseling Pt (patient) to restart Revlimid. Plan signed by provider A copy of the resident's Medication Clarification was provided on [DATE] at 10:10 a.m. by OPCC. The Medication Clarification included, in pertinent part: - [DATE] at 2:07 p.m.: Documented by resident's oncologist's nurse Received call from pt's wife. [MEDICATION NAME] was stopped in the hospital .Pt wife feels that since stopping the [MEDICATION NAME] he has increased cognitive decline. She is inquiring if pt should be put back on this med .Pt is currently admitted to obs (observations) at hospital. - [DATE] at 1:19 p.m.: Documented by resident's oncologist nurse Pt to restart [MEDICATION NAME] and Revlimid 5mg. Orders placed by provided. M (message) for pt's wife to contact me back to discuss. - [DATE] at 12:01 p.m.: Documented by resident's oncologist nurse Revlimid approved and sent to (Name) Specialty Pharmacy. [MEDICATION NAME] sent to (Pharmacy Name) on file. Orders faxed and sent to (nursing facility name) where pt currently resides. Facility will run meds through Director of Nursing (DON) for approval. They will notify me once approved. - [DATE] at 12:21 p.m.: Documented by resident's oncologist nurse Discussed information with (DON's name) at facility. They are unable to let pt use home supply of Revlimid due to regulations. She states that pt should be d/c (discharged ) in about 3 days. Family is having care meeting at center today. DON to call me following family meeting to let me know plan. ¿- [DATE] at 4:11 p.m.: Documented by resident's oncologist nurse DON returning call regarding plan of care. Pt will be d/c in the next few days. D/C planner is working with family to find a F (facility) for pt. They have started him on [MEDICATION NAME]. Facility not approving pt brining in Revlimid from home. Pt will not be able to start this until he is home. - [DATE] at 4:22 p.m.: Documented by resident's oncologist nurse, note to oncologist Pt will not be able to re-start Revlimid until home. Facility has declined request for pt to restart. - [DATE] at 8:19 a.m.: Documented by resident's oncologist to Manager, Clinic Operations (MCO) at oncology center, I am having issues with patients in rehab. They are refusing to give him his oral chemo ([MEDICAL CONDITION]) while there. He is likely going to pass away either way as his prognosis is quite poor, but I feel this is wrong to withhold that from him. What should we do about this? - [DATE] at 8:35 a.m.: Documented by resident's oncologist nurse to oncology nurse practitioner The rehab center is declining the use of home meds for this pt. I have spoken with the DON at rehab multiple times to try and get it approved. On [DATE] at 9:10 a.m. the patient service coordinator (PSC) from the Oncology Center was interviewed, via telephone. The PSC said she had talked with the facility DON the day before ([DATE]), in the afternoon. She said the DON said the facility would be willing to administer the Revlimid to the resident at the facility. She said she provided information, via fax, to the facility which included prescribing information and boxed warnings for Revlimid. 2. Emails from Oncology Center Staff On [DATE] at 9:26 a.m. the patient services coordinator (PSC) from the oncology center provided email communication between the PSC and resident #1's oncologist. The documentation revealed, in pertinent part: - [DATE] at 5:22 p.m. - Email from the PSC to the oncologist: Is it your opinion that this patient would suffer an adverse outcome due to having the Revlimid withheld for the period he is anticipated to reside in the rehab facility? The facility is refusing to provide the medication, refusing to allow the family bring what he has from home, daughter is concerned that he has become progressively worse since his admission to the SNF (skilled nursing facility/facility) and is worried that not receiving his Revlimid is contributing to his rapid decline. Is it your opinion that it is medically necessary for him to receive it while he's in the SNF, then they were obligated to provide it as the (SNF) assessed him for appropriateness of admission. I plan to contact the director of nursing Monday ([DATE]) to further investigate the issue - the daughter got the impression that they won't let her bring his home supply in for verification/administration because of Medicare were to audit, they would be expected to provide the Revlimid. - [DATE] at 4:09 p.m. - Response email from oncologist to PSC: I do feel it is medically necessary. - [DATE] at 1:57 p.m. - Response email from PSC to oncologist and oncologist's nurse: I contacted the director of nursing (Name) at facility - they are working on getting the Revlimid for the patient. - [DATE] at 2:29 p.m. - Response email from oncologist nurse to oncologist and PSC: I have faxed them what I have that we give out at pt (patient) education. Interview on [DATE] at 9:10 a.m. with the PSC by phone confirmed she had talked with the facility DON on [DATE], in the afternoon. At that time, the DON said the facility would be willing to administer the Revlimid to the resident at the facility. She said provided information, via fax, to the facility which included prescribing information and boxed warnings for Revlimid. On [DATE] at 4:51 p.m. the PSC sent an email to the oncologist, the subject was: Resident's Revlimid. The email included, in pertinent part: We just received a call from the DON at (facility name) - apparently the SNF is not going to provide his Revlimid (or allow the family to bring his home supply in for verification and administration), and they are therefore going to discharge (resident #1) to home Tuesday ([DATE])? He really needs to be taking his Revlimid . he ' s already been without it for more than a week, and according to reports we ' re receiving, his health has rapidly declined since admission to the SNF On [DATE] at 8:31 p.m. the PSC sent an email to the oncologist, the subject was: Resident's Revlimid. The email included, in pertinent part: Just a quick update, (DON) is stating that (facility) can ' t properly handle/dispose of the contaminated bio-waste associated with a patient taking oral [MEDICAL CONDITION] agents like Revlimid. This declaration comes after she told us Wednesday ([DATE]) that they WOULD provide and administer his Revlimid, and they were just working on how to acquire it. They waited to call us until 1645 (4:45 p.m.) on a Friday evening, ensuring that we would not be able to dispute their decision until Monday, at which point fighting with them would be pointless, since they ' re discharging him Tuesday. The waste handling for patients on Revlimid should be treated just as they would treat waste and contamination risk [MEDICAL CONDITION] .Red biohazard bags for waste disposal, gloves, and bleach would be required .strict non-contact is really only indicated in women of child-bearing age who may be pregnant or are pursuing pregnancy . We feel it is arguably inappropriate for the SNF to be claiming that the patient ' s placement in this facility is inappropriate after 2 weeks, and essentially ignoring the Revlimid order sent [DATE] until they were confronted . We also feel it could be argued that their decision to withhold treatment has caused potentially irreparable harm to the patient and great distress to his family members . They didn ' t even ask for information regarding Revlimid precautions until I called the DON [DATE] to dispute their withholding tx (treatment). This patient ' s treatment has been delayed 9 days now, and his daughter reports his condition has rapidly declined since his discharge from the hospital. B. Facility Documentation and Interviews Regarding the Administration of Resident #1's Revlimid 1. Care conference Record review revealed a care conference regarding the administration of Revlimid was held on [DATE]. The reasons the facility refused to administer and resident #1's options were discussed. Interviews confirmed the family was told Revlimid was not covered by Medicare and would not be administered by the facility to the resident #1. a. Non- interview information on care conference 1) On [DATE] at 4:10 p.m. the MDSC provided an undated summary from the care conference held on [DATE]. The note read in pertinent part: - RCC (resident care conference) occurred on Thursday, [DATE]th, discussion occurred regarding administration of the medication Revlimid (lenalidomide). This writer (Nurse Manager) (MDSC) explained that specific medication is excluded under a Medicare Rehab stay. - Family requested to see a list of excluded medications, referred to BOC (Business Office Coordinator) and Administrator. Multiple discharge options were discussed that could expedite administration of medication if that was what the family so desired. - The follow-up plan also included finding out if it was medically necessary to administer the medication prior to discharge despite discharge anticipated in next few day or if arrangements needed to be made to receive medication at an alternate location. Contrary to the above summary, the Medical Records Supervisor (MRS), interviewed on [DATE] at approximately 12:30 p.m., said she was not aware the MDPOA/Proxy had requested a list of medications that were not covered by Medicare. She said she had asked other staff, including the business office manager (BOM) and the DON, if they were aware that the family had requested this documentation. She said both the BOM and the DON were not aware of such a request. 2) Progress Notes The resident's progress notes revealed, in pertinent part: - The SW progress note, recorded as a late entry on [DATE] at 4:38 p.m. documented Family inquired [MEDICAL CONDITION] medication that resident is unable to receive while in facility. NM (nurse manager) explained that all medications and treatment must be approved and this medication was not approved at this time. Family has additional questions about this med (medication), NM to follow up. 3) Recording of Care Conference On [DATE] the MDPOA/Proxy provided, via email, a recording of the resident care conference held on [DATE]. The MDPOA/Proxy said the SW, the speech language pathologist (SLP) and the MDSC attended the care conference with multiple family members and the resident. The MDPOA/Proxy said the MDSC told the family the facility had gotten verification from the NHA that Revlimid was not covered under Medicare A benefits. Therefore, if the family wished to pursue [MEDICAL CONDITION] medication, he could not receive it at the facility and the facility would pursue discharge planning. Review of the recording confirmed the MDSC's statements to the facility regarding the facility's position on administering Revlimid and that administration would require discharge. b. Interviews on care conference 1) Interview with Social Worker (SW) On [DATE] at 1:25 p.m. the SW was interviewed. She confirmed she attended the care conference with the SLP and the MDSC. She said family members and the resident also attended including the MDPOA/Proxy, the resident's son-in-law and the resident's spouse. She said during the care conference the MDSC explained the medications the resident was currently taking. She said the family discussed [MEDICAL CONDITION] medications but they were told [MEDICAL CONDITION] medication was excluded from the resident's stay because the medication was not covered by Medicare. She said the MDSC said to the family that ultimately the NHA would decide whether the facility would pay for the medication. She said she knew the MDSC was working with the family. She said the last covered day was discussed and notified the family the last covered day was [DATE]. She said she was not certain whether the medication was covered or not but knew the DON and/or ADON was working on it. She said she was aware the family wanted the [MEDICAL CONDITION] medications but she said it was not approved by the NHA. She said all she knew was that some medications do not go in the Medicare Purse and others do. She said usually typical medications are approved while a resident received rehab services. 