BERKLEY MANOR CARE CENTER

A recertification survey was conducted from 2/23/26 to 2/26/26. Nine deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/23/26 to 2/26/26. No deficiencies were cited

Based on observations, record review and interviews, the facility failed to provide the necessary services to maintain personal hygiene for one (#23) of four residents reviewed for services to maintain the highest practicable quality of life out of 41 sample residents. Specifically, the facility failed to ensure Resident #23 received timely incontinence care. Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADL) policy, dated 9/4/24, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, “A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.”II. Resident #23A. Resident statusResident #23, age greater than 65, was admitted on 4/22/2020. According to the February 2026 computerized physician orders (CPO), diagnoses included nondisplaced fracture of the body of the right calcaneus (a break in the right heel bone where the bone pieces remain in proper alignment), type 2 diabetes mellitus (chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency leading to high blood sugar), chronic kidney disease (long term irreversible loss of kidney function) and unspecified obesity. The 1/23/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent upon staff to help with toilet transferring and toileting hygiene. The MDS assessment identified that Resident #23 was frequently incontinent of urine and bowel. B. Resident interviewResident #23 was interviewed on 2/23/26 at 3:19 p.m. Resident #23 said sometimes she did not receive help with toileting assistance on time. She said she had to wait a long time to get to the bathroom and sometimes she had accidents because she had to wait too long for help. Resident #23 said she asked staff to put two briefs on her so the urine would be contained. Resident #23 said sometimes even with two briefs, urine would leak through to the outside of her pants. She said leaking through the two briefs would happen often but it was worse at night time. Resident #23 said sometimes staff tried to bring her to the dining room when they knew she was wet. Resident #23 said staff brought her food to her bedroom instead and then changed her once they were done with everything in the dining room or before they went home. Resident #23 said that made her feel terrible and she said she felt desperate. C. Observations On 2/24/26 at 5:40 p.m. Resident #23 was in her wheelchair in the dining room next to an unidentified certified nurse aide (CNA). Resident #23 had liquid underneath her wheelchair. There was an odor of urine coming from the area underneath her wheelchair. At 6:12 p.m. Resident #23 came out of the dining room. She was pushing herself in her wheelchair down the hallway toward her room and had sizable amounts of urine dripping from behind her wheelchair. At 6:33 p.m. the resident had wheeled herself into her room. Urine was dripping from her wheelchair onto the tile floor. At 6:44 p.m. CNA #1 and CNA #2 entered Resident #23’s room with the sit-to-stand mechanical lift. The CNAs hooked Resident #23’s sling to the sit-to-stand lift and brought the resident up to a standing position from the wheelchair. CNA #2 said the resident’s wheelchair cushion had urine on it. The CNAs assisted the resident to bring her pants down. The resident was observed to have two briefs on. There was a strong urine smell in the room. Both of Resident #23’s briefs were saturated with urine and were heavy. The CNAs cleaned up Resident #23 and put cream on her perineal area. A fresh brief and a fresh gown were put on the resident. Before exiting the room, CNA #1 wiped up the urine off of the floor. D. Record reviewThe ADL care plan, revised 3/7/19, revealed Resident #23 was incontinent and needed assistance for toileting and hygiene. Pertinent interventions included assisting Resident #23 with toileting. The bowel and bladder care plan, revised 5/13/22, revealed Resident #23 was incontinent and needed assistance for toileting and hygiene. Pertinent interventions included assisting Resident #23 with toileting, utilizing spanish speaking CNAs whenever possible, implementing good personal hygiene following any incontinence episode, and providing perineal care, to include barrier cream for skin protection. The urinary incontinence care plan, revised 3/7/19, revealed Resident #23 was incontinent related to diabetes mellitus, chronic pain, opioids, and incontinence. The pertinent interventions included a prompted toileting program upon arising, before and after meals and before bed. An additional intervention for assisting Resident #23 with toileting and perineal care as needed was initiated on 1/26/22.