Every finding on record at Parkview Care Center

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections in three of four hallways.Specifically, the facility failed to:-Ensure staff donned (put on) the appropriate personal protective equipment (PPE) for a resident requiring enhanced barrier precautions (EBP) during wound care for Resident #10;-Ensure housekeeping staff cleaned the residents' toilets in a sanitary manner;-Ensure sterility was maintained during tracheostomy care and suctioning for Resident #66; and,-Ensure staff performed hand hygiene while providing meal assistance. Findings include: I. Facility policy and procedure The Infection Control and Surveillance policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 5/19/26 at 8:40 a.m. It read in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Important facets of infection prevention include identifying possible infections or potential complications of existing infections; instituting measures to avoid complications or dissemination; educating staff and ensuring that they adhere to proper techniques and procedures; communicating the importance of standard precautions and cough etiquette to visitors and family members; enhancing screening for possible significant pathogens; immunizing residents and staff to try to prevent illness; implementing appropriate isolation precautions when necessary; and, following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). II. EBP failures A. Professional reference Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), 4/2/24, was retrieved 5/25/26. It read in pertinent part, EBP expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for EBP include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; and, wound care: any skin opening requiring a dressing. In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. B. Facility policy and procedure The EBP policy, dated December 2024, was provided by the NHA on 5/21/26 at 3:45 p.m. It read in pertinent part, EBP are utilized to prevent the spread of MDROs to residents. EBP refers to infection prevention and control interventions designed to reduce the transmission of MDROs during high contract resident care activities. EBP applies when: a resident is infected or colonized with a CDC-targeted MDRO but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained; a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices and does not have secretions or excretions that are unable to be covered or contained; and, contact precautions do not otherwise apply. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen. EBP employs targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include: dressing, bathing/showering, providing hygiene, changing briefs or assisting with toileting, transferring, changing linens, prolonged contact with items in the resident's room, device care or use and wound care. C. Record review Review of Resident #10's May 2026 computerized physician orders (CPO) revealed the following physician's order: EBP: staff to utilize gowns and gloves for high-contact resident care activities (wound), ordered 4/4/26. Review of Resident #10's skin integrity care plan, initiated 9/29/24, revealed the resident had a right medial malleolus (ankle) diabetic ulcer. Pertinent interventions included following EBP including gowns and gloves for high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator). D. Observation On 5/19/26 at 11:25 a.m. wound care for Resident #10's diabetic foot wound was observed with licensed practical nurse (LPN) #1. She donned a pair of gloves and placed a towel on the floor beneath the resident's right foot. LPN #1 completed wound care according to the physician's orders. -However, LPN #1 failed to don a gown while providing wound care to Resident #10. E. Staff interviews LPN #1 was interviewed on 5/19/26 at 11:45 a.m. LPN #1 said she did not know what EBP was. She said Resident #10 was not on any precautions and the sign and supplies might have still been up from a recent roommate. LPN #1 said she thought the MDS coordinator or the infection preventionist was responsible for making sure the isolation precaution signage were updated and accurate for each resident. Certified nurse aide (CNA) #3 was interviewed on 5/21/26 at 10:52 a.m. CNA #3 said when a resident was on EBP she should wash her hands and wear gloves, a mask and a gown. She said she knew a resident should be on EBP because it was documented on the facility's documentation system and posted on the resident's door. CNA #3 said Resident #10 was on EBP for her foot wound. She said it was important to follow EBP so that she would not come in contact with any infections. Registered nurse (RN) #2 was interviewed on 5/21/26 at 10:50 a.m. RN #2 said EBP was indicated when the resident had an infection, and EBP was documented in the resident's MAR as well as posted on the resident's door. She said if there was a change in isolation status it would be discussed in shift to shift report. RN #2 said Resident #10 was on EBP for a wound on her foot. She said it was important to follow EBP because the nurse would not want to get contaminated with bacteria while performing wound care. RN #2 said staff should wear the necessary equipment to protect themselves and others. The clinical nurse consultant was interviewed on 5/21/26 at 12:51 p.m. The clinical nurse consultant said she was filling in for the infection preventionist. She said in order to determine if EBP should be implemented for a resident she would have to identify the organism. The clinical nurse consultant said quite a few residents at the facility were on EBP due to gastrostomy tubes (a medical device inserted through the abdomen directly into the stomach that delivers nutrition, hydration and medications to people who cannot safely eat or consume enough calories by mouth), tracheostomies (an opening in the neck to the trachea that provides an alternative airway for breathing and clearing lung secretions), catheters and wounds. She said the staff knew which residents were on EBP because there was signage outside the resident's door that told the staff which isolation precaution to use, and there were EBP supplies ready to go on the resident's door. The clinical nurse consultant said Resident #10 should be on EBP due to a chronic wound. The assistant director of nursing (ADON) was interviewed on 5/21/26 at 2:04 p.m. The ADON said she was filling in for the director of nursing (DON) while she was out. The ADON said EBP was for when a resident had a wound, a foley catheter, a colostomy (a surgical procedure that brings a section of the large intestine to the outside of the abdominal wall to create an opening called a stoma), ileostomy (a stoma that connects the small intestine to the outside of the abdominal wall) or urostomy (a surgical procedure that creates an alternative pathway for urine to leave the body through a stoma). She said staff needed to wear a gown and gloves to provide resident care. The ADON said Resident #10 was on EBP. She said the staff knew to wear the gown and gloves because it was posted on the resident's door. The ADON said it was important to follow EBP to prevent contamination of potential infectious organisms from resident to resident. III. Housekeeping failure A. Professional references Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 5/25/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 5/25/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Observations On 5/20/26 at 9:23 a.m. housekeeper (HK) #1 prepared to enter room [ROOM NUMBER], a double occupancy room. Before HK #1 entered the room, HK #2 came over to help HK #1. HK #1 and HK #2 performed hand hygiene with sanitizer, donned a clean pair of gloves and entered the room together. HK #2 began spraying the Clorox fuzion disinfectant spray on high-touch surfaces, including side A's bedside table, bed remote and call light. HK #1 entered the residents' bathroom with a toilet brush and toilet cleaner. HK #1 scrubbed the inside of the toilet bowl with the toilet brush, then used the toilet brush to scrub the toilet seat. Next, HK #1 raised the toilet seat and scrubbed the inside of the toilet bowl with the toilet brush again. -HK #1 failed to clean the toilet in a sanitary manner from the cleanest area to the dirtiest area in room [ROOM NUMBER]. On 5/20/26 at 9:37 a.m. HK #1 was cleaning room [ROOM NUMBER], a double occupancy room. HK #1 entered the resident's room with clean rags and the Clorox fuzion disinfectant spray. At 9:39 a.m. she sprayed the light switch and side A's bedside table, call light, bed remote, the door handles to the resident's room and bathroom, all surfaces of the sink and the faucet, the toilet/toilet riser and the bathroom grab bars. At 9:41 a.m. HK #1 used a clean rag to wipe the sink's surfaces before she wiped the toilet's pipes and flush handle, the toilet riser and the exterior of the toilet. HK #1 emptied the trash from the bathroom's trash can and placed a new trash bag in the can before she returned to the housekeeping cart at the entrance of the room. -HK #1 failed to clean the inside of the toilet bowl with a toilet brush in room [ROOM NUMBER]. HK #1 disposed of the dirty rags in a plastic bag, doffed her gloves, performed hand hygiene with sanitizer and donned a clean pair of gloves. At 9:43 a.m. HK #1 re-entered the room and was observed disinfecting side B's high-touch surfaces, sweeping and mopping the room. -However, HK #1 did not return to the toilet to finish cleaning it in a sanitary manner. C. Staff interviews HK #1 was interviewed on 5/20/26 at 9:53 a.m. HK #1 said it was not bad to clean the inside of the toilet bowl before she cleaned the toilet seat in room [ROOM NUMBER]. She said she did not clean the toilet in room [ROOM NUMBER] because the toilet was already clean. HK #1 said the housekeeping staff used the toilet brush to clean when the toilet got very dirty. She said the housekeeping staff should clean the toilet everyday. The clinical nurse consultant was interviewed on 5/21/26 at 12:51 p.m. The clinical nurse consultant said she was filling in for the infection preventionist. The clinical nurse consultant said the resident's toilets should be cleaned at least daily and with deep cleans. She said the toilet should be cleaned starting with the cleanest area and ending with the dirtiest area, so the inside of the toilet bowl should be cleaned last. IV. Tracheostomy suctioning failure A. Facility policy and procedure The Tracheostomy Care policy and procedure, revised in October 2023, was provided by the NHA on 5/21/26 at 3:33 p.m. The facility policy read in pertinent part, The purpose of this procedure was to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. General guidelines dictate aseptic technique must be used during cleaning and during all dressing changes. Sterile gloves must be used during aseptic procedures. After removing old trick dressings, pull soil gloves over the dressings and discard into appropriate receptacles and perform hand hygiene. B. Observations On 5/19/26 at 11:59 a.m. RN #3 turned on the suction machine and suctioned the Resident #66 via his tracheostomy. RN #3 suctioned the residents via his tracheostomy opening and then suctioned the resident's mouth with the same tubing. The resident began coughing during the suctioning procedure. The nurse proceeded to change the resident's trach dressing with a new clean trachestomy dressing. -However, the nurse failed to change her gloves or perform hand hygiene prior to initiating the tracheostomy dressing change. On 5/19/26 at 12:54 p.m. RN #3 entered Resident #30's room, donned sterile gloves to perform tracheostomy suctioning. The nurse used her left hand to turn on the suction machine. The nurse touched the bedside table with her left hand and her right (clean) hand while wearing her sterile gloves and moved the table closer to her. The nurse suctioned the residents' trach two times with a return of clear frothy sputum noted. -However, RN #3 failed to change her gloves or perform hand hygiene after touching the non-sterile surface with her sterile gloves. C. Staff interviews LPN #4 was interviewed on 5/21/26 at 8:55 a.m. LPN #4 said he was trained by the facility regarding nursing technique for tracheostomy suctioning and care. LPN #4 said sterile gloves should always be used for tracheostomy suctioning to prevent infection. LPN #4 said if a nurse touched a non-storeal surface with sterile gloves, then the gloves should be removed and don a new pair of sterile gloves. The clinical nurse consultant was interviewed on 5/21/26 at 1:05 p.m. The clinical nurse consultant said RN #3 should have changed her gloves and washed her hands after she touched the bedside table with her sterile gloves. The clinical nurse consultant said the gloves were no longer sterile after she touched a non-sterile surface. The clinical nurse consultant said RN #3 should have changed her gloves after suctioning Resident #66 before applying a clean dressing to his tracheostomy site. The clinical nurse consultant said her expectation was for the nursing staff to maintain sterility to prevent the residents from getting an infection. V. Hand hygiene failures A. Professional reference According to The CDC Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 5/27/26 from https://www.cdc.gov/cleanhands/ hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics. Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings. B. Observations During a continuous observation of the lunch meal in the main dining room on 5/18/26, beginning at 11:17 a.m. and ending at 12:50 p.m., the following was observed: At 12:30 p.m. certiCNA #6 was assisting two unidentified dependent residents with eating. CNA #6 alternated offering each resident a bite of food before offering a bite of food to the other resident using the same hand. CNA #6 continued alternating offering each resident a bite of food through 12:50 p.m. -CNA #6 did not perform hand hygiene between offering bites of food to each resident, and no hand sanitizer was available at the table for CNA #6 to use. During a continuous observation of the lunch meal in the main dining room on 5/19/26, beginning at 11:18 a.m. and ending at 12:28 p.m., the following was observed: At 12:16 p.m. CNA #6 sat down between two unidentified residents before turning to one resident, preparing her straw in her cup of water, unwrapping her silverware and preparing a bite on the resident's fork. CNA #6 offered a bite of food to the resident, then turned to the other resident at the table and began speaking with him while unwrapping his silverware and offering him a bite of food. CNA #6 continued alternating offering each resident a bite of food using the same hand through 12:25 p.m. -CNA #6 did not perform hand hygiene between offering bites of food to each resident, and no hand sanitizer was available at the table for CNA #6 to use. C. Staff interview The clinical nurse consultant was interviewed on 5/21/26 at 1:07 p.m. The clinical nurse consultant said if the nursing staff touched something such as a resident's clothing or wiped the resident's mouth they should get up and wash their hands prior to assisting the next resident with eating. The clinical nurse consultant said CNA #6 should have performed hand hygiene when alternating between the two residents.

Based on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature.Findings include:I. Facility policy and procedureThe Food Preparation and Service policy and procedure, revised November 2022, was received from the clinical nurse consultant on 5/21/26 at 3:27 p.m. It read in pertinent part, Proper hot and cold temperatures are maintained during food distribution and service. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.II. Resident interviewsResident #53 was interviewed on 5/18/26 at 10:02 a.m. Resident #53 said the food sucked in taste half the time. Resident #53 said she ate in her room and her food was always cold when it got to her room.Resident #52 was interviewed on 5/18/26 at 10:05 a.m. Resident #52 said his room meal trays were delivered cold, but said the facility staff would reheat it if he requested. Resident #52 said his meal trays were cold because he was the last room on the hallway to be served. Resident #52 said he had asked if the staff could alternate which hallways got served last, but said nothing ever came from his request.Resident #10 was interviewed on 5/18/26 at 10:45 a.m. Resident #10 said she usually ate in her room. Resident #10 said her room meal trays were consistently cold. Resident #10 said the kitchen staff often forgot to give her items she requested such as tomatoes or extra pickles.Resident #20 was interviewed on 5/18/26 at 2:22 p.m. Resident #20 said none of the food was ever spiced or seasoned and everything tasted bland. Resident #20 said she usually ate breakfast in her room and her breakfast meal tray was always cold. Resident #20 said she always had to send her breakfast meal tray back to the kitchen to have it warmed up.III. Resident group interviewA group interview was conducted on 5/20/26 at 11:23 a.m. with six alert and oriented residents (#43, #64, #2, #29, #21 and #1) who were deemed interviewable per the facility and assessment.Several residents said the facility's food was so-so, and said the food was often undercooked. Resident #2 and Resident #21 said they received a lot of the same food over and over. Resident #64 said there was not enough seasoning on the food.IV. Test trayA test tray for a regular diet was evaluated by four surveyors immediately after the last resident was served their room tray for lunch on 5/20/26 at 12:30 p.m.The test tray consisted of pork fried rice, sugar snap peas, mini egg rolls, sweet and sour sauce and fruited gelatin. Temperatures of the food items were taken immediately on arrival and were measured as followed:-The pork fried rice measured 118.4 degrees Fahrenheit (F);-The sugar snap peas measured 111.2 degrees F; and,-The egg rolls measured 119.1 degrees F.The test tray was sampled by each of the four surveyors and the following was noted:-The pork in the fried rice was not seasoned and the meat was chewy;-The rice was chewy and overcooked;-The contents of the egg roll were chewy/mushy; and,-The sugar snap peas were unseasoned, overcooked and slimy. V. ObservationsDuring a continuous observation of the 5/18/26 lunch meal room tray service, from 12:01 p.m. through 12:21 p.m., the following was observed:At 12:01 p.m. the meal tray cart was wheeled to the Pacifico nurse's station and the first tray was delivered. The meal tray cart was an open metal rack with no walls or insulation.At 12:21 p.m. the last meal tray on the unit was delivered.During a continuous observation of the 5/20/26 lunch meal service, from 10:35 a.m. through 12:51 p.m., the following was observed:At 11:30 a.m. the temperatures of each menu item were measured. These measurements were recorded as follows:-The pork fried rice measured 168 degrees F;-The beef fried rice measured 158 degrees F;-The sugar snap peas measured 180 degrees F;-The pureed beef fried rice measured 157 degrees F;-The pureed carrots measured 181 degrees F; and,-The diced carrots measured 145 degrees F.At 11:34 a.m. the covers for each of the food items on the steam table were removed and lunch service began.At 12:46 p.m. the dietary manager served one of the final plates to a resident in the dining room and said there was one more resident who they were waiting on to come to the dining room so they could serve them. Final menu item temperatures were assessed and measured as follows:-The beef fried rice measured 133 degrees F;-The egg rolls measured 117 degrees F;-The diced carrots measured 109 degrees F;-The pureed eggroll measured 124 degrees F;-The pureed carrots measured 128 degrees F; and,-The pureed beef fried rice measured 106 degrees F.-All items measured, with the exception of the pork fried rice and the sugar snap peas, had fallen below the safe hot food holding temperature of 135 degrees F.VII. Staff interviewsThe dietary manager (DM) was interviewed on 5/21/26 at 1:38 p.m. The DM said one side of the steam table seemed to be running hotter than the other, which seemed to correlate with where the heating element of the table was located. The DM said safe hot food holding temperatures were to be maintained above 135 degrees F, and said they tried to hold their food at higher temperatures especially with their room trays. The dietary manager said she had not been told about any issues with any cold room meal trays and said it was not a concern brought up in their food committee meetings. The dietary manager said the kitchen had received a grievance about cold room trays back in October 2025, and when the facility completed an audit they found it had taken the certified nurse aides (CNA) a while to pass out the meal trays that day because they had been busy. The DM said the registered dietitian conducted a monthly audit to test the meal trays' palatability and time it took for the trays to be passed, and said she had not identified any issues in her audits.The DM said she had been emailing with the nursing home administrator (NHA) to see what options they could implement to improve room tray service. The DMsaid the kitchen did not have a plate warmer, so the hot food was served on a cold plate, and the room tray carts were not insulated. The DM said she had recently changed meal service to have three people working to plate food instead of one to make the process go faster. The DM said she had initiated that change starting 4/12/26.The DM said she had begun emailing the NHA in February 2026 about the different room tray improvement options. The DM said she and the NHA discussed switching to doing room tray service first, which they had implemented, and getting new thermal bases and tops for the room meal trays. The DM said the thermal bases and tops used on the current room meal trays looked pretty old and she was not sure how well they held in heat. The DM said they had been working on getting quotes for these options.With regard to the post-service temperatures on 5/20/26, the dietary manager said she thought the temperatures of the menu items had dropped throughout service because they were rushing around that day and had laid out the steam table bins differently from how they normally would.The NHA was interviewed on 5/21/26 at 2:29 p.m. The NHA said the facility had a food committee, through which she had heard from some residents the food was too seasoned or not seasoned enough. The NHA said she had not heard many complaints from residents about the food temperatures for their room meal trays. The NHA said the facility had been working on new systems to see if they could have drinks pre-poured on the room trays to see if they could reduce the amount of time between when the food was served and when it was delivered to the residents. The NHA said she and the dietary manager had been brainstorming options for plate warmers or new thermal containers for the room tray plates, but said it was difficult to decide on because the metal pellets in the thermal bases could get hot or be heavy. The NHA said these improvements were on her to-do list.

