Every finding on record at Liberty Heights

Based on interviews and record review, the facility failed to ensure one (#1) of three out of six sample residents who required respiratory care were provided such care consistent with professional standards of practice.Specifically, the facility failed to ensure Resident #1 received oxygen according to the physician's orders.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/15/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/18/26.I. Incident on 3/17/26On 3/17/26 Resident #1's representative visited the resident in the dining room during the dinner meal. The representative said the resident appeared anxious and he noticed she was cyanotic (a bluish or purplish discoloration of the skin, lips, or nail beds, indicating that the blood oxygen is low) in her lips and fingers. The resident's representative noted that the resident's portable oxygen tank, which should have been at 6 LPM (liters per minute), was turned off. The representative turned the portable oxygen tank on as high as it could go and the resident's cyanosis went away after about 10 minutes.The resident's representative informed the certified nurse aide (CNA) and the nurse that Resident #1's portable oxygen was not on when he arrived in the dining room and the resident was assessed by the nurse and her oxygen saturations were noted to be at baseline.II. Facility's corrective actionThe corrective action plan the facility implemented in response to Resident #1's oxygen incident on 3/17/26 read as follows: A. Immediate corrective actionResident #1's portable oxygen tank was immediately turned on and she received a full assessment from the nurse on 3/17/26 and was noted to be at her baseline.B. Identification of othersThe facility has determined that all residents at the facility are potentially at risk. An oxygen administration audit was performed 3/18/26 by the director of nursing (DON) on all residents to ensure all residents are receiving oxygen according to physician's orders. Plan of care was updated on all residents with oxygen use.C. Systemic changesOn 3/18/26, the DON re-educated all nursing staff on oxygen use and administration. An attendance sheet was kept and reconciled with the active staff roster and those staff unable to attend in-servicing will be provided one-to-one re-education prior to working with the residents. Oxygen administration will be included in the new hire orientation.D. MonitoringOngoing monitoring will continue through weekly oxygen audits using a spreadsheet by the DON/designee for a minimum of 90 days or until compliance is established to review resident oxygen use and administration. Any issues identified will be corrected immediately and also reported to the nursing home administrator (NHA). Results of the audits will be discussed at the community's monthly QAPI (quality assurance performance improvement) meetings.III. Facility policy and procedureThe Oxygen Administration policy and procedure, revised 9/9/25, was provided by the NHA on 4/15/26 at 2:00 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 plans and the resident's goals and preferences.IV. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 3/24/26. According to the March 2026 computerized physician orders (CPO), diagnoses included heart failure, acute and chronic respiratory failure with hypoxia, pulmonary hypertension, congestive heart failure (CHF) (chronic, progressive condition where the heart muscle is too wreck or stiff to pump blood efficiently, causing blood to back up and fluid to accumulate in the lungs, legs and other tissues), pleural effusion (abnormal buildup of fluid in the space between the lungs and chest cavity) and Alzheimer's disease.The 2/6/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on staff assistance with toileting, bathing, dressing and moderate assistance with bed mobility, personal hygiene and transfers.The MDS assessment indicated the resident used continuous oxygen.B. Resident's representative interviewResident #1's representative was interviewed on 4/15/26 at 1:34 p.m. The resident's representative said he visited Resident #1 on 3/17/26 at the facility. He said she was sitting in the dining room and she looked like she was having an episode of anxiety, but when he got closer, he noticed she was cyanotic in the lips and fingers. He said the portable oxygen tank, which should have been at 6 LPM, was turned off. He said he immediately cranked it as high as it could go to bring the resident's blood oxygen level up. He said the cyanosis went away after about 10 minutes.Resident #1's representative said he informed the CNA and the nurse that Resident #1's portable oxygen was not on when he arrived. He said the nurse checked it and informed him that it was on. He said he told the nurse he was the one that turned it on. He said the nurse took Resident #1's vital signs and said the resident's oxygen saturation level was normal. The resident's representative said he told the nurse it was normal because he had put her on a high flow of oxygen before the nurse walked over.Resident #1's representative said he was concerned that Resident #1 was sitting in the dining room and no one noticed she was having difficulty breathing and was cyanotic.C. Record reviewReview of Resident #1's March 2026 CPOs revealed the following physician's order:Continuous oxygen at 6 LPM due to hypoxia. Administer via nasal cannula. Notify the provider if oxygen saturation is less than 90% for further orders, ordered 2/6/26.The oxygen use care plan, initiated 2/6/26, documented Resident #1 used oxygen therapy related to CHF, ineffective gas exchange, COPD (chronic obstructive pulmonary disease - a progressive, incurable lung disease that causes obstructed airflow, making it hard to breathe), emphysema and acute and chronic respiratory failure. The pertinent interventions included giving medications as ordered by the physician; monitoring for signs and symptoms of respiratory distress and reporting to the physician as needed; and providing oxygen via nasal cannula at 6 LPM.The 3/17/26 nursing progress note documented the nurse was notified by the previous shift's nurse during shift change report that Resident #1's representative notified staff that there was a lack of oxygen to the resident during mealtime. After mealtime, the nurse assessed the resident and vital signs were all within normal range for the resident with no signs or symptoms of cyanosis. The resident's oxygen saturation was 92%.-A review of Resident #1's electronic medical record (EMR) did not reveal an assessment of the resident at the time of the incident in the dining room; the nurse waited until after mealtime was over to assess the resident. -Additionally, documentation did not reveal the physician had been notified of the resident's lack of oxygen during the mealtime.The facility's investigation of the incident on 3/17/26 documented Resident #1 was assessed by a nurse following the incident, and nursing staff received education from the DON regarding oxygen use best practices. A nurse assessed Resident #1 in the dining room once the resident's oxygen was turned on, and the resident was assessed again after the incident when the resident returned to her unit. The investigation indicated the resident's representative was interviewed and stated that upon his arriving to visit Resident #1 that evening (3/17/26), he noticed the resident's lips and fingers were blue. The resident's representative checked Resident #1's oxygen tank and encouraged the resident to take deep breaths. This did not seem to help, so the resident's representative checked the oxygen tank again and noticed it was turned off. The resident's representative turned on the oxygen tank then got up in the dining room and exclaimed that Resident #1's oxygen tank was not turned on.The investigation documented the nurse who was in the dining room came over and checked on Resident #1. The nurse saw that the resident's oxygen tank was turned on, reported the resident was at her baseline, and the resident had resumed eating her dinner.The internal investigation concluded that Resident #1 was transported to the dining room the evening of 3/17/26 with a full tank of oxygen, which may not have been turned on.Nursing staff received education on oxygen use and best practices to ensure continued understanding of procedures. Management initiated random audits of multiple residents' oxygen use to ensure compliance with care plans by staff.V. Staff interviewsThe NHA, the DON and the executive director were interviewed together on 4/15/26 at 2:16 p.m. The NHA said he was notified of the incident with Resident #1 on 3/17/26, the night it happened. He said the resident's representative reported he found Resident #1 in the dining room without her oxygen concentrator turned on. The NHA said by the time the nurse got to the resident, the oxygen had been turned on and the resident was not showing signs or symptoms of cyanosis.The NHA said when he interviewed the CNA who took Resident #1 to the dining room on 3/17/26, the CNA said she filled the portable oxygen concentrator and remembered turning it on.The executive director said the facility provided immediate education to the facility staff on professional standards of practice for oxygen usage. She said the facility put a performance improvement plan in place, which included audits being conducted and monitoring through the facility's quality assurance meeting.The executive director said the nurses and the CNAs were both responsible for checking each residents' portable oxygen concentrator to ensure it was turned on and at the appropriate oxygen liter flow rate according to the physician's orders.

Based on record review and interviews the facility failed to ensure residents were treated with dignity and respect for one (#4) of three residents out of six sample residents. Specifically, the facility failed to ensure Resident #4 was treated with dignity and respect by certified nurse aide (CNA) #1.Findings include: I. Facility policy and procedure The Skilled, Promoting, Maintaining Resident Dignity policy, dated 9/10/25, was provided by the executive director on 4/16/26 at 3:38 p.m. The policy read in pertinent part, It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and environment that maintains or enhances resident quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident identity and respect resident rights. During interactions with residents, staff must report and act upon information regarding resident preferences, and interview results will be documented. The provision of care and care plans will be revised, if appropriate, based on information obtained from resident interviews. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the residents needs and preferences. When interacting with a resident, pay attention to the resident as an individual. Respond to requests to assist in a timely manner. Explain care and procedures to the resident before initiating the activity, groom and dress the resident according to the resident preference and speak respectfully to the resident.II. Facility investigation of the incident involving Resident #4 and CNA #1 on 2/28/26The 2/28/26 facility investigation of the incident involving Resident #4 and CNA #1 was provided by the executive director on 4/15/26 at 12:30 p.m. The investigation revealed Resident #4's alleged assailant (CNA) #1 told the resident he stunk and really needed a shower. During the bedbath given by CNA #1, Resident #4 experienced pain due to his back issues and had tears in his eyes when CNA #1 was rolling the resident from side to side. Despite the resident's pain, CNA #1 finished providing care prior to getting the nurse. The resident reported being in a lot of pain and stated CNA #1 was too rough in completing the care. Resident #4 was interviewed by the nursing home administrator (NHA) and the director of nursing (DON) on 3/2/26, Resident #4 reported that CNA #1 told him he stunk and CNA #1 was too rough during the bedbath. The resident described starting a new medication around the same time as the alleged incident, and believed it may have affected him. At the resident's request, the medication was discontinued and the resident stated his initial allegations about CNA #1 were more severe because of his reaction to the medication. Resident #4 stated the care provided by CNA #1 could have been more gentle and he was in pain during the bed bath, but he did not believe CNA #1 was physically abusive or intended to hurt him during the bed bath. CNA #1 was suspended once the allegations from Resident #4 were reported. CNA #1 was interviewed on 3/2/26 about the incident. CNA #1 stated that she spoke with the resident an hour prior to the bath to give him time to take pain medications. She said she proceeded to assist the resident with a bedbath, turning him side to side four or five times. She said she explained to him he may be uncomfortable with the bed linen change from rolling often. She said she noticed he had tears and stopped the bed bath and went to get the nurse.Three additional residents who received bed baths and cares provided by CNA #1 were interviewed for similar situations. None of the residents expressed concerns that their bed baths were too rough.The conclusion of the facility's investigation of the incident was that CNA #1 did tell Resident #4 that he stunk and needed to bathe, and that the resident did experience pain during the bed bath. The resident stated there was no physical abuse and CNA #1 should have been more careful while rolling him over during care.The facility did not substantiate that abuse occurred, but did substantiate that Resident #4 was not treated with dignity by CNA #1 and CNA #1 was educated regarding her communication and approach with residents and recognition of resident's non-verbal queues. III. Resident #4 A. Resident statusResident #4, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included methicillin staphylococcus aureus (infection in the blood), spinal stenosis (narrowing of the spinal canal), discitis (inflammation of the disc), osteomyelitis (infection of the bone) and osteoporosis. The 4/8/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 of 15. He required substantial maximum assistance with activities of daily living (ADL) for bathing. The assessment indicated the resident experienced pain.B. Resident interviewResident #4 was interviewed on 4/15/26 at 11:45 a.m. Resident #4 said CNA #1 told him he stunk and he needed a bath. He said her approach bothered him and he felt she needed continued education. He said he requested for her not to care for him in the future. He said he did experience pain during the bed bath provided by CNA #1 and he felt she was rough when turning him side to side; however, he did not feel like she physically abused him. Resident #4 said he had increased pain and the physician was working with him on medication changes. He said he was more concerned about CNA #1 getting properly trained on providing care to residents. C. Record review The potential for pain care plan, dated 2/3/26, revealed Resident #4 was at risk for pain related to discitis and osteomyelitis. Interventions included identifying, recording and treating existing conditions which may increase pain and or discomfort, monitoring and documenting probable causes of each pain episode and removing or limiting causes of pain where possible.A progress note, dated 2/28/26 at 2:47 p.m., revealed Resident #4 was reporting increased pain not alleviated with non-pharmacological interventions and the nurse was unable to administer PRN (as needed) medications at the time.A progress note, dated 2/28/26 at 7:10 p.m., revealed the resident had sharp stabbing pain daily with positioning and as needed medication was provided. The resident reported increased pain after a bed bath today (2/28/26). A progress note, dated 3/3/26 at 6:21 a.m., revealed Resident #4 was reporting significantly more pain in his lumbar back since the weekend (of 2/28/26). He was describing the pain as very sharp jabbing pain, similar to previous pain he had, but much worse. The resident stated the pain started after a transfer over the weekend (of 2/28/26). He said he started a new pain medication Friday (2/27/26) and Saturday (2/28/26), but he became more tearful and angry and requested the medication be discontinued. IV. Staff interviews The NHA and the DON were interviewed together on 4/15/26 at 2:58 p.m. The NHA said he completed an investigation related to the incident with CNA #1 and Resident #4. He said CNA #1 was suspended for a few days and the facility decided she would no longer care for Resident #4. The NHA said he verbally spoke with CNA #1 about her remarks made to the resident, about the resident stinking, and educated her on approach. He said he did not have anything documented to show he completed the training with her. The NHA said the facility had annual training on treating residents with dignity and respect and a class was scheduled for 4/21/26 and 4/23/26. The DON said she had conversations with CNA #1 regarding her approach with residents and implemented the intervention to have CNA #1 not care for Resident #4 any longer. She said she did not complete a hands-on care skills demonstration with CNA #1 since the allegation from Resident #4, but she said she would do so going forward. -The facility was unable to provide documentation of the education completed for CNA #1.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents received food prepared in a form designed to meet individual needs.The facility failed to ensure Resident #1 was served the correct diet texture as ordered by the physician. Resident #1, who was diagnosed with Barrett's esophagus (a condition where the tissue lining the esophagus changes to resemble intestinal lining), Zenker's diverticulum (a pouch that forms at the top of the esophagus, in the throat, due to a weak spot where the throat muscles and esophagus meet, often caused by the upper esophageal muscle not relaxing properly during swallowing, leading to trapped food), difficulty swallowing, regurgitation, bad breath, risk of aspiration, dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD) and dementia, was admitted to the facility on [DATE] with a physician ordered dysphagia diet, level 6 - soft and bite sized. The facility failed to input the diet order into the resident's medical record, document the correct diet on the baseline care plan and communicate with the dietary department to ensure the resident was served the medically appropriate diet. Once the diet order was communicated to the dietary department on 12/25/25, the resident continued to receive the incorrect diet texture for dinner.Resident #1 received regular textured food, which included pork loin and sausage links, between 12/24/25 (date of admission) until after breakfast on 12/25/25. The meat was not altered to be soft and bite sized per the physician's order. An interview with the speech language pathologist (SLP) revealed that even if the meat was cut up, it was still the incorrect texture. The meat should have been soft and able to be depressed with a fork from a cube to flat. After the resident's diet order was communicated to the dietary department (dysphagia level 6 - soft and bite sized), Resident #1 was still served an egg salad sandwich with whole bread and a bag of potato chips for dinner on 12/25/25. The SLP said the resident should have been evaluated prior to consuming the potato chips and the crust on the bread no longer made the sandwich dysphagia appropriate.On 12/26/25, the family arrived at the facility, felt the resident had decompensated and requested for him to be sent to the hospital for evaluation. At the hospital, on 12/26/25, an upper GI (gastroenterology) endoscopy was performed with a noted bleeding Zenker's diverticulum with a large opening with impacted food, which required surgical intervention.The facility's failure to ensure residents received the physician ordered diet texture placed residents at risk for serious harm or death if not corrected immediately. Findings include:I. Immediate jeopardyA. Situation of immediate jeopardyThe facility failed to ensure Resident #1 was served the correct diet texture as ordered by the physician. Resident #1, who was diagnosed with Barrett's esophagus, Zenker's diverticulum, dysphagia, GERD and dementia, was admitted to the facility on [DATE] with a physician ordered dysphagia diet, level 6 - soft and bite sized. The facility failed to input the diet order into the resident's medical record, document the correct diet on the baseline care plan and communicate with the dietary department to ensure the resident was served the medically appropriate diet. Once the diet order was communicated to the dietary department on 12/25/25, the resident continued to receive the incorrect diet texture for dinner.The facility's failure led to Resident #1's change of condition and surgical intervention to remove the impacted food in the Zenker's diverticulum.The facility's failure to ensure residents received the physician ordered diet texture placed residents at risk for serious harm or death if not corrected immediately.B. Facility notice of immediate jeopardyOn 1/7/26 at 12:20 p.m., the nursing home administrator (NHA), the executive director (ED) and the director of nursing (DON) were notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #1 received the physician ordered diet texture.C. Facility plan to remove immediate jeopardyOn 1/7/26 at 4:27 p.m., the facility submitted a plan for the immediate jeopardy. The plan read:1. Corrective actionThe identified resident, Resident #1 no longer resides in the community.2. Action planThe facility conducted an audit on 1/6/26 at 12:30 p.m. to identify other residents who may be receiving the incorrect diet texture. Physician orders and dietary tickets were reviewed. No other issues were identified.The DON or designee provided education of the following: therapeutic (mechanically altered) diets, admission process regarding diet order transcription to the medical record and communication of diet to the dietary department and accurate documentation in the baseline care plan of the resident's physician ordered diet. Education was provided to all nursing and dining staff on 1/7/26 currently working in the facility and will continue to provide education until all staff have been re-educated. Staff will not be permitted to work until they have received the required education.The speech language pathologist (SLP) provided education of therapeutic (mechanically altered) diet textures according to the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines on 1/7/26 to all dietary staff working on those coming onto shift. Education will continue until all dietary staff have been educated prior to working.Education was provided on 1/7/26 to nursing staff by the DON on how to read the resident's tray card, and how to properly identify correct altered textured diets. All training was completed by DON for staff on shift. Education is to continue to ensure all staff are sufficiently trained and will be completed by DON/designee.All new staff hired post 1/7/26 will be given the same training prior to working in the kitchen or serving any residents their food, snack or beverage.The DON reviewed all identified residents with altered diet texture care plans on 1/7/26 and updated it accordingly to reflect each resident's specific dietary interventions and needs.3. Systemic changesThe DON or designee will review all new admissions within 24 hours beginning 1/7/26 for two meals per week for four weeks to validate that the meals are being prepared and served according to the residents' specific dietary requirements. Any issues identified will be corrected immediately and will also be reported to the NHA.4. MonitoringThe DON or designee will conduct three random resident meal observations per week for four weeks, then weekly for eight weeks using an audit tool to ensure residents are receiving the appropriate therapeutic diet as ordered by the physician. Any issues identified will be corrected immediately and will be reported to the NHA.D. Removal of the immediate jeopardyOn 1/7/26 at 4:27 p.m., the NHA, the DON and the ED were notified that the facility's plan to remove immediate jeopardy was accepted based on the facility's plan to implement the measures above. However, the deficient practice remained at a G level, actual harm.II. Facility policy and proceduresThe Therapeutic Diet Orders policy and procedure, reviewed 10/22/25, was provided by the NHA on 1/7/26 at 4:00 p.m. It revealed in pertinent part, The facility provides all residents with food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic diet is a diet ordered by the physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease or increase specific nutrients in the diet. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: inadequate nutrition; nutritional deficits; weight loss; medical conditions such as diabetes; renal disease; or heart disease; swallowing difficulty. The reason for a therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.The Therapeutic Diets - Transmission of Diet Orders policy and procedure, reviewed 8/20/18, was provided by the NHA on 1/7/26 at 4:00 p.m. It revealed in pertinent part, The dietary department should be notified, in writing, of all diet orders and changes by the nursing department. Upon admission, a dietary form should be completed and dated by the dining services director or designee. Food preferences, allergies, and diets should be noted. The information from the dietary form should be transferred to the master serving list or other designated form. The master serving list notes the resident's name, diet, preferences, and allergies. It is used on the tray line.The IDDSI Soft and Bite Sized, dated January 2019, was provided by the NHA on 1/7/26 at 4:00 p.m. It revealed in pertinent part, Level 6: soft and bite sized foods: soft, tender and moist, but with no thin liquid leaking/dripping from the food. Ability to bite off a piece of food is not required. Ability to chew bite sized pieces so they are safe to swallow is required. Bite sized pieces no bigger than 1.5 centimeters (cm) x 1.5 cm in size. Food can be mashed/broken down with pressure from a fork. A knife is not required to cut this food. Level 6 - soft and bite sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft and bite sized foods need a moderate amount of chewing, for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. The pieces are bite sized to reduce choking risk. To make sure the food is soft enough, press down on the fork until the thumbnail blanches to white, then lift the fork to see that the food is completely squashed and does not regain its shape. Meat cooked tender and chopped so pieces are no bigger than 1.5 cm x 1.5 cm lump size. If can not serve soft and tender, serve as minced and moist. No regular dry bread due to high choking risk.III. Professional referencesAccording to the IDDSI reference https://www.iddsi.org/faqs/q-do-all-foods-at-level-6-%E2%80%93-soft-bite-sized-adult-guidelines-need-to-meet-the-1.5 by 1.5cm-particle-size-requirements, retrieved on 1/7/26, All foods (sandwiches included) need to meet the particle size requirements for Level 6 - soft and bite sized. The relationship between particle size and risk of asphyxiation has been identified in the literature. In order to avoid asphyxiation, particles should be small enough to pass through rather than block the trachea. The average tracheal size for adult males is 22 millimeters (mm) and for adult females, 17 mm. Particle sizes of 15 mm size are therefore more likely to pass through the trachea, than block it. IDDSI appreciates that provision of food like sandwiches is very difficult at this particle size and asks clinicians and carers to consider providing soaked breads as an alternative. For example, finely chop bread and add equal amounts of water and butter to create a softened bread texture, re-shape and service. The combination of the water and fat content reduces stickiness and improves bolus cohesion.IV. Failure to ensure a resident was served the physician ordered diet textureA. Resident #1 statusResident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia, dysphagia, Barrett's esophagus, Zenker's diverticulum (esophageal diverticulum), influenza type A, pneumonia and dementia. According to the 12/24/25 admission assessment, Resident #1 required total assistance of one staff member for eating. B. Resident representative interviewResident #1's representative was interviewed on 1/6/26 at 11:15 a.m. Resident #1's representative said Resident #1 had a history of Barrett's esophagus and Zenker's diverticulum (esophageal diverticulum) since 2022 and was recently diagnosed with dementia within the past year. She said Resident #1 had significant cognitive impairment.Resident #1's representative said the resident was admitted to the facility on [DATE]. She said she specifically asked if the facility was able to handle the resident's diet restrictions because of the holiday. She said she was told the facility was able to handle a dysphagia diet and to trust us to provide the correct care for the resident.She said on 12/24/25, her husband and herself sat with the resident in the dining room waiting to be served. She said because of the time and how long it was taking, they had to leave prior to him being served dinner. She said they left the facility and returned a couple hours later. She said Resident #1 could not verbalize what he had for dinner. She said prior to leaving the facility that night, she reminded the certified nurse aide (CNA) Resident #1 had a bad swallowing problem and was assured he would be taken care of.She said she did not return to the facility until Christmas Day (12/25/25) with Resident #1's spouse. She said Resident #1 was served a boxed dinner with a full egg salad sandwich, with the crust and bread intact and a side bag of potato chips. She said Resident #1 had consumed a good portion of the meal when she had arrived. She said she looked for a staff member, but was unable to find anyone. She said Resident #1's spouse was becoming agitated and restless, so she had to leave to take her home.She said the following morning (12/26/25), she attempted to call the facility multiple times, however no one answered the phone. She said when she arrived at the facility, she saw Resident #1 sitting on the couch on the unit he resided. She said he was having difficulty breathing and felt his condition had worsened. She said the nurse told her he was fine, but she insisted the physician be called and wanted him to be sent to the hospital for further evaluation.She said he was admitted to the hospital on [DATE] and had surgery to remove impacted food from the resident's Zenker's diverticulum.C. Record review1. Resident history prior to admissionThe 12/17/25 history and physical hospital notes documented that the resident had dementia with Influenza A, right lower lobe infiltrate and hypoxemic respiratory failure. The resident was diagnosed with both Influenza A and pneumonia. The resident had a past medical history of Barrett's esophagus and Zenker's diverticulum. The radiology studies were pertinent for a patchy right lower lobe infiltrate for which he was admitted to the intensive care unit (ICU). The 12/20/25 GI consult physician progress notes documented the resident had dysphagia for two years and failed the barium swallow twice. He was able to tolerate a regular diet at his previous facility but now had failed the barium swallow studies. The 12/23/25 hospital physician progress notes documented Resident #1 required inpatient hospitalization for further evaluation of dysphagia. The esophagram documented the following: thick barium was given to the resident, however despite multiple requests, the resident would not swallow. The resident had difficulty following instructions and tolerating positions for modified esophagram. Multiple positions were attempted and the resident requested to discontinue esophagram. The impression revealed an incomplete esophagram, as the resident could not tolerate positioning or follow directions for the exam. Partial imaging of a rounded structure which could represent esophageal diverticulum.The 12/24/25 swallow assessment documented the resident had ongoing oral and suspected pharyngeal dysphagia (swallowing difficulties in the mouth and throat area) with overt signs and symptoms of laryngeal penetration and aspiration on thin liquids and regular solids. The precautions for the resident included sit upright as possible (preferably in a chair), take small single bites/[NAME] at a slow rate, no straws, full supervision with meals, provide frequent oral care and the resident must be fully awake/alert for by mouth intake to eliminate distractions during meals.The diet recommendations included soft and bite sized, dysphagia diet level 6 with thin liquids.The 12/24/25 hospital discharge summary documented Resident #1's discharging diagnosis was dysphagia. The resident's discharge had been delayed due to concerns with dysphagia and aphasia. The resident was discharged from the hospital on a dysphagia diet.2. Failure of the facility to ensure Resident #1 received the correct meal textureThe functional care plan, initiated on 12/24/25, documented Resident #1 required total assistance with one person physical assistance with eating.The 12/24/25 admission progress note documented Resident #1 was confused, disoriented, had disorganized thinking with unclear speech. The resident had short-term and long-term memory impairment and was only oriented to himself.It indicated Resident #1 had difficulty chewing, swallowing at times and required assistance with eating as needed.The baseline care plan, initiated on 12/24/25, documented Resident #1's physician prescribed diet was regular texture with thin liquids, with specifications for the resident to eat two bites and then drink some water.-However, based on hospital discharge documentation and the hospital SLP recommendation, the resident should have received a dysphagia level 6 - soft and bite sized diet.-The facility failed to ensure the baseline care plan had accurate documentation regarding Resident #1's diet texture, which was documented in the discharge instructions and notes from the hospital.A review of Resident #1's medical record did not reveal a physician order for diet texture.-The facility failed to transcribe the physician ordered diet for Resident #1 from the hospital discharge orders.The 12/24/25 nursing progress note, documented as a late entry on 12/29/25 at 11:57 a.m., revealed the resident was observed sitting upright in the dining room with family at the dining table. Resident #1 consumed small, bite-sized dinner. During the meal, the resident was noted to pocket small pieces of food in his cheek. The nurse provided repeated reminders to take one bite followed by a sip of liquid to promote safe swallowing.-However, according to the interview with Resident #1's representative, the family had left prior to the resident being served his meal. Additionally, the nursing progress note was documented five days later (12/29/25).The 12/26/25 nursing progress note documented Resident #1's representative came to visit the resident and reported the resident was in worse condition than he was at his admission to the facility. She and the resident's power of attorney (POA) said the resident was coughing and having pain swallowing. They requested the resident be sent to the hospital for evaluation. The physician was notified and agreeable.The 12/28/25 communication progress note written by the NHA documented he was notified Resident #1's family had concerns regarding the resident's re-hospitalization. The family was unable to speak with the NHA regarding their concerns.3. Resident #1's change of conditionThe 12/26/25 hospital physician notes documented the resident presented with suspected aspiration pneumonia in the setting of dysphagia with suspected esophageal diverticulum. The resident was currently stable and on antibiotics. The chest Xray revealed a right lower lobe infiltrate, which was present on the resident's previous admission to the hospital, however the resident presented with new and elevated leukocytosis (new or recent finding of a high white blood cell count often indicating the body is fighting an infection).The 12/26/25 upper GI endoscopy findings revealed a bleeding Zenker's diverticulum with a large opening with impacted food.The 12/30/25 hospital progress notes documented the resident failed the SLP evaluation. The impacted food was removed from the diverticulum.V. Staff interviewsThe registered dietitian (RD) was interviewed on 1/6/26 at 3:20 p.m. The RD said for new admissions at the facility, the hospital documentation was reviewed by the interdisciplinary team to determine the discharging diet for each resident. She said the nursing department completed a pink form with the physician diet ordered information and gave it to the dietary department. The RD said the dietary department was then responsible for inputting the diet information into the diet ticket system.The RD said she was not working on the day (12/24/25) Resident #1 was admitted to the facility. She said she was not involved in the care provided for Resident #1.The RD said she thought Resident #1's diet was changed the day after his admission [DATE]) to a dysphagia level 6 - small and bite sized.The dietary manager (DM) was interviewed on 1/6/26 at 3:45 p.m. The DM said the nursing department completed a pink form for all new admissions which documented the residents' physician ordered diet.The DM said a text message thread was completed on 12/24/25, the day Resident #1 was admitted to the facility. She said she was preparing and serving meals on that day and did not read the text thread. The DM said the nursing department did not submit the form to indicate Resident #1's physician ordered diet to the dietary department when he was admitted . She said the text thread was not a formal system within the facility for communicating resident diets.The DM said Resident #1 was served a regular texture meal, cut up on 12/24/25 until after breakfast on 12/25/25. She said the dinner Resident #1 was served on 12/24/25 was pork loin and for breakfast he was served eggs and sausage links.The DM said Resident #1 was served an egg salad sandwich with potato chips for dinner on 12/25/25. She said she thought the egg salad sandwich was considered dysphagia appropriate. She said she had been taught since the potato chips were thin, it was appropriate for a dysphagia diet.The SLP was interviewed on 1/7/26 at 9:54 a.m. The SLP said dysphagia diet level 6: soft and bite sized required food to be chopped up into 1.5 cm pieces and should be able to be depressed completely flat with a fork. She said residents with dysphagia would have residue and have a hard time clearing it to swallow.The SLP said she had not evaluated Resident #1 when he was admitted due to the holiday. She said if Resident #1 was served a cut up meal with regular texture, it would not be the same as dysphagia level 6: small and bite sized because of the consistency of the meat. She said oftentimes with regular texture meals, the meat could be dry and hard. She said a resident who required a dysphagia level 6 diet would have difficulty swallowing the consistency of regular texture meat.The SLP said Barrett's esophagus was a narrowing of the esophagus and could make it difficult to swallow. She said Resident #1 was diagnosed with Barrett's esophagus, but also Zender's diverticulum, which was an open pouch in the esophagus where food would get caught. She said based on Resident #1's diagnoses, Resident #1 would have difficulty breaking down the food items, creating a ball and moving it past the Zender's diverticulum.The SLP said thin potato chips were easily dissolvable in the mouth, however prior to them being served to a resident with a dysphagia diagnosis, she would perform a formal assessment. She said based on the information in the hospital records, potato chips and an egg salad sandwich would not be appropriate for Resident #1.The SLP said Resident #1 had the risk of choking, aspiration and an impacted Zender's diverticulum by eating regular texture food.The DON was interviewed on 1/7/26 at 10:17 a.m. The DON said prior to a resident being admitted to the facility, the interdisciplinary team would review the hospital paperwork. The DON said upon admission, the nursing department was responsible for completing a diet form and providing that form to the dietary department. She said the dietary department then input the diet into the system, which would appear on the resident's meal tray card with their physician ordered diet.The DON said the admitting nurse was responsible for getting all physician orders verified and transcribed into the resident's medical record, including the diet and diet texture. She said the admitting nurse completed the baseline care plan based on information from the hospital and interview with the resident and/or family.The DON said the facility did not follow their process when Resident #1 was admitted . She said the nursing department did not complete the diet form to provide to the dietary department. She said the admitting nurse did not transcribe the diet order into the resident's medical record nor ensure the baseline care plan reflected Resident #1's accurate diet order.The DON said Resident #1 should have been provided a dysphagia level 6 soft and bite sized diet upon admission to the facility. She said Resident #1 was served a regular texture diet from 12/24/25 until after breakfast 12/25/25. She confirmed Resident #1 was also served an egg salad sandwich and potato chips for dinner on 12/25/25.The DON said facility management was aware Resident #1's representative was upset about the diet texture of the meals he was served, but had not spoken to her.