-The care plan did not include interventions to educate the resident on limiting the number of briefs that should be worn to prevent skin breakdown. Review of Resident #23’s progress notes did not reveal that Resident #11 requested to wear two briefs. The progress notes did not identify that Resident #11 refused to be cleaned or changed more frequently. III. Staff interviewsCNA #1 was interviewed on 2/24/26 at approximately 6:50 p.m. CNA #1 said Resident #23 was wet with urine. She said it was important for the resident to be dry because if the skin was not dry, it could break down. CNA #1 said Resident #23 had two briefs on that day (2/24/26) because the resident wanted to play bingo both on the first and second floor. CNA #1 said that on days when the resident wanted to play bingo, the staff put two briefs on her. CNA #1 said that Resident #23 attended bingo that day at 2:00 p.m. Licensed practical nurse (LPN) #3 was interviewed on 2/25/26 at approximately 2:30 p.m. LPN #3 said staff came onto shift at 2:00 p.m. LPN #3 said that at that time, staff were supposed to change Resident #23. She said the goal was to change Resident #23 before she went to the dining room. LPN #3 said most residents that were in wheelchairs were supposed to be checked to ensure they were clean and dry before going to the dining room. LPN #3 said they worked as a team to ensure Resident #23 was clean, but CNAs most often helped change the residents. LPN #3 said residents should not wear two briefs because it affected skin integrity and the staff tried to protect the residents’ skin. LPN #3 said if a resident requested to wear two briefs, she expected the CNAs to educate the resident on why it was not a good idea. LPN #3 said if the resident requested to wear two briefs, she would document that in the progress notes. The director of nursing (DON) was interviewed on 2/26/26 at 7:23 p.m. The DON said nursing staff were supposed to provide incontinence care per facility protocol or every two hours and as needed. The DON said nursing staff should put only one brief on residents. She said facility protocol was to put one brief on residents and if a resident requested more than one, nursing staff should educate the resident on the risks of wearing more than one brief. The DON said risks to wearing two briefs would include skin breakdown, irritation, redness and being overly wet. The DON said nurses could educate residents on risks and CNAs could remind residents about risks. The DON said staff should be documenting if a resident was requesting to wear two briefs. She said it could be documented in the care plan, nursing progress notes or behavioral notes. The DON said the facility recently edited the care plan to reflect that Resident #23 was requesting two briefs and that this was sometimes a preference of hers. -However, the electronic medical record (EMR) did not not reflect that Resident #23 was requesting two briefs or that this was the preference of Resident #23 (see record review above).

Based on record review and interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical records for two (#53 and #11) of two residents reviewed for advance directives out of 41 sample residents. Specifically the facility failed to:-Ensure Resident #53 and Resident #11’s medical orders for scope of treatment (MOST) forms matched their physician’s orders; and,-Ensure staff were able to locate the residents' MOST forms in order to follow the residents' choices for cardiopulmonary resuscitation (CPR). III. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on 1/30/26. According to the February 2026 CPO, diagnoses included parkinsonism (a neurological disorder causing movement issues), type 2 diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) and contractures (the permanent, abnormal tightening of skin, muscles, tendons, or ligaments, causing joint rigidity, pain, and severely reduced movement). The 2/5/26 MDS assessment revealed the resident was unable to complete the BIMS assessment. According to the staff assessment for mental status, the resident’s cognitive skills for daily decision making were severely impaired. The resident was dependent upon staff for personal hygiene, dressing, and assisting with eating. B. Record review Review of the facility’s MOST form binder identified Resident #11 was a DNR status. Review of the electronic charting system identified Resident #11 as a full code. Review of the medication administration record (MAR) revealed Resident #11’s code status was changed from full code (resident wanted all available life saving measures used to revive them if their breathing or heart stopped) to a DNR on 2/24/26 at 2:37 p.m., during the survey. C. Staff interviewsCNA #4 was interviewed on 2/24/26 at 2:18 p.m. CNA #4 said in the case of an emergency, if a nurse had directed him to find the code status of a resident, he would check the online charting system on the wall. CNA #4 checked the charting system on the wall but said he could not find the code status there. CNA #4 said he would go to the computer charting system and check for the resident's code status there. CNA #4 checked the computer but could not find the code status of residents. CNA #4 then said he would instead ask another nurse for help and find out the code status for residents that way. LPN #3 was interviewed on 2/25/26 at 2:25 p.m. LPN #3 said nurses filled out the MOST forms with the residents and their families if needed. She said they completed MOST forms when residents were admitted to the facility or if the resident had a change of condition and wanted to change or update their MOST forms. LPN #3 said in the case of an emergency, staff should look in the MOST form binder for resident statuses. LPN #3 found Resident #11’s code status in the MOST form binder where Resident #11’s code