Every finding on record at North Shore Health & Rehab Facility

Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for two (#92 and #56) of two residents reviewed for pain management out of 54 sample residents. Resident #92 was admitted to the facility on [DATE]. Resident #92 had a history of osteoarthritis and pain. On 7/6/26, the facility failed to ensure the resident's oxycodone medication was administered timely. Resident #92's medication was not administered until five hours after it was scheduled, which resulted in Resident #92 experiencing increased pain.Resident #56 was admitted to the facility on [DATE]. The resident had a history of a stroke with hemiplegia and hemiparesis affecting the left non-dominant side and a history of chronic pain. The resident received scheduled oxycodone for her chronic pain. On 7/6/26 Resident #56 received her 12:00 p.m. dose of oxycodone at 1:40 p.m., one hour and 40 minutes after it was scheduled to be administered. On 7/7/26 the resident received her 8:00 a.m. dose of oxycodone at 9:55 a.m., one hour and 55 minutes after it was scheduled to be administered. Observations of the resident revealed she was grimacing and crying and grabbing her lower back. Record review revealed there were other instances of the resident receiving her pain medication late.Specifically, the facility failed to ensure Resident #92 and Resident #56's scheduled pain medications were administered as ordered in a timely manner, which resulted in increased pain for the residents. Findings include: I. Facility policy and procedure The Pain Management policy, revised 4/11/25, was provided by the nursing home administrator (NHA) on 7/9/26 at 9:57 a.m. It read in pertinent part, In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychological well-being and to prevent or manage pain, the facility will: Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include, but are not limited to: -Change in gait, skin color, vital signs (increased heart rate, respirations and/or blood pressure) and perspiration; -Loss of function or immobility to perform activities of daily living (ADL), including rubbing a specific location of the body or guarding a limb or other body parts); -Fidgeting, increased or recurring restlessness; -Facial expressions (grimacing, frowning, fright, or clenching of the jaw); -Behaviors such as: resisting care distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities; -Difficulty eating or loss of appetite; -Weight loss; -Difficulty sleeping; -Negative vocalizations (groaning, crying, whimpering, or screaming); -Decline in activity level; and, -Skin conditions. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. Opioid treatment for acute pain, subacute pain, and chronic pain will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences. II. Resident #92 A. Resident status Resident #92, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included osteoarthritis of left hip, right hip, left upper arm and right upper arm, abnormal posture and diabetes. According to the 6/19/26 minimum data set (MDS) assessment, Resident #92 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment identified Resident #92 required set up assistance with eating, showering, dressing and transferring. The MDS assessment documented Resident #92 took a scheduled opioid (narcotic) medication for pain. B. Resident observations and interviews On 7/6/26 at 12:35 p.m. Resident #92 was in his room lying in bed and grimaced several times as he spoke. Resident #92 was restless, moving frequently in the bed and twice observed groaning in pain while reaching for his left hip. Resident #92 said his morning pain medication had not been administered. He said once the facility finally administered his pain medication, it would take much longer for him to get relief from the medication because it was not administered to him on time. Resident #92 said he kept asking for his pain medication, but they had not yet given him the medication. Resident #92 said he was told he was not administered the pain medication that morning (7/6/26) because it was not available for administration. Resident #92 said his pain had increased and it would get worse and worse and worse and he would not be able to sleep because he had not received the pain medication when it was due. Licensed practical nurse (LPN) #4 entered Resident #92's room on 7/6/26 at 12:41 p.m. LPN #4 administered oxycodone pain medication to Resident #92. LPN #4 said she had spoken to the assistant director of nursing (ADON), who helped her obtain the medication from the automated medication dispensing system because her (LPN #4's) code for the automated medication dispensing system machine did not work. -LPN #4 did not administer Resident #92's oxycodone pain medication until approximately five hours after the medication was scheduled to be administered (see record review below). Resident #92 was interviewed a second time on 7/7/26 at 9:26 a.m. Resident #92 said he still had increased hip pain due to the delayed administration of oxycodone the day before (7/6/26). Resident #92 said when the nurses gave his pain medication on time, his pain was not as bad. During the interview, Resident #92 grimaced, held his hip and turned his chin up toward the ceiling as he spoke. C. Record review Review of Resident #92's pain care plan, revised 4/23/26, revealed Resident #92 was on pain medication therapy related to osteoarthritis of his left hip. Interventions included administering analgesic medications as ordered by the physician and monitoring for side effects and effectiveness of the medication. Review of Resident #92's July 2026 CPO revealed the following physician's orders: Oxycodone hydrochloride (HCL) oral tablet 5 milligrams (mg) two times a day for hip pain, scheduled at 8:00 a.m. and 12:00 p.m., ordered on 6/25/26. Oxycodone HCL oral tablet 5 mg, give two tablets by mouth at bedtime for hip pain, ordered 6/25/26. The medication administration record (MAR) documentation on 7/6/26 at 12:45 p.m. revealed Resident #92 rated his pain level at a 5 out of 10 on a 0-10 pain scale. -Review of Resident #92's medication administration audit report, provided by the NHA on 7/8/26 at 1:52 p.m. revealed the resident's oxycodone medication scheduled on 7/6/26 at 8:00 a.m. was not documented as administered until 7/6/26 at 1:04 p.m. D. Staff interviews The ADON was interviewed on 7/9/26 at 1:00 p.m. The ADON said she assisted LPN #4 when she obtained the oxycodone medication from the automated medication dispensing system for Resident #92 on 7/6/26. The ADON said she did not know the medication was overdue for administration at the time that she assisted LPN #4. The ADON said if the oxycodone medication was ordered for 8:00 a.m., she would expect the nurse to administer the medication prior to 9:00 a.m. The director of nursing (DON) was interviewed on 7/9/26 at 1:30 p.m. The DON said administering oxycodone medication five hours late was not acceptable. The DON said she thought LPN #4 might have been waiting for the pharmacy to provide the medication, however the medication was available in the automated dispensing system for administration and therefore it should have been given. The DON said the pharmacy should have been notified that the medication was needed for Resident #92. She said it was a five minute process to ask the pharmacy for approval and remove the medication from the automated medication dispensing machine for administration. The DON said she did not know why LPN #4 did not obtain the medication sooner and did not know if the nurse was aware that it was a quick process to remove the medication from the automated medication dispensing system. The DON said a resident's pain was a priority and she planned to follow up with staff education. She said the late pain medication administration could have contributed to Resident #92's worsening pain. III. Resident #56 A. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included left-sided weakness following a stroke, chronic obstructive pulmonary disease (COPD), generalized muscle weakness, hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. According to the 5/21/26 MDS assessment, Resident #56 was cognitively intact with a BIMS score of 14 out of 15. The MDS assessment identified that Resident #56 was dependent on staff for assistance and required two-person assistance for personal hygiene and transfer from bed to chair. The MDS assessment documented that Resident #56 took scheduled, as-needed pain medications and had non-pharmacological interventions for pain management. The assessment indicated she had the presence of pain during the past five days of the look-back assessment period. B. Resident interview Resident #56 was interviewed on 7/6/26 at 1:21 p.m. Resident #56 said she had pain when the nursing staff repositioned her and during care. She said she was always in pain when she moved or repositioned in bed, and she was always tired. Resident #56 said she had not received her scheduled pain medication that was due at 12:00 p.m. She said she was currently in excruciating pain because she had not received her scheduled pain medication. She said that when she did not receive her scheduled pain medication on time, her pain increased to 9 out of 10 pain level all over her body. She said her pain usually remained unresolved when she received her pain medication late. Resident #56 said her oxycodone pain medication was given late at all times, with the exception of a few days, which sometimes prevented her from getting out of bed due to her pain level. Resident #56 was interviewed a second time on 7/9/26 at 11:15 a.m. Resident #56 said she missed her physical therapy due to an increased pain level. She said her pain level was unbearable when she did not receive her pain medication on time as scheduled. Resident #56 said her prescribed pain medication, oxycodone, was an immediate release form of medication, so it did not remain in her body for her to be okay to receive her scheduled dose two hours late. She said the delay resulted in increased pain, to the point of causing her to cry. C. Observations and additional interviews On 7/6/26 at 1:35 p.m. (35 minutes past the allotted administration time for the 12:00 p.m. oxycodone dose), Resident #56 was in her room, lying in bed, crying, grimacing, and clutching her lower back. The resident was guarding her left side and unable to reposition herself due to severe discomfort. When asked to rate her pain on a 1 to 10 pain scale, the resident tearfully said her pain was a 9 out of 10. -Review of the July 2026 medication administration record (MAR) confirmed that, as of 1:35 p.m., the 12:00 p.m. dose of oxycodone had not yet been administered (see record review below). On 7/7/26 at 9:45 a.m. (45 minutes past the allotted administration time for the resident's scheduled 8:00 a.m. oxycodone dose), Resident #56 was in her room, lying in bed, visibly distressed. The resident was lying flat on her back, tossing her head from side to side, and letting out soft groans with any movement. She kept rubbing her arms, complaining of a severe ache that was all over her body. When asked to rate her pain on a 1 to 10 pain scale, Resident #56 tearfully said her pain was a 9. She said her whole body was on fire and hurting because the nurse was late with her pain medication. -Review of the July 2026 MAR confirmed that, as of 9:50 a.m., the resident's scheduled 8:00 a.m. dose of oxycodone had not yet been administered to the resident. D. Record review Resident #56's pain care plan, initiated 11/17/25, revealed the resident had pain and was receiving pain-relieving therapy, including opioids, related to severe spinal stenosis, left arm hemiparesis, left elbow pain, and rib fracture. Interventions included administering analgesia as ordered, evaluating the effectiveness of the pain intervention, reviewing compliance, alleviating symptoms, assessing dosing schedules and resident satisfaction with results, impact on functional ability, impact on cognition, and monitoring pain level prior to, during treatment, and treating pain as per physician's orders to ensure the resident's comfort as needed. -The care plan did not include a non-pharmacological approach and an acceptable level of pain for the resident. Resident #56's behavior care plan, initiated 5/21/25 and revised 5/7/26, revealed Resident #56 had a behavior problem related to the history of being emotionally labile (rapid, intense, and unpredictable shifts in mood), refusal of care, demanding excessive care, accusations towards staff, including physical and sexual abuse, and refusal of a second staff member in the room for care in pairs. Interventions included anticipating and meeting the resident's needs, behavior monitoring, and intervening as necessary to protect the rights and safety of others. Resident #56's July 2026 CPO revealed the following physician's orders: Oxycodone HCl oral tablet 10 mg. Give 10 mg by mouth every four hours for chronic pain in the upper back, arms, and neck. Scheduled at 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., 12:00 a.m., and 4:00 a.m., ordered 4/8/26. Review of Resident #56's July 2026 MAR revealed the following: On 7/4/26 at 12:00 a.m. Resident #56 was scheduled to receive a dose of 10 mg oxycodone HCI; however, the pain medication was not administered until 1:31 a.m. (31 minutes past the allotted administration time). On 7/4/26 at 4:00 a.m. Resident #56 was scheduled to receive a dose of 10 mg oxycodone HCl; however, the pain medication was not administered until 5:21 a.m. (21 minutes past the allotted administration time). On 7/6/26 at 8:00 a.m. Resident #56 was scheduled to receive a dose of 10 mg oxycodone HCl; however, the pain medication was not administered until 9:20 a.m. (20 minutes past the allotted administration time). On 7/6/26 at 12:00 p.m. Resident #56 was scheduled to receive a dose of 10 mg oxycodone HCl; however, the pain medication was not administered until 1:40 p.m. ( 40 minutes past the allotted administration time - see observation above). On 7/7/26 at 8:00 a.m. Resident #56 was scheduled to receive a dose of 10 mg oxycodone HCl; however, the pain medication was not administered until 9:55 a.m. (55 minutes past the allotted administration time - see observation above). -Additionally, on 7/7/26 at 12:00 p.m. Resident #56 was scheduled to receive a dose of 10 mg oxycodone HCl; however, the pain medication was given at 12:27 p.m., 2 hours 32 minutes after the resident was administered the previous dose of medication at 9:55 a.m.(see administration records above) -There was no documentation to indicate that the physician was notified about the late pain medication administrations or the ineffectiveness of the resident's pain medication. E. Staff interviews LPN #2 was interviewed on 7/9/26 at 2:15 p.m. LPN #2 said she was familiar with Resident #56's care. LPN #2 said the resident had pain, and she complained about the pain a lot. She said Resident #56 had pain in her arms, neck, and upper back. LPN #2 said the resident's pain goal was not documented in her care plan. LPN #2 said the resident complained about pain every day and would sometimes refuse care due to complaints of extreme pain. LPN #2 said most of the time, medications were given late due to staffing shortages. LPN #2 said nurses had no choice but to assist the certified nurse aides (CNA) during staffing shortages, which resulted in medications being administered late. The DON was interviewed on 7/9/26 at 5:15 p.m. The DON said a pain assessment assessed the resident's pain history, the impact of the pain on the resident's life, the resident's pain management goal, the acceptable level of pain, and the location of the pain. The DON said pain medications should be given as ordered by the physician. The DON said it was important to ensure scheduled times for pain medication administration were followed. The DON said following the scheduled times helped to determine whether the pain medications were effective in order to ensure a better quality of life for the resident. The DON said administering pain medication too early or too late could have several adverse effects, based on the medical conditions of the resident. She said administering the pain medication before the previous dose had fully metabolized carried a risk of toxicity, respiratory failure, and oversedation. The DON said administering pain medication past the allotted administration time when it was due allowed the drug level in the resident's blood to drop far below the minimum effective concentration, breaking the therapeutic window, which could result in breakthrough pain agony, loss of therapeutic control, and physical and psychological trauma. The DON said that when any of these happened, it should be documented in a progress note and on the MAR. The DON said the physician should be informed of the variation in the administration times and the reason should be provided. The DON said she started working at the facility a short time ago and she was not familiar with Resident #56. She said she would review the residents' pain medication regimens and immediately provide education for the nursing team to ensure scheduled pain medications were administered according to the physician's order.