Based on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen.Specifically, the facility failed to ensure employees performed hand hygiene appropriately during meal service and avoided cross contamination. Findings include:I. Professional referenceThe Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)II. Facility policy and procedureThe Hand Hygiene versus Alcohol based Hand Rub policy, reviewed 10/23/24, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It read in pertinent part, Staff should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to residents including before resident contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves does not replace hand hygiene). Indications for hand washing: when hands are visibly dirty, contaminated, or soiled, wash with soap and water. Duration of the entire procedure: 20 to 30 seconds, or sing happy birthday twice. Specific indications for hand washing: after known or suspected exposure to spores such as c-diff (clostridium-difficile - bacteria causing intestinal infection), before eating, preparing, or serving food.III. ObservationsDuring a continuous observation of the evening meal on 7/15/25, beginning at 4:25 p.m. and ending at 5:40 p.m., the following observations were made: At 4:47 p.m. cook (CK) #1, while wearing gloves, cut a piece of cooked chicken on a cutting board, put the cut chicken in the food processor and ground the chicken. CK #1 discarded and removed his gloves, without performing hand hygiene, donned (put on) new gloves and put the ground chicken on a plate. CK #1 took the food processor to the dish room, placed it on a dish rack, pushed the rack into the dish machine and then closed the dish machine door. CK #1 returned to the line and donned a new pair of gloves. CK #1 picked up the resident meal tickets and set the tickets back on the counter. Wearing the same gloves, CK #1 touched a ready to eat quesadilla held in a steam table pan. CK #1 removed and discarded the gloves.-CK #1 did not wash his hands after removing gloves donning new gloves, and touched a ready to eat food item with contaminated gloves.CK #1 donned on a new pair of gloves and picked up the meal tickets and set the mail tickets on the cutting board. CK #1 removed and discarded his gloves and donned new gloves. Wearing the same gloves, CK #1 touched ready to eat French fries held in a steam table pan. CK #1 removed and discarded the gloves. -CK #1 did not wash his hands after removing gloves donning new gloves, and touched a ready to eat food item with contaminated gloves.CK #1 walked to the dish room, opened the dish machine door and removed the food processor from the dish machine and returned to the front of the kitchen. CK #1 donned a clean glove on his left hand and removed the meal tickets that previously placed on the cutting board and placed a chicken breast on the same cutting board. CK #1 cut the chicken and while holding the chicken with his left hand placed the chicken in the food processor. CK #1 wiped the blade of the knife on his left glove. CK #1 removed and discarded the glove on his left hand and assembled a resident's meal plate. CK #1 took the food processor to the dish room, sprayed the food processor and placed it in the dish machine. CK #1 removed and discarded his glove, returned to the front of the kitchen and donned a pair of new gloves. CK #1 used tongs to place a chicken breast on the cutting board. CK #1 cut the chicken, holding the chicken with his left gloved hand and cutting the chicken with the knife in his right hand. CK #1 removed and discarded his gloves.At 4:56 p.m. CK #1 used his sanitizer towel to wipe off his cutting board. CK #1 donned a glove on his left hand. CK #1 used a utensil to place vegetables on the cutting board and cut the vegetables on the cutting board, touching the vegetable with his left hand and holding the knife in his right hand.-CK #1 did not wash his hands after removing gloves donning new gloves, and touched a ready to eat food item with contaminated gloves.CK #1 removed and discarded his glove and donned a new glove on his left hand. CK #1 picked up the meal tickets with his left hand. CK #1 used tongs to place a chicken and on the cutting board, cut the chicken on the cutting board, touching the chicken with his left hand and holding the knife in his right hand. CK #1 removed and discarded his left glove and then put on a new left glove. -CK #1 did not wash his hands after removing gloves donning new gloves, and touched a ready to eat food item with contaminated gloves.At 5:00 p.m. CK #1 retrieved the clean food processor from the dish room and returned to the front of the kitchen. CK #1 donned a glove on his left hand and placed a chicken breast on the cutting board. CK #1 cut the chicken and put it in the food processor with his gloved left hand, blended it in the food processor and placed it on the plate. CK #1 removed and discarded his left glove, donned a new glove on his left hand and placed the chicken from the food processor on the plate. CK #1 removed and discarded the glove and then touched the meal tickets and picked them up and looked at them with his left hand. CK #1 used his right hand to open the refrigerator then donned a new glove on his left hand. CK #1 with his left gloved hand he removed a piece of lettuce, a slice of tomato and sliced red onion and placed it on a plate. CK #1 removed and discarded his left glove. CK #1 used his right gloved hand to open a plastic container with a green lid and removed a slice of cheese with the same hand and placed it on the hamburger. CK #1 put the lid back on the plastic container and placed it back in the refrigerator. -CK #1 did not wash his hands after removing gloves donning new gloves, and touched a ready to eat food item with contaminated gloves.At 5:35 p.m. CK #1 picked up the meal tickets and then donned new gloves. CK #1 placed a meal ticket on the cutting board. CK #1 removed and discarded his left glove and donned a new clean glove. CK #1 placed a piece of cooked chicken on the cutting board without cleaning or sanitizing the cutting board after setting the meal tickets on it. -CK #1 did not clean or sanitize the cutting board before placing a ready to eat piece of chicken on the cutting board.IV. Staff interviewsThe director of dining services, the dietary supervisor (DS) and the registered dietitian (RD) were interviewed together on 7/16/25 at 10:45 a.m.The RD said she thought the staff should wash their hands after every three glove changes and she was not aware it should be changed prior to putting on new gloves when working with food. The RD said they did ongoing handwashing training for the dietary department.The director of dining services said CK #1 was diligent about changing his gloves but was not washing his hands in between the glove changes. The dining services director said they wanted to set up their meal service to have everything prepared so they could eliminate glove changes and use utensils instead. He said they had not recognized that setting the meal tickets on the cutting board was an issue.