status was a DNR. LPN #3 next looked in Resident #11’s electronic charting system for her code status where the online code status documented the resident as a full code. LPN #3 said the electronic charting system was telling her Resident #11 was a full code and that was incorrect, because staff should always go off of the signed MOST form document in the binder. LPN #3 said the binder and the electronic charting system should show matching code statuses because staff would not want to make any mistakes with CPR. LPN #3 said medical records staff were responsible for ensuring code statuses matched in the binder and in the electronic charting system. LPN #3 said nursing staff were also responsible for ensuring the binder and electronic charting system code statuses matched because nurses helped residents fill out the code status and updated the MOST forms in the binder. She said after the MOST form was updated in the binder, that same nurse should then make sure the code status was correct in the electronic charting systemas well. LPN #3 said social services, nurses and medical records staff worked together as a team to ensure everything was corrected.

Based on observations, record review and interviews, the facility failed to communicate effectively with the dialysis centers for two (#61 and #4) of two residents reviewed for dialysis out of 41 sample residents. Specifically, the facility failed to ensure dialysis communication forms between the facility and the dialysis center were thoroughly completed consistently for Resident #61 and Resident #4. III. Resident #4A. Resident statusResident #4, age less than 65, was admitted on 9/1/23 and re-admitted on 12/4/23. According to the February 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, hypertensive chronic kidney disease, end stage renal disease (renal failure), dependence on renal dialysis, hemiplegia (paralysis) following cerebral infarction affecting left non-dominant side, amputation of left lower extremity and depression. The 12/4/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She used a wheelchair for mobility and required assistance from one staff member for toileting, personal hygiene, and transfers. The MDS assessment indicated the resident received hemodialysis (treatment to filter wastes and water from blood using an artificial membrane). B. Record reviewReview of Resident #4’s February 2026 CPO revealed a physician’s order for dialysis every Tuesday, Thursday, and Saturday, ordered on 6/1/24. Review of review of Resident #4’s hemodialysis care plan, initiated 9/1/23, revealed the resident received hemodialysis. Interventions included encouraging the resident to go to scheduled dialysis appointments, observing and reporting signs and symptoms of renal insufficiency, including changes in level of consciousness, changes in skin turgor and changes in heart and lung sounds as needed (revised 12/1/25), observing and reporting bleeding, hemorrhage, signs and symptoms of infection or septic shock or peripheral edema as needed (revised 10/20/25) and assessing the resident’s shunt site (abnormal direct connection between an artery and a vein) for bruit (swishing sound) and thrill (buzzing vibration) in the upper leg (revised 9/8/23). Review of Resident #4’s dialysis communication forms revealed the following:-The dialysis center’s section of the form was not completed on 1/13/26, 2/7/26, 2/17/26 and 2/26/26.-The post-dialysis section of the form, to be completed by the facility, was not completed on 2/12/16, 2/24/26 and 2/26/26. Review of Resident #4’s progress notes did not include communication notes with the dialysis center. C. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/26/26 at 12:30 p.m. RN #1 said all the nurses were responsible for documenting on the dialysis communication forms RN #1 said the nurse on duty was responsible for documenting the pre-dialysis and post-dialysis sections of the forms. RN #1 said every time the dialysis center staff did not document the dialysis section, the facility nurses should call the dialysis center, ask for the information and update the dialysis communication form. RN #1 said it was important to keep the dialysis communication form updated so the next nurse could have an idea about the resident’s condition after dialysis. RN #1 said the dialysis communication forms were not uploaded to the resident’s electronic medical record (EMR), but were kept in a dialysis binder. The director of nursing (DON) was interviewed on 2/26/26 at 7:25 p.m. The DON said the nurses were responsible for calling the dialysis center if the dialysis center did not complete the dialysis section of the document. The DON said the pre-dialysis section of the form needed to be completed to determine the resident's status before the resident went to dialysis, including the resident’s pre-dialysis weight and vital signs. The DON said the post-dialysis section of the form was equally as important for the nurses to document. The regional clinical resource was interviewed on 2/26/26 at 7:25 p.m. The regional clinical resource said she was not sure whether the nurses were documenting the dialysis communication forms and calling the dialysis centers each time the dialysis center staff failed to document in the dialysis section.