2) Interview with MDSC On [DATE] at 1:58 p.m. the MDSC was interviewed. She confirmed she attended the [DATE] care conference. She said she discussed overall nursing concerns during the care conference. Although she would not confirm that she had told the family that if the resident wanted to receive Revlimid he would have to seek alternate placement, she said she had learned prior to the care conference that Revlimid was not covered by Medicare A and she informed the family of this. She said the facility not only looks at cost of a medication but also looks at the safety of administering a medication, whether there was [MEDICAL CONDITION] certified nurses who could administer the medication, the ability to manage waste from the medication and the safety of the resident receiving the medication. She said during the care conference the last covered day was discussed, which was [DATE]. She confirmed that during the care conference they discussed discharge options and encouraged the family to discuss what they would like to do next. 3) Interview with Speech Language Pathologist (SLP) On [DATE] at 2:25 p.m. the Speech Language Pathologist (SLP) was interviewed. She confirmed she was in the care conference which was held on [DATE]. She said the MDSC attended the care conference and discussed with the family that the [MEDICAL CONDITION] medication was not covered by Medicare and was not directly related to the resident's rehabilitation stay. She said the son-in-law who was attending the care conference asked whether the family could purchase the medication and have the facility administer the drug. She said the MDSC said that was not allowed. The SLP said the daughter, also the MDPOA/Proxy, requested guidelines as to why the medication could not be administered if the family brought the medication in and what medications were covered with Medicare A benefits. The SLP was asked if the MDSC told the family during the care conference that if they wished to pursue receiving the Revlimid the resident was not able to receive it in the facility and an alternate discharge plan would be discussed. The SLP said, that sounds about right. 2. Medication - Record Review and Interviews a. Record review On [DATE] at 1:58 p.m. the DON and the MDSC provided a copy of the fax received by the facility from the hospital on [DATE] at 11:30 a.m. Review of the fax revealed it included a cover page and three medication orders from the resident's oncologist. The orders included: - [MEDICATION NAME] ([MEDICATION NAME]), ([MEDICAL CONDITION] drug), 400mg to start on [DATE], two times daily, take one tablet by mouth daily. - Lenalidomide (Revlimid), (Immunomodulatory drugs), 5 mg to start on [DATE], one capsule by mouth daily, take on days one through 21 out of a 28 day cycle. Written in by the Lenalidomide was $18,000 28d (day) - [MEDICATION NAME] ([MEDICATION NAME]), (corticosteroid), 40 mg to start on [DATE], 5 capsules by mouth once a week [MEDICAL CONDITION]. On the bottom right corner of the [MEDICATION NAME] and [MEDICATION NAME] orders were documented noted [DATE] (nurse initials). b. Interview The registered nurse/unit manager (RN/UM) was interviewed on [DATE] at 7:07 p.m. She confirmed there was no documentation on [DATE], noting the resident's order for Revlimid and said she had never had heard of the medication. She confirmed the resident started both Acyclovair and [MEDICATION NAME], as ordered. She reviewed progress notes and confirmed there were no notes from facility staff to indicate facility staff initiated contact with oncologist to start the Revlimid. On [DATE] at approximately 10:50 a.m. the ward clerk/licensed practical nurse (LPN #2) was interviewed. She said when an order was received via fax the nurse would fax the request to the pharmacy to determine availability. She said if there were any problems with the medication or if the medication was not available the family and the physician would be notified and a progress note would be written regarding the notifications. On [DATE] at 11:05 a.m. RN #2 was interviewed. She was provided a copy of the faxed orders above. She confirmed her initials were in the bottom right corner of both the [MEDICATION NAME] and [MEDICATION NAME]. She said her initials indicated that she had entered the order into the computer on [DATE]. She said she had never seen the order for the Lenalido

Based on family and staff interviews and record reviews the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for three residents (#1, #4, #2) of six sample residents. Specifically: Resident #1: Cross Reference F333: Failure to Administer Medication Ordered by Oncologist On [DATE] the medical durable power of attorney (MDPOA) of a resident, who was currently residing in the facility, reported the facility was discharging the resident on [DATE] due to the cost of the resident's medication and the facility had not administered the ordered medication; therefore, the resident had not received the medication ordered on [DATE] for the next 21 days. Record review and interviews revealed the resident's oncologist had ordered three medications for the resident to start on [DATE]. Two of the three medications were started timely; however, the facility refused to obtain and administer the third medication Revlimid, citing cost and safety (waste) concerns as prohibitive factors. Per the oncologist, Revlimid was a medically necessary medication for the resident to receive. As a result of the facility's action, the resident failed to receive the medication from ,[DATE] to current date ([DATE]), which jeopardizes his health and created a situation of immediate jeopardy for potential for serious harm. Residents #4 and #2 the facility failed to: - Follow physician MEDICATION ORDERS FOR [REDACTED] - Ensure resident's medications were readily available for administration The findings included: I. Immediate Jeopardy (IJ) A. Imposition of IJ On [DATE] at 12:44 p.m., the nursing home administrator (NHA) and director of nursing (DON) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures to timely administer medication left facility residents vulnerable and created a situation of immediate jeopardy for serious harm. B. Facility Response to the IJ The abatement plan was accepted on [DATE] at 2:00 p.m. The IJ remains in effect until the resident is discharged from the facility. The abatement plan included: Provision of necessary care and services to attain and maintain the residents highest's practicable physical, mental and psychosocial well being Current Plan of Care Nursing: Nursing staff continue to provide cares to resident in order to achieve highest level of function as possible. - Resident has history of chest pain requiring use of PRN Nitro at times. Resident's risk for unrelieved chest pain will be minimized by the following approaches; monitor and record any complaints of pain: location, sensation, [MEDICAL CONDITION], duration, alleviating factors. Obtain vital signs during episodes of pain per facility protocol. Encourage resident to take [MEDICATION NAME] as soon as pain begins. Stress to resident importance of stopping all activity as soon as pain begins. - Anti-coagulant medication (ASA) therapy related to CAD. Resident's risk for side effects from the use of anti-coagulant medication will be minimized by the following approaches; administer medication as ordered, consult MD about changes in drug regimen, monitor for excessive bleeding and/or bruising. - Resident with [DIAGNOSES REDACTED]. The goal is to minimize risk for complications will be minimized by the follow approaches; Monitor food and fluid intake, monitor for acute episodes of pain, monitor vital signs and labs for any changes, monitor bowel habits, and psychosocial needs. Report any significant changes to PCP and/or oncologist. Resident is at risk for potential skin break down related to decreased mobility. Goal is for risk to be minimized by using the following approaches: Check frequently for incontinent episodes and provide peri care after each episode, check skin weekly during baths, keep skin clean and dry, provide diet, supplements, vitamins/protein/minerals as ordered to promote skin integrity. - Resident has impaired daily decision making related to BlMs score of ,[DATE] indicating moderate impairment. Goal for resident is to complete his activities of daily living (ADLs) with use of daily structured programs. This is approached by calming resident if signs of distress develops during the decision making process, do not rush resident and allow extra time for processing thoughts, structure resident choices (ex: would you like to wear the red or blue shirt today?), provide cues and supervision for ADLs and provide the resident opportunities to make decisions independently. - Resident experiences incontinence related to unknown cause. Suggesting urge incontinence. Benefits from a prompted toileting program to improve/ maintain continence. Program is based on resident's voiding pattern. Resident is able to feel urge and not calling for assist. Likes urinal and benefits from staff prompting. Goal is for resident to remain clean, dry, and odor free. This is approached by following prompting toileting schedule, apply barrier cream to skin after each incontinent episode, report any signs of skin breakdown, report any signs or symptoms of infection, use incontinent product when resident in and out of bed. - Resident has impaired visual function and wears glasses for compensation. Goal is for resident to use appropriate visual appliance to negotiate environment. This is approached by assuring resident's glasses are clean and in good repair, arrange ophthalmologist consult as needed, assure the floor is free of