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 infections.Specifically, the facility failed to:-Ensure resident rooms were cleaned in hygienic manner;-Ensure housekeeping staff performed hand hygiene appropriately during room cleaning;-Ensure linen and resident clothing were transported in hygienic manner;-Ensure dirty linen was transported appropriately; and, Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP).Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 7/22/25 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. “Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping and Laundry- Resident Room Cleaning policy, revised 5/14/2020, was received from the executive director (ED ) on 7/17/25 at 2:18 p.m. It revealed in pertinent part, “Resident rooms, including bathrooms, are cleaned and disinfected on a regularly scheduled basis, and per chemical manufacturer instructions. “Skilled nursing, cleaning frequency daily. Living areas disinfect all high touch surfaces, including appliances and bed frames as appropriate. Dust/wipe down personal belongings, windows and window coverings. Change bedding and towels, mop floor using neutral disinfectant or vacuum carpet where appropriate. Bathroom clean and disinfect vanity, countertop, sink bathtub/shower and toilet. Mop floor with neutral disinfectant. Clean the mirror and other surfaces.” The Hand Hygiene versus Alcohol Based hand run policy and procedure, revised 12/23/24, was received from the ED on 7/17/25 at 2:18 p.m. It revealed in pertinent part, “Staff should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to residents including before resident contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves does not replace hand hygiene). “Alcohol-based hand rubs are the preferred routine method of hand hygiene if hands are not visibly soiled. Guidelines developed by the Centers for Disease Control and Prevention (CDC) and infection-control organizations recommend that healthcare workers use an alcohol-based hand rub (a gel, rinse, or foam) with at least 60% alcohol to routinely clean their hands between resident contact, as long as hands are not visibly contaminated. Use an alcohol-based hand-rub: before having direct contact with residents; after having direct contact with a resident’s skin; before performing an aseptic task or handling invasive medical devices; after having contact with wounds or broken skin; before moving from work on a “soiled” body site to a “clean” body site on the same resident; after touching equipment or furniture near the resident; after handling any soiled clothing or linens (if clothing/linens were contaminated with blood, use soap and water to wash hands); and after removing gloves.” C. Observations During a continuous observation on 7/15/25, beginning at 10:04 a.m. and ending at 10:33 a.m. the following was observed: At 10:04 a.m. housekeeper (HK) #1 was cleaning resident room C-12, a single occupancy room. HK #1 applied gloves without performing hand hygiene, reached into a bucket that was on her cleaning cart that contained multiple rags in a cleaning solution called DNC-15. HK #1 collected one rag, rang it out and entered the resident room and began cleaning the sink by cleaning the rim then the bowl and back to wiping the rim then the sink handles and wiping the bowl again. HK #1 collected trash from the trash can, placed a new bag and returned to wiping the sink bowl and the rim of the sink three more times. -HK#1 failed to perform hand hygiene prior to applying gloves and she failed to clean the sink in hygienic manner from cleanest to dirtiest. Without changing gloves or performing hand hygiene, HK #1 then entered the resident’s bathroom. She touched the resident’s wheelchair and the light switch with solid gloves. HK #1 began wiping the toilet seat, then the rim of the toilet and then stopped to tie the trash bag in the bathroom. HK #1 returned to her cleaning cart with trash that she had collected from the resident’s room. While she was at the cart she grabbed the broom. Without changing gloves or performing hand hygiene, HK #1 swept the resident’s room from the window towards the main doorway moving the resident’s fall mat. HK#1 returned to her cleaning cart with debris from sweeping. HK #1 then removed her gloves and applied new gloves, without performing hand hygiene. -HK #1 failed to perform hand hygiene after removing dirty gloves and failed to change her gloves after cleaning the toilet. Without performing hand hygiene, HK #1 grabbed a new rag from the bucket, rang it out and entered the resident’s room. She wiped down the bedside table around the resident’s personal items and wiped the heater and window seal. HK #1 returned to her cart, without changing gloves, she grabbed a mop pad out of a bucket that had multiple clean mop pads in a cleaning solution. HK #1 rung out the mop pad from the bucket and mopped the resident’s room starting by the window moving towards the entrance of the room, mopped the bathroom and finished mopping the room. -HK #1 failed to perform hand hygiene prior to putting her hands in the mop pad bucket and she mopped the room and bathroom with one mop pad. HK #1 returned to her cleaning cart after mopping, removed her gloves and indicated she had completed cleaning the resident room at 10:16 a.m. -HK #1 failed to clean high touch areas in the resident’s room like call light, bed control, light switches and the handles to dresser or doors. At 10:18 a.m., without performing hand hygiene after cleaning room C-12, HK #1 began cleaning a single occupancy resident room, C-9. Without performing hand hygiene, HK #1 applied gloves and collected one rag from the bucket of rags on her cleaning cart prior to entering the resident’s room. -HK #1 failed to perform hand hygiene between resident rooms or prior to applying new gloves. HK #1 started wiping down the sink rim, then the bowl took water and splashed it onto the mirror. HK #1 then took a paper towel and wiped the mirror down. HK #1 went to the bathroom and began wiping down the toilet riser seat and rise handles then rim of toiler. -HK #1 failed to use a separate rag for the bathroom and failed to clean the toilet and riser from the cleanest area to the dirtiest areas. Without changing gloves or performing hand hygiene, HK #1 returned to her cleaning cart and collected a broom and dust pan. HK #1 swept the residents’ room from the window towards the main door stopping short at bathroom swept bathroom bringing debris from bathroom into the room and swept into debris collected from the rest of room. HK #1 collected debris from the room and discarded it into the trash compartment on the cleaning cart. -HK #1 failed to change her gloves and perform hand hygiene after cleaning the toilet. Without changing gloves or performing hand hygiene, HK #1 reached into her mop pad bucket to retrieve a mop pad and rung it out, then began mopping the resident room from the window to the bathroom entrance then mopped the bathroom and entry way of the room. -HK #1 failed to change her soiled gloves prior to collecting a clean mopping pad from the bucket and she mopped the entire room and bathroom floor using the same mop pad. HK #1 said she completed cleaning the resident's room, closing the resident room door with soiled gloves. HK #1 removed her gloves while the housekeeping director (HKD) placed a wet floor sign outside of the resident room. -HK #1 failed to clean high touch surfaces in the resident room. D. Staff interviews HK #1 was interviewed on 7/15/25 at 10:27 a.m. She said she recently started her position a few months ago. She said upon hire another HK showed her the housekeeping process. She said the other HK showed her to wipe the sink, toilet, sweep and mop the floor. HK #1 said she should use at least two rags to clean a resident’s room, one for their room and one for the bathroom. HK #1 said one mop pad was to be used in a private room. HK #1 said high touch areas in the resident’s room were the sink, bedside tables, toilet and door handles and the high touch areas should be cleaned daily to prevent spread of infection and germs. HK #1 said she was to complete hand hygiene prior to entering a resident’s rooms and was not aware she needed to perform hand hygiene with each glove change. HK #1 said she was not aware that she placed her soiled gloves into the mop bucket when collecting a mop pad. The housekeeping director (HKD) was interviewed on 7/16/25 at 11:42 a.m. She said the housekeepers were trained upon hire to follow a step by step of room cleaning. She said these steps were kept in a binder in the housekeeping cart for them to reference. The HKD said the staff should perform hand hygiene and apply new gloves prior to entering a resident’s room. The HKD said the housekeeper should enter the room and begin cleaning from the furthest point in the room from the doorway, clean from top to bottom or from the cleanest area to the dirtiest area. The HKD said it was important to clean from the cleanest area to dirtiest to prevent moving contamination from the dirtiest area to a cleaner area. The HKD said high touch areas in a resident’s room included the lights, blinds, heater, night stands, phones, remotes, bed side tables, sink, counters, hand rails, toilet floor, light switches, handles/knobs and call light. The HSD said high touch areas should be cleaned daily to prevent the spread of infection. The HKD said provided HK #1 education regarding proper cleaning techniques. The minimum data set coordinator (MDSC), who was covering for the infection preventionist (IP) at time of survey, was interviewed on 7/16/25 at 2:12 p.m. The MDSC said housekeeping staff should perform hand hygiene upon entering a resident’s room, during glove changes and on completion of cleaning resident rooms to prevent the spread of infection. The MDSC said high touch areas in resident rooms were the call light, door knobs, light switches and bed side tables and these areas should be cleaned daily to prevent spread of infection. The MDSC said the housekeeper should clean resident rooms from the cleanest area to dirtiest to prevent contaminating a cleaner area. II. Linen and clothing transportation A. Professional reference The Guidelines for Environmental Infection Control in Health Care Facilities: Laundry and Bedding, (revised 1/8/24) was retrieved on 7/23/25 from https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html#cdc_generic_section_3-3-collecting-transporting-and-sorting-cotaminated-textiles-and-fabrics, It revealed in pertinent part, “Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics: The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patients' rooms, surgical/operating areas, and laboratories. Handling contaminated laundry with a minimum of agitation can help prevent the generation of potentially contaminated lint aerosols in patient-care areas. “Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage. Single bags of sufficient tensile strength are adequate for containing laundry, but leak-resistant containment is needed if the laundry is wet and capable of soaking through a cloth bag. Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service. “Contaminated textiles and fabrics in bags can be transported by cart or chute. Loose, contaminated pieces of laundry should not be tossed into chutes, and laundry bags should be closed or otherwise secured to prevent the contents from falling out into the chute. Health-care facilities should determine the point in the laundry process at which textiles and fabrics should be sorted.” B. Facility policy and procedure The Laundry and Linen policy and procedure, revised 4/29/2020, was received from the ED on 7/17/25 at 2:18 p.m. it revealed in pertinent part, “The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. “Bagging and Handling Soiled Linen: All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Do not sort or pre-rinse soiled linens in resident or resident-care areas. Place any linen saturated with blood or body fluids into a leak-resistant bag before placing it into the hamper. Handle soiled linen as little as possible to prevent agitation. Hold laundry out away from your body. Do not shake dirty laundry. If laundry chutes are used, only closed and leak-resistant bags will be put into the chute. Do not place loose items in the laundry chute. Clean and disinfect clothes hampers. “Sorting Soiled Linen: Employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected. Use heavy-duty rubber gloves for sorting laundry. Always wash hands after completing the task and removing gloves. “Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. “Remove barrier attire when leaving the soiled linen area.” C. Observations On 7/13/25 at 12:19 p.m. an unidentified staff member was transporting personal clothing items without a cover over the clothing in the A-pod. On 7/13/25 at 1:25 p.m. an unidentified laundry staff member was transporting linen to the A-pod via a three level cart without covering the linen. On 7/15/25 at 12:08 p.m. an unidentified laundry aide was rolling a laundry cart with personal clothing items for residents. The cart was not covered and she parked the cart near the entrance to the B -pod common area. The unidentified laundry aide then would walk to individual rooms delivering clothing from the stationed cart throughout the B-pod. On 7/16/25 at 8:22 a.m. a laundry aide was in the B-pod with a large grey container on wheels. She was wearing a rubber apron. She reached into the soiled linen container on the B-pod, pulling out loose blankets and sheets from the bin and placing them into the grey container. Once the bin was empty she closed the lids to both containers and walked down the hall with the grey container on wheels towards the other pods. D. Staff interviews The laundry aide was interviewed on 7/15/25 at 10:55 a.m. She said she took a grey bin on wheels to the different pods to collect soiled linen from the bins on the pods. She said she then brought the bins to the soiled laundry room. She said she applied PPE to sort linen to be washed according to recommendations. She said once as the laundry was washed and dried she folded it or hung the clothes on a rack to be delivered to the resident’s rooms. The laundry aide said when she was delivering linen or clothing to the resident’s rooms or the linen closet, the clothes and linens needed to be covered at all times to prevent contamination when in transit. The HKD was interviewed on 7/16/25 at 11:42 a.m. She said soiled linen was collected by the laundry aides. The HKD said the laundry aide should perform hand hygiene, apply gloves and water proof apron and go to each pod with a grey bin on wheels and collect linen from the bins on each pod. The HKD said the linen should be in a bag and the bag should be tied up and removed and placed into the grey bin the laundry aide brought with them. The HKD said the laundry aide returned to the soiled laundry room to sort the linen as needed based on washing recommendations. The HKD said the residents’ soiled laundry was placed into mesh laundry bags in their rooms and can be transported to the laundry room either by nursing staff or the laundry aide to be washed. The HKD said she was not aware that soiled linen was not being transported in bags when being moved from the pod bin to the grey bin for transportation. The HKD said any clean linen or clothing should be transported to the pods while being covered to prevent contamination from the environment. The MDSC was interviewed on 7/16/25 at 2:12 p.m. She said linen should be covered when transported to prevent cross contamination. MDSC said soiled linen should be transported, covered and sorted only in the soiled laundry room. III. EBP failures A. Professional reference Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), 4/2/24, was retrieved 7/22/25. It read in pertinent part, “Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. “Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; and, wound care: any skin opening requiring a dressing. “In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.” B. Observations On 7/14/25 at 11:25 a.m. Resident #29’s room was observed. Resident #29 had a stage 2 pressure ulcer on his toe. There was no PPE inside or outside the room for staff to put on when providing direct care to the resident. On 7/14/25 at 11:29 a.m. certified nurse aide (CNA) #2 and licensed practical nurse (LPN) #3 were in the common area. Resident #29 was in his wheelchair and LPN #3 told Resident #29 they were going to sit him on the couch so that he would be more comfortable. CNA #2 retrieved a gait belt from the desk in the common area and put the gait belt around Resident #29’s waist. LPN #3 said they were going to stand on the count of three. LPN #3 and CNA #2 counted to three, CNA #2 grabbed the gait belt, with her arm under Resident #29’s arms and transferred Resident #29 to the couch. -LPN #3 and CNA #2 did not don PPE prior to providing direct care to Resident #29, who was on EBP. On 7/14/25 at 2:58 p.m. Resident #29 was in the common area and said he had to go to the bathroom. CNA #2 left the common area, returned with a wheelchair and placed the wheelchair in front of Resident #29. CNA #2 removed the gait belt from the seat of the chair and placed the gait belt around the resident's waist. CNA #2 placed her arms under the residents arms, and LPN #3 grabbed the resident’s gait belt and transferred the resident into the wheelchair. CNA #2 assisted Resident #29 to his room in the wheelchair and CNA #2 assisted Resident #29 to his bathroom. -LPN #3 and CNA #2 did not don PPE prior to providing direct care to Resident #29, who was on EBP. On 7/14/25 at 3:34 p.m. Resident #29 was in his wheelchair. CNA #2 attached a gait belt to Resident #29 around his waist and asked him to lift his feet. CNA #2 pulled the resident’s wheelchair forward next to the couch. CNA #2 held the gait belt with her arms under Resident #29’s arms and transferred the resident to the couch. -LPN #3 and CNA #2 did not don PPE to transfer Resident #29 who had a stage 2 pressure ulcer and required EBP. C. Staff interviews CNA #3 was interviewed on 7/16/25 at 10:18 a.m. CNA #3 said when a resident needed to be on EBP but did not have the PPE in front of their door, a nurse or nurse manager could also tell the staff the resident was on EBP. CNA #3 said she would follow the EBP if she was told about the resident requiring EBP regardless if an EBP sign was posted or not. CNA #3 said she referred to the EBP sign before she entered a resident's room to provide care and followed the instructions on the sign. CNA #3 said she would put on a gown to transfer a resident or assist the resident to the toilet or commode if the resident were on EBP. LPN #4 was interviewed on 7/16/25 at 10:31 a.m. LPN #4 said the infection preventionist or director of nursing (DON) would put the PPE in front of a resident's door if a resident was on EBP. LPN #4 said if she noticed PPE was needed she could put the PPE out herself as the facility had containers of PPE ready to go in each of the linen closets. LPN #4 said EBP was needed for any open area that would require wound care or a catheter. LPN #4 said Resident #29 should be on EBP due to his pressure ulcer and staff should wear a gown for his two person transfer. The MDSC was interviewed on 7/16/25 at 2:12 p.m. She said the facility currently only had residents that were on EBP. She said the staff should apply PPE when providing direct care to prevent coming in contact with the area of concern. The ED was interviewed on 7/16/26 at 2:20 p.m. The ED said staff should put on a gown to transfer a resident on EBP and PPE was available for staff to use and place at a resident’s room for EBP.

Based on observations, record review and interviews, the facility failed to ensure accurate assessments and informed risks were in place for three (#18, #3 and #7) of five residents with bed rails out of 27 sample residents.Specifically, the facility failed to:-Ensure Resident #18, Resident #3 and Resident #7 were assessed for the use of bed rails and less restrictive alternatives were attempted prior to use; and,-Ensure the risks of bed rails were explained to and informed consent for use was obtained from Resident #18, Resident #3 and Resident #7.Findings include: I. Facility policy and procedure The Use of an Enabler policy, reviewed 5/21/25, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It read in pertinent part, “The community will ensure accurate and timely completion of an enabler review in the resident’s medical record and evaluation for the appropriate and safe use of an enabler device. The community is to have a protocol in place to look at the device in use and at the effect the device has on the resident and their ability. Enabler devices are pieces of equipment or technology that assist a person with a disability or impairment to improve their function or independence. “Each resident shall have an enabler review in their medical record completed when an enabler is placed on admission and when triggered by the admission review. This review will automatically be triggered to be completed at a minimum quarterly and as needed (PRN). If the device is placed after the initial admission review then the community staff will be required to manually start this review to be completed. The review shall include: identification of specific symptoms and diagnosis that warrants the use of an enabler, the ruling out of other possible interventions, identify the least restrictive intervention, and obtain a physician order for the use of the device. “The interdisciplinary team (IDT) shall evaluate all factors leading to the consideration of the device, investigate that all alternative measures have been exhausted and found to be unsuccessful, weigh the risk and benefits of the enabler to be used, and determine if the resident’s safety is compromised by not using the device. “A comprehensive plan of care shall be developed that included input from the resident/personal representative, was based on informed choice, addressed safety issues as a result of the enabler being used, specified the type of enabler to be used and was reviewed and evaluated for continued use as necessary, at a minimum quarterly. The determination must include whether the resident is capable of independently removing the enabler and whether the device restricts the residents freedom of movement. The resident’s care plan should be updated to reflect any changes in the community’s interventions. Interventions must be individualized to the resident’s specific needs.” II. Manufacturing instructions The manufacturing instructions for the facility’s assist bars were provided by the ED on 7/15/25 at 11:42 a.m. It read in pertinent part, “The purpose of the assist bar was to provide the resident a grab bar in which they could assist themselves from a sitting position to standing while exiting a long-term care bed. Clinical staff must decide whether a resident would benefit from the use of the aid. Vulnerable patient needs should be considered before using the product. The manual must be given to the user of the product before using the product. “Conditions such as restlessness, mental deterioration and dementia or seizure disorders (uncontrolled body movement), sleeping problems, and incontinence can significantly impact a patient's risk of entrapment. Monitor patients with these conditions frequently. To avoid patient entrapment from the use of an assist par in the up position, only use the assist position while attending to the resident and return the assist bar to the storage down position when unattended. III. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (lack of blood supply to the brain), respiratory failure, hepatic failure (liver failure), vascular dementia (brain damage due to multiple strokes) and type 2 diabetes mellitus. The 5/15/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She needed set up assistance for meals and was dependent on assistance for all other activities of daily living (ADL). The MDS assessment documented bed rails were not used. -However, observations and interviews revealed bed rails were being used (see below). B. Observations On 7/13/25 at 10:39 a.m. a rounded assist bar was on each side at the head the resident's bed. On 7/14/25 at 12:19 p.m. Resident #18 was in her bed and her meal tray was delivered to her room. The meal tray was set up on the residents bedside table and placed in front of her while in bed. An assist bar was on each side of the resident’s bed. On 7/14/25 at 12:37 p.m. and 12:50 p.m. Resident #18 was leaning her head on the right assist bar and holding the bar with both hands. On 7/15/25 at 12:28 p.m., 12:50 p.m., 1:04 p.m. and 1:21 p.m. Resident #18 was leaning her head on the right assist bar and holding the assist bar with both hands. C. Record review Resident #18’s ADL care plan, revised 10/28/24, documented the resident had an ADL self-care performance deficit related to diagnoses of cerebral infarction, history of falling, venous insufficiency (improper functioning of vein valves in the leg) and vascular dementia. Pertinent interventions, revised 10/28/24, documented the resident required assistance by one staff member to turn and reposition in bed and needed the assistance of one person for transferring. Resident #18’s fall care plan, initiated 11/22/24, documented the resident was at risk for falls due to gait and balance problems, being unaware of safety needs, history of falls, and seizures. Pertinent interventions included the resident having signs placed in her room to remind her to ask for assistance with all transfers (initiated 11/22/24) and a defined perimeter mattress was delivered by hospice (initiated 4/14/25). -Resident #18 did not have a care plan or care planned intervention for the use of an assist bar. A 7/14/25 (completed during the survey) enabler review (assist bar) documented Resident #18 required assistance to move in bed, assistance to transfer, and assistance to stand. The assessment documented she had behavior issues impairing safety and judgement, had a recent history of falls and other assistive devices were unsuccessful. -The assessment did not document other alternatives or assistive devices attempted prior to the assist bar. The 7/14/25 enabler review documented it was determined to initiate a grab bar due to the resident’s decreased strength and endurance, to promote a higher level of physical and mental functioning and the benefits outweighed the risks at the time of the assessment. -The assessment did not document the risks of using the grab bar, or if the risks were explained to the resident or the resident’s representative, and if informed consent was obtained. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 7/15/25 at 10:15 a.m. LPN #3 said the nursing staff checked the assist bars to ensure the bars were used for mobility and for optimal level of functioning while the residents were in bed. LPN #3 said upon admission the staff talked to the residents and sometimes the residents requested to have an assist bar if it was needed to move around in bed or the staff noticed the resident might benefit from an assist bar and try to promote more independence. LPN #3 said the staff would then notify the maintenance department and get the bar attached and the facility completed an enabler assessment. LPN #3 said the enabler review was in the assessments tab in the resident’s record. LPN #3 said the initial nursing assessment documented if the resident asked for an assist bar and then staff can initiate an enabler assessment to be completed. LPN #3 said the resident should be assessed prior to getting the bar for safety so the resident did not hurt themselves. LPN #3 said she was not sure of the risk or injury associated with the assist bar. Certified nurse aide (CNA) #2 was interviewed on 7/15/25 at 11:30 a.m. CNA #2 said the enabler bar had been on Resident #18’s bed for a few months. CNA #2 said the resident used the enabler bar independently. The director of rehabilitation (DOR) was interviewed on 7/16/25 at 1:25 p.m. The DOR said as long as a resident needed assistance and did not have precautions to use the bar, the facility would use the bar to maximize independence. He said the bar was used to regain strength, assist the resident to sit up and then as the resident improved the facility tried to minimize use of the bar. The DOR said his team notified him when a resident would use an assist bar and the installation was added to the maintenance list for installation. The DOR said alternatives offered to the bed rail would depend on the goal of the resident. The director of rehabilitation said he was not sure who obtained informed consent for the use of the assist bar. The ED was interviewed on 7/16/25 at 2:20 p.m. The ED said Resident #18 did not have an enabler assessment completed prior to installation because the need for the assessment was not triggered by the initial nursing assessment. The ED said informed consent was not obtained for the assist bars because the bars were not considered restraints. IV. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the July 2025 CPOs diagnoses included cerebral infarction , dysphagia (difficulty swallowing), hemiplegia (decrease in mobility) affecting left side and hypertension (high blood pressure). The 6/6/25 MDS assessment revealed the resident was moderately cognitive impaired with a (BIMS score of nine out of 15. He was dependent on staff for dressing, toileting, personal hygiene and transfers. He required moderate staff assistance with eating. The MDS assessment documented bed rails were not used. -However ,observations and interviews revealed bed rails were being used (see below). B. Observations On 7/13/25 at 10:40 a.m. Resident #3 was lying in bed with bilateral bed canes attached to the bed near the head of the bed. On 7/14/25 at 10:35 a.m. Resident #3 was lying in bed with bilateral bed rails. C. Resident interview Resident #3 was interviewed on 7/13/25 at 10:40 a.m. He said he has had assist bars on his bed for a while now and that he used them to aid in rolling in bed. Resident #3 said he was unable to recall if staff had talked to him about the risk of using an assist bar. D. Record review Resident #3’s ADL care plan, revised 6/18/25, documented the resident had an ADL self-care performance deficit related to cerebral infarction, dysphagia, weakness left side, atrial fibrillation (abnormal heart function), insomnia (impaired sleep), history of falling and generalized pain. Pertinent interventions documented resident required one to two staff members to turn and reposition in bed. Resident #3 used enabler bars to maximize independence with turning and repositioning. Review of the July 2025 CPO revealed the following physician’s Enabler bars to bed to assist residents with turning and bed mobility, ordered 7/15/25 (during the survey). -The facility failed to have physician’s order in place prior to enabler bars being installed on Resident #3’s bed. The 7/14/25 ( during the survey) enabler review documented Resident #3 required assistance to move in bed, assistance to transfer, and assistance to stand. It documented other assistive devices that were not unsuccessful. -The review did not identify alternative assistive devices attempted prior to the enabler bars. The review determined enabler bars to both sides of the bed were needed for mobility in bed and getting out of bed related to left sided weakness from cerebral infarction to promote higher level of physical and mental functioning. -The review did not document the risk of using the enabler bars. -Review of Resident #3’s electronic medical record (EMR) did not reveal documentation indicated consent was obtained for use of the grab bars/enabler bars to the resident bed. V. Resident #7 A. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO diagnoses included dementia (memory issues), hypertension (high blood pressure) and heart failure. The 3/31/25 MDS assessment revealed the resident was severely cognitive impaired with a BIMS score of two out of 15. She was dependent on staff for toileting, personal hygiene and dressing. She required maximal staff assistance with bed mobility, transfers. She required set up assistance with eating. The MDS assessment documented bed rails were not used -However, observations and interviews revealed bed rails were in use (see below). B. Observations On 7/13/25 at 1:18 p.m. there were bilateral bed rails towards the head of the bed and were rounded on Resident #7’s bed. Both of the bars were wobbly. On the left side of the bed, on the opposite side of the window, there was approximately a two to three inch gap between the bar and the mattress. On 7/14/25 at 3:13 p.m. there were bilateral bed rails on Resident #7’s bed. On 7/15/25 at 2:07 p.m. LPN #1 observed Resident #7 bed rails and said the grab bars were wobbly and that there was a gap between the bar and the mattress. C. Record review Resident #7’s ADL care plan, revised 7/14/25 (during the survey), revealed document the resident Resident #7 had an ADL self-care performance deficit related to weakness, dementia, and pain. Pertinent interventions, included Resident #7 required moderate to maximum assistance from one to two staff to assist to turn and reposition in bed and ensuring enabler bars on the resident bed to assist residents with turning and bed mobility (initiated 7/14/25). Review of the July 2025 CPO revealed the following physician’s order: Enabler bars to bed to assist residents with turning and bed mobility, ordered 7/15/25 (during the survey). -The facility failed to have physician’s order in place prior to enabler bars being installed on Resident #7’s bed. -The facility failed to ensure the use of the enabler bars were documented on the resident’s care plan. The 7/14/25 (during the survey) enabler review documented the resident required assistance to move in bed, transfer, stand and ambulate. She had behavior issues impairing safety and judgment and a history of falls. It documented other assistive devices that were unsuccessful. -The review did not document what alternatives assistive devices were attempted prior. The enabler review documented it was determined to initiate grab bars to both sides of the bed to treat decreased safety awareness. To promote bed mobility, getting out of bed, higher level of physical and mental functioning. -The enabler review did not document risk of using the enabler bar, or if the risk were explained to Resident #7 or responsible party for consent to use the enabler bars. Review of Resident #7’s EMR did not reveal documentation indicated consent was obtained for use of the grab bars/enabler bars to the resident bed. VI. Staff interviews LPN #1 was interviewed on 7/15/25 at 2:07 p.m. She said the enabler bars on beds were in place to increase resident mobility in bed. LPN #1 said a resident could be assessed on admission by nursing staff or later by the therapy department. LPN #1 said staff needed to complete an enabler bar assessment prior to the installation of the bars. LPN #1 said it was the responsibility of the maintenance department to install them and do periodic safety checks. LPN #1 was not sure how often the grab bars were assessed for safety. LPN # 1 said if she was assisting a resident and noted an issue with the grab bars she would notify maintenance to assess them as soon as possible. LPN #1 said she was not aware the gap between the mattress and the enabler bar was a safety concern. LPN #1 said the bars fit differently on beds depending on what type of mattress was being used by the resident. LPN #1 said she was unaware consent was to be obtained from the resident or responsible party for the use of enabler bars on a resident’s bed. The DOR was interviewed on 7/16/25 at 1:26 p.m. He said the facility used enabler bars to increase resident mobility in bed to maximize the residents independence, regain strength and then remove them from resident use once they are no longer needed. The DOR was unaware who was responsible for obtaining a consent for the use of enabler bars. The DOR said Resident #3 initially came to the facility and was assessed by the therapy department on 5/23/25 and it was determined then he would benefit from the use of enabler bars. The DOR said Resident #3 was still receiving therapy services and still required the use of enabler bars at this time. The DOR said Resident #7 was no longer on therapy case load, but had been previously. The DOR said Resident #7 required enabler bars and was assessed by therapy for them 7/25/24. The DOR said Resident #7’s goal was to return to assisted living at that time which made her a good candidate for use of the enabler bars to increase independence.