Based on observations and interviews the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for one of four medication carts and one of one medication rooms reviewed for storage and labeling. Specifically, the facility failed to ensure prescription medications were discarded after the expiration date and after they were discontinued. Findings include:I. Professional referencesThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24), was retrieved on 5/27/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.II. Facility policy and procedureThe Storage of Medication policy, revised February, 2026, was received from the nursing home administrator (NHA) on 5/21/26 at 3:33 p.m. It revealed in pertinent part, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.II. ObservationsOn 5/21/26 at 10:33 a.m. medication cart #2 on the Santa [NAME] unit was observed with licensed practical nurse (LPN) #5. The following items were found:The drawer for Resident #17 contained the following:-Gabapentin (a medication used to manage nerve pain) oral tablets 300 milligrams (mg). The medication was discontinued on 3/1/26. The blister pack holding the pills contained seven pills. -Gabapentin oral tablets 300 mg. The medication was discontinued on 3/31/26. The blister pack holding the pills contained seven pills. -Gabapentin oral tablets 300 mg. The medication was discontinued on 3/1/26. The blister pack holding the pills contained 28 pills. The drawer for Resident #48 contained the following:-Oxycodone HCI (A medication used to treat severe and persistent pain) oral tablet 10 mg. The blister pack holding the pills contained 10 pills. -However, the resident was discharged from the facility on 5/19/26 (see interviews below).On 5/21/26 at 11:10 a.m. the medication room was observed with registered nurse (RN) #2. The shelf in the medication storage room contained the following:-Two vials of Daptomycin 600 mg intravenous (IV) (an IV antibiotic used to treat severe and complicated gram-positive infections) 1 gram (gm) that expired on 2/27/26. -Seven vials of Daptomycin 600 mg IV 1 gm, expired on 4/2/26. -Eight vials of Daptomycin 600 mg IV 1 gm. Expiration date 3/14/26. III. Staff interviewsLPN #5 was interviewed on 5/21/26 at 10:40 a.m. She said it was the responsibility of the nurses assigned to the individual medication card to ensure medications were removed after expiration date. She said the medications should have been discarded after the medications were observed to be expired. She said Resident #48 was discharged on 5/19/26. She said she notified her unit manager that the medication for Resident #48 needed to be removed from her medication cart. She said because the director of nursing (DON) was on vacation, the facility was unable to remove the medication. She said the DON had the keys to the locked disposal cabinet used for narcotics. She said she did not notice the medication for Resident #17 was in her medication cart. RN #2 was interviewed on 5/21/26 at 11:15 a.m. She said the vials of antibiotics in the storage room should have been removed after the expiration date was reached. She said the DON was responsible for ensuring that the medication storage room did not hold medications that were expired. The assistant director of nursing (ADON) was interviewed on 5/19/26 at 12:18 p.m. The ADON said she was the nurse assigned to work on the medication cart #2 on the Santa [NAME] unit yesterday. She said she should have discarded the medication for Resident #17, but she was too busy with other nursing tasks. The ADON said because the DON was on vacation the facility was unable to discard the medication for Resident #48. She said the DON had the keys to the locked disposal cabinet used for narcotics. She said all of the staff nurses on the unit were responsible for ensuring discarded medications were removed from medication carts and rooms after residents had either been discharged or the medication had expired or discontinued.

Based on observations, record review, and interviews, the facility failed to ensure three (#66, #30 and #7) of five residents out of 45 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to:-Ensure professional standards were used when nursing staff completed oral and tracheostomy suctioning for Resident #66;-Ensure Resident #30's head of his bed was elevated 30 to 45 degrees while administering a water flush through his gastrostomy tube (a small device inserted through the abdomen directly into the stomach); and,-Create and implement a comprehensive care plan for Resident #7's insomnia or his use of Trazodone (antidepressant with off label use of sleep aid), and failed to follow Resident #7's physician's orders to track his hours of sleep. Findings include: I. Tracheostomy failures A. Professional reference The Tracheostomy Care & Suctioning (revised in 2021), was retrieved on 6/2/26 from https://www.ncbi.nlm.nih.gov/books/NBK593189/. It read in pertinent part, Oral Suctioning Standards is performed using clean technique for oropharyngeal suctioning, typically using a Yankauer suction tip. Safety with care must be taken to avoid penetrating deep into the throat to prevent gagging, aspiration, or trauma to sensitive tissues. Tracheostomy suctioning standards require the maintenance of strict sterile technique (open or closed systems) to prevent respiratory tract infections. Pre/Post-Assessment: Nurses must assess ABCs (airway breathing and circulation) , lung sounds, and oxygen saturation before and after the procedure. Pre-oxygenation is strongly recommended for pediatric and adult patients. B. Facility policy and procedure The Tracheostomy Care policy, revised October, 2023, was received from the nursing home administrator (NHA) on 5/21/26 at 3:33 p.m. It revealed in pertinent part, The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. C. Resident #66 1. Resident status Resident #66, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included sepsis, dementia, tracheostomy, muscle weakness and dysphagia (difficulty swallowing). The 5/6/26 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status (BIMS) assessment. The assessment indicated the resident was fully dependent on staff for oral hygiene, bathing and shower hygiene, chair-to-chair transfers, toileting hygiene, and lower body dressing. The MDS indicated the resident had a tracheostomy upon admission. The facility indicated that the facility should not conduct a staff assessment. The delirium assessment indicated that there were no acute mental changes. 2. Observations On 5/19/26 at 11:59 a.m. registered nurse (RN) #3 turned on the suction machine and suctioned Resident #66 via his tracheostomy. RN #3 then suctioned the resident's mouth with the same tubing. The resident began coughing during the suctioning procedure. The nurse proceeded to change the resident's tracheostomy dressing with a new clean trach dressing. -RN #3 failed to switch her suctioning device from the sterile suction catheter used to suction device for his trach, to an oral Yankauer catheter for his mouth (a firm rigid oral suction tool used in medical and emergency settings). 3. Staff interviews The clinical nurse consultant was interviewed on 5/21/26 at 1:05 p.m. She said RN #3 should have used a separate Yankauer catheter device after suctioning Resident #66's tracheostomy and before suctioning his mouth. II. Gastrostomy failures A. Professional reference The Applying the nursing process guidelines (revised in 2023), was retrieved on 6/2/26 from https://www.ncbi.nlm.nih.gov/books/NBK594494/. It read in pertinent part, The head of the bed (HOB) to be elevated to a minimum of 30 to 45 degrees during and for at least (30 to 60 minutes after administering tube feeds or fluids. This universally adopted standard aims to prevent aspiration and gastric reflux. B. Facility policy and procedure The Enteral Feedings and Safety Precautions policy, revised April, 2026, was received from the NHA on 5/21/26 at 3:33 p.m. It revealed in pertinent part, The purpose of this is to ensure the safe administration of enteral nutrition. The facility will remain current in and follow accepted best practices in enteral nutrition. Elevate the head of the bed (HOB) at least 30 degrees during tube feeding and at least one hour after feeding. If elevating the HOB is medically contraindicated, use the reverse Trendelenburg position. C. Resident #30 1. Resident status Resident #30, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included sepsis, dementia, tracheostomy, muscle weakness and dysphagia. The 2/25/26 MDS assessment revealed the resident was unable to complete the BIMS assessment. The resident was dependent on staff for oral hygiene, bathing and shower hygiene, chair-to-chair transfers, toileting hygiene, and lower body dressing. The MDS assessment indicated the resident had a feeding tube upon admission and was receiving 51% or more of his calories through a feeding tube. The facility indicated that the facility should not conduct a staff assessment. The delirium assessment indicated that there were no acute mental changes. 2. Observation On 5/20/26 at 10:11 a.m. Resident #30's bed was flat upon entering his room. RN #5 entered the resident's room and began providing care to the resident. RN #5 entered Resident #30's room. RN #5 disconnected the resident's gastronomy tube from the continuous feeding pump device. Resident #30 lying in bed flat on his back with the head of the bed not elevated 30 to 45 degrees. RN #5 proceeded to flush the resident's gastronomy tube with 60 milliliter (ml) of water without raising the residence head of the bed. 3. Record review The enteral feeding care plan, revised 1/3/26, revealed Resident #30 required tube feeding to meet his nutritional needs. Pertinent interventions included ensuring the resident's head of the bed was to 45 degrees during and 30 minutes after tube feed (initiated 7/30/20) and monitoring/documenting/reporting any signs and symptoms of aspiration- fever, shortness of breath and tube dislodged. ( initiated 7/30/20) Review of Resident #66's CPO revealed the following orders for his tube feed management: -Resident is to be NPO (nothing by mouth), only tube feeds, ordered on 3/28/26. -Enteral feed order every shift. Elevate head of bed 30 to 45 degrees during feeding and for 30 minutes following feedings, ordered on 3/28/26. 4. Staff interviews RN #5 was interviewed on 5/20/26 at 10:11 a.m. She said when flushing a gastronomy tube for a resident, the head of the bed must be elevated 30 to 45 degrees to prevent possible aspiration (inhaling foreign substances into the lungs) of fluids. She said Resident #30's head of his bed was usually elevated by the certified nurse aides (CNA) staff when he was in bed. She said she did not notice that the head of the bad was flat when she provided the flush to Resident #30. She said she should have ensured that the head of the bed was elevated prior to performing the task. The clinical nurse consultant was interviewed on 5/21/26 at 1:05 p.m. She said RN #5 should have elevated the head of the bed for Resident #30 while administering the scheduled water flush. She said facility nurses were trained on the professional nursing technique in regards to the safest way to administer gastronomy tube water flushes. III. Following and implementing physician's orders failures A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the May 2026 CPO, diagnoses included schizoaffective disorder, anxiety disorder, insomnia, depression and chronic pain. The 4/23/26 MDS assessment revealed the resident cognitively intact with a BIMS assessment score of 14 out of 15. The assessment documented the resident was taking antipsychotic, antidepressant and opioid medications. B. Record review The antidepressant care plan, revised 4/2/26, revealed Resident #7 received an antidepressant medication to treat his schizoaffective disorder, depressive type. Pertinent interventions included monitoring, documenting and reporting any adverse reactions to antidepressant therapy including changes in mood or cognition, fatigue or insomnia. The antipsychotic care plan, revised 6/19/25, revealed Resident #7 received an antipsychotic medication. Pertinent interventions included monitoring, documenting and reporting any adverse reactions to psychotropic medications including sedation, fatigue or insomnia. -Review of Resident #7's comprehensive care plan did not reveal any care plan focus, interventions or monitoring specific to his diagnosis of insomnia. A progress note, dated 4/1/26 at 11:41 p.m., revealed Resident #7 reported insomnia lasting the last three nights. Resident #7's physician was notified and new orders for Trazodone 50 milligram (mg) once a day at bedtime were received. Resident #7 was resting well in bed. A progress note, dated 4/2/26 at 8:06 p.m., revealed Resident #7 was taking 50 mg of Trazodone at bedtime. Resident #7 reported he slept very well the night prior (4/1/26). A progress note, dated 4/13/26 at 9:31 p.m., revealed Resident #7 complained he had not slept the three days prior and requested an extra dose of Trazodone. The nurse contacted Resident #7's physician and received orders for a one time additional dose of Trazodone 50 mg which was then administered to the resident. A progress note, dated 4/21/26 at 9:43 p.m., revealed Resident #7 complained he had not been sleeping well with the 50 mg Trazodone dose and requested the nurse reach out to his physician. The nurse contacted Resident #7's physician who gave new orders to increase his Trazodone dose to 75 mg. -However, there was no documentation indicating the resident was not sleeping well or that a physician assessed the resident prior to increasing the medication. A physician note, dated 5/5/26 at 5:57 p.m., revealed Resident #7 was seen by his physician due to Resident #7 reporting insomnia. Resident #7 had asked his physician to increase his Trazodone dose, but the physician did not want to oversedate him. The note documented he increased his Trazodone dose for a week with plans to return to the original 75 mg dose. The physician documented Resident #7 said he was not sleeping at all. The physician documented she did not see any sleep tracking data for the resident. The physician's plan included continuing with Trazodone 100mg at bedtime with plans to monitor sleep tracking and return to the 75 mg dose in a week if possible. -However, review of Resident #7's electronic medical record (EMR) did not reveal the facility implemented sleep tracking. A physician note, dated 5/12/26 at 10:17 p.m., revealed Resident #7 was seen by his physician. The physician documented she had increased Resident #7's Trazodone dose from 75 mg to 100 mg per dose at her last visit and did not see any sleep tracking data. Resident #7 said he was sleeping much better and did not report any daytime sedation. The physician's plan included continuing with Trazodone 100 mg at bedtime with plans to monitor sleep tracking. -However, Resident #7's hours of sleep were not recorded from 5/12/26 through 5/21/26 (during the survey process). Review of Resident #7's April 2026 CPO revealed the following physician's orders: -Aripiprazole (an atypical antipsychotic medication) 5 mg, give 5 mg by mouth one time a day related to schizoaffective disorder, ordered 1/22/26; -Hydroxizine (an antihistamine used to treat anxiety and itching) 25 mg, give one tablet by mouth in the morning every Monday, Wednesday and Friday for anxiety prior to dialysis appointments, ordered 3/4/26 and discontinued 5/5/26; -Seroquel (an atypical antipsychotic medication) 25 mg, give 25 mg by mouth two times a day related to schizoaffective disorder, ordered 4/8/26; -Oxycodone (an opioid pain medication) 10 mg, give one tablet by mouth every six hours as needed for hip and leg pain rating 7 to 10 on a scale of 10, ordered 1/22/26 and discontinued 5/4/26; -Trazodone 50 mg tablets, give one tablet by mouth at bedtime for insomnia, ordered 4/1/26 and discontinued 4/21/26; -Trazodone 50 mg tablets, give 1.5 tablets by mouth at bedtime for insomnia, ordered 4/21/26 and discontinued 5/5/26; and, -Record hours of sleep each shift for 14 days, ordered 4/1/26 and completed 4/15/26. Review of Resident #7's May 2026 CPO revealed the following physician's orders: -Trazodone 50 mg tablets, give 1.5 tablets by mouth at bedtime for insomnia, ordered 4/21/26 and discontinued 5/5/26; -Trazodone 50 mg tablets, give two tablets by mouth at bedtime for insomnia, ordered 5/5/26; -Record hours of sleep each shift for insomnia, ordered 5/4/26 and discontinued 5/12/26; -Sleep tracking for one week, ordered 5/6/26 and completed 5/12/26; -Record hours of sleep each shift for insomnia, ordered 5/12/26 and discontinued 5/21/26 (during the survey process); and, -Monitor hours of sleep every shift, ordered 5/21/26 (during the survey process). Review of Resident #7's treatment administration record (TAR) from 4/1/26 through 4/30/26 revealed the following: -Resident #7's sleep was monitored and documented three times per day beginning the evening shift on 4/2/26 through the afternoon of 4/15/26; and, -From 4/3/26 through 4/14/26, it was documented Resident #7 slept an average of 11.25 hours per day. -Resident #7's hours of sleep were not recorded from the evening of 4/15/26 through 4/30/26. Review of Resident #7's TAR from 5/1/26 through 5/21/26 revealed the following: -The number of hours Resident #7 slept was recorded each shift from the evening of 5/4/26 through 5/11/26; -From 5/5/26 through 5/11/26, it was documented Resident #7 slept an average of 9.1 hours per day; and, -The order to record hours of sleep each shift was marked completed nearly every shift from 5/12/26 through 5/21/26. -However the number of hours Resident #7 slept each shift was not recorded in the TAR from 5/12/26 through 5/21/26. -Additionally, Resident #7's hours of sleep were not recorded from 5/1/26 through the morning of 5/4/26. -Review of Resident #7's electronic medical record (EMR) did not reveal any documentation of Resident #7's hours slept from 5/12/26 through 5/21/26. C. Staff interviews RN #4 was interviewed on 5/20/26 at 3:59 p.m. RN #4 said residents receiving antidepressant medications or medications for insomnia needed to be monitored for behaviors and side effects, including drowsiness or aggression, and needed to have their hours of sleep monitored and documented. RN #4 said the actual number of hours the resident slept were documented in the TAR, and it was not something the nursing staff could just check off. RN #4 said the nursing staff needed to monitor the number of hours a resident slept while on those medications to see if the medication was effective, if it needed to be removed or changed, or if it made the resident too drowsy. Licensed practical nurse (LPN) #3 was interviewed on 5/21/26 at 12:49 p.m. LPN #3 said residents receiving medications to treat their insomnia needed to be monitored for the number of hours they slept. LPN #3 said the nursing staff would monitor the resident each shift for seven days after they started the medication to see how much they slept and if they had any drowsiness in order to determine if the medication was effective. LPN #3 said she also monitored the number of hours a resident slept if they were taking any psychotropic medications. LPN #3 said she documented the number of hours the resident slept in the TAR and did not just check it off. The assistant director of nursing (ADON), who was filling in for the director of nursing (DON), was interviewed on 5/21/26 at 2:07 p.m. The ADON said for residents on psychotropic medications, the nursing staff monitored them for mood, isolation, weight gain, nausea and tics each shift. The ADON said if a resident was taking Trazodone for insomnia, the nursing staff would monitor the resident to see if they were too sedated, any mood changes, and monitor the number of hours the resident slept. The ADON said the nursing staff documented the number of hours the resident slept in the TAR, and needed to actually document the number, not just check it was done. The ADON said she found Resident #7's order in his CPO to record the number of hours he slept each shift. The ADON said as long as the order was put in correctly it should have given the nursing staff the option to record the number of hours Resident #7 slept each shift. The ADON reviewed Resident #7's TAR and said there was only an option to check yes or no on the order, and did not have an option for the nursing staff to record a number for the hours slept. The ADON said it must have been a glitch in the system. The ADON said the nursing staff should have documented the number of hours Resident #7 slept in a progress note if they could not enter it in the TAR. The clinical nurse consultant was interviewed on 5/21/26 at 3:26 p.m. The clinical nurse consultant said the DON was ultimately responsible for overseeing residents' medication orders and making sure their hours slept was being monitored. The clinical nurse consultant said if a resident was receiving a medication for sleep, the nursing staff needed to make sure they were monitoring the number of hours the resident slept. D. Facility follow-up The NHA submitted additional information via email after the survey process on 5/24/26 at 9:19 p.m. The information submitted included the progress notes from 4/1/26 and 4/21/26, the physician note from 5/5/26, and the April 2026 and May 2026 MAR (see record review above). Also included was a psychiatric physician note, dated 5/20/26 at 6:45 a.m. (during the survey), which revealed Resident #7 was seen by his psychiatrist. The physician note documented Resident #7 reported experiencing anxiety and poor sleep quality, which the psychiatrist noted could be related to adjustments in his other psychotropic medications. -However, the facility did not provide any additional documentation of sleep monitoring for Resident #7 during the periods specified in the record review above.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically, the facility's medication error rate was 7.69%, or two errors out of 26 opportunities.Findings include:I. Facility policy and procedureThe Administration of Medication policy and procedure, revised April, 2019 was provided by the nursing home administrator (NHA) on 5/21/26 at 3:33 p.m The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. As required or indicated for a medication, the individual administers the medication records in the resident's medical record. The date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered and any results achieved and when those results were observed.II. Observations On 5/20/26 at 8:05 a.m. registered nurse (RN) #1 prepared to administer medications to Resident #10. RN #1 dispensed the resident's medications into a medication cup, including one tablet of the glipizide (medication used to treat diabetes ) 10 milligram (mg) oral tablet, and refresh tears ophthalmic solution (an over the counter medication used to treat dry eyes).-However, Resident #10's May 2026 computerized physician's order (CPO) ) indicated the resident was to receive two tables of glipizide 10 mg (see physician's order below). RN #1 completed dispensing the medication, picked up the medication cup for the resident and locked the medication cart. RN #1 said he completed his five rights and was ready to administer the medications to the resident. RN #1 then took the medication cup, which contained one tablet of the glipizide 10 mg, to administer the medication to Resident #10. Upon prompting, RN #1 did not administer the medication after he was informed it was the incorrect dose. RN #1 went back to the medication cart and retrieved another tablet of the glipizide 10 mg.RN #1 administered the medications to Resident #10, including the refresh tears ophthalmic solution, and gave two drops into each eye.-RN #1 administered the incorrect dose of refresh tears ophthalmic solution to Resident #10 (see physician's order below).III. Record reviewReview of Resident #10's May 2026 CPO revealed the following physician's order:Glipizide oral tablet extended release 24 hour 10 mg, give two tablets, every day, ordered 8/28/25. Refresh tears ophthalmic solution one drop to each eye, ordered 7/1/25.IV. Staff interviews RN #1 was interviewed on 5/20/26 at 8:10 a.m. RN #1 said he looked at the resident's orders in the medication administration record (MAR) while dispensing medications to make sure he followed the five rights of medication administration: right name, right time, right dosage, right route and accurate documentation. He said it was important to compare the medication order to the medication he was dispensing because the orders changed frequently, and the nursing staff would not know if the dose had changed. He said he did not review the orders thoroughly for Resident #10.The assistant director of nursing (ADON) was interviewed on 5/19/26 at 12:18 p.m. The ADON said RN #1 should have reviewed the MAR for Resident #10 prior to administering the medications. The ADON said she planned to complete additional in person education as soon as possible for RN #1 and all of the facility nursing staff. The ADON said if nursing staff failed to review the residents MAR prior to administering medications, it could result in significant medication errors.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#7) of five residents reviewed for accident hazards out of 45 sample residents.Specifically, the facility failed to prevent a second-degree burn from food for Resident #7.Findings include:I. Facility policy and procedureThe Accidents and Incidents - Investigating and Reporting policy and procedure, revised July 2017, was provided by the clinical nurse consultant on 5/21/26 at 10:57 a.m. It read in pertinent part, All accidents or incidents involving residents occurring on [facility] premises shall be investigated and reported to the administrator. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.II. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included schizoaffective disorder, type 2 diabetes, legal blindness, end stage renal disease, and second degree burn of abdominal wall.The 4/23/26 minimum data set (MDS) assessment revealed the resident cognitively intact with a brief interview for mental status (BIMS) assessment score of 14 out of 15. The resident required substantial to maximal assistance from staff for most activities of daily living (ADL), including eating.The assessment documented the resident's vision was severely impaired.B. Facility incident investigationThe facility incident investigation, dated 3/23/26 at 10:04 a.m., was received from the nursing home administrator (NHA) on 5/20/26 at 12:15 p.m The investigation included the following:A progress note, dated 3/17/26 at 9:30 a.m., documented licensed practical nurse (LPN) #3 was performing wound treatment on Resident #7 at approximately 9:30 a.m. that morning when she noted a new bruise/blister to his right upper quadrant on his abdomen which measured 12 centimeters (cm) by 5 cm. Resident #7 reported to LPN #3 that he had burned himself the morning prior with noodles. When the nurse asked if he had told anyone he said he had told the certified nurse aide (CNA). LPN #3 asked Resident #7's CNA who said she was not aware of the blister. Resident #7 denied any pain/discomfort at the time. The nurse notified Resident #7's physician, the NHA and the resident's representative. LPN #3 educated the CNA to ensure residents' noodles/food temperature was checked and was safe. The CNA expressed understanding and said she made sure she poured out the soup and it was not too warm that morning.An interdisciplinary team (IDT) note, dated 3/23/26 at 10:04 a.m., revealed Resident #7 was reviewed by the IDT for his burn on 3/17/26. The root cause of the incident was determined to be Resident #7's blindness/poor vision. The treatment required for Resident #7's burn was silvadene cream with a dry dressing. Interventions put into place included retraining all staff on putting cups of noodles or similar foods in an open bowl so it cooled down faster and was more stable, and ensuring residents were in proper position.The investigation included an action plan, undated, revealed an identified concern after Resident #7 was burned from hot liquids/fluids inside of food (a cup of noodles). The action plan included the following:-All staff education regarding safe food and beverage temperatures, completed 3/18/26;-Dietary staff education on how to heat noodles without being placed in the microwave or stovetop using the water from the coffee machine which was regulated at 155 degrees Fahrenheit (F), completed 3/18/26;-Identify/evaluate all residents for safety in regard to hot beverages/liquids, no date of completion;-Thermometers placed at the kitchen microwave, completed 3/18/26;-Microwave safety sign posted on coffee machine in dining room, completed 3/18/26;-Thermometer placed by the coffee machine in the dining room to record temperatures of coffee and hot water used to make drinks/food, completed 3/18/26;-Thermometer placed in the breakroom for the microwave for staff to use outside of kitchen hours, completed 3/18/26;-Sign created for the nurses' stations for how to properly heat items in the microwave and measure their temperature outside of dietary hours, completed 3/18/26; and,-The dietary manager/designee will report findings to the quality assurance and performance improvement (QAPI) committee monthly for 90 days. The QAPI committee will identify any trends and take corrective action as needed.-However, observations during the survey process revealed staff failed to monitor the resident's positioning or encourage him to sit up while eating (see observations below).The Hot Food and Hot Liquid Safety Policy education, dated 3/18/26, revealed facility staff had received education on hot food/liquid safety, which included ensuring foods and liquids were heated/held between 135 and 165 degrees F, but allowed to cool to a safe consumption temperature of 135 to 150 degrees F prior to being consumed by a resident.-However, interviews revealed the staff were not aware of the process included in the action plan (see staff interviews below).C. Resident interview and observationsResident #7 was interviewed on 5/20/26 at 8:13 a.m. Resident #7 said he sustained a burn a while ago, because he was eating ramen noodles and the cup tipped down too much and spilled on him. Resident #7 said the nursing staff had prepared the ramen noodles for him. Resident #7 said he was blind, but could still see some shadows. Resident #7 was lying in bed with the head of his bed elevated to approximately 30 degrees. Resident #7 was attempting to feed himself breakfast while lying down with his tray table over him. Resident #7 activated his call light and told LPN #3 he could not eat his breakfast due to his nausea. LPN #3 attempted to adjust Resident #7's tray table down so he could reach his tray more easily but she said his table could not be lowered.D. ObservationsOn 5/20/26 at 10:54 a.m. a sign was posted on the microwave in the kitchen which read in part, Got hot food or hot beverage? Safe food/fluid for food/fluid safety and burn prevention. Staff rules for mandatory safe microwave use:-Check temperature of warm foods/fluids-Use a thermometer every time-Sanitize the thermometer equipment with an alcohol wipe before and after every use-Heat/reheat all food/fluids to 165 degrees then cool to 150 degrees-Staff will check the temperature every time to be sure and safe and prevent possible burn occurrences or other injury to others.On 5/21/26 at 12:03 p.m. two microwaves were observed in the employee breakroom. Neither microwave had any visible postings related to safe serving temperatures. No thermometers were visible in the surrounding area.-However, interviews with staff revealed these microwaves were also used to reheat residents' food.At 12:59 p.m. the same sign observed posted on the microwave in the kitchen (see above) was posted on the coffee station in the dining room. Another sign was posted next to the coffee machine which read in part, For safety reasons, if you are adding hot water to noodle cups please place the noodles in a bowl after heating and before giving to the resident. Please make sure the temperature is 150 degrees F or lower. A thermometer is on the left side of the coffee machine.A thermometer was attached to the side of the coffee machine.At 2:40 p.m. the NHA and the clinical nurse consultant entered the staff breakroom and began looking on top of the microwave and through the breakroom cabinet drawers to try to find the safe reheating signage and a thermometer. The NHA found a sign which read cool food to 150 degrees F before serving to a resident under several papers and napkins on top of the microwave and placed it on the counter. It was not easily visible to staff using the microwave.-Neither the NHA nor the clinical nurse consultant were able to find a thermometer in the breakroom.E. Record reviewThe skin integrity care plan, revised 3/3/26, revealed Resident #7 was at risk for impaired skin integrity due to his chronic kidney disease. Pertinent interventions included evaluating Resident #7's skin for areas of blanching or redness and monitoring his bony prominences.Review of Resident #7's March 2026 CPO revealed the following order:Treatment for burn to the right side of abdomen: clean with wound cleanser and apply silvadene cream and cover with a dry dressing. Change daily and as needed, ordered 3/18/26 and discontinued 3/30/26.A weekly skin assessment, dated 3/20/26 at 10:56 a.m., revealed Resident #7 needed extensive assistance with ADLs including feeding himself. The skin assessment documented Resident #7 had old wounds to his left ankle, left heel and right heel, and that he was being followed by the WCP and facility wound nurse.-The assessment did not document the burn on Resident #7's abdomen that occurred on 3/16/26.The wound care physician notes, dated 3/23/26, revealed Resident #7 was being followed by the wound care physician for multiple wounds. The wound care physician documented Resident #7 had a right abdomen upper quadrant burn which had not healed. The wound measurements were 1.5 cm length by 0.8 cm width by 0.1 cm depth. There was a scant amount of serous (a thin, watery plasma) drainage noted. Resident #7 reported a wound pain level of 0 on a scale from 0 to 10.A physician note, dated 3/27/26, revealed Resident #7 had been seen by his physician. The physician documented Resident #7 had a burn on the right side of his abdomen after spilling hot noodles on it. The physician documented Resident #7's burn had previously had a small blistering area on it which had by then almost completely healed. F. Staff interviewsCNA #5 was interviewed on 5/20/26 at 3:54 p.m. CNA #5 said if a resident needed their food reheated there was a microwave in the kitchen to do so. CNA #5 said the facility staff needed to check the temperature of the item before serving it to the resident to make sure it was safe. CNA #5 said she thought the safe temperature would be at least under 80 degrees F, but was not sure what temperature exactly was safe.Registered nurse (RN) #4 was interviewed on 5/20/26 at 3:59 p.m. RN #4 said she usually worked on the night shift. RN #4 said during the day if a resident needed their food or beverage reheated she could bring it to the kitchen and they would reheat it for her. RN #4 said the kitchen was closed during the night, so if a resident needed something reheated she would use the microwave in the staff breakroom to reheat it there. RN #4 said she had recently been trained on what temperatures were safe for serving to residents, but said she could not remember the exact temperatures. RN #4 said there was a sign that said the temperatures on it. CNA #4 was interviewed on 5/21/26 at 12:43 p.m. CNA #4 said if a resident needed their food reheated the nursing staff could bring it to the kitchen to have the dietary staff reheat it. CNA #4 said she was not able to reheat a resident's food after the kitchen was closed, so she would just give them snacks instead. CNA #4 said the nursing staff were not allowed to use the staff breakroom microwave to reheat residents' food.LPN #3 was interviewed on 5/21/26 at 12:49 p.m. LPN #3 said if a resident needed their food reheated, she would bring it to the dietary staff and have them reheat it. LPN #3 said the dietary staff checked the food or beverage's temperature to make sure it was safe to serve. LPN #3 said she never used the breakroom microwave to reheat things since they did not have a thermometer in the breakroom to check to make sure the temperature was safe after heating. LPN #3 said she had told the administration they needed a thermometer at every nurse's station because the kitchen staff left at 8:00 p.m. and the night shift nursing staff needed to be able to reheat items for residents and check the temperature.The dietary manager (DM) was interviewed on 5/21/26 at 1:38 p.m. The DM said when the kitchen was open, the nursing staff brought in residents' food to be reheated. The DM said the residents' food would be heated up to 165 degrees F then cooled to 150 degrees F before serving. The DM said there was not really an option for nursing staff to reheat residents' food after the kitchen was closed at night. The DM said there was a microwave in the breakroom, but she did not want staff members to use that to reheat residents' food for cross-contamination reasons.The assistant director of nursing (ADON), who was filling in for the director of nursing (DON), was interviewed on 5/21/26 at 2:07 p.m. The ADON said after the incident involving Resident #7 on 3/18/26 came to light, the administration no longer allowed nursing staff to reheat residents' food in the microwave. The ADON said the nursing staff needed to use the water in the coffee machine to heat up food and make sure Resident #7 was sitting up when he ate. -However, observations revealed Resident #7 was not sitting upright when eating his meals (see observations above).The ADON said maybe at one point nursing staff were reheating residents' food in the breakroom microwave, but they were not doing so anymore.The NHA was interviewed on 5/21/26 at 2:29 p.m. The NHA said for Resident #7's burn incident, someone in the kitchen had heated up the cup of noodles. but not checked its temperature prior to serving it. The NHA said the staff member had instead followed the instructions on the back of the package. The NHA said after the incident they placed signs on the microwaves with the specific safe serving temperatures, had thermometers available, and had the nursing staff reheat all food during the day through the kitchen and dietary staff. The NHA said the nursing staff were allowed to use the microwave in the staff breakroom to reheat residents' food, and said there were safe temperature signs posted there as well as a thermometer for the staff to use. -However, the sign with the safe serving temperatures was inaccessible, and there was not a thermometer available in the breakroom to use (see observations above).G. Facility follow-upAdditional information was provided via email from the clinical nurse consultant on 5/21/26 at 4:25 p.m. (after the survey exit), which included the following information:A noncompliance concern, identified on 3/18/26, involved kitchen staff warming up a cup of noodles and serving hot food to Resident #7. Resident #7 then spilled the soup onto himself causing small blisters to his abdomen. Resident #7 was treated by nursing staff immediately upon report of the spill and was assessed by the nurse practitioner. The staff member who warmed the food was immediately reeducated by the Food and Nutrition manager and disciplinary action was taken. No other residents were affected.Systemic changes to ensure the deficient practice would not recur included:-Staff present on shift were educated on not serving liquids or food items to residents from the microwave until the temperature of the item was below 150 degrees F;-A sign was placed on all microwaves as a reminder;-A digital thermometer was placed near the microwave for use whenever food or liquids were being reheated;-All staff were educated on the proper use of the microwave to warm residents' food or liquids, including using a thermometer to check for proper temperature for food safety and allowing to cool to a safe servable temperature (heated to 165 degrees F and cooled to 150 degrees F prior to serving); and,-For prepackaged food or soups available in Styrofoam containers, the item would be heated then poured into a bowl or cup prior to serving.The plan to monitor for sustained compliance included the Food and Nutrition Manager or designee conducting weekly rounds to ensure food thermometers were in place at all microwaves and signs for safe food handling were posted. The results of the rounds would be reported monthly to the QAPI committee.-However, observations and interviews throughout the survey process revealed thermometers and signage were not available at all microwaves in the facility, and nursing staff were not aware of what temperature it would be safe to serve reheated food to a resident (see observations and staff interviews above).

Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 1/27/26 to 1/28/26, resulting in the deficiency being cited as past noncompliance, with a correction date of 12/25/25.I. Facility plan of corrective actionMeasure to address systemic concernsThe facility provided immediate staff education to all nursing staff to:-Document all resident monitoring activities when the resident was on a one to one or line of sight supervision;-Cover units to provide supervision for resident to ensure health and safety of the residents in need, when staff are on break;-Be knowledgeable on identifying types of abuse, reporting requirements and timelines for reporting allegations of abuse; and -Understand the importance and steps to document initial statements form the residents involved and witnesses to gather all possible preinvestigation information to support the facility investigation. Plan to monitor for sustained compliance-The facility chief executive office (CEO)/designee will review all allegations of abuse and the interview packets to ensure that allegations are reported timely, interventions to prevent abuse are followed and care planned and the investigation packet completion was timely; and include detailed interviews, preventative measures, and any education needed. -The CEO/designee will report the findings from the audits or the quality assurance performance improvement committed monthly for 90 days. The QAPI committee was to identify any trend and take corrective actions. II. Facility policy and procedureThe Abuse Reporting and Investigating Policy, dated 2/6/23, was provided by the nursing home administrator (NHA) on 1/28/26 at 8:42 a.m. It revealed in pertinent part, All allegations of abuse or occurrences will be thoroughly investigated. The administrator/designee initiates the investigations.-The administrator/designee provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation.-Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction.-The administrator/designee is responsible for keeping the resident and his/her responsible party informed of the progress of the investigation.-Reviews all events leading up to the alleged incident; and-Documents the investigation completely and thoroughly. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement.-The investigator will record the findings of the investigation and provide the completed documentation to the administrator.III. Allegation of sexual abuse between Resident #5 and Resident #4 on 12/15/25A. Facility investigationThe facility investigation, dated 12/17/25, documented on 12/15/25 at approximately 10:30 p.m., a certified nurse aide (CNA) #1 heard Resident #4 yelling from inside her room. CNA #1 entered Resident #4's room and found Resident #5 standing near Resident #4's bed. CNA #1 immediately intervened and redirected Resident #5 out of the room. Resident #5 was placed on one-to-one supervision. The investigation report documented CNA #1 first said she was not sure if Resident #5 placed his hands on Resident #4 or not. Upon further investigation and follow-up interviews with CNA #1, it was clarified that Resident #5 placed his hands over Resident #4's clothing and bedding in the area of her chest and abdomen. After clarification of the witness statement that Resident #5 had touched Resident #4 on her chest area, the facility started an internal investigation. -However, based on interviews (see below) and record review (of the facility investigation), no effort was made to start the investigation into the allegation of sexual abuse immediately following the incident, while the resident, both with dementia, would have had better recall of the incident. The resident interviews and Resident #4 was not examined for injuries until the next morning. The facility investigation revealed the facility's investigator interviewed the alleged victim, the alleged assailant, the alleged victim's roommates, twelve additional residents, and five staff members who were working at the time of the incident. -Both Resident #4 and Resident #5 had severely impaired cognition and neither was able to report details of the incident the next morning when they were interviewed. The investigation documented that the facility investigator reviewed the facility hallway video surveillance footage from the hallway outside the resident rooms. The investigation documented review of video surveillance (with audio capability) from 10:04 p.m. to 10:24 p.m. revealed Resident #5 was observed coming out of his room and standing outside Resident #4's room before standing in her doorway and then going into the room. Resident #5 was not in the room long before he was seen peeking out down the hallway. He did this a couple of times. Then Resident #5 walked all the way down the hallway, stopped in front of a door that CNA #1 went in and continued walking back towards his room. Resident #5 then went in his room and then back out into the hallways into Resident #4's room. The CNA was in a room next door answering the call light when she appeared back into the hallway. CNA #1looked towards Resident #4's room and went into the room. At 10:25 p.m., Resident #5 was observed walking out of Resident #4's room back into his own room. At 11:25 p.m. CNA #1 was observed walking out of Resident #4's room into Resident #5's room and then exiting a minute later. -The findings of the video surveillance failed to document the exact time Resident #5 entered Resident #4's room, for how long he was in her room before CNA #1 responded to Resident #4's yelling. According to the facility investigation, Resident #4 was not interviewed until 10:30 a.m., 12 hours after the incident occurred and per the facility investigation, Resident #4 did not remember anything that happened the night prior; she did not remember anyone coming into her room, nor did she remember anyone touching her. Resident #5 was not interviewed until 12:30 p.m., 14 hours after the incident occurred and per the facility investigation, he did not remember going into another resident's room last night and does not remember hearing anyone calling out for help. As a part of the facility investigation, Resident #17 was interviewed on 12/17/25 at 11:25 a.m. Resident #17 lived in the room next door to Resident #4. Resident #17 told the facility investigator he was in his room in bed and he heard Resident #4 calling out for help for about 10-15 minutes, next he heard the CNA telling someone they could not be going into other people's rooms and had to leave. That was when Resident #4's yelling stopped. -There was no document of further investigation to determine the root cause of resident #4's yelling out for help and CNA#1's witness statement failed ot provide details of what the resident was yelling about or saying when she heard the resident yelling (see CNA's interview statement below). The facility investigator interviewed Resident #4's roommate on 12/16/25. The roommate gave answers that were not relevant to the questions asked and was unable to follow the conversation. CNA #1 was interviewed on 12/16/25. CNA #1 said she heard yelling coming from Resident #4's and observed Resident #5 standing over Resident #4's bed with his hand resting on her chest and abdomen area (on top of her clothes and the blanket). She said she immediately told Resident #5 to leave the room and go to his room. Resident #5 immediately responded and left the room and did not return. -CNA #1's witness statement failed to provide any detail about the type of touch or a description of either resident's demeanor. The witness statement failed to document what Resident #4 was saying or yelling about. Additionally, there was no explanation of why the witness first reported that Resident #5's hands were hovering over Resident #5 and then said he was touching her. The investigation documented none of the other four nursing staff on duty that evening said they witnessed the incident or heard Resident #4 yelling. B. Record reviewReview of Resident #4's electronic medical record (EMR) revealed one entry of an increase in distressing behaviors occurring on 12/14/25.A behavior progress note, dated 12/14/25 at 12:39 p.m., documented Resident #4 was noted to be having behaviors that day. She was calling out asking for help and when the staff attempted to help her she was becoming upset, yelling, cursing, name-calling and even pinching staff. Resident #4 checked on frequently and interventions initiated as needed. A progress note dated 12/15/25 at 5:17 p.m. documented a call was placed to the resident's power of attorney (POA) to notify her that the resident was experiencing behaviors and the physician ordered a blood draw for lab work and a urine analysis. The physician also recommended Resident #4 to restart Risperidone (antipsychotic medication) oral tablet at 1mg per day. The POA agreed to the orders. -However, there was no documentation of staff monitoring the resident for continued behavior and or of the resident calling out for help that evening (12/15/25). There was no documentation of the staffs actions to monitor and provide interventions on the evening of the alleged allegation of sexual abuse. C. Other resident interviewResident #17 was interviewed on 1/28/26 at 6:00 p.m. Resident #17 said around the change of shift on the evening of 1/15/26, he clearly heard Resident #4 in the next room yelling out loudly in Spanish for about 20 minutes before staff responded to her yelling. Resident #17 said the yelling out was unusual behavior for Resident #4Resident #17 said he could not remember the exact time she started yelling out or when he heard a female nursing staff tell a male resident, you cannot be going into other residents' rooms. Resident #17 said later that same night he heard the female CNA and the nurse on duty talking about the incident and saying that a male resident was in Resident #4's room and was touching and groping her.-This degree of detail was not documented in Resident #4's initial interview with the facility investigator. Resident #17's initial witness statement was very brief and did not expand upon any details. Additionally, when the resident initially reported that the resident was yelling for several minutes, the investigator did not inquire why the staff did not hear the resident yelling when she was in a nearby room helping another resident. IV. Staff interviewsCNA #4 was interviewed on 1/28/26 at 1:00 p.m. CNA #4 said that when a resident-to-resident abuse was observed, staff were expected to break up the situation and call for nursing to do an assessment and then report the incident to administration. CNA #4 said after that there was nothing else to report. CNA #5 was interviewed on 1/28/26 at 3:45 p.m. CNA #5 said she not have any information about the incident between Resident #4 and Resident #5. She said Resident #4 was bossy but social. She said Resident #4 would approach other residents to interact or try to communicate with them but her ability to communicate was limited due to her cognitive and hearing deficits.CNA #5 said Resident #4 was not physically aggressive with other residents or staff. CNA #5 said she would report any observed instance of abuse to the director of nursing (DON) immediately after making sure the resident was safeThe NHA, the social services director (SSD), the director of nursing (DON), the nurse consultant and the regional consultant were interviewed on 1/28/26 at 4:15 p.m. The regional consultant said the CNA's initial report was that Resident #5's hand was hovering over Resident #4 but when administration talked to the CNA in more detail the CNA reported that she did observe Resident #5 with his hands on Resident #4 on her chest and abdomen. Initially the incident was not considered sexual abuse. -However, the administrative staff were not able to demonstrate that the facility's investigator interviewed the CNA for details of the exact location of his hands on what part of her chest or if he was rubbing her or just laying his hands on Resident #4. Additionally, no one was able to explain what the CNA heard the resident yelling about. The corporate nurse consultant said the resident initially denied anything happened. The corporate nurse consultant said when interviewed some of the night staff members thought Resident #5 might have have been going into Resident #4's room to see if she needed help. The corporate nurse consultant said hovering does not mean a lot until the figured out the situation.-However, only one staff observed and reported hearing Resident #4 yelling and non of this was documented in the facility investigation as a part of the investigation. There was no documentation to indicate that this latest assessment of what might have occurred was a part of the investigation or post incident and investigation review. The social services director (SSD) said she reached out to Resident #5's family and they said laying hands on a person in distress was a cultural thing and they did not believe it was inappropriate. The SSD said the resident's son said Resident #5 used to be an energy healer. The NHA said following this incident she implemented the expectation for the night time and weekend charge nurse to start the interview process with the staff and residents involved to gain immediate information that could be forgotten at a later time. The NHA said she also educated staff report alleged incidents to administration immediately and to provide a more detailed description of the incident and what they observed.The NHA said Resident #5 was no longer in the facility and was moved to an all male secured unit.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one nourishment room and the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely in the nourishment room freezer, main dining room refrigerator/freezer, and kitchen dry storage area; -Ensure food was properly cooled; -Ensure artificial fingernails with polish were not worn by a food worker; -Ensure appropriate hand washing occurred in the main kitchen; -Ensure dishes were dried appropriately; -Ensure the nourishment room freezer was monitored to ensure it was at the correct temperature; and, -Ensure towels were stored properly. Findings include: I. Ensure food was labeled and dated and disposed of timely A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Facility policy and procedure The Food from Outside Sources policy, revised [DATE], was provided by nursing home administrator (NHA) #2 on [DATE] at 4:20 p.m. It read in pertinent part, If food is not consumed upon arrival, it may be stored in a suitable container and labeled with date, resident name and item description if needed. Resident's food stored under refrigeration shall have name, date, and expiration date on the label. Perishable food is discarded within three days from any resident refrigerator source unless the food item is safe until a printed expiration date. C. Observations During a continuous observation of the kitchen on [DATE], beginning at 11:16 a.m. and ending at 12:50 p.m., the following was observed: -In the dry storage area there was a container of sweet and sour sauce that was opened on ,d+[DATE] and three containers of teriyaki sauce that were opened on ,d+[DATE]. -The teriyaki sauce and the sweet and sour sauce containers said to refrigerate after opening. On [DATE] at approximately 2:00 p.m. the following was observed in the Pacifico unit resident freezer: -A bag of unidentifiable brown substance with no label or date; -A milkshake from an outside source with no label or date; -An ice cream sandwich with no date; -A breakfast sandwich with no label or date; -A frozen meal that expired on [DATE]; and, -Another frozen meal that expired on [DATE]. On [DATE] at approximately 2:10 p.m. the following was observed in the refrigerator and freezer in the main dining room: In the refrigerator there was: -A bag of spaghetti labeled ,d+[DATE]; and, -A container of chinese food that did not have a label or date. In the freezer, there was: -A bag of tamales with no label or date; -A half gallon of frozen milk that expired on [DATE]; and, -A bag of frozen zucchini labeled ,d+[DATE]. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at approximately 2:00 p.m. LPN #1 said she was unsure who was responsible for maintaining the refrigerator and freezer that were on the Pacifico unit. LPN #1 said the unidentifiable brown substance, milkshake, ice cream sandwich, breakfast sandwich and the frozen meals needed to be thrown out. The nutrition services director (NSD) and NHA #2 were interviewed together on [DATE] at 2:22 p.m. NHA #2 said the refrigerator and freezer in the main dining room needed to be locked. The NSD said all foods needed to be labeled and dated. The NSD was interviewed again on [DATE] at 1:24 p.m. The NSD said all foods should be labeled and dated. The NSD said foods should be disposed of three days after the date written on the item. The NSD said the housekeeping department was responsible for maintaining the refrigerator and freezer on the Pacifico unit. The NSD said the frozen meals and anything without a date needed to be disposed of. The housekeeping supervisor (HSKS) was interviewed on [DATE] at 1:37 p.m. The HSKS said the housekeepers cleaned the refrigerator and freezer on the Pacifico unit. The HSKS said the nursing staff was responsible for labeling and dating the food items in the refrigerator and freezer. The DON was interviewed on [DATE] at 1:51 p.m. She said she had not heard that the nursing staff was responsible for labeling and dating the foods that were in the refrigerator and freezer on the Pacifico unit. The DON said she would look into it. II. Ensure foods were cooled properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part, Maintain the records required to confirm that cooling and cold holding refrigeration time/temperature parameters are required as part of the HACCP (hazard analysis critical control point) plan. B. Facility policy and procedure The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised [DATE], was provided by NHA #2 on [DATE] at 4:23 p.m. It read in pertinent part, Leftover foods and chilled with HACCP (Hazard Analysis Critical Control Points) guidelines if product is acceptable. C. Observations During the initial kitchen tour on [DATE] at 8:56 a.m., the following was observed in the walk-in refrigerator: -A container of chicken gravy that was hot to the touch, a container of cooked ground sausage, two breakfast meal trays, a container of cooked sausage patties and a container of cooked sausage. During a continuous observation on [DATE] beginning at 11:16 a.m. and ending at 12:50 p.m.: the following was observed: -In the walk-in refrigerator, there was a leftover breakfast meal tray, a container of cooked sweet potatoes with condensation in the container, a container of cooked beans, a container of gravy and a container of sausage. D. Record review -A request was made for the documented cooling monitor system on [DATE]. The NSD said the facility did not have a documented cooling monitor system in place (see interview below). E. Staff interviews Cook #2 was interviewed on [DATE] at 12:44 p.m. She said after lunch was over she pulled the containers of food from the steam table and put them in ice or on the preparation table. Cook #2 said she would leave the food there until right before she left at 1:30 p.m. Cook #2 said they did not utilize a log to monitor the temperature of food as it cooled. The NSD was interviewed on [DATE] at 1:24 p.m. The NSD said food needed to be cooled properly to prevent bacteria growth. The NSD said foods should not be hot to the touch when they were put into the walk-in refrigerator. III. Ensure artificial fingernails were not worn by a food service worker A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part, Unless wearing intact gloves in good repair,a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. B. Facility policy and procedure The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised [DATE], was provided by NHA #2 on [DATE] at 4:23 p.m. It read in pertinent part, Nail polish, gel polish or nails are not allowed by any persons working in the department and handling food. C. Observations During a continuous observation on [DATE] beginning at 11:16 a.m. and ending at 12:50 p.m.: the following was observed: -At 11:32 a.m. the NSD put on oven mitts and took hot plates out of the microwave. -At 11:30 a.m. the NSD put her hands on the cutting board attached to the steam table with her finger tips pointed down where the underside of her nails were touching the cutting board. The NSD had painted artificial nails that were approximately one inch long. D. Staff interviews The NSD was interviewed on [DATE] at 1:24 p.m. The NSD said artificial nails and painted nails were not allowed in the kitchen and she would remove them. IV. Ensure appropriate hand washing occurred in the main kitchen while doing dishes and properly dried dishes A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, 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 singled 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 caring for or handing service animals or aquatic animals, after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, 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 dining gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands. Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warwashing or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part, Unless used immediately after sanitization, all equipment and utensils shall be air-dried. B. Facility policy and procedure The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised [DATE], was provided by NHA #2 on [DATE] at 4:23 p.m. It read in pertinent part, Food is handled properly with frequent handwashing and proper handwashing and proper sanitation guidelines per local, state and federal guidelines and codes. Handwashing is done regularly after using the restroom, after breaks and after handling raw foods. C. Observations During a continuous observation on [DATE] beginning at 11:16 a.m. and ending at 12:50 p.m.: the following was observed: -At approximately 12:52p.m. Cook #1 was rinsing and sorting dirty dishes into a tray and pushed the tray into the dishwasher. While the dishwasher was running she stood in the dish pit with her hand on her hip. When the dishwasher was finished she pulled the dishes out of the dishwasher and pushed another tray of dirty dishes into the dishwasher. -Cook #1 began putting away clean dishes without performing hand hygiene. Cook #1 put more dirty dishes in the dishwasher and then went back to putting clean dishes away. -Cook #1 left the dish room and put on a pair of gloves. She did not perform hand hygiene prior to putting on gloves. -She got a plastic bag and used her gloved hands to put potato chips into the bag. Cook #1 gave the chips to a resident in the dining room. -Cook #1 took the gloves off and washed her hands. -At 12:19 p.m. Cook #1 was putting away clean dishes. Cook #1 put on gloves and started handling dirty dishes. Cook #1 continued touching dirty dishes. -At 12:26 p.m. Cook #1 removed the gloves. She touched dirty dishes with her bare hands and rinsed her hands under water. -Cook #1 dried her hands on her shirt and put on a new pair of gloves. -Cook #1 began using a towel to dry off the wet dishes in the dish room and put them away. -Cook #1 took clean dishes out of the dishwasher and continued to dry them with a towel. -At 12:33 p.m. Cook #1 took off her gloves and began putting away more clean dishes without performing hand hygiene. , -At 12:40 p.m. Cook #1 put dirty dishes into the dishwasher and then went back to putting away clean dishes without performing hand hygiene. On [DATE] at 12:19 p.m. an unidentified dietary staff member was handling dirty dishes in the dish room. Without performing hand hygiene, she began picking up clean trays and putting them away. D. Staff interviews The NSD was interviewed on [DATE] at 1:24 p.m. The NSD said hand hygiene should be performed frequently in the kitchen. The NSD said hand hygiene should be performed before and after gloves usage. The NSD said hand hygiene should be performed after handling dirty dishes and before handling clean dishes. The NSD said all dishes should be air dried. The NSD said Cook #1 was new. V. Ensure the nourishment the nourishment room freezer was monitored to ensure it was the correct temperature A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part; Each mechanically refrigerated food storage unit storing potentially hazardous food (time/temperature control for safety food) shall be provided with a numerically scaled indicating temperature measuring device. The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part; Time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 (degrees) F (Farenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. In a mechanically refrigerated storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit. B. Observations On [DATE] at approximately 2:00 p.m. the refrigerator on the Pacifico unit was 60 degrees fahrenheit (F). -The freezer did not have a thermometer inside of it to monitor the temperature. There was a breakfast sandwich that was soft and an ice cream sandwich that was squishy inside the freezer. C. Record review -A request was made for the monitoring of the freezer on the Pacifico unit on [DATE]. The maintenance director (MTD) said the facility did not have a documented monitoring log for the freezer on the Pacifico unit (see interview below). D. Staff interviews LPN #1 was interviewed on [DATE] at approximately 2:00 p.m. LPN #1 said there were items in the freezer that were not fully frozen. LPN #1 said the refrigerator was 60 degrees fahrenheit. NHA #1 was interviewed on [DATE] at approximately 2:15 p.m. NHA #1 said the refrigerator on the Pacifico unit was 60 degrees fahrenheit. NHA #1 said when the refrigerator was opened it hit the electrical plug, which caused the refrigerator to become unplugged. NHA #1 said he would take the refrigerator and freezer out of order until a solution was found to ensure the refrigerator and freezer stayed plugged in. The MTD was interviewed on [DATE] at 2:22 p.m. The MTD said he had never been asked to monitor the temperature of the Pacifico unit freezer. The MTD said the staff touched the food regularly to ensure it was frozen. VI. Ensure towels were stored properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part, Cloths in-use for wiping food spills from tableware and carry-out containers that occur as food is being served shall be: maintained dry and used for no other purpose. Cloths in-use for wiping counters and other equipment surfaces shall be: held between uses in a chemical sanitizer solution at a concentration specified under ,d+[DATE].114 and laundered daily. Dry wiping cloths and the chemical sanitizing solutions specified in subparagraph (B)(1) of this section in which wet wiping cloths are held between uses shall be free of food debris and visible soil. B. Observations During a continuous observation on [DATE] beginning at 11:16 a.m. and ending at 12:50 p.m.: the following was observed: -At 11:34 a.m. Cook #1 placed wet towels on the cutting board that was attached to the steam table. The wet towels covered the entire cutting board surface. The towels were close to the food that was in the steam table. -During the meal service Cook #1 and Cook #2 placed plates and clamshells onto the wet towels that were on the cutting board surface. C. Staff interviews Cook #2 was interviewed on [DATE] at 12:32 p.m. She said she put the wet towels on the steam table to prevent the plates from falling off the steam table. Cook #2 said the cutting board attached to the steam table was slanted slightly towards the ground which caused the plates to fall. The NSD was interviewed on [DATE] at 1:24 p.m. The NSD said she would notify maintenance to look at the steam table. The NSD said towels should be stored in sanitizer or in use.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerator, one of two treatment carts and one of four medication carts. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator; -Ensure medications were not left on top of the medication cart when unattended; and, -Ensure the treatment cart was locked when left unattended. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, not dated, was provided by the nursing home administrator on 3/7/24 at 8:40 a.m. It read in pertinent part, Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, cans, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. II. Observations On 3/4/24 at 8:52 a.m., the medication cart was observed. There was one medication card for Xarelto (a blood thinning medication used to treat and prevent blood clots) sitting on top of the medication cart. There was not any staff in sight of the cart and the nurse was behind a closed door attending to a resident. A resident was sitting in his wheelchair near the medication cart. On 3/4/24 at 8:59 a.m., the treatment cart was observed on the Pacifico unit. The nurse had accessed the treatment cart and left it unlocked as she went into room [ROOM NUMBER] and closed the door. She was not in line of sight of the unlocked treatment cart. The treatment cart contained multiple topical medications and biologicals. There were several residents nearby and passing by the treatment cart. On 3/5/24 at 2:41 p.m., the medication refrigerator was observed with licensed practical nurse (LPN) #3. A vial of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) was in a ziploc bag on the door shelf. -It was not in the permanently affixed locked compartment inside of the refrigerator. III. Staff interviews LPN #3 was interviewed on 3/5/24 at 2:46 p.m. LPN #3 said she did not know why the vial of Ativan was not in the locked box inside of the refrigerator. She said she understood that anyone with access to the refrigerator could just take the Ativan out of the refrigerator. The director of nursing (DON) and infection preventionist (IP) were interviewed together on 3/7/24 at 9:32 a.m. The DON said medications should never be left on top of the medication cart when the nurse was not in line of sight of the medication cart. She said the facility had many residents with dementia and they could take the medications. She said leaving medications out on top of an unattended medication cart could put the residents at risk of overdose or significant adverse reactions if they were to take the medication. The DON said treatment carts should not be left unlocked and unattended. She said residents with poor safety awareness could take the treatments which could result in harm to those residents. The DON said controlled medications should always be kept in secure compartments. She said when controlled medications were not secured they could be taken by unauthorized persons.