glare, liquids or foreign objects, keep call light in reach at all times, orient resident when there has been new furniture placed or other changes in the environment, keep environment free of clutter, provide resident/family community resources, report any concerns or changes to vision to doctor. - Resident is at risk for fluid imbalance related to decreased fluid intake, disease process, and need for extensive cueing for meals/ fluids. The goal is to minimize risk of fluid imbalances by the following approaches daily; assess for dizziness on sitting, standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, cracked lips, dry mucous membranes, fever, infection, monitor intake and output as needed, and keep fluids accessible. - Resident has complaints of chronic pain. The goal is to minimize risk for experiencing pain. This is approached by assessing for pain daily, utilize non¿ pharmacological approaches such as calm environment, distraction, repositioning, relaxation techniques, reassuring words/ touch, ice or heat, position for comfort with support as necessary, administer pain medications as needed, assess effectiveness of pain medications, report to provider if pain is not controlled. - Resident's ability to perform ADLs has deteriorated since hospitalization . The goal is for resident's risk for further deterioration will be minimized by the following approaches; follow physical therapy recommendations, follow occupational therapy recommendations, allow extra time to complete ADLs, have consistent approach among caregivers, monitor for pain or intolerance with ADLs, provide frequent rest periods, report any further deterioration to doctor. - Monitor for adequate pain control; was seen by nurse practitioner on ,[DATE] who ordered: [MEDICATION NAME] 25 mcg q (every) 72 hours. Nursing staff continue to monitor for increasing confusion and/or change in LOC of pain. - Change in status noted on [DATE]. Monitor for increased confusion, meal refusals, monitor for upper extremity tremors. - CNA's continue to provide Resident with contact guard assistance using FWW for transfers and ambulation for short distances, frequent cues for safety, wheelchair for long distance mobility, minimum to moderate assistance for ADLs, and restorative dining for meals. Nutrition: Restorative dining to continue. Resident has an alteration in nutritional status related to increased calorie and protein need for weight stability as evidence by increase in activity throughout the day. Staff has noted a significant weight decline since admission. Goal is to be able to accept meals and snacks throughout the day. Approaches are providing a regular diet as ordered, offer snacks, offer supplements as ordered, and monitor weekly weights. Registered Dietician will continue monitoring resident through direct observation and chart review. Physical, Occupational, and Speech Therapy: The Resident will continue PT/OT services until discharge where they are working on strengthening and transferring. Therapeutic Pass for Thanksgiving day- SW met with Resident and daughter. Resident is requested a therapeutic pass to go home for thanksgiving dinner on [DATE]. SW set up car transfer training with Therapy and the daughter. Car transfer training was completed on [DATE]. Received order for pass from NP. Resident and family are appreciative of this. Physical Therapy (PT) note for pass [DATE] - Car Transfer training completed with pt's daughters in preparation of therapeutic pass for holiday. Daughters instructed on gait belt application and use - facility belt left in pt's room for family use. Daughters instructed on car transfers and pt able to get in/out of car with cueing and Minimal assistance. Instructed daughter's on how to safely maneuver wc (wheelchair) up/down platform steps in order to enter daughter's home. Toilet transfer training reviewed. Daughter's both expressed understanding. Activities: Activity staff has been encouraging and inviting resident for group activities. Resident has attended an intellectual activity, accepted visits from the chaplain, been outdoors when the weather was nice, attended a music program, and exercise group since admission. Resident often declines to attend the group activities. Resident has accepted visits with staff on a daily basis. Resident, at times, has requested staff to read the daily activity sheet to him, staff will then read the activity sheet to resident. Resident is on the extra newspaper list, resident has received the newspaper. Resident's daughter has been present on a regular basis, often throughout the majority of the day. Staff will continue to invite and encourage activities of interest, provide visits as tolerated, and provide materials desired for leisure. Discharge Goal: Goal at Admission [DATE] - the residents stated goal was to discharge home. Discharge Planning: Resident skilled Medicare stay ended [DATE]. Responsible Party appealed to Kepro on [DATE], 1:00pm. Kepro found not in the resident's favor and that Medicare coverage to end [DATE]. Responsible Party submitted 2d level appeal to Maximus on [DATE]. [DATE] at 5:40 p.m. Maximus found not in the resident's favor and that Medicare coverage ended [DATE]. [DATE] 11:30am. Resident's daughter/Medical Proxy notified SW that resident plans to discharge home with his spouse next Tuesday, [DATE], with non-skilled and skilled HHC services. Resident ordered a w/c. Wheelchair delivered to the facility prior to discharge. The SW was notified that the wheelchair may not be covered by Medicare; daughter notified. Daughter reports that the resident has all medications at home, with exception of pain medication started today; Nurse Practitioner to write script for pain medication. Discharge Planning is continuing and ongoing to meet the Resident's needs and goals. Corrective action [DATE] - The Corporate Clinical Director (CCD) called the facility Medical Director (FMD), at 9:57 am on [DATE] to discuss the situation about possible discharge arrangements if the family wanted the resident to get the medication. The CCD let him know we needed physician input in the plan and really needed to reach the oncologist. The FMD reported he would coordinate with the resident's PCP, to reach oncology for input. - 11:15 Social Service Director, Discharge Planner, and Business Office Coordinator spoke with resident's daughter/proxy in facility, reviewed SNF ABN, discharge goals, and pending appeal. Scheduled meeting for end of business day. To further discuss the following options: Explained that Resident would not be able to receive Revlimid during his stay at LAHR as it is a safety concern to manage hazardous waste. Daughter expressed that they do wish for Resident to receive this medication as soon as they receive it from their pharmacy on Saturday [DATE]. Reviewed LAHR recommendation for 24hr care, DME, and possible discharge options; such as home with 24hr care, ALF, or alternative SNF. Daughter expressed that she would like Resident to admit to another SNF, only if it is under a Medicare A stay or discharge home with home health care skilled and non-skilled. Daughter expressed that she would consider ALF if skilled home care was not available. Daughter reported that Saturday would be the goal day for discharge, but was not certain and wished to discuss with Residents and family before making a final decision. Daughter plans to meet with Discharge planner after these conversations occur. Daughter gave consent to send referral to any accepting agencies. - 11:16 The resident's PCP called the CCD and reported he had spoken with FMD and PCP had left a message on oncologist's cell phone expressing urgency to contact him directly on his cell phone. - The CCD sent a text message to PCP at 12:18 to see if he had been able to reach oncologist. PCP contacted the CCD at 12:23 and reported he had left a message on oncologist's cell and PCP was keeping his phone at his side . - The Director of Clinical Services received another text from PCP at 12:29 reporting he left another message on oncologist cell expressing the urgency of having oncology input to the patient's plan of care. - The Director of Clinical Services sent a text to FMD at 12:26 asking if he had heard from oncology and he said he was waiting for PCP to discuss the clinical situation first so he had not tried. FMD was informed that PCP had not heard back and FMD stated he would escalate with the oncology office and see if an alternate oncologist could assist with the resident . - The facility Medical Director contacted the oncologist's supervising physician, Oncology Supervisor (ONCS), who provided the Medical Director with the following information on [DATE], which FMD communicated to the facility at 1:40pm: ONCS stated the medication is not an emergency medication and can wait until Dr. Shuster is available to make a determination, ONCS expressed to FMD, the facility Medical Director, that it was his understanding the medication cannot be provided in a skilled nursing setting based on the safety issues with the medication. - 2:00pm PCP gave verbal hold order the administration of the medication until further orders were obtained by oncology. - 5:40pm Family chooses the option of resident remaining in facility until [DATE]. The family has requested to set a discharge plan for [DATE], as they feel this is the best day for them to be ready to meet Resident's needs at home. They understand and are in agreement with the plan that Resident will not receive this medication while at LAHR. - Heard back from Sava at 4:25 pm on ,[DATE] and they may have a facility that can do chemo precautions and will continue to work through the referral process and will be in touch with our facility - ,[DATE] 5pm discussed this with daughter/Proxy. Daughter declined as they now feel discharge home on ,[DATE] is the best option for them. - Home Care Agency - Agreed to review further for this Resident, accepted resident as they would not be administering the medication or dealing with medical waste. The family would need to administer the medication and a non-medical home care or the family would need to manage the waste (incontinence, emesis, or other body fluids). [DATE], initial call was around 2:00 pm with a return call at 3:01 pm. [DATE] at 1:30 pm: ONCS stated to the facility Medical Director that the medication was not emergent. How the facility will identify other residents at risk. - Chart audit NOC shift. [DATE] Night Shift - Review of pending order file. [DATE] 10:30pm - NM statements that they review all new orders and have no pending orders in their possession. [DATE] Systemic changes to ensure deficient practice does not recur. The corporation has specially trained admissions liaison's who prescreen all residents prior to admission. They then refer potential residents to the facility admission's coordinator who works closely with the Director of