Based on observations and interviews, the facility failed to ensure residents had the right to a dignified existence.Specifically, the facility failed to provide an environment of engagement and promote quality of life for residents.Findings include:I. Facility policy and procedureThe Quality of Life: Dignity policy and procedure, reviewed on 2/23/24, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It revealed in pertinent part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining or enhancing his or her self-esteem and self-worth. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her preferred name and not ‘labeling' or referring to the resident by his or her room number, or by using terms such as ‘dear' or ‘honey. Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed, and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. Staff shall maintain an environment in which confidential clinical information is protected, for example: verbal staff to staff communications (change of shift reports) shall be conducted outside the hearing range of any residents and visitors.II. Resident interviewsResident #3 was interviewed on 7/13/25 at 10:40 a.m. Resident #3 said the staff were not very compassionate with him and never took the time to talk to him. He said the facility staff would just come into his room, ask what was needed, complete the task and then leave. He said the staff did not interact with the residents who resided in the facility unless they had to.A resident group interview was conducted on 7/15/25 at 10:00 a.m. Resident #13 said she felt like the facility staff did not enjoy spending time with the residents. She said the facility staff were good at their job when asked, but did not feel an emotional connection to the residents.Resident #22 and Resident #27 said the facility staff members were not chatty with the residents and it felt lonely to live at the facility. Resident #22 said the staff were good at providing care when you asked, but other than that, they did not ever have any interactions with the residents.Resident #27 said no one just sat and talked to the residents and sometimes the residents just wanted someone to sit and care.The group of residents said they felt bad for residents who were not able to speak up for themselves because they received even less staff interaction than those that were able to ask for assistance.III. ObservationsDuring a continuous observation of the A unit on 7/13/25, beginning at 9:45 a.m. and ending at 3:00 p.m., the following was observed:At 10:30 a.m. Resident #2 was observed lying in bed, sleeping. The resident was dressed in a hospital gown.At 12:25 p.m. certified nurse aide (CNA) 1 entered Resident #2's room. He placed the resident's lunch meal tray down on the overbed table that was positioned to the side of the bed and not within reach of the resident. He did not speak to Resident #2, nor attempt to arouse the resident, who was still sleeping.At 1:08 p.m. CNA #1 entered Resident #2's room again. He did not speak to the resident. He uncovered the resident's lunch meal and left it open to air. He exited the room and told the nurse on the unit he was going on his lunch break.At 1:44 p.m. CNA #1 entered Resident #2's room a third time. He did not speak to the resident, picked up the meal tray and removed it from the room.-Resident #2 did not receive any form of verbal interaction from facility staff from 10:30 a.m. until 3:00 p.m., a period of four and a half hours.During the same continuous observation, Resident #6 was sitting in the common area on the unit in front of the television. The television volume was not turned on and Resident #6 was sitting with her head down and sleeping.At 11:15 a.m. Resident #6 was wheeled from the common area on the unit and taken to the dining room by an unidentified staff member. The unidentified staff member did not speak to the resident nor tell her where they were going.At 1:07 p.m. Resident #6 was brought from the dining room and placed back in front of the television in the unit's common area. The volume on the television was not turned on.Throughout the continuous observation, multiple staff members were observed walking in between Resident #6 and the television, however, no staff member was observed interacting with the resident.During the same continuous observation, the following was additionally observed:At 9:45 a.m. Resident #13 was lying in her bed, facing the wall and window. The blinds were closed.At 10:45 a.m. Resident #16 was sitting in a recliner chair in his room, staring off, not looking at the television. CNA #1 delivered the resident's lunch meal tray at 12:30 p.m. on the over bed table and left the room. He did not interact with the resident. The resident did not have any meaningful staff interaction during the continuous observation.On 7/13/25 at 11:20 a.m. Resident #30 was sitting in the common area of the C unit. There was a television in front of Resident #30 but it was not turned on. Resident #30 kept looking up at the ceiling, directly into the sun coming in through the skylights. Multiple staff members were observed walking past the resident, but they did not interact with him. Staff only interacted with him when they wanted him to stop propelling himself in his wheelchair.At 1:19 p.m. an unidentified nurse entered Resident #13's room, looked at the resident and then left. The nurse did not interact with the resident. A couple of minutes later, Resident #13 was observed taking a drink from her coffee cup. Resident #13 did not have any meaningful interaction with staff during the continuous observation.On 7/14/25 at 2:43 p.m. Resident #29 was sitting in the common area on the couch on the B unit. Licensed practice nurse (LPN) #3 and CNA #2 were seated at the desk in the common area. While Resident #29 was on the couch, LPN #3 and CNA #2 discussed residents who recently passed away. Resident #29 sat on the couch with his hands in his lap and his knees tightly together and frowning during the conversation.On 7/15/25 at 9:40 a.m. Resident #30 was again sitting in the common area of the C unit. Resident #30 was slouched over with his eyes closed in his wheelchair. An unidentified hospice nurse was talking on the phone about another resident in the facility who sat in an armchair slightly behind Resident #30 to his right side. The unidentified hospice nurse finished her call and left the C unit.The television in front of Resident #30 was not turned on. Resident #30 picked up his head three different times, looked around and then would slouch back down when he did not see anyone. On 7/15/25 at 11:50 a.m. CNA #1 was sitting in a chair at a desk in the common area of the A unit, staring up at the ceiling and whistling. He did not interact with any residents unless their call lights were activated.Resident #6 was sitting in front of the television in the common area with the volume not turned on. CNA #1 got up from the chair at the desk, walked up to Resident #6 and began wheeling her down the hallway to the dining room. He did not speak to Resident #6 and did not tell her where they were going. CNA #1 wheeled her up to a table in the dining room and took a seat near the table. He sat staring at the ceiling but not talking to Resident #6 who was the only resident sitting at the table at that time. Resident #6 began rummaging through the silverware place settings.IV. Staff interviewsCNA #1 was interviewed on 7/15/25 at 3:11 p.m. CNA #1 said all residents deserved to be treated with dignity and respect. He said CNAs were responsible for rounding every two to three hours. He said during rounding, the CNAs should talk to each resident and ask them if they needed any assistance. He said he did not really have time to sit and chat with the residents because he was busy completing his job duties.The activity director (AD) was interviewed on 7/16/25 at 10:25 a.m. The AD said all residents in the facility deserved to be treated with dignity and respect, which included interaction from the staff. She said she had worked at the facility for a few months and had noticed it was very quiet unless there was a group activity happening. She said the environment lacked a lot of interaction between the staff and the residents. She said she was trying to change the culture through the activities program and trying to get more staff involved with the residents.The ED was interviewed on 7/16/25 at 2:19 p.m. The ED said all residents should be treated with dignity and respect. She said staff should interact with residents throughout the day and not only when they were providing care. She said she was sad to hear that residents felt lonely. She said she understood focusing on care, but that was not the only part of their job. She said she wanted the residents to enjoy living at the facility and feel cared about as well as cared for.

Based on record review and interviews, the facility failed to ensure one (#18) residents of six residents was free from significant medication errors out of 27 sample residents.Specifically, the facility failed to ensure Resident #18 was administered Keppra oral solution (for seizure prevention) per physician's orders. Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment.Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights:-The right medication;-The right dose;-The right patient;-The right route;-The right time;-The right documentation; and,-The right indication.II. Facility policy and procedureThe Medication Administration policy, reviewed 2/23/24, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It read in pertinent part, Medications shall be administered in a safe and timely manner and as prescribed by a physician or other authorized practitioner. Medications shall be administered in accordance with the physician/authorized practitioner orders, including any required time frames. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate in the medication administration record the appropriate/related corresponding code and also complete a progress note in the resident record. If critical medication is not given, such as Coumadin (blood thinner), Digoxin (blood pressure medication), Lasix (medication used to treat water retention), the licensed nurse will be responsible for informing the physician of such. Exception to this will be that the defined parameters have been established by the physician for holding the medication ordered. The licensed nurse will be responsible for informing the physician of related (three day) non-critical medication refusal by the resident.III. Resident #18A. Resident statusResident #18, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included cerebrovascular disease (conditions affecting blood flow to the brain), history of falling, history of transient ischemic attack (TIA - temporary disruption of blood flow to the brain), vascular dementia, weakness, seizures and depression.The 5/6/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 10 out of 15. She was dependent or needed maximal assistance with activities of daily living (ADL) and supervision with eating.The assessment documented the resident was prescribed an anticonvulsant. B. Record reviewThe seizure disorder care plan, initiated 10/25/24, documented she had a seizure disorder related to history of a stroke. Pertinent interventions, initiated 10/25/24, documented to give seizure medication as ordered by the doctor; and, monitor and document the side effects and effectiveness. A review of Resident #18's July 2025 CPO revealed the resident had physician's orders for the following medication:Keppra oral solution 100 milligrams/milliliter (mg/mL). Give 5 ml by mouth two times a day for seizure prevention per hospice, ordered 1/15/25.Review of Resident #18's February 2025 (2/1/25 to 2/28/25) and March 2025 (3/1/25 to 3/31/25) medication administration record (MAR) revealed the resident did not receive the Keppra oral solution as ordered on 2/28/25 and 3/1/25.A 2/28/25 medication administration note documented at 11:06 p.m. revealed Resident #18's Keppra oral solution was not administered and the medication was not available.A 3/2/25 medication administration note documented at 12:43 a.m. revealed Resident #18's Keppra oral solution was not administered (on 3/1/25 in the evening) and the medication was not available.-There were no progress notes documented to indicate the pharmacy, hospice or the physician had been contacted or notified that Resident #18's Keppra oral solution medication was not available and had not been administered to the resident on 2/28/25 and 3/1/25.IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 7/15/25 at 10:15 a.m. LPN #3 said Resident #18's medications were provided by hospice, her family and the pharmacy. LPN #3 said the Keppra solution was provided by hospice. LPN #3 said the facility should notify hospice if they needed a medication refilled. LPN #3 said there should have been a phone call to notify the physician the medication was not available. LPN #3 said the physician would give a recommendation and that recommendation would be documented. LPN #3 said she would document in the resident's record if she spoke with a person, what that person said and if they gave her an order. LPN #3 said the facility notified the resident's physician regardless of who provided or ordered the medication.The ED was interviewed on 7/16/25 at 2:20 p.m. The ED said the staff should notify the physician if a medication was not available and the notification should be documented in the record. The ED said if the family provided certain medications and the staff should notify the family if the medication needed to be reordered. The ED said the physician would give orders on what to do next, such as hold the medication.

Based on observations, record review and interviews, the facility failed to ensure two (#3 and #33) of two out of 27 sample residents with limited range of motion (ROM) received appropriate treatment and services.Specifically the facility failed to:-Ensure parameters were clearly identified to indicate the length of time, how often and by whom the brace should be donned (put on) and doffed (taken off) by Resident #3;-Ensure staff were monitoring the skin condition under the brace for Resident #3;-Follow physician's orders for Resident 33's contracture management; and,-Ensure Resident #33's carrot split was included on the care plan, monitored and reviewed for effectiveness. Findings include: I. Facility policy and procedure The Care Plan Process policy, revised 2/23/24, was received from the executive director (ED) on 7/17/25 at 2:18 p.m. It revealed in pertinent part, “To ensure the timeliness of each resident’s person-centered baseline and comprehensive care plan, and to ensure that care plans are reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. “A comprehensive care plan must describe the following: The services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.” The Weekly Skin Review policy and procedure, revised 3/6/25, was received from the ED on 7/17/25 at 2:18 p.m. It revealed in pertinent part, “The facility must have a system in place to evaluate skin condition (skin color, moisture, temperature, integrity, and turgor) at least weekly. “The nursing staff must be aware of any devices that were in use that may cause pressure.” II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO) diagnoses included cerebral infarction (lack of blood supply to the brain), dysphagia (difficulty swallowing), hemiplegia (decrease in mobility) affecting left side and hypertension (high blood pressure). The 6/6/25 minimum data set (MDS) assessment revealed the resident was moderately cognitive impaired with a brief interview of mental status (BIMS) score of nine out of 15. He was dependent on staff for dressing, toileting, personal hygiene and transfers. He required moderate staff assistance with eating. The MDS assessment did not indicate Resident #30 used a brace/splint or had a contracture. -However, record review revealed the resident had a physician’s order for removal of splint (see record review below). B. Observations On 7/13/25 at 10:40 a.m. Resident #3 was lying in his bed. Resident #3 was not wearing a brace to his left hand. The brace was lying on a chair in the corner of Resident #3’s room. At 2:45 p.m. the resident was not wearing a brace to his left hand. On 7/14/25 at 10:35 a.m. Resident #3 was lying in his bed with no brace in place to his left hand. C. Resident interview Resident #3 was interviewed on 7/13/25 at 10:40 a.m. He said he had limited mobility on his left side of his body related to a stroke. Resident #3 said he usually wore a brace on his left hand but it was not on at the time of interview. Resident #3 said he needed to wear the brace to help prevent his hand from curling under into his palm and getting stuck in that position. Resident #3 said he did not know if he was to wear the brace during the day or night but that he should wear it every day. He said the staff usually helped him put it on whenever they get the time to put it on. D. Record review Resident #3’s skin care, revised 5/24/25, revealed the resident had the potential for alteration in skin integrity related to fragile skin. Interventions, initiated on 6/23/25, included removing the immobilizer/brace/splint every shift and as needed (if ordered okay to do so) and reviewing skin for any non-blanching, redness, skin alterations and implementing treatment as indicated. Review of July 2025 CPOs revealed the following physician’s orders: -Remove hand splint at bedtime every day, ordered 7/3/25. -The resident was to wear a wrist brace during the day Monday through Friday as tolerated. The brace was to be applied by occupational therapist/physical therapist and removed by care staff at bedtime, upon resident requests, bathing or hygiene. Skin check to be completed daily, ordered 7/15/25 (during the survey). -The resident was to wear a left wrist brace during the day, as tolerated, apply upon rising and remove at bedtime, at resident requests, bathing or hygiene tasks. Skin check to be completed every shift, ordered 7/16/25 (during the survey). -The facility failed to have physician’s orders in place for donning the wrist brace and monitoring skin under brace prior to the survey. The July 2025(7/1/25 to 7/15/25) treatment administration record (TAR) revealed documentation was completed for the hand splint to be removed at bedtime since order was initiated on 7/3/25. -However there was no order in place to don the splint to resident #3. Review of the occupational therapy (OT) notes (6/9/25 to 7/15/25) revealed: The 6/9/25 OT progress note documented Resident #30 was given initial instructions regarding donning/doffing assessed for new orthotic device and adjusted. The 6/19/25 OT note documented the splint was applied following manual treatment to reposition fingers and wrist. The note documented the resident had a contracture following a period without splint in addition to increase in pain. The 6/26/25 OT note documented instructions were provided to the resident in the wearing scheduling and the orthotic (splint) was assessed for fit and adjustments were made following manual treatment, heat and exercise for improved joint positioning in left upper extremity. The 7/1/25 OT note documented the splint was adjusted and training was completed with the resident. Resident #30 demonstrated self donning with minimal assistance. New splint measurements were obtained and training was completed with the family to facilitate order of new more supportive splint/brace to prevent and manage left upper extremity contracture. The 7/3/25 OT note documented the initial instructions were provided to the resident in donning and doffing splint. Initial instructions were provided to resident for wearing splint and scheduling. The note documented a new brace was assessed for fit and issued to the resident. The new brace was applied successfully after manual treatment and fingers placed into splint. -The facility failed to obtain a physician’s order indicating resident schedule for wearing brace and to identify who was responsible for donning splint. E. Staff interviews Licensed practical nurse (LPN) # 1 was interviewed on 7/15/25 at 2:18 p.m. She said Resident #3 used a brace to his left hand. LPN #1 reviewed Resident #3’s physician’s orders and was unable to find any physician's orders for donning brace or monitoring of resident skin in the electronic medical record (EMR). LPN #1 said there should be a physician’s order to don the brace. LPN #1 said staff needed to know who was donning the brace, when it should be placed and for how long. She said the staff needed to know if they needed to monitor the brace for anything in particular. LPN #1 said she did not know who was responsible for donning the brace to Resident #3’s left hand. LPN #1 said she reviewed Resident #3’s care plan and was only able to locate the use of the brace being mentioned in the skin integrity section of his care plan (see record review above). The director of rehabilitation (DOR) was interviewed on 7/16/25 at 1:26 p.m. He said if a resident required the use of brace/splint they should be wearing it to prevent a contracture and to improve or maintain range of motion. The DOR said there should be a physician’s order for placement of brace and skin monitoring. The DOR said staff should be trained to apply the brace and the nursing staff were to monitor the skin for breakdown. The DOR said it was the responsibility of the occupational therapist to train staff on use of brace. The DOR said Resident #3’s wrist brace was ordered after his admission to the facility and it was recommended he wear his wrist brace daily. The DOR said Resident #3 was missing physician's orders for the brace for application and monitoring but had orders in place now. The DOR said the occupational therapist had taken it upon himself to apply the brace to residents when in the facility. The DOR said the occupational therapist did not work weekends. -However, there was no monitoring of when the brace was applied by the occupational therapist (see record review above). The executive director (ED) was interviewed on 7/16/25 at 3:24 p.m. She said there should be physician's orders in place for the use of braces on a resident. The ED said if a brace was not worn the contracture could worsen and the resident could lose activities of daily living capabilities. III. Resident #33 A. Resident status Resident #33, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included encephalopathy (brain dysfunction), altered mental status, chronic kidney disease stage 3, dementia and left hand contracture. The 5/9/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of four out of 15. She required supervision while eating and was dependent on help or needed maximal assistance with activities of daily living (ADL). The assessment documented her functional limitation in range of motion was impaired on one side of her upper extremity (shoulder, elbow, wrist and hand). B. Observations On 7/13/25 at 12:30 p.m. Resident #33 was seated at a dining room table. The resident had a drink cup with a straw and no lid. A staff member asked her if she wanted to try something else for lunch. -The resident did not have a drink with a two handled cup for her drink. On 7/14/25 during a continuous observation, from 11:11 a.m. to 11:37 a.m., Resident #3 was seated in the common area with a bedside table in front of her. She had a drink in a clear cup with a straw and no lid. At 11:15 a.m. licensed practical nurse (LPN) #3 poured more soda into the resident's cup. Resident #33 attempted to pull her cup toward her to drink four times. The resident was able to use her bent pointer fingers slightly and pull the cup toward her with the mouthpiece of the cup, lean forward and drink from a straw. The resident was unable to grab the cup with her open hands and could only guide the cup with her two bent pointer fingers. -The resident did not have a two handled cup for her drink. On 7/15/25 at 2:03 p.m. Resident #33 was observed in her wheelchair in the common area. She had a drink in front of her with a straw and no lid. -The resident did not have a drink with a two handled cup for her drink. C. Record review The ADL care plan, revised 4/24/25, documented Resident #33 had an ADL self-care performance deficit related to her diagnoses of encephalopathy, altered mental status, dementia, history of falling, weakness, contracture of the left hand, chronic kidney disease and malnutrition. Pertinent interventions, revised 4/24/25, documented the resident needed set up assistance from one staff member to eat. The nutrition risk care plan, revised 5/9/25, documented the resident was at greater risk for nutritional decline related to her advanced age, inadequate oral intake and dementia status. Pertinent interventions, revised 8/23/24, recommended the resident to be in the dining room at an assisted feeding table and have two handled cups with meals per occupational therapy recommendations. -The resident’s comprehensive care plan did not include a care plan or intervention for the use of a carrot splint for the resident’s left hand contracture, nor did the care plan include the resident’s refusal to use the splint (see physician’s orders and interviews below). A review of the July 2025 CPO revealed the following physician’s orders related to Resident #33’s contractures: Please apply a left hand carrot splint as tolerated, to maintain skin integrity due to left hand contracture, ordered 8/20/24; and, Provide a two handled cup for liquids to improve resident independence and hydration with drinking, ordered 8/23/24. -However, the July 2025 (7/1/25 to 7/16/25) medication and treatment administration record (MAR/TAR) failed to include documentation to indicate Resident #15's splints had been applied. -A review of the 6/17/25 to 7/15/25 certified nurse aide (CNA) task documentation failed to reveal documentation indicating the resident's splints were being applied per the physician orders. D. Staff interviews LPN #3 was interviewed on 7/15/25 at 10:15 a.m. LPN #3 said Resident #33 had a soft carrot shaped splint, and the splint was designed for the resident to hold in her hand. LPN #3 said the resident often refused the splint or pulled it out of her hand. LPN #3 said the resident’s splint use was easier to track if the order was on the MAR/TAR. LPN #3 said the resident could open her hand slightly and would either take the splint out or refuse to have it in her hand. LPN #3 said the resident could not open her hand enough that the splint could fall out of her hand. LPN #3 said she was unsure how often the resident was supposed to use the splint without its specified order. LPN #3 said ideally the resident's use of the splint was recorded in nursing in the MAR/TAR and tasks so the staff can record the task was completed. -However, the physician’s order did not specify parameters for use of the splint and the resident’s record did not document her use or refusals of the splint. CNA #2 was interviewed on 7/15/25 at 11:28 a.m. CNA #2 said she tried to keep the splint in the Resident #33’s hand all day but she did not force it. CNA #2 said she received direction from her nurse to use the splint and did not see the resident’s splint order as a CNA. CNA #2 said when the resident refused the splint, the resident would just keep her hand grip shut. CNA #2 said if the resident refused the splint she might mention it to the nurse or will try the splint again in a little bit. CNA #2 said the resident often refused the splint. CNA #2 said the resident did not refuse the splint all day but in the mornings she would not open that hand to grip the splint. CNA #2 said the resident used the splint better while in bed and while the resident slept. CNA #3 was interviewed on 7/16/25 at 10:18 a.m. CNA #3 said Resident #3 used a double handled sippy cup and she had a difficult time with a regular cup because of her hands. CNA #3 said she went to the kitchen to get a double handled cup for the resident if there was not one at the nurses’ station. CNA #3 said if the resident was given a small amount of something to drink the staff might hold the cup for her. LPN #4 was interviewed on 7/16/25 at 10:31 a.m. LPN #4 said she was aware the resident had a physician’s order for the double handled cup to be placed at meal times. LPN #4 said she never had difficulty getting a two handed cup for the resident. The registered dietitian (RD) was interviewed on 7/16/25 at 10:45 a.m. The RD said the kitchen staff put the adaptive equipment on the top of the meal cart sent to the units. The RD said a CNA would also provide the drink for the resident in the dining room, however the staff might not see the resident’s meal ticket that included the double handled cup prior to getting the resident their drink. The director of rehabilitation (DOR) was interviewed on 7/16/25 at 1:45 p.m. The DOR said Resident #33 struggled with grasping things and was previously doing well with the two handled mug to improve intake. He said the resident liked to keep her hand in the clenched posture and there was a time she clenched so much that was how the carrot came into place. The DOR said the carrot splint was also used to prevent skin breakdown and to maintain skin integrity. He said it would be up to the nursing team to include the splint on the resident’s care plan and if the resident used and was offered the splint or not. He said the physician’s order included ‘as tolerated’ sometimes the resident would allow it or not. He said there should be some type of tracking for use of the splint and the splint was recommended by the previous occupational therapist. He said consistent use of the carrot splint would help delay worsening of the resident’s contracture. The ED was interviewed on 7/16/25 at 2:20 p.m. The ED said the nurse was responsible for updating the care plan. The ED said the best practice was to monitor to see if care planned interventions were effective. E. Facility follow-up A review of Resident #33’s July 2025 CPO revealed an updated physician order: Please apply a left hand carrot splint as she will allow every morning, remove at bedtime and inspect the integrity of the hand. This is to maintain skin integrity due to a left hand contracture, ordered 7/15/25 (during the survey).