Based on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for eight (#50, #7, #58, #2, #12, #56, #110 and #21) of 12 residents reviewed for accommodation of needs out of 54 sample residents. Specifically, the facility failed to ensure Resident #50, Resident #7, Resident #58, Resident #2, Resident #12, Resident #56, Resident #110 and Resident #21, who relied on bedside halo bars and transfer poles for mobility, had appropriate accommodations after the facility removed all bedside halo bars and transfer poles from resident rooms. Findings include: I. Facility policy and procedure The Safe Resident Handling/Transfers policy, implemented on 4/11/25, was provided by the nursing home administrator (NHA) on 7/9/26 at 11:06 a.m. It read in pertinent part, The interdisciplinary team (IDT) or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies. Resident lifting and transferring will be performed according to the resident's individual plan of care. II. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included morbid obesity (overweight), unsteadiness on feet, abnormal posture, and muscle weakness. The 6/25/26 minimum data set (MDS) assessment revealed Resident #50 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required partial to moderate assistance with transfers, supervision assistance with sit to stand, and setup assistance with lying to sitting. B. Resident observations and interviews On 7/6/26 at 1:05 p.m. Resident #50 was lying in bed. There was no transfer pole or halo bar on Resident #50's bed. Resident #50 said she missed having the transfer pole and halo bar because they helped her move in bed and transfer more independently. Resident #50 said she was unhappy the devices had been removed and felt she had lost some of her independence without them. On 7/9/26 at 9:26 a.m. Resident #50 was lying in bed. One transfer pole had been reinstalled next to the resident's bed. Resident #50 said the facility had reinstalled the transfer pole that morning (7/9/26). Resident #50 said she would receive the second transfer pole later that day. Resident #50 said she previously used the transfer pole and halo bar to move in bed and to get in and out of bed. Resident #50 said since the devices were removed, bed mobility and transfers had become more difficult, and she now required a Hoyer lift (mechanical lift) and increased staff assistance. Resident #50 said she was not happy the devices were removed. Resident #50 said the facility decided to remove the devices and did not ask how removing the devices would affect her ability to move safely. Resident #50 said she was able to move and transfer more easily with the transfer pole and halo bar and, without them, she felt she had lost her independence. C. Frequent visitor interview A frequent visitor to the facility was interviewed on 7/8/26 at 1:29 p.m. The frequent visitor said residents did not want to wait for staff assistance to be repositioned in bed or to use the bathroom. She said the residents wanted to use the transfer devices. The frequent visitor said, after concerns had been raised at another facility regarding the use of transfer devices without assessments, several sister facilities had removed the devices. The frequent visitor said residents reported needing more assistance from staff after the devices were removed. D. Record review The comprehensive care plan, initiated 7/28/25 and revised 8/5/25, revealed Resident #50 was at risk for falls related to a history of falls and weakness. Pertinent interventions included anticipating and meeting the resident's needs, assessing the resident's need for adaptive devices as indicated, having physical therapy, occupational therapy, and speech-language pathology evaluate and treat the resident as ordered. The 5/12/26 nursing progress note revealed staff spoke with Resident #50 regarding the removal of halo bars, mobility bars, and transfer poles. The resident was provided a letter of intent regarding the removal, and the resident's husband was informed of the changes. -However, the progress note did not indicate that alternative assistive devices had been evaluated and implemented or that alternative devices had been discussed with the resident to assist the resident with mobility. E. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 7/8/26 at 9:36 a.m. CNA #8 said residents used the halo bars to roll themselves in bed and used the transfer poles to help them stand, which gave them more independence. CNA #8 said since the devices were removed, many residents now needed staff to help them move in bed and some could no longer sit up independently. CNA #8 said residents often commented that they had lost their independence. CNA #8 said no replacement devices were provided for the residents, and some residents now used walkers or required a two-person assist. CNA #8 said residents needed more help after the devices were removed, which took more staff time and caused more call lights while staff were trying to catch up. Registered nurse (RN) #3 was interviewed on 7/8/26 at 9:45 a.m. RN #3 said residents were not individually assessed before the transfer poles and halo bars were removed. RN #3 said residents' transfer abilities, bed mobility, and fall risk were assessed during their quarterly assessments. RN #3 said the devices were removed due to concerns about entrapment risk. RN #3 said no alternative equipment was provided, other than therapy evaluating residents for other options. CNA #7 was interviewed on 7/8/26 at 5:00 p.m. CNA #7 said the facility removed the transfer devices about a month ago (June 2026). CNA #7 said residents complained when the devices were removed, and some residents continued to complain periodically. CNA #7 said the transfer devices provided residents with more independence and helped some residents with their mobility. CNA #7 said Resident #50 previously used the transfer pole to stand and transfer to her wheelchair, but required a Hoyer lift after the removal of the transfer poles. CNA #7 said Resident #50 missed the independence the transfer pole had provided her. CNA #7 said that because the transfer devices were removed, some residents now required a two-person assist for rolling during care. RN #4 was interviewed on 7/8/26 at 5:13 p.m. RN #4 said the facility removed the transfer devices one to two months ago May 2026/June 2026), following an incident at a sister facility. RN #4 said the transfer devices helped residents and allowed them to be more independent. RN #4 said residents would be happy if the transfer devices were brought back. The physical therapy assistant and the regional therapy manager were interviewed together on 7/9/26 at 10:47 a.m. The regional therapy manager said Resident #50 was assessed before the transfer poles were removed. The regional therapy manager said Resident #50 had previously had transfer poles on both sides of the bed to assist her with bed mobility, moving from lying to sitting, and pivot transfers to the wheelchair and recliner. The regional therapy manager said the transfer poles were removed after a sister facility determined that the devices were not safe. The physical therapy assistant said a four-wheel walker was placed next to Resident #50's bed to be used like a modified bed cane, but it had not been successful. The physical therapy assistant said staff were now using a Hoyer lift for transferring Resident #50. The regional therapy manager said occupational therapy planned to reassess the Resident #50's need for a transfer pole, but did not want to install both poles because they would interfere with Hoyer lift transfers. The NHA was interviewed on 7/9/26 at 12:18 p.m. The NHA said the transfer pole that was reinstalled for Resident #50 that day (7/9/26) was for the purpose of completing an evaluation for the resident. III. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included hemiplegia (paralysis on one side), hemiparesis (weakness on one side) following cerebral infarction (stroke) affecting the right non-dominant side, and dependence on a wheelchair. The 5/14/26 MDS assessment revealed Resident #7 was cognitively intact with a BIMS score of 15 out of 15. He was dependent on staff for transfers, sit to stand, lying to sitting, sitting to lying and chair/bed-to-chair transfer. B. Resident observation and interview On 7/9/26 at 8:51 a.m. Resident #7 was sitting in his wheelchair in his room. There were no halo bars observed on either side of his bed. Resident #7 said when he was admitted to the facility, staff evaluated his strength. He said restorative staff began exercises to maintain his strength, and occupational therapy and physical therapy re-evaluated him every six months. Resident #7 said he had two halo bars, one on each side of his bed, for about five and a half years before the facility removed them. Resident #7 said that before the facility removed the halo bars, he used the right halo bar because his right side was paralyzed. Resident #7 said he used the halo bar while rolling in bed, during transfers with the mechanical lift, and while staff turned him for incontinence care to help prevent him from falling. Resident #7 said he had always required a two-person assist with mobility. He said since the halo bars were removed, staff had to brace him during care as a precaution. Resident #7 said since the halo bars were removed, he was terribly afraid of falling during care. Resident #7 said he had come close to the edge of the bed on several occasions but had not fallen. Resident #7 said he now required more assistance with bed mobility because he had no core strength and could not hold onto the halo bar for stability. He said he depended completely on staff assistance to keep him from falling and he no longer felt as comfortable during care. Resident #7 said no one asked him how removing the halo bars might affect his ability to move safely. Resident #7 said staff told him that if he fell, they would take him to the hospital. Resident #7 said no alternative device or method had been provided to assist with transfers or bed mobility after the halo bars were removed. Resident #7 said removing the halo bars had decreased his independence and increased his fear of falling during care. C. Record review The comprehensive care plan, initiated 9/8/23, revealed Resident #7 had an activity of daily living (ADL) self-care performance deficit related to hemiplegia, limited mobility, and stroke. Pertinent interventions included that Resident #7 required a sit-to-stand lift with assistance from two staff members for transfers between surfaces. Review of the 2/17/26 Assistive Device/Potential Restraint Evaluation revealed that the Resident #7's assistive device was a bed halo, which assisted with the resident's participation and independence with bed positioning and mobility. The resident required a mechanical lift for mobility, used the device appropriately, and had no adverse outcomes related it's use. The evaluation revealed the less restrictive measure attempted since the last assessment was no halo. The IDT rationale revealed that the resident demonstrated appropriate use of the device and that it assisted with his bed mobility. -However, Resident #7's electronic medical record (EMR) did not reveal that an evaluation had been completed at the time the resident's transfer poles were removed to determine if an alternative device would be effective for assisting the resident with continued mobility. D. Staff interviews RN #4 was interviewed on 7/8/26 at 5:13 p.m. RN #4 said Resident #7 loved using the halo transfer bar. RN #4 said Resident #7 had previously been able to roll and reposition himself using the halo transfer bars but was then completely dependent on staff assistance for those tasks after the halo bars were removed. RN #4 said the halo transfer bars also helped prevent Resident #7 from falling. The physical therapy assistant and the regional therapy manager were interviewed together on 7/9/26 at 10:47 a.m. The physical therapy assistant said Resident #7 had previously had halo bars on both sides of his bed, which were used for rolling, repositioning, and assisting with care. The physical therapy assistant said she was not sure whether the halo bars were replaced with another device when they were removed. The regional therapy manager said Resident #7 was evaluated before the halo bars were removed. -However, there was no documentation to indicate and alternative device had been discussed or implemented for the resident to assist the resident with continued mobility IV. Resident #58 A. Resident status Resident #58, age less than 65, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included incomplete paraplegia (paralysis of lower body), lack of coordination, unsteadiness on feet, and muscle weakness. The 6/16/26 MDS assessment revealed Resident #58 was cognitively intact with a BIMS score of 15 out of 15. She required setup assistance with rolling from left to right, sitting to lying, and supervision or touching assistance with lying to sitting on side of bed, and sitting to stand. B. Resident observation and interview On 7/8/26 at 9:12 a.m. Resident #58 was lying in bed. There were no transfer poles on her bed or in the bathroom. Resident #58 said she previously had two transfer poles, one in her bedroom and one in her bathroom, as well as bed rails, which had been removed. Resident #58 said therapy evaluated her and trained staff on the use of the transfer devices. Resident #58 said before the transfer poles and bed rails were removed, she required assistance from one staff member for mobility. Resident #58 said she raised the bed and used the bed rails, transfer pole, and staff assistance to get in and out of bed and on and off the toilet. Resident #58 said since the devices were removed, she required assistance from two staff members for bed mobility and transfers. Resident #58 said she was unhappy about the removal of the devices. Resident #58 said she had not fallen since the devices were removed and felt she had enough support during transfers. Resident #58 said staff told her the devices were removed because they were considered unsafe. Resident #58 said no alternative device or method had been provided to assist her with bed mobility or transfers. Resident #58 said removing the devices had decreased her independence because she was previously able to stand upright using the transfer poles, but she could no longer do so. Resident #58 said therapy was working with her three times per week to help prevent decline. C. Record review The 1/18/26 Nursing-Physical Restraint/Assistive Device Evaluation was provided by the NHA on 7/9/26 at 11:59 a.m. It revealed that Resident #58 was re-evaluated for an existing transfer pole. The resident was alert and oriented, had paraplegia, required stand-pivot transfers with therapy, and required a full mechanical lift with floor staff. The resident benefited from and was able to use the transfer pole because it assisted with safety during transfers. The resident was not at risk for entrapment or harm from use of the device and had been assessed by physical or occupational therapy for its use. -However, Resident #58's EMR did not reveal that an evaluation had been completed at the time the resident's transfer poles were removed to determine if an alternative device would be effective for assisting the resident with continued mobility. The comprehensive care plan, initiated 11/7/23 and revised 5/27/26, revealed Resident #58 had an ADL living self-care performance deficit related to paraplegia and chronic pain syndrome. Pertinent interventions included providing care in pairs, providing evaluation and treatment as needed to increase strengthening, providing maximum assistance with bed mobility and that the resident could request a [NAME] sit-to-stand lift as needed. D. Staff interviews The physical therapy assistant and the regional therapy manager were interviewed together on 7/9/26 at 10:47 a.m. The physical therapy assistant said Resident #58 previously had transfer poles in the bathroom to assist with standing pivot transfers and a transfer pole near the bed to assist with bed transfers. The physical therapy assistant said the resident also previously had two halo bars to assist with repositioning in bed. The physical therapy assistant said the devices were removed after the resident's transfer status was downgraded and the resident was transitioned to a sit-to-stand device for toileting. The physical therapy assistant said nursing staff and therapy collaborated to assess residents for transfer poles and halo bars. The physical therapy assistant said therapy typically evaluated residents with transfer or mobility difficulties before the devices were installed. The regional therapy manager said after the devices were removed, each affected resident was re-evaluated to determine whether another device would better meet the resident's needs. The physical therapy assistant said many residents were upset when the devices were removed because the halo bars helped them reposition and roll in bed, reduced the need for staff assistance during care, and made them feel safer. The director of nursing (DON) and the NHA were interviewed together on 7/9/26 at 12:18 p.m. The NHA said the decision to remove transfer poles and halo bars was prompted by an incident at another facility, indicating the devices posed a high risk for entrapment. The NHA said the corporate chief nursing officer communicated concerns regarding the risks associated with the devices. The DON said the facility wanted to move away from high-risk devices and evaluate whether less restrictive measures could be used to prevent injury. The DON said the facility assessed each resident to determine whether the transfer device was safe and appropriate before removing it. The DON said assistive device evaluations had been completed previously and were reviewed quarterly. The DON said the facility completed a nursing evaluation on 2/17/26 to assess Resident #58's use of a transfer pole for transfer safety, consideration of less restrictive measures, and therapy involvement. The DON said the process used to assess and implement assistive transfer devices was probably not done correctly. The DON said the facility would begin having quarterly assistive device evaluations completed by charge nurses and nurses. The DON said alternative mobility devices included walkers and use of the headboard for bed mobility. The DON said some residents did not need the devices because they had been using them for comfort rather than for functional assistance. The DON said the affected residents' care plans were updated on 5/27/26, and residents were evaluated by therapy upon admission and reassessed regularly. -However, there was no documentation to indicate the residents had been evaluated for alternative devices for mobility at the time the assistive devices were removed (see record review above). The NHA said the facility implemented a performance improvement plan, completed a facility-wide audit, and sent letters to residents affected by the removal of the assistive transfer devices prior to removal of the devices. The NHA said he became aware that some residents were unhappy after the devices were removed and believed their concerns had been addressed through therapy reassessments. The NHA said follow-up should have occurred with residents who remained unhappy. The NHA said, going forward, the facility would address resident concerns regarding assistive devices through IDT meetings and the facility's grievance process. III. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included chronic respiratory failure, type 2 diabetes mellitus, chronic kidney disease and generalized muscle weakness. The 5/8/26 MDS assessment revealed Resident #2 was moderately cognitively impaired with a BIMS score of 11 out of 15. She was dependent on staff assistance and required substantial to maximum assistance with personal hygiene, toileting, and sit-to-stand transfers. She required a wheelchair for mobility. B. Resident observation and interview On 7/9/26 at 10:38 a.m. Resident #2 was sitting in her wheelchair in her room. There was no halo bar (a circular or oval-shaped mobility device attached to a bed) attached to her bed. Resident #2 said she used to have one halo bar attached to her bed for repositioning during care and transfers. Resident #2 said the facility removed the halo bar from her bed. Resident #2 said prior to the device's removal, she was able to reposition herself independently while in bed. She said she could no longer effectively turn or shift her weight in the bed without staff assistance. Resident#2 said she previously utilized the halo bar to stabilize herself and actively participate during transfers. She said since its removal, she was unable to assist staff during transfers, which increased her reliance on staff. Resident #2 said the removal of the halo bars affected her mobility, and she expressed frustration that the change had restricted her baseline physical capabilities during daily care routines. Resident #2 said no alternative device or method had been provided to assist her with transfers or bed mobility after the halo bar was removed from her bed. C. Record review The comprehensive care plan, initiated 8/29/23, revealed Resident #2 had an ADL self-performance deficit related to impaired mobility, dementia and chronic obstructive pulmonary (COPD). Interventions included Resident #2 required a sit-to-stand lift with assistance from two staff members for transfers to move between surfaces. Review of an undated Assistive Device/Potential Restraint Evaluation revealed Resident #2 had a halo for assistance with participation in bed mobility and repositioning. Resident #2 was alert and oriented times two and required a mechanical lift for mobility, used the device appropriately, and had no adverse outcomes related to its use. The evaluation revealed the less restrictive measure attempted since the last assessment was no halo. The IDT rationale revealed that the resident demonstrated proper use of the device and it assisted with her bed mobility. -However, Resident #2's EMR did not reveal that an evaluation was completed at the time the halo device was removed to determine if the removal would affect the resident's independence and safety and also to determine if an alternative device would be appropriate for assisting the resident with continued participation in her care and transfers. IV. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included type 2 diabetes, acute respiratory failure, obstructive sleep apnea, and morbid obesity. The 7/7/26 MDS staff assessment revealed Resident #12's short-term memory was intact, with the resident recalling information after five minutes. Cognitive skills for daily decision-making reflected modified independence, demonstrating some difficulty only in new situations. Additionally, the evaluation for signs and symptoms of delirium revealed no evidence of acute onset mental status changes from baseline, inattention, disorganized thinking, or altered level of consciousness. She required supervision or touch assistance with transfers, partial/moderate assistance with toileting, and partial/moderate assistance with mobility. B. Resident observation and interview On 7/7/26 at 2:14 p.m. Resident #12 was lying in her recliner in her room. There was no transfer pole in the resident's room. Resident #12 said the facility removed her transfer pole from her room just a few days after it was installed. Resident #12 said using the transfer pole was a specific goal she had set with the physical therapy department to achieve independence when transferring from her bed to her chair. Resident #12 said she was never given the opportunity to use the device before it was removed, and no alternative assistive device was provided to help her reach her goal. Resident #12 said she usually remained in her recliner all the time, including sleeping in the recliner, because she could no longer get into her bed without assistance. Resident #12 said it took too long for staff to respond to her call light when she needed help getting out of bed. C. Record review Review of Resident #12's 3/23/26 Nursing-Physical Restraint/Assistive Device Evaluation revealed that Resident #12's assistive device was a transfer pole to assist with transfer in and out of bed and for bed repositioning. Resident #12's mobility status was contact guard assist with one-person assistance. The evaluation revealed Resident #12 would work with therapy to assist with safety with transfers in and out of bed. The transfer pole was approved and ordered by a physician on 3/23/26 with the resident's approval and the resident's representative's approval on 3/23/26. The IDT rationale revealed the transfer pole was beneficial for the resident. -However, Resident #12's EMR did not include alternative measures that were put in place for the resident to achieve her goal of gaining independence with transfers in and out of bed at the time the transfer pole was removed. D. Staff interviews The physical therapy assistant and the regional therapy manager were interviewed together on 7/9/26 at 10:47 a.m. The physical therapy assistant said she did not remember if assessments were completed for all the residents before the transfer poles and bed halos were removed. The physical therapy assistant said a specific physical therapy goal was established for Resident #12 to achieve independence with bed-to-chair transfers using a transfer pole. The physical therapy assistant said this goal did not materialize because the facility removed the device shortly after installation. She said no alternative assistive device or safety measure was put in place to help Resident #12 achieve her functional goal. The physical therapy assistant said multiple residents across the facility, including Resident #12, had expressed significant frustration and complained regarding the removal of the transfer devices. The NHA and the director of nursing (DON) were interviewed together on 7/9/26 at 12:18 p.m. The NHA said Resident #12 preferred to sleep in her bed but had not inquired about the reason she slept in her recliner. V. Resident #56 A. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included left-sided weakness following a stroke, chronic obstructive pulmonary disease (COPD), generalized muscle weakness, hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. According to the 5/21/26 MDS assessment, Resident #56 was cognitively intact with a BIMS score of 14 out of 15. The MDS assessment identified that Resident #56 was dependent on staff for assistance and required two-person assistance for personal hygiene and transfer from bed to chair. B. Resident observation and interview On 7/8/26 at approximately 2:30 p.m. Resident #56 was lying in bed in her room. There were no halo bars observed on either side of her bed. Resident #56 said the facility removed the halo bars from her bed. Resident #56 said she missed having the halo bars because they helped her move in bed and assisted her with transfers. Resident #56 said she was unhappy the devices had been removed and felt she had lost some of her independence without them. C. Record review The comprehensive care plan, initiated 5/9/25, revealed Resident #56 had an ADL performance deficit related to severe spinal stenosis, left arm hemiparesis, and left elbow pain. Interventions included that Resident #56 required a sit-to-stand lift with assistance from two staff members for transfers between surfaces. Review of an undated Assistive Device/Potential Restraint Evaluation revealed that Resident #56's assistive device was a bed halo, which assisted with the resident's participation and independence with bed positioning and mobility. The resident required a mechanical lift for mobility, used the device appropriately, and had no adverse outcomes related to its use. The evaluation revealed the less restrictive measure attempted since the last assessment was no halo. The IDT rationale revealed that the resident demonstrated proper use of the device and that it assisted with his bed mobility. -However, Resident #56's EMR did not reveal that an evaluation had been completed at the time the resident's halo bars were removed to determine if an alternative device would be effective for assisting the resident with continued mobility. VI. Resident #110 A. Resident status Resident #110, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included acute respiratory failure, Covid-19, chronic congestive heart failure, and generalized muscle weakness with a history of falling. The 4/29/26 MDS assessment revealed Resident #110 was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff assistance with toileting and required substantial to maximum assistance with transfers, mobility and setup assist with personal hygiene. B. Resident observation and interview On 7/9/26 at 11:38 a.m. Resident #110 was sitting in her chair in her room. There was no halo bar attached to her bed. Resident #110 said she previously had one halo bar attached to her bed for repositioning during care and transfers. Resident #110 said the facility removed it from her bed. Resident #110 said prior to the device's removal, she was able to reposition herself independently while in bed. She said now during care, she had nothing to hold on to and had to rely on staff. Resident#110 said she previously utilized the halo bar to stabilize herself and actively participated during transfers. She said since its removal, she was unable to assist staff with transfers, which increased her dependence on staff. Resident #110 said the removal of the halo bars affected her mobility, and she expressed frustration that the change had restricted her baseline physical capabilities during daily care routines. Resident #110 said no alternative device or method had been provided to assist her with transfers or bed mobility after the halo bars were removed from her bed. C. Record review Review of an undated Assistive Device/Potential Restraint Evaluation revealed that Resident #110's assistive device was a bed halo, which assisted with the resident's independence with bed mobility. Resident #110's mobility status was contact guard assist (one person holding for steadying/balance) during a sit-to-stand transfer, with the resident exhibiting noted increased weakness. Resident #110 used the device appropriately and had no adverse outcom

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances.Specifically, the facility failed to effectively address, resolve and document resolutions to residents' concerns regarding long call wait times in a timely manner.Findings include: I. Facility policy and procedure The Grievance policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 7/9/26 at 11:06 a.m. It revealed in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The Grievance Officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary. A resident or family member may voice grievances regarding care and treatment that has been furnished, as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their stay. The Grievance Officer will take steps to resolve the grievance and record information about the grievance and those actions on the grievance form. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow-up. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Officer. 'Prompt efforts' include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances, and will share them only with those who have a need to know. The Grievance Officer, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances. II. Resident group interview Seven residents (#43, #46, #49, #56, #77, #114 and #113) who regularly attended the resident council meetings were interviewed on 7/7/26 at 3:00 p.m. The residents were identified as alert, oriented, and interviewable per the facility's assessment. The group of residents expressed significant ongoing concerns regarding the facility's failure to address and resolve grievances related to extended call light response times. Resident #77 said long call light wait times had been a longstanding, unresolved issue within the facility. Resident #56 said she sometimes waited over an hour for staff to respond to her call light and said these excessive delays occur daily. The remaining residents in the group agree with Resident #77 and Resident #56, saying that long call wait times were a daily problem across all shifts that had continued despite multiple complaints brought to the administration's attention. Resident #43 and Resident #46 said call lights often went unanswered for 45 to 60 minutes, particularly during shift changes and evening hours, leaving them feeling the facility staff was there just to collect a paycheck. Resident #49 and Resident #113 said they often had to wait prolonged periods for urgent personal assistance or toileting needs, resulting in accidents which required more time for the staff to clean. Resident #114 and Resident #77 said that although residents had repeatedly voiced these concerns during resident council meetings and submitted formal grievance forms, the facility had taken no visible action or corrective measures to improve call light response times or resolved the issue. III. Additional resident interviews Resident #70 was interviewed on 7/6/26 at 1:23 p.m. Resident #70 said that staff took about one and a half hours to answer his call light at least three to four days a week. Resident #70 said that yesterday afternoon (7/5/26), he waited over an hour after using his call light to get a drink of water. Resident #70 said that he felt frustrated because there was hardly anybody at the facility to help. Resident #58 was interviewed on 7/6/26 at 3:43 p.m. Resident #58 said that staff took a very long time to answer her call light. Resident #58 said that about two weeks ago, in the morning, she waited about two hours for a CNA to help her change after she became soiled. She said that she felt bad because she had to stay in soiled garments for about two hours while waiting for help. She said that she did not have any skin issues or infections because of the delay. Resident #7 was interviewed on 7/6/26 at 4:00 p.m. Resident #7 said he sometimes waited 45 minutes to two hours after activating his call light for staff to come answer it. Resident #7 said a week ago, in the afternoon, he waited two hours for staff assistance because he needed to be changed. He said he was angry because he sat in soiled clothes/briefs and he was incontinent. He said he filed a grievance form but no one had followed up yet. Resident #100 was interviewed on 7/6/26 at 4:47 p.m. Resident #100 said staff response times to her call light were extremely long. She said when she timed the staff's response a few days prior, it took up to one hour and 14 minutes for an employee to answer her call light. Resident #100 said she sometimes could hear the staff talking in the hallway, yet they would not answer the call light. Resident #121 was interviewed on 7/7/26 at 9:41 a.m. Resident #121 said facility staff took too long to respond to his call light. The resident said when his call light was activated, it could take up to an hour for staff to respond and address his needs. The resident said sometimes the staff would go to his room, turn the call light off, and say they would be right back, but they would never show up or would return 30 minutes to an hour later. IV. Call light audit report The call audit report for Resident #7 was provided by the NHA on 7/9/226 at 11:00 a.m. Review of the call audit report for the period of 7/1/26 through 7/8/26 revealed multiple prolonged call light response times, including response times of 46 minutes and 18 seconds (on 7/1/26), 31 minutes and 32 seconds (on 7/3/26), 29 minutes and 42 seconds (on 7/7/26) and 27 minutes and 8 seconds (on 7/2/26). The report documented the resident had 65 call light activations with an average response time of 13 minutes and 24 seconds (see Resident #7's interview above). V. Additional record review A review of the resident council meeting minutes, dated 2/9/26, revealed group concerns from residents regarding waiting too long for their call lights to be answered and that this has been an ongoing problem for a long time. -There were no written grievances and documentation that indicated the resolutions for the long call light wait times concerns from the February 2026 resident council meeting. A review of the grievance form, dated 6/4/26, revealed Resident #28 had a concern regarding long call light wait times. It documented that the resident waited almost two hours before a staff member answered his call light. Resident #28 was interviewed, the certified nurse aide (CNA) was interviewed, and the facility left a voicemail for the resident's representative. The grievance form documented that two separate call light audits confirmed a call light wait time of one hour and 15 minutes for Resident #28. The facility provided education regarding call lights to all CNAs on 6/4/26, including the CNA who was involved in the grievance. -However, there were no additional residents interviewed when the call light audits for Resident #28 were completed to ensure the call light concern was not widespread. -The facility was unable to provide further documentation to indicate the call light concern was being monitored to ensure residents were not waiting too long for their call lights to be answered. VI. Staff interviews CNA #6 was interviewed on 7/8/26 at 9:35 a.m. CNA #6 said residents had been complaining about waiting too long for staff to answer call lights. CNA #6 said the residents had been complaining about the long call light wait times ever since she had started working at the facility. CNA #6 said she reported the residents' concern to the nurse on duty. CNA #3 was interviewed on 7/8/26 at 9:50 a.m. CNA #3 said the call light system occasionally crashed because it performed updates and would log staff out, which prevented staff from knowing which residents were calling for assistance at the time. CNA #3 said this had happened on the Parkview unit during her shift. CNA #3 said call lights should be answered in less than 10 minutes. CNA #3 said during meal times, it was hard to answer call lights in a timely manner. CNA #3 said residents had complained about long call light wait times, and she said she felt really bad when a resident reported having to wait 30 minutes for a call light response. The NHA was interviewed on 7/9/26 at 5:15 p.m.The NHA said grievances were reviewed daily at the morning meeting and each department head followed up on grievances. The NHA said the grievance official ensured that all grievances were resolved in a timely manner. The NHA said the long call light wait times were unacceptable and did not align with the facility's standard of care. The NHA said to ensure compliance, he would immediately implement mandatory call light responsiveness training for all nursing staff and initiate audits of call light response logs.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen.Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition;-Ensure food items were properly covered, labeled and dated;-Ensure food was thawed according to safe food handling practices; and,-Ensure the dishwasher washed his hands and changed single-use glove use appropriately during meal service.Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 7/14/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. (6-501.12) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11) The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment. (6-501.114)B. Facility policy and procedureThe Sanitation Inspection policy, implemented 12/22/25, was provided by the nursing home administrator (NHA) on 7/9/26 at 9:54 a.m. The policy revealed in pertinent part, All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.C. ObservationsThe initial tour was completed on 7/6/26 at 8:44 a.m., and revealed the following:At 8:55 a.m., the walk-in freezer floor had an accumulation of dark unidentified residue, debris around the storage shelving. Multiple pieces of ice buildup were present on the floor, along with visible food particles and other unidentified debris adjacent to the shelving and beneath shelving. Dark staining and food residue extended across portions of the floor under the shelving, and the floor surfaces were soiled.A second observation of the kitchen was conducted on 7/8/26 at 11:25 a.m. The observations identified the same concerns as identified on 7/6/26 during the initial tour.D. Staff interviewsThe dietary aide was interviewed on 7/8/26 at 3:10 p.m. The dietary aide said all dietary staff were responsible for ensuring the walk-in freezer floor was kept clean and free of food debris, ice buildup, and residue. The dietary aide said if food debris or excessive residue accumulated on the freezer floor, the dietary aide would notify the dietary manager (DM) and clean the floor with a broom. The dietary aide said debris on the freezer floor could create a slipping hazard and allow bacteria to build up and contaminate food.The cook was interviewed on 7/8/26 at 3:34 p.m. The cook said the DM was responsible for ensuring the walk-in freezer floor was maintained in a clean and sanitary condition. The cook said the walk-in freezer should be inspected and cleaned every other dietary aide. The cook said food debris and residue should be removed from the walk-in freezer floor because someone could slip and pests, such as ants, could be attracted.The DM was interviewed on 7/8/26 at 3:54 p.m. The DM said she was responsible for ensuring the walk-in freezer was maintained in a clean and sanitary condition because the DM stocked groceries in the freezer twice a week. The DM said the walk-in freezer was normally monitored and cleaned by removing the floor mat, removing ice buildup, and sweeping the floor. The DM said maintaining a clean walk-in freezer was important for sanitary reasons.II. Failure to properly label, cover, and date food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 7/14/26, read in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location and, where it is not exposed to splash, dust, or other contamination. (3-305.11) Working containers holding food or food ingredients that are removed from their original packages for use in the food establishment shall be identified with the common name of the food. (3-302.12) Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. (3-501.17)B. Facility policy and procedureThe Food Safety Requirements policy, implemented 4/11/25 and revised 5/6/26, was provided by the NHA on 7/9/26 at 9:54 a.m. The policy revealed in pertinent part that food shall be stored in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded, and Keeping foods covered or in tight containers.C. ObservationsThe initial tour was completed on 7/6/26 at 8:44 a.m., and revealed the following:A turkey sandwich stored in a plastic bag was observed in the kitchen refrigerator. The sandwich was unlabeled and did not include a preparation date.An opened package of turkey deli meat in a plastic bag was stored in the refrigerator. The package was unlabeled and did not include a preparation date or open date.A pan of cooked rice was stored in the kitchen refrigerator. The pan was unlabeled and partially covered with plastic wrap, with portions of the rice exposed at the corners where the wrap did not completely cover the pan.Two sheet pans were stored on a rack in the dry storage room. One sheet pan contained four muffins and was covered with plastic wrap; the pan was not labeled and did not include a preparation date. A second sheet pan contained four apple pies that were uncovered, not labeled, and did not include a preparation date.D. Staff interviewsThe dietary aide was interviewed on 7/8/26 at 3:10 p.m. The dietary aide said all dietary staff, especially the staff member who placed the item in the refrigerator, were responsible for labeling, dating, and covering food. The dietary aide said food should be labeled when it was prepared. The dietary aide said the label should include the product name, the date prepared, and the expiration date. The dietary aide said baked foods should also be labeled and covered. The dietary aide said unlabeled food should be discarded because staff would not know when it was prepared. The dietary aide said partially covered food should be discarded and the DM notified because staff would not know how long it had been uncovered. The dietary aide said labeling, covering, and dating food helped prevent residents from being served expired food.The cook was interviewed on 7/8/26 at 3:34 p.m. The cook said the staff member who prepared the food was responsible for labeling, dating, and covering it. The cook said refrigerated food should be labeled with the date and time it was opened and the expiration date. The cook said if food was not labeled, the cook would ask the staff member or the DM when it was opened. The cook said if the date could not be verified, the food should be discarded because they would not know if it was safe to serve. The cook said baked foods should be covered during storage to protect them from flies, hair, and other contaminants. The DM was interviewed on 7/6/26 at 8:53 a.m. The DM said the apple pies were prepared on 7/5/26 around 4:00 p.m. and stored in the dry storage room.The DM was interviewed again on 7/8/26 at 3:54 p.m. The DM said all dietary staff were responsible for labeling, dating, and covering prepared food and opened food items. The DM said labels and markers were available, and staff were reminded daily to label and date food. The DM said unlabeled or undated food should be discarded, and staff would be reminded and educated. The DM said baked goods should be cooled, wrapped, and dated before storage. The DM said labeling and dating identified the food item and helped make sure food was not expired. The DM said plastic wrap, plastic bags, and bakery bags were available to cover food. The DM said the partially covered rice without a label was discarded because staff did not know how long it had been there.III. Failure to thaw food safelyA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 7/14/26. It revealed in pertinent part, Time/temperature control for safety food shall be thawed: under refrigeration that maintains the food temperature or completely submerged under running water. (3-501.13)B. Facility policy and procedureThe Food Safety Requirements policy, implemented 4/11/25 and revised 5/6/26, was provided by the NHA on 7/9/26 at 9:54 a.m. The policy revealed in pertinent part, Thawing - approved methods for thawing frozen foods include thawing in the refrigerator, submerging under cold water, thawing in a microwave oven, or as part of a continuous cooking process. Thawing at room temperature is not acceptable. C. ObservationsThe initial tour was completed on 7/6/26 at 8:44 a.m., and revealed the following:At 8:50 a.m., two pans containing frozen black beans were stacked and submerged in water were in the food preparation sink. -However, the beans were not being thawed under continuous running water.D. Staff interviewsThe dietary aide was interviewed on 7/8/26 at 3:10 p.m. The dietary aide said the cooks and dietary aides were responsible for ensuring frozen food was thawed using an approved method. The dietary aide said the preferred method was to thaw frozen food in the refrigerator overnight. The dietary aide said frozen food could also be thawed by submerging it in a pan of tap water. The dietary aide said thawing food in standing water could cause bacterial growth. The dietary aide said if food was observed thawing in standing water, the cook should be notified.The cook was interviewed on 7/8/26 at 3:34 p.m. The cook said frozen food should be removed from the freezer the day before and thawed in the refrigerator. The cook said if the food remained frozen, it should be thawed under cold running water in the sink. The cook said thawing food in standing water could cause bacterial growth and make the food unsafe to serve. The cook said the cook did not know why the black beans were submerged in standing water instead of under running water.The DM was interviewed on 7/8/26 at 3:54 p.m. The DM said frozen food should be thawed in the refrigerator or under cold running water. The DM said thawing food in standing water was not an approved practice because it could make residents sick and place food in the danger zone. The DM said she monitored staff by observing food handling practices and would correct staff if they did not follow an approved thawing method.IV. Hand hygieneA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 7/14/26. It revealed 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)B. Facility policy and procedureThe Food Safety Requirements policy, implemented 4/11/25 and revised 5/6/26, was provided by the NHA on 7/9/26 at 9:54 a.m. It revealed in pertinent part, Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Staff shall wash hands according to facility procedures, and Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas.C. ObservationsDuring a continuous observation of the lunch meal on 7/8/26, beginning at 11:30 a.m. and ending at 1:18 p.m., the following was observed in the kitchen:At 12:15 p.m.,the dishwasher handled dirty dishes by loading them into the dish machine. While wearing the same gloves, he handled beverage cups, poured lemonade into cups, placed lids on the cups, returned the beverages to resident meal trays, and transferred approximately three completed meal trays from the service line to the meal cart.At 12:26 p.m. the dishwasher closed the dish machine door while wearing the same gloves and then continued handling clean beverage cups and transferring meal trays to the meal cart.At 12:34 p.m. the dishwasher filled a bucket with ice and poured ice into beverage cups while wearing the same gloves.At 12:36 p.m. the dishwasher touched the interior surface of beverage cup lids while placing the lids on beverage cups without changing his gloves or washing his hands.At 12:36 p.m. the dishwasher removed clean cups from the dish machine and placed them on resident meal trays without changing his gloves or performing hand hygiene.At 12:37 p.m. without changing his gloves, the dishwasher rinsed a cup in the sink and filled it with ice and water. He then handled meal trays, placed plate covers on plates, filled additional cups with ice, and transferred the trays to the meal cart.At 12:51 p.m. the dishwasher pushed the meal cart while wearing the same gloves, filled a cup with lemonade, touched the interior surface of a beverage cup lid, and placed the lid on the cup.At 1:00 p.m. the dishwasher opened the dish machine and removed a tray of cups. He then filled a cup with ice and a beverage from the fountain, touched the interior surface of a beverage cup lid, placed the lid on the cup, and handled a meal tray without changing his gloves or performing hand hygiene.At 1:05 p.m. the dishwasher handled dirty dishes by loading them into the dish machine. While wearing the same gloves, he handled clean plate covers, meal trays, tongs, and removed clean dish racks from the dish machine.At 1:07 p.m. the dishwasher emptied trash containing discarded food and debris from dirty dishes while wearing the same gloves.At 1:13 p.m. the dishwasher removed his gloves and handled clean meal trays without washing his hands or putting on a new pair of gloves.At 1:14 p.m. the dishwasher touched a clean metal pan, closed the dish machine door, wiped sweat from his forehead with the back of his wrist, removed a clean rack from the dish machine, placed dirty silverware into the silverware holder, and then handled clean scoops without performing hand hygiene.D. Staff interviewsThe dishwasher was interviewed on 7/8/26 at 2:40 p.m. using an interpreter. The dishwasher said he had worked at the facility as a dishwasher for three weeks. The dishwasher said he should change his gloves after handling dirty dishes and before touching clean dishes, because bacteria from dirty dishes could contaminate clean dishes and make residents sick. The dishwasher said he changed his gloves every time a dish rack was completed and when he switched from loading dirty dishes into the dish machine to removing clean dishes. The dishwasher said he also changed his gloves before placing dishes on resident meal trays.The dietary aide was interviewed on 7/8/26 at 3:10 p.m. The dietary aide said staff should wash their hands with soap and water after handling dirty dishes and before touching clean dishes. The dietary aide said if wearing gloves, staff should remove the gloves, wash their hands, and put on a new pair of gloves before handling clean dishes. The dietary aide said gloves should be changed when switching tasks, after touching other surfaces, after leaving and returning to the kitchen, and after taking out the trash. The dietary aide said hands should be washed when moving from the dirty side to the clean side of the dishwashing area. The dietary aide said staff prevented contamination between dirty and clean dishes by washing their hands, making sure dishes were clean after they came out of the dish machine, and making sure the dish machine reached the correct temperature.The cook was interviewed on 7/8/26 at 3:34 p.m. The cook said gloves should be changed after each task and hands should be washed before putting on a new pair of gloves. The cook said if staff handled dirty dishes and then touched clean dishes without washing their hands or changing gloves, the dishes should be washed again.The DM was interviewed on 7/8/26 at 3:54 p.m. The DM said dirty dishes should remain on the dirty side until they were washed and sanitized before being handled on the clean side. The DM said staff were trained to wash their hands before handling clean dishes, between tasks, and after touching dirty dishes. The DM said staff should perform hand hygiene and change gloves before handling clean dishes.