Nursing, Director of Social Services, and the facility Administrator to determine if potential resident's needs can be met based on assessment and identified needs at that time. The facility has worked closely with all area hospitals to ensure a transparent process related to referrals and to ensure necessary information is received prior to accepting the potential resident. Work on this effort has been done through Joint Operating Committees between corporation and nearby hospitals, as well as through transitions of care work groups and meetings with both organizations. Corporation hospital liaisons, facility admissions coordinators and key facility staff have direct access to the electronic medical records for community hospitals, so the facility is able to review information not only provided by the hospital for review, but is also able to review additional information in the electronic medical record. We have also been able to collaboratively review cases through the Joint Operating Committees in the past when it was felt corporation did not receive needed information or if the hospital did not receive needed information if residents were transferred to the hospital, and corrective actions have been taken as identified and the process has improved greatly over the past few years to ensure smooth transitions of care. These committees remain active and include not only the hospitals, but also membership from primary care and specialty physician practices to ensure better coordination and transitions of care throughout the community. Members of these committees are able to review specific cases and help determine widespread actions for improvement. The facility strives to admit all residents that would like to receive care and services at the facility and does not wish to exclude residents [MEDICAL CONDITION] [DIAGNOSES REDACTED]. process related to hazardous waste should the treatment plan change. This information is also well known to hospital discharge planners. Two processes will be improved and outlined below and will include the preadmission process and the process after admission separately. Pre-admission process: - The admission assessment will include review of potential need for medications and/or services that are beyond the ability of the facility to provide. On identification of such possibility the Corporation Hospital Liaison and the facility Admissions Coordinator will work with the Director of Nursing, the facility Administrator, other facility department heads as needed, and the CHS Director of Clinical Services to determine whether the potential resident's needs can be met at the facility. - If potential resident needs cannot be met at the facility, the referral/responsible party will be notified and such communications will be documented on the inquiry/referral form. - The facility has revised its Reasonable Accommodation policy to further clarify that there are certain medications and procedures that are beyond the facility's ability to provide. - This includes, but is not limited to [MEDICAL CONDITION] agents requiring yellow bag process related to handling hazardous waste; ventilators, including invasive and non-invasive; chest tubes to water seal; peritoneal [MEDICAL TREATMENT]; and IV push medications unless approved through the Director of Clinical Services or Director of Nursing at the facility. Since the facility can get referrals for medications, services, and treatments that have not been done before at the facility and the types of referrals are ever changing, it is not possible to list all scenarios that could occur. There can also be referrals that require a higher intensity or frequency of nursing monitoring and intervention that are beyond what the facility can provide, such as the types of patients who are cared for in a long-term acute hospital or an acute care hospital. It is not possible to list all possible scenarios, which is the reason for having trained admissions liaisons who prescreen residents and then involve others as needed, including both facility and corporate level employees. Post-admission process: - The facility Ward Clerks process orders that are received by the facility. They are already familiar with the types of medications typically given by the facility, the treatments typically prescribed to residents of the facility , and the services the facility typically provides. The Ward Clerk will also review medications, treatments and services whose cost is excessive in order to determine a payment source, any prior authorization that is needed, and to obtain permission by the resident/POA. - If the Ward Clerk identifies a medication, treatment, or service they are unfamiliar with, or that is not one routinely administered/provided at the facility, or is one they are aware cannot be provided at the facility, or one that is excessive in cost, the Ward Clerk will provide a copy of the order to nurse manager (original must stay on the chart) within one hour of identification of the order. - The Nurse Manger will research information regarding the medication, treatment or service being ordered and possible scenarios and actions including the following; - If the Nurse Manager is unfamiliar with the medication, treatment or service being ordered, the nurse manager will research information and will collaborate with the Director of Nursing, facility Administrator, and the CHS Director of Clinical Services to determine if the facility is able to provide the medication, treatment or service being ordered and to ensure all systems are in place to safely manage the resident if it is determine it can be provided. - For high cost medications, treatments, or services, the Nurse Manager will involve the Business Office Coordinator (BOC) to determine payment source and begin the prior-authorization process if needed. The Nurse Manager will also contact the ordering physician for treatment options that might be less costly in the event the medication, treatment or service is not covered. - If it is determined the medication, treatment or service is unable to be provided by the facility, the ordering provider will be contacted and information provided regarding why it can't be provided and to determine if there are alternate medications, treatments or services that are possible or if the resident needs to be discharged to an alternate location to receive the medication, treatment or service. Communication will be made promptly with the resident/POA regarding information and available options. - In order to ensure the process occurs within a reasonable timeframe, the following changes are being made: - The Ward Clerks and Nurse Managers will be educated regarding classes of medication and possible services that require additional review. Education has been started and will be completed by 11/ 28/ 2016. - The designated Nurse Manager (of which there are seven Nurse Managers - either the Nurse Manager assigned to the resident in question or On-Call Nurse Manager for weekends and off hours or the covering Nurse Manager in the event that the assigned Nurse Manager is on out of the facility) will review the service or medication order at the earliest opportunity and inform the resident/responsible party and the ordering physician of any specific complications on the day the order is received. If the order is not a stat order and is received after business hours, this process will occur the following day. - If it is determined after initial review by the Nurse Manager that the medication, treatment or service is not able to be done by the facility or that based on the complexity of the situation more time is needed to make a determination or put processes in place (see education sheet for further definition), or alternatives are still being explored, the Nurse Manager will request a Hold Order from the ordering provider while under review. If the ordering provider expresses urgency for the medication, treatment, or services to be provided, the Nurse Manager will work with the ordering provider and the resident/POA at that time on an immediate plan for the resident. The Nurse Manager will involve other department heads, the DON and NHA as needed at that time to facilitate expedition of the plan. - If a Hold Order is obtaine d by the provider, the Nurse Manager will communicate at that time with the DON, NHA, Director of Social Services, and other department heads as needed based on the situation to help research and put necessary systems in place to provide the medication, treatment, or service as quickly as possible or make a determination of an acceptable plan with the resident/POA and medical providers as quickly as possible. The medical provider and resident/POA will be updated as information is provided and will be included in developing and executing and acceptable plan. Communication will be no less frequent than daily, but more often as information is received, and will be documented in the medical record. - If a plan is unable to be determined by the end of the 2nd day, the facility will reach out to additional resources, including but not limited to the CHS Director of Clinical Services, the CHS Health System's Director, the facility Medical Director, the CHS Medical Director, and the Ombudsman, to help facilitate a plan to meet the needs in the facility or to develop and execute a plan that is acceptable to all parties involved. The medical provider and resident/POA will be updated as information is provided and will be included in developing and executing and acceptable plan. Communication will be no less frequent than daily, but more often as information is received, and will be documented in the medical record. - Education of this corrective action will be completed with all involved parties by [DATE]. Monitoring and sustained compliance Chart audit by night shift nurses to determine if there are any ordered meds not being administered for any reason daily for one week, if no concerns step to once a week for one month, if no concerns monthly for one quarter. Results of audits reported to DON and presented to QA committee. Continuation and duration of auditing to be determined by QA Committee per need based on the review following the final quarter audit results. Corrective action will be taken in a timely manner for any concerns or instances of non-compliance. All medications or services determined by review to not be in facility's ability to provide will be reported to and reviewed by the QA Committee. II. Facility Policies on Medication Administration A. Physician order [REDACTED]. - If the order is not complete or there are any questions regarding the appropriateness of the order for the resident, the appropriate dose, the appropriate frequency or any other questions or concerns, the ordering provider shall be contacted for clarification prior to administration or beginning treatment. - A licensed