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for two (#6 and #30) of three residents out of 27 sample residents.Specifically, the facility failed to provide a program of meaningful activities for Resident #6 and Resident #30.Findings include: I. Facility policy and procedure The Basic Program Requirements policy and procedure, reviewed 2/3/25, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It revealed in pertinent part, “The overall purpose of an activity program is to provide residents with opportunities for continued functioning and quality of life. The community will have an activity program suited to the needs and interest of the residents. Programs will address the physical, intellectual, emotional, spiritual, social and vocational needs of the residents. “Programs/activities shall be available seven days per week, evenings and holidays.” II. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer’s disease, protein-calorie malnutrition and dementia without behavioral disturbance. The 6/5/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent upon staff assistance with transfers, bed mobility, oral hygiene, toileting, bathing, dressing and personal hygiene. The 3/5/25 MDS assessment documented the resident’s activity preferences were not assessed. B. Observations During a continuous observation on 7/13/25, beginning at 9:45 a.m. and ending at 3:45 p.m., the following was observed: At 9:45 a.m. Resident #6 was sitting in the common area on the unit in front of the television. The television volume was not turned on and Resident #6 was sitting with her head down and sleeping. At 11:15 a.m. Resident #6 was wheeled from the common area on the unit and taken to the dining room by an unidentified staff member. At 1:07 p.m. Resident #6 was brought from the dining room by an unidentified staff member and placed back in front of the television in the unit’s common area. She was looking around and not focused on the television. She was not provided any meaningful independent activities. At 3:00 p.m., Resident #6 was still sitting in front of the television in the common area. -No one was observed interacting with Resident #6 during the continuous observation. -Additionally, during the continuous observation, the activity calendar documented a 10:00 a.m. church service, Game Time: Dominos at 11:00 a.m. and a Name That Tune activity at 2:00 p.m. However, Resident #6 was not invited to attend any of the group activities. During a continuous observation on 7/14/25, beginning at 8:30 a.m. and ending at 3:00 p.m., the following was observed: At 8:30 a.m. Resident #6 was in the dining room for breakfast. At 9:00 a.m. Resident #6 was taken from the dining room to the common area by an unidentified staff member. She was placed in front of the television with the sound not turned on. She had a baby doll in her arms. Resident #6 was not offered any meaningful activities. At 10:39 a.m. an activity staff member was observed inviting one resident on the unit to a group activity. Resident #6 was not asked if she wanted to attend and continued to sit in front of the television with no interaction from staff members. At 11:21 a.m. the nurse on the unit walked over to Resident #6 and asked her if she wanted to be able to hear the television and if she wanted to watch a movie. Resident #6 nodded her head, indicating “yes” and the nurse turned up the volume and put on a movie. At 11:55 a.m. certified nurse aide (CNA) #1 asked Resident #6 if she was ready to go to lunch. He began wheeling her down to the dining room before she was able to answer. At 1:19 p.m. Resident #6 was taken from the dining room to the common area on the unit. Upon reaching the unit, the resident was placed in the common area in front of the television. She was not offered any meaningful activities. At 2:12 p.m. an activity staff member approached Resident #6 and asked her if she wanted to attend the group exercise activity and then BINGO. Resident #6 nodded enthusiastically, “yes” and was taken to the exercise program. At 2:19 p.m., seven minutes later, the activity assistant took Resident #6 from the group exercise program back to the unit to sit in the common area in front of the television. She did not speak to the resident, and it was unclear why the resident left the activity early and was not taken to BINGO. At 3:00 p.m. Resident #6 was still sitting in the common area in front of the television without any meaningful activities. At 3:23 p.m. CNA #1 wheeled Resident #6 to her room and said he was going to provide her with incontinence care. During the continuous observation, the activity calendar documented Game Time at 11:00 a.m., Exercise program at 2:30 p.m. and BINGO at 3:00 p.m. -However, Resident #6 was brought back to the common area from the exercise group seven minutes after an activity assistant took her to the group activity and she did not attend BINGO, despite the activity assistant asking her if she wanted to attend (see observation above). On 7/16/25 at 1:54 p.m. Resident #6 was sitting in the activity room. Another resident, whose primary language was the same as Resident #6’s primary language of Japanese, was sitting across from her and they were verbally interacting. Resident #6 was smiling and visibly enjoying herself. The activity director (AD) was observed grabbing an IPad (electronic device) and pulling up a digital translator. The AD spoke into the device, the device translated it into Japanese and the AD then spoke to the resident. The resident spoke back and the AD had a full conversation with Resident #6. The AD said, “Next time, I will get a translator for you.” -This interaction with Resident #6 was the first time, during the survey process, that facility staff were observed using a translation device to interact with Resident #6 in her native language (see staff interviews below). Cross reference F677: the facility failed to ensure Resident #6 was provided activities of daily living according to her plan of care and developed a communication plan for the resident to receive interactions in her native language. Cross reference F550: The facility failed to provide an environment of engagement and promote quality of life. C. Record review The activities care plan, revised 5/7/25, documented Resident #6’s primary language was Japanese, but she was also able to understand English. The resident’s family said she enjoyed both group and independent activities such as coloring, painting, crosswords, puzzles, watching HGTV (home and garden television network) and the food network, going outside, music, making jewelry and being around others. The interventions included providing Resident #6 with leisure materials as well as assisting her to all activities of her interest in the community due to her cognitive, visual, language, pain and physical limitations and providing signs in her preferred language so she could more easily communicate her needs with staff due to a language barrier. The 5/29/25 quarterly activities review documented the resident participated in independent and group activities daily and enjoyed coloring, puzzles, games, making jewelry and watching television. D. Staff interviews CNA #1 was interviewed on 7/15/25 at 3:11 p.m. CNA #1 said Resident #6 was completely dependent upon staff for all activities of daily living (ADL). He said she was unable to propel herself in a wheelchair and required staff assistance. He said Resident #6 usually spent all day in the common area in front of the television on the “A” unit. CNA #1 said Resident #6’s native language was Japanese but she was able to understand some English. He said she could answer yes and no questions, but he did not know how much she understood. He said he did not speak to her too often because she could not hold a conversation in English. He said he had used a digital translator once but he had not used it since. He said he thought there was another resident in the facility who spoke Japanese, but he was not sure. He said he was not aware of any communication boards in Japanese to be used for the resident to be able to communicate. CNA #1 said there was a baby doll in Resident #6’s room, but he did not know too much about it. He said one day, the baby doll just appeared. He said Resident #6 was happy holding the baby doll, but he did not know if she knew it was a toy or if she thought it was real. He said he thought she knew it was a toy. He said he did not know the purpose of the baby doll. He said he had never been given a report about it, so he did not know if it was part of her plan of care. He said if she wanted it he would give it to her, but she did not often ask for the baby doll. CNA #1 said Resident #6 would attend group activities at times, but did not attend all group activities. The activity director (AD) was interviewed on 7/16/25 at 10:25 a.m. The AD said she was responsible for the development of the activity calendar, completing assessments and participating in care conferences. She said the activities assistants were responsible for inviting residents and running all group activities. She said she had worked at the facility for the past three months and had begun to make changes in the activity department. She said documentation of resident participation in group activities was documented on a new computer system that her staff was still learning. She said she had two full-time activity staff members so activities were provided seven days per week. The AD said Resident #6 spoke Japanese but she was able to understand some English as long as the question was yes or no. She said she had not used a digital translator prior to that day (7/16/25) for Resident #6. She said Resident #6 had resided at the facility for approximately four to five months. She said Resident #6 was able to carry on a complete conversation with the use of the digital translator that day, 7/16/25. The AD said a resident on another unit also spoke Japanese. She said she did not know how often the two residents got together to interact. She said it was not part of Resident #6’s comprehensive care plan. The AD said staff should try and interact with each resident in their native language. She said the facility staff had access to a digital translator to assist with different languages and should use it every day with Resident #6. The AD said the baby doll was provided by Resident #6’s family. She said when Resident #6 resided in a memory care unit, she would take all the baby dolls in the facility and hide them in her room, so when she was admitted to the facility, Resident #6’s son provided her with a baby doll. She said it had been at the facility for about a month. She said the doll should be provided to the resident every morning so she was able to take it with her everywhere she went during the day. She said Resident #6 did not like it when other people would touch the baby doll. The AD said she did not know how the baby doll intervention or the digital translator was communicated with the nursing staff. She said she was not aware of a clear process. The AD said all residents should be invited to group activities. She said inviting Resident #6 to all group activities was part of her plan of care. She said Resident #6 was not included in the one-to-one activity program. The ED was interviewed on 7/16/25 at 2:19 p.m. The ED said all residents should be invited to group activities. She said it was a collaborative effort across all the departments, not just activities. The ED said communication should be provided to each resident in their native tongue. She said the facility staff had access to communication boards in multiple languages as well as access to a digital translator. She said Resident #6’s native language was Japanese. She said the facility staff should have been using a digital translator since her admission, so the resident was able to interact with others. The ED said there should be communication between the activities department and nursing to ensure each resident’s socialization needs were being met. She said this included an understanding of Resident #6’s use of the baby doll. III. Resident #30 A. Resident status Resident #30, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included cerebral infarction (lack of blood flow to the brain), epilepsy (abnormal electrical activity in the brain), dysphagia (difficulty swallowing) and type 2 diabetes (abnormal blood sugar level). The 6/27/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of eight out of 15. He required maximum staff assistance with dressing and toileting. He required moderate staff assistance with personal hygiene, bed mobility and transfers. He required supervision for eating. The MDS assessment indicated it was very important to the resident to get fresh air, somewhat important to be around animals and not very important to participate in religious services and books. B. Observations On 7/13/25 at 11:20 a.m. Resident #30 was sitting in the common area of the C-pod. There was a television in front of Resident #30 but it was not on. Resident #30 kept looking up at the ceiling, directly into the sun coming in through the skylights. Staff were observed to walk past him with no conversation and only spoke to him when he was attempting to self propel his wheelchair. -The facility failed to ensure Resident #30 had meaningful activities available while he was sitting in the common area of the C-pod. On 7/14/25 at 10:30 a.m. Resident #30 was left sitting in his wheelchair in the common area of the C-pod by an unidentified therapy staff member. Resident #30 remained sitting in the common area for 15 minutes just looking around before he was spoken to by anyone. The television in the common area was not on and there was nothing for the resident to do while he was sitting in the common area. -The facility failed to ensure Resident #30 had meaningful activities available while sitting in the common area of the C-pod. On 7/15/25 at 9:40 a.m. Resident #30 was again in the common area of the C-pod. Resident #30 was slouched over with his eyes closed in his wheelchair. There was an unidentified hospice nurse sitting in an arm chair slightly behind Resident #30 on his right side. The unidentified hospice nurse was talking on the phone about another resident in the facility. The unidentified hospice nurse finished her call and left the C-pod. There were no other staff members in the common area of C-pod. The television in front of Resident #30 was not on and there were no other meaningful activities available. Resident #30 picked up his head three different times, looked around and then would slouch back over when he did not see anyone. -Resident #30 was not provided with any meaningful activities while he was sitting in the common area of the C-pod. C. Resident’s representative interview Resident #30’s representative was interviewed on 7/14/25 at 11:40 a.m. The representative said Resident #30 was an avid reader and was active in his faith. She said she was unsure if Resident #30 had been provided with any reading material by the facility, but she said she had not seen a book in his room. She said she was not sure if Resident #30 had been provided an opportunity to engage in faith-based activities since coming to the facility. D. Record review The activities care plan, initiated 6/21/25, revealed Resident #30 enjoyed playing board games, reading western books and watching television and movies. Resident #30 enjoyed his family visits and enjoyed time outside, weather permitting. The activities goals identified on the care plan revealed Resident #30 would engage in watching television programs of choice weekly (initiated 6/26/25) and he would participate in religious services/practices weekly (initiated 6/23/25). Interventions included encouraging Resident #30 to engage in religious programs/services that were offered in the community, inviting, encouraging and assisting Resident #30 to all activities occurring in the community, providing Resident #30 with a television guide and ensuring his television and remote were properly working and within reach, encouraging and assisting Resident #30 to go outside when the weather permitted. -However, observations revealed Resident #30 was sitting in the common area of the C-pod but the television was not on (see observations above). On 7/16/25 at 10:50 a.m. the activities director (AD) provided a copy of Resident #30’s activity participation log for June 2025. The log revealed the only program being tracked was daily program and chronicle/leisure cart pass out. The AD was unable to provide an activities log for Resident #30’s participation for July 2025. The AD said the facility had changed their charting system for the activities department and she did not know how to pull a report. Review of the activities calendar for July 2025, provided by the ED on 7/21/25 at 12:46 p.m. (after the survey exit), revealed there were no scheduled religious services for residents who were Catholics. There were catholic communion visits scheduled on Thursdays at 1:00 p.m. -However, review of Resident #30’s activity participation log did not reveal that the resident attended the catholic communion visits (see above). E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/15/25 at 2:07 p.m. LPN #1 said the activities staff would give her a list of residents who wanted to participate in an activity and she would help facilitate getting the residents to the activity. LPN #1 said she knew which residents on her C-pod would attend which activities, but she said she did not go ask all of the residents if they wanted to attend. She said Resident #30 admitted to the facility very weak and slept a lot but he had since started to be more active and social. LPN #1 said she was not sure what Resident #30’s preferences were for activities other than family visits. The AD was interviewed on 7/16/25 at 10:25 a.m. The AD said the facility currently did not offer religious services for residents. The AD said the facility had a volunteer who came on Thursdays to provide catholic communion for residents. -The AD reviewed her activities log for resident participation. She said Resident #30 was not on her list of residents for catholic communion to be provided to. The AD said Resident #30 slept a lot and he had not been assessed to see if he would like to be woken up for activities. The AD said Resident #30 was nonverbal and struggled to communicate. The AD said she was unaware that Resident #30 would respond to yes or no questions.

Based on observations, record review and interviews, the facility failed to ensure two (#6 and #2) of five residents who required assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities out of 27 sample residents.Specifically, the facility failed to:-Conduct a safe transfer, develop a communication plan to ensure the resident was provided interaction in her native language and ensure timely incontinence care and repositioning was provided for Resident #6;-Ensure timely incontinence care, repositioning and eating assistance was provided for Resident #2; and,-Ensure Resident #2's comprehensive care plan was revised to accurately depict the resident's current level of care with ADLs.Findings include:I. Facility policy and procedureThe Activities of Daily Living policy and procedure, reviewed 3/13/23, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It revealed in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the assistance necessary to maintain good nutrition, grooming, and personal hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care); mobility (transfer and ambulation), bowel and bladder elimination (toileting), dining (meals and snacks); and communication (speech, language, and any functional communication systems). A resident's ability to perform ADLs will be measured using clinical tools, including the MDS (minimum data set) assessment. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: Independent: resident completed activity with no help or staff oversight at any time during the last seven days. Supervision: oversight, encouragement or cueing provided three or more times during the last seven days. Limited assistance: resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance of three or more times during the last seven days. Extensive assistance: while the resident performed part of the activity over the last seven days, staff provided weight-bearing support. Total dependence: full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over the entire seven day look back period. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assisted needs, preferences, stated goals and recognized standards of practice.The Resident Need for Translator/Interpreter Services policy and procedure, reviewed 2/23/24, was provided by the ED on 7/17/25 at 2:18 p.m. It revealed in pertinent part, The community will ensure that residents or personal representatives with limited English proficiency, or who have hearing or sight impairments, shall have meaningful access to information and services provided by the community in a manner in which they can understand.The Care Plan Process policy and procedure, reviewed 2/23/24, was provided by the ED on 7/17/25 at 2:18 p.m. It revealed in pertinent part, To ensure the timeliness of each resident's person-centered baseline and comprehensive care plan and to ensure that care plans are reviewed and revised by an interdisciplinary team (IDT) composed of individuals who have knowledge of the resident and his/her needs, and that each resident and representative, if applicable, is involved in developing the care plan and making decisions about his or her care.II. Resident #6A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, protein-calorie malnutrition and dementia without behavioral disturbance. The 6/5/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent upon staff assistance with transfers, bed mobility, oral hygiene, toileting, bathing, dressing and personal hygiene. The 3/5/25 MDS assessment documented the resident's activity preferences were not assessed. B. ObservationsDuring a continuous observation on 7/13/25, beginning at 9:45 a.m. and ending at 3:45 p.m., the following was observed:At 9:45 a.m. Resident #6 was sitting in the common area on the A unit in front of the television. The television volume was not turned on and Resident #6 was sitting with her head down and sleeping.At 11:15 a.m. Resident #6 was wheeled from the common area on the unit and taken to the dining room by an unidentified staff member. The unidentified staff member did not speak to the resident nor tell her where they were going. The unidentified staff member did not offer Resident #6 incontinence care or repositioning prior to taking the resident to the dining room.At 1:07 p.m. Resident #6 was brought from the dining room by an unidentified staff member and placed back in front of the television in the unit's common area. She was not offered toileting assistance or repositioning.At 3:00 p.m. Resident #6 was still sitting in front of the television in the common area. -Resident #6 had not been offered toileting or repositioning for over five hours.-No staff members were observed interacting with Resident #6 during the continuous observation, nor attempting to speak with Resident #6 in her native language of Japanese.During a continuous observation on 7/14/25, beginning at 8:30 a.m. and ending at 3:00 p.m., the following was observed:At 8:30 a.m. Resident #6 was in the dining room for breakfast.At 9:00 a.m. Resident #6 was taken from the dining room to the A unit common area by an unidentified staff member. She was placed in front of the television with the sound not turned on. Resident #6 was not offered toileting assistance or repositioning.At 10:15 a.m. a nurse practitioner (NP) informed the nurse she was taking Resident #6 to her room for a pain evaluation. At 10:17 a.m. the NP returned the resident to the common area.At 10:39 a.m. an activity staff member was observed inviting one resident on the unit to a group activity. Resident #6 was not asked if she wanted to attend the activity and continued to sit in front of the television with no interaction from staff members.Cross reference F679: The facility failed to ensure the socialization needs were met for Resident #6.At 11:21 a.m. the nurse on the unit walked over to Resident #6 and asked her if she wanted to be able to hear the television and if she wanted to watch a movie. Resident #6 nodded her head, indicating yes and the nurse turned up the volume and put on a movie. -However, the nurse did not offer Resident #6 toileting assistance or repositioning.At 11:55 a.m. certified nurse aide (CNA) #1 asked Resident #6 if she was ready to go to lunch. He began wheeling her down to the dining room before she was able to answer. CNA #1 returned to the unit at 11:57 a.m., after leaving Resident #6 in the dining room. He did not offer Resident #6 toileting assistance or repositioning prior to being taken to lunch in the dining room.At 1:19 p.m. Resident #6 was taken from the dining room to the common area on the unit. Upon reaching the unit, the resident was placed in the common area in front of the television. She was not offered toileting assistance or repositioning.At 2:12 p.m. an activity staff member approached Resident #6 and asked her if she wanted to attend the group exercise activity and then BINGO. Resident #6 nodded enthusiastically, yes and was taken to the exercise program. At 2:19 p.m., seven minutes later, the activity assistant took Resident #6 from the group exercise program back to the unit to sit in the common area in front of the television. She did not speak to the resident, and it was unclear why the resident left the activity early and was not taken to BINGO.At 3:00 p.m. Resident #6 was still sitting in the common area in front of the television. Resident #6 had not been offered toileting assistance or repositioning during the six-hour observation period.At 3:23 p.m. CNA #1 wheeled Resident #6 to her room and said he was going to provide her with incontinence care. He asked the nurse on the unit to assist him since Resident #6 required a two staff member assisted transfer.CNA #1 and the nurse assisted Resident #6 with a transfer from the wheelchair to the bed with the front wheel walker. CNA #1 placed a gait belt on the resident above the breast/nipple line. The resident was unable to follow the commands being given by CNA #1 and the nurse, such as straightening her legs and bearing weight onto her legs to stand.A mechanical lift sling was observed in the wheelchair and CNA #1 said they only used the mechanical lift if they had to, but he said staff tried transfer Resident #6 with the walker before using a mechanical lift.During the pivot transfer, Resident #6's right foot was on top of her left foot and she was not able to straighten her legs or bear any weight. The resident was approximately six inches below the top of the mattress. CNA #1 was observed lifting her up and placing her on top of the mattress. CNA #1 and the nurse were then observed placing their arms in Resident #6's armpits on both sides, lifting and moving her back on the mattress so her knees were hitting the mattress. They assisted Resident #6 to lay down, rolling her to her right and left and then lowering her pants.CNA #1 opened the tabs on the incontinence brief and pulled it down. An immediate pungent urine smell filled the room. CNA #1 grabbed wipes and began wiping the resident's peri area (area of skin between the genitals and the anus). Once the front of the peri area was cleaned, Resident #6 was able to turn to the right side with cueing and using the grab bars. CNA #1 wiped the resident's buttocks. The resident's brief contained visible stool and the indicator line on the brief was blue, which indicated the resident was soiled.Further observation of the soiled brief revealed stool and a significant amount of urine with a very pungent smell.Cross reference: F807: The facility failed to ensure hydration was provided and offered.Resident #6 had noticeable redness to the buttocks. The nurse used her finger to demonstrate the redness was blanchable (skin turns pale or white when pressed but returns to original color when pressure is removed). A new brief was applied to the resident and her pants were pulled up.CNA #1 and the nurse assisted Resident #6 to sit on the edge of the bed. The gait belt remained above the resident's breast and nipple line. It was not adjusted to the appropriate location (around the resident's waist, just above the hips) and continued to transfer Resident #6. CNA #1 placed the walker in front of the resident and the wheelchair was parallel to the bed. CNA #1 was on the resident's left side, holding onto the gait belt. CNA #1 placed his foot in front of the resident's feet to prevent her from slipping. The nurse was unable to reach the resident from the left and had to move the wheelchair away from the bed. The resident was instructed to use the walker to help her stand. Resident #6 was unable to stand and pivot safely and the walker tipped forward onto two points of contact versus four points of contact. The nurse and CNA #1 had to remove the walker and physically lift the resident into the wheelchair, as she was unable to stand and bear any weight. CNA #1 said it was a difficult transfer.On 7/16/25 at 1:54 p.m. Resident #6 was sitting in the activity room. Another resident, whose primary language was the same as Resident #6's primary language of Japanese, was sitting across from her and they were verbally interacting. Resident #6 was smiling and visibly enjoying herself. The activity director (AD) was observed grabbing an IPad (electronic device) and pulling up a digital translator. The AD spoke into the device, the device translated it into Japanese and the AD then spoke to the resident. The resident spoke back and the AD had a full conversation with Resident #6. The AD said, Next time, I will get a translator for you.-This interaction with Resident #6 was the first time, during the survey process, that facility staff were observed using a translation device to interact with Resident #6 in her native language (see staff interviews below).C. Other resident interviewsA group interview of residents was conducted on 7/15/25 at 10:00 a.m. Resident #24, who was determined to be cognitively intact by facility assessment, said Resident #6 sat in front of the television in the common area of the unit every day. She said the staff never laid her down to take a nap and she would often see her sleeping in her wheelchair in front of the television.Resident #27 and Resident #22, who were determined to be cognitively intact by facility assessment, said their bottoms would hurt to sit in the wheelchair all day and never be laid down.Resident #24 said Resident #6 was not able to speak up for herself and tell the staff when she wanted someone. She said she felt sorry for Resident #6.D. Record reviewThe ADL care plan, revised 3/1/25, documented Resident #6 had a self-performance deficit related to a fracture of the left femur, dementia, Alzheimer's disease and a history of falling. Resident #6 required two-person assistance from staff for turning, repositioning and transfers of moving between surfaces.The cognitive function care plan, revised 3/14/25, documented Resident #6 had impaired cognitive function due to a diagnosis of dementia. The interventions included promoting dignity, conversing with the resident and ensuring privacy when providing care.The communication care plan, revised 3/7/25, documented Resident #6 had an impaired ability to make herself understood. The interventions included anticipating the resident's needs, using simple, consistent and brief words and cues, asking yes or no questions and being conscious of the resident's position when in groups, activities and in the dining room to promote proper communication with others.The activity care plan, revised 5/7/25, documented Resident #6's primary language was Japanese; however, she was able to understand English (see staff interviews below). The interventions included providing signs for the resident in her preferred language so she could more easily communicate her needs with staff due to her language barrier.The Kardex (a tool utilized by staff to provide consistent resident care) documented to turn and reposition Resident #6 for care and services as she would allow while in bed side to side and assisting and encouraging repositioning and shifting of weight often while she was seated in the wheelchair.-However, observations revealed Resident #6 was not provided with repositioning assistance for extended periods of time (see observations above).E. Staff interviewsCNA #1 was interviewed on 7/15/25 at 3:11 p.m. CNA #1 said he had worked on Resident #6's unit and with Resident #6 for a while. He said Resident #6 was completely dependent on staff for all ADL assistance. He said Resident #6 required assistance from two people with all transfers and was not able to reposition herself in the bed or wheelchair.CNA #1 said Resident #6 usually woke up around 6:30 a.m. He said he assisted her with grooming, incontinence care, dressing and personal hygiene. He said he would wheel her out of her room and place her in front of the television in the common area. CNA #1 said she usually stayed there until breakfast and then she would go to the dining room for all meals. He said Resident #6 usually spent all day in the common area in front of the television. He said he did not usually lay her down to take a nap during the day.CNA #1 said Resident #6 was incontinent of bowel and bladder and required assistance with incontinence care. He said Resident #6 could not tell the staff when she required incontinence assistance. CNA #1 said incontinence care should be given every three to four hours or sooner if there was a noticeable odor.CNA #1 said Resident #6's native language was Japanese but she was able to understand some English. He said she could answer yes and no questions, but he did not know how much she understood. He said he did not speak to her too often because she could not hold a conversation in English. He said he had used a digital translator once but he had not used it since. He said he thought there was another resident in the facility who spoke Japanese, but he was not sure. He said he was not aware of any communication boards in Japanese to be used for Resident #6 to be able to communicate.The AD was interviewed on 7/16/25 at 10:25 a.m. The AD said Resident #6 spoke Japanese but was able to understand some English, as long as the question was yes or no. She said she had not used a digital translator prior to that day (7/16/25) for Resident #6. She said Resident #6 had resided at the facility for approximately four to five months.The AD said a resident on another unit also spoke Japanese. She said she did not know how often the two residents got together to interact. She said it was not part of Resident #6's comprehensive care plan.The AD said staff should try and interact with each resident in their native language. She said the facility staff had access to a digital translator to assist with different languages and should use it every day with Resident #6.The director of rehabilitation (DOR) was interviewed on 7/16/25 at 1:18 p.m. The DOR said the gait belt should be placed as low as possible and snug on a resident. He said the gait belt should not be placed near the breast and above the nipple line on a resident. He said the transfer by CNA #1, as described, was not considered a safe transfer. He said CNA #1 should have switched to a mechanical lift transfer when Resident #6 was unable to follow commands, fully straighten her legs and bear weight.III. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included pulmonary embolism, displaced intertrochanteric fracture of the right femur and multiple fractures of the ribs. The 6/12/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She required total assistance with toileting, bathing, dressing and bed mobility. She required set-up assistance with eating. B. ObservationsDuring a continuous observation on 7/13/25, beginning at 10:30 a.m. and ending at 2:30 p.m., the following was observed:At 10:30 a.m. Resident #2 was lying in bed, sleeping. The resident was dressed in a hospital gown.At 12:25 p.m. CNA #1 entered Resident #2's room. He placed the resident's lunch meal tray down on the overbed table that was positioned to the side of the bed and not within reach of the resident. He did not speak to Resident #2 nor attempt to arouse the resident, who was still sleeping.At 1:08 p.m. CNA #1 entered Resident #2's room again. He did not speak to the resident. He uncovered the resident's lunch meal and left it open to air. He exited the room and told the nurse on the unit he was going on his lunch break.At 1:44 p.m. CNA #1 entered Resident #2's room a third time. He did not speak to the resident, picked up the meal tray and removed it from the room.No staff were observed entering Resident #2's room from 1:44 p.m. to 3:00 p.m.-Resident #2 was not aroused to eat lunch and was not provided assistance with eating her meal.Cross reference: F807: The facility failed to ensure hydration was provided and offered.-Resident #2 was not offered incontinence assistance or repositioning from 10:30 a.m. until 3:00 p.m., a period of four and a half hours.C. Record reviewThe ADL care plan, revised 3/25/25, documented Resident #2 had a self-care performance deficit related to a fracture of the right femur, left rib fractures and weakness. Resident #2 required moderate to maximum assistance of one to two staff members for turning, repositioning and toileting.The ADL care plan documented the resident was able to feed herself after the meal was set-up by facility staff.The CNA Kardex documented Resident #2 required set up assistance with meals.-However, the resident had a recent decline in health and was no longer able to feed herself (see observations above and staff interviews below).-The facility failed to update the comprehensive care plan and the CNA Kardex with the resident's current level of care.The cognitive impairment care plan, revised 3/25/25, documented Resident #2 had an impaired thought process due to a diagnosis of dementia. The interventions included asking yes or no questions, communicating with the resident's family regarding the resident's capabilities and needs and keeping the resident's routine consistent.The potential for pressure injury development care plan, revised 3/25/25, documented Resident #2 had the potential to develop a pressure injury related to decreased mobility and incontinence. The interventions included providing an air mattress to the bed, a cushion to the wheelchair, assisting and instructing the resident to shift her weight while seated in the wheelchair and monitoring for any new areas of skin breakdown.The incontinence care plan, revised 5/8/25, documented Resident #2 had functional bladder incontinence related to impaired mobility, dementia and weakness. The resident used disposable briefs.D. Staff interviewsCNA #1 was interviewed on 7/15/25 at 3:11 p.m. CNA #1 said Resident #2 had a recent decline and required total assistance with ADL care. He said the resident was incontinent of bowel and bladder and required incontinence care. He said the resident required assistance with repositioning.CNA #1 said Resident #2 used to be able to feed herself, however, he said she was no longer able to feed herself and required staff assistance. He said if the resident was sleeping during meals, staff should attempt to arouse the resident to try and get her to eat.The registered dietician (RD) was interviewed on 7/16/25 at 11:25 a.m. The RD said Resident #2 had a recent decline in health and was being evaluated for hospice care. She said the resident had experienced fast weight loss. She said her weight loss had recently slowed down, however she was still losing weight.The RD said she was not aware of Resident #2's assistance level with eating. She said Resident #2 used to come to the dining room for meals, but since her decline, she had been staying in her room.The RD said Resident #2 should be aroused for all meals and offered and assisted with all meals if that was her current level of care.IV. Additional staff interviewThe ED was interviewed on 7/16/25 at 2:19 p.m. The ED said the director of nursing was not available during the survey process. The ED said she was a registered nurse (RN). She said rounding should occur every two hours and each resident should be asked if they needed toileting assistance and repositioning. She said for a dependent resident with cognitive impairment, the CNA should check the resident every two hours and provide incontinence care as needed and repositioning.The ED said communication should be provided to each resident in their native language. She said the facility staff had access to communication boards in multiple languages as well as access to a digital translator. She said Resident #6's native language was Japanese. She said the facility staff should have been using a digital translator since her admission, so the resident was able to interact with others.The ED said each resident should be aroused when their meal tray was delivered to their room, if they chose not to go to meals in the dining room. She said, based on the level of assistance, each resident should receive assistance or cueing from staff. She said she was aware of Resident #2's recent decline and said the resident should have been assisted with the lunch meal on 7/13/25.The ED said the IDT was responsible for updating the residents' comprehensive care plans and the CNA Kardex with any changes to the residents' abilities and care needs.