Based on record review and interviews the facility failed to provide choices for preference of bathing schedule for one (#24) of 10 residents reviewed for self-determination out of 54 sample residents.Specifically, the facility failed to provide Resident #24 with showers according to her preferences.Findings include:I. Facility policy and procedureThe Resident Showers policy, revised 12/4/25, was provided by the nursing home administrator (NHA) on 7/9/26 at 9:54 a.m. It read in pertinent part, Residents will be provided showers as per request or as per facility schedule protocols and based upon resident preferences and safety. II. Resident #24A. Resident statusResident #24, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included morbid obesity (overweight) and irritable bowel syndrome with diarrhea (chronic diarrhea).The 6/16/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. The resident required partial to moderate assistance from staff with tub/shower transfer and bathing and setup and clean-up assistance with personal hygiene and toileting hygiene. The MDS assessment did not reveal the resident refused care.B. Resident interviewResident #24 was interviewed on 7/6/26 at 1:44 p.m. Resident #24 said she had received only one bath per week since last month (June 2026). Resident #24 said she felt frustrated because she wanted two baths per week but had not received her second bath. Resident #24 said she told staff she wanted a second bath, and staff said they did not have enough staff. Resident #24 said the certified nurse aides (CNA) did not have enough time to provide a second bath.Resident #24 was interviewed again on 7/8/26 at 4:58 p.m. Resident #24 said staff had not provided a full-body sponge bath on days she did not receive a scheduled second bath. Resident #24 said the CNAs only cleansed her catheter area with wipes each night.C. Frequent visitor interviewA frequent visitor to the facility was interviewed on 7/8/26 at 1:29 p.m. The frequent visitor said residents had reported that there were a lot of new staff members who provided baths and were not trained well. The frequent visitor said baths were still a concern for residents as of 7/8/26. D. Record reviewThe activities of daily living (ADL) care plan, initiated 9/1/23 and revised 5/18/24, revealed Resident #24 had an ADL self-care performance deficit related to failure to initiate self-care. Pertinent interventions included the resident being dependent on one staff member for bathing, providing a sponge bath when a full bath or shower could not be tolerated, and providing a bed bath as an alternative when the resident did not want to shower.-However, the care plan did not include the resident's preferred shower frequency.Review of the 3/27/26 progress note revealed Resident #24 preferred showers twice a week on Mondays and Fridays.Review of Resident #24's shower records, from 4/1/26 to 7/8/26 revealed the following:Review of shower records for April 2026 revealed Resident #24 received showers on 4/1/26, 4/8/26, 4/15/26, 4/22/26, and 4/29/26.-Resident #24 received five baths out of nine potential bathing opportunities for April 2026.-Additionally, all of the baths documented as given to the resident were documented as given on Wednesdays, which was not the resident's preferred days of Monday and Fridays (see progress note above).Review of shower records for May 2026 revealed Resident #24 received showers on 5/3/26, 5/13/26, 5/17/26, 5/20/26, and 5/26/26.-Resident #24 received five baths out of nine potential bathing opportunities for May 2026.-Additionally, none of the baths documented as given to the resident were documented as given on the resident's preferred days of Monday and Friday (see progress note above).Review of shower records for June 2026 revealed Resident #24 received showers on 6/3/26, 6/5/26, 6/8/26, 6/15/26, 6/21/26, and 6/26/26.-Resident #24 received six baths out of nine potential bathing opportunities for June 2026.-Additionally, two of the six baths documented as given to the resident were documented as given on the resident's preferred days of Monday and Friday (see progress note above).Review of shower records for July 2026, through 7/8/26, revealed Resident #24 received showers on 7/3/26 and 7/8/26.-The resident had received the preferred number of baths through 7/8/26, however, the bath given on 7/8/26 was given on a Wednesday, which was not one of the resident's preferred bathing days.III. Staff interviewsCNA #5 was interviewed on 7/9/26 at 10:10 a.m. CNA #5 said Resident #24 was scheduled to receive showers on Mondays and Fridays. CNA #5 said the CNAs were responsible for ensuring Resident #24 received her scheduled showers. CNA #5 said some scheduled showers were missed because staff did not have enough time. CNA #5 said staff informed the resident they had run out of time, notified the nurse, and attempted to provide the shower the following day.CNA #5 said staff used a shower sheet to identify residents' scheduled shower days and document completed showers. CNA #5 said residents signed a refusal form when they refused a shower, the form was provided to the director of nursing (DON), and staff offered the shower again the following day.CNA #5 said Resident #24 should receive a full-body sponge bath if she did not receive her scheduled shower. CNA #5 said the Kardex (a tool utilized by staff to provide consistent resident care) identified a sponge bath as Resident #24's alternative bathing preference. CNA #5 said Resident #24 did not receive her scheduled shower on Monday, 7/6/26, because staff were busy. CNA #5 said if there was no documented refusal and no documented sponge bath, then Resident #24 did not receive the scheduled bath.Registered nurse (RN) #3 was interviewed on 7/9/26 at 10:25 a.m. RN #3 said when a resident missed a scheduled shower, staff determined why the shower was missed and tried to provide the shower the following day. RN #3 said if staff could not provide the shower the next day, they attempted to provide it on the resident's next scheduled shower day because they did not want residents to miss their baths.RN #3 said CNAs were responsible for ensuring Resident #24's scheduled showers were completed. RN #3 said when a CNA was not available, another CNA would provide the shower while the RN answered the CNA's call lights.RN #3 said she did not always verify scheduled showers were completed, especially on busy days. RN #3 said CNAs notified the nurse when a resident refused a shower. RN #3 said CNAs did not always notify the nurse when they were unable to provide a scheduled shower. RN #3 said if a scheduled shower was missed, staff communicated the missed shower to the oncoming shift.The DON was interviewed on 7/9/26 at 12:43 p.m. The DON said CNAs were responsible for ensuring residents received their scheduled baths. The DON said the facility assigned bath aides; however, when staff called in or a bath aide was unavailable, the responsibility fell to the CNA to ask for assistance if the CNA could not complete the scheduled baths.The DON said bath sheets were the most accurate way to verify residents received their scheduled baths. The DON said the facility maintained a refusal book to track refusals, identify trends, and follow up as needed. The DON said staff provided education when a resident refused a bath, including education about possible consequences, such as developing a rash.The DON said the expectation was for scheduled baths to be completed on the scheduled day. The DON said if a CNA did not have enough time, the CNA notified the nurse, the charge nurse, or unit manager for assistance. The DON said CNAs documented baths on the bath sheet and placed missed baths on the follow-up list for the next day so the resident could receive the bath.The DON said the facility expected residents to receive their scheduled baths unless the resident refused. The DON said a missed scheduled bath without a documented refusal or documented sponge bath did not meet the facility's expectations.

Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for residents on one of three nursing units.Specifically, the facility failed to report an incident of potential neglect to the State Agency when licensed practical nurse (LPN) #8 left the facility for an extended period of time without ensuring adequate supervision of residents and staff.Findings include:I. Facility policy and procedureThe Compliance with Reporting Abuse, Neglect, Exploitation policy, revised 7/10/25, was provided by the nursing home administrator (NHA) on 7/9/26 at 6:17 p.m. It read in pertinent part, Identification: The facility will identify events, occurrences, patterns and trends that may constitute neglect- failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated- the licensed nurse will:-Respond to the needs of the resident and protect him/her from further incident;-Remove the accused employee from other resident cares;-Notify the administrator of designee;-Notify the attending physician, resident's family/legal representative and medical director;-Monitor and document the resident's condition, including response to medical treatment or nursing interventions;-Document actions taken in the medical record;-Complete an incident report if indicated; and,-Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. The administrator or designee will:-Notify the appropriate agencies immediately,as soon as possible, but no later than two hours after the discovery of the incident forming the suspicion;-Obtain statements from direct care staff;-Suspend the accused employee pending completion of the investigation;-Follow up with appropriate agencies, during business hours, to confirm the report was received;-Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service; and,-Within five working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. Employee training: New employees should be educated by the department manager on alleged violations and reporting requirements during initial orientation. Annual education and training is provided to all existing employees. Front line supervisors can provide education as situations arise.II. Record reviewA document titled Incident Detail Report was provided by the local police department on 7/8/26 at 9:13 a.m. It documented a welfare check on LPN #8 was completed at the facility on 6/6/26 at 2:46 a.m. It documented a report of LPN #8 being passed out in his vehicle and staff had not seen him since 12:30 a.m. (more than two hours earlier). The report documented a conclusion finding that LPN #8 fell asleep while on his lunch break and there were no signs of impairment.III. Staff interviewsThe infection preventionist (IP) was interviewed on 7/8/26 at 3:37 p.m. The IP said he was on-call for the facility on 6/6/26. The IP said LPN #10 called him and reported that LPN #8 was sleeping in his car and the staff were unable to wake him up. The IP said he instructed the nurse to call emergency medical services (EMS) because staff could not wake LPN #8. The IP said he was on the phone with LPN #10 when the police arrived and conducted a sobriety test of LPN #8. The IP said he called the NHA prior to the arrival of police at the facility to let the NHA know that LPN #8 had been reported asleep in his car. The IP said he did not interview LPN #10 after the incident and he did not know how long LPN #8 had been out of the facility and away from his supervisory duties for residents and staff on his assigned unit when the police arrived.LPN #8 was interviewed on 7/8/26 at 5:57 p.m. LPN #8 said he thought he took his lunch break on 6/6/26 at about 1:00 a.m. LPN #8 said he thought he told another nurse, registered nurse (RN) #5, that he was leaving for his break. LPN #8 said he usually took a 30-minute lunch break. LPN #8 said he did not think he missed any resident care while he was out of the facility. LPN #10 was interviewed on 7/9/26 at 3:57 p.m. LPN #10 said she was working on the night of 6/5/26 into 6/6/26. LPN #10 said shortly after midnight, a medication delivery arrived from the pharmacy. She said the delivery person needed to check in the medications with LPN #8. She said the delivery person went to LPN #8's assigned unit and waited for approximately 30 minutes for LPN #8 to arrive. LPN #10 said the CNAs on LPN #8's assigned unit went out to LPN #8's vehicle. LPN #10 said the CNAs returned and said they observed LPN #8 punching the roof of his vehicle. LPN #10 said when LPN #8 had not returned to his assigned unit, she checked in the medications for LPN #8 and she brought the medications to her assigned cart. LPN #10 said multiple residents on LPN #8's assigned unit asked for pain medications while LPN #8 was gone and she was told by a CNA that a resident had been asking for a colostomy bag change since 9:00 p.m. LPN #10 said she addressed the colostomy bag issue when LPN #8 did not return. LPN #10 said she called the police at about 2:30 a.m. because the CNAs were unable to wake LPN #8 and he was slumped over in his vehicle. LPN #10 said when the police arrived she observed them banging on the vehicle's glass and shining a bright light on LPN #8 and he did not wake. She said LPN #8 finally woke up and the police performed a sobriety test with LPN #8. LPN #10 said LPN #8 was cleared to work following the sobriety test and the on-call administrator at the facility allowed him to return to his duties. LPN #10 said no one from the facility reached out to ask her questions about the incident. LPN #10 said she did not think LPN #8 ever told another nurse that he was going on a break. LPN #10 said RN #5 (whom LPN #8 said was covering his residents - see above) was not at the facility when LPN #8 took this break.The IP and the NHA were interviewed together on 7/9/26 at 4:48 p.m. The IP said he was unaware that LPN #8 had been gone from the facility for two and a half hours when the police arrived on 6/6/26. The IP said LPN #10 had reported that staff were unable to wake LPN #8 when he was sleeping in his car. The IP said he did not remember if LPN #10 said how long LPN #8 had been away from his assigned unit.The NHA said the facility did not do a formal investigation for neglect. The NHA said both he and the IP assumed LPN #8 was on his lunch break. The NHA said they were concerned that LPN #8 might be impaired until the police performed a sobriety test for LPN #8. The NHA said he could have interviewed LPN #10 to find out how long LPN #8 was away from his assigned unit and about any resident care that might have been missed. The NHA said he would report and investigate the incident for neglect (during the survey).Cross reference F610 for failure to investigate/prevent/correct an alleged violation.The NHA was interviewed a second time on 7/9/26 at 6:00 p.m. The NHA said he had reported the 6/6/26 alleged neglect incident involving LPN #8 to the State Agency within the past hour (during the survey).

Based on record review and interviews, the facility failed to thoroughly and timely investigate neglect of residents on one of three nursing units.Specifically, the facility failed to investigate whether residents and staff had received adequate supervision by licensed practical nurse (LPN) #8 when LPN #8 left the facility for an extended period of time.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy was provided by the nursing home administrator (NHA) on 7/9/26 at 6:19 p.m. It read in pertinent part, Employee Training: New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. Existing staff will receive annual education through planned in-services and as needed. Training topics will include: prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation; identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; and understanding behavioral symptoms of residents that may increase the risk of abuse and neglect. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include:-Identifying staff responsible for the investigation;-Exercising caution in handling evidence that could be used in a criminal investigation (not tampering or destroying evidence);-Investigating different types of alleged violations;-Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;-Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; and,-Providing complete and thorough documentation of the investigation.II. Record reviewA document titled Incident Detail Report was provided by the local police department on 7/8/26 at 9:13 a.m. It documented a welfare check on LPN #8 was completed at the facility on 6/6/26 at 2:46 a.m. It documented a report of LPN #8 being passed out in his vehicle and staff had not seen him since 12:30 a.m. (more than two hours earlier). The report documented a conclusion finding that LPN #8 fell asleep while on his lunch break and there were no signs of impairment.III. Staff interviewsThe infection preventionist (IP) was interviewed on 7/8/26 at 3:37 p.m. The IP said he was on-call for the facility on 6/6/26. The IP said LPN #10 called him and reported that LPN #8 was sleeping in his car and the staff were unable to wake him up. The IP said he instructed the nurse to call emergency medical services (EMS) because staff could not wake LPN #8. The IP said he was on the phone with LPN #10 when the police arrived and conducted a sobriety test of LPN #8. The IP said he called the NHA prior to the arrival of police at the facility to let the NHA know that LPN #8 had been reported asleep in his car. The IP said LPN #8 had worked at the facility for a few months and he did not know LPN #8 well. The IP said he did not interview LPN #10 after the incident and he did not know how long LPN #8 had been out of the facility and away from his supervisory duties for residents and staff on his assigned unit when the police arrived.LPN #8 was interviewed on 7/8/26 at 5:57 p.m. LPN #8 said he thought he took his lunch break on 6/6/26 at about 1:00 a.m. LPN #8 said he thought he told another nurse, registered nurse (RN) #5, that he was leaving for his break. LPN #8 said he usually took a 30-minute lunch break. LPN #8 said he did not think he missed any resident care while he was out of the facility. -However, record review and an interview revealed certified nurse aides (CNA) on LPN #8's assigned unit tried to locate LPN #8 and LPN #8 had left his assigned unit at 12:30 a.m., and the police did not arrive at LPN #8's vehicle until 2:46 a.m., a timeframe of over two hours.LPN #10 was interviewed on 7/9/26 at 3:57 p.m. LPN #10 said she was working on the night of 6/5/26 into 6/6/26. LPN #10 said shortly after midnight, a medication delivery arrived from the pharmacy. She said the delivery person needed to check in the medications with LPN #8. She said the delivery person went to LPN #8's assigned unit and waited for approximately 30 minutes for LPN #8 to arrive. LPN #10 said the CNAs on LPN #8's assigned unit went out to LPN #8's vehicle. LPN #10 said the CNAs returned and said they observed LPN #8 punching the roof of his vehicle. LPN #10 said when LPN #8 had not returned to his assigned unit, she checked in the medications for LPN #8 and she brought the medications to her assigned cart. LPN #10 said multiple residents on LPN #8's assigned unit asked for pain medications while LPN #8 was gone and she was told a resident had been asking for a colostomy bag change since 9:00 p.m. LPN #10 said she addressed the colostomy bag issue when LPN #8 did not return. LPN #10 said she called the police at about 2:30 a.m. because the CNAs were unable to wake LPN #8 and he was slumped over in his vehicle. LPN #10 said when the police arrived she observed them banging on the vehicle's glass and shining a bright light on LPN #8 and he did not wake up. She said LPN #8 finally woke up and the police performed a sobriety test with LPN #8. LPN #10 said LPN #8 was cleared to work following the sobriety test and the on-call administrator at the facility allowed LPN #8 to return to his duties. LPN #10 said no one from the facility reached out to ask her questions about the incident. LPN #10 said she did not think LPN #8 ever told another nurse that he was going on a break. LPN #10 said RN #5 (whom LPN #8 said was covering his residents - see above) was not at the facility when LPN #8 took this break.The IP and the NHA were interviewed together on 7/9/26 at 4:48 p.m. The IP said he was unaware that LPN #8 had been gone from the facility for two and a half hours when the police arrived on 6/6/26. The IP said LPN #10 had reported that staff were unable to wake LPN #8 when he was sleeping in his car. The IP said he did not remember if LPN #10 told him how long LPN #8 had been away from his assigned unit.The NHA said the facility did not do a formal investigation of the incident involving LPN #8 for neglect. The NHA said both he and the the IP assumed LPN #8 was on his lunch break. The NHA said they were concerned that LPN #8 might be impaired until the police performed a sobriety test for LPN #8. The NHA said he could have interviewed LPN #10 to find out how long LPN #8 was away from his assigned unit and about any resident care that might have been missed. The NHA said he would report and investigate the incident for neglect (during the survey).Cross reference F609 for failure to report an alleged violation.The NHA was interviewed a second time on 7/9/26 at 6:00 p.m. The NHA said RN #5 was not scheduled on 6/5/26 after 10:00 p.m.The NHA said he thought LPN #8 said RN #5 was covering for him when LPN #8 was asked during an interview because LPN #8 was nervous. The NHA did not identify a nursing staff member who was covering for LPN #8 when he left the facility for two and a half hours.

Based on observations, record review and interviews, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice for one (#46) of two residents out of 54 sample residents.Specifically, the facility failed to maintain, clean, sanitize and properly store Resident #46's nebulizer machine (breathing treatment device) and mask.Findings include:I. Facility policy and procedure The Continuous Positive Airway Pressure (CPAP)/Bi-level Positive Airway Pressure (BiPAP) Cleaning policy, dated 5/1/2026, was provided by the nursing home administrator (NHA) on 7/9/26 at 9:54 a.m. It read in pertinent part, It is the policy of this facility to clean CPAP/BiPAP (a type of non-invasive ventilation that helps people breathe by providing pressurized air through a mask or nasal plugs) equipment in accordance with current CDC (Center For Disease Control and Prevention) guidelines and manufacturer's recommendations in order to prevent the occurrence or spread of infection.II. Resident #46A. Resident statusResident #46, age [AGE], was admitted on [DATE], discharged on 5/28/26 and readmitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (sudden breathing failure with low oxygen) and shortness of breath.The 4/28/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status(BIMS) score of 13 out of 15. The resident required partial to moderate assistance from staff with personal hygiene and was independent with oral hygiene.The MDS assessment did not indicate that the resident used oxygen therapy.B. Resident interview and observationsResident #46 was interviewed on 7/7/26 at 9:55 a.m. Resident #46 said staff did not clean her nebulizer mask as often as they should. Resident #46 said that during her stay in the facility, staff had cleaned the nebulizer mask only twice.Resident #46's nebulizer mask, connected to the tubing, was observed on a paper towel on the nightstand. The inside of the nebulizer mask had visible yellow residue.On 7/8/26 at 10:40 a.m. Resident #46's nebulizer mask was observed in the same condition as the previous observation, with visible yellow residue remaining inside the mask. Resident #46 said she received nebulizer treatments twice daily, with the first treatment administered after breakfast and the second treatment administered after dinner.C. Record reviewA review of Resident #46's July 2026 CPO revealed the following physician's order:Ipratropium-Albuterol Solution (0.5 milligrams (mg) -2.5 mg/3 milliliters (ml), 3 ml inhale orally via nebulizer every six hours as needed for wheezing or shortness of breath, ordered on 6/5/26.-However, there were no physician's orders for cleaning, sanitizing, or storing the nebulizer equipment.Resident #46's respiratory care plan, initiated 12/3/25, revealed Resident #46 had emphysema. Pertinent interventions included giving medications as ordered, giving nebulizer treatments and oxygen therapy as ordered, monitoring for signs and symptoms of respiratory distress, encouraging fluid intake to help liquefy secretions, and encouraging prompt treatment of respiratory infections.-The care plan failed to include interventions related to cleaning, sanitizing, or storing the resident's nebulizer equipment.III. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 7/9/26 at 2:13 p.m. CNA #6 said nurses were responsible for administering nebulizer treatments to residents and cleaning the nebulizer equipment after each use. CNA #6 said she did not know the appropriate storage location for nebulizer equipment. CNA #6 said if she observed residue inside a nebulizer mask, she would notify the nurse. CNA #6 said nebulizer masks should be cleaned after use to reduce the risk of infection.Licensed practical nurse (LPN) #1 was interviewed on 7/9/26 at 2:36 p.m. LPN #1 said nurses were responsible for cleaning and sanitizing residents' nebulizer equipment. LPN #1 said after each treatment, the nebulizer mask should be rinsed with warm water, placed on a paper towel to air dry, and stored on the nightstand near the nebulizer machine. LPN #1 said the nebulizer mask should be cleaned after each use to reduce bacterial growth and prevent infection. LPN #1 said nebulizer masks should be replaced monthly and staff were expected to monitor the cleanliness of the equipment. LPN #1 said she was not aware Resident #46's nebulizer mask had residue buildup inside. LPN #1 said Resident #46 should have physician's orders for cleaning of the nebulizer equipment.The director of nursing (DON) was interviewed on 7/9/26 at 2:46 p.m. The DON said nebulizer equipment should be cleaned after each use by rinsing it with water and allowing it to air dry. The DON said nebulizer masks should be cleaned after each use for infection prevention because moisture could accumulate in the equipment. The DON said staff received training on nebulizer equipment maintenance and infection prevention during orientation as part of the new hire training. The DON said nurses were expected to clean the nebulizer equipment as part of standard practice and she would prefer to have physician's orders for cleaning the equipment.