nurse shall note the order to indicate the order has been processed and necessary steps taken to proceed with the order. The undated documentation policy documented in pertinent part, Documentation - If it wasn't charted, it wasn't done. B. Review of the facility's policies and procedures revealed no policy regarding the administration of [MEDICAL CONDITION] medications, such as how administration would be evaluated and determinations made on administration within the facility. III. Resident #1 A. Allegation of Facility Refusal to Administer Necessary Medication to Resident #1 A complaint was received by CDPHE alleging resident #1 was being discharged on [DATE] because the facility would not administer the resident a medication, Revlimid, ordered by his oncologist. Record review revealed resident #1, age 79, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the resident's face sheet, he had [DIAGNOSES REDACTED]. B. Revlimid and Administration of [MEDICAL CONDITION] Drugs A. Professional Reference 1. Revlimid According to Sruti Krishna, The Myeloma Beacon, Study Finds Revlimid-[MEDICATION NAME] Is Effective And Safe For Relapsed/Refractory Myeloma In 'The Real World', [DATE], <http://www.myelomabeacon.com/news/[DATE]/revlimid-lenalidomide-[MEDICATION NAME]-relapsed-refractory-myeloma> ([DATE]), in pertinent part: - Study's findings confirm that Revlimid <http://www.myelomabeacon.com/resources/[DATE]/revlimid/> (lenalidomide) plus ¿¿[MEDICATION NAME] <http://www.myelomabeacon.com/resources/[DATE]/[MEDICATION NAME]/>([MEDICATION NAME]) is effective and safe in day-to-day use among relapsed myeloma patients; - The majority of the patients in the study (77 percent) responded to treat¿ment with Revlimid and Dexa¿metha¿sone, with 20 percent achieving a complete response; and - Revlimid plus Dexa¿metha¿sone is more effective as a treatment for [REDACTED].¿metha¿sone alone, and numer¿ous clinical studies have further studied the efficacy and safety of the combination. 2. Administration of [MEDICAL CONDITION] Drug - Discussion of Risks According to Department of Health and Human Services, Center for Disease Control and Prevention, National Institute for Occupational Safety and Health, NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016, DHHS (NIOSH) Publication No. ,[DATE], Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Cincinnati, OH, 2016, pp. 8 & 32. Pertinent information included: - The actual risk to healthcare workers depends on toxicity of the drugs, how the drugs can enter the body (e.g. dermal, inhalation, or ingestion), and how the drugs are handled; - Dispensing a single tablet to a patient may pose a relatively low risk to the healthcare worker. A single pair of gloves may be adequate; - Intact tablet or capsule, administration from unit-does package, single gloves can be used, no protective gown required, no respiratory protection required and no respiratory protection required; and - Working with hazardous drugs in health settings: drugs and metabolites in body fluids, disposal and cleaning, double chemo-therapy gloves required, protective gown required, eye/face protection required if liquid that could splash, and respiratory protection required if inhalation potential exists. C. Interviews with Oncology Clinic Staff On [DATE] at 9:50 a.m. the Oncology Pharmacy Clinical Coordinator (OPCC) was interviewed. -The OPCC said that [MEDICATION NAME] was a supportive medication for the [MEDICATION NAME] and the Revlimid. She said the [MEDICATION NAME] and the Revlimid were more effective when used together to treat the myeloma. She said that patients live longer when using the combination. She said there was very little effect when a patient was using [MEDICATION NAME] alone. She said the standard is the combination of both [MEDICATION NAME] and Revlimid. She said the Revlimid required a specialty pharmacy to develop the compound and would usually arrive in approximately 48 hours after ordering the medication. -The OPCC provided a copy of the NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016. She

Based on record review, and staff interviews the facility failed to ensure that 12 hours of continuing education was provided for five out of five certified nurse aide (CNA). Specifically, the CNAs failed to receive the required 12 hours for in-service training within 12 months. The findings included: Staff interview: The staff development coordinator was interviewed on 11/23/16 at 11:15 a.m. The SDC said that she tracked the hours which the CNAs were required. The SDC said that the education was to be at least 10 to 12 hours which were required. Transfer training, and yearly competency tests were completed. She said that the facility just had a skills fair which consisted of handwashing, blood pressure, nail care and oxygen. The skills fair was 45 minutes of training for everyone. She said that not all in-services provided were mandatory. She said that the assistant director of nurses (ADON) made the decision if the in-service was mandatory. Record Review: The data spread sheet of CNAs in-service education was reviewed with the SDC. The following CNAs failed to have had the required 12 hours of education in a calendar year. CNA #5 data sheet showed she had five hours in twelve months. Her start date of employment was 11/24/14. CNA #6 data sheet showed she had 4.5 hours of education in twelve months. Her start date of employment was 3/30/15. CNA #7 data sheet showed she had one hour of education in twelve months. Her start date was 6/8/15. CNA #8 data sheet showed the CNA had seven hours of in-service education. Her start date was 6/19/07. CNA #9 data sheet showed the CNA had 11 hours of education in twelve months. Her start date was 2/5/11. The assistant director of nurses (ADON) was interviewed on 11/23/16 at 11:40 a.m. The ADON said that she was new in the position for the past three months. She said that all training was expected to be logged into the data sheets. She said that not all in-services were mandatory, but that the facility did just have a mandatory training on the restorative program and charting.

Based on observations and interviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure oxygen safety in one of one beauty shops in the facility. The findings included: Policy and Procedure The Medical Oxygen Use policy and procedure dated 4/9/14 and provided by the nursing home administrator (NHA) on 5/18/16 at 11:20 a.m., included: - Medical oxygen should be kept 15 feet from open sources of heat including; open flames, space heaters, toasters, hair dryers, sparking electrical appliances. - Residents using medical oxygen should be kept 15 feet from open sources of heat including; open flames, space heaters, toasters, hair dryers, sparking electrical appliance. - Residents using medical oxygen should be removed from the supply of medical oxygen and the oxygen enriched environment for 15-20 minutes prior to coming within 15 feet of an open heat source. Certified Nurse Aide Training The undated Oxygen Administration: General Information policy, provided by the NHA on 5/18/16 at 11:20 a.m., included: Oxygen may not be used in the beauty shop or around electric heat sources, such as hair dryers or curling irons. Observations/Interview Upon entering the beauty shop on 5/18/16 at 10:44 a.m. one resident was observed sitting under the hair dryer with oxygen tubing in her nose. The hair dryer and the oxygen were both on. No one but the resident was in the beauty shop. Upon observation of the doorway to the beauty shop no sign was present which indicated risks of using oxygen in the beauty shop. In approximately one minute the beautician entered the beauty shop. She said she knew that oxygen could not come in direct contact with a heat source or an open flame. She said she did not think the oxygen was on but then agreed it was on after observations of the portable tank being set to two liters. During the interview, the beautician turned off the hair dryer and pushed the resident near the door to remove the rollers from her hair. The beautician said typically, if a resident came into the beauty shop she would remove the oxygen from the resident. When asked how she would know if removing the oxygen from the resident was okay, she said, I would check with the nurse first. She said she usually did not leave a resident alone in the beauty shop. On 5/18/16 at 11:13 a.m. the beauty shop door was closed. No sign related to oxygen safety was present. Interviews Certified nurse aide (CNA) #2 was interviewed on 5/18/16 at 10:58 a.m. She was wearing a name tag with her name and preceptor on it, under her picture. She said prior to taking a resident to the beauty shop she would ensure the resident's portable oxygen tank was filled. She said she knew a resident could not be left alone in the beauty shop. She said she was aware there were risks of using oxygen in the beauty shop. CNA #1 was interviewed on 5/18/16 at 10:55 a.m. She was wearing a name tag with her name and preceptor on it, under her picture. She said prior to taking a resident to the beauty shop she would ensure the resident's portable oxygen tank was filled so the resident would not run out of oxygen while in the beauty shop. Upon concluding the interview, the CNA asked if having oxygen in the beauty shop was concerning. She said she was not aware that there were risks involved related to oxygen use in the beauty shop. The nursing home administrator (NHA) and the staff development coordinator (SDC) were interviewed on 5/18/16 at 11:22 a.m. The NHA said, in reference to oxygen use in the beauty shop, training was not consistent with the oxygen use policy. He said he would ensure staff in the building and the beautician was trained. He also said he was unaware that the beauty shop should have a sign posted outside of the beauty shop. He said that as a preceptor, and agreed both CNAs who were interviewed were preceptors; they should be experts in all training areas for new CNAs. He said preceptors needed to meet certain expectations and mentor new CNAs. He said he was surprised the two CNAs (#2 and #1) who were interviewed were unaware of the oxygen use policy. The NHA agreed to place a sign outside of the beauty shop. The SDC said she generally covered oxygen use annually and would educate staff on turning oxygen off around a heat source, including a hair dryer. She said she thought she had educated the beautician last fall about oxygen. She said the oxygen education included turning oxygen off around a heat source. She said she had told the beautician if she were to turn off the oxygen she would need to monitor the resident for distress which included shortness of breath and increased breathing. She agreed the beautician was not qualified to monitor such things and she should talk to a nurse first. She said she would reeducate everyone in the building on oxygen use.