Based on observations, record review and interviews, the facility failed to ensure two (#6 and #2) of two residents received a sufficient amount of drinks to maintain hydration out of 27 sample residents.Specifically, the facility failed to ensure Resident #6 and Resident #2 were offered and provided hydration.Findings include:I. Facility policy and procedureThe Management of Dehydration policy and procedure, reviewed 4/19/24, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It revealed, in pertinent part Residents will receive adequate fluids to prevent dehydration. Fresh water should be available at the resident's bedside 24 hours a day, unless there is an order for fluid restrictions. Ensure adaptive devices needed, such as a sippy cup, are available. Staff should offer residents fluids with each interaction/care task performed.II. Resident #6A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, protein-calorie malnutrition and dementia without behavioral disturbance.The 6/5/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. She was dependent upon staff assistance with transfers, bed mobility, oral hygiene, toileting, bathing, dressing and personal hygiene. B. ObservationsDuring a continuous observation on 7/13/25, beginning at 9:45 a.m. and ended at 3:45 p.m., Resident #6 was sitting in the common area on the A unit in front of the television. The television volume was not turned on and Resident #6 was observed with her head down and sleeping. A water pitcher was not present.-At 11:15 a.m. Resident #6 was assisted from the common area on the unit and taken to the dining room by an unidentified staff member. Resident #6 was served cranberry juice and hot chocolate in eight ounce (oz) cups. She struggled to drink the beverages by herself and did not receive any assistance from staff members. She struggled to grip her hand to get the liquid to her lips. Resident #6 consumed four oz of cranberry juice and four oz of hot chocolate during lunch.-At 1:07 p.m. Resident #6 was assisted from the dining room by an unidentified staff member and was seated in front of the television. She was not provided nor offered a water pitcher.-At 3:00 p.m. Resident #6 remained sitting in front of the television in the common area. She had not been provided or offered any hydration since lunch.During a continuous observation on 7/14/25 beginning at 8:30 a.m. and ended at 3:00 p.m. Resident #6 was observed in the dining room for breakfast.-At 9:00 a.m. Resident #6 was assisted from the dining room to the common area by an unidentified staff member. She was seated in front of the television with the sound not turned on. She was not provided with or offered a water pitcher.-At 10:07 a.m. the nurse provided a nutritional supplement in a cup with a straw. The resident consumed 100 percent (%) the nutritional supplement.-At 11:09 a.m. the nurse filled a plastic four oz cup halfway with water from the medication cart and asked Resident #6 if she wanted a drink. She shook her head yes and proceeded to take multiple drinks through the straw. She consumed the entire half cup, 2 oz. The nurse did not offer or provide a water pitcher for Resident #6.-At 11:55 a.m. certified nurse aide (CNA) #1 assisted Resident #6 to the dining room. She was served an eight oz cup of cranberry juice that was only filled halfway and an eight oz cup of hot chocolate, filled halfway.Resident #6 picked up the cup of hot chocolate and brought it toward her face very slowly. She stuck her tongue out trying to lick the liquid until she was able to bring the cup to her mouth. She was unable to turn the cup to get access to the liquid. She placed it back down on the table and used a spoon to stir the hot chocolate.Resident #6 then picked up the eight oz cup of cranberry juice that was filled halfway. She was able to bring the cup to her mouth and take a small sip and then put it down on the table. She did this four more times in succession, trying to get more of the beverage. She was only able to take small sips at a time.-At 12:34 p.m. Resident #6 attempted to take a drink from the coffee cup. She had difficulty bringing it to her face. She moved her lips like she was drinking; however the cup was not close to her face. After 45 seconds, she was able to put her mouth to the cup, took a sip and set it back down on the table.Resident #6 attempted to drink both the cranberry juice and the hot chocolate multiple times throughout the meal with the same result. By the end of lunch, there was a quarter cup of cranberry juice and hot chocolate left in the cups. She consumed approximately two oz of cranberry juice and two oz of hot chocolate. Staff did not provide assistance to the resident with drinking her beverages.-At 1:19 p.m. Resident #6 was taken from the dining room to the common area on the unit. Upon reaching the unit, the resident was placed in the common area in front of the television. She was not provided a water pitcher.-At 2:12 p.m. an unidentified activity staff member approached Resident #6 and asked her if she wanted to attend the group exercise activity and then Bingo. Resident #6 nodded enthusiastically, yes and was taken to the exercise program. Seven minutes later, the activity assistance took Resident #6 from the group exercise program back to the unit to sit in the common area in front of the television. She did not speak to the resident, and it was unclear why the resident left the activity early and was not taken to Bingo. She did not offer or provide the resident with a water pitcher.-At 3:00 p.m. Resident #6 was observed sitting in the common area in front of the television without a water pitcher present.-At 3:23 p.m. CNA #1 assisted Resident #6 to her room and said he was going to provide her with incontinence care.During incontinence care, CNA #1 opened the tabs on the incontinence brief and pulled it down. An immediate pungent urine smell filled the room. Once he was finished providing care, he wheeled Resident #6 back to the common area and placed her in front of the television. He did not offer or provide a water pitcher.Cross reference F677: the facility failed to provide activities of daily living (ADL) in accordance with Resident #6's plan of care.C. Record reviewThe ADL care plan, revised on 3/1/25, documented the resident had a self-performance deficit related to a fracture of the left femur, dementia, Alzheimer's disease and a history of falling. Resident #6 required two-person assistance from staff for turning, repositioning and transfers of moving between surfaces. She required assistance with meal set-up and cueing.The hydration care plan, revised on 3/7/25, documented Resident #6 had the potential of a fluid deficit due to her assistance level with ADLs, impaired mobility and diagnosis of dementia. The interventions included ensuring the resident had access to cold water and any other beverage of her choice; inviting the resident to activities that promoted additional fluid intake, offering drinks during one-to-one visits and monitoring for any signs and symptoms of dehydration.III. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, the diagnoses included pulmonary embolism, displaced intertrochanteric fracture of the right femur and multiple fractures of the ribs.The 6/12/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She required total assistance with toileting, bathing, dressing and bed mobility. It indicated she required set-up assistance with eating. B. Observations During a continuous observation on 7/13/25, beginning at 10:30 a.m. and ended at 2:30 p.m., Resident #2 was lying in bed, sleeping. A water pitcher was observed with a water line at the number 8 mark on the overbed table that was not within reach of Resident #2.-At 12:25 p.m. CNA #1 entered the resident's room. He placed the lunch meal try down on the overbed table that was positioned to the side of the bed and not within reach of the resident. He did not speak to Resident #2, nor attempted to arouse the resident. An eight oz glass of cranberry juice was observed on the tray.-At 1:08 p.m. CNA #1 entered Resident #2's room. He did not speak to the resident. He uncovered the resident's lunch meal and left it open to air. He exited the room and told the nurse on the unit he was going on his lunch break.-At 1:44 p.m. CNA #1 entered Resident #2's room. He did not speak to the resident, picked up the meal tray and removed it from the room.Resident #2 was not aroused to eat lunch and was not provided assistance with eating her meal or drinking her beverage. -At 3:00 p.m. Resident #2 was observed lying in bed. The line of water in the water pitcher remained at the 8 mark. Staff did not attempt to arouse the resident or encourage her to drink water throughout the entire observation period. The water pitcher was not within reach of the resident during the observation period. C. Record review The ADL care plan, revised on 3/25/25, documented Resident #2 had a self-care performance deficit related to a fracture of the right femur, left rib fractures and weakness. Resident #2 required moderate to maximum assistance of one to two staff members for turning, repositioning and toileting.It documented the resident was able to feed herself after the meal was set-up by facility staff.-However, the resident had a recent decline in health and was no longer able to feed or drink herself (see staff interviews). IV. Staff interviews CNA #1 was interviewed on 7/15/25 at 3:11 p.m. CNA #1 said he had worked on with Resident #6 for a while. He said Resident #6 was completely dependent on staff for all ADL assistance. He said Resident #6 required assistance from two people with all transfers and was not able to reposition herself in the bed or wheelchair. He said she was able to feed herself but required some queuing.CNA #1 said Resident #6 usually woke up around 6:30 a.m. He said he assisted her with grooming, incontinence care, dressing and personal hygiene. He said he assisted her out of her room and sat her at the television in the common area. CNA #1 said she usually stayed there until breakfast and then would go to the dining room for all meals. He said Resident #6 usually spent all day in the common area in front of the television. CNA #1 said he was unsure if Resident #6 was able to express that she was thirsty. He said he did not know when she was thirsty. CNA #1 said Resident #2 used to be able to feed and drink herself, however she was no longer able to and required staff assistance. He said if the resident was sleeping during meals, staff should attempt to arouse the resident to try and get her to eat.CNA #1 said there was no set time to go around and fill water pitchers. He said he would do it when he remembered. He said he tried to look at the water pitchers during rounding which was between 10:00 a.m. to 12:00 p.m. and 2:45 p.m. to 6:00 p.m.The registered dietitian (RD) was interviewed on 7/17/25 at 11:25 a.m. The RD said each resident should receive 1400 milliliters (ml) per day, which was approximately 47 ounces of hydration. She said hydration could come in the form of food, but each resident required liquid hydration each day. She said fluids should be offered multiple times throughout the day for each resident.The RD said she was not aware Resident #6 was having difficulty drinking her beverages and would observe her. She said she would make a referral to the speech therapist if needed.The RD said she was aware Resident #2 had a recent physical decline. She said staff should be physically assisted Resident #2 with hydration and eating.The ED was interviewed on 7/16/25 at 2:19 p.m. The ED said rounding should be completed every two hours. She said during rounding, the water pitcher should be filled, and each resident should be encouraged to take a drink. She said a water pitcher should be filled and within each reach of each resident.

Based on record review and interviews, the facility failed to thoroughly investigate allegations related to an injury of unknown origin and incidents of resident-to-resident physical and verbal altercations for two (#35 and #18) of eight residents reviewed out of 27 sample residents.Specifically, the facility failed to:-Ensure an investigation was conducted for incidents of physical and verbal altercations involving Resident #35; and,-Ensure a complete and thorough investigation was completed for injuries of unknown origin on the wrist for Resident #18. Findings include:I. Facility policy and procedureThe Abuse Investigations including Resident-to-Resident Altercation policy, reviewed 3/6/25, was provided by the executive director (ED) on 7/17/25 at 2:18 p.m. It read in pertinent part, The community will investigate all suspicions or allegations of abuse, neglect, or misappropriation of resident property/funds. All staff are required to immediately report to the director of nursing (DON) and/or NHA (nursing home administrator)/ED any of the following: Any allegations of abuse, neglect or misappropriation of resident property verbalized/expressed by residents, families and/or other staff, even if they do not feel the act actually occurred; any physical signs of abuse which necessitate further investigation as a potential or actual abusive situation, resident exhibiting new fears/behaviors with employees, unexplained bruises/cuts, injuries inconsistent with explanation, non-specific complaints about an employee. The employee(s) involved or suspected to be involved will have their statements obtained related to the situation and then be placed on immediate suspension until completion of the investigation. The DON or NHA/ED will notify the appropriate state regulatory agencies of the incident as soon as possible but not to exceed 24 hours of the allegation. The NHA/ED will complete the investigative process with the assistance of the DON as necessary. No investigation should be conducted by a person directly involved in the allegation. The individual(s) conducting the investigation will: Review the resident's medical record to determine events leading up to the incident, if any; interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident (if cognitively able to make a statement). As a method of validation a second person should also interview the resident to ascertain consistency of the reported incident; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors, as indicated; interview other residents to whom the accused employee provides care or service, as indicated. Each interview will be conducted separately and in a private location. Witness statements shall be written by each individual. Witnesses will be required to sign and date all statements. If two residents are involved in an altercation, the community staff will: Separate the residents, and institute measures to calm the situation; evaluate all involved residents for any injuries and provide/request medical treatment as indicated; identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; consult with the attending physician to identify contributing conditions and possible psychological/psychiatric evaluation and treatment for both involved residents; and complete an incident report.II. Resident-to-resident altercationsA. Resident #351. Resident statusResident #35, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (lack of blood supply to the brain), respiratory failure, hepatic failure (liver failure), vascular dementia (brain damage due to multiple strokes) and type 2 diabetes mellitus.The 5/15/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. She needed set up assistance for meals and was dependent on assistance for all other activities of daily living (ADL).2. Record reviewResident #35's behavior care plan, initiated 8/14/24, documented she had a behavior problem related to hitting staff during care. The care plan documented the resident had a history of being aggressive towards another resident. Pertinent interventions, initiated 6/10/25, included the resident would come to activities but would have a safe distance between her and other residents during meals and other activities. The care plan indicated the physician and the DON were notified.A 5/4/25 behavior note documented Resident #35 was in the dining room for lunch. While in the dining room, the resident threw dishes on the floor and was calling her tablemate names. The resident was removed from the dining room and brought to the unit.A 5/26/25 behavior note documented that while at an activity for Memorial Day, Resident #35 snatched glasses off of another resident's face and snatched the other resident's food from the resident. The other resident did not want to stay in the activity and asked to be taken back to her room. Resident #35 stayed in the activity but not close to other residents.A 6/10/25 behavior note documented Resident #35 was in the dining room sitting next to another resident. Resident #35 slapped a piece of burger out of the other resident's hand and then proceeded to slap the other resident's hand. Resident #35 was moved to a different area of the dining room to prevent any further reactions. When asked why she did that, the resident stated, That big fat man slapped it out of my hand. The resident was not aware that she slapped another resident. The other resident had no injury or markings from the slap.-A request was made for the facility's investigation regarding the incident on 6/10/25 involving Resident #35, however the facility was unable to provide documentation that an investigation was completed (see interviews below).3. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 7/15/25 at 10:15 a.m. LPN #3 said she was not present when Resident #35 had behaviors toward another resident but was told about the resident's behavior. LPN #3 said she did not know what triggered Resident #35's behaviors. LPN #3 said she received abuse training at the facility on a regular basis. She said the abuse training was through their electronic training system and was also provided as an in-person training. LPN #3 said she would report a resident hitting another resident in the face to the NHA or the DON and then separate the residents involved. She said if a resident hit another resident it would be reportable.The NHA was interviewed on 7/16/25 at 3:45 p.m. The NHA said abuse reporting was dealing with actual harm and expressions of fear or pain. The NHA said since the resident involved in the incident with Resident #35 did not express fear, it did not meet reportable abuse and that was why it was not investigated as abuse.III. Injuries of unknown originA. Resident #181. Resident statusResident #18, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included cerebrovascular disease (conditions affecting blood flow to the brain), history of falling, history of transient ischemic attack (TIA - temporary disruption of blood flow to the brain), vascular dementia, weakness, seizures and depression.The 5/6/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 10 out of 15. She was dependent or needed maximal assistance with ADLs and supervision with eating.2. Observation and resident representative interviewResident #18's representative was interviewed on 7/13/25 at 10:39 a.m. The representative said the staff told her the bruise on the resident's wrist was likely from a blood draw, but did not confirm with the resident's representative if the resident had a blood draw. On 7/13/25 at 10:39 a.m. Resident #18's wrist was observed. The resident had a bruise on her outer left wrist, approximately two inches by two inches round. The bruise was dark purple throughout, with a black spot in the middle approximately a half inch in size.3. Record reviewResident #18's skin integrity care plan, initiated 10/25/24, documented she had the potential for an alteration in skin integrity due to decreased mobility and fragile skin. Pertinent interventions, initiated 7/8/25, revealed she had a change of condition with a bruise to the left posterior wrist and to follow all medications and treatment as ordered until resolved and to monitor pain or discomfort. The care plan indicated the family, the DON and the physician were notified.The 7/8/25 change in condition evaluation documented a change in skin color; the resident's son-in-law was visiting and asked LPN #3 to look at Resident #18's left wrist. LPN #3 noted a large dark purple discoloration to the posterior wrist. The evaluation documented the resident could have hit it on the bedside table. The resident was not sure what occurred to cause discoloration.The 7/8/25 social services note documented the NHA took a statement from Resident #18 with the social services director (SSD) as a witness. Resident #18 stated no one here did it to me. Resident #18 said she did not know how she got the bruise but she bruised very easily. She said she did not recall bumping her wrist against any object, that she felt safe at the facility and was not fearful of any staff in the facility. The note documented the resident's statement was used to rule out abuse.The 7/12/25 weekly skin observation documented Resident #18 had a big bruise above the back of the left hand.-A request was made for the facility's investigation regarding Resident #18's bruise of unknown origin, however the facility was unable to provide documentation that an investigation was completed (see interviews below).4. Staff interviewsLPN #3 was interviewed on 7/15/25 at 3:15 p.m. LPN #3 said Resident #18 did not normally have the dark spot on her wrist present in the center of the bruise. LPN #3 said she was not sure if any other staff or residents were interviewed about Resident #18's bruise, but she had assessed the resident and completed the change of condition assessment.The NHA was interviewed on 7/16/25 at 3:45 p.m. The NHA said abuse reporting dealt with actual harm and expressions of fear or pain. The NHA said since Resident #18 did not express fear the incidents did not meet reportable abuse and that is why the bruises of unknown origin were not investigated as abuse.