Based on record review and interviews, the facility failed to notify a resident's representative of changes in medication for one (#6) of seven residents out of 11 sample residents.Specifically, the facility failed to notify Resident #6's representative when the resident's donepezil (medication used to manage cognitive symptoms) was discontinued.Findings include:I. Facility policy and procedureThe Resident Change of Condition/Status policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 4/21/26 at 5:12 p.m. The policy read in pertinent part, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include circumstances that require a need to alter treatment. This may include new treatment or discontinuation of current treatment. Competent individuals: the facility must still contact the resident's physician and notify the resident's representative, if known. A family that wishes to be informed would designate a member to receive calls, when a resident is mentally competent, such as a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.II. Resident #6A. Resident statusResident #6, age [AGE], was admitted on [DATE] and discharged to the hospital on 3/30/26. According to the March 2026 computerized physician's orders (CPO), diagnoses included dementia in other diseases classified elsewhere, mild, frontal lobe and executive function deficit. The 2/11/26 minimum data set (MDS) assessment revealed Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was dependent on staff for assistance with her activities of daily living (ADL). B. Resident's representative interviewResident #6's representative was interviewed on 4/20/26 at 4:48 p.m. Resident #6's representative said Resident #6 had been on donepezil for her dementia and she was taken off this medication without any discussion with her (the representative). The representative said she was not contacted by the facility prior to the medication being discontinued and she was very upset when she was advised of the discontinuation two months after it was discontinued.C. Record reviewThe pharmacist note, dated 10/30/25, recommended to de-prescribe the donepezil as the medication did not modify disease and there was no current data to show efficacy but there were many unwanted side effects associated with the use. The pharmacist recommended discontinuing the medication. This recommendation was signed by the physician on 12/22/25.The physician's orders documented Resident #6's donepezil HCL 5 mg (milligrams) was discontinued on 1/7/26 at 1:30 p.m. by the physician. -Review of Resident #6's electronic medical record (EMR) did not reveal documentation to indicate that the facility communicated with Resident #6 or Resident #6's representative regarding the pharmacist's recommendation to discontinue the medication or about the actual discontinuation of the medication. The physician's progress note, dated 3/27/26, documented the physician notified Resident #6's representative that Resident #6 had been taken off the donepezil per the pharmacist's request, on 1/7/26, which was upsetting to the resident's representative. The physician apologized to Resident #6's representative for the representative not being notified of this change. After further discussion between the physician and Resident #6's representative, the resident was not restarted on the medication. III. Staff interviewsThe director of nursing (DON) and the chief nursing officer were interviewed together on 4/21/26 at 9:10 a.m. The DON said if a resident had the cognitive capacity to understand medication changes, the resident should be notified of any changes and the resident's representative would be notified per the resident's request. The DON said if the resident lacked cognitive capacity, the staff should be discussing medication changes with the resident's representative.The DON was interviewed again on 4/21/26 at 10:55 a.m. The DON said Resident #6's donepezil was discontinued on 1/7/26 per the physician's order and the pharmacist's recommendation. She said Resident #6's representative was not notified at the time of the medication's discontinuation.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet order of level six soft and bite-sized texture as indicated on their meal tray cards. Findings include: I. Professional reference The International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (a tool to standardize mechanically altered diets and liquids) (January 2019), was retrieved on 5/21/24, from https://iddsi.org/Resources/Patient-Handouts read in pertinent part, Level six soft and bite-sized, for safety avoid these food textures that pose a choking risk for adults who need level six soft and bite-sized food: -Bread (no regular dry bread, sandwiches or toast of any kind). Use IDDSI level five minced and moist sandwich recipe to prepare bread; use pre-gelled 'soaked' breads that are very moist and gelled through the entire thickness; -Food with skins or outer shell foods with husks such as peas, grapes, chicken skin, salmon skin, and sausage skin. II. Record review The diet spreadsheet for level six (soft and bite-size) mechanically altered diets was provided by the consulting registered dietitian (CRD) on 5/15/24 at 4:30 p.m. The soft and bite-size texture spreadsheet documented the following modifications for menu items served during the lunch meal on 5/15/24: -The green peas were to be omitted and sliced cooked carrots served instead; and, -The wheat dinner roll was to be omitted and a slice of puree bread produced from a commercially prepared mix was to be served instead. -The facility failed to ensure the residents who were prescribed a soft and bite-size mechanically altered diet received foods that were altered to the correct texture for the lunch meal on 5/15/24. -Residents prescribed the level six soft and bite-size diet were served a regular wheat roll for lunch and green peas. III. Meal service observation and staff interviews During a continuous observation of the lunch meal service on 5/15/24, beginning at 11:30 a.m. and ending at 12:55 p.m., the following was observed: The posted menu in the dining room documented the lunch meal consisted of baked chicken, peas, baked potatoes, wheat roll, and fruit crisp. -According to the diet spreadsheets (see above), the level six soft and bite-size restricted regular wheat rolls and peas. The diet spreadsheets indicated a sliced puree bread made with a commercial mix and cooked sliced carrots were to be served instead of a regular wheat roll and peas. At 11:45 a.m. service for the lunch meal began. Between 11:30 a.m. and 12:15 p.m., nine meal plates were assembled and delivered to residents who were prescribed a level six soft and bite-size mechanically altered diet. -The nine plates included a regular roll and peas instead of the puree bread slice and cooked sliced carrots. -At 12:00 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; -At 12:01 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; -At 12:15 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; -At 12:16 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; -At 12:18 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; and, -At 12:22 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll. The dietary manager (DM) was interviewed on 5/15/24 at 12:23 p.m. during the lunch meal. The DM said the facility served a regular wheat roll and peas to the residents who were prescribed a soft and bite size texture and had done so in the past. The DM said recipes and menu spreadsheets for the level six soft and bite size texture were in the kitchen and kept in binders. At 12:24 p.m. the DM reviewed the recipes for wheat rolls and peas in the binders in the kitchen. -Neither the recipe for the peas or the wheat roll listed a modification for mechanically altered diets on the recipe. -The DM did not review a diet spreadsheet (see above) after reviewing the wheat roll and pea recipes and dietary staff continued to serve residents prescribed the soft and bite-size texture diet a regular wheat roll and peas. -At 12:26 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; -At 12:44 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll; and, -At 12:46 p.m. a soft and bite-size plate was served that included peas and a regular wheat roll. The DM was interviewed again on 5/15/24 at 12:50 p.m., during the lunch meal service. The DM said the facility had not yet switched to using a commercially prepared puree bread mix to offer at meals. The DM said the puree mix was for residents on the level five mince and moist texture diet and not the level six soft and bite-size texture diet. IV. Additional staff interviews The DM was interviewed a third time on 5/16/24 at 9:00 a.m. The DM said the facility had offered the IDDSI diet textures for approximately a year. The DM said the diet spreadsheets were in the kitchen for the lunch meal served on 5/15/24, however, she said cook (CK) #2 did not refer to the spreadsheet to prepare the modified textures. She said the cooks tried to use the spreadsheets as much as possible. The DM said she was concerned the residents would not like the commercially prepared puree bread mix. The DM said the facility had been offering regular rolls to residents on the level six soft and bite-sized mechanically altered diet, however, the DM said she had scheduled an inservice for the following week to begin using the puree bread mix. The DM said she started a plan and put together staff education because further training was needed for the dietary staff on mechanically altered diet production. -The DM initiated the date for the inservice and the action plan during the survey. The registered dietitian (RD) was interviewed on 5/16/24 at 9:00 a.m. The RD said she audited the diets in the residents' electronic medical records (EMR) to ensure the prescribed diets matched what was on the residents' meal tickets. The RD said there had been no recent changes to many of the residents' diet orders. Dietary aide (DA) #2 was interviewed on 5/16/24 at 10:20 a.m. DA #2 said she did not cook but helped assemble and plate residents' meals. DA #2 said she knew the diet spreadsheets were located in the binders in the kitchen. DA #2 said the diet spreadsheets used to be posted near the back preperation table but were no longer posted so she asked the cooks which diet modifications were to be served during meals. The executive chef (EC) was interviewed on 5/16/24 at 10:30 a.m. The EC said he was not fully trained on how to use the diet spreadsheets and had not used the spreadsheets previously to prepare the mechanically altered diets. The EC said the modifications on the spreadsheets were to help reduce the risk of choking and swallowing issues for the residents. V. Facility follow up The quality mentor (QM) provided additional information on 5/18/24 (after the survey) at 9:00 a.m. An action plan with an identified concern of following portions, extensions and diets was identified and created on 5/15/24 (during the survey). The plan included for staff to follow portion sizes, diet extensions and changes as listed on the diet spreadsheets with bimonthly meal observations to occur.

Based on observations, interventions and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically the facility failed to: -Ensure the high temperature dish washing machine functioned at the proper temperatures for one of two facility dish washing machines; -Ensure, for a high temperature dish washing machine, an irreversible registering surface temperature indicator (test strip) was present at the facility and readily accessible for measuring the utensil surface temperature; and -Ensure staff performed proper hand hygiene while plating and serving resident meals. Findings include: I. High temperature dish washing machine not at proper temperature and failure to monitor with an irreversible registering temperature indicator (test strip) A. Professional reference The Colorado Retail Food Regulations, ([DATE]), retrieved on [DATE] from https://cdphe.colorado.gov/environment/food-regulations, read in pertinent part, A warewashing machine and its auxiliary components shall be operated in accordance with the machine's data plate (label) and other manufacturer's instructions. The temperature of the hot water sanitizing rinse as it enters the manifold (dish washing compartment) may not be less than 180 degrees fahrenheit (F). In hot water mechanical warewashing operations, an irreversible registering temperature indicator (test strip) shall be provided and readily accessible for measuring the utensil surface temperature. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: Hot water mechanical operations by being cycled through equipment achieving a utensil surface temperature of 160 degrees fahrenheit (F) as measured by an irreversible registering temperature indicator; chemical, manual or mechanical operations, including the application of sanitizing chemicals by immersion with a contact time of at least 10 seconds for a chlorine solution. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified under sanitizers, criteria, shall be used in accordance with the EPA- registered label use instructions, and shall be used as follows: a chlorine solution shall have a minimum temperature based on the concentration and ph of the solution as listed in the following chart concentration range (mg/l). Mg/L means milligrams per liter, which is the metric equivalent of parts per million (ppm). B. Observations and interviews On [DATE] the following observations were made in main kitchen: At 9:15 a.m. the high temperature dish machine completed a dish washing and rinse cycle in the main kitchen. The label on the dish machine front panel listed these instructions: The rinse temperature should be 180 degrees F for a minimum of 10 seconds. -However, the dish machine gauges showed the rinse temperature was 170 degrees F. At 9:18 a.m. the high temperature dish machine completed another dish washing and rinse cycle. The dish machine gauges showed the rinse temperature was 172 degrees F. At 9:20 a.m. the [DATE] high temperature dish machine log was reviewed. The log instructions documented the wash and rinse cycle temperatures for the high temperature dish machine were to be recorded once during each meal period and the rinse temperature requirement was 180 degrees F. -However, observations of the high temperature dish machine gauge failed to show the rinse temperature reached 180 degrees F to adequately sanitize the dishes in the dish machine. The [DATE] dish machine log also failed to show documentation the rinse cycle reached 180 degrees F for the first 12 days or list any corrective actions. The facility also failed to have back up temperature indicator strips to monitor that the surface temperature of dishes in the machine reached 160 degrees F. Dietary aide (DA) #1, who was washing dishes during the observation of the dish machine, was interviewed on [DATE] at 9:20 a.m. DA #1 said the proper rinse temperature for the dish machine needed to be between 170 degrees and 180 degrees F to sanitize the dishes (However, the dish machine needed to reach 180 degrees F to properly sanitize the dishes using heat). DA #1 said if the dish machine was not operating at the correct rinse temperature a staff member should inform the dietary manager (DM). DA #1 said she was not aware the operating instructions for the dish machine were on the dish machine's label. The DM was interviewed on [DATE] at 9:25 a.m. The DM said the dish machine rinse temperatures should be between 170 degrees and 180 degrees F (However, the dish machine needed to reach 180 degrees F to properly sanitize the dishes using heat). The DM said the dish machine was connected to a chemical sanitizer to sanitize the dishes. The DM said she would tell the nursing home administrator (NHA) if the dish machine rinse temperature was not reaching the minimum temperature. The DM said she did not have any temperature indicator strips to measure the surface temperature of the utensils and dishes inside the dish machine. The DM said she was unable to determine if the dishes washed on [DATE] were sanitized. The DM said she was unaware that the label on the dish machine front panel provided operating instructions. -The chemical connected to the dish machine was not a chemical sanitizer but a rinse aid which expedited the dishes drying and did not function as a sanitizing agent. The DM was interviewed again on [DATE] at 10:10 a.m. The DM said the facility placed a call to their contracted kitchen repair vendor to check the dish machine. The DM said the facility would utilize paper products for lunch. The contracted kitchen repair vendor was interviewed on [DATE] at 10:55 a.m. The vendor said he tested the high temperature dish machine in the main kitchen. The vendor said he used temperature indicator strips and the strips showed dishes in the dish machine reached the required 160 degrees F during three separate cycles. The vendor said he left temperature indicator strips with the dietary manager and instructed the dietary staff to run temperature indicator strips through the dish machine once every eight dish washing cycles. He said the dish machine would also be connected to a chemical sanitizer should the rinse cycle not meet the minimum temperature of 180 degrees F. The DM was interviewed again at 5:00 p.m. The DM said the dish machine worked properly throughout the day after the kitchen repair vendor checked the machine and washed the dishes. The DM said she used the temperature indicator strips as instructed by the kitchen repair vendor to monitor the surface temperature of the dishes and the indicator strips turned black, which meant the surface temperature of the dishes in the machine reached the minimum requirement of 160 degrees F. The DM said she found registering temperature indicator strips in her desk previously and did not know what the strips were for and had never used them. The DM said a chemical sanitizer was also now connected to the dish machine. At 5:05 p.m. additional cycles of the high temperature dish washing machine were observed. The dish machine ran for six cycles and temperature indicator strips and chemical sanitizing strips were used to test the sanitation levels in the dish machine. The first two dish machine cycles operated with a temperature indicator strip on a dish in the machine. The temperature gauge on the gauge showed a maximum rinse cycle temperature of 166 degrees F during both cycles. The temperature indicator strips on the dish inside the machine did not indicate the dishes had reached a minimum 160 degrees F surface temperature. The DM used a chlorine sanitizer test strip at the end of the rinse cycle to test the strength of the chemical sanitizer solution in the dish machine. The test strip read 10 parts per million (ppm) instead of the minimum of 50 ppm. A temperature indicator strip was placed on a different dish in the machine and the dish machine ran for two more cycles. The temperature gauge at the end of each cycle showed a maximum rinse temperature of 170 degrees F. The temperature indicator strips on the dish inside the machine did not indicate the dish had reached a minimum 160 degrees F surface temperature. The DM used a new chlorine sanitizer test strip at the end of the rinse cycle to test the strength of the chemical sanitizer solution in the dish machine. The test strip read 10 ppm instead of the minimum of 50 ppm. A temperature indicator strip was placed on a different dish in the machine and the dish machine ran for a total of two more cycles. The temperature gauge at the end of each cycle showed a maximum rinse temperature of 172 degrees F. The temperature indicator strips on the dish inside the machine did not turn black to indicate the dish had reached a minimum 160 degrees F surface temperature. The DM used a new chlorine sanitizer test strip at the end of the rinse cycle to test the strength of the chemical sanitizer solution. The test strip read 10 ppm instead of the minimum of 50 ppm. The NHA was notified at 5:30 p.m. the dish machine did not reach the minimum internal rinse temperature and the temperature indicator strips did not show the surface temperature of dishes in the machine reached a minimum of 160 degrees F and the chemical sanitizer test strips did not reach 50 ppm. -The NHA said the facility would utilize paper products for resident meals going forward and rewash any dishes that needed to be sanitized in the dish machine in the rehabilitation unit dishwasher. The NHA and the environmental services director (ESD) were interviewed on [DATE] at 9:30 a.m. The ESD said the facility called the kitchen repair vendor who came to the facility again on [DATE]. The ESD said the kitchen repair vendor instructed the staff to test the sanitizer concentration in the dish machine. The ESD said the staff needed to use the test strip in pooled water in a utensil for a correct reading. The ESD said the facility would continue to test the chemical sanitizer concentration for 24 hours and ensure the sanitizer was at the correct concentration prior to transitioning back to reusable dishes for residents' meal service. The NHA said the facility would use paper products for the next 24 hours while continuing to monitor the dish machine in the main kitchen for proper sanitization prior to transitioning back to china. The NHA said dietary staff were provided additional education on how to test the dish machine to ensure it was sanitizing properly (see facility follow up). C. Record review The dishwashing machine temperature logs were reviewed from [DATE] to [DATE]. The log listed the rinse temperature requirement for the dish machine was 180 degrees F and wash and rinse temperatures were to be recorded once each meal. Any temperatures outside of the acceptable range should be reported to a supervisor or maintenance person immediately. The logs revealed the following: -In [DATE] the rinse temperature was recorded as being below 180 degrees F for 21 meals. -In [DATE] the rinse temperature was recorded as being below 180 degrees F for 53 meals, and no temperatures were recorded for 25 meals. -In February 2024 the rinse temperature was recorded as being below 180 degrees F every meal. -In [DATE] the rinse temperature was recorded as being below 180 degrees F every dinner meal and at three lunch meals -In [DATE] the rinse temperature was recorded as being below 180 degrees F every breakfast meal and four dinner meals. -The dish machine temperature logs documented the dish machine rinse temperature as below the recommended 180 degrees F and failed to list a corrective action for rinse temperatures below 180 degrees F. D. Staff interviews The DM was interviewed on [DATE] at 9:00 a.m. The DM said she did not think staff knew during the dishwashing cycle when to check the rinse temperature. The DM said she was not aware if staff had previously reported the incorrect dish machine temperatures to anyone in the facility. The DM said she had long term dietary staff and those staff members assisted training the new staff how to wash dishes and monitor the dish machine temperatures. The DM said all dietary staff washed dishes in the dish machine except for the cooks. The DM said she had not yet followed up the training staff (during the survey) since the issue with the dish machine was identified. The DM said she was not aware of the dish machine instructions on the label prior to the survey, but she began showing the staff the label (during the survey) and planned to incorporate the label instructions as part of staff training on the dish machine. The DM said staff were now to notify her, the chef, the ESD, or the administrator if the dish machine was not working correctly. The DM said she planned to change how she monitored the functionality of the dish machine and how the staff monitored the dish machine temperatures, and would check the dish machine every morning to verify staff monitored and recorded the sanitizer ppm properly and require that staff demonstrate how to monitor the sanitizer ppm. The consulting registered dietitian (CRD) was interviewed on [DATE] at 9:10 a.m. The CRD said the gauge on the dish machine had been replaced (during the survey) and the booster heater for the dish machine was faulty so the facility would continue with a chemical sanitizer for the dish machine. Dietary aide (DA) #2 was interviewed on [DATE] at 10:20 a.m. DA #2 said the dish machine in the kitchen had been adjusted (during the survey) to be used with a chemical sanitizer instead of high temperature sanitizing. She said she used the machine to wash dishes on occasion and the temperature for rinse sanitizing should be 180 degrees and temperature indicator strips could be used to test the temperature during the rinse cycle. She said if the dish machine temperatures were below the minimum standard she would stop washing dishes and tell a supervisor immediately. She said she had not identified any temperature issues with the dish machine prior to the survey. E. Facility follow up The quality mentor (QM) provided additional information on [DATE] (after the survey) at 9:00 a.m. A kitchen education was provided to the dietary staff on [DATE] at 6:30 p.m. by the NHA. The inservice provided instructions (below) on how to test the chemical sanitizer concentration of the dish machine and corrective action. The dish machine sanitizes by using correct sanitizer measured with sanitizing test strips. Sanitizing strips should measure 50 ppm for proper sanitizing of dishes and utensils. If the strip did not turn the correct color, measure using another test strip. Make sure the strips were not expired and did not show signs of wetness and contamination. Measure the water immediately after the rinse cycle by collecting a drip from the door. Record ppm measured and temperature of the machine on the proper recording sheet. If the machine test (verification) was not correct, contact a supervisor and/or kitchen repair vendor. If in doubt, serve food on disposable products until the dish machine was repaired. An inservice covering how to properly record dish machine chemical sanitizer ppm was provided to the dietary staff on [DATE]. The updated dish machine log listed the updated minimum temperature standards for the dish machine as 120 degrees F and the minimum sanitizer concentration as 50 ppm and staff were to report inappropriate temperatures or sanitizing issues to the supervisor immediately for corrective action. An action plan with an identified concern of the dish machine not at optimal temperature of 180 degrees F (rinse temperature) was identified and created on [DATE]. The plan included the following steps: Call for repair for machine and evaluation for booster (heater); the high temperature dish machine was converted to a chemical sanitizing machine and reviewed with the chemical company; appropriate test steps were in place for checking sanitizing levels; and, an inservice was created for staff on recording sanitation levels, checking temperature and proper test strips; director/chef was to check recording daily and verify as needed. II. Ensure staff performed proper hand hygiene while plating and serving resident meals A. Professional reference The Colorado Retail Food Regulations, ([DATE]), retrieved on [DATE] from https://cdphe.colorado.gov/environment/food-regulations, 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; When switching between working with raw food and working with ready-to-eat food; Before donning gloves to initiate a task that involves working with food; After engaging in other activities that contaminate the hands. B. Observations During a continuous observation of the lunch meal service on [DATE], beginning at 11:30 a.m. and ending at 12:50 p.m., cook (CK) #1 was observed touching her mask and hair with her hands and then handing clean dishes throughout resident meal service: At 11:47 a.m. while standing at the steam table where the lunch meal was held hot for the lunch meal service, CK #1 touched her mask with both hands. Without performing hand hygiene CK #1 picked up a plate with one hand and a serving utensil with her other hand and dished food onto the plate. CK #1 placed the plate of food in the serving window to be served to a resident. CK #1 picked up a soup bowl with one hand and with her other hand picked up a utensil to scoop food into the soup bowl. CK #1 then touched her mask, picked up a lid and placed the lid on the soup bowl. At 11:50 a.m. CK #1 touched her hair with her bare hand, then walked to the back of the kitchen and touched her hair again. CK #1 returned to the steam table in front of the serving window and touched her hair again. Without performing hand hygiene, CK #1 picked up a plate with the same hand she touched her hair with, picked up a utensil with her other hand and scooped food onto the plate. CK #1 then touched her surgical mask, picked up a disposable wipe, wiped off the steam table and threw the wipe away. CK #1 touched her mask again, picked up a disposable towel to wipe off her steam table and threw the towel away. At 11:53 a.m. CK #1 exited the kitchen into the dining room. After returning to the kitchen, CK #1 did not perform hand hygiene before she picked up a utensil and stirred food in the steam table. At 11:55 a.m. CK #1 touched her mask with both hands and touched her cheeks with both hands. CK #1 turned around, touched a shelf on the food preparation table and walked through the kitchen with her hands on her hips before she returned to the steam table. CK #1 touched the front of her shirt and pants with her right hand, failed to hand hygiene, picked up a plate with her right hand and a utensil with her other hand and scooped food onto a plate to be placed in the serving window to be served to a resident. CK #1 then touched her mask, picked up tongs and a plate and scooped food on a plate, placed the plate in the serving window. CK #1 then prepared another plate and placed the plate in the serving window. Both plates were served to a resident. At 12:00 p.m. CK #1 put an oven mitt on her left hand. CK #1 picked up a hot pan, placed the hot pan on a preparation table and removed the oven mitt from her left hand. Without performing hand hygiene, CK #1 then put on single use gloves. At 12:05 p.m. CK #1 adjusted her name tag on the front of her shirt with both hands. Without performing hand hygiene, CK #1 picked up a plate and utensil and scooped food onto the plate and set the plate in the serving window and then touched her mask with both hands. At 12:07 p.m. CK #1 picked up a hot pad and used the hot pad to place a pan of hot rolls on a food preparation table and then returned to the steam table to continue to assemble meal plates. At 12:11 p.m. without performing hand hygiene, CK #1 put on single use gloves and picked up a food item with her hand. CK #1 cut the food item and placed it on a plate to be served to a resident. CK #1 discarded the gloves and returned to the steam table. At 12:12 p.m. CK #1 adjusted her shirt and pants with both hands, touched her face with her right hand and picked up a scoop with her right hand and a plate with her left hand. CK #1 scooped food onto the plate and then placed the plate in the serving window to be served to a resident. Without performing hand hygiene, CK #1 picked up a plate with her bare hand and brushed her hand over the center of the plate. CK #1 scooped food onto the plate and placed the plate in the serving window to be served to a resident. At 12:15 p.m. CK #1 touched her hair and then touched her mask with both hands. CK #1 picked up a bowl and scooped food into a bowl. CK #1 walked to the back of the kitchen into dry storage. As she returned to the steam table CK #1 touched her hair then picked up a plate with a dessert covered with plastic wrap, placed it in the serving window and an unidentified staff member served the dessert to a resident. At 12:22 p.m CK #1 touched her nose with her left hand and then donned (put on) single use gloves without washing her hands. CK #1 used a knife to cut a food item on the steam table and used the knife and her gloved hand to place the food item on a plate. CK #1 discarded her gloves then touched her mask with both hands. CK #1 then picked up a plate and a serving utensil and continued to assemble meal plates to be served to residents. At 12:30 p.m CK #1 picked up a styrofoam cup and filled the cup at a juice machine in the kitchen. CK #1 pulled her mask down below her mouth and drank from the cup while walking through the kitchen and into the break room. CK #1 returned to the steam table, did not perform hand hygiene and placed a four ounce dish of food in the window. CK #1 continued to assemble resident meal plates to be served to residents. D. Staff interviews DA #2 was interviewed on [DATE] at 10:20 a.m. DA #2 said she had received hand hygiene education from the facility's infection preventionist (IP). She said staff should wash their hands anytime the staff changed tasks in the kitchen and wash their hands in between glove changes. DA #2 said gloves should be worn to handle raw meat. She said hand hygiene needed to be performed anytime someone entered the kitchen. DA #2 said hand hygiene needed to be performed after touching a face mask or hair. The DM was interviewed on [DATE] at 9:00 a.m. The DM said the facility's IP provided education to the dietary staff that included how to properly wash hands and when to perform hand hygiene. The DM said the IP included in the education that staff needed to wash their hands after touching their mask. The DM said if a staff member touched their mask or hair during food preparation the staff member should wash their hands E. Facility follow-up The QM provided a hand washing inservice on [DATE] (after the survey) at 9:00 a.m. The hand washing in-service was provided to dietary staff on [DATE] and included the following topics:education for food and nutrition staff on the proper usage of masks and gloves and hand washing. Staff must wash their hands after touching face masks, face or any part of the body before returning to serve (meals) or prepping foods. The inservice included a demonstration with return demonstration from the staff.