Based on observations, interviews and record review, the facility failed to provide fluids to maintain hydration for one (#4) of three sample residents. Specifically, the facility failed to ensure that the resident had fluids available and in reach in order to meet hydration needs. The findings included: Resident Status: Resident #4, age 77, was admitted on [DATE]. According to the 5/16 computerized physician orders, [DIAGNOSES REDACTED]. The 3/16/16 quarterly minimum data set (MDS) assessment showed the resident had short and long term memory problems and was severely impaired for decision making. The resident required with supervision for eating and drinking. The resident was totally dependent on staff for transfers and for locomotion on and off the unit. The fall prevention care plan, initiated on 7/12/15, stated the resident had a history of [REDACTED]. One approach in the care plan directed staff to keep frequently needed items in reach. The fluid maintenance care plan, initiated on 7/12/15, stated the resident was at risk for fluid balance issues of dehydration and fluid volume overload. The goal was to minimize risk for fluid imbalance. Pertinent approaches included keeping fluids accessible; and notifying the provider if the resident was not taking fluids and assisting the resident as needed in accordance with the resident information/resident profile document (RIS). The nutritional status care plan, initiated on 7/12/15, stated the resident was at risk for alteration in nutritional status. The goal was for the resident to consistently consume greater than 50% of meals. Pertinent approaches included providing supplements as ordered and encouraging fluids during and between meals. Observations: The resident was observed in bed on 5/25/16 at 7:59 a.m. The resident did not have fluids in reach. The resident's cup of light pink colored liquid was on the sink several feet away from the bed. The resident's fluids were observed out of reach on 5/25/16 at 8:19 a.m. The fluids were moved into reach by the resident's daughter upon her arrival at 8:36 a.m. The resident was observed in bed with fluids out of reach on 5/25/16 at 5:05 p.m. and with no fluids in the room on 5/26/16 at 7:18 a.m. Family Interviews: Resident #4's daughter was interviewed on 5/25/16 at 8:36 a.m. and on 5/26/16 at 7:23 a.m. The daughter said the facility did not keep fluids in reach for her mother. The daughter said this was a concern because her mother could attempt to get up from bed to look for fluids if thirsty. Additionally, the daughter was concerned about her mother's having fluids in reach to drink because the resident was prone to urinary tract infections and having poor hydration could contribute to infections. The daughter said the resident had two urinary tract infections in the past several weeks. The daughter said the fluid cup that was empty by the sink on the morning of 5/26/16 had been empty when she left the previous evening. She was concerned no fluids were available or offered overnight. Record Review: An untitled, undated documented in the certified nurse aide (CNA) resident information (RIS) book on the unit where the resident resided directed staff to ensure that the resident had fluids in reach at the bedside and when up in chair in room. A review of the resident's clinical record revealed the resident had urinary tract infections with two different organisms (Proteus and then [MEDICATION NAME]/Pseudomonas) as evidenced by labs dated 4/21/16 and 5/6/16. Staff Interviews: Certified nurse aide (CNA) #3 was interviewed on 5/25/16 at 2:47 p.m. The CNA stated she regularly worked on the floor where the resident resided and provided care for the resident. The CNA said fluids were provided to residents on each shift. Residents should always have cool, fresh water available. The CNA said residents should have fluids in reach at all times, unless the resident had a special care plan to keep fluids elsewhere related to swallowing problems. The CNA listed residents that were not permitted to drink unattended. The resident was not on the list. Registered nurse (RN) #2 was interviewed 5/26/16 at 7:23 a.m. The RN observed the resident in her room and stated the resident did not fluids available or in reach. The RN said she had been in early and provided the resident with a protein drink. She had not noticed the resident did not have fluids at that time. The RN agreed with the resident's daughter, who was present; the resident should have fluids in reach. The director of nursing (DON) was interviewed on 5/26/16 at 9:00 a.m. The DON stated that fluids were passed to residents three times daily. The DON stated it was her expectation that residents have fluids in reach when in their room in order to promote hydration. The DON stated the resident did not drink water and had sugar free juice or another sugar free beverage that should be available. The DON reviewed the resident's care plan and stated that it was on the resident's care plan to keep fluids in reach.

Based on observations and staff interview, the facility failed to ensure the labeling of medications in accordance with currently accepted professional principles, and to include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, medications were found expired in one of two medication rooms, and medications were found to be unlabeled in one of six medication carts. The findings include: a. Observations --On [DATE] at 1:55 p.m., the Pikes/Longs medication cart was observed to have an Advair Diskus ,[DATE] micrograms (mcg) (an inhaled corticosteroid) opened with no date of opening. --On [DATE] at 2:15 p.m., the first floor medication room refrigerator was observed to have a vial of Tubersol ([DIAGNOSES REDACTED] test) opened with no date of opening. --On [DATE] at 2:24 p.m., the Big Thompson Canyon medication cart was observed to have one loose pill in a plastic crush bag with Norco ,[DATE] E-Kit written in black ink on the plastic crush bag taped to the inside lid of the narcotic box. -Maxorb Extra Ag silver antimicrobial wound dressing with an expiration date of ,[DATE] was also present in the cart. b. References --According to the package insert for Advair Diskus, revised ,[DATE], https://www.gsksource.com/gskprm/htdocs/documents/ADVAIR-DISKUS-PI-MG.PDF ([DATE]) in pertinent part: .ADVAIR DISKUS should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard ADVAIR DISKUS one month after opening the foil pouch or when the counter reads zero (after all blisters have been used), whichever comes first . --According to the product information for Tubersol (Tuberculin Purified Protein Derivative (Mantoux), [DATE] (http://www.old.health.gov.il/units/pharmacy/trufot/alonim/tubersol_dr.pdf) ([DATE]), in pertinent part: . A vial of TUBERSOL® (Tuberculin Purified Protein Derivative (Mantoux)) which has been entered and in use for 30 days should be discarded because oxidation and degradation may have reduced the potency . c. Interviews --On [DATE] at 2:02 p.m., the licensed practical nurse (LPN) #1stated the medications should have been dated when opened. --On [DATE] at 2:30 p.m., the assistant director of nursing (ADON) stated medications should not be removed from their original packaging and should have been discarded. She also state the Tubersol should have been dated when opened and the expired Maxorb should have been discarded when expired.

Based on record review, resident interview and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (resident #45) of one out of 32 sample residents. Specifically, the facility failed to consistently measure and monitor pain for resident #45's prn (as needed) pain medications. The findings included: A. Facility Pain Policy On 9/16/15 at 3:22 p.m. the director of nursing (DON) provided a copy of an undated, Pain Assessment and Management policy. This policy revealed that, In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manager pain, the facility, to the extent possible: Recognize when the resident is experiencing pain and identifies circumstances when pain can be anticipated . Evaluates the existing pain and the cause(s) .Unrelieved pain has a negative physical and psychological consequences, including the potential for threatening functional ability .Upon admission, at least daily, and as the resident's condition dictates, the resident's pain will be assessed. Whenever possible, obtain all information directly from the resident .Ongoing evaluation of the status of a resident's pain shall be done, including the response to interventions to prevent or manage pain, and the possible presence of adverse consequences of treatment. B. Resident Status 1. Resident #45 According to the face sheet, the [AGE] year old resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30 day minimum data set (MDS) assessment dated [DATE] revealed the following information: -The brief interview for mental status (BIMS) (Section C) exam revealed a score of 13 out of 15 that indicated the resident's cognition was intact. -The mood interview (section D) assessment revealed a score of zero indicating no current symptoms of depression. -The activities of daily living (Section G) revealed that resident required supervision with bed mobility, personal hygiene and walking in the room. The resident was independent with eating. The resident required limited assistance from one person with transfer, walking in corridor, dressing, locomotion on/off the unit and toileting. The resident was able to bathe independently with set up assistance. -The resident's health conditions (Section J) revealed that resident was on a scheduled pain medication regimen over during the last five days prior to assessment. The resident also received a PRN (as needed) pain medication. A pain assessment was completed and the resident reported that she had occasional pain. She did limit her day to day activities due to pain. The resident described her pain as moderate. - On 9/17/15 at approximately 4:00 p.m. the DON provided a copy of the MDS Health Conditions assessment (section J) dated 9/9/15. This document revealed that a pain assessment interview was completed and the resident had reported pain over the previous five days. It was occasional pain. The pain did make it difficult to sleep at night but no longer limited her day to day activities. The resident described the pain as severe with a score of three on a scale of one to ten, ten being the worst pain. C. Resident Interviews On 9/16/15 at 9:14 a.m. the resident reported that she had chronic pain. She had pain in her left leg and left hip as a result of a fall one year ago. She did have surgery on the left leg/hip and it continued to bother her. She reported that she had chronic back pain. She was in an automobile accident about [AGE] years ago and she had to have her back fused. She reported that it took about 20 minutes after taking a pain pill to start feeling better. She reported that she had a scheduled pain medication. She did have breakthrough pain and she could ask for more medication if needed. She did not keep track of the time frames. She understood that she could ask for an additional pain pill every four hours as needed. There were times that she would ask for pain pills and the nurses would tell her that she had to wait for another 20 minutes before time would allow for another dose. The resident reported that when she did have pain, it was sharp and constant. She would sometimes get up to walk the floor to help alleviate the pain at night. She would cry and get very frustrated when coping with pain. On 9/21/15 at 1:04 p.m. the resident reported that she had pain last night (920/15) in her back. It was a, terrible night for her and she did not sleep well. She had pushed her call light and summoned staff for a pain pill. When the nurse arrived, she was asked on a scale of one to ten, how she would rate her pain. She told them it was a nine. She received medication immediately. She reported that normally, nursing staff would ask her about her pain and then the nurse would request a number to rate her pain. She reported, 'They don't always ask a number to rate my pain, they just give me my medications and leave the room. D. Record Review 1. Telephone Order -A telephone order dated 8/6/15 revealed, Change [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME] pain medication) 5/325 (dosage) to Q4H (every four hours) PRN. 2. Physician Referral Form -A physician referral from dated 8/21/15 revealed a progress note, Wakes up overnight with pain and sometimes she is not due for [MEDICATION NAME] and can't sleep well due to that. The orders/recommendations were to continue current meds (medications) except to change [MEDICATION NAME] to one tablet every four hours prn pain (the same order was noted on 8/6/15, see above telephone order). 