Based on observations, record review and interviews, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#7) of one reviewed out of 24 sample residents. Specifically, the facility failed to timely assess, investigate, notify the physician and implement interventions to prevent reoccurance when Resident #7 had a bruise of unknown origin to her right arm. Findings include: I. Facility policy The Change of Condition guideline, dated 3/24/23, was requested and received from the director of nursing (DON) on 9/13/23 at 5:37 p.m. The guideline documented in pertinent part: The community should reevaluate residents who have had a change in condition and update the individualized service plan appropriately to ensure all resident needs can and will be met within the community. -Any change in resident's condition identified by staff will be reported to the Health and Wellness Director (HWD) or designee; -Changes in condition may include but are not limited to: rashes, bruising, skin tears or change in skin color; -The HWD or designee should document the change in the progress notes; -The HWD or designee should notify the physician and responsible party of change of condition and document notifications in the progress notes; If the change in condition is significant, the HWD or designee should reevaluate the resident using the community evaluation tool and update their individualized service plan with the appropriate services and/or interventions. All care staff should be informed of the changes; -If the change in condition is temporary, the HWD or designee should implement a temporary service plan with appropriate series and/or interventions included. All care staff should be informed of the changes. II. Resident status Resident #7, age 89, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's dementia, psychotic disorder and atrial fibrillation. The 8/8/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired. She required extensive assistance of one person for bed mobility, dressing, eating and locomotion on and off the unit. She required extensive assistance of two people for transfers, toileting and personal hygiene. III. Resident observation and interview On 9/12/23 the resident was observed in the dining room and hallway. She wore a short-sleeve blouse. The resident had a large bruise on her right forearm. The resident said she was unaware she had the bruise and did not recall how or when the bruise developed. IV. Record review On 9/5/23 a change in condition assessment revealed the resident had a bruise on her left knee. The physician was notified and evaluated the resident. A new CPO was initiated to withhold administering the resident's aspirin, which could contribute to bruising. On 9/8/23 the nurse documented on a change in condition follow-up assessment the resident now had a bruising on her right forearm. -The nurse failed to complete an assessment of the bruise, to notify the family and the physician about the new bruise. On 9/13/23, during the survey, the nurse completed a new change of condition assessment and documented the right foremare bruise measured 8.5 centimeters (cm) x 11.0 cm. The nurse notified the family and provider on 9/13/23. The physician initiated a new CPO to monitor the bruise and ask the resident to wear bilateral geri-sleeves to help protect the skin on her arms. V. Staff Interviews Certified nurse aide (CNA) #2 was interviewed on 9/13/23 at 4:20 p.m. She said when she noticed a change in the resident it was her responsibility to notify the nurse. Licensed practical nurse (LPN) #2 was interviewed on 9/13/23 at 4:32 p.m. She said when a CNA reported a concern about a resident, she was responsible to complete a focused assessment and to report changes in condition to the DON, charge nurse, physician and family. She said changes in condition were documented in the resident's medical record and if applicable, an incident report was completed. LPN #1 said when a resident had a change in condition, the resident status was communicated with a shift report for 72 hours after the resident's change was reported. Registered nurse (RN) #1 was interviewed on 9/13/23 at 11:05 a.m. He said he was unaware of the resident's forearm bruise. He said that he would complete an assessment and notify the family and physician. The RN said when a nurse was notified there was a change in the resident's condition, the nurse was responsible to complete a change of condition assessment and intervene as appropriate. The RN said for a bruise, the RN said the resident was taking blood thinning medication, which made the resident at higher risk for internal bleeding/bruising. The DON was interviewed on 9/13/23 at 4:50 p.m. She said that when a nurse identified a change of condition in a resident the nurse was to complete an assessment to identify immediate needs of the resident, provide immediate care and to notify responsible parties which included the family, facility administration and the prescribing provider. The DON said for the bruise documented on 9/6/23 she had not been notified of the change in condition and was unable to locate documentation the nurse completed an assessment. The DON said when a change in condition assessment was completed, the electronic health record automatically cued the nurse in subsequent shifts to monitor and assess the identified area of concern. The DON said because the nurse did not initiate a change of condition assessment, nurses on subsequent shifts did not complete ongoing assessments to monitor the resident's condition.

Based on record review and interviews, the facility failed to prevent accidents for two of six residents (#23 and #27) reviewed out of 24 sample residents. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions in place to reduce falls for Resident #23 and Resident #27. Findings include: I. Facility policy and procedure The Falls Program-Skilled policy, reviewed 9/13/22, was provided by the nursing home administrator (NHA) on 9/13/23 at 2:48 p.m. It revealed in pertinent part, Evaluation of the factors leading to a resident falls helps support relevant and consistent interventions to try to prevent future occurrences. An evaluation of the factors also includes reviewing for previous falls and if so, are there any similarities. Fall prevention is achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce the risk for falls. II. Resident #23 A. Resident status Resident #23, age 86, was admitted on [DATE]. According to the September 2023 computerized physician order (CPO), the diagnoses included prostate and bone cancer, pressure ulcer of sacral region, severe protein-calorie malnutrition, insomnia and atrial fibrillation. The minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of ten out of fifteen. He required two person assistance with bed mobility and transfers. He required one person assistance with toileting and hygiene. It indicated that the resident had sustained a fall in the last month prior to admission and had a fall since he was admitted . B. Record review The resident had two care plans related to falls. One care plan, initiated 7/14/23, was that the resident was at risk for falls and had non-injury falls prior to admission and after admission. The interventions included anticipate and meet the resident's needs, be sure the resident's call light light was within reach, complete fall risk screen on admission and as needed to identify risk factors, encourage residents to participate in activities that promote exercise, physical activity for strengthening and ensure resident is wearing appropriate footwear. -The fall risk care plan did not include any individualized person-centered interventions. It did not document the resident's daily routine to determine effective interventions to prevent falls and injuries. The 7/13/23 fall risk assessment revealed the resident was ambulatory, incontinent, decreased muscular coordination, blood pressure would be high when lying and standing. The resident scored 17, which indicated the resident was a high fall risk. -Based on the comprehensive fall care plan, person-centered interventions were not put in place, even though the facility was aware the resident had a history of falls and was at a high fall risk. 1. Fall incident on 7/16/23 The post fall investigation revealed the resident was found in his room after falling from his bed onto the floor on 7/16/23 at 3:30 a.m. The investigation documented the fall was caused by the resident trying to get out of bed but was too weak to walk. -The new intervention was to have safety checks every 30 minutes. 2. Fall incident on 7/30/23 The post fall investigation revealed the resident was found near the door in his room on 7/30/23 at 1:00 a.m. The investigation documented the fall was caused by the resident trying to get out of bed. The post fall assessment revealed that the resident had a skin tear to his left elbow and an abrasion to his forehead. -The new intervention was to notify the hospice provider and start wound care. -There was no documentation that a person-centered immediate intervention was in place to prevent additional falls or potential injuries. 3. Fall incident on 8/4/23 The post fall investigation revealed the resident had a witnessed fall in his room during an assisted transfer on 8/4/23 at 9:00 p.m. The post fall assessment revealed the resident had 0.5 cm abrasion on the front of his right knee. -The new intervention was to increase safety checks in the evening. 4. Fall incident on 8/12/23 The post fall investigation revealed the resident had an unwitnessed fall in his room when trying to ambulate by himself on 8/12/23 at 9:20 p.m. The resident was taking sedatives/hypnotics, antihypertensives and narcotics. -The new intervention was for staff to have the resident out of bed two to three times a day to closely monitor at the nurse's station. 5. Fall incident on 9/1/23 The post fall investigation revealed the resident had an unwitnessed fall in his room when trying to ambulate by himself on 9/1/23 at 2:00 a.m. The resident was on sedatives/hypnotics and narcotics. The post fall assessment revealed the resident had a skin tear on the top of his head. -The new intervention was to have a bolster mattress when available. III. Resident #27 A. Resident status Resident #27, age 85, was admitted on [DATE]. According to the September 2023 CPO, the diagnoses included Parkinson's disease, neurocognitive disorder with Lewy body, history of falling, difficulty in walking, type two diabetes, hypertension, hyperlipidemia and anemia. The MDS assessment revealed the resident was severely cognitive impaired with a brief interview for mental status score of six out of fifteen. He required two person assistance with bed mobility and transfers. He required one person assistance with dressing, toileting and hygiene. It indicated that the resident had sustained a fall in the last month prior to admission. B. Record interview The resident had a impaired cognitive function/dementia care plan, initiated 7/5/23. The interventions included to ask yes or no questions to determine the resident's needs, communicate with the resident regarding his capabilities and needs and keep the resident's routine consistent to decrease confusion. The resident had two care plans related to falls. One care plan, initiated 7/5/23, was that the resident was at risk for falls due to muscle weakness, Parkinson's disease, history of falling and difficulty in walking. The interventions included anticipate and meet the resident's needs, be sure the resident's call light light is within reach and complete fall risk screen on admission and as need to identify risk factors. -The fall risk care plan did not include any individualized person-centered interventions. It did not document the resident's daily routine to determine effective interventions to prevent falls and injuries. The 7/5/23 fall risk assessment revealed the resident had intermittent confusion, was ambulatory, incontinent, decreased muscular coordination, change in gait when walking through doorway, jerking or unstable when making turns and required use of an assistive device. The resident scored 18, which indicated the resident was a high fall risk. -Based on the comprehensive fall care plan, person-centered interventions were not put in place, even though the facility was aware the resident had a history of falls and was at a high fall risk. 1. Fall incident 8/10/23 The post fall investigation revealed the resident had a witness fall in his room during an assisted transfer on 8/10/23 at 2:30 p.m. -The new intervention was for staff to have the resident in his wheelchair when he was awake at the nurse's station to closely monitor. 2. Fall incident 8/19/23 The post fall investigation revealed the resident had an unwitnessed fall out of his wheelchair in his room on 8/19/23 at 11:35 a.m. The nurse went to the resident's room after she heard a loud noise from his room. She found him lying on his right side under his bedside table. The wheelchair was positioned behind him. The resident reported he was trying to stand. The resident was taking antidepressants, antihypertensives and hypoglycemic agents. -The new intervention was to increase frequency checks during the shift and to ensure the call light was in front of the resident. 3. Fall incident 9/9/23 The post fall investigation revealed the resident had an unwitnessed fall in the activity area on 9/9/23 at 4:30 p.m. He was in his wheelchair and fell when he tried to go outside the facility. The fall assessment revealed the resident had an abrasion on his forehead and his nose. -The new intervention was therapy to do an assessment and start therapy for strengthening and environmental safety awareness. IV. Additional record review The nursing home administrator (NHA) provided a copy of the Kardex (an abbreviated care plan for staff) for Resident #21 and #27 on 9/13/23 at 3:16 p.m. The Kardex had a separate page that provided specific interventions for fall risk. For Resident #23, interventions included high risk, low bed and fall mat. For Resident #27, interventions included high risk, low bed and fall mat. The NHA stated if a resident was a high fall risk was how staff knew the resident required frequent checks. V. Interviews Certified nurse aide (CNA) #1 was interviewed on 9/13/23 at 1:21 p.m. She said she knew a resident was a high fall risk by looking at the Kardex. She said interventions for residents to prevent falls was to have a low bed, check every two hours or 30 minutes. She said she did not document when she completed frequent checks. She said for Resident #23, his interventions were to have a low bed and for Resident #27, his interventions was to watch him, have a fall mat and a low bed. Licensed practical nurse (LPN) #1 was interviewed on 9/13/23 at 1:32 p.m. She said she knew a resident was at a high fall risk by looking in the Kardex and at the shift change report. She said fall interventions were documented in Kardex. She said interventions used that were shared in Kardex and during shift change report were using a low bed, a fall mat or leave the door open of a resident's room. She said frequent checks would be every 10-15 minutes depending on the resident. She did not document that she completed frequent checks. She said for Resident #23, he was not as much of a fall risk as he used to be. She said interventions included a low bed and to check on him every 15 minutes. She said Resident #27 was not a fall risk. The director of nursing (DON) and the NHA was interviewed on 9/13/23 at 2:40 p.m. The DON said the CNA knew the fall interventions for the residents by the Kardex and the nurses knew the resident fall interventions by Kardex and in their care plan. The NHA said it was not defined on how often frequent checks should be done. She said all staff did frequent checks and it was not documented when the staff completed the checks. The DON stated they could add frequent checks in Kardex as a task for CNAs. The DON and the NHA were interviewed again on 9/13/23 at 4:55 p.m. The NHA said frequency checks were personalized based on the assessment and in post fall review. She said they needed to define frequency in order to demonstrate how the care plans were personalized for Resident #23 and Resident #27. The NHA and DON reviewed the comprehensive care plan for Resident #23 and Resident #27 and said person-centered interventions were not put into place. The NHA said Resident #23 and Resident #27 were at high fall risk.

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19 in two of three neighborhoods. Specifically, the facility: -Failed to ensure residents had face coverings while staff were in their rooms. Findings include: I. CDC recommended guidelines The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (4/28/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (Update April 13, 2020) Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. Healthcare Personnel As part of source control efforts, HCP should wear a facemask at all times while they are in the healthcare facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. If there are anticipated shortages of facemasks, facemasks should be prioritized for HCP and then for patients with symptoms of COVID-19 (as supply allows). Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required. HCP should have received job-specific training on PPE and demonstrated competency with selection and proper use (e.g., putting on and removing without self-contamination). II. Lack of using necessary PPE A. Observations and interviews On 5/13/2020 at 9:46 a.m., registered nurse (RN) #1 was observed going into room C 13 to assist a resident. She left room C 13, and entered room C 1. She did not ask either resident to put on a face mask. She said residents were to wear a face mask when they left their rooms. She said if a resident was in their room they did not have to wear a face covering at any time. On 5/13/2020 at 9:52 a.m. certified nurse aide (CNA) #1 was observed entering room C 13. She did not ask the resident to cover their face with a mask or a tissue. On 5/13/2020 at 10:01 a.m., RN #1 and CNA #2 were observed entering room C 1. The resident was not offered a face covering. On 5/13/2020 at 10:03 a.m. housekeeping (HSK) #1 was observed cleaning room B 3 with the resident in her room. She said she had not received any training on face masks for the residents to include when she would be in their room cleaning. B. Interviews RN #2 was interviewed on 5/13/2020 at 10:13 a.m. She said residents were encouraged to wear face masks when they left their room. She said staff were to ask a resident who was coughing to wear a mask when staff were in the room. She said a coughing resident would be the only time staff would request a resident to wear a face covering in their private room. CNA #1 was interviewed on 5/13/2020 at 10:19 a.m. She said residents only had to wear a mask in their room if they were coughing. She said they did not have to wear a face covering in their room, only if the resident left their room. CNA #2 was interviewed on 5/13/2020 at 10:51 a.m. She said residents only wore a mask in their room if the resident had a cough. She said residents did not have to wear a face covering if they did not cough. She said if a resident left their room, they would have to wear a face mask. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 5/13/2020 at 11:10 a.m. The DON said she did not know residents needed to have their faces covered when anyone entered the room. She said she would provide education to the staff.

Based on interviews and record review, the facility failed to ensure one (#2) of two residents reviewed for falls, out of 23 sample residents, received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure Resident #2 received adequate supervision to prevent an avoidable fall with minor injury. Findings include: I. Facility policy and procedures The Use of Mechanical Lifting procedure, revised 2/12/19, was provided by the director of nursing on 12/18/19 at 11:00 a.m. The procedure read in part: At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Make sure that all necessary equipment is on hand and in good condition. II. Resident status Resident #2, age 90, was admitted on [DATE] with [DIAGNOSES REDACTED]. The 9/15/19 minimum data set (MDS) assessment revealed the resident was unable to speak and she was not able to understand others. Her cognitive skills for daily decision making were severely impaired. She was totally dependent on two staff with bed mobility, transfers, dressing and toilet use. She was totally dependent on one person with eating and personal hygiene. She had no history of falls. She was on hospice care. III. Record review [NAME] Care plan The comprehensive care plan, dated 9/9/19 and revised 9/24/19, documented the resident required total assistance of one to two staff with all activities of daily living. She was mostly non-verbal and did not participate in cares. Interventions included mechanical lift with assistance of two persons for all transfers. The risk for falls care plan (CP) revealed Resident #2 received routine antianxiety and narcotic [MEDICATION NAME] medication, and did not usually attempt to perform self-transfers nor self-ambulation. (CP revised 9/24/19 and 12/16/19). Intervention included: anticipate and meet needs. Be sure call light is within reach and encourage use. Complete fall risk screen on admission and as needed (PRN) as indicated to identify risk factors. Coordinate care with the hospice team. Educate (resident ' s name) and family/caregivers about safety reminders and what to do if a fall occurs. Floor mats to bilateral sides of bed and lipped alternate pressure mattress (APM) to bed. Review information on past falls and attempt to determine cause of falls. Record possible root causes. B. Interdisciplinary notes On 11/30/19 a registered nurse documented the resident fell from her bed at 6:45 a.m. and was transported by emergency medical technicians (EMT) to a hospital. Resident returned to the facility at 11:35 a.m. with bandage to forehead. On 12/2/19 the physician assistant (PA) documented, in part: She is being seen regarding report of fall with new skin laceration . Nursing report that the patient fell from her bed in the morning on 11/30/19. 911 was called for assistance and the patient was transported by EMT to (hospital) for further evaluation. No records available for this visit but the patient was returned to the facility a few hours later with a bandage to her forehead. Otherwise no new orders. Abrasion to forehead was cleansed and bandaged by provider in the ED (emergency department) on 11/30/19. Exam today shows closed wound with eschar. No drainage, [DIAGNOSES REDACTED] or excessive warmth. On 12/6/19 DON documented: Resident had a fall in past week that resulted in [MEDICAL CONDITION] and periorbital bruising. Staff dressed resident for morning, stepped out to obtain Hoyer lift and resident was noted on floor upon CNA return. Resident has never initiated turning since admit. Fall mats and lipped mattresses are new interventions, no falls in past week since that. She is declining overall which is expected. The Post Fall Investigation was provided by the DON on 12/18/19 at 8:50 a.m., read in part, 11/30/19 at 6:45 a.m. (CNA name) getting resident up for breakfast. Positioned and ready to be lifted. CNA left room to retrieve Hoyer. Upon return resident was on the floor. Immediate Interventions included change bed - one that lowers down to floor. Fall pads on either side of mattress. A review by the interdisciplinary team (IDT) revealed, 1st fall at facility. Resident has not show ability to turn independently. CNA was out of room grabbing Hoyer lift. Out of room < (less than) 3 minutes. Interventions included: low bed, fall mats, lipped APM. RN fall description read, Resident was in her bed waiting to be transferred in Hoyer. She was laying on her back with the sling under her. Staff went to get the Hoyer. When she returned, resident was on floor. On 12/18/19 at 9:50 a.m. the DON provided Emergency Department Provider Note (11/30/19 at 8:28 a.m.), read in part, the resident for evaluation of a head injury and [MEDICAL CONDITION] after unwitnessed fall this morning at (facility name). The paramedic stated that she is on hospice for her dementia and is nonverbal .She is noted to have a laceration to her mid forehead. CT brain impression read, left frontal scalp hematoma and bilateral frontal scalp [MEDICAL CONDITION]. The hematoma size was 1.9x0.5 cm. The facility failed to provide two staff during the resident's transfer from bed to a wheelchair. The facility failed to provide adequate staff training after the resident's fall to ensure resident's safe transfers according to the care plan and policy. C. Fall risk assessment The 9/8/19 Fall Risk Review total score was nine (9) and revealed the resident was a low risk for falls. IV. Interviews Resident #2's personal caregiver was interviewed on 12/16/19 at 11:30 a.m. She said she had been assisting the resident since she had been in the assisted living memory care unit. She said she had known the resident for over 21 months. She said she had been hired by the resident's family as a companion when the resident was admitted to the nursing facility. She said the resident was unable to roll from supine to side in bed or move from supine to sitting position for several weeks. She said the resident required total care with all activities of daily living. The DON was interviewed on 12/18/19 at 9:40 a.m. She said the CNA should have the Hoyer lift in the resident's room. She said the expectation was two staff with each mechanical lift transfer.