Based on observations, record review and interviews, the facility failed to assess, accurately document and provide treatment for one (#32) of four residents reviewed for pressure ulcers out of 31 sample residents. Specifically, the facility failed to: -Ensure the progress of Resident #32's pressure ulcers was documented consistently and accurately; -Identify Resident #32 had a pressure wound which had reopened on her coccyx; and, -Obtain appropriate physician's orders for wound care treatment for Resident #32's reopened coccyx pressure ulcer. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 5/23/24 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Resident #32 Resident status Resident #32, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, chronic kidney disease Stage II (mild), type II diabetes and a history of a right buttock stage 3 pressure ulcer. The 4/5/24 minimum data set (MDS) assessment revealed the resident had a brief interview for mental status (BIMS) score of three out of 15. She was dependent on help for bed mobility, transfers, and showering, and required maximal assistance with toileting. The assessment indicated Resident #32 was at risk for developing pressure ulcers. She had two unhealed stage 2 pressure ulcers and one unhealed stage 3 pressure ulcers and no unstageable pressure ulcers. The assessment indicated the resident was not on a turning/repositioning program, had no nutritional interventions to manage skin problems and had no diabetic foot ulcers. B. Observations On 5/13/24, the following observations were made: At 12:30 p.m. the resident was observed sitting in her wheelchair and eating in the main dining room. At 1:03 p.m. the resident was observed sitting in her wheelchair across from the nurses' station. At 1:25 p.m. the resident was asleep and sitting in her wheelchair, still across from the nurses' station. At 1:44 p.m. staff was observed bringing the sit-to-stand machine out of the resident's room. The resident was on her back, asleep on a low air loss mattress (a specialty mattress designed to relieve pressure). On 5/14/24, the following observations were made: At 11:41 a.m. Resident #32 was in the dining room sitting in her wheelchair. At 12:08 p.m. the resident was still sitting in her wheelchair in the dining room. At 12:24 p.m. the resident was sitting in her wheelchair by the nurses' station. At 12:34 p.m. the resident's family wheeled her to her room. On 5/15/24 at 9:23 a.m. Resident #32 was observed during incontinence care. A wound about the size of a nickel was observed on the left of the resident's coccyx area. The wound was open and pink. The resident screamed in pain when staff wiped her bottom and put cream on the wound. She yelled, oh my god it hurts! C. Record review A Braden Scale assessment (a tool used for determining pressure ulcer risk) dated 1/8/24 revealed Resident #1 was at mild risk for developing pressure ulcers. -There were no additional Braden Scale assessments documented following the 1/8/24 assessment. The May 2024 CPO included the following physician's order: Barrier cream to sacrum and peri-areas with brief changes, ordered 1/10/24. -The order failed to reveal that the barrier cream was for treatment or protection of the resident's wound. On 3/29/24, the following wounds were documented At 9:15 a.m. the wound care physician (WCP) documented a resolved stage 3 pressure ulcer on the left buttock, and a Kennedy terminal ulcer on the left buttock with dimensions 0.3 centimeters (cm) by 0.3 cm by 0.2 cm. (A Kennedy terminal ulcer is a wound that can develop in people who are terminally ill or nearing the end of their life. It is a type of pressure ulcer that is characterized by its sudden onset and rapid progression). -No coccyx wound was noted. At 1:55 p.m., an NP/MD documented an evaluation of Resident #32's sacral wounds. The provider documented the resident had three small ulcers, two on the left gluteal cleft region and one on the right (the groove in between the left and right buttocks). The wounds were below the coccyx. The one on the right was a stage 2 that measured 0.3 cm by 0.3 cm. The one on the left was 0.2 cm by 0.4 cm and was consistent with a resolving stage 3. The third was 0.3 cm by 0.4 cm. The wounds were consistent with pressure ulcers and not skin failure and so it was the provider's opinion that the wounds should not be classified as Kennedy ulcers. At 2:36 p.m., a nursing staff member documented a stage 2 pressure wound on the right buttock with an onset date of 3/29/24 and dimensions of 0.3 c.m. by 0.3 c.m. by 0.1 c.m. At 2:50 p.m., a nursing staff member documented a stage 2 pressure wound on the coccyx with an onset date of 3/25/24 and dimensions of 0.5 cm by 0.5 cm by 0.1 cm. -The documentation, including the stage of wound, location and measurements of the wounds, from the WCP and the facility nursing staff did not match. At 2:54 p.m. a nursing staff member documented the resident had a stage 3 pressure wound on the left buttocks with moderate serosanguinous drainage, present since 12/10/24. The wound was cleansed, measured, and a new dressing applied. -The nursing staff member inaccurately documented the date as 12/10/24 instead of 12/10/23. On 4/4/24 at 2:28 p.m. the WCP documented a stage 3 pressure ulcer on the left buttock with dimensions of 1.2 cm by 0.4 cm by 0.2 cm had moderate serosanguinous drainage (a combination of blood, and clear, straw-colored liquid), but was stable. On 4/9/24 at 7:35 p.m., nursing staff documented the resident had no new skin concerns. -The nursing note did not indicate if the previously mentioned pressure wounds were still present. On 4/11/24 at 4:01 p.m. the WCP documented a resolved stage 3 pressure ulcer on the left buttock with prior dimensions of 1.2 cm by 0.4 cm by 0.2 cm and a stage 2 pressure ulcer on the coccyx with dimensions of 0.5 cm by 0.5 cm by 0.2 cm and prior dimensions of 1 cm by 0.5 cm by 0.2 cm. The care plan, revised 4/12/24, documented Resident #32 was to have a gel cushion to her wheelchair, have a low air loss mattress and offload (lay down) between meals. On 4/16/24 at 10:51 p.m. the weekly skin assessment documented the resident had no new skin concerns. On 4/19/24 at 9:01 a.m. the WCP documented a resolved stage 2 pressure ulcer stage on the coccyx. The care plan, revised 4/19/24, identified the resident had the following resolved wounds: -Stage 3 pressure wound on left buttocks - resolved 4/11/24; -Stage 2 pressure wound on coccyx - resolved 4/19/24; and, -Stage 2 pressure wound on right buttocks- resolved 4/3/24. On 4/23/24 at 7:17 a.m. the nursing skin assessment documented the resident had no new skin concerns. On 4/25/24 at 9:33 a.m. the food and nutrition progress note documented the resident had a stage 3 pressure injury on the right buttock. -However, according to the care plan revised 4/19/24, Resident #32's pressure wounds were all resolved as of 4/19/24. The care plan, revised 4/28/24, documented a dietary supplement was to be provided as ordered for wound prevention and healing and staff was to use a barrier cream for Resident #32 as prescribed. -The care plan did not specify where the barrier cream was to be applied. On 5/7/24 at 9:51 a.m. the nursing skin assessment documented the resident had no new skin concerns. On 5/7/24 at 8:28 p.m. RN #5, who was a hospice nurse documented that the resident's skin was intact. On 5/13/24 at 10:50 a.m., RN #6, who was a hospice nurse documented Resident #32 had erythema (redness) of the peri area (private area). On 5/14/24 at 10:58 p.m., a nursing note documented Resident #32 had a new skin concern. The new skin concern was a bruise on the back of the resident's right hand due to hitting the table in the dining room. -The skin assessment did not document any new wounds as skin concerns. -There was no documentation to indicate the facility had identified that Resident #32's wound on her coccyx had reopened and that a physician had been notified (see observations above). D. Staff interviews The wound care nurse (WCN) was interviewed on 5/14/24 at 1:05 p.m. The WCN said she mostly cared for pressure, diabetic and vascular (arterial, venous, diabetic) wounds and sometimes skin tears. She said she typically monitored closed wounds, but once they opened up, she said she got the wound care physician (WCP) involved. She said Braden Scale assessments were completed on admission, quarterly and upon any change in condition. She said wounds were not typically measured upon admission, and there usually were not orders for barrier cream because barrier cream was a standard of care for incontinence. The WCN said Resident #32 had two stage 2 pressure wounds that were resolving. The WCN was interviewed again on 5/14/24 at 1:26 p.m. The WCN said the resident had no pressure injuries. The WCN said the resident previously had two pressure wounds, however, she said they were resolved. -However, the WCN said in her interview at 1:05 p.m. that Resident #32 had two stage 2 pressure wounds that were resolving. On 5/15/24 at 9:29 a.m., RN #1 said the wound on Resident #32's coccyx had been present for some time. She said it would heal and open up again repeatedly. She said the wound used to have a dressing but the resident was incontinent of bowel and they had to change the dressing multiple times throughout the day. She said removing dressings frequently was not good for the skin. RN #1 said the barrier cream seemed to work just as well as a dressing. She said the wound team was following Resident #32 and decided the cream was better than a dressing. She said the wound team was not following her anymore because her wounds were healed, and the staff just used zinc barrier cream on the wound. She said the staff had been using the cream without a dressing for at least a month. -However, Resident #32 was observed to have an open wound to her coccyx on 5/15/24 (see observations above). Nurse practitioner (NP) #1 was interviewed on 5/16/24 at 9:14 a.m. NP #1 said she was not notified that Resident #32 had an open wound on her coccyx or that staff were just using barrier cream to treat it. The director of nursing (DON) was interviewed on 5/16/24 at 11:44 a.m. The DON said she believed the coccyx wound was a fragile area. She said for wounds that were shallow, they could potentially be treated with zinc barrier cream, especially if the resident was incontinent. She said the physician should be contacted when there was a new wound or a reopened wound. E. Facility follow-up On 5/17/24 at 5:34 p.m. (after the survey exit) the facility submitted the following documentation: An Interdisciplinary team (IDT) note, dated 5/16/24 at 3:43 p.m. (during the survey) which documented Resident #32 had an open area on the left buttock. Zinc barrier cream was to be applied with each check and change and an order to monitor until resolved was entered.

Based on observations, record review and interviews, the facility failed to ensure two (#32 and #1) of five residents reviewed for pain management out of 31 sample residents received timely, adequate pain control. Specifically, the facility failed to: -Ensure pain was effectively managed during incontinence care for Resident #32; -Ensure Resident #32 was provided as needed (PRN) pain medication prior to brief changes per physician's orders; -Ensure staff consistently documented Resident #32's pain levels every shift; and, -Ensure individualized non-pharmacological interventions were documented for Resident #32 and Resident #1. Findings include: Facility Policy The Pain Management policy, revised on 5/3/23, was provided by the director of nursing (DON) on 5/17/24 at 5:36 p.m. It read in pertinent part: Pain is subjective and is what the resident says it is, existing when and where the resident says it does. All residents will be evaluated for pain by utilizing a pain evaluation tool in the electronic medical record (EMR). The pain evaluation will be completed upon admission, readmission, quarterly, and with any significant change in condition. The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness. All subsequent pain evaluations will be documented on the Pain Evaluation in the EMR and/or the MAR (medication administration record) as applicable to include location, intensity rating, and response to pain management interventions. When a resident complains of pain, ask the resident to rate the level of pain using the numerical Scale using a pain level of zero (none) to ten (severe). Cognitively impaired residents or residents unable to respond verbally may not be able to rate their pain using a numeric scale. Non-verbal indicators of pain include: increased agitation, crying, grimacing, holding the area where the pain is located, calling out, decreased appetite, and any other behaviors which are unusual for the resident. Cognitively impaired residents have pain evaluated using the PAINAD (Pain Assessment in Advanced Dementia) Scale. Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent (PRN) analgesic administration. (Every shift pain checks on the MAR should be completed after the resident receives the routine medication.) Do not forget the non pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage, and humor therapy etc. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan. II. Resident #32 Resident status Resident #32, age greater than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, chronic kidney disease, type two diabetes and a history of a right buttock stage 3 pressure injury. The 4/5/24 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She was dependent on two staff members for assistance with bed mobility, transfers and showering. She required maximal assistance of two staff members with toileting. B. Resident observations and interview On 5/13/24 at 10:36 a.m. moaning and yelling was heard from behind the closed door to Resident #32's room. At 10:42 a.m. certified nurse aide (CNA) #5 exited the room. CNA #5 said the resident was in a lot of pain during the transfer. She said the resident was in such pain that she did not feel comfortable proceeding with incontinence care and was on the way to inform the nurse about the pain. She said it was her first encounter with the resident as the resident was recently admitted to hospice care. At 10:44 a.m. registered nurse (RN) #1 entered the resident's room where the Resident #32 was lying in bed. RN #1 touched the resident's right foot and heel and the resident cried out in pain. RN #1 left the room and returned to give the resident pain medication. -RN #1 did not ask the resident where her pain was or what her level of pain was. On 5/15/24 Resident #32 was observed during a continuous observation, beginning at 9:03 a.m. and ending at 9:40 a.m. The following observations were made: At 9:08 a.m., Resident #32 was moaning while she waited for CNA #1 to return to help her transfer to bed. The resident said her whole right leg hurt. The resident was unable to describe her pain further or give a pain level for the right leg pain. At 9:23 a.m., after the resident was transferred to bed by RN #1 and CNA #1, RN#1 told CNA #1 the resident's brief should be changed. RN #1 told Resident #32 she needed to change her brief and started taking the resident's pants down. The resident started yelling No and hit RN #1 several times. The resident continuously yelled out, No while RN #1 and CNA #1 moved and changed her. Resident #32 yelled oh my god it hurts and hit RN #1 several times on her back. RN #1 asked the resident what hurt but the resident did not answer. The resident was breathing heavily and grimacing. During the incontinence care, an open wound was observed on the resident's left buttock. Resident #32 screamed in pain when the staff was wiping and putting cream on the wound. After incontinence care was completed, Resident #32 was positioned on her back, she stopped yelling and fell asleep. Resident #32 was hyperventilating, moaning loudly, groaning, crying, showed facial grimacing and was pulling and pushing away from the staff during the incontinence care. She was only able to be momentarily distracted by reassurances from RN#1 and CNA #1. C. Record review The care plan for pain, initiated 7/21/23 and revised 5/7/24, identified the resident had the potential for pain related to a wound and a history of a fracture. Pertinent interventions included the following: -Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; -Monitor/document for probable cause of each pain episode. Remove/limit causes where possible; -Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting, dizziness and falls. Report occurrences to the physician; -Monitor/record pain characteristics: including quality (sharp, burning), severity (1 to 10 pain scale) anatomical location, onset duration (continuous, intermittent) aggravating factors and relieving factors; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain; -Observe resident closely for signs of pain, administer pain medications as ordered, and notify hospice nurse timely if there is breakthrough or uncontrolled pain; and, -Offer non-pharmacological interventions for pain prior to administering medication and PRN (as needed). -However, the care plan did not document what individualized non-pharmacological interventions were effective for Resident #32. The May 2024 CPO included the following physician's orders: Monitor pain every shift using the PAINAD scale, ordered 3/29/24. Tramadol HCl oral tablet (medication used to treat pain) 50 milligrams (mg), give 50 mg orally two times a day for pain, ordered 4/16/24. Acetaminophen (analgesic) 325 mg, give two tablets by mouth four times a day for pain, ordered 6/22/23. Tramadol HCl oral tablet 50 mg, give 50 mg orally for pain level of 6-10 on a pain scale of 1-10 twice daily as needed (PRN) before wound care and brief changes, ordered 4/19/24. Review of Resident #32's medication administration record (MAR) and treatment administration record (TAR) from 5/1/24 through 5/14/24 revealed Resident #32 received 13 out of 14 doses of scheduled, with one refusal. She received 52 out of 60 doses of scheduled acetaminophen, with three refusals and the resident was documented as sleeping for five administrations. -Resident #32 did not receive any doses of PRN Tramadol from 5/1/24 through 5/14/24, despite the resident having a physician's order to administer PRN Tramadol prior to wound care and brief changes. -The required monitoring of Resident #32's pain every shift was documented as completed on the TAR, however, the documentation did not include a pain score or description of the pain. -A pain score was documented six times in the first 14 days of May and was noted to be zero out of 10 for each. -No pain score was documented on 5/13/24, after the resident was observed yelling in pain and was given pain medication. A nursing pain evaluation, dated 4/12/24 at 10:38 a.m. by RN #1, revealed the resident had a chronic wound to the coccyx that contributed to pain. The resident was unable to describe what the pain felt like but additional symptoms associated with pain included decreased appetite, non-verbal signs including facial grimacing and moaning and verbal indications. The evaluation documented the resident's preferred pain scale was PAINAD but she was unable to state her acceptable level of pain. Measures that helped relieve pain were medication and relaxation. A progress note, documented on 3/17/24 at 7:00 p.m., revealed Resident #32 had yelled out in pain during incontinence care and resisted care when wipes touched her buttocks region. D. Staff interviews RN #1 was interviewed on 5/15/24 at 9:24 a.m. RN #1 said the resident's reaction during the incontinence care was typical for the resident during incontinence care. She said sometimes the resident hit her when she was providing incontinence care. RN #1 said she assumed, based on the resident's reaction, that her pain was a 10 out of 10. RN #1 said she did not notify a physician of the resident's pain and did not document it in the progress notes. Nurse practitioner (NP) #1 and the director of nursing (DON) were interviewed together on 5/16/24 at 9:14 am. NP #1 said she had seen Resident #32 during cares before and she had assessed her with catheter care the other day. She said even when there was no open wound, the resident would still complain of pain during incontinence care. NP #1 said the resident was very good about telling her that she was in pain. She said when staff was doing wound care in the past (when she had a documented open wound), the staff would pre-medicate the resident but that had not been the case for a while so she was not aware if her pain had gotten worse. -NP #1 was unaware the resident had a current open wound observed on the resident's buttocks (see observations above). NP #1 said the resident's family was somewhat resistant to medication changes. She said she did not think all of Resident #32's reaction during incontinence care was pain related. She said she thought some of it had been the transition to long-term care. She said the resident was used to being at home with her large family. She said she had a phone call with hospice later that day and they would also do another pain assessment to see if there was a change in the resident's condition. NP #1 said the resident's family had requested hospice services when the resident's decline started a few weeks ago. She said the last pain assessment documented on 4/12/24 was probably when the resident's decline started. NP #1 said she felt that the resident's dementia was part of what was contributing to her resisting care. She said she thought when the nurse heard the resident yelling in pain that the nurses might collaborate with social services and look at the care plan. The DON said nurses should document something in the progress notes which said what happened during the incontinence care and that the resident complained of pain. E. Facility follow-up On 5/17/24 at 5:34 p.m. (after the survey exit) the facility submitted the following documentation: 1. Record of pain audit performed 5/17/24 at 3:53 pm: 88 residents were audited for pain orders and documentation of pain level, and orders were in place. The audit was signed by the DON. An Interdisciplinary team (IDT) note, dated 5/16/24 at 3:43 p.m. documented the IDT was in collaboration regarding pain/anxiety/skin with the DON, social services director (SSD), RN #3, NP #2 and Resident #32's representative/power of attorney (POA). The IDT note read, in pertinent part, Pain management: pain is well controlled at this time, no need for changes identified. POA declined any changes to medications/pain plan of care for pain. -However, per the observations and RN #1's interview during the survey, Resident #32's pain was not well controlled during incontinence care (see observations and interviews above). 48112 III. Resident #1 A. Resident status Resident #1, over [AGE] years old, was readmitted on [DATE]. According to the May 2024 CPO, diagnoses included hemiplegia (paralysis on one side) and hemiparesis (weakness or inability to move one side of the body) post cerebrovascular disease affecting the left non-dominant side, a psychotic disorder with delusions, peripheral vascular disease (reduction in blood circulation), insomnia and depression. The 2/20/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. She had an impairment to the lower extremity on one side and used a wheelchair. She was dependent for oral hygiene, toileting hygiene, showering, dressing and personal hygiene. The resident was on a scheduled pain medication regimen, received as needed pain medication and non-pharmacological interventions for pain. The assessment revealed the resident was almost constantly in pain which frequently affected her sleep and the pain intensity was severe. B. Resident observation and resident representative interview The resident's representative was interviewed on 5/15/24 at 2:10 p.m. He said the resident complained to him a lot about pain on her right buttock from a wound. He said it was difficult visiting with the resident today (5/15/24) because the facility had just administered morphine and she was pretty drowsy. He said the facility had not found the right balance of medication so she could be awake to participate in her daily activities. -During the interview, Resident #1 was sitting in her wheelchair with two family members present. The resident's eyes were closed. C. Record review The pain care plan, revised 8/23/23, revealed the resident had pain related to arthritis, hemiplegia and contractures. Interventions included administering pain medication per orders, evaluating the pain intervention's effectiveness, monitoring and documenting the probable cause of each pain episode and monitoring and recording pain characteristics. -The care plan did not identify the location of the resident's pain or what non-pharmacological interventions were being provided to help alleviate the resident's pain. A pain assessment, dated 2/16/24, revealed the resident had pain due to cerebral vascular disease and cancer. She had pain in the past five days. She said the pain was sharp and throbbing. She said she could not sit up in a wheelchair for an extended period because it caused pain. She said the pain was worse mid day. Her acceptable level of pain was three out of ten. She said pain medication and position change relieved her pain. -The onset and duration of pain was not identified. The May 2024 CPO revealed the following physician's orders: Morphine sulfate 15 milligrams (mg). Administer 15 mg by mouth two times a day for pain, ordered2/20/24. Tylenol 500 mg. Administer two tablets by mouth three times a day for pain, ordered 2/20/24. Morphine sulfate 20 mg/ml (milliliter). Administer 0.5 ml by mouth every two hours as needed for pain and shortness of breath, ordered 4/12/24. Monitor pain every shift using a zero to ten pain scale. Acceptable level of pain is two, ordered 11/16/23. -The orders did not specify where the resident had pain and did not identify any non-pharmacological interventions for pain. Review of the May 2024 medication administration record (MAR) from 5/1/24 through 5/13/24 revealed the following: -The as needed morphine sulfate was administered at least once a day on 5/2/24 through 5/5/24 and 5/10/24 through 5/13/24. -The May 2024 MAR did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/13/24 nurse progress note said morphine sulfate 20 mg/ml was administered for pain. -The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/12/24 nurse progress note revealed the resident was yelling out all night. The nurse stayed with the resident and gave juice and water. The resident kept asking for her sister and complained of pain. At 1:15 a.m. the resident was administered as needed morphine and it was effective. -The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/4/24 nurse note revealed the resident complained of pain and was restless. As needed morphine and scheduled ativan was administered. -The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. A 5/5/24 nurse progress note revealed the resident had an elevated blood pressure and pulse due to increased pain and fearfulness of being alone. As needed morphine was administered with scheduled ativan. Resident #1 was tearful and wanted her family to stay with her. The nurseried to provide comfort yet the resident was forgetful. -The progress note did not document where the resident had pain and did not identify if non-pharmacological interventions were offered when the as needed morphine sulfate was administered. D. Staff interviews Certified nurses aide (CNA) #4 was interviewed on 5/16/24 at 1:18 p.m. CNA #4 said she was familiar with Resident #1. She said the resident had pain in her leg, her back and her head. She said when she moved from her bed to her wheelchair it was one intervention that alleviated the resident's pain. CNA #4 said talking to the resident about her family also helped distract her from her pain. Licensed practical nurse (LPN) #1 was interviewed on 5/16/24 at 11:12 a.m. LPN #1 said pain assessments were completed for residents at admission and quarterly. She said the pain assessment addressed if the resident had any pain and if the resident had a diagnosis which caused pain. She said the pain assessment also addressed if the resident had scheduled or as needed pain medications and the location and severity of the pain. She said non-pharmacological interventions included redirection, reassurance and a calm environment. LPN #1 said she was familiar with Resident #1. She said she had pain on her coccyx, her left leg, back pain and generalized pain. She said repositioning helped minimize her pain. She said the minimum was to reposition the resident every two hours. LPN #1 said the resident was unable to shift her weight on her own so staff should reposition her to help with her pain. Nurse practitioner (NP) #1 was interviewed on 5/16/24 at 9:42 a.m. NP #1 said she was unsure if Resident #1 had pain. She said she was unable to identify the location of the resident's pain. NP #1 said it was possible when the resident's anxiety was high, the resident could be saying she was in pain. She said the lack of documentation by the nursing staff regarding Resident #1's pain made it difficult for her to provide direction to the facility on the best way to manage the resident's pain. She said hospice, the facility and the resident's representative needed to meet so everyone could be on the same page on what the goals were for her pain. The DON was interviewed on 5/16/24 at 11:44 a.m. The DON said pain assessments were completed at admission, quarterly and every shift. She said the pain assessment covered where the pain was located, what the pain management goal was and what non-pharmacological interventions helped alleviate the pain. She said the pain interventions were documented in the care plan and in the progress notes. She said she was familiar with Resident #1. She said the resident had pain but was unable to verbalize where the pain was. The DON said, in the past, the resident's pain was from her contractures and arthritis. She said she could check with the resident. She said the resident's care plan and orders needed to be updated to reflect what helped alleviate her pain besides pain medication.