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Ensure proper hand hygiene was conducted during medication administration; -Follow infection control practices during enteral nutrition administration (feeding through a tube placed in the stomach or small intestine); and, -Follow infection control practices during tracheostomy care. Findings include: I. Failure to ensure hand hygiene was performed effectively during medication administration A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 2/29/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations. Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. B. Observations On 3/6/24 at 9:16 a.m., licensed practical nurse (LPN) #1 prepared medications for a resident. LPN #1 walked to the resident's room and administered medications to the resident. She took the empty medicine cup and water cup back from the resident and discarded them in the trash. At 9:20 a.m., LPN #1 went into the residents' bathroom and began to wash her hands. - She washed her hands with soap and water for six seconds. At 9:21 a.m., LPN #1 returned to the medication cart and began to prepare medications for the next resident. She used the mouse for her computer and unlocked the medication cart with her keys. LPN #1 carried the medication cup and a cup of water to the resident's room and knocked on the door. She opened the door, entered the room and administered the medications. After the resident took the medication, LPN #1 took the medication cup and the water back from the resident and discarded them in the trash. At 9:23 a.m. LPN #1 went into the resident's bathroom and began to wash her hands. -She washed her hands with soap and water for five seconds. C. Interviews The director of nursing (DON) and infection preventionist (IP) were interviewed together on 3/7/24 at 9:32 a.m. The DON and the IP said staff should wash their hands with soap and water for 20 seconds. The DON and IP said it was important for staff to wash their hands for 20 seconds to remove all of the germs from their hands. The DON said staff failure to wash thir hands for the full 20 seconds would lead to the spread of germs, viruses and infections from resident to resident. II. Failure to follow infection control practices during enteral nutrition administration A. Professional Reference According to the National Library of Medicine Enteral tube feeding: using good practice to prevent infection (January 12, 2017) retrieved on 3/14/24 from https://pubmed.ncbi.nlm.nih.gov/28079411/, Enteral tube feeding is the delivery of nutritionally complete feed via a tube into the gut. It is used for patients who are unable to meet their nutritional needs orally. Enteral feeding can be given through a variety of different tubes that access the gastrointestinal tract either via the stomach or the small bowel. The contamination of enteral feed can often be overlooked as a source of bacterial infection. Enteral feeds can become contaminated in a variety of different ways. Most often infections result in extended lengths of stay in hospital and patients also need additional therapies and treatments in order to resolve these infections. Healthcare-associated infections not only affect the patients who acquire them but also have an impact on the staff involved in their care. Each acute trust will have its own local policies and guidelines regarding enteral feeding and infection control and prevention. These local documents will be based on national initiatives and guidelines. It is important for nurses to refer to their local policies and guidelines before they start a patient on enteral feeding to ensure that they are doing so in the safest manner possible. Nurses' practice is key to preventing bacterial contamination in such patients. B. Observations On 3/5/24 at 4:11 p.m., LPN #2 was observed administering enteral nutrition for a resident. She removed the clear plastic cap from the tube feeding line and placed it on top of the IV pole while she primed the line. When she finished priming the line she removed the clear plastic cap from the top of the IV pole and put it back on the tube feeding line. LPN #2 continued to feed the line into the pump and then removed the clear plastic cap and inserted the feeding tube line into the resident's gastrostomy tube. -The clear plastic cap was not sanitized after being placed on the metal on the top of the IV pole. C. Interviews The DON and IP were interviewed together on 3/7/24 at 9:32 a.m. The DON said the cap for the feeding tube line should not be placed on the IV pole because the IV pole was not a clean surface. She said doing this would introduce germs to the resident and put the resident at risk of infection or illness. The IP said the process for administering enteral nutrition was a clean process and all supplies used should be clean. III. Failure to follow infection control practices during tracheostomy care A. Professional Reference According to Tracheostomy Education, Preventing Infection in Individuals with Tracheostomy (August 3, 2019), retrieved on 3/14/24 from https://tracheostomyeducation.com/infection-control-issues-in-caring-for-patients-with-tracheostomy/, Maintaining a high level of infection control is the responsibility of all health care staff working with any patient, particularly with individuals with tracheostomy and mechanical ventilation in order to ensure the safety of the patient, visitors and staff. Infection may be bacterial (gram negative organisms, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococci and b Haemolytic Streptococcus Group A) or viral (respiratory synctial virus, parainfluenza) in nature. According to the National Library of Medicine Nursing Skills for Tracheostomy Suctioning (2021), retrieved on 2/29/24 from https://www.ncbi.nlm.nih.gov/books/NBK593189/, nurses should Don the sterile gloves from the kit for suctioning. B. Observations On 3/5/24 at 4:21 p.m., LPN #2 was observed during tracheostomy care and suctioning for a resident. LPN #2 opened the sterile tray for tracheostomy care and placed the sterile glove packaging on the resident's bed. -LPN #2 opened the sterile gloves and put a glove on her left hand and immediately tore the glove. She continued to put the other sterile glove on her right hand and proceeded with suction preparation. During preparation, the alarm began sounding on the tube feeding pump. LPN #2 attempted to correct the alarm by silencing the alarm and checking the line inside the pump door. Once the alarm was silenced she returned to suction preparation. The alarm continued to sound on the tube feeding pump four more times and each time she silenced the alarm and tried to correct the failure by first silencing the alarm on the pump, realigning the tubing in the pump, adjusting the line in the nutrition bag and checking the line in the resident's abdomen. During this process LPN #2 had a problem with her gown falling off of her right shoulder and she had to pull it back up on her shoulder. The gown was not tied around her neck or waist. The alarm on the feeding pump was temporarily silenced and LPN #2 removed the suction catheter and began to suction the residents tracheostomy. -LPN #2 did not replace the damaged sterile glove. -LPN #2 did not replace either of the gloves or perform hand hygiene after touching multiple surfaces before beginning suction. C. Interviews The DON and IP were interviewed together on 3/7/24 at 9:32 a.m. The DON said tracheostomy suctioning should be performed with sterile gloves. She said if the gloves were damaged at any point the glove should be changed after performing hand hygiene again. The DON said the nurse should not touch any other surfaces or items that are not directly related to suctioning during the suctioning process. The IP said failure to maintain sterile gloved hands during tracheostomy care could lead to contaminating the resident and spreading germs. She said touching other surfaces not related to suctioning could spread germs and compromise the resident's health.