3. Physicians Orders -an order for [REDACTED].Special instructions: dx (diagnosis) pain NTE (not to exceed) 3250 mg of [MEDICATION NAME] in 24 hours .non-pharm (pharmacological) approaches: 1. position for comfort .2.distraction .3.rest/soothing environment .4.icepack .Every 4 (four) hours- PRN 1 (one), PRN 2 (two), PRN 3 (three), PRN 4 (four), PRN 5 (five), PRN 6 (six). This order was started on 7/27/15 and discontinued on 8/4/15. -an order for [REDACTED].Special instructions: dx pain NTE 3250 mg of [MEDICATION NAME] in 24 hours .non-pharm approaches: 1. position for comfort .2.distraction .3.rest/soothing environment .4.icepack .Every 4 hours- PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6. This order was started on 8/5/15 and was open ended. 4. Care Plan -A revised care plan dated 8/8/15 revealed that, Resident has complaints of pain R/T (related to) R (right) wrist, chronic back pain d/t (due to) fusions, mouth pain d/t teeth that need to be removed from chemo tx (therapy) damage. Dental appts (appointments) on hold while she recovers from pacemaker placement. Is receiving routine pain medication, and has prn. The targeted goal date for resident was 9/18/15 and, Resident will verbalize reduction in pain and/or demonstrate a decrease in non-verbal indicators of pain. The approaches revealed were, Address resident's emotional needs .Administer medications as ordered. Monitor and record effectiveness .Monitor for and report adverse consequences, such as falling, constipation, loss of appetite, or excessive drowsiness .Allow sufficient uninterrupted rest periods .Assess effects of pain on resident (disturbances in sleep, activity, self care, appetite, psychosocial .) Clarify misconceptions about addiction to pain medications .Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge .Monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors .Monitor and record any non-verbal signs of pain: ( .crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal .) Use non-medicated pain relief measures distraction, application of heat/cold, massage, physical therapy, stretching and strengthening exercises, relaxation, position to comfort, handle gently. Monitor effectiveness . 5. MARS (medication administration records) -The July MARS for dates of 6/3/15 through 7/3/15 revealed that resident had a PRN order for, [MEDICATION NAME] .5/325 mg; Amount to administer: 1 tab; oral .every 6 hours- PRN .dx: pain .NTE 3250 mg of [MEDICATION NAME] in 24 hours. Non pharm approaches: 1. Position for comfort .2. Distraction .3. rest/soothing environment .4. Icepack. This order revealed the resident was monitored for, Time . Reason .Site .Pain Level .Non-Pharm Approach .Result. The MARS revealed that resident had been administered this medication for the first three days in July prior to being discontinued. The dates and times the resident received medications were on 7/1/15 at 2:10 a.m.; 10:21 a.m. and 9:11 p.m. The resident received medications on 7/2/15 at 11:02 p.m. and on 7/3/15 at 4:37 a.m. and 10:08 a.m. All spaces included the necessary information to measure and monitor the resident's pain. -The July MARS for dates of 7/3/15 through 7/11/15 revealed that resident had a PRN order for, [MEDICATION NAME] .5/325 mg; Amount to administer: 1 tab; oral .every 4 hours .dx: pain .NTE 3250 mg of [MEDICATION NAME] in 24 hours. Non pharm approaches: 1. Position for comfort . 2.Distraction . 3.rest/soothing environment . 4.Icepack. The MARS revealed options for documentation for time, site, pain level, and non-pharm approaches. It did not include the reason for PRN medications to be given and it did not include the effectiveness/results of medication given. The document revealed that resident had received the PRN medication on the evening of 7/3/15 at 4:00 p.m. and 8:00 p.m. All the boxes were completed as required. The document revealed that resident had received the medications every four hours from 7/4/15 through 7/7/15 (with the exception of 7/4/15 at 12:00 p.m. medication was noted not to be given). All spaces were filled in. There was no documentation in comments/reasons to reveal the reason for medications and effectiveness of the medication. The document revealed from 7/7/15 at 8:00 a.m. through 4:00 a.m. on 7/11/15 that resident had received the PRN medications 16 times. There were nurse initials in the sixteen spaces. These 16 spaces were not filled in to indicate site, pain level, and non -pharmacological approaches. There was no comments/documentation on the MARS to show effectiveness or measurement of pain when giving PRN pain medications during this date span. There were no progress notes during this date span to show that PRN pain medications effectiveness and that resident's pain had been measured. -The July MARS for the dates of 7/11/15 through 7/27/15 revealed that resident had a PRN order for, [MEDICATION NAME] .5/325 mg; Amount to administer: 1 tab; oral .every 4 hours .dx: pain .NTE 3250 mg of [MEDICATION NAME] in 24 hours. Non pharm approaches: 1. Position for comfort . 2.Distraction . 3.Rest/soothing environment . 4.Icepack. The MARS revealed options for documentation for time, reason and results. There were no options to indicate site, pain level and non-pharm approaches. The resident had received her PRN pain medications 38 times over the span of sixteen days. There were four comments on the MARS indicating a pain level for PRN medication administration. There were comments/documentation regarding the pain site 21 times. There were three comments regarding non-pharmacological approaches that were utilized. There was no documentation the resident had refused all other approaches. -The July MARS for the dates of 7/28/15 through 7/31/15 revealed that resident had a PRN order for, [MEDICATION NAME] .5/325 mg; Amount to administer: 1 tab; oral .every 6 hours- PRN .dx: pain .NTE 3250 mg of [MEDICATION NAME] in 24 hours. Non pharm approaches: 1. Position for comfort . 2.Distraction . 3. Rest/soothing environment . 4. Icepack. The MARS revealed options for documentation for time, reason and results. There were no options to indicate site, pain level and non-pharm approaches. The resident received her PRN pain medications six times over the span of four days. There was one comment on the MARS that indicated pain level. There were five comments on the MARS that indicated the pain site. There were no comments/reasons on the MARS that indicated a non-pharm approach was utilized or that resident had refused. -The August MARS for the dates of 8/1/15 through 8/4/15 revealed that resident had a PRN order for, [MEDICATION NAME] .5/325 mg; Amount to administer: 1 tab; oral .every 6 hours- PRN .dx: pain .NTE 3250 mg of [MEDICATION NAME] in 24 hours. Non pharm approaches: 1. Position for comfort . 2.Distraction . 3. Rest/soothing environment . 4.Icepack. The MARS revealed options for documentation for time, reason and results. There were no options to indicate site, pain level and non-pharm approaches. The resident received her PRN pain medications four times over the span of four days. There was no measurement of pain levels noted for these four days in the comments/reasons. The comments/reasons on the MARS for pain site were indicated on three of the four days. -The August MARS for the dates of 8/5/15 through 8/31/15 revealed that resident had a PRN order for, [MEDICATION NAME] .5/325 mg; Amount to administer: 1 tab; oral .every 4 hours- PRN .dx: pain .NTE 3250 mg of [MEDICATION NAME] in 24 hours. Non pharm approaches: 1. Position for comfort . 2.Distraction . 3. Rest/soothing environment . 4. Icepack. The MARS revealed options for documentation for time, reason and results. There were no options to indicate site, pain level and non-pharm approaches. The resident received her PRN pain medications 30 times over 21 days out of 26 days total. The pain site was referenced 25 times. The resident's pain level was documented in comments/reasons two times. The non-pharmacological approaches were referenced one time in the comments/reasons. -The September MARS for the dates of 9/1/15 through 9/16/15 revealed that resident had a PRN order for, [MEDICATION NAME] .5/325 mg; Amount to administer: 1 tab; oral .every 4 hours- PRN .dx: pain .NTE 3250 mg of [MEDICATION NAME] in 24 hours. Non pharm approaches: 1. Position for comfort . 2.Distraction . 3. Rest/soothing environment . 4.Icepack. The MARS revealed options for documentation for time, reason and results. There were no options to indicate site, pain level and non-pharm approaches. The resident received her PRN pain medications 15 times over the span of 13 days out of 16 days total. The pain site was referenced 12 times. The resident's pain level was documented in comments/reasons four times. The non-pharmacological approaches were referenced two times in the comments/reasons. 