Based on record review, observations and interviews, the facility failed to ensure one (#1) of five residents reviewed for unnecessary medications out of 31 sample residents were free from unnecessary medications. Specifically the facility failed to: -Ensure Resident #1 had appropriate non-pharmacological interventions for behaviors initiated; -Ensure Resident #1 was monitored for side effects of a psychotropic medications; and, -Ensure Resident #1 was monitored consistently for behaviors to justify the use of psychotropic medications. Findings include: I. Facility policy The Psychopharmacological policy, revised 3/10/23, was provided by the director of nursing (DON) on 5/16/24 at 1:44 p.m. It read in pertinent part, Licensed nurses and additional staff will monitor and document any targeted behaviors that occur. The care plan will include the resident's focus and target behaviors for the medication. Realistic and measurable goals will be utilized and approaches will include alternatives to psychopharmacological drug use. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on 7/9/99 and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on one side) and hemiparesis (weakness or inability to move one side of the body) post cerebrovascular disease affecting the left non-dominant side, a psychotic disorder with delusions, peripheral vascular disease (reduction in blood circulation), insomnia and depression. The 2/20/24 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for a mental status (BIMS) score of three out of 15. She had an impairment to one lower extremity and used a wheelchair. She was dependent on staff assistance for oral hygiene, toileting hygiene, showering, dressing and personal hygiene. B. Observations Resident #1 was observed during a continuous observation on 5/13/24, beginning at 11:15 a.m. and ending at 11:33 a.m. The following observations were made: Resident #1 was lying in bed and had her legs bent to her right side at 45 degrees. The sheets and blankets were pushed to the end of the bed. She yelled nurse thirteen times between 11:15 a.m until 11:27 a.m. At 11:22 a.m. an unidentified certified nurse aide (CNA) walked into the room across from Resident #1's room when the resident was asking for a nurse. -The unidentified CNA did not acknowledge Resident #1 when she was calling out for a nurse and the resident continued to call out. At 11:27 a.m. the unidentified CNA entered Resident #1's room and asked if she wanted to get out of bed for lunch. -However, the CNA proceeded to leave Resident #1's room without getting the resident out of bed and the resident continued to call out. From 11:27 a.m until 11:33 a.m. the resident yelled nurse and I need help ten times. At 11:33 a.m. CNA #4 walked into the resident's room (five minutes after the previous CNA had initially entered the room) and asked Resident #1 if she wanted to get out of bed for lunch. C. Record review The 2/16/24 care plan revealed the resident used hypnotic, sedative and sleep disorder medications related to anxiety and agitation with expressed difficulty sleeping as evidenced by calling out at night. Interventions included a gradual dose reduction of Restoril (initiated 5/15/24), review medications with the interdisciplinary team (IDT) quarterly and as needed and attempt gradual dose reduction when clinically indicated (initiated 2/16/24). The 6/29/23 care plan, revised 9/15/23, revealed the resident used an antidepressant medication related to generalized anxiety. Interventions included to monitor, document and report adverse reactions to antidepressant therapy, changes in behavior and to review medications with IDT quarterly. The 8/28/23 care plan revealed the resident used an antipsychotic medication for symptoms and behaviors associated with psychotic disorders with delusions. Interventions initiated on 8/28/23 included to monitor for side effects and effectiveness, behavior monitoring and to review medications with the IDT quarterly. The May 2024 CPO revealed the following physician's orders: -Duloxetine (medication used to treat depression and anxiety) 60 milligrams (mg). Administer 60 mg by mouth in the morning for anxiety, ordered 1/15/24. -Mirtazapine (medication used to treat depression) 15mg. Administer 15 mg by mouth at bedtime for anxiety and depression, ordered 2/5/24. -Restoril (medication used to treat insomnia) 15 mg. Administer 7.5 mg by mouth in the evening for sleep for 14 days, ordered 5/11/24. -Lorazepam (medication used to treat anxiety) 2mg/ml (milliliters). Administer 0.5 ml by mouth three times a day for anxiety, ordered 5/10/24. -Review of the May 2024 medication administration record (MAR) revealed there was no documentation the medications were monitored for effectiveness and side effects. -The May 2024 MAR revealed there was no documentation Resident #1's behaviors were consistently monitored. -The May 2024 MAR revealed there no documentation non-pharmacological interventions were attempted with Resident #1 when she was exhibiting behaviors, such as calling out. -There was no documentation in Resident #1's electronic medical record (EMR) to indicate the facility was monitoring the resident for the effectiveness of the medications or potential side effects of the medications. -There was no documentation in the resident's EMR to indicate the facility was consistently monitoring the resident for behaviors or that staff were attempting non-pharmacological interventions to address the resident's behaviors. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/16/24 at 11:10 a.m. LPN #1 said she continuously monitored for resident's for behaviors. She said it was not consistent where she documented the behaviors. She said some residents had an order to monitor behaviors so she documented the behavior in the treatment administration record (TAR). LPN #1 said the resident did not have an order to document behaviors in the TAR then she documented in a progress note. She said she monitored residents for side effects of psychotropic medications based on if the resident was sleepy, had agitation or if there was a change in the dose of the medication. She said she documented side effects in the TAR. LPN #1 said non-pharmacological interventions included companionship, social service intervention, room changes, contacting the family and activities. She said she was familiar with Resident #1. She said she monitored the resident's behavior. She said the resident's behavior included she did not want to get out of bed. She said sitting with the resident helped the resident's behavior and the family helped too. LPN #1 said one on one care would be helpful for Resident #1. She said she monitored side effects of her medications. She said the resident's Duloxetine was decreased a while ago and the resident yelled more, had agitation, confusion and helplessness. She said the resident was very lonely. LPN #1 said she had not documented Resident #1's behavior, if non-pharmacological interventions were offered or if there were side effects. She said the medication was given to reduce fearfulness, loneliness, pain and agitation. She said Resident #1 responded well to music, a stuffed monkey was comforting, putting a pillow between her legs, doing her hair and offering fluids. Nurse practitioner (NP) #1 was interviewed on 5/16/24 at 9:42 a.m. NP #1 said Resident #1's anxiety was not managed. She said hospice, the facility and the resident's representative needed to meet so everyone could be on the same page on what the goals were for her anxiety. She said without the behaviors documented it was hard to provide direction to reduce the resident's anxiety. The DON was interviewed on 5/16/24 at 11:44 a.m. The DON said the facility did not document medications were monitored for effectiveness and side effects. She said the facility did not document that behaviors were monitored and if non-pharmacological interventions were offered. She said it was important to document because it helped determine if gradual dose reduction was an option for a medication, if the resident needed the medication and if the resident should continue to have the medication. IV. Facility follow up The DON sent a physician's progress note on 5/20/24 (after the survey). The 5/17/24 physician progress note revealed Resident #1 continued to have periods of restlessness, that in the past, were managed with antipsychotics. The medications were no longer appropriate but her anxiety and sleep issues were being addressed with benzodiazepines (depressant medications). The resident was non-ambulatory and the benefit of these medications for quality of life outweighed the potential risks that would occur if she were ambulatory. There would continue to be a collaborative and interdisciplinary approach to the care of the resident. -However, the physician's progress note was dated on 5/17/24, the day after the survey exit, and failed to address the monitoring of medication side effects, behavior monitoring or non-pharmacological interventions.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one of three units. Specifically, the facility failed to: -Follow proper infection control processes for cleaning and disinfecting lifts and vital signs equipment on the Parkview unit; and, -Use proper infection control procedures during a vaccination clinic. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Healthcare Facilities (2019), retrieved on 5/25/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/index.html, read in pertinent part, Careful cleaning of patient rooms and medical equipment contributes substantially to the overall control of Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-intermediate Staphylococcus aureus (VISA) and Vancomycin-resistant Enterococci (VRE) transmission. Direct patient-care items (blood pressure cuffs) should be disposable whenever possible when used in contact isolation settings for patients with multiply resistant microorganisms. Non-critical items (those that come in contact with intact skin but not mucous membranes), are divided into noncritical resident care items (blood pressure cuffs, stethoscopes, wheelchairs, therapy equipment) and noncritical environmental surfaces (bed rails, bedside tables). They require cleaning followed by either low or intermediate level disinfection following manufacturers' instructions. Disinfection should be performed with an Environmental Protection Agency (EPA)-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products must be followed (use-dilution, shelf life, storage, material compatibility, safe use and disposal). II. Mechanical lifts (sit-to-stand machine) and vital signs equipment A. Observations On 5/13/24 at 1:44 p.m. certified nurse aide (CNA) #1 was observed bringing the sit-to-stand mechanical lift out of a resident's room on the Parkview unit. CNA #1 took the equipment to a holding area with other lifts and left the lift. -CNA #1 failed to disinfect the sit-to-stand mechanical lift after using the lift with the resident. On 5/15/24 during a continuous observation, beginning at 11:06 a.m. and ending at 11:20 a.m., an unidentified CNA was observed using a vital signs machine. The unidentified CNA was observed leaving a room on the Parkview unit with the vital signs machine and equipment, including blood pressure cuffs, a pulse oximeter, and a thermometer. -There were no cleaning wipes stored with the equipment. -The unidentified CNA wheeled the equipment down the hall and placed it next to the nurses' station. The CNA failed to disinfect the vital signs machine and equipment C. Interviews The infection preventionist (IP) was interviewed on 5/15/24 at 4:06 p.m. The IP said she had been working at the facility since 2020. She said the cleaning policy for vital signs equipment depended on if there was an outbreak. She said hydrogen peroxide was readily available and more gentle on skin and the equipment. The IP said the dwell time for hydrogen peroxide was about 30 seconds. She said if there was a range for the dwell time, she usually recommended the longer time listed, but she did not usually see a range. She said disinfection of the equipment depended on what was going on in the building. The IP said it was okay to clean all the equipment with the same wipe, however, she said it should be done after each use with a resident. She said CNAs were responsible for cleaning the equipment after every use with the hydrogen peroxide wipes. 37166 III. Hand hygiene during vaccination administration A. Observations On 5/15/24 a contract pharmacist (CP) was administering vaccinations to the residents in the presence of the infection preventionist (IP). At 11:28 a.m. the CP was observed standing next to room [ROOM NUMBER]. She put clean gloves on, took band aids, peeled them on one end and stuck them to a sharps container. She used her gloved hands to adjust her skirt, took paper records from the cart and went into room [ROOM NUMBER]. She exited the room holding paper records and wearing the same gloves. -Without changing her gloves or performing hand hygiene, the CP proceeded to take two prefilled vaccine syringes from the cart, stuck one band aid on her watch and one bandaid on her gloved hand and approached the resident in room [ROOM NUMBER] to administer the vaccination. After administering the vaccination, the CP removed her gloves and exited room [ROOM NUMBER] holding both syringes in her hands. She placed the syringes into the sharps container on the cart. -The CP did not perform hand hygiene before documenting the vaccination in the resident's record and pushing the cart to the next room At 11:31 a.m. the CP approached room [ROOM NUMBER]. She put clean gloves on, without performing hand hygiene, stuck band aids to her glove and entered room [ROOM NUMBER] with two syringes. After administering the vaccinations to the residents, the CP exited the room with gloves on, threw the syringes into a sharps container and took her gloves off. -The CP did not perform hand hygiene prior to putting clean gloves on. -With the new pair of clean gloves on, she adjusted her shirt, organized paper records and pushed the cart to the next room still wearing the gloves. At 11:38 a.m. the CP approached room [ROOM NUMBER]. She put clean gloves on, without performing hand hygiene, stuck band aids to her glove and entered room [ROOM NUMBER] with two syringes. After administering the vaccinations to the residents, the CP exited the room wearing gloves, put the two syringes into a sharps container and removed her gloves. -The CP did not perform hand hygiene after she removed the gloves. B. Staff interviews The IP was interviewed on 5/6/24 at 4:15 p.m. The IP said the pharmacist that was administering vaccinations was from the contracted company. She said the CP was not an employee of the facility. The IP said band aids should not be placed on the sharps container as the sharps container was considered to be unclean from contact with syringes and blood products. The IP said once the CP had applied clean gloves, other potentially unclean surfaces such as the cart, paper records, personal clothes and pens should not have been touched. She said once gloves were removed after administering the vaccinations, the CP should have performed hand hygiene prior to reapplying clean gloves.

Based on record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#3, #7, #11 and #18) of five residents out of eight sample residents. Specifically, the facility failed to: -Address continued call light complaints voiced during resident council for several months; and, -Ensure Resident #3, Resident #7, Resident #11 and Resident #18 experienced a dignified living experience by answering the residents' call lights in a timely manner. Findings include: I. Facility policy and procedures The Answering the Call Light policy, revised September 2022, was provided by the nursing home administrator (NHA) via email on 6/28/23 at 3:08 p.m. It read in pertinent part, The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Answer the resident call system immediately. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request requires another staff member, notify the individual. If the resident's request is something you can fulfill, complete the task within five minutes if possible. II. Resident council minutes Review of the 2/17/23 resident council minutes revealed the residents reported call lights were taking too long to get answered or nursing staff went into resident rooms and turned off the call lights and said they would be back but never returned. -There was no follow-up response to address the resident's call light concerns documented in the resident council minutes. Review of the 3/9/23 resident council minutes revealed call lights taking too long to be answered was a continued concern for residents. The minutes documented nurse managers were completing call light audits and there was an ongoing process improvement plan for call light times. Review of the 4/14/23 resident council minutes revealed the residents reported call lights were taking too long to be answered. The minutes documented the NHA said he was getting the manager pagers fixed so that the facility could monitor call lights better. Review of the 5/12/23 resident council minutes revealed the residents reported call lights were taking too long to be answered. The minutes documented the NHA said he was getting the manager pagers fixed so that the facility could monitor call lights better. -The NHA response documented in the resident council minutes was the same response that had been provided in the 4/14/23 resident council minutes. Review of the 6/9/23 resident council minutes revealed the residents reported call lights were taking too long to be answered. The minutes documented the NHA said pagers were in place for call lights and they were being monitored by all the nursing managers including the NHA and the social services director. III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included congestive heart failure, age-related osteoporosis (weak, brittle bones), pain in left and right hips, low back pain and glaucoma. The 2/20/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers and toilet use. She required one-person limited assistance for dressing and personal hygiene. B. Resident interview Resident #3 was interviewed on 6/26/23 at 2:59 p.m. Resident #3 said she sometimes had to wait for a long time for staff to come assist her when she put her call light on. She said she had waited for longer than 30 minutes at times for staff to answer her call light. Resident #3 said she was not supposed to go to the bathroom without assistance, however, she said she sometimes had to take herself to the bathroom because she could not wait any longer for a staff member to answer her call light and assist her. C. Record review Review of Resident #3's activities of daily living (ADL) care plan, initiated 12/4/2020 and revised 4/4/23, revealed that the resident needed limited to extensive assistance with some ADL activities related to weakness and deconditioning. Pertinent interventions included ensuring the call light was within reach and staff was to respond promptly to requests for help. If the resident was unable to use or was inconsistent with call light use, staff was to monitor the resident every one to two hours for needs and safety and anticipate the resident's needs as able. Review of Resident #3's call light log report from 6/1/23 to 6/25/23 revealed the following: -6/1/23 at 4:29 a.m: the call light was on for 31 minutes; -6/2/23 at 4:33 p.m: the call light was on for 23 minutes; -6/5/23 at 7:17 p.m: the call light was on for 26 minutes; -6/8/23 at 11:21 a.m: the call light was on for 25 minutes; -6/8/23 at 11:47 a.m: the call light was on for 33 minutes; -6/10/23 at 4:28 p.m: the call light was on for 21 minutes; -6/12/23 at 7:23 p.m: the call light was on for one hour and 38 minutes; -6/17/23 at 12:17 p.m: the call light was on for one hour and 20 minutes; -6/17/23 at 7:37 p.m: the call light was on for 20 minutes; -6/18/23 at 10:36 a.m: the call light was on for 21 minutes; -6/19/23 at 7:16 a.m: the call light was on for 47 minutes; -6/19/23 at 8:59 a.m: the call light was on for one hour and 41 minutes; -6/19/23 at 7:12 p.m: the call light was on for 21 minutes; -6/19/23 at 9:00 p.m: the call light was on for one hour and 33 minutes; -6/22/23 at 7:32 p.m: the call light was on for 21 minutes; and, -6/26/23 at 6:09 a.m: the call light was on for one hour and 15 minutes. IV. Resident #7 A. Resident status Resident #7, age 66, was admitted on [DATE] and readmitted on [DATE]. According to the June CPO, diagnoses included hemiplegia (complete paralysis of an extremity on one side of the body) and hemiparesis (weakness of an extremity on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, muscle weakness and muscle spasms. The 6/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required two-person extensive assistance for bed mobility, transfers and toilet use. He required one-person extensive assistance for dressing and personal hygiene. B. Resident interview Resident #7 was interviewed on 6/26/23 at 11:38 a.m. Resident #7 said he sometimes had to wait 30 minutes or longer for his call light to be answered. He said he required two people to transfer him with the mechanical lift. He said staff would answer his call light quickly at times, however, he said they would turn off his call light and tell him they would return with another staff member to assist with his transfer. Resident #7 said it would often take the initial staff member who answered his call light 15 minutes or more to return to assist him. He said sometimes they did not return and he would have to put his call light back on. C. Record review Review of Resident #7's ADL care plan, initiated 8/28/2020 and last revised 12/20/22, revealed the resident needed limited to extensive to total assistance with some ADL activities related to weakness and pain. Pertinent interventions included ensuring the call light was within reach and staff was to respond promptly to requests for help. If the resident was unable to use or was inconsistent with call light use, staff was to monitor the resident every one to two hours for needs and safety and anticipate the resident's needs as able. Review of Resident #7's call light log report from 6/1/23 to 6/25/23 revealed the following: -6/1/23 at 11:32 a.m: the call light was on for 23 minutes; -6/1/23 at 1:03 p.m: the call light was on for 29 minutes; -6/2/23 at 6:11 a.m: the call light was on for 32 minutes; -6/2/23 at 7:48 a.m: the call light was on for 54 minutes; -6/2/23 at 11:22 a.m: the call light was on for 24 minutes; -6/3/23 at 6:19 a.m: the call light was on for 49 minutes; -6/3/23 at 8:23 a.m: the call light was on for 36 minutes; -6/5/23 at 7:47 a.m: the call light was on for 58 minutes; -6/6/23 at 6:11 a.m: the call light was on for 23 minutes; -6/6/23 at 7:47 a.m: the call light was on for 29 minutes; -6/6/23 at 11:33 a.m: the call light was on for 24 minutes; -6/7/23 at 6:11 a.m: the call light was on for 24 minutes; -6/7/23 at 7:36 a.m: the call light was on for 40 minutes; -6/8/23 at 7:27 a.m: the call light was on for one hour and 10 minutes; -6/8/23 at 11:23 a.m: the call light was on for 28 minutes; -6/8/23 at 12:27 p.m: the call light was on for 24 minutes; -6/9/23 at 7:44 a.m: the call light was on for one hour and 15 minutes; -6/9/23 at 7:20 p.m: the call light was on for 45 minutes; -6/10/23 at 11:21 a.m: the call light was on for 25 minutes; -6/11/23 at 6:15 a.m: the call light was on for 45 minutes; -6/11/23 at 8:02 a.m: the call light was on for 52 minutes; -6/12/23 at 7:44 a.m: the call light was on for 27 minutes; -6/12/23 at 7:13 p.m: the call light was on for 31 minutes; -6/13/23 at 7:45 a.m: the call light was on for 51 minutes; -6/13/23 at 12:35 p.m: the call light was on for 33 minutes; -6/14/23 at 7:42 a.m: the call light was on for 29 minutes; -6/22/23 at 6:18 a.m: the call light was on for 28 minutes; -6/22/23 at 10:05 a.m: the call light was on for 24 minutes; -6/22/23 at 8:39 p.m: the call light was on for 31 minutes; -6/23/23 at 5:27 a.m: the call light was on for 23 minutes; -6/23/23 at 12:35 p.m: the call light was on for 37 minutes; -6/24/23 at 5:37 a.m: the call light was on for 37 minutes; and, -6/24/23 at 6:31 a.m: the call light was on for one hour and 21 minutes. V. Resident #11 A. Resident status Resident #11, age 74, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO, diagnoses included shortness of breath, lack of coordination, fatigue and weakness. The 5/10/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person limited assistance for dressing. She required one-person extensive assistance for personal hygiene. She was totally dependent on one staff person for toilet use. B. Resident interview Resident #11 was interviewed on 6/26/23 at 11:01 a.m. Resident #11 said she had experienced long wait times for staff to respond to her call light. She said it usually happened when she needed her brief changed or she wanted to get into or out of her bed. She said it did not happen all the time, however, she said it happened often enough that it was very frustrating. She said she had to wait 20 minutes or longer at times. Resident #11 said 20 minutes was too long to have to wait for her to get the assistance she needed. C. Record review Review of Resident #11's ADL care plan, initiated 7/12/18 and revised 5/24/23, revealed that the resident needed limited to extensive to total assistance with some ADL activities. Pertinent interventions included providing assistance for ADLs and mobility as needed. Review of Resident #11's call light log report from 6/1/23 to 6/25/23 revealed the following: -6/1/23 at 6:37 a.m: the call light was on for 49 minutes; -6/1/23 at 8:19 a.m: the call light was on for 28 minutes; -6/1/23 at 10:57 a.m: the call light was on for 46 minutes; -6/1/23 at 12:34 p.m: the call light was on for 34 minutes; -6/1/23 at 9:26 p.m: the call light was on for one hour; -6/4/23 at 10:14 a.m: the call light was on for 25 minutes; -6/4/23 at 11:26 a.m: the call light was on for 27 minutes; -6/5/23 at 9:52 a.m: the call light was on for 26 minutes; -6/8/23 at 5:55 a.m: the call light was on for 40 minutes; -6/8/23 at 12:29 p.m: the call light was on for 22 minutes; -6/8/23 at 4:04 p.m: the call light was on for 51 minutes; -6/8/23 at 7:03 p.m: the call light was on for 24 minutes; -6/9/23 at 7:44 p.m: the call light was on for 25 minutes; -6/10/23 at 2:08 p.m: the call light was on for 37 minutes; -6/10/23 at 7:06 p.m: the call light was on for 40 minutes; -6/12/23 at 8:12 a.m: the call light was on for 55 minutes; -6/14/23 at 8:04 a.m: the call light was on for 33 minutes; -6/15/23 at 8:52 p.m: the call light was on for 25 minutes; -6/15/23 at 5:51 p.m: the call light was on for 47 minutes; -6/17/23 at 3:51 a.m: the call light was on for 21 minutes; -6/17/23 at 7:52 a.m: the call light was on for two hours and two minutes; -6/17/23 at 10:36 a.m: the call light was on for 45 minutes; -6/17/23 at 1:13 p.m: the call light was on for 43 minutes; -6/17/23 at 4:18 p.m: the call light was on for 57 minutes; -6/18/23 at 6:46 a.m: the call light was on for 49 minutes; -6/18/23 at 8:33 a.m: the call light was on for 33 minutes; -6/19/23 at 12:44 p.m: the call light was on for 23 minutes; -6/20/23 at 7:25 p.m: the call light was on for 38 minutes; -6/20/23 at 9:46 p.m: the call light was on for 24 minutes; -6/21/23 at 6:58 p.m: the call light was on for 47 minutes; -6/22/23 at 4:16 p.m: the call light was on for 23 minutes; -6/22/23 at 8:38 p.m: the call light was on for 39 minutes; -6/23/23 at 8:51 a.m: the call light was on for 31 minutes; -6/23/23 at 6:09 p.m: the call light was on for 48 minutes; -6/24/23 at 8:05 a.m: the call light was on for 26 minutes; -6/24/23 at 8:39 a.m: the call light was on for 21 minutes; -6/24/23 at 11:27 a.m: the call light was on for 24 minutes; -6/24/23 at 12:43 p.m: the call light was on for 33 minutes; -6/24/23 at 3:58 p.m: the call light was on for 30 minutes; and, -6/24/23 at 9:20 p.m: the call light was on for 39 minutes. VI. Resident #18 A. Resident status Resident #18, age 84 was admitted on [DATE]. According to the June 2023 CPO, diagnoses included pain, lack of coordination, muscle weakness and contracture (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part) of the left elbow. The 4/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. B. Resident interview Resident #18 was interviewed on 6/26/23 at 2:30 p.m. Resident #18 said she sometimes had to wait at least 30 minutes to get her call light answered. She said she put her call light on when she needed to have her brief changed or she wanted to get up or go back to bed. Resident #18 said she understood staff were very busy, however, she said it was frustrating to have to wait so long to receive assistance from staff. C. Record review Review of Resident #18's ADL care plan, initiated 5/12/18 and revised 4/10/23, revealed that the resident had experienced a decline in function from baseline with increased weakness, deconditioning and/or functional limitations. Review of Resident #18's call light log report from 6/1/23 to 6/25/23 revealed the following: -6/1/23 at 12:56 p.m: the call light was on for 24 minutes; -6/2/23 at 6:45 a.m: the call light was on for 49 minutes; -6/3/23 at 9:16 a.m: the call light was on for 39 minutes; -6/4/23 at 8:56 a.m: the call light was on for 20 minutes; -6/7/23 at 1:02 p.m: the call light was on for 25 minutes; -6/8/23 at 1:00 p.m: the call light was on for 29 minutes; -6/8/23 at 2:17 p.m: the call light was on for 25 minutes; -6/8/23 at 4:31 p.m: the call light was on for 21 minutes; -6/9/23 at 8:18 a.m: the call light was on for one hour and seven minutes; -6/9/23 at 10:58 a.m: the call light was on for 36 minutes; -6/10/23 at 4:42 p.m: the call light was on for 21 minutes; -6/13/23 at 6:28 a.m: the call light was on for one hour and 26 minutes; -6/14/23 at 6:33 a.m: the call light was on for 29 minutes; -6/15/23 at 7:13 a.m: the call light was on for 55 minutes; -6/16/23 at 7:10 a.m: the call light was on for 30 minutes; -6/16/23 at 1:12 p.m: the call light was on for 20 minutes; -6/17/23 at 10:10 a.m: the call light was on for 58 minutes; -6/18/23 at 1:38 p.m: the call light was on for 25 minutes; -6/19/23 at 6:37 a.m: the call light was on for one hour and six minutes; -6/19/23 at 10:04 a.m: the call light was on for 55 minutes; -6/20/23 at 9:20 a.m: the call light was on for 42 minutes; -6/20/23 at 12:59 p.m: the call light was on for 28 minutes; -6/23/23 at 9:04 a.m: the call light was on for 26 minutes; -6/25/23 at 5:58 p.m: the call light was on for 30 minutes; and, -6/26/23 at 7:26 a.m: the call light was on for 47 minutes. VII. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/22/23 at 12:56 p.m. CNA #1 said resident call lights should be answered by staff as quickly as possible. She said residents' call lights should not be turned off until the resident had been assisted. She said if a second person was needed for a transfer, the call light should be turned off to acknowledge that the resident's request had been noted. CNA #1 said the call light should then be turned back on until that staff person found a second staff member to help with the transfer. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said call lights should not be on longer than 20 minutes if possible. She said call lights should be answered as quickly as possible. CNA #3 said staff should not turn off call lights until the resident's need had been met. The nursing home administrator (NHA) was interviewed on 6/26/23 at 4:20 p.m. The NHA said call lights should be answered as quickly as possible. She said call lights should be answered in under 20 minutes whenever it was possible. She said a mechanical lift or a second staff person to help with a resident transfer might not be available at times and the wait time for the resident might have to wait a little longer. The NHA said if a mechanical lift and a second person was needed for a transfer, the CNA should acknowledge the resident's request and turn off the call light. She said the CNA should explain to the resident that they would return after they obtained the lift and another staff member. She said the CNA should make every effort to return to finish assisting the resident as soon as possible.