Based on observations, record review and interviews the facility failed to ensure for five (#21, #22, #2, #36 and #30) of six residents reviewed were provided with services or treatments to prevent the reduction in range of motion, out of 35 sample residents. Specifically, the facility failed to ensure Residents #21, #22, #2, #36 and #30 were provided preventative measures to help minimize the worsening of contractures. Findings include: I. Resident #21 A. Resident status Resident #21, age 67, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included encephalopathy and anoxic brain damage. The 8/9/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score of five out of 15. He required extensive assistance of two people with bed mobility, dressing, toileting and personal hygiene. B. Observations On 11/15/22 at 9:30 a.m. Resident #21 was observed in the common area with no splints on his hands and no protection to his palm. His hands were contracted. The left hand was balled up with his fingers touching his palm. The right hand fingers were stuck in the flexed position with the thumb pressed to his palm. On 11/16/22 at 10:00 a.m. the resident was observed sitting in his geri chair in the common area. He did not have any splints or preventative measures in place. On 11/16/22 at 1:30 p.m. the resident was observed lying in his bed watching television. His hands were laying on his chest with no preventative measures in place. C. Record review The mobility care plan, initiated on 7/17/19 and revised on 11/10/22, documented that the resident had limited physical mobility, was bed ridden, and required total assistance. This put him at risk for contractures, thrombus formation and skin-breakdown. The intervention included physical therapy and occupational therapy referrals as needed. -The resident's comprehensive care plan did not address the resident's bilatera hand contractures or any interventions and preventative measures to be put into place to prevent the worsening of the contractures. II. Resident #22 A. Resident status Resident #22, age 59, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included persistent vegetative state and tracheostomy. The 11/9/22 MDS assessment revealed the resident had short-term and long-term memory impairment and required assistance in making decisions about tasks of daily life. She required extensive assistance of two people with bed mobility, dressing, toileting and personal hygiene. B. Observations On 11/16/22 at 10:00 a.m. Resident #22 was observed being transferred to her geri chair from her bed using a mechanical lift. The resident's right hand was balled up with her fingers touching her palm and the left hand was contracted at a 90 degree angle. The resident did not have any splints or preventative measures in place for her bilateral hand contractures. On 11/16/22 at 10:30 a.m. the resident was visited by an unidentified restorative nurse aide (RNA) for passive range of motion exercises to the resident's upper extremities that lasted for 10 minutes. The RNA did not provide any preventative measures or don splints to the resident's bilateral hand contractures. The unidentified RNA said he moved her arms around and gave her a massage. On 11/17/22 at 9:16 a.m. Resident #22 was observed sitting in her geri chair in her room. There were no splints or preventative measures in place for her bilateral hand contractures. C. Record review The mobility care plan, initiated on 4/9/21 and revised on 4/20/21, documented that the resident had chronic pain from contractures. The interventions included administering analgesia as per orders; monitoring any sign or symptoms of non-verbal pain; and notifying the physician if the interventions are unsuccessful or if the resident's current complaint of pain was a significant change from residents past experience of pain. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/16/22 at 1:30 p.m. She said Resident #21 had contractures to both hands. She said that when she tried to put his splints on she was unsuccessful because he was experiencing too much pain. She said she had been directed by the director of nursing (DON) that the restorative team would be responsible for splints and preventative measures. She said she did not provide any preventative measures to the resident's contractures. RNA #1 was interviewed on 11/17/22 at 2:00 p.m. She said that she received the plan of care for residents needing restorative services from the director of rehabilitation (DOR). She said that both Resident #21 and #22 did not tolerate splints for their contractures because the splints caused them too much pain. She said she did not know if this was documented in their medical records. She said she was not aware of any other preventative measures for both Resident #21 and Resident #22. The DOR was interviewed on 11/17/22 at 3:20 p.m. She said that she was responsible for creating the plan of care for the residents who required restorative services. She said she sent the plan of care to the restorative team and DON to execute the plan. She said any changes to the plan of care were determined by the DON. She said both Resident #21 and Resident #22 did not have splints in place because they caused pain. She said that should be documented on the resident's care plan. She said she did not know if any other preventative measures were in place for either resident. The DON was interviewed on 11/17/22 at 3:30 p.m. She said that the therapy department evaluated resident's every quarter and determined if the resident continued on or was placed on a restorative nursing program. She said the plan of care should indicate if the resident required preventative measures. She said she was unsure if Resident #21 and #22 had any preventative measures in place for their contractures. 43135 IV. Resident #2 A. Resident status Resident #2, age under 70, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included, dementia without behavioral disturbances, epilepsy, quadriplegia (paralysis of all limbs), obesity, hypertension (high blood pressure), contractures of both the right and left elbow and hand, and contractures of both the right and left feet. The 11/8/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. She had total dependence on staff for transfers, locomotion on and off the unit, and bathing. She did not reject care from staff. B. Observations Observations during the day on 11/14/22 at 9:30 a.m. to 3:00 p.m, 11/15/22 at 9:00 a.m. to 4:00 p.m., 11/16/22 at 9:00 a.m. to 4:00 p.m., and 11/17/22 at 9:00 a.m. to 4:00 p.m. revealed the resident was observed not wearing hand splints or boots for contractures. C. Resident interview Resident #2 was interviewed on 11/14/22 at 10:06 p.m. She said she did not wear splints in her hands because the material was too hard for her and she said she did not like wearing them. She said she was unaware there were items she could wear in her hands that were a soft material. She said she wore slippers every day and she said she did not wear anything on her legs or feet for her contractures. She said she did not receive restorative care. D. Record review The comprehensive care plan 9/7/22 revealed in pertinent part, Interventions: Resident will work with restorative staff with assisted active range of motion for 15 minutes or more six days per week. Restorative staff will apply right hand splints/ (brand name) boots to bilateral legs to be work(ed) for two hours or more as tolerated . at least six days a week. The 11/14/22 MDS assessment for restorative seven day look back revealed, -zero days for passive range of motion. -six days for active range of motion. -six days for splint or brace assistance. -The facility did not provide documentation of these six visits that were documented in the 11/14/22 MDS assessment before exit on 11/17/22. The 11/17/22 kardex (certified nurse aide CNA daily tasks), Splint/brace program restorative staff will apply right hand splints and boots to bilateral legs to be worn for two hours or more as tolerated at least six days a week. On 11/18/22 at 7:21 a.m. the nursing home administrator (NHA) emailed the documentation of restorative nursing visits. The resident was to have restorative visits six days per week. The resident had documented visits from restorative nursing on only two days, 10/18/22 and 10/18/22. There were no refusals to wear hand splints or boots to the bilateral legs from the resident documented. V. Resident #36 A. Resident status Resident #36, age under 70, admitted on [DATE]. According to the November computerized physician orders (CPO), the diagnoses included a stage four pressure ulcer, type two diabetes mellitus, cognitive communication deficit, multiple sclerosis, hypertension (high blood pressure), contracture of the left hand and wrist, contracture of the right and left shoulder, contracture of the left and right knee, transient ischemic attack (TIA, temporary symptoms similar to a stroke), gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach), anxiety disorder, and depression. The 10/11/22 minimum data set (MDS) assessment revealed the resident was unable to conduct a brief interview for mental status score. She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. She normally used a manual wheelchair and was dependent on staff to propel the wheelchair. B. Observations On 11/14/22 through 11/17/22 Resident #36 was observed in her bed not wearing splints on her left hand. C. Record review The 10/20/22 MDS assessment seven day look back revealed, -The resident had therapy for only one day for 30 minutes. -The resident had zero minutes with restorative therapy which included splint or brace assistance. The comprehensive care plan 10/18/22 revealed, -The resident would receive restorative nursing six days per week for her left side hand splint for one hour, and bilateral knee splints for two hours. On 11/18/21 at 7:21 a.m. the NHA emailed the documentation of restorative nursing visits which revealed the resident received restorative nursing on 11/10/22. There were no other dates of restorative nursing visits provided. There was no documentation of resident refusals to wear a splint or brace. VI. Staff interview Certified nurse aide (CNA) # 1 was interviewed on 11/16/22 at 9:27 a.m. She said when she worked with Resident #36 she repositioned her but she did not put any braces on her because that was restorative nursing's job. The director of nursing (DON) was interviewed on 11/17/22 at 2:46 p.m. She said the director of the restorative program was out of town for the week. She said she would email the visits provided to Resident #2 and #36 by the restorative staff. She said there was a big caseload of residents in the facility who received restorative nursing care. She said Resident #36 was looked at upon admission by physical therapy and occupational therapy (the NHA emailed the documented visits, see above). The DON said she would look into the residents receiving restorative nursing services if they were missed. 47350 VII. Resident #30 A. Resident status Resident #30, age younger than 65, was admitted on [DATE]. According to the November 2022 CPO, the diagnoses included traumatic brain injury, cerebral infarction (stroke), chronic respiratory failure, persistent vegetative state and contractures. The 8/15/22 MDS assessment revealed the resident had severe cognitive impairment with severe impairment in making decisions regarding tasks of daily life. She required total assistance of two people for bed mobility, transfers, personal hygiene and totally dependent and total assistance of one person for dressing and toileting. B. Observations On 11/14/22 at 9:30 a.m. Resident #30 was observed lying in bed with bilateral hand contractures. The resident's fingers on her bilateral hands were curled inward touching the palm There were no preventative measures in place for the contractures to the resident's bilateral hands. -At 1:40 p.m. Resident #30 was observed sitting in the geri-chair. The resident was leaving toward the left side of the wheelchair. The resident's fingers were observed contracted toward her palms. There were no preventative measures in place. On 11/15/22 from 9:10 a.m. Resident #30 was observed lying in bed on her back. There were no preventative measures in place for the resident's bilateral hand contractures. -At 10:30 a.m. certified nurse aide (CNA) #6 was observed entering the room and leaving eight minutes later. The resident remained lying in the same position with no preventative measures in place for her bilateral hand contractures. -At 3:50 p.m. Resident #30 was observed lying in the same position with no preventative measures in place. During a continuous observation on 11/16/22 beginning at 9:50 a.m. and ended at 4:00 p.m. Resident #30 was observed lying in bed, on her back, with no preventative measures in place for her bilateral hand contractures. During the continuous observation, the facility staff were not observed entering the resident's room and attempting passive range of motion or applying any preventative measures to the resident's bilateral hand contractures. On 11/17/22 at 8:55 a.m. deflated carrots (preventative measure) were observed in the resident's room. They were sitting on the bottom of a bookshelf, were deflated, and appeared newer and unused. B. Record review The activities of daily living (ADL) care plan, initiated 8/10/18 and revised 9/30/22, documented the resident required total assistance with all ADLs. The interventions included physical therapy and occupational therapy evaluation and treatment as per physician orders, providing a restorative passive range of motion (ROM) program, ensuring the restorative staff work on the resident's on bilateral lower extremities and bilateral upper extremities as tolerated for 15 minutes or more per day for six days per week (initiated 4/24/21 and revised 8/31/22) and ensuring bilateral hand carrots were placed for four hours per day, six days per week. The August 2022 occupational therapy (OT) discharge summary note recommended compensatory pain management techniques before light passive stretching techniques to help improve the resident's tolerance and decreased pain response. It indicated that the resident had an excellent prognosis with consistent staff support and the restorative nurse program. The splint and orthotic recommendations included a restorative nurse program for passive range of motion and application of bilateral upper extremity carrots to be donned throughout the day for eight hours. The restorative nursing notes on 10/26/22 and 11/10/22 revealed that restorative staff had not been able to proceed with Resident #30's passive ROM and splints because resident was showing signs of refusal by making unpleasant sounds when measures were attempted in bilateral hands. Pain medication was tried before the restorative measures but it was unsuccessful. The recommendation was documented to continue with the resident's current plan of care. The restorative nursing task flow sheets from 9/15/22 to 11/16/22 were signed off daily as Resident #30 refused passive range of motion and carrot application to bilateral hands, however based on observations conducted throughout the survey process, the bilateral carrots and passive range of motion was not offered to the resident. C. Staff interviews CNA #4 was interviewed on 11/17/22 at 9:00 a.m. She said Resident #30 had boots for her bilateral feet and a pillow for between her knees. She said that the resident had carrots for both of her bilateral hand contractures. She said the carrots were kept on a shelf in the resident's room. She said the restorative nursing aide (RNA) worked with the resident every day for her contractures. She said they were responsible to apply the carrots for the resident. RNA #1 was interviewed on 11/17/22 at 2:04 p.m. She said they had been trying to work with Resident #30 every day Monday through Saturday. She said the resident had refused treatment and preventative measures that week, however according to the observations during the survey process, the resident was never provided or offered any preventative measures.