6. Progress Notes a. July Nursing Progress Notes -On 7/14/15 at 5:04 am, Resident with C/O sharp mouth pain during the night that radiates to her (R) (right) jaw and neck. Resident guarding (R) side of face and has K-pad placed on (right) cheek. Resident educated on proper use of k-pad, warm moist compress given to Resident instead .Res (Resident) medicated with PRN [MEDICATION NAME] times two (x2) with some good effect. No pain level was indicated. -On 7/14/15 at 7:03 p.m., Resident C/O back pain [MEDICATION NAME] 1 tab (tablet) given at 5:20, pain mediation effective. No pain level was indicated. -On 7/16/15 at 3:15 p.m., Resident denies pain to mouth. C/O left buttock pain in which she was medication (sic) with one [MEDICATION NAME] twice during the shift and was given ice pack which was effective. No pain level was indicated. -On 7/16/15 at 9:13 p.m., Resident denies any mouth pain at this time. PRN [MEDICATION NAME] administered at HS (hours of sleep) for back pain. There was no documentation regarding pain level. -On 7/17/15, Resident with no c/o of mouth pain/discomfort, PRN [MEDICATION NAME] given for back pain, res stated not very effective. No pain level was indicated. -On 7/18/15, Patient awake during rounds and complained of pain in hip. Informed her pain medication was not due for an hour. Patient repositioned herself. Once medication was administered patient fell asleep, medication somewhat effective for about 2.5 hours. Requested ice pack for hip again. No pain level was indicated. -On 7/21/15, Resident denied mouth pain this shift, did report back pain PRN [MEDICATION NAME] given with good effect. No pain level was indicated. -On 7/22/15, No c/o any pain or discomfort to mouth/gums noted or reported. C/O of back pain, PRN [MEDICATION NAME] give at 2:00 a.m., effective. No pain level indicated. -On 7/24/15, Res c/o Left hip and lower back pain at 6:34 p.m. and 9:45 p.m. PRN [MEDICATION NAME] 3 (three) 5/325 mg tabs administered, K-pad in use t/o shift and ice pack applied at HS. Effect pending. There was no pain level indicated. -On 7/25/15, Res complaining of left hip/lower back pain. PRN [MEDICATION NAME] 5/325 mg given at 6:00 p.m. and 10:30 p.m. Res reports min effect with [MEDICATION NAME]. K-pad in use throughout shift. Ice applied at this time. Res reports ice helped last night and she was able to sleep. NP (Nurse practitioner) notified via communication book. PCP (personal care provider) to be notified if PRN [MEDICATION NAME] or ice is ineffective. No pain level was indicated. -On 7/26/15, Received request from resident to be given PRN [MEDICATION NAME] at 2:30 a.m. Medicate per request at 2:40 a.m.-with nurse waking resident for administration. Visualized partial effectiveness-Res. sleeping soundly one hour later. No further voiced or visualized s/s (signs/symptoms) acute distress. Call light in reach. No pain level was indicated. -On 7/29/15, Res c/o tingling underneath L (left) breast to (left) axillary. No warmth or redness noted to area. Res expressed fear that her [MEDICAL CONDITION] will return. Res reported applying barrier cream underneath underarm, stating It helps. NP notified via notebook. Routine and PRN [MEDICATION NAME] 5/325 mg administered at 9:00 p.m. for lower back/shoulder/neck pain. K-pad in use t/o shift. Res denies chest pain/pressure or tightness. No pain level indicated. -On 7/30/15, Res denies any chest/pain at this time. Reports mild back pain, K-pad in use and res is currently resting in bed. Complaining of upper mouth/gum pain, PRN [MEDICATION NAME] 5/325 mg administered at this time. No pain level was indicated. b. August Nursing Progress Notes -On 8/3/15 at 3:29 a.m., Res c/o of back pain and request for [MEDICATION NAME]. K-pad noted to be turned off, res unaware. Kpad turned on and PRN [MEDICATION NAME] admin and effective. No pain level was indicated. -On 8/3/15 at 11:41 a.m., Res c/o back pain this am, scheduled [MEDICATION NAME] given at 7 am with some effect, K-pad on and in place, res requesting PRN [MEDICATION NAME] to be q 4 hours instead of every 6 hours, note written in NP book. Res cont (continued) to c/o pain. PRN [MEDICATION NAME] given at 11:30 am, awaiting effect. No pain level was indicated. -On 8/4/15, Called 1x (one time) with c/o tight, non-productive cough, sore throat and 'pain in chest from coughing so much' .Pain relieved by PRN [MEDICATION NAME]. No pain level indicated. -On 8/8/15, Res c/o severe back pain. PRN [MEDICATION NAME] was give at 6:40 a.m. with little to no effect. No pain level was indicated. -On 8/11/15, .Medicated x1 (times one) PRN [MEDICATION NAME] for general discomfort with stated effectiveness . No pain level was indicated. -On 8/14/15, PRN [MEDICATION NAME] given at 4:30 a.m. for generalized moderate pain. No pain level was indicated. -On 8/16/15, PRN [MEDICATION NAME] given at 12:40 a.m. for mod (moderate) pain to L side and R shoulder. Res called around 2:00 a.m. c/o pain, stating mediation ineffective. K-pad filled with H2O (water) and ice pack offered. Res stated these interventions effective. Res called at 4:00 a.m. asking for another pain med. Again ice and k-pad in use and effective. No PRN give at 4:00 a.m. d/t (due to) time of prior dose given. No pain level was indicated. -On 8/17/15, 2:10 a.m. Res c/o mod back pain and request for pain med. PRN [MEDICATION NAME] administered. Res repositions in bed. No pain level was indicated. -On 8/18/15, Res complained of Right shoulder pain. K-pad applied and PRN [MEDICATION NAME] 5/325 mg administered at 9:00 p.m. with effect pending. No pain level was indicated. -On 8/19/15, Res c/o back pain. PRN [MEDICATION NAME] is provided at 2:45 p.m. along with heat. This is somewhat effective. No pain level was indicated. -On 8/21/15, Res c/o L hip/leg pain. K-PAD to site. PRN [MEDICATION NAME] administered x1 with reported 'partial' effectiveness . No pain level was indicated. -On 8/30/15, 12:20 a.m. Res c/o of back pain and request [MEDICATION NAME]. PRN [MEDICATION NAME] administered and effective . No pain level was indicated. -On 8/31/15 at 1:58 p.m, PRN [MEDICATION NAME] given this morning with positive effect. No pain site or pain level was indicated. -On 8/31/15 at 8:31 p.m., Routine and PRN [MEDICATION NAME] administered at 4:22 p.m. for breakthrough pain. Res reports increase back pain after taking a walk. No pain level was indicated. c. September Nursing Progress Notes -On 9/1/15 at 2:24 a.m., PRN [MEDICATION NAME] requested and given at 2:45 a.m. for mod pain to R shoulder and back and was effective. K-Pad in use and ice pack offered. Res repositioned and resting in soothing environment at this time. No pain level was indicated. -On 9/9/15, Pain Assessment Interview completed this day. Res is on a scheduled pain mgmt (management) regimen, along with PRN pain medication that resident is able to request. She does report pain, specifically at night that is breaking through. She states that she does not want a scheduled pain medication put in place that she will ask when I need it. E. Staff Interviews On 9/21/15 at 9:56 a.m. the certified nursing assistant (CNA) #3 reported that if a resident reported that they were in pain, she would tell the charge nurse on the floor immediately. The residents often told her where the pain was located when indicating discomfort. If the resident did not indicate location of pain, she would ask them about their pain and then inform the nurse on duty. On 9/21/15 at 10:00 a.m. the licensed [MEDICATION NAME] nurse (LPN) #1 reported that if she had a resident who took an unscheduled pain medication she would ask the resident about their current comfort level. She would always ask a resident about location of pain, description of pain, when onset of pain began, and to rate pain on a scale of one to ten. She would always ask a resident what would make the pain better. She looked at the medications that had been ordered for the resident and what options were available. She would also offer non-pharmacological approaches. Examples of these approaches were to try ice and repositioning. She would wait 30 minutes before completing a follow up for pain effectiveness. If the pain medication or non-pharmacological approaches were not working, she would look at orders and offer other approaches/alternatives. Whether the resident was taking a scheduled medication or a PRN medication, she would still follow the same line of questioning to dispense the medications. She would document this on the medication administration record sheet (MARS). She could document this in the progress notes. She would only document pain in progress notes if it was uncontrolled or there were additional concerns. When she documented on the MARS for PRN medications, she would record the time, pain level, location of pain site, any non-pharmacological approaches and results. On 9/21/15 at 10:41 a.m. the DON reported that when a nurse offered a PRN pain medication, they should be asking the resident about location of pain, rating pain levels and looking to see what PRN medications were ordered for the resident. The nurse should also be offering non-pharmacological approaches. Some residents did not want a non-pharmacological approach and would just request the pain pills. All PRN medications on the MARS should have a space to document the time, reason for dispensing PRN medication, the resident's pain level, the site of pain, non-pharmacological approaches and result for effectiveness. The nurse could document in the progress notes. She would only expect the nurse to document in progress notes if the resident's pain was not controlled and a pain event needed to be opened. The MARS for the months of July, August and September were reviewed by the DON. On the July MARS for PRN pain medications, the nursing staff had the spaces to document time, reason, pain level, pain site, non-pharmacological approaches and effectiveness. These options for documenting were not available on the August and September MARS. She had four ward clerks that were responsible for data entry of the physician's orders [REDACTED]. If the ward clerks were not available, the charge nurse or the on-duty nurse would be responsible. The DON agreed that there were inconsistencies in documenting for the PRN pain medications for the months of July, August and September. F. Facility Response On 9/21/15 at 11:58 a.m. the DON reported that she had reviewed the resident's MARS and progress notes. There were some missed progress notes. There were inconsistencies with rating pain and documenting effectiveness of medications. Some of the nurses would document mild or moderate pain in lieu of using a pain scale from one to ten. The pain scale was a good baseline to measure pain. She would be educating the nursing staff to improve the documentation. She had corrected the orders for PRN pain medications on the MARS to include all the areas that should be asked during a resident pain interview when administering PRN pain medications. G. Facility Follow Up On 9/22/15 after completion of the survey on 9/21/15, the nursing home administrator (NHA) provided physical therapy documentation which was irrelevant to the deficient practice of not consistently measuring and monitoring pain with the use of a prn pain medication for this resident. The NHA also provided progress notes for the resident which had already been received prior to the survey exit date. The NHA also provided the September MARS which had been corrected on 9/21/15 to include time, reason, pain level, pain site, non-pharmacological approaches and effectiveness. The September MARS from 9/1/15 through 9/21/15 did not have documentation in place to evidence pain levels, pain site, and non-pharmacological approaches per interview with the DON (See staff interview above).