Based on record review and interviews, the facility failed to ensure residents had a right to make choices about aspects of their life in the facility that were significant to the resident for three (#6, #7 and #11) of four residents reviewed for choices out of eight sample residents. Specifically, the facility failed to identify and honor resident preferences regarding wake up times for Resident #6, Resident #7 and Resident #11. Findings include: I. Facility policy and procedures The Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) on 6/29/23 at 10:38 a.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. When assisting with care, residents are supported in exercising their rights. For example, residents are allowed to choose when to sleep, eat and conduct activities of daily living. II. Resident #6 A. Resident status Resident #6, age 83, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included hemiplegia (complete paralysis of an extremity on one side of the body) and hemiparesis (weakness of an extremity on one side of the body) following cerebral infarction (stroke) affecting the left dominant side, lack of coordination and muscle weakness. The 3/22/23 minimum date set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The 10/7/22 annual MDS assessment revealed that it was very important to the resident to choose her own bedtimes. Wakeup times were not included in the MDS preferences assessment. B. Resident interview Resident #6 was interviewed on 6/26/23 at 11:13 a.m. Resident #6 said she liked to get up at 8:00 a.m. She said staff frequently did not get her up at her preferred wake up time. She said staff would often come into her room to get her up at 7:30 a.m. Resident #6 said she did not want to get up at 7:30 a.m. and staff would tell her they would return to get her up at 8:00 a.m. She said staff did not always come back at 8:00 a.m. and there had been many mornings when she did not get up until 9:00 a.m. or after. Resident #6 said not getting up at her preferred wake up time occurred at least three times per week. C. Record review -Review of Resident #6's comprehensive care plan, initiated 12/2/2020 and last revised 6/16/23, did not include specific preferences. -Review of Resident #6's resident information sheet, which was a tool used by staff to provide consistent care for the resident, did not include the resident's preferences for wake up times. -There was no documentation of preferences in the resident's medical record, other than the MDS assessments. III. Resident #7 A. Resident status Resident #7, age 66, was admitted on [DATE] and readmitted on [DATE]. According to the June CPO, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle weakness and muscle spasms. The 6/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required two-person extensive assistance for bed mobility, transfers and toilet use. He required one-person extensive assistance for dressing and personal hygiene. The 7/5/22 annual MDS assessment revealed that it was somewhat important to the resident to choose his own bedtimes. Wakeup times were not included in the MDS preferences assessment. B. Resident interview Resident #7 was interviewed on 6/26/23 at 11:38 a.m. Resident #7 said he liked to get up at 6:30 a.m. every day. He said he had always been an early resident information sheeter. He said he liked to eat breakfast around 7:00 a.m. in the dining room. He said he pushed his call light at 6:30 a.m. and a certified nurse aide (CNA) would often come into his room and tell him they needed to go find someone to help with his mechanical lift transfer and they would be back. He said the CNAs would turn off his call light and not return until 7:00 a.m. or later. Resident #7 said it did not happen every day, however, he said it happened often enough that it was frustrating. He said on the days he did not get up at his preferred time of 6:30 a.m. he did not get to the dining room for breakfast until at least 8:00 a.m. C. Record review -Review of Resident #7's comprehensive care plan, initiated 8/27/2020 and last revised 5/31/23, did not include specific preferences. -Review of Resident #7's resident information sheet did not include the resident's preferences for wake up times. -There was no documentation of preferences in the resident's medical record, other than the MDS assessments. IV. Resident #11 A. Resident status Resident #11, age 74, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO, diagnoses included shortness of breath, lack of coordination, fatigue and weakness. The 5/10/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person limited assistance for dressing. She required one-person extensive assistance for personal hygiene. She was totally dependent on one staff person for toilet use. It was very important to the resident to choose her own bedtimes. Wakeup times were not included in the MDS preferences assessment. B. Resident interview Resident #11 was interviewed on 6/26/23 at 11:01 a.m. Resident #11 said she liked to get up at 6:00 a.m. every day because she liked to eat breakfast early. She said staff often did not come to get her up until 7:00 a.m. She said it was frustrating to not be able to get up at the time she would like to get up every morning. C. Record review -Review of Resident #11's comprehensive care plan, initiated 7/21/18 and last revised 5/24/23, did not include specific preferences. -Review of Resident #11's resident information sheet did not include the resident's preferences for wake up times. -There was no documentation of preferences in the resident's medical record, other than the MDS assessments. V. Staff interviews CNA #2 was interviewed on 6/22/23 at 1:10 p.m. CNA #2 said residents were asked what time they wanted to get up in the morning and their preferences were supposed to be documented on the resident information sheet so CNAs knew what time each resident preferred to get up for the day. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said resident preferences, such as wake up times were documented on the resident information sheet. She said CNAs used the resident information sheet to provide consistent care for each resident, including their preferences. -After looking at the resident information sheet which she was carrying in her pocket, CNA #3 said the resident information sheet did not document the residents' preferences. She said the preferences used to be on the resident information sheet and she was not aware that they were no longer on the sheet. CNA #4 was interviewed on 6/26/23 at 3:43 p.m. CNA #4 said preferences for each resident were documented on the resident information sheet. He said the resident information sheet was supposed to contain preferences such as when each resident liked to get up in the morning so CNAs knew how to care consistently for each resident. The NHA was interviewed on 6/26/23 at 4:20 p.m. The NHA said she had only been the administrator at the facility since March 2023, so she was not sure exactly where resident preferences were documented. She said she would think if a resident expressed a preference for wake up times their preference should be documented on the resident information sheet so CNAs would know when to get the resident up in the morning. She said preferences should be documented on the resident's care plan. The NHA said resident preferences should be followed because the facility was their home and staff should do everything possible to honor their choices and create the best homelike environment for each resident.

Based on observation, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene for four (#3, #6, #11 and #18) of eight residents out of eight sample residents. Specifically, the facility failed to ensure Resident #3, Resident #6, Resident #11 and Resident #18 were provided consistent baths according to their plan of care. Findings include: I. Facility policy and procedures The Activities of Daily Living policy, revised 2/9/22, was provided by the nursing home administrator (NHA) via email on 6/28/23 at 3:08 p.m. It read in pertinent part, The facility will provide necessary care and services for residents based upon the comprehensive assessment of each resident and consistent with each resident's needs and choices. A resident who is unable to carry out activities of daily living (ADLs) will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Upon admission each resident is assessed to determine ADL ability. Resident's are encouraged to participate in ADLs to maintain the highest level of independence. If it is determined that a resident is unable to adequately perform an ADL, the facility will assist the resident to the extent necessary as stated in the plan of care. II. Resident council minutes Review of the monthly resident council minutes revealed the following: -4/14/23: residents had concerns regarding bath schedules not being followed; -5/12/23: residents continued to have concerns regarding bath schedules not being followed; and, -6/9/23: residents again indicated bath schedules continued to be an issue for some residents. III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included congestive heart failure, age-related osteoporosis (weak, brittle bones), pain in left and right hips, low back pain and glaucoma. The 2/20/23 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers and toilet use. She required one-person limited assistance for dressing and personal hygiene. She required one-person physical help in part of her bathing activity. B. Resident interview Resident #3 was interviewed on 6/26/23 at 2:59 p.m. Resident #3 said she only received one bath per week. She said she would prefer at least two baths and would be happier if she could have three baths per week. Resident #3 said sometimes she did not even receive one bath per week. She said she had gone at least two weeks on occasion without receiving a bath. C. Record review Review of Resident #3's activities of daily living (ADL) care plan, initiated 12/4/2020 and revised 4/4/23, revealed that the resident needed limited to extensive assistance with some ADL activities related to weakness and deconditioning. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request; utilizing resident's preferences for bathing products and individualized bathing schedule and providing the resident with two baths a week unless otherwise indicated. -The care plan did not document how many baths per week the resident preferred. Review of the preprinted weekly bath schedule revealed Resident #3 was scheduled for one bath per week on Friday evenings. -Despite the care plan documenting the resident was to be provided with two baths per week unless otherwise indicated, Resident #3 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #3's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following: -5/1/23 to 5/7/23: The resident received one bath on 5/3/23; -5/8/23 to 5/14/23: The resident received one bath on 5/10/23; -5/15/23 to 5/21/23: There was no bath documented for the resident; -5/22/23 to 5/28/23: The resident received one bath on 5/26/23 (16 days after her last bath on 5/10/23; -5/29/23 to 6/4/23: The resident received one bath on 6/2/23; -6/5/23 to 6/11/23: The resident received one bath on 6/8/23; -6/12/23 to 6/18/23: The resident received one bath on 6/16/23 (eight days after her last bath on 6/8/23; and, -6/19/23 to 6/25/23: The resident received one bath on 6/23/23. -The weekly bath schedules had no documentation to indicate Resident #3 had refused any baths. IV. Resident #6 A. Resident status Resident #6, age 83, was admitted on [DATE]. According to the June 2023 CPO, diagnoses included hemiplegia (complete paralysis of an extremity on one side of the body) and hemiparesis (weakness of an extremity on one side of the body) following cerebral infarction (stroke) affecting the left dominant side, lack of coordination and muscle weakness. The 3/22/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She required one-person physical help in part of her bathing activity. B. Resident interview Resident #6 was interviewed on 6/26/23 at 11:13 a.m. Resident #6 said she received one bath per week. She said one bath was okay, however, she said it would be nice to have two baths per week. Resident #6 said she did not always get her bath every week. She said she had gone two weeks without a bath before and she felt dirty and smelly. She said she was very particular about her baths and would occasionally refuse a bath if she did not like how the certified nurse aide (CNA) gave her a shower. She said she usually took her baths when they were offered. C. Record review Review of Resident #6's ADL care plan, initiated 12/2/2020 and revised 3/27/23, revealed that the resident needed limited to extensive assistance with some ADL activities. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request; utilizing resident's preferences for bathing products and individualized bathing schedule and providing the resident with two baths a week unless otherwise indicated. -The care plan did not document how many baths per week the resident preferred. Review of the preprinted weekly bath schedule revealed Resident #6 was scheduled for one bath per week on Tuesday evenings. -Despite the care plan documenting the resident was to be provided with two baths per week unless otherwise indicated, Resident #6 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #6's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following: -5/1/23 to 5/7/23: The resident received one bath on 5/2/23; -5/8/23 to 5/14/23: The resident received one bath on 5/9/23; -5/15/23 to 5/21/23: The resident received one bath on 5/16/23; -5/22/23 to 5/28/23: The resident received one bath on 5/26/23 (10 days after her last bath on 5/16/23); -5/29/23 to 6/4/23: The resident received one bath on 5/31/23; -6/5/23 to 6/11/23: There was no bath documented for the resident; -6/12/23 to 6/18/23: There was no bath documented for the resident; and, -6/19/23 to 6/25/23: There was no bath documented for the resident (the resident's last documented bath was 5/31/23 and she had not had a bath in over 21 days). -The weekly bath schedules had no documentation to indicate Resident #6 had refused any baths. V. Resident #11 A. Resident status Resident #11, age 74, was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO, diagnoses included shortness of breath, lack of coordination, fatigue and weakness. The 5/10/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. She required two-person extensive assistance for bed mobility and transfers. She required one-person limited assistance for dressing. She required one-person extensive assistance for personal hygiene. She was totally dependent on one staff person for toilet use. The MDS assessment documented that bathing activity had not occurred during the seven day look back period. B. Resident interview Resident #11 was interviewed on 6/26/23 at 11:01 a.m. Resident #11 said she received one bath per week. She said she would like to have two baths per week. She said there were weeks when she did not receive a bath at all. She said she had gone two weeks without a bath. Resident #11 said she felt unclean when she did not receive her baths. C. Record review Review of Resident #11's ADL care plan, initiated 7/12/18 and revised 5/24/23, revealed that the resident needed limited to extensive to total assistance with some ADL activities. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request of two per week and utilizing resident's preferences for bathing products and individualized bathing schedule. Review of the preprinted weekly bath schedule revealed Resident #11 was scheduled for one bath per week on Friday evenings. -Despite the care plan documenting the resident was to be provided with two baths per week, Resident #11 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #11's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following: -5/1/23 to 5/7/23: The resident received one bath on 5/6/23; -5/8/23 to 5/14/23: The resident received one bath on 5/13/23; -5/15/23 to 5/21/23: There was no bath documented for the resident; -5/22/23 to 5/28/23: The resident received a bath on 5/26/23 (13 days after her last bath on 5/13/23); -5/29/23 to 6/4/23: There was no bath documented for the resident; -6/5/23 to 6/11/23: The resident received a bath on 6/9/23 (14 days after her last bath on 5/26/23); -6/12/23 to 6/18/23: The resident refused her bath on 6/16/23. There were no documented attempts to offer the resident another bath this week; and, -6/19/23 to 6/25/23: There was no bath documented for the resident (the resident's last documented bath was 6/9/23 and she had not had a bath in over 14 days). -The weekly bath schedules documented Resident #11 had refused one bath on 5/16/23. There was no other documentation to indicate the resident had refused any of her other baths. VI. Resident #18 A. Resident status Resident #18, age 84, was admitted on [DATE]. According to the June 2023 CPO, diagnoses included pain, lack of coordination, muscle weakness and contracture (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part) of the left elbow. The 4/5/23 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She was totally dependent on one staff person for bathing activity. B. Resident interview Resident #18 was interviewed on 6/26/23 at 2:30 p.m. Resident #18 said she received one bath per week. She said one bath per week was enough for her, however, she said she did not always receive her one bath. She said she sometimes went two weeks without a bath. C. Record review Review of Resident #18's ADL care plan, initiated 5/12/18 and revised 4/10/23, revealed that the resident had experienced a decline in function from baseline with increased weakness, deconditioning and/or functional limitations. Pertinent interventions included assisting the resident as needed with bathing; encouraging independence as much as possible; bathing frequency per resident's request; utilizing resident's preferences for bathing products and individualized bathing schedule and providing the resident with two baths per her preference. Review of the preprinted weekly bath schedule revealed Resident #18 was scheduled for one bath per week on Fridays during the day. -Despite the care plan documenting the resident was to be provided with two baths per week, Resident #18 was only scheduled to receive one bath per week on the bath schedule. Review of Resident #18's weekly bath schedules from 5/1/23 to 6/23/23 revealed the following: -5/1/23 to 5/7/23: The resident one bath on 5/4/23; -5/8/23 to 5/14/23: The resident one bath on 5/12/23; -5/15/23 to 5/21/23: There was no bath documented for the resident; -5/22/23 to 5/28/23: The resident received one bath on 5/26/23 (14 days since her last bath on 5/12/23); -5/29/23 to 6/4/23: There was no bath documented for the resident; -6/5/23 to 6/11/23: The resident received one bath on 6/9/23 (14 days since her last bath on 5/26/23); -6/12/23 to 6/18/23: The resident received one bath on 6/16/23; and, -6/19/23 to 6/25/23: The resident received one bath on 6/23/23. -The weekly bath schedules had no documentation to indicate Resident #18 had refused any baths. VII. Staff interviews CNA #2 was interviewed on 6/22/23 at 1:10 p.m. CNA #2 said the Mountain View unit was staffed with four to five CNAs for 45 residents. He said there was not a designated bath aide. He said the CNAs on the floor completed the baths for the residents on their individual hall assignments. CNA #2 said residents were supposed to receive two baths per week. He said sometimes the CNAs were not able to complete all of the baths for the day. He said if a resident refused a bath or it was not completed, attempts were made to complete the bath on a different day that same week. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said residents were scheduled for one bath per week. She said floor CNAs were responsible for completing the baths scheduled for their own hall assignments. She said the CNAs did the best they could, however, she said there were days that not all of the resident baths were completed. CNA #3 said if a bath was not completed attempts were made to complete the bath on a different day. The NHA and the director of nursing (DON) were interviewed together on 6/26/23 at 4:20 p.m. The NHA said she had been at the facility since March 2023. The DON said she had been at the facility for less than one week. The NHA said when she became the NHA at the facility in March 2023 residents were receiving one bath per week. She said the facility had recently identified that residents would prefer more than one bath per week. She said the facility had started a performance improvement plan the week of 6/19/23 to update residents' bathing preferences and work on ensuring residents received their preferred number of baths per week. She said the facility did not have designated bath aides. The NHA said that each CNA was assigned to complete the baths each day for the residents on their hall assignment. She said the facility was staffed so that each CNA could reasonably complete their resident baths each day. VIII. Facility follow-up On 6/29/23 at 10:38 a.m., after the survey exit, the NHA sent a copy via email of a Personal Bathing Preferences form. The form included questions for residents' preferred type of bath, number of baths preferred per week, preferred days of the week for bathing and preferred time of day for bathing. -The NHA did not provide a copy of the facility's performance improvement plan which the NHA said was started the week of 6/19/23.

Based on observations and interviews the facility failed to ensure residents resided in a sanitary and comfortable environment for five of 15 rooms observed for cleanliness. Specifically the facility failed to ensure resident rooms were free from dirty clothes/linens and trash and debris on the floor. Findings include: I. Facility policy and procedures The Homelike Environment policy, last revised February 2021, was provided by the nursing home administrator (NHA) via email on 6/28/23 at 3:08 p.m. It read in pertinent part, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. II. Observations A. room [ROOM NUMBER] On 6/22/23 at 12:59 p.m., a wadded up facial tissue was on the floor just inside the entrance to the room by the door. There were several small bits of trash debris on the floor. A small decorative pillow was on the floor underneath the resident's bed. At 5:08 p.m., the wadded up facial tissue was still on the floor near the door of the room and the small bits of trash debris on the floor were still present. The decorative pillow was still on the floor underneath the bed. -No staff members had picked up the trash on the floor of the room in over four hours. On 6/26/23 at 2:59 p.m. the small decorative pillow was still on the floor underneath the resident's bed. -No staff member had picked up the decorative pillow in four days. B. room [ROOM NUMBER] On 6/22/23 at 1:02 p.m., there were several bits of small trash debris on the floor throughout the entire room. An empty brown sugar instant oatmeal packet was on the floor on the window side of the room near the half full trash can. A small pillow covered in a pillow case was on the floor by the bed on the window side of the room and a red square sticky note was on the floor in the middle of the room. At 5:03 p.m., the small trash debris including the red sticky note and the empty oatmeal packet had been picked up, however, the small pillow remained on the floor by the bed on the window side of the room. -No staff members had picked up the pillow on the floor of the room in over four hours. C. room [ROOM NUMBER] On 6/22/23 at 1:35 p.m., there were several small pieces of trash debris observed on the floor of the room. There was a pair of wadded up red pants on the floor in front of a large grandfather clock in the room. At 4:42 p.m., the small pieces of trash debris were no longer on the floor, however, the wadded up red pants were still on the floor in front of the clock. -No staff members had picked up the wadded up red pants on the floor of the room in over three hours. D. room [ROOM NUMBER] On 6/22/23 at 5:11 p.m., the resident's bed was stripped of all bed coverings. There was a white plastic spoon and a wadded up facial tissue on the floor under the bed. There was a pillowcase on the floor at the foot of the bed. At 5:12 pm, two certified nurse aides (CNAs) looked into the room and commented about the bed not being made. The CNAs proceeded down the hall after looking in the resident's room. -Neither CNA attempted to pick up the spoon, facial tissue or pillowcase that were on the floor in the room. E. room [ROOM NUMBER] On 6/26/23 at 10:56 a.m., a folded up piece of paper was on the floor under a small table by the window. There was a blouse on the floor of the room by a desk chair. At 3:30 p.m., the folded up piece of paper and the blouse were still on the floor in the room. -No staff member had picked up the folded piece of paper or the blouse in over four hours. III. Interviews The housekeeping supervisor (HSKS) was interviewed on 6/26/23 at 1:20 p.m. The HSKS said all resident rooms were cleaned one time daily. She said all high touch areas were cleaned daily. She said the floors were swept and mopped daily. The HSKS said if trash or clothing/linens were observed on the floor after the room had been cleaned by the housekeeper, it was the duty of all staff to pick it up. CNA #3 was interviewed on 6/26/23 at 2:50 p.m. CNA #3 said if any staff member observed trash, clothes, linens or pillows on the floor of a resident's room the staff member should pick the items up. She said it was not just the housekeeper's job. CNA #4 was interviewed on 6/26/23 at 3:43 p.m. CNA #4 said picking up trash on the floor of resident rooms was any staff's responsibility. He said dirty clothes and pillows should not be on the floor and should be picked up if they were noticed by a staff member. The nursing home administrator (NHA) was interviewed on 6/26/23 at 4:20 p.m. The NHA said resident rooms were cleaned every day by the housekeeping staff. She said picking up trash or other items off the floor of a resident's room was not just a housekeeper's job. The NHA said every staff member was responsible for picking up items off the floor when they noticed them. She said most people would not leave trash or clothes/linens lying on the floor of their homes. The NHA said the facility had a responsibility to provide the residents with an environment that was as homelike as possible, which included keeping their rooms clean and picked up.