Based on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#10) of nine residents reviewed for medication errors of 35 sample residents. Specifically, the facility failed to ensure that Resident #10 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Professional reference According to the Humalog Kwikpen manufacturer guidelines, last updated March 2020, retrieved from https://uspl.lilly.com/humalog/humalog.html#ug1 retrieved on 11/21/22 included the following recommendations, Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. II. Resident #10 A. Resident status Resident #10, age younger than 65, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included schizophrenia and type two diabetes mellitus. The 9/6/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. He required the supervision of one person with bed mobility and eating, was independent with transfers and required extensive assistance of one person with dressing, toileting and personal hygiene. B. Observations On 11/15/22 at 4:30 p.m. licensed practical nurse (LPN) #2 checked Resident #10's insulin order of Humalog 4 units to be administered at the evening meal. She obtained his labeled Humalog insulin pen. She then placed the disposable needle onto the Kwikpen and dialed four units into the Humalog Kwikpen. She then entered Resident #10's room and pushed insulin through the pen before she administered it to the resident. She administered insulin into the back of Resident #10's left arm. She then placed the needle from the Kwikpen into the sharps container. C. Record review The 6/6/22 CPO revealed Humalog Solution Cartridge 100 units/ml to inject four units subcutaneously once a day with the evening meal for diabetes mellitus. D. Staff interviews LPN #2 was interviewed on 11/15/22 at 4:45 p.m. She said prior to administering insulin in a Kwikpen, she dialed in the units of insulin that were ordered by the physician to be administered. She said she then pushed the insulin through the pen to prime it and then administered the insulin to the resident. The director of nursing (DON) was interviewed on 11/16/22 at 11:40 a.m. She said insulin pens should be primed by pushing one to two units through the pen prior to administering the ordered dose of insulin. She said this needed to be done to ensure air was eliminated in the pen and ensure the resident received the correct dosage of insulin. She confirmed that by not priming the insulin pen properly, the resident could receive a misdose of insulin.

Based on interviews, observations and record review, the facility failed to ensure two (#265 and #30) of three out of 35 sample residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to: -Ensure a sterile technique was used within accepted standards of practice for tracheostomy care suctioning for Resident #265 and #30; and, -Ensure physician's orders were followed for Resident #265's tracheostomy care. Findings include: I. Professional reference A. [NAME], T. C. et al. American Association for Respiratory Care Clinical Practice Guidelines: Artificial Airway Suctioning. Respiratory Care. 2022 February 67(2): 258-271. https://www.aarc.org/wp-content/uploads/2022/10/cpg-artificial-airway-suctioning.pdf retrieved on 11/21/22 at 12:20 p.m. Therefore, based on committee experience, it is recommended that the clinician use a sterile procedure, when possible, for open suctioning events to protect the patient from potential cross-contamination. II. Facility policy and procedure The Tracheotomy Care policy and procedure, revised August 2013, was provided by the nursing home administrator (NHA) on 11/17/22 at 3:50 p.m. It revealed, in pertinent part, Aseptic technique must be used during cleaning and sterilization of reusable tracheostomy tubes, during all dressing changes until the tracheostomy wound has granulated (healed), and during tracheostomy tube changes, either reusable or disposable. The Suctioning the Upper Airway policy and procedure, revised October 2010, was provided by the NHA on 11/17/22 at 3:50 p.m. It reads in pertinent part, Put on sterile gloves. The dominant hand will remain sterile. Pick up the catheter with sterile hand and attach to the suction tubing (held in non-sterile hand). Disconnect the catheter from the tubing, Wrap the catheter around the gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle. III. Resident #265 A. Observations and interviews On 11/16/22, Resident #265 was observed from 11:45 a.m. to 12:46 p.m. No suctioning was observed as ordered every four hours, however the physician's order was signed off in medication administration record (MAR) as having been completed by licenced practical nurse (LPN) #2. LPN #2 was not observed entering Resident #265's room. On 11/16/22 Resident #265 was observed from 2:50 p.m. to 3:46 p.m. No suctioning was completed but the order was signed off in MAR that the order had been completed by LPN #4. LPN #4 said she did suction the resident when she tested his blood glucose at 3:41 p.m. Continuous observation showed that Resident #265 was never suctioned in that time period. On 11/17/22 at 11:22 a.m. LPN #5 was observed providing suctioning to Resident #265. LPN #5 performed hand hygiene before setting up the procedure and opened a sterile suction kit and placed it on a clean table. LPN #5 removed the sterile gloves from the kit and donned the gloves using a sterile technique. She then opened a non-sterile bottle of saline with both sterile gloved hands, which contaminated them. LPN #5 then turned on the bedside suction, with the contaminated gloves, and then attached the sterile suction catheter to the suction tubing. She then proceeded to suction Resident #265's tracheostomy. She said that the resident's oxygen concentration was set to 4.5 liters per minute, however according to the discharge orders from the hospital, the resident should have been on humidified high flow oxygen at 10 liters per minute. LPN #5, during the tracheostomy suctioning, touched sterile supplies with a non-sterile gloved hand, therefore potentially introducing bacteria into the respiratory tract. B. Resident status Resident #265, age under 65, was admitted on [DATE]. According to the November computerized physician orders (CPO), the diagnoses included cerebral palsy, pneumonia and a tracheostomy. The 11/4/22 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory impairment with moderate impairment in making decisions about tasks of daily life. He required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene. It indicated the resident required oxygen therapy, suctioning and tracheostomy care. C. Record review The tracheostomy care plan, initiated on 10/6/22, documented the resident required the use of a tracheostomy. The interventions included ensuing the tracheostomy ties were secured at all times; monitoring and documenting for restlessness, agitation, confusion and increased heart rate; monitoring and documenting the resident's level of consciousness, mental status and lethargy; providing good oral care daily and as needed; and providing suctioning as necessary. The November 2022 CPO revealed the following physician orders: -The resident will be checked every four hours and will be suctioned if clinically indicated-ordered on 11/14/22. -Humidified high flow oxygen via the tracheostomy-ordered on 10/6/22. The 10/25/22 nursing progress note documented Resident #265 mouthed to the nurse that he did not feel good at 5:19 p.m. It indicated the resident had yellow secretions. The physician was notified and ordered a chest x-ray. The 10/27/22 at 9:39 p.m. nursing progress note documented the chest x-ray result indicating the resident had left lower lobe infiltrate. The physician ordered Vancomycin/Sodium Chloride 250 mg (milligrams) every 12 hours. The 11/3/22 nursing progress note documented Resident #265 had an oxygen saturation between 75% (percent) and 90%. It indicated the nurse suctioned the resident but his oxygen saturation did not improve. On 11/4/22, the nursing progress note documented the resident was sent to the hospital due to oxygen desaturation. The 11/4/22 hospital intensive care unit (ICU) doctor update documented the resident arrived at the hospital with an oxygen saturation in the 60% range. The resident had coarse breath sounds in both lungs as well as a severe infection (sepsis). It indicated the lungs being the source of the infection. The 11/4/22 hospital chest x-ray result documented the resident had a pleural effusion (diffuse fluid in the lungs) caused by bacterial pneumonia. The 11/4/22 hospital CTA (computerized tomography angiogram) documented the resident had multifocal (more than one spot) pneumonia and small left pleural effusion. D. Staff interviews LPN #4 was interviewed on 11/16/22 at 3:46 p.m. She said Resident #265 should be suctioned every fours and as needed. She said the suction times were scheduled at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. 8:00 p.m. She said the resident should also be suctioned when staff heard gurgling from the resident, whenever the resident gestured that it needed to be done or when his oxygen saturation dropped below 80%. She confirmed she signed off the MAR that the suctioning was completed as ordered by the physician at approximately 3:45 p.m. She said she entered the room and performed the suctioning right before she signed off the MAR, however based on observations LPN #4 did not enter the resident's room and did not provide suctioning as was ordered by the physician. The director of nursing (DON) was interviewed on 11/17/22 at 11:40 a.m. She said that sterile supplies should be used during the suctioning procedure of a tracheostomy. She said sterile gloves should be donned before touching sterile supplies. She said one sterile gloved hand was designated as a clean hand. She said the clean hand should be the hand that only touched sterile supplies. She said one sterile gloved hand was designated as the dirty hand. She said the dirty hand should only touch the non sterile supplies or equipment. She said that a break in sterile technique, during suctioning, would increase the resident's risk of infection by introducing bacteria into the respiratory tract. She said Resident #265 had recently had two pneumonia infections. She confirmed five residents at the facility, who required tracheostomy care, had been diagnosed with pneumonia in the past six months. She said out of the five residents, two residents had been diagnosed with pneumonia twice. She said training was completed on 10/12/22 and 11/9/22 to review the tracheostomy care policy and procedure through handouts and resources in a binder located at the nurses station. She said return demonstrations were not done with the nursing staff. She provided in-service sign off sheets for 10/12/22 and 11/9/22 training. LPN #5 was not listed as having attended the training on these dates. 47350 IV. Resident #30 A. Observations On 11/17/22 at 8:55 a.m. LPN #1 was observed performing tracheostomy suctioning for Resident #30. LPN #1 opened, in a sterile fashion, the sterile suction catheter, inner cannula, sterile gauze dressing and sterile gloves and then poured sterile saline into the sterile catheter tray. LPN #1 was observed picking up the non-sterile suction tubing with her sterile gloved right hand while her sterile gloved left hand picked up the sterile suction catheter and connected it to the non-sterile tubing. LPN #1's now non-sterile right hand let go of the non-sterile tubing and picked up the sterile suction catheter and manipulated it into the tracheostomy while the sterile gloved left hand touched the non-sterile suction tubing and controlled the suction at the distal (away from the point of attachment) end of the suction catheter. LPN #1 did not remove or replace his gloves at any time during the suctioning the tracheostomy. LPN #1 gathered up the suction tubing and suction catheter with both gloved hands and disposed of them in the trash. He picked up the sterile tracheostomy inner cannula with the right gloved (now non-sterile) hand and placed it into Resident #30's tracheostomy. LPN #1 picked up the sterile tracheostomy dressing with his non-sterile gloved hands and placed it around the tracheostomy stoma. With the same gloved hands, LPN #1 gathered the supplies, replaced the tracheostomy mask and adjusted the resident's pillow. LPN #1, during the tracheostomy suctioning, touched sterile supplies with a non-sterile gloved hand, therefore potentially introducing bacteria into the respiratory tract. B. Resident status Resident #30, age younger than 65, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included traumatic brain injury, cerebral infarction, chronic respiratory failure and contractures. The 8/15/22 MDS assessment revealed the resident had severe cognitive impairment with severe impairment in making decisions regarding tasks of daily life. She required total assistance of two people for bed mobility, transfers, personal hygiene and totally dependent and total assistance of one person for dressing and toileting. C. Record review The tracheostomy care plan (initiated on 8/10/18) documented the resident required the use of a tracheostomy due to impaired breathing mechanics. The interventions included ensuring the tracheostomy ties were secure; monitoring the resident's heart rate, restlessness, agitation, confusion, lethargy, respiratory rate, depth and quality; and maintaining the oxygen settings at three liters per minute via tracheostomy collar and suctioning as necessary. On 5/3/21 the physician orders revealed tracheal suctioning was to be done using a #14 French suction catheter with suction pressure of 80-120 millimeters of mercury (mmHg) every four hours for patency and as necessary for increased secretions. D. Staff interviews LPN #1 was interviewed on 11/17/22 at 9:20 a.m. He said Resident #30 needed to be suctioned every four hours and as needed to maintain the patency of the tracheostomy. He said when suctioning Resident #30's tracheostomy the nurse should complete hand hygiene first, put on clean gloves and remove the inner cannula. He said the gloves should be removed, perform hand hygiene and set up sterile supplies. He said the nurse should use one hand to manage the tracheostomy catheter and left hand to manage the suction. He did not describe a designated sterile hand for touching the sterile supplies and a contaminated hand for touching non sterile supplies or equipment.

Based on observations, record review and interviews the facility failed to ensure for one (#4) of three residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 35 sample residents. Specifically, the facility failed to provide a plan of care specific and personalized to the resident to address an unexpected 8.65% (percent) weight loss in six months. Findings include: I. Facility policy and procedure The Food and Nutrition Services policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 11/21/22 at 2:00 p.m. It showed in pertinent part, The staff will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. Reasonable efforts will be made to accommodate resident choices and preferences. II. Resident #4's status Resident #4, age 74, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included end stage renal disease and type 2 diabetes. The 9/27/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. She required minimal assistance with bed mobility, dressing, toileting and personal hygiene. It indicated the resident had not experienced a significant weight loss. A. Resident interview and observations Resident #4 was interviewed on 11/17/22 at 2:30 p.m. She said that she did not eat the food at the facility because she did not like it. She said the facility did not provide any alternates that she wanted to eat. She said the facility only provided what was on the always available menu. She said she liked it when her family brought food from home but that only happened a couple times per week. She said if she told the facility a certain food item she liked, she would end up getting it every day and would not receive a variety. She said she did not want to eat the same thing every day. On 11/16/22 at 5:00 p.m. Resident #4 was observed eating dinner in her room. The resident was served a sandwich, a bowl of soup, sweet potato fries, food her family had brought to the facility, a soda and apple juice to drink. She picked at her food only choosing to eat the food from her family (six small sopas) and had a few bites of fries. She also finished her soda. She said this was about how much she ate at every meal. B. Record review The nutrition care plan, initiated on 6/11/14 and revised on 10/10/22, documented the resident had unplanned weight loss. It indicated the resident received dialysis three times per week for approximately [AGE] years and had type two diabetes with insulin. It indicated the resident's family brought her preferred foods into the facility The interventions included observing for signs and symptoms of dehydration (initiated on 6/19/14); offering alternatives at meals to include the resident's preference of food brought in by her family (initiated on 11/1/21); providing liquid protein (initiated on 2/7/22); and providing the resident's preference of Atole (a drink made with cornmeal and milk) instead of milk (initiated on 8/29/22). A review of the comprehensive care plan did not reveal documentation that additional interventions had been added to the resident's comprehensive plan of care since the addition of the resident's preferred beverage of Atole. According to the November CPO, the resident received the following: -Regular diet, regular texture, thin consistency-ordered 9/27/21; -Nepro supplement-ordered 2/7/22; -Magic cup supplement every evening-ordered 4/25/22; and -Liquid protein supplement two times per day-ordered 4/25/22. -The facility did add or make any changes to the nutritional supplements since 4/25/22. On 5/15/22 her weight was recorded as 136.4 lbs (pounds) and on 11/17/22 her weight was recorded as 124.6 lbs, a 8.65% lbs weight loss in six months. The 6/23/22 nutrition progress notes documented the resident had experienced a weight loss. It indicated the resident had accepted the Nepro at night (put in place on 2/7/22), the Magic Cup nutritional supplement (put in place on 4/25/22), the liquid protein supplement (put in place on 4/25/22), and continued to have meals brought in by her family. -It did not include any additional or new interventions to address the resident's weight loss. The 8/29/22 nutrition progress note documented the physician recommending the resident be encouraged to drink milk with all meals. The resident preferred the beverage, Atole and that was updated on the plan of care to be offered with all meals. The 9/29/22 nutrition progress note documented the resident had experienced continued weight fluctuations, but her meal intakes had not changed. It indicated the registered dietitian (RD) would contact the dialysis dietitian to coordinate the resident's care, however it did not include any further interventions to address the resident's weight loss. The 10/10/22 nutrition progress note documented the RD discussed Resident #4's weight loss with the dialysis dietitian, who believed it was related to the resident's disease process, as she had been on dialysis for over [AGE] years. It indicated the RD requested an appetite stimulant. The new interventions included liberalizing the resident's diet (however the resident had been on a regular diet since 9/27/21) and encouraging increased caloric intake. The 11/3/22 nutrition progress note documented the resident continued to experience weight loss. The resident now weighed 126 lbs (down 8.6 % in six months). The RD indicated to continue current supplements and encourage the resident to consume meals brought in by her family. A review of the resident's medical record did not show documentation the RD or other dietary staff had met with the resident to determine a person-centered meal program or interventions that would provide the resident food items she would consume, to encourage increased meal intake and address the resident's weight loss. The facility continued the same plan of care, other than liberalizing the resident's diet and adding the beverage Atole. From 10/18/22 to 11/16/22 (30 days), the facility documented the resident consuming 26% to 50% on 13 occasions, 51% to 75% of her meal on 50 occasions, and 76% to 100% of her meal on 15 occasions. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 11/16/22 at 5:30 p.m. She said that the resident did not eat more than 50% of her meals. She said that the resident really enjoyed the food her family brought into the facility, but she only got food from them a couple times per week. She said that she encouraged the resident to eat her food but the resident did not like it. The RD was interviewed on 11/17/22 at 2:00 p.m. She said that she had been working with the dialysis RD for a plan to mitigate the resident's weight loss. She said she had put a liquid protein supplement and a Magic cup supplement in place in April 2022 but no changes had been made since then. She said that the facility physician declined placing the resident on an appetite stimulant. She said in September 2022 the dialysis RD had recommended liberalizing the resident's diet. She said, there had not been any other interventions put in place since then. She said she felt the resident's weight loss was attributed to the resident not liking the food at the facility. She said Resident #4's family would bring in meals a couple times per week, but they did not have enough to feed the resident homemade food every meal. She said she had not met with the resident to set up a person-centered nutrition plan to address that the resident did not like the facility's food. She confirmed the resident did not like the food that was offered on the always available menu. The DON (director of nursing) was interviewed on 11/17/22 3:10 p.m. She said the facility conducted an at risk meeting for any resident that triggered a significant weight loss. She said the interdisciplinary team, that included the dietitian, determined different approaches to address weight loss during the at risk meeting. She said that Resident #4 loved the food the family brought in but since it was only a few times a week, the resident could not rely on those meals for her only nutrition. She said that the order for a Magic cup and liquid protein nutritional supplements had been put into place in April 2022 but no changes had been made since that time. She said that in October 2022 the resident's dialysis provider recommended an appetite stimulant for the resident but the facility physician declined the recommendation due to the resident's history of obesity. She said the facility had not involved the resident's family in determining a person-centered plan to address the resident's continued weight loss.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#22) of two residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to ensure Resident #22 was invited to group activities, which was her preference, and developed a comprehensive care plan which addressed the resident's socialization and activity needs. Findings include: I. Facility policy and procedure The Activities Program policy and procedure, revised November 2022, was provided by the nursing home administrator (NHA) on 11/17/22 at 5:00 p.m. It revealed, in pertinent part, The community will provide daily activities that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies and the culture of the participants and community. Activities will be designed to meet and support the participants physical, mental, intellectual and psycho-social well-being. II. Resident #22 status Resident #22, age 59, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included persistent vegetative state and the use of a tracheostomy. The 11/9/22 minimum data set (MDS) assessment revealed the resident was unable to be cognitively assessed due to her persistent vegitative state. She required extensive assistance of two people with bed mobility, dressing, toileting and personal hygiene. A. Observations On 11/16/22 beginning at 10:20 a.m. and ended at 10:50 a.m. Resident #22 was observed sitting in her geri chair in her room, facing the door. She was not taken to the music therapy group activity in the dining hall. Other residents with similar abilities and limitations were brought to the group music therapy activity. The television or radio were turned on. -On 11/17/22 beginning at 8:50 a.m. and ended at 9:20 a.m. Resident #22 was observed sitting in her geri chair, in her room, facing the door. She was not taken to the 9:00 a.m. morning gathering group activity. The activity had other residents with similar abilities and limitations to Resident #22 gathered and listened to the music. The television or radio were turned on. -At 9:30 a.m. the music therapy group activity began. Resident #22 was not taken to the music therapy activity. B. Record review The activity care plan, revised on 7/25/21, documented the resident was in a vegetative state and required assistance with transfers and all care. It indicated the resident enjoyed watching movies, being read to and listening to music, especially jazz and rhythm and blues (R&B). The interventions included inviting the resident to structured activities that may be of interest; positioning the resident in the common areas to spend time around peers and provide exposure to external stimulation; interacting with resident during group activities, as possible, to engage resident actively in the group; and ensuring that the resident's TV (television)/radio is on during waking hours. A review of the resident's medical record on 11/17/22 at 11:00 a.m. revealed documentation of a comprehensive care plan that was developed to identify and address the socialization and activity needs of the resident including a record of structured activity and one-to-one participation/response to establish a baseline and monitor for any change. -However, during the survey process, Resident #22 had no documented one-to-one progress notes showing group participation from June 2022 to November 2022. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 11/17/22 at 10:00 a.m. She said that the resident attended group activities from time to time but she had not seen the resident attend any activities in months. She said when the resident did attend group activities she had a smile on her face and seemed to enjoy them. The activities Director (AD) was interviewed on 11/17/22 at 1:30 p.m. She said that morning meetings were when the facility staff tried to get everyone up but it had been hard getting the residents who used a tracheostomy to attend. She said it was very labor intensive for the certified nurse aides to get everyone up in time. She said that she was working with the director of nursing (DON) to have care staff be more involved in getting the residents to activities. She said she only started as the AD in August 2022. The DON was interviewed on 11/17/22 at 2:30 p.m. She said it was difficult for the staff to get residents up in time for activities. She said she would like to improve the process with the new AD. She said Resident #22 would benefit from spending time with her peers outside of her room.

Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for two (#30 and #36) of three sample residents out of 35 sample residents. Specifically, the facility failed to ensure that Resident #30 and #36, who were at risk for skin breakdown, were repositioned timely. Findings include: I. Professional reference According to A. [NAME], T.V. et al. Review of the Current Management of Pressure Ulcers. Advances Wound Care. 2018 [DATE]; 7(2): 57-67. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5792240/ retrieved on 11/23/22. Nursing home patients have a pressure ulcer prevalence of 11% (percent) and are most likely to develop pressure ulcer over the sacrum or heels. Nursing home patients were also found to have contractures at a prevalence of 55%. Contractures are caused by decreased elasticity of the tissue surrounding major joints, and the resulting lack of full mobility in the affected extremities significantly the risk of pressure ulcer formation. According to Pechlivanoglou, P. et al. Turning high risk patients: An economic evaluation of repositioning frequency in long term care. Journal of the American Geriatrics Society. 2018 July; 66(7): 1409-1414. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6097929/ retrieved on 11/22/22. According to current US (United States) practice guidelines, nursing home residents should be repositioned as frequently as required by their condition. Practice guidelines in Canada and the US recommend that patients at high risk of pressure ulcers be repositioned every two hours. II. Resident #30 A. Resident status Resident #30, age 54, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included traumatic brain injury, cerebral infarction (stroke), chronic respiratory failure, contractures and persistent vegitative state. The 8/15/22 MDS assessment revealed the resident had severe cognitive impairment with severe impairment in making decisions regarding tasks of daily life. She required total assistance of two people for bed mobility, transfers, personal hygiene and totally dependent and total assistance of one person for dressing and toileting. B. Observations On 11/15/22 at 12:50 p.m. Resident #30 was observed lying in bed and on her back. An unidentified licensed practical nurse (LPN) entered the room. She checked the water in the humidifier and the resident's tracheostomy tubing and left the room. She did not reposition the resident. -At 3:50 p.m. Resident #30 was observed still lying in bed on her back. The resident had not been repositioned in over three hours. During a continuous observation on 11/16/22 beginning at 9:50 a.m. and ended at 4:00 p.m. Resident #30 was observed lying in bed on her back. -At 1:25 p.m. an unidentified nurse was observed entering the resident's room. She checked the resident's tracheostomy and then left. She did not provide repositioning to the resident. -At 2:10 p.m. two unidentified CNAs were observed entering the resident's room. The CNAs provided Resident #30 incontinence care, with a strong bowel movement odor. The CNAs positioned Resident #30 on her right side with a pillow propped under her left shoulder and side. -This was the first time the resident had been repositioned in four hours. C. Record review The activities of daily living (ADL) self-care deficit care plan, initiated on 8/10/18 and revised on 9/10/21, documented the resident required assistance with all ADLs due to a traumatic brain injury and a chronic vegitative state. It indicated the resident required total assistance with bed mobility, bathing and dressing. The resident required the use of a mechanical lift for transfers. The interventions included ensuring the resident was up in her geri chair for morning activities for up to two hours or as tolerated. The pressure and skin injury care plan, initiated on 8/10/18 and revised on 1/5/21, documented the resident was at risk for skin breakdown due to immobility and the resident's diagnosis of persistent vegitative state. The interventions included educating the resident/family/caregivers as to causes of skin breakdown and frequent repositioning. D. Staff interviews Certified nurse assistant (CNA) #5 was interviewed on 11/16//22 at 2:10 p.m. She said the resident should be repositioned every one to two hours. The director of nursing (DON) was interviewed on 11/17/22 at 3:25 p.m. She said that Resident #30 was completely dependent upon staff for her activities of daily living and was unable to make her needs known. She said it was the facility's policy that dependent residents were turned and repositioned every two hours. 43135 III. Resident #36 A. Resident status Resident #36, age under 70, admitted on [DATE]. According to the November computerized physician orders (CPO), the diagnoses included a stage four pressure ulcer, type two diabetes mellitus, cognitive communication deficit, multiple sclerosis, hypertension (high blood pressure), contracture of the left hand and wrist, contracture of the right and left shoulder, contracture of the left and right knee, transient ischemic attack (TIA, temporary symptoms similar to a stroke), gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach), anxiety disorder, and depression. The 10/11/22 minimum data set (MDS) assessment revealed the resident was unable to conduct a brief interview for mental status score. She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. She normally used a manual wheelchair and was dependent on staff to propel the wheelchair. B. Record review The comprehensive care plan 10/7/22 revealed the following: -Focus: The resident has a stage four pressure injury. Sacrum or potential for pressure injury with development for immobility. -Interventions: Educate the resident/family/caregivers as to the causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Encourage (the) resident to reposition (her) self throughout (the) shift and assist as needed. Utilize pressure relieving devices/adaptive equipment when appropriate to potential pressure areas. C. Observations On 11/15/22 from approximately 10:15 a.m. through 2:15 p.m. Resident #36 was in her bed on her back. The facility staff did not go into her room and reposition her during the four hour observation. At 2:10 p.m. two staff members carrying sheets quickly walked in and out of Resident #36's room but did not reposition her. The resident did not have a wheelchair in her room (cross-reference F558 for accommodation of needs). D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 11/17/22 at 8:55 a.m. She said Resident #36 had a wheelchair when she came into the facility but she did not know where it went. She said Resident #36 had stayed in bed all day every day for over a month since she arrived at the facility. She said if she had a wheelchair or a recliner the staff would get her up to change positions because she has wounds on her tailbone. She said Resident #36 should be repositioned about every two hours. Licensed practical nurse (LPN) #3 was interviewed on 11/17/22 at 9:04 a.m. She said over two weeks ago she had requested to the staff management that they get a wheelchair for Resident #36 but it had not happened yet. She said staff should reposition her every two hours. She said the resident had been in bed since she arrived over a month ago. The director of nursing (DON) was interviewed on 11/17/22 at 3:22 p.m. She said the facility was working on getting a wheelchair for Resident #36. She said she did not know the MDS assessment documented she had a wheelchair. She said she was aware that the resident had been in bed and not been out of bed for about six weeks. She said the resident had a wound on her coccyx and it was very important that she changed positions throughout the day so that the wound could heal. She said therapy evaluated what wheelchair was appropriate for each resident. She said the resident had medically complex conditions. She said she did not know where her being repositioned and getting up in a chair got missed but she would fix it today. She said would have therapy evaluate Resident #36 for a wheelchair and order an appropriate wheelchair right away. She said staff were expected to reposition her about every two hours. She said she was unaware she was not being turned or repositioned by staff. She said she would educate staff again about repositioning.

Based on record review and interviews, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (#2) of one resident reviewed for investigations out of 35 sample residents. Specifically, the facility failed to investigate a resident's allegation of verbal abuse that a staff member called her a bad word in Spanish. The facility failed to investigate the resident's allegation of physical abuse that a staff member pulled her hair. The facility began their investigation on 11/17/22, during the survey, although the allegation had happened on 8/17/22. Cross-reference F609, Failure to report alleged violation. Findings include: I. Facility policy The Abuse policy, revised 10/26/22, was emailed by the nursing home administrator (NHA) on 11/17/22 at 3:50 p.m. It revealed in pertinent part: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. In addition to an investigation by the Police Department, the facility conducts an internal investigation. While the investigation is ongoing, the alleged assailant has interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. When an employee of the facility abuses or is suspected of abuse of a resident, the employee is placed on immediate suspension while the matter is under investigation. When the investigation shows that abuse did not occur, the employee is reinstated. A report of those findings will be available to any persons or agencies notified of the allegations as required. When the investigation shows violation of facility policy other than abuse, the employee will be subject to disciplinary action appropriate to the violation. In the event the investigation concludes that abuse did occur, appropriate disciplinary action will be carried out. Where nursing personnel are involved, the facility may file a report with the Board of Nursing. II. Resident #2 status Resident #2, age under 70, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbances, epilepsy, quadriplegia, obesity, hypertension (high blood pressure), contractures of both the right and left elbow and hand, and contractures of both the right and left feet. The 11/8/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. She had total dependence on staff for transfers, locomotion on and off the unit, and bathing. She did not reject care from staff. III. Record review The progress note on 8/17/22 revealed the certified nurse aides (CNAs) said a bad word to Resident #2 in Spanish, pulled her hair, and the director of nursing (DON) said she would look into it. IV. Staff interviews The DON was interviewed on 11/17/22 at 2:10 p.m. She said she remembered when the incident of physical and verbal abuse about Resident #2 was reported to her. She said, I did not document and I did not follow through to report this as I should have. I educated the CNAs but I did not document that I educated them. She said she spoke to the CNAs about cursing in Spanish. She said she believed the hair pulling was not done deliberately while caring for the resident's hair. She said she did not know who the staff member was in that situation. She said normally the management would have reported this incident to the State Agency (cross-reference F609). She said no staff from the facility reported the allegation to the State Agency. She said the facility did not do an investigation into the matter. The nursing home administrator (NHA) was interviewed on 11/17/22 at 2:15 p.m. He said, I did not know about this allegation of abuse that happened back in August. I will report it to the state agency today and begin our investigation that we did not do. V. Facility follow-up On 11/17/22 at 2:52 p.m. the nursing home administrator (NHA) reported the 8/17/22 alleged physical abuse to the State Agency. The initial report revealed: Describe the event: Resident reported that a staff member pulled her hair and called her (a) name. Immediate safety measures put in place: A follow up interview was conducted with the resident who reports no current concerns with care. Resident able to recall event in question and believed the staff member (unable to identify or describe) pulled her hair unintentionally and was 'just moving too fast with my hair.' Routine monitoring to continue. The NHA's documentation to the State Agency revealed, Unfortunately the dates are correct. (The reporting in November 2022 of an August 2022 incident.) We are doing education with all staff and vendors on our abuse policies and regulations on reporting.

Based on observations, record review and interviews, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of the resident needs and preferences for two (#53 and #36) of four residents reviewed for reasonable accommodations out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #53 a dependent resident could watch his television in his room. His television was positioned behind his bed where he was unable to see it; and, -Ensure Resident #36 was provided a wheelchair so that she could get out of her bed. She had been bed bound daily for about six weeks. Findings include: I. Facility policy The Accommodation of Needs policy, revised March 2021, was provided by the nursing home administrator (NHA) on 11/17/22 at 3:50 p.m. It revealed in pertinent part, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. II. Resident #53 A. Resident status Resident #53, age 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included, traumatic brain injury, epilepsy, unspecified convulsions, persistent vegetative state, tracheostomy (a tube in the windpipe to help a person breathe), and a gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach). The 11/14/22 minimum data set (MDS) revealed the resident was unable to conduct a brief interview for mental status score. He had total dependence on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. The activity assessment was not completed for the resident by himself or a family member. B. Observations and interview On 11/14/22 at 9:03 a.m. and at 11:42 a.m. Resident #53 was in his room seated in a high back wheelchair. His television was located behind his head hanging where the ceiling and wall met. His television was on and he was staring out the window. He was unable to view his television and he was unable to turn his wheelchair around to see the television. Aat 9:04 p.m. Resident #53 was asked why he could not see his television. He responded by slightly raising his right forearm and he used his right thumb to point behind him at the television. He made groaning sounds as he pointed to the television which was on the wall behind him. At 3:04 p.m. Resident #53 was in bed with the head elevated to a 30 degree angle. He was staring straight ahead of him and also stared out the window. His bed was positioned where his television was behind his head hanging where the ceiling and the wall met. His television was turned off. III. Resident #36 A. Resident status Resident #36, age under 70, admitted on [DATE]. According to the November computerized physician orders (CPO), the diagnoses included a stage four pressure ulcer, type two diabetes mellitus, cognitive communication deficit, multiple sclerosis, hypertension (high blood pressure), contracture of the left hand and wrist, contracture of the right and left shoulder, contracture of the left and right knee, transient ischemic attack (TIA, temporary symptoms similar to a stroke), gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach), anxiety disorder, and depression. The 10/11/22 minimum data set (MDS) assessment revealed the resident was unable to conduct a brief interview for mental status score. She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. She normally used a manual wheelchair and was dependent on staff to propel the wheelchair. It was very important for her to go outside when the weather was good. It was somewhat important for her to do things with groups of people. B. Observations On 11/15/22 from approximately 10:15 a.m. through 2:15 p.m. Resident #36 was in her bed on her back. The facility staff did not go into her room and reposition her during the four hour observation (cross-reference F677 for activities of daily living). At 2:10 p.m. two staff members carrying sheets quickly walked in and out of Resident #36's room but did not reposition her. C. Record review The comprehensive care plan 10/7/22 revealed an intervention to ensure appropriate positioning in (the)wheelchair. Provide assistance with repositioning as indicated. IV. Staff interviews The activity director (AD) was interviewed on 11/16/22 at 5:00 p.m. She said Resident #36 was visited by the activity staff when she was in bed. She said she did not take the resident out of her room or outside. Certified nurse aide (CNA) #3 was interviewed on 11/17/22 at 8:55 a.m. She said she did not know why Resident #53's television was positioned behind his bed. She said he seemed to enjoy watching the television but he could not see it in his room because it was on the wrong wall where he could not see it. She said Resident #36 had a wheelchair when she came into the facility but she did not know where it went. She said Resident #36 had stayed in bed all day every day for over a month since she arrived at the facility. She said if she had a wheelchair or a recliner the staff would get her up to change positions because she had wounds on her tailbone. Licensed practical nurse (LPN) #3 was interviewed on 11/17/22 at 9:04 a.m. She said Resident #53 could in his own way communicate things he wanted. She said she did not know why his television was placed where he could not see it. She said over two weeks ago she had requested to the staff management that the facility get a wheelchair for Resident #36 but it had not happened yet. The social service director (SSD) was interviewed on 11/17/22 at 11:15 a.m. She said no staff noticed Resident #53 could not see his television from his bed or his wheelchair while he was in his room. She said she had spoken to him while he was in his room but she had not noticed the placement of the television. She said no staff told the maintenance director that the television needed to be rearranged where the resident could see it. She said the resident could not move himself to see the television. She said, All I can say about the television is that this will be an educational moment for all of us. The director of nursing (DON) was interviewed on 11/17/22 at 3:22 p.m. She said the facility was working on getting a wheelchair for Resident #36. She said she did not know the MDS assessment documented she had a wheelchair. She said she was aware that the resident had been in bed and not been out of bed for about six weeks. She said the resident had a wound on her coccyx and it was very important that she changed positions throughout the day so that the wound could heal. She said therapy evaluated what wheelchair was appropriate for each resident. She said she would have therapy evaluate Resident #36 for a wheelchair and order an appropriate wheelchair right away. V. Facility follow-up The environmental service director (ESD) was interviewed on 11/17/22 at 10:03 a.m. He said that the facility staff had a meeting yesterday and the nursing home administrator (NHA) told him to move Resident #53's television so that he could see it from his bed. He said he would move the television to a different wall today.

Based on observations, record review and interviews, the facility failed to provide resident care in a dignified and respectful manner for two (#53 and #36) of three residents reviewed for dignity out of 35 sample residents. Specifically, the facility failed to ensure two residents (#53 and #36) were provided with clothes to wear. Both residents daily wore hospital gowns in their rooms as well as in other areas in the facility. Findings include: I. Facility policy The Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) via email on 11/17/22 at 3:50 p.m. It revealed 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. 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: encouraged to dress in clothing that they prefer. II. Resident #53 A. Resident status Resident #53, age 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included, traumatic brain injury, epilepsy, unspecified convulsions, persistent vegetative state, tracheostomy (a tube in the windpipe to help a person breathe), and a gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach). The 11/14/22 minimum data set (MDS) revealed the resident was unable to conduct a brief interview for mental status score. He had total dependence on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing. III. Resident #36 A. Resident status Resident #36, age under 70, admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included a stage four pressure ulcer, type two diabetes mellitus, cognitive communication deficit, multiple sclerosis, hypertension (high blood pressure), contracture of the left hand and wrist, contracture of the right and left shoulder, contracture of the left and right knee, transient ischemic attack (TIA, temporary symptoms similar to a stroke), gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach), anxiety disorder, and depression. The 10/11/22 minimum data set (MDS) assessment revealed the resident was unable to conduct a brief interview for mental status score. She required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. It was very important for the resident to choose what clothes to wear. IV. Observations Resident #53 and Resident #36 were observed only wearing hospital gowns all day 11/14/22 at 9:00 a.m. through 11/17/22 at 9:00 a.m. Resident #53 was observed in his room and in the main foyer entrance area. Resident #53 was in his hospital gown in his wheelchair during activities in the main entrance area. He was in the entrance area across from the receptionist desk by the main entrance doors in his hospital gown. Resident #36 only wore a hospital gown from 11/14/22 through 11/17/22 at 9:00 a.m. while she was in her bed. V. Staff interviews Certified nurse aides (CNA) #1 and #2 were interviewed on 11/16/22 at 9:18 a.m. CNA #1 said Resident #53 did not have any clothing to wear and he wore hospital gowns in his room and throughout the building. CNA #1 said Resident #36 did not have any clothes to wear. CNA #2 looked in the closets of Resident #53 and Resident #36. CNA #2 said there were no clothes in either resident's closet. CNA #2 said in the laundry room there were extra clothes for the residents that the staff could take for residents that needed clothing. Both CNA #1 and CNA #2 said they did not know why these individuals did not have any clothes to wear. CNA #3 was interviewed on 11/17/22 at 8:55 a.m. She said the director of nursing (DON) told the staff today to provide clothes for Resident #53 and Resident #36. CNA #3 said she did not know where the clothing came from today but she would dress the residents in clothes and not in hospital gowns today. Licensed practical nurse (LPN) #3 was interviewed on 11/17/22 at 9:04 a.m. She said both Resident #53 and #36 would be in regular clothing today and not hospital gowns. She said she called Resident #53's family and asked them to provide clothes for him but they never did. The social service director (SSD) was interviewed on 11/17/22 at 11:15 a.m. She said she told the previous activity director several months ago to order clothes for Resident #53 because he had no clothes. She said the AD had a corporate card to pay for items that could be ordered online for the residents. She said she would get an email corresponding with the AD. -However, no email proof was provided before exit on 11/17/22. She said Resident #36 did not have any clothing because she came into the facility without any money. She said Resident #36 did not have any clothes to wear. She said she did not know why staff did not get either of the residents' clothing from the laundry where there may be extra clothing. She said the DON was working on getting both residents clothes today. She said the facility was a small community and getting clothes should not fall on one staff person to get clothing for individuals. She said she knew Resident #53 did not have any clothes a few months ago. She said no staff told her that Resident #36 did not have any clothing to wear. The DON was interviewed on 11/17/22 at 3:22 p.m. She said she did not know where the staff got clothing today for Resident #53 and Resident #36. She said typically the social services and activities department worked together to order clothing. She said typically a staff member would fill out an inventory sheet for each resident that had all items each resident admitted with. She said the situation would be fixed and both residents would be provided clothing today.