Based on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional standards or practice and accounting for the residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#40) of two residents reviewed for trauma-informed care out of 41 sample residents. Specifically, the facility failed to ensure Resident #41 had a trauma-informed care plan which identified potential triggers that had the potential to re-traumatize the resident. Findings include:I. Facility policy and procedureThe Trauma-Informed Care policy and procedure, revised 1/6/26, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, “Based on the comprehensive assessment of a resident, this facility ensures that residents who are diagnosed with mental disorder and psychosocial adjustment difficulty, or who have a history of trauma and/or post-traumatic stress disorder, receive treatment and services in accordance with professional standards of practice, and has a comprehensive person-centered care plan that reflects the resident’s goals to eliminate or mitigate triggers that may cause re-traumatization of the resident.” II. Resident #41A. Resident statusResident #41, age 71, was admitted on 6/29/23. According to the February 2026 computerized physician orders (CPO), diagnoses included acute on chronic diastolic congestive heart failure, major depressive disorder and post-traumatic stress disorder (PTSD). The 12/3/25 minimum data set (MDS) assessment revealed Resident #41 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #41 had no documented behaviors. The MDS assessment identified Resident #41 had a diagnosis of PTSD. B. Resident interviewResident #41 was interviewed on 2/23/26 at 10:59 a.m. Resident #41 said she had trauma from when her husband completed suicide in front of her. She said he had shot himself. She said gunfire sounds were a trigger for her. C. Record review-Review of Resident #41’s comprehensive care plan revealed there was not a trauma-informed care plan focus for the resident. Review of Resident #41’s electronic medical record (EMR) revealed her most recent trauma-informed care assessment was dated 10/21/25. The assessment revealed the resident experienced trauma when her husband shot himself in front of her and her daughter. -However, the assessment did not document any triggers for the resident that could lead to re-traumatization of the resident. III. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 2/26/26 at 1:40 p.m. CNA #3 said Resident #41 did not have any trauma or PTSD. She said the only time that she had seen Resident #41 cry or have any other emotions other than being happy or mad, was when one of her close friends had passed away. The social services director (SSD) was interviewed on 2/26/26 at 6:14 p.m. The SSD said she was the person who created the residents’ care plans for trauma and PTSD. She said the care plans for trauma and PTSD should be created when she completed the trauma-informed assessment when the residents first admitted to the facility or if something was brought up to her after admission. The SSD said the trauma-informed care plans should consist of specific triggers and interventions for mitigating the triggers that could re-traumatize a resident. She said it was important for floor staff to know when a resident had a history of trauma or PTSD so that the staff could help prevent any triggers or re-traumatization. She said Resident #41 did not have her PTSD care planned because she said she did not have any triggers. She said if she had mentioned any triggers she would have care planned it immediately. -However, during an interview on 2/23/26, Resident #41 indicated gunfire was a trigger for her (see resident interview above).