Based on record review and interviews, the facility failed to keep the resident environment as free of accident hazards as possible, and provide adequate supervision to prevent accidents for two (#3 and #4) of three residents out of 10 sample residents. Specifically, the facility failed to: -Ensure Resident #3 was safe with the use of his motorized wheelchair which resulted in an injury to another resident; and, -Conduct routine motorized wheelchair safety assessments for Resident #4. Findings include: I. Facility policy and procedure The Electric Wheelchairs policy, revised 5/16/22, was provided by the nursing home administrator (NHA) on 7/26/22 at 1:35 p.m. It read, in pertinent part, The facility will allow the use of electric wheelchairs/scooters when medically necessary and if the resident is capable to operate the electric wheelchair/scooter in a manner which does not endanger the safety of others. Documentation of medical need and on-going safety assessment by a trained professional are required for clearance to use an electric wheelchair/scooter for medical purposes while residing at the facility. A resident interested in obtaining an electric wheelchair/scooter should consult with their social services representative, or with the admissions coordinator if prior to admission. A physician's order for an occupational or physical therapy evaluation will be requested. After the therapy evaluation, a recommendation will be made. If the occupational or physical therapist determines that an electric wheelchair/scooter is medically necessary, an assessment will be completed to determine if the resident is capable of safely operating the equipment in the facility. Ongoing evaluations by an occupational therapist, physical therapist, restorative supervisor, or nurse manager will occur at least annually, and more often if necessary, to ensure the resident remains capable of safely operating the electric wheelchair/scooter. These evaluations may be prompted by any number of situations, including but not limited to operating the equipment at unsafe speeds, unsafe handling of the electric wheelchair/scooter around other residents, staff, and/or family members, and accidents involving the use of the electric wheelchair/scooter. If it is determined that a resident is unsafe to use an electric wheelchair/scooter, the electric wheelchair must be removed from the facility. If a resident intentionally or unintentionally harms another individual, such as bumps into, hits, runs over, etc., the resident may lose the clearance to use the equipment while residing at the facility. Wheelchair/scooter must be on the 'slow' speed setting in the facility. II. Resident #3 A. Resident status Resident #3, age younger than 70, was admitted on [DATE], and readmitted on [DATE]. According to the July 2022 computerized physician orders (CPO), diagnoses included [CONDITION(S)], attention and concentration deficit, major depressive disorder, lack of coordination, and functional [CONDITION(S)]. The 6/29/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status of 14 out of 15. He required two-person extensive assistance for bed mobility. He required one-person extensive assistance for dressing, toilet use, and personal hygiene. He was totally dependent on staff for transfers and locomotion. B. Resident observation and interview On 7/26/22 at 11:20 a.m., Resident #3 was observed seated in a Broda wheelchair (a tilt-in-space positioning wheelchair) in his room. He was watching television (TV). Resident #3 said he used to have an electric wheelchair but the facility took it away because he ran into another resident in the dining room. He said he accidentally hit forward instead of reverse with the wheelchair control. He said he pushed a dining room table into the other resident which hurt the other resident. He said the facility said it was unsafe for him to use the electric wheelchair because he was having trouble controlling the electric wheelchair. He said he received therapy services to help him use a manual wheelchair, however he did not like the manual wheelchair and chose to use the Broda wheelchair. He said therapy did not work with him on being safer with his electric wheelchair. C. Record review Review of Resident #3's electronic medical record (EMR) revealed the following progress notes, documented in pertinent part: 2/18/22 at 9:36 p.m: Resident bumped into both me and another registered nurse (RN) as he was passing in his wheelchair without any attempt to slow down. I discussed with him the need to slow down and/or give people time to move so that he could pass safely. No indication made of understanding. 2/20/22 at 9:38 p.m: Resident used his wheelchair to block access to his room from the outside and fell asleep. A certified nurse aide (CNA) asked him to relocate his chair, that his behavior was unsafe and, also, it was unsafe to tip his chair as far back as he does. Resident #3 replied, 'Watch me. 2/22/22 at 10:37 p.m: Resident had announced that he wanted to be in bed by 7:30 p.m. At 7:00 p.m., Resident #3 began going up and down the halls in search of a CNA to put him to bed. As he began going down the hospice hall, I asked him to turn around and return to his room. His reply was, 'I don't want to.' As he approached my cart, I again asked him to return to his room and wait for the CNA to arrive. He did as he was asked but, within minutes, jammed his chair against his bed and required assistance to get his chair moving again. He then remained in his room. 3/16/22 at 12:19 p.m: Resident went into rooms 2 and 4. Staff spoke with resident to get resident to come out of the rooms. Resident was also spoken to by the administrator. Resident backed onto another resident's feet with his wheelchair. The other resident yelled out in pain and was able to get feet out from under the wheelchair. 3/20/22 at 9:32 a.m: Resident in room 18 came out yelling for the nurse to remove Resident #3 from her room. He was not invited and specifically told not to come in and he proceeded to continue rolling into the room. When approached by this writer to leave the room, he attempted to turn around and caught his chair on the outer door jam. When asked to stop to maneuver around this, Resident #3 continued to push forward causing damage to the door jam. 3/20/22 at 1:15 p.m: Resident went into room 16 without occupant's permission. Resident #3 was asked by this nurse to leave the room as he was not invited in. Resident backed out and hit the door two times but continued to power his wheelchair through. 3/22/22: Resident was chasing a CNA in hallway to and from dining room. Upon approaching the nurses station, Resident #3 was asked to wait a moment while the resident sitting there could complete her blood draw. Resident #3 continued to push his wheelchair, bumping the other resident while the phlebotomist had a needle in the other resident's vein. Resident #3 was asked to stop yet he proceeded to push through. Will continue to monitor. -Despite the above incidents and concerns for Resident #3 to operate his electric wheelchair safely, there was no documentation indicating the facility's interdisciplinary team (IDT) had met to discuss the safety concerns. -Despite the above incidents, an electric wheelchair safety evaluation was not conducted by therapy until 3/24/22. The evaluation concluded Resident #3 was safe to continue using his electric wheelchair, despite the safety concerns from the above incidents (see the electric wheelchair safety evaluation below). 4/13/22 at 12:40 p.m: Resident in room 19 just reported Resident #3 hitting her in her wheelchair, on two separate occasions, while down in the Mountainview parlor. She also reported witnessing Resident #3 back into another resident from another unit down in the parlor around the same time. No injuries reported. Will continue to monitor. 4/22/22 at 10:29 a.m: Another resident came to the front desk, complaining that Resident #3 had run over her foot with his electric wheelchair. She said she told the nurse at the station. 4/23/22 at 12:53 a.m: This resident ran over another resident's foot on the dayshift on 4/22/22. Follow up with day charge and day nurse for details. -Despite the above incidents, which occurred after the electric wheelchair evaluation on 3/24/22, and concerns for Resident #3 to operate his electric wheelchair safely, there was no documentation indicating the facility's interdisciplinary team (IDT) had met to discuss the safety concerns. -Despite the above incidents, another electric wheelchair safety evaluation was not conducted by therapy. -Despite the above incidents, Resident #3 was allowed to continue using his electric wheelchair in the facility. 6/14/22 at 5:59 p.m: At 5:15 p.m. as Resident #3 came to the dining room, resident rammed the dining table and then backed up electric wheelchair and sped forward ramming the dining tables, causing the tables to slide and rammed into the resident across the table causing a skin tear to her right arm as the resident was trying to protect herself with her arm. Resident #3 was asked to transfer to a manual wheelchair after refusing to leave the dining room as female residents were nervous. Resident was transferred into a manual wheelchair. This caregiver explained to the resident how female residents were feeling. So at this time the resident is in a manual wheelchair. Contacted charge nurse of occurrence and charge nurse contacted the director of nursing (DON). 6/16/22 at 10:19 a.m: IDT met on this date to review policy regarding electric wheelchair use and incident involving resident in the dining room evening of 6/14/22. Camera footage was reviewed by DON, social services director (SSD), and NHA on 6/15/22 in which the resident appeared to lose control of his electric wheelchair, running into a dining room table and pushing the table and the resident sitting on the other side of the table. Per policy, therapy will assist in transitioning the resident to a manual wheelchair in order to prevent other residents from being injured. 6/16/22 at 5:00 p.m: Met with resident early this afternoon to inform him that he would no longer be allowed to use his electric wheelchair in this facility per company policy due to the incident in the dining room on the evening of 6/14/22 in which another resident was injured when he lost control of his wheelchair. Resident initially did not understand why the chair needed to be taken away since he stated that the incident was an accident. Physical therapist (PT) explained that whether the incident in question was accidental or on purpose, it did not matter as the policy states that a resident must be able to control their electric wheelchair at all times to ensure their safety and the safety of others in the facility. Discussed other seating options with resident including Broda chair and the manual wheelchair that he has been using with occupational therapy (OT). Resident reported that he wanted to use the Broda chair full time even if it meant that he would be dependent for mobility. Once realization of the situation set in, the resident became very tearful. Resident was assisted into the Broda chair and encouraged to express his feelings as PT was aware that this was a big change and that it was okay for him to be upset about it. PT checked on the resident later in the afternoon and he stated that he was doing better and was glad that the Broda chair was at least comfortable. Resident's mother was present for both interactions on this date and expressed understanding regarding the facility's need to remove the electric wheelchair. Review of Resident #3's EMR revealed an electric wheelchair safety evaluation was conducted by therapy on 3/24/22. The resident scored a 34 out of 40 on the safety evaluation which indicated he was safe to use the electric wheelchair in the facility. -Despite the safety concerns documented in Resident #3's EMR (see progress notes above), there was no documentation to indicate the IDT had met to discuss whether or not the resident was safe to continue the use of his electric wheelchair as the safety evaluation concluded. -Despite the safety concerns documented in Resident #3's EMR (see progress notes above), there was no documentation the resident was provided with therapy services until 4/20/22. Review of therapy services documentation revealed the following progress notes, documented in pertinent part: 4/20/22: Resident currently seated in power tilt in space wheelchair, however, due to poor safety and behavioral choices in recent months, it has been recommended resident trial use of manual wheelchair to improve overall safety within the facility. OT provided education to resident and resident's mom on role of OT and goals related to manual wheelchair use. OT plans to trial the manual chair this week to work on positioning and the resident's ability for self propulsion. 4/22/22: Resident participated in wheelchair positioning/fit and self propulsion of manual wheelchair. Staff later alerted this OT that the resident was still up in manual wheelchair five hours after initially getting up in chair. Resident was reported to be heavily side leaning with concerns of discomfort and falling. OT went to the resident's room to provide further education to CNA staff and charge nurse of being left in chair, despite OT request to CNA staff to put him back into power chair four hours prior to this later event. 4/26/22: Resident seen for skilled OT to address wheelchair mobility and training, along with positioning in manual wheelchair. Lift used for transfer with the assistance of two people for safety from the power wheelchair to standard wheelchair. 5/2/22: Resident participated in functional mobility training using manual wheelchair. Resident trialed use of sit-to-stand lift with the assistance of two people with power wheelchair to standard wheelchair transfers with education on safety and positioning to facilitate safe transfer. 5/3/22: Resident seen for skilled OT to address manual wheelchair mobility, positioning and sitting tolerance. Resident performed transfer from power wheelchair to manual wheelchair with the use of sit-to-stand lift with two people. Resident tolerated transfer with good safety and improved positioning with legs. Resident encouraged to stay up in manual wheelchair for one and one-half hours to begin to build tolerance. 5/4/22: Resident in search of this OT early this morning with a report that his electric wheelchair was not working, and he needed to get in the manual wheelchair. Pt's (patient's) charger for the power chair does not seem to be working, as the chair has no charge. OT had CNA assist with full lift to manual wheelchair. Resident participated in self propulsion of 40 feet with several rest breaks. Resident encouraged to continue working on propulsion throughout the day with rest breaks as needed. 5/10/22: Resident back in power wheelchair this date after charger has been repaired. Resident reported the weekend in the manual wheelchair and Broda wheelchair, 'were terrible'. Resident and OT discussed poor safety and behavioral choices in power wheelchair, may result in having to be in manual wheelchair at all times if staff continues to report concerns. Resident reported he would 'follow the rules', not to lose his power wheelchair. Episodes of safety concerns were discussed including speed of mobility, going into other people's rooms, pushing others wheelchairs with his power chair, getting too close to staff and other residents during mobility, etc. 5/11/22: Resident seen for manual wheelchair management including schedule of getting up to manual wheelchair in morning, from 7:00 a.m. until 10:00 a.m. as discussed on day prior. When OT arrived to resident's room he was seated in power wheelchair at 9:00 a.m. Resident reported he did not get up to the manual wheelchair this morning as discussed because, 'I didn't want to'. OT provided education to both resident and staff on the purpose of manual wheelchair schedule to build tolerance for sitting upright and increase opportunities for self propulsion. Pt agreed to get into manual wheelchair with OT after education was provided and to allow him to be able to go out of the facility to park with the activities department. Resident stayed up in manual chair for three and a half hours without complaints. OT to follow up for schedule carryover and to continue to build tolerance. 5/18/22: Resident participated in skilled OT to work on self propulsion in manual wheelchair. Pt was able to self-propel 50 feet with two rest breaks. 5/24/22: Resident seen for wheelchair positioning and schedule this date. Resident was seated in the manual wheelchair without a cushion, reporting his bottom was hurting. OT provided education to resident/staff to remind them to move the cushion from power wheelchair to manual wheelchair with each transfer. OT verbally discussed schedule and positioning changes with CNA staff, resident and family. 5/31/22: Resident continues to report he is following the recommended manual wheelchair schedule of being in chair during the morning for approximately five hour intervals. Resident was seated with good positioning and no signs of hips sliding forward. 6/2/22: Resident seen for wheelchair positioning and mobility this date to monitor for comfort, posture, mobility and schedule in chair. 6/16/22: IDT meeting held this date to discuss plans to remove power wheelchair. Resident's most recent episode in the dining room causing injury to another resident has been cause for chair removal, along with months of other safety and behavioral concerns related to power wheelchair. OT provided an update on current manual wheelchair use and tolerance up to four hours at maximum due to reported pain and discomfort. Resident has used BRODA wheelchair in the past and this chair does provide comfort and positioning to allow for safety while seated and offloading for skin integrity. Resident is unable to self propel BRODA chair, therefore will need full staff assist with all mobility needs at this time. OT discsussed with resident a schedule for use of manual wheelchair versus BRODA wheelchair. Resident at this time has chosen to use BRODA wheelchair at all times, and does not wish to pursue manual wheelchair use due to discomfort. OT provided education to CNA and nursing staff on how to reposition and use handles to adjust BRODA with reclining and tilting options as needed. OT provided education on initial positioning when getting into the BRODA chair. Verbal education was provided to staff as well as visual signs hung in the room and at the nurses station. OT will further pursue outside vendors to research manual tilt-in-space wheelchair options that will allow him to self propel. -There was no documentation to indicate Resident #3 was receiving therapy services to address improving his safety with the use of his electric wheelchair. D. Resident interviews Resident #12 was interviewed on 7/26/22 at 10:22 a.m. Resident #12 said Resident #3 used to have an electric wheelchair but the facility took it away from him. She said the facility thought Resident #3 was being unsafe with his electric wheelchair and running into people. Resident #12 said sometimes Resident #3 would go too fast in his electric wheelchair, however she said she never saw him run into anyone. She said Resident #3 got his wheelchair taken away when he accidentally pushed his electric wheelchair into a dining room table and caused another resident to get a scratch on her arm. Resident #7 was interviewed on 7/26/22 at 11:05 a.m. Resident #7 said Resident #3 ran over her foot one time with his electric wheelchair. She said it hurt, however she did not think he did it on purpose. Resident #7 said Resident #3 continued to use his electric wheelchair in the facility after he ran over her foot. Resident #14 was interviewed on 7/26/22 at 10:35 a.m. Resident #14 said the facility had taken away Resident #3's electric wheelchair in June 2022. She said the wheelchair was taken away because he pushed a table in the dining room into her with his electric wheelchair. She said it was an accident, and that Resident #3 pushed forward on his electric wheelchair control instead of backward. Resident #14 said she got a skin tear and a bruise on her arm from the incident. Resident #14 said she had heard from other residents that Resident #3 had run into other people prior to the incident in the dining room. E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/26/22 at 11:35 a.m. LPN #1 said Resident #3 used to have an electric wheelchair, however it was taken away from him due to safety concerns. She said he would drive his electric wheelchair too fast in the hallways, and tilt the chair back so far that the chair was unsafe for him. LPN #1 said Resident #3 ran over a couple of resident's feet with his electric wheelchair and pushed a table in the dining room into another resident which caused her to get a skin tear on her arm. LPN #1 said Resident #3 would also enter other residents' rooms without being invited. She said the injury to the resident in the dining room was what caused the resident to lose the use of his electric wheelchair. CNA #1 was interviewed on 7/26/22 at 11:43 a.m. CNA #1 said Resident #3 would enter other residents' rooms without the other residents inviting him in. She said he also had a few instances where he bumped into things with his electric wheelchair and also ran over a resident's toes. She said he caused another resident to get a skin tear in the dining room when he ran into a table with his electric wheelchair. She said Resident #3 would also follow staff into other rooms in his electric wheelchair when they went in to assist other residents with care. CNA #1 said Resident #3 would drive his chair at unsafe speeds. She said she did not know if therapy ever tried to turn the speed down on his wheelchair. She said she knew therapy was working with the resident for a while with a manual wheelchair before his Broda chair, however she did not know if therapy had tried to improve his safety with the use of his electric wheelchair. The charge nurse (CN) was interviewed on 7/26/22 at 12:26 p.m. The CN said Resident #3 had had some safety concerns with the use of his electric wheelchair, and the facility had taken it away from him in June 2022 after he caused an injury to a resident in the dining room. She said he had driven his electric wheelchair into some tables which caused the other resident to get a skin tear on her arm when a table was pushed into her. The CN said she did not know if Resident #3 intentionally ran into the tables, however, she said he endangered another resident and so the wheelchair was taken away from him. She said Resident #3 could be safe with his electric wheelchair when he chose to be, as evidenced by his ability to pass the safety evaluation when he was being watched by the therapist. She said the resident did not choose to follow the safety protocols all of the time. She said the resident would also use his electric wheelchair to corner staff in the hallways and enter other residents' rooms without being invited in. The director of therapy (DOT) was interviewed on 7/26/22 at 12:55 p.m. The DOT said if a resident was noted to be unsafe with an electric wheelchair, including causing damage to doors with the wheelchair, or injury to themselves or others with the wheelchair, or using excess speed in the hallways, a new electric wheelchair safety assessment would be performed with that resident. She said Resident #3 could be careful and safe when he knew he was being watched. She said that was why the assessment conducted in March 2022 said he was safe with his electric wheelchair even after he had had some safety incidents with it. She said the facility might have been lenient with Resident #3 because of his age and diagnosis, and they wanted to be able to keep him as independent as possible for as long as they could. She said the IDT team had discussed the incidents and decided to keep monitoring him because we did not want to take away his independence. The DOT said she did not know if those conversations had been documented. She said she did not know if changing the speed of his wheelchair would have made a difference with his safety. She said therapy worked with the resident to enable him to build up tolerance to using a manual wheelchair in case the facility needed to take away his electric wheelchair for safety reasons. The DOT said maybe the facility should have taken away the resident's electric wheelchair prior to the incident in the dining room, however, she reiterated they did not want to take away his independence. She said she performed a safety assessment of the resident a couple of days prior to the dining room incident because he wanted to be able to take himself to the park. She said the resident was able to pass that safety evaluation as well. -The safety evaluation which was conducted just prior to the incident in the dining room in June 2022 could not be found in the resident's EMR at the time of the survey. The social services director (SSD) was interviewed on 7/26/22 at 1:30 p.m. The SSD said Resident #3 had been using his electric wheelchair to enter other residents' rooms uninvited at the beginning of 2022. She said the facility reached out to the ombudsman for recommendations and the ombudsman said they could not take away his wheelchair because he had the right to use it. The SSD said the facility felt like their hands were tied, and then he started having issues with safety, such as running over another resident's foot and he also damaged some doors with his wheelchair. She said his wheelchair was ultimately taken away from him when he caused a skin tear to another resident in the dining room when he used his wheelchair to push some tables into her. The SSD said the facility did talk about the safety incidents when they came up, however the ombudsman kept reiterating that his right to the wheelchair was a federally protected right and so the facility allowed him to keep using the electric wheelchair. She said perhaps the facility should have moved sooner to have discussions as an IDT team in regards to taking away Resident #3's electric wheelchair, prior to him injuring another resident. She said if the ombudsman had not been so adamant, the facility might have acted after the resident first ran over another resident's foot, and taken away the electric wheelchair until he could demonstrate the ability to use the wheelchair safely at all times. The NHA was interviewed on 7/26/22 at 2:33 p.m. The NHA said Resident #3 initially had unsafe behaviors with his electric wheelchair where he was cornering staff in the hallways, following staff, and blocking hallways with his wheelchair. He said the resident then began using his electric wheelchair to go into other residents' rooms without being invited. He said the resident then transitioned into physical safety concerns with the wheelchair, including running over another resident's foot, backing his wheelchair into another resident who was getting her blood drawn, and finally the incident in the dining room where he pushed a table into another resident with his wheelchair causing an injury to the other resident. The NHA said the incident in the dining room was the incident that caused the facility to take away the resident's electric wheelchair. He said the facility had multiple conversations after the incidents to talk about whether or not he should be allowed to continue using the electric wheelchair. He said the conversations should be documented in the resident's EMR. The NHA said the facility did not want to take away the resident's independence if it was not warranted. He said the severity of the incident in the dining room, which was more severe than the prior safety incidents, was what warranted the resident to lose the use of his electric wheelchair. He said in hindsight, perhaps the facility should have taken away the resident's chair sooner, prior to him causing an injury to another resident. F. Facility followup On 7/27/22, following the survey, the NHA provided, via email, a timeline of unsafe incidents which occurred with Resident #3 and his electric wheelchair. The timeline documented the following three incidents: -3/25/22: incident where a resident had her wheelchair bumped during a blood draw at the nurses station; -4/23/22: incident where a resident had her toes run over; and, -6/14/22: incident in the dining room where Resident #3 ran into the tables and pushed them into another resident. -The 3/25/22 incident referred to actually occurred on 3/22/22. -The 4/23/22 incident referred to actually occurred on 4/22/22. -The NHA did not address any of the incidents which occurred prior to 3/22/22 (see progress notes above). The NHA said The facility reviewed the first two incidents in IDT and rather than removing the wheelchair, put interventions in place to work with Resident #3 on wheelchair safety rather than remove at that time (PT/OT eval and treat, monitor and redirect). The severity of the third incident which occurred in the dining room was reviewed by the IDT team to include the Medical Director. At that time the decision was made to remove the wheelchair. -There was no documentation found in Resident #3's EMR to indicate the IDT team reviewed the first two incidents in the timeline, and none was provided by the facility during or after the survey (see record review above). -Therapy notes did not document that electric wheelchair safety was being addressed during therapy sessions (see therapy progress notes above). III. Resident #4 A. Resident status Resident #4, age 90, was admitted on [DATE]. According to the July 2022 CPO, diagnoses included pain in right and left hips, difficulty in walking, lack of coordination, polyneuropathy, and [CONDITION(S)]. The 6/14/22 MDS assessment revealed that the resident was cognitively intact with a BIMS of 14 out of 15. She was independent with bed mobility, transfers, toilet use, and personal hygiene. She required supervision with dressing. B. Record review -Review of Resident #4's EMR did not reveal documentation of an electric wheelchair safety assessment performed upon the resident's admission to the facility in August 2020. -There were no electric wheelchair safety evaluations documented in the resident's EMR since her admission to the facility. C. Resident interview Resident #4 was interviewed on 7/26/22 at 11:20 a.m. Resident #4 said she could not remember if therapy had conducted an electric wheelchair safety evaluation since she had been admitted to the facility. D. Interviews LPN #1 was interviewed on 7/26/22 at 11:35 a.m. LPN #1 said residents were assessed by therapy for electric wheelchair safety when they were admitted to the facility with an electric wheelchair. She said staff would monitor residents for speed and safety issues. She said if safety issues were identified, then therapy would usually get involved and work with the resident to try to improve their safety with using the electric wheelchair. CNA #1 was interviewed on 7/26/22 at 11:43 a.m. CNA #1 said residents were assessed by therapy for electric wheelchair safety when they were admitted . She said if therapy concluded the resident was safe with the electric wheelchair then the resident was allowed to use the chair in the facility. She said if there were some safety concerns, then the resident would usually work with therapy to see if they might be able to use the electric wheelchair after some therapy. The charge nurse (CN) was interviewed on 7/26/22 at 12:26 p.m. The CN said therapy conducted an electric wheelchair safety evaluation with all residents with an electric wheelchair upon admission to the facility. She said if therapy deemed [TRUNCATED]