Based on record review and interviews, the facility failed to report an alleged violation of abuse to the State Survey and Certification Agency for one (#2) out of one resident reviewed for abuse out of 35 sample residents. Specifically, the facility's director of nursing (DON) knew of a resident's allegation of a staff member's verbal and physical abuse. The facility failed to report the resident's alleged violation to the State Survey Agency. Cross-reference F610, Failure to investigate/prevent/correct alleged violation. Findings include: I. Facility policy The Abuse policy, revised 10/26/22, was emailed by the nursing home administrator (NHA) on 11/17/22 at 3:50 p.m. It revealed in pertinent part: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. Reporting abuse: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing. 'Immediately' is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Notification is also made to the following persons and agencies within the time frames defined by regulation or statute: -The state licensing/certification agency responsible for surveying/licensing the facility; -The local/state ombudsman; -The resident's representative; -Adult protective services (where state law provides jurisdiction in long-term care); -Law enforcement officials (for all abuse allegations); -The resident's attending physician; -The Medical Director (when necessary), and -Board of Nursing. II. Resident #2 status Resident #2, age under 70, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included, dementia without behavioral disturbances, epilepsy, quadriplegia, obesity, hypertension (high blood pressure), contractures of both the right and left elbow and hand, and contractures of both the right and left feet. The 11/8/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. She had total dependence on staff for transfers, locomotion on and off the unit, and bathing. She did not reject care from staff. III. Record review The progress note on 8/17/22 revealed, the certified nurse aides (CNAs) said a bad word to Resident #2 in Spanish, pulled her hair, and the director of nursing (DON) said she would look into it. IV. Staff interviews The DON was interviewed on 11/17/22 at 2:10 p.m. She said she remembered when the incident of physical and verbal abuse involving Resident #2 was reported to her. She said, I did not document the incident and I did not follow through to report this as I should have to the State. I educated the CNAs but I did not document that I educated them. She said she spoke to the CNAs about cursing in Spanish. She said she believed the hair pulling was not done deliberately while caring for the resident's hair. She said she did not know who the staff member was in that situation. She said normally the management would have reported this incident to the State Agency. She said no staff from the facility reported the allegation to the State Agency. The nursing home administrator (NHA) was interviewed on 11/17/22 at 2:15 p.m. He said, I did not know about this allegation of abuse that happened back in August. I will report it to the State Agency today and begin our investigation that we should have done. V. Facility follow-up On 11/17/22 at 2:52 p.m. the nursing home administrator (NHA) reported the 8/17/22 alleged physical abuse to the State Agency. The initial report revealed: Describe the event: Resident reported that a staff member pulled her hair and called her (a) name. Immediate safety measures put in place: A follow up interview was conducted with the resident who reports no current concerns with care. Resident able to recall event in question and believed the staff member (unable to identify or describe) pulled her hair unintentionally and was 'just moving too fast with my hair.' Routine monitoring to continue. The NHA's documentation to the State Agency revealed, Unfortunately the dates are correct. (The reporting in November 2022 of an August 2022 incident.) We are doing education with all staff and vendors on our abuse policies and regulations on reporting. -However, the initial report did not report the alleged verbal abuse.

Based on observations, record review, and resident and staff interviews, it was determined the facility failed to provide care and services to attain or maintain the highest practicable physical well-being of one (#95) of 36 sample residents. Specifically: The facility failed to accurately assess, address and document a contusion and abrasion to the resident's left (L) knee and shoulder that was associated with swelling (of the knee) and pain in both the shoulder and knee. The facility failures contributed to the resident experiencing unrelieved pain. The findings include: A. Facility policy The facility policy on pain management was requested and provided by the Director of Nursing (DON) on 4/21/14 at 3:24 p.m. The policy read in pertinent part: "Pain is subjective and is what the resident says it is, existing when and where the resident says it does ...Acceptable (tolerable) pain control is determined by the resident ...All residents will be assessed for pain by utilizing a pain scale tool ... The pain assessment includes the following ...location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors ...All subsequent pain assessment will be documented on the Pain Assessment Flow sheet (PAFS)/or MAR (medication administration record) as applicable, to include location, intensity rating, and response to pain management interventions ... When the resident complains of pain, ask the resident to rate the pain on a scale of zero (none) to five (severe)...Document your findings on the Pain Assessment Tool (PAT) or the Pain Assessment Flow Sheet and/or MAR as applicable. Upon completion, place the pain assessment in the medical record in the appropriate section per facility policy ...Around the clock (ATC) dosing for continuous pain, whether chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent (PRN) [MEDICATION NAME] administration." B. Resident #95 Resident #95, 80+ years old, initially was admitted to the facility on [DATE]. The resident was discharged from the facility to home on 10/3/13. The resident fell while he was home and was transferred to a hospital. On 4/10/14, the resident was readmitted to the facility following his hospital stay for rehabilitation services. According to the resident's face sheet, the resident had [DIAGNOSES REDACTED]. 1. Resident status on admission An admission summary dated 4/10/14 read in pertinent part, "C/O (complaint of) left knee pain, scheduled meds given. Knee is red swollen and large scab over knee no s/s (signs or symptoms) of infection, abrasion on right lower leg and left lower leg ...Bruises to left inner arm." Another admission assessment dated [DATE] further indicated [MEDICAL CONDITION] was present to the resident's (L) knee and the resident "verbalizes presence of pain ...interventions used to address pain management ...Scheduled pain med (medication) [MEDICATION NAME]." The assessment further revealed the resident was to receive therapy services, specifically physical therapy (PT) and occupational therapy (OT). The resident had an unsteady gait requiring supervision and utilized a wheelchair for mobility. The resident required limited assistance of one staff for most activities of daily living (ADLs). Additional assessments dated 4/10 and 4/11/14 indicated resident #95 was oriented to "self" and "can communicate ideas hard of hearing/no hearing aids." 2. Pain management plan See above; the resident complained of knee pain on admission and his left knee was documented as red and swollen. Pain Assessment: A clinical Assessment Report dated 4/15/14, included a pain assessment which read in pertinent part, "LOCATION ...For each site listed, describe type of pain (stabbing, burning, sharp, throbbing), duration and frequency and whether it is continuous or intermittent in the description box." The assessment indicated two sites of pain for resident #95: "Right shoulder (front) ...Description ...continuous throbbing pain ....Left knee (front) ...continuous aching pain ...." The assessment further identified pain medication gives relief and activities made it worse. The assessment indicated the resident's pain affected his sleep and rest. Care Plan: The resident's pain management Care Plan dated 4/10/14 read in pertinent part, "Pain ...Goal to maintain APL (acceptable pain level) ...Meds [MEDICATION NAME]/Tylenol ...Non-drug interventions ...Monitor pain q (every) shift ...Assess pain tolerance." The care plan failed to identify the location of the resident's pain, the resident's APL, and specific non-drug interventions to promote pain relief. Physician orders: Review of current physician computerized physician orders [REDACTED]. - "[MEDICATION NAME] HCL Tablet (opioid [MEDICATION NAME]) 5 MG (milligrams). Give 0.5 (2.5 mg) tablet by mouth every 6 hours for Pain until 4/21/14." The [MEDICATION NAME] was scheduled to be given every six hours at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. - "Acetamin Tablet 500 MG ([MEDICATION NAME]). Give 2 tablets (1000 mg) by mouth every 8 hours for Pain as needed (PRN) for pain." - " Acetamin Tablet 500 MG ([MEDICATION NAME]). Give 2 tablets (1000 mg) by mouth every 8 hours for Pain until 4/21/14." The Tylenol was scheduled to be given at 12:00 a.m., 8:00 a.m. and 4:00 p.m. -Pain assessment 0-10 ...Scale every shift." 3. Failure to assess and monitor the resident's L knee contusion and abrasion and shoulder pain and failure to administer pain medication as ordered. a. 4/14/14 Observations and interview: On 4/14/14 at 3:30 p.m., the unit licensed practical nurse (LPN #3) was observed as he administered the resident his routine Tylenol. After the administration of Tylenol, LPN #3 asked the resident to rate his pain level and the resident stated, "7" (on a scale of 0-10 with 10 being the worst pain.) The LPN did not ask the resident to further describe his pain, including where it was located. The LPN did not assess the resident's knee. After LPN #3 left the room, the resident was asked where his pain was located. The resident stated, "I have right shoulder pain."Then, the resident pulled his trousers up and exposed his L knee which was noted to be swollen with a large scab in the middle of the knee. The large scabbed area surrounding tissue was swollen and red in color. Record review: Review of the resident's April MAR revealed the resident did not receive his scheduled [MEDICATION NAME] on 4/14/14 at either 12 p.m. or 6 p.m.; his only dose of scheduled [MEDICATION NAME] was administered at 6 a.m. on 4/14/14. Pain assessments recorded on the MAR for 4/14/14 revealed pain level of 0. Review of the resident's nurses' notes for 4/14/14 revealed a note at 12:47 p.m. that read, "waiting for MD to fax refill authorization to pharmacy." Another note at 9:04 p.m. read,"Unable to administer pharm is waiting for md autho (authorization) number." There was no documentation in the nurses' notes regarding the resident's pain, pain management (without administration of his scheduled [MEDICATION NAME] that day) or status of the resident's knee and shoulder. Moreover, there was no documentation the physician was notified the resident had failed to receive his scheduled [MEDICATION NAME] that day. b. 4/15/14 Record review: Review of the resident's April MAR revealed that on 4/15/14, the resident's scheduled [MEDICATION NAME] was not administered at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. The MAR read to "see progress notes." Pain assessments recorded on the MAR for 4/15/14 revealed 0. Review of nurses' notes for 4/15/14 revealed a note at 1:02 a.m. that read the resident did not receive the scheduled [MEDICATION NAME] pain medication (scheduled for 12 a.m.). Another note at 2:40 p.m. read in pertinent part, "awaiting delivery from pharmacy." There was no progress note regarding the failure to administer the scheduled [MEDICATION NAME] at 6:00 a.m. and 6:00 p.m. There was no documentation staff communicated the delivery failure to the Director of Nurses or took further steps to ensure delivery of the medication. Moreover, there was no assessment that documented the status of the resident's shoulder and knee on any of the 4/15/14 nursing shifts and no notation that the physician was notified the resident was not receiving his scheduled [MEDICATION NAME] for the second day. c. 4/16/14 Observation and interview: On 4/16/14 at 2:31 p.m. observations revealed the resident in his room with the certified occupational therapist (COTA) at his bedside. The COTA said she was trying to convince the resident to go for therapy and it was not easy. The resident continued to refuse to go. After the COTA left, the resident said his left knee was "too painful" and he did not want to walk across the bars as it hurt "too much." Record review: Review of the resident's April MAR revealed that on 4/16/14, the resident's scheduled [MEDICATION NAME] was not administered at 12:00 a.m. Pain assessments recorded on the MAR for 4/16/14 revealed 0. On 4/16/14 at 1:05 a.m. nurses' notes read in pertinent part, "(Scheduled [MEDICATION NAME]) not administered call pharm to ask for ekit (emergency kit) spoke with (pharmacy staff) stated to take it ([MEDICATION NAME]) out from ekit however they can't give autho (authorization) number... Meds ([MEDICATION NAME]) not administered." There was no documentation in the nurses' notes on 4/16/14 regarding the resident's pain, pain management (without administration of his scheduled [MEDICATION NAME] that day) or status of the resident's knee and shoulder. d. 4/17/14 Record review: Review of MAR revealed scheduled [MEDICATION NAME] was administered as ordered. Review of pain assessments recorded on the MAR for 4/17/14 revealed no pain (0). e. 4/18/14 Observation and interview: On 4/18/14 at 2:30 p.m., LPN #2, who confirmed she was responsible for resident #95's care including his assessments, was interviewed. -LPN #2 said she assessed the resident's knee earlier today. She confirmed that other than the initial assessment completed on 4/10/14 (see above), there were no further detailed assessments of the resident's knee. -LPN #2 stated, "There are no measurements for abrasions...from the time he came in I'm just watching it... I did the initial assessment...unless he is receiving treatment and wound care, we just monitor for signs and symptoms of problems... He has no treatment..It (L knee) (is) still red just like when he came in...I assessed it today with no change or sign or symptom of infection." On 4/18/14 at 2:45 p.m., the resident's knee was observed (with his permission) by LPN #2 and two surveyors. Observations revealed the resident's left knee was swollen scab in the middle. The surrounding tissue was purple and boggy and painful when palpated; this represented new findings from the 4/11/14 assessment, as the knee was not documented as boggy previously. The resident stated his pain level was 10/10. On 4/18/14 at 3:15 p.m., the resident's knee was observed by the DON and two registered nurse surveyors. The resident complained of pain in his L knee as he pulled up his trousers to expose his knee. The resident stated again, as the DON assessed the resident's knee, that his pain level in his L knee was 10/10. The DON stated, "The surrounding area of the scab is purple and boggy." The DON acknowledged the resident's pain and stated she would call the MD and draw some labs to rule out infection. f. 4/18/14 - Actions taken following DON assessment Review of the resident's CPO and MAR, and nurses' notes revealed the following actions were taken following DON's assessment above: (1) Medications Record review: -Review of the narcotics medication administration record indicated the resident received his 6 p.m. scheduled [MEDICATION NAME] 2.5 mg at 2:44 p.m. on 4/18/14, as documented by LPN #1. Another dose was not administered at 6 p.m. (the 6 a.m. and 12 noon had been given) -Review of a nurses' note on 4/18/14 at 3:08 p.m. read in part, "[MEDICATION NAME] given earlier due to pain level of 10 (10/10). The note did not indicate the physician was notified the scheduled dose was given about 3 hours early. -Review of the CPO and MAR dated 4/14 revealed a MD order dated 4/18/14 at 4:50 p.m. that read in part, "[MEDICATION NAME] HCL Tablet 10 mg. Give 1 tablet by mouth every 4 hours as needed for pain." However, review of the MAR revealed the resident was not administered the PRN 10 mg [MEDICATION NAME] on 4/18/14 or any other day or time through 4/21/14 (survey exit date). Interview: On 4/21/14 at 3:50 p.m., LPN #1, who was the resident's nurse the evening of 4/18/14 and obtained the PRN order above, was interviewed. -LPN #1 said she was aware of the resident's pain the afternoon of 4/18/14. She said she did not administer the PRN 10 mg [MEDICATION NAME] when the resident complained of pain 10/10 because the medication "did not come in" from the pharmacy. She said it still had not been delivered from the pharmacy on 4/21/14. -LPN #1 confirmed she administered the resident's scheduled 2.5 mg [MEDICATION NAME] at 2:44 p.m. She confirmed the physician was not notified of this early administration of the scheduled medication. She further confirmed the 6 p.m. scheduled [MEDICATION NAME] was not administered. On 4/21/14 at 3:58 p.m., the above findings were brought to the DON's attention. The DON said that PRN medications are documented on the MARs if given. -The DON said she was not aware the resident had not received his scheduled [MEDICATION NAME] on 4/14, 4/15, and 4/16/14, or PRN [MEDICATION NAME] on 4/18/14, when he complained of pain at a level of 10/10. -The DON said LPN #1 had called the physician for the PRN order on 4/18/14 and "I thought they increased the [MEDICATION NAME] would expect that it ([MEDICATION NAME] 10 mg) would come and he would get it with that level of pain...I was not aware that [MEDICATION NAME] 10 mg was not received. (2) X-ray and Assessment On 4/19/14 at 10:27 a.m., nurses' notes read in part, "called (MD) office...received orders for left knee x-ray and treat left knee with ice/ice pack over a towel for 10 minutes (every) shift for left knee [MEDICAL CONDITION]." an order for [REDACTED]. On 4/19/14 at 11:26 a.m., a RN note read in part, "assess of lt knee requested per LPN...obs (2.5cm x 3 cm) dry scab to knee with underlying localized area of [MEDICAL CONDITION] (7.5 cm x 7 cm circumference with 2.5 cm elevation) area of [MEDICAL CONDITION] circumference, [MEDICAL CONDITION] area slight warmer to touch than lower or upper leg but not significantly so, also noted faint green skin discoloration extending diffusely distally to anterior/lateral lt calf, green discoloration measure 11x6 cm laterally and 9x5cm anterior lt calf...no redness observed no drng.. will place call to Md tx/labs/x-ray." (The x-ray showed no mechanical issues. Impression - soft tissue swelling most bursitis.) 4. Additional interviews The resident's physician was interviewed on 4/21/14 at 3:30 p.m. The physician said he had just assessed the resident and said the resident did not have an infection. He said the resident would have decreased pain if ice and compression were applied. He said the resident reported no pain, but with the swelling, movement of the ligaments would likely stretch and cause pain. On 4/21/14 at 4:58 p.m. the DON was interviewed. She confirmed resident #95 had not received his scheduled [MEDICATION NAME] as ordered on 4/14, 4/15, and 4/16/14. She said she was not aware they had not received the medication from the pharmacy; she said sometimes there's an issue when the physician does not sign the order. She said she was never informed of the ekit issue (see above). On 4/21/14 at 5:37 p.m., LPN #1, the DON and the consultant RN (CRN) were interviewed together. -The DON said resident #95 had gotten a 3 day supply of his scheduled [MEDICATION NAME] which ran out 4/14/14. She said he was denying pain on these days including 4/14/14 (but see above observation and interview). She said on 4/18/14, when he was observed and complaining of pain 10/10, he had just finished therapy; that's why his knee was swollen and warm. The DON said LPN #1 had contacted the pharmacist (since 4/18/14) about the delay in delivering the PRN 10 mg [MEDICATION NAME]. The pharmacist told LPN #1 the pharmacy did not receive the order on 4/18/14. When LPN #1 checked again on (4/19/14), she was told "it was on the run." The DON said the nurses would receive education on facility policy. -LPN #1 said she called the physician for the PRN order on 4/18/14 and administered the 2.5 mg scheduled [MEDICATION NAME] early and it helped. -The CRN stated LPN #1 notified the doctor after the fact that she had given the scheduled 2.5 mg [MEDICATION NAME] early.