Based on observations and interviews, the facility failed to store, prepare and serve food under sanitary conditions. Specifically, the facility failed to: -Properly dry and prevent moisture between stacked steam pans during storage; -Resurface or replace heavily scored and stained cutting boards; -Cover foods during cooling and cold storage; and -Ensure staff followed single purpose glove use practices when handling ready-to-eat foods to prevent cross-contamination. Findings include: I. Drying A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (CRFERR), effective (MONTH) 2013, page 67, Unless used immediately after sanitization, all equipment and utensils shall be air-dried. B. Observations The facility is a part of a campus of care having different levels of support. There is one main campus kitchen where food is prepared and then delivered to each service area. The nursing facility has a small kitchen with a steam table set up for service. An initial tour of the nursing facility kitchen was completed on 12/17/18 at 10:35 a.m. Several steam pans, of varying sizes were stacked together on a storage rack. A small stream of water dripped from a small pan when separated from another. Moisture was observed between the surfaces of two more stacked pans as well. A tour of the main campus kitchen was completed on 12/20/18 at 11:15 a.m. Multiple pans were of varying sizes were stacked together on a storage rack. There was moisture between the surfaces of three small stacked pans. A follow up visit to the nursing facility kitchen was completed on 12/20/18 at 11:55 a.m. There was moisture between the surfaces of two small pans stacked together on a storage rack. II. Cutting boards A. Professional reference According to the CRFERR, effective (MONTH) 2013, page 55, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation During the tour of the main campus kitchen on 12/20/18 beginning at 11:15 a.m., multiple cutting boards with heavily scored and brown-stained surfaces were observed. Two white cutting boards with heavily scored and stained surfaces were being used for preparation of the lunch meal. III. Food storage A. Professional reference According to CRFERR, effective (MONTH) 2013, page 37, Packaged food, once the container is opened in the retail food establishment prior to use or retail sale, shall be kept covered. Food, whether raw or prepared, if removed from the container in which it was originally packaged, shall be stored in a clean, covered container, except during necessary periods of preparation or cooling. Foods uncovered during preparation or cooling must be protected from contamination. B. Observations During the tour of the main campus kitchen on 12/20/18 beginning at 11:15 a.m., two opened and uncovered bags of hamburgers and frozen chopped potatoes (tater tots) were observed in the walk-in freezer. Additionally, a pork loin roast was left uncovered on a rack in the walk-in refrigerator. A fan was blowing air directly across the surface of the uncovered roast. IV. Cross contamination A. Professional references According to the CFRERR, effective (MONTH) 2013, page 34, If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. B. Observations The main meal selection for lunch served on 12/20/18 consisted of spaghetti with meat sauce, french cut green beans, a breadstick and a peanut butter bar. The alternate meal included autumn pork loin, mashed sweet potatoes, french cut green beans, bread with butter and/or margarine and a peanut butter bar. An observation of the lunch meal service at the nursing facility on 12/20/18 began at 12:28 p.m. -At 12:42 p.m., the cook washed his hands and donned gloves. He used his gloved hands to retrieve a pen and the temperature log. He wiped a thermometer and measured the temperature of the pureed foods just added to the steam table. -At 12:43 p.m., the cook used his gloved hands to retrieve meal ticket orders from the top of the steam table and began filling the orders. The tickets had been taken by other dietary staff who entered and exited the kitchen multiple times without washing or sanitizing their hands. The cook used a measuring cup to portion out the pasta noodles. He placed his gloved hand along side the plate to prevent the noodles from spilling, creating contact between the glove surface and the ready-to-eat food item. He also used his gloved hand to guide green beans onto the plate. He used his gloved hand to retrieve a dinner roll, substituted for the breadstick, from the product bag and placed it on the plate. -At 12:45 p.m., the cook dropped a meal ticket to the floor. He used his gloved hand to retrieve the ticket and continued to use the same gloved hand to handle the green beans and pasta when plating the food. -At 12:52 p.m., the cook used his gloved hand to remove some excess green beans from the plate he was serving and returned the green beans to the steam table container. Based on numerous observations, the examples cited above were consistent with the practice used by the cook for plating foods for all residents receiving spaghetti, green beans and a dinner roll for lunch. The practice was also consistent for residents receiving green beans and a dinner roll with the alternate meal. V. Staff interviews The director of dining services (DDS) was interviewed on 12/20/18 at approximately 1:50 p.m. The DDS said staff should use the drying rack to dry all food service items. She said moisture between stacked pans could lead to the development of pathogens. She said she was aware the cutting boards were worn and planned to replace them soon. She said heavy scoring could make it difficult to wash and sanitize the cutting surfaces and may possibly lead to the spread of pathogens. She said foods should be covered when stored. She said she recently had similar observations and was working with the main campus kitchen staff to store foods properly. She said leaving items uncovered could lead to potential contamination of that food. She said she did not know what happened with the cook's performance during the meal service. She said he was usually conscientious about maintaining a clean meal service. She said staff were inserviced about hand hygiene in the kitchen and during the meal service and she would re-address the staff's use of gloves during meal preparation and service. The DDS said she would reinforce to staff that gloves were for single purpose use only and would consider having staff work without gloves so they can better identify where problematic practices might occur. The director of nursing (DON) was interviewed on 12/20/18 at 2:58 p.m. The DON said improving the kitchen/dining process was a focused area for the facility. The DON said the progress that had been made should be credited to the DDS and the dietitian who were working closely to address issues as they come up. The DON acknowledged all staff should continue to improve their practices in order to avoid potential cross contamination or the development/spread of pathogens when preparing and serving foods.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions. Specifically, the facility failed to: - Ensure cutting boards were free from heavily scored and stained surfaces; - Failed to ensure foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; and, - Failed to ensure foods were held for service at safe temperatures. The findings included: I. Cutting Boards A. Professional Standard According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated March 1, 2013), page 55, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour, conducted on 10/3/17 at 8:30 a.m., revealed five cutting boards, which were heavily stained and scored. C. Staff Interview The dietary manager (DM) was interviewed on 10/4/17 at 12:20 p.m. The DM looked at the stains on all the cutting boards and said, We will replace the cutting boards. They do need replacing. II. Food Temperatures A. Mechanically Altered Food 1. Professional References According to the CRFERR, pg. 39, The temperature of potentially hazardous foods shall be 41 degrees F (5 degrees C) or below or 135 degrees F (57 degrees C) or above at all times, except during necessary periods of preparation or as otherwise provided in this code. According to the United States Public Health Service Food and Drug Administration (FDA) 2013 Food Code 3-403.11 (A) pg. 87 .Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. 2. Menu Review of the 10/4/17 lunch menu included battered dipped fish or hickory smoked turkey, Yukon gold potato wedges, Brussels sprouts, banana spice cake and choice of beverage. 3. Observation On 10/4/17 at 11:30 a.m., dietary aide (DA) #1 was observed preparing the hickory smoked turkey for the pureed and mechanical soft meals. The cook was observed to place five thick slices of turkey into the food processor. The cook added approximately ¾ of a cup of broth to turkey and pureed the turkey until correct consistency had been reached. The cook then placed the pureed turkey into four plastic cups and wrapped each cup with clear plastic wrap. He placed each container on metal shelf above the food preparation area. DA #1 then placed five scoops of Brussels sprouts into the food processor. He added broth to the Brussel sprouts and pureed the Brussels sprouts until correct consistency had been reached. After processing, the cook placed the Brussel sprouts into four small white bowls. He wrapped each container with plastic wrap and placed them on the shelf above the food preparation area. The cook was not observed taking the temperature of the prepared pureed fish. 4. Interviews At 11:40 a.m., DA#1 was asked if he documented the temperature of the pureed and mechanical foods. DA #1 said, No, I do not take the temperatures of the pureed foods after I puree them. The cook took the food temperatures, which read 124 degrees F for the pureed turkey and 126 degrees F for the pureed Brussel sprouts. The cook then placed all containers back on the metal shelf. DA #1 said his expectations was to have all food at serving temperatures of 141 degree Fahrenheit (F). DA #1 said he was not aware of any food regulations dealing with modified consistency foods or temperatures. The dietary manager (DM) was interviewed on 10/4/17 at 12:20 p.m. She said her expectation of pureed food temperatures was 141 degrees F. The DM said she was not aware of any food regulations dealing with modified food temperatures and reheating. B. Holding Temperatures 1. Professional References According to the CRFERR pg. 39, The temperature of potentially hazardous foods shall be 41 degrees F (5 degrees C) or below or 135 degrees F (57 degrees C) or above at all times, except during necessary periods of preparation or as otherwise provided in this code. According to the United States Public Health Service Food and Drug Administration (FDA) 2013 Food Code 3-403.11 (A) pg. 87 .Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. 2. Menu Review of the 10/4/17 lunch menu included battered dipped fish or hickory smoked turkey, Yukon gold potato wedges, Brussels sprouts, banana spice cake and choice of beverage. 3. Observation The lunch meal was observed on 10/4/07 beginning at 11:30 p.m. DA #1 was placing all food items onto the steam table. DA #1 proceeded to take the temperatures of the turkey, which read 124 degrees F, the battered fish was at 125 degrees F, the potato wedges 114 degrees F and the Brussel sprouts were at 126 degrees F. 4. Interviews DA #1 said his expectations was to have all food at serving temperatures of 141 degree F. DA #1 began serving the food to residents and was immediately stopped. DA #1 was asked what was the procedure to follow when food was below acceptable temperatures. DA#1 said, I don't know what to do. The dietary manager (DM) was interviewed on 10/4/07 at 12:20 p.m. She said food should be served at 141 degree F and cold food product served below 41 degrees F. The DM was told of the earlier observations. The DM said it was her expectation the hot food should have been served at 141 degrees F and would in service the dietary aides immediately.

Based on resident and staff 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 for two (#63 and #30) of 22 sample residents. Specifically, the facility: - Failed to keep resident #63s indwelling catheter drainage bag off the floor. - Failed to initiate isolation precautions for resident #30 timely. - Failed to maintain contact isolation precautions for resident #30. The findings included: I. Catheter Care A. Facility Policy and Procedures The Catheter Care, Urinary policy and procedure, revised 9/14, revealed the purpose of the procedure was to prevent catheter-associated urinary tract infections. The section titled, Infection Control read, Be sure the catheter tubing and drainage bag are kept off the floor. B. Failure 1. Resident #63 A. Resident Status Resident #63, age 87, was admitted from the hospital with an indwelling foley catheter on 9/18/17. B. Observations The resident was observed lying in bed in his room on 10/3/17 at 8:15 a.m. The catheter drainage bag was observed lying on the floor beside the low bed. The resident was observed lying in bed on 10/4/17 at 7:30 a.m. The catheter drainage bag was observed lying on the floor beside the low bed. 2. Staff Interviews Registered nurse (RN) #1 was interviewed on 10/5/17 at 8:30 a.m. She said the resident ' s catheter drainage bag should be kept off the floor as this practice decreases his risk for infection. The director of nursing (DON) was interviewed on 10/5/17 at 11:30 a.m. She said the catheter drainage bag should be kept off the floor at all times to decrease the risk for infection. II. Isolation Precautions A. Professional Reference According to the Centers for Disease Control and Prevention (CDC), Preventing [MEDICATION NAME] in Health Care Settings, 7/16, https://www.cdc.gov/chickenpox/hcp/healthcare-setting.html, Nosocomial transmission of [MEDICATION NAME]-[MEDICATION NAME] virus (VZV) is well-recognized and can be life threatening to certain groups of patients. Reports of nosocomial transmission are relatively uncommon in the United States since introduction of [MEDICATION NAME] vaccine. Patients, healthcare providers, and visitors with [MEDICATION NAME] or herpes [MEDICATION NAME] can spread VZV to susceptible patients and healthcare providers in hospitals, long-term-care facilities, and other healthcare settings. These transmissions have been attributed to delays in the [DIAGNOSES REDACTED]. B. Facility Policies The Infection Prevention and Control Program policy and procedure, revised 8/16, revealed important facets of infection prevention included: - Identifying possible infections or potential complications of existing infections. - Instituting measures to avoid complications or dissemination. - Educating staff and ensuring that they adhere to proper techniques and procedures. - Implementing appropriate isolation precautions when necessary. - Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). The Isolation - Initiating Transmission-Based Precautions policy and procedure, revised 1/12, read, Transmission-based precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. When transmission-based precautions are implemented, the infection preventionist shall ensure that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained near the resident ' s room and ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident ' s room. The Isolation - Categories of Transmission-Based Precautions policy and procedure, revised 1/12, revealed contact isolation would be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment. Steps to follow for contact isolation included, in part: - Remove gloves before leaving the room and perform hand hygiene. - Wear a disposable gown upon entering the contact precautions room. C. Failure 1. Resident #10 A. Resident Status Resident #10, age 92, was admitted [DATE] and readmitted [DATE]. According to the October 2017 computerized physician orders [REDACTED]. The 8/29/17 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing and toilet use. B. Observations On 10/3/17 at 12:53 p.m., certified nurse aide (CNA) #2 was observed to knock on the resident ' s door. The resident told her she needed to use the bathroom. CNA #2 looked through the isolation cart outside of the room and found there were no gowns. She proceeded to enter the room, without donning a gown, and obtain gloves from the wall. (See CNA #2 interview) On 10/4/17 at 7:52 a.m., RN #1 exited the isolation room with the gown and gloves on. She removed the gown and gloves in the hallway and deposited them in the trash cart located approximately ten feet away from the resident ' s door and in the common area on A hall. She then walked to the medication cart and put away the medications she had in her hand. She did not sanitize or wash her hands after removing the personal protective equipment (PPE). C. Record Review The Temporary Problem List or plan of care, revealed a red rash started on 9/27/17. The interventions included, Tx (treatment) for shingles and Isolation Precautions. The care plan failed to inform the staff the type of isolation to use. The 9/28/17 change of condition assessment revealed the resident complained of a rash that goes from R (right) should blade underneath arm to R breast. The assessment revealed the symptoms started on 9/27/17. The note read, Awaiting Dr. (name) to look at. The assessment failed to document the resident was placed on contact isolation precautions. The 9/28/17, 2:57 p.m. nurse ' s note revealed the physician had examined the resident and determined she had shingles. The note failed to identify the resident was placed on contact isolation precautions at that time. The October 2017 CPO revealed the following orders: - 9/28/17: [MEDICATION NAME] HCl (antiviral) one (1) GM (gram), give one tablet by mouth every eight hours for shingles for seven days. - 9/29/17: Isolation precautions for shingles. Continue until all blisters have crusted over. The order failed to inform the staff of the type of isolation required. The September 2017 medication administration record (MAR) revealed the [MEDICATION NAME] was started on the evening of 9/28/17 but the isolation precautions did not start until the evening of 9/29/17. 2. Staff Interviews CNA #2 was interviewed on 10/3/17 at 1:05 p.m. She reported that the resident was contained and for that reason she did not wear a gown to assist her to the bathroom. RN #1 was interviewed on 10/5/17 at 8:30 a.m. She said the resident was on contact precautions. She said a gown, gloves and mask should be worn upon entering the room. She reported the personal protective equipment was then removed outside of the room. The DON was interviewed on 10/5/17 at 11:30 a.m. She said the resident should have been put on contact isolation precautions when the rash was suspected to be shingles. She said the isolation carts should be kept stocked at all times with gowns, gloves and masks. She reported the staff should wear gown, gloves and mask when providing direct patient care. She said the personal protective equipment should be removed in the resident ' s room and staff should wash their hands after removing the PPE.

Based on observations, resident and staff interviews, and record review, the facility failed to promote care for two (#33 and #10) of 28 sample residents in a manner and environment that maintained dignity and respect. Specifically, resident #33 was not provided with requested care, causing him to articulate prolonged feelings of being treated a "less than a person" since his admission to the facility. Resident #10 was observed wearing a dirty, stained Ace wrap for several days, causing her to perseverate over the stained area. The findings include: 1. Sample resident #33, age 81, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of lower back and lower extremity pressure ulcers, difficulty walking, muscle weakness, pneumonia, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], and hypertension. The 1/31/11 admission minimum data set (MDS) assessment documented: -The resident was able to make himself understood and able to understand others. He had short- and long-term memory problems and required modified independence with daily decision-making. -The resident exhibited verbal behavioral symptoms toward others, and rejection of care. -The resident felt it was somewhat important to choose his own bedtime. -The resident required total assistance with bed mobility, transfers, locomotion, dressing, toilet use, and bathing. He required extensive assistance with eating and personal hygiene. -The resident used a wheelchair as his primary mode of locomotion. -The resident used an indwelling catheter for urinary elimination and was always incontinent of bowel. The resident was on a toileting program to manage his bowel continence. -The resident was at risk of developing pressure sores, had three current stage four pressure sores that were present on admission, and received a pressure-relieving device for his bed and chair, a turning/repositioning program, nutrition intervention for skin problems, ulcer care, and applications of dressings and ointments. 2. Record Review The 1/19/11 admission nursing assessment documented the resident had pressure ulcers on his sacrum and his right calf. The resident also had a history of [REDACTED]. He had weakness in his right and left upper and lower extremities. The resident was alert and oriented and his cognition was intact. He had no mood or behavioral symptoms. Cross-reference F279: Comprehensive Care Plan - the resident did not have a care plan in place addressing his bowel incontinence and need for incontinence care and disposable bed pads. 3. Resident Interview On 2/28/11 at 1:56 p.m., the resident stated he felt the staff did not treat him with respect and dignity. He stated, "I punch the call light, but sometimes have to wait for an hour for any help. I have laid in my own bowel movement (BM) for an hour. It seems like nobody cares." The resident stated he felt like he was treated as "less than a human" at the facility and was "tired of it." He stated he had felt this way since he was first admitted to the facility (1/19/11). The resident stated, "I need to get out of here, I feel so terrible because they don't give a s*** about me." The resident also stated he was going to have his friend "sneak him out" of the facility because he couldn't "stand it anymore." 4. Resident Observation On 3/1/11 at 2:24 p.m., the resident stated he had been lying in his own BM since 2:00 p.m. He stated he had told a certified nurse aide (CNA) right before 2:00 p.m. that he had a BM and needed to be changed, but the CNA told him her shift ended at 2:00 p.m. and the next shift would help him. The resident's room smelled strongly of feces. The resident was very angry, exclaiming cuss words and saying the staff were "against him." He stated he refused to push the call button, as he already told the CNA he needed assistance. He stated, "I shouldn't have to push it, they already know, they just don't care." The resident also stated he was "pissed off" and he had every right to be because of the situation. On 3/1/11 at 3:28 p.m., the resident was observed lying in bed on his back covered with linens. His room smelled of feces. The resident again stated he told a nurse at 2:00 p.m. that he had a BM. At 3:30 p.m., the resident pushed the call button. CNA #1 answered the call light at 3:35 p.m. The CNA stated she was not told by the previous shift that the resident had a BM and needed to be changed when her shift began at 2:00 p.m. The CNA left the room at 3:38 p.m. and returned at 3:43 p.m. with supplies and another CNA. Both CNAs assisted the resident with incontinence care. There was an oval-shaped, brown stain approximately 12 inches long by 6 inches wide on the bottom flat sheet. The stain was visible below the green disposable pad and extended beyond the green pad. Hardened, dried feces and brown stains were observed on the resident's legs and inner thighs. A wound dressing was observed on the resident's sacrum with brown stains on it. On 3/3/11 at 10:40 a.m., the director of nursing (DON) stated she had not heard the resident voice complaints of call lights not being answered and not being changed in a timely manner. She stated it was unacceptable for the resident not to be changed for over an hour. The DON added at 1:14 p.m. that she had no proof the resident told a CNA on 3/1/11 at 2:00 p.m. that he needed to be changed. On 3/3/11 at 1:15 p.m., CNA #4 stated the resident had stated to her at around 2:00 p.m. on 3/1/11 that he had been incontinent of bowel and needed to be changed. She stated she told the resident the next shift would help him and she passed this information onto CNA #1 at shift change. On 3/3/11 at 1:20 p.m., the DON was alerted to the above interview. She stated this was absolutely not acceptable and would be handled immediately. On 3/7/11 at 10:30 a.m., the facility's 2/11 and 3/11 call light response time reports were requested. The executive director declined to provide the reports, stating they were confidential quality assurance documents. 2. Sample resident #10, age 89, was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of malaise and fatigue, dementia, spinal stenosis, [MEDICAL CONDITION] arthritis, symbolic dysfunction, gout, depression, convulsions, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The 1/11/11 quarterly MDS assessment documented the resident was usually able to make herself understood and usually able to understand others. The resident was severely impaired with daily decision-making and had short- and long-term memory problems. The resident had hallucinations, but did not exhibit any behavioral symptoms. She required total assistance with bed mobility, transfers, and locomotion and required extensive assistance with dressing and personal hygiene. The resident had limited functional range of motion in her upper and lower extremities on one side. The 1/4/11 care plan addressing the resident's need for assistance with activities of daily living (ADLs) documented the pertinent approach to apply a glove to the resident's left hand for protection. The care plan documented the resident required assistance of one to two staff members with personal hygiene and documented an approach to provide assistance with ADLs as needed. On 3/1/11 at 2:38 p.m., the resident was observed lying in bed with an Ace wrap on her left wrist and hand. She had put her call light on and stated to the surveyor she wanted her left arm ace wrap cleaned. The wrap and the top of her left hand had yellow crusty stains on them (which looked like mustard). At 2:45 p.m., the resident's call light was answered, but the CNA did not clean the resident's hand or Ace wrap. At 3:00 p.m., the resident was taken to an activity program without her hand and wrap being cleaned. At 4:50 p.m., the resident was observed seated in the dining room for supper. She still had the yellow crusty stains on her left hand and the Ace wrap. The resident stated she needed to get the stains "taken care of" and was hiding her left hand under her clothing protector. She remained with her left hand under the clothing protector as she began to eat her supper. On 3/2/11 at 9:05 a.m., the resident was observed seated in the activity area with an Ace wrap on her left hand. The Ace wrap still had the yellow crusty stains on it that were observed the day before. On 3/2/11 at 2:35 p.m., the resident was observed with the yellow crusty stain on her Ace wrap. She stated, "I am deathly afraid of this," and pointed at the stain. On 3/3/11 at 10:00 a.m., the resident was again observed with yellow crusty stains on her Ace wrap. On 3/3/11 at 10:40 a.m., the DON stated the resident's Ace wrap should be cleaned whenever dirty and the resident should have more than one wrap to allow for cleaning daily or as needed. On 3/3/11 at 12:45 p.m., the resident pointed to the yellow crusty stains on her Ace wrap and stated to the nurse it was a "worry." On 3/3/11 at 12:50 p.m., the DON provided a physician's telephone order, dated 3/3/11, which clarified the resident's ace wrap was to be changed every night.