Based on record review and interviews, the facility failed to ensure one (#17) of one resident out of 41 sample residents received dental services timely. Specifically, the facility failed to assist Resident #17 with finding another dental service that accepted his dental insurance. Findings include:I. Facility policy and procedureThe Dental Services policy and procedure, reviewed 9/3/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, “The facility is responsible for assisting the resident in obtaining needed dental services, including routine dental services. The facility will provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident. “Residents will be assisted with making appointments and arranging transportation to and from the dentist’s office if necessary.”II. Resident #17 A. Resident statusResident #17, age 71, was admitted on 8/30/24. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic diastolic congestive heart failure, chronic kidney disease and atherosclerotic heart disease. The 12/4/25 minimum data set (MDS) assessment revealed Resident #17 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed that Resident #17 was independent with most of his activities of daily living (ADL), including oral hygiene. He needed assistance with showering and footwear. B. Resident interviewResident #17 was interviewed on 2/23/26 at 5:30 p.m. Resident #17 said he saw the dentist when they came to the facility and the dentist had recommended that he have a procedure done. He said the dentist came back and took some Xrays for the procedure. He said when he went to the appointment to have the procedure done, he sat in the waiting room for more than an hour and then he said he was told that the dental office did not accept his insurance. He said he had not heard anything about trying to go to a different dental office to have the procedure done. dent #17 was interviewed a second time on 2/24/26 at 10:30 a.m. Resident #17 said had pain on the lower left side of his mouth and said it felt like cavity pain. He said he remembered someone saying something about his wisdom teeth but he could not remember what they had said. C. Record reviewResident #17’s ADL care plan, initiated 9/10/24 and revised 9/10/24, documented Resident #17 had a self-care performance deficit related to pain, decreased mobility, incontinence, medications, diuretics and decreased ADL functions. Interventions related to oral care revealed Resident #17 required assistance of one staff member with oral care. Resident #17’s Kardex (staff directive tool) revealed he needed the assistance of one staff member for oral hygiene and to use a soft-bristle toothbrush. Review of Resident #17’s electronic medical record (EMR) revealed a dental service note, dated 6/24/25. The note documented Resident #17 was seen for a consultation for a planned extraction of two teeth. The note documented the necessity of an external dental specialist for the procedure and Resident #17 would have to coordinate with the referred specialist to schedule the extraction. A health status note, dated 8/14/25 at 10:45 a.m., documented the dental office where Resident #17’s oral surgery was scheduled to take place on 8/20/25 had called to let the facility know that they did not take Resident #17’s dental insurance and Resident #17 would have to pay out of pocket. The note documented Resident #17 said to cancel the appointment and that he was not having tooth pain. A second dental service note, dated 9/5/25, revealed the dental provider discussed the need for Resident #17 to have his teeth extracted. The note documented that there was a scheduling issue when he was supposed to go in August 2025. The note documented that Resident #17 lost a broken tooth while brushing his teeth. The note documented the dental service would attempt to get a new referral as soon as possible. -However, there was no additional documentation to indicate the facility made further attempts to get a new appointment scheduled for Resident #17 for his oral surgery. III. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 2/26/26 at 8:43 a.m. CNA #3 said Resident #17 had never mentioned mouth or tooth pain to her. The social services director (SSD) was interviewed on 2/26/26 at 6:14 p.m. The SSD said she was the person who scheduled and coordinated ancillary services, including dental services. She said she was responsible for helping with coordinating any follow-up dental appointments. She said she was not aware that Resident #17’s insurance was not accepted at his dental appointment for the oral surgery. She said she asked him how his appointment went and he had told her that he did not get anything done. She said she did not follow up with him any further. She said that in September 2025, the dental service company was going to refer Resident #17 for another dental appointment. She said she was unsure of why Resident #17 had not been seen or referred to another appointment.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the upstairs kitchen. Specifically, the facility failed to:-Ensure dietary staff performed appropriate hand hygiene during meal service; and,-Ensure the rims of cups were not touched by staff when serving beverages. Findings include:I. Failed to ensure dietary staff performed appropriate hand hygiene during meal serviceA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 3/3/26. It revealed in pertinent part, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands." (2-301.15)B. Facility policy and procedureThe Hand Hygiene policy and procedure, revised 10/28/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, “The facility has adopted the CDC’s (Centers For Disease Control And Prevention) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings for indications for hand hygiene that are generally consistent with the World Health Organization’s 5 (five) moments for hand hygiene. “Unless hands are visibly soiled, an alcohol-based hand rub (ABHR) is preferred over soap and water in most clinical situations. “Associates perform hand hygiene (even if gloves are used) in the following situations:before and after contact with the resident; after contact with blood, body fluids, or visibly contaminated surfaces; after contact with objects and surfaces in the resident’s environment; after removing personal protective equipment (gloves, gown, eye protection, facemask).“Staff should wash hands with soap and water under the following situations as ABHR is not appropriate in these circumstances: before eating; after using a restroom; when their hands are visibly soiled (blood, body fluids); after caring for a resident with known or suspected C-difficile infection (CDI) or norovirus during an outbreak, or if endemic rates of CDI are high.”C. ObservationsDuring a continuous observation on 2/24/26, beginning at 4:45 p.m. and ending at 6:19 p.m., the following was observed during the dinner meal service in the upstairs kitchen:At 4:45 p.m. dietary aide (DA) #1 entered the kitchen pushing the insulated food cart and immediately began unloading the food into the steam table. -DA #1 did not perform hand hygiene prior to unloading the food from the food cart into the steam table. At 4:53 p.m. DA #1 calibrated the food temperature thermometer and began uncovering the food. -DA #1 did not perform hand hygiene after calibrating the food temperature thermometer and prior to uncovering the food. At 4:55 p.m. DA #2 entered the upstairs kitchen area. DA #2 took over taking the temperatures of the food for DA #1 so DA #1 could go use the bathroom.-DA #2 did not perform hand hygiene upon entering the kitchen or prior to taking the temperature of the food. At 4:58 p.m. DA #1 came back from the bathroom. -DA #1 did not perform hand hygiene upon entering the kitchen. -At 4:59 p.m. DA #1 answered the telephone but did not perform hand hygiene afterwards. At 5:01 p.m. DA #2 moved the large trashcan by touching the lid, opened her energy drink and took a drink. -DA #2 did not perform hand hygiene after touching the lid of the trashcan and taking a drink of her energy drink. At 5:11 p.m. DA #1 washed her hands and then proceeded to touch her face. -DA #1 did not perform hand hygiene again after touching her face. At 5:12 p.m. DA #2 took the evening meal menu that was taped to the wall and hung it over the steam table where the uncovered food was on the serving line. -DA #2 did not perform hand hygiene after removing the evening menu from the wall and hanging it over the steam table. At 5:17 p.m. DA #2 answered the telephone but did not perform hand hygiene afterwards. At 5:20 p.m. DA #1 and DA #2 were told to stop serving because the mixed salad was not down to the correct temperature. At 5:37 p.m. DA #1 put her hands in her pockets and then touched her face. -DA #1 did not perform hand hygiene after putting her hands in her pockets and touching her face. -At 5:45 p.m. DA #1 and DA #2 were able to start serving again, however, neither DA #1 or DA #2 performed hand hygiene prior to resuming meal service. At 5:55 p.m. DA #1 answered the telephone, scratched the back of her neck and required prompting to perform hand hygiene afterwards. At 5:56 p.m. DA #1 finished washing her hands and then brought the paper towel that she had used to dry her hands and set it on the serving table while she waited for more sandwiches to be delivered. -At 5:58 p.m. DA #2 rested her forehead and forearms on the serving table while waiting for sandwiches to be delivered and did not sanitize her hands or the serving table afterwards. At 6:01 p.m. the upstairs kitchen ran out of plates and were still waiting on more sandwiches to be delivered. At 6:02 p.m. DA #1 and DA #2 began to load the food cart with dirty dishes while waiting for the plates and sandwiches. DA #2 touched her face and touched the beanie that she was wearing. DA #2 did not perform hand hygiene after touching her face and her beanie. At 6:03 p.m. The additional sandwiches were delivered to the upstairs kitchen. At 6:04 p.m. DA #1 and DA #2 were still loading the dirty dishes onto the cart when the additional plates were delivered. DA #1 and DA #2 resumed plating room trays for residents. -DA #1 and DA #2 did not perform hand hygiene after handling the dirty dishes and prior to resuming plating room trays. At 6:07 p.m. DA #2 leaned her forearms and forehead on the serving table and touched her face and hat.-DA #2 did not perform hand hygiene or sanitize the serving table. At 6:08 p.m. the registered dietitian (RD) sent DA #2 downstairs to the main kitchen and helped DA #1 finish plating the room trays. DA #1 began placing a small pile of used gloves and paper towels on the serving table while food was still being served. -The RD did not instruct DA #1 to remove the soiled gloves and paper towels from the serving table.-At 6:19 p.m. the last room tray was served and the pile of used gloves and paper towels was still sitting on the serving table. II. Failed to ensure the rims of cups were not touched by staff when serving beverages A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/3/26. It revealed in pertinent part, “Single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food- and lip-contact surfaces is prevented.” (4-904.11)B. Observations On 2/23/26 at 11:38 a.m. an unidentified staff member delivered a beverage to a female resident while holding the rim of the cup. On 2/23/26 at approximately 11:56 a.m. an unidentified staff member moved drinks on the table around by the rims of the cups so she could put the plates down for the residents. On 2/23/26 at approximately 11:58 a.m. another unidentified staff member was serving drinks to a resident by holding the rim of the cup. On 2/23/26 at 12:06 p.m. an unidentified staff member was moving drinks around by the rim of the cups getting them ready for room trays. III. Staff interviewsDA #3 was interviewed on 2/25/26 at 3:21 p.m. DA #3 said employees should wash their hands anytime they came into contact with a resident, handled anything that was raw or soiled and after they were finished pushing a cart. He said that staff should never touch the rim of a cup when they were serving beverages to residents. Cook (CK) #1 was interviewed on 2/25/26 at 3:25 p.m. CK #1 said employees should wash their hands all the time. He said hand hygiene should be performed whenever dietary switched tasks, came back to the kitchen after using the bathroom, when they were prepping food, after they touched their face and when they took their gloves off. The dietary manager (DM) was interviewed on 2/26/26 at 2:23 p.m. The DM said dietary staff should be washing their hands anytime they entered the kitchen, when they switched their gloves, when they went from touching dirty dishes to touching clean dishes, after touching their faces, when leaving the serving line and after touching the garbage bin. She said staff should not be touching the rims of cups or glasses when they were serving drinks to residents.

Based on record review and interviews, the facility failed to meet all requirements for the provision of hospice care for three (#3, #58 and #33) of three residents reviewed for hospice services out of 41 sample residents. Specifically, the facility failed to ensure hospice notes were readily accessible and the comprehensive care plan was developed with delineation of care responsibilities established between the facility and hospice for Resident #3, Resident #58 and Resident #33. Findings include:I. Facility policy and procedureThe Hospice policy and procedure, revised 9/3/25, was provided by the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part “The facility provides hospice care under a written agreement and must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the long-term care (LTC) facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.“The facility must designate a member of the interdisciplinary team (IDT) to ensure hospice representatives are oriented to the facility and that the resident receives quality care in collaboration with the facility staff and the hospice staff. The designated IDT member facilitates communication between the facility and hospice and includes the resident’s representative in decision-making.” II. Resident #3A. Resident statusResident #3, age 89, was admitted on 4/21/25. According to the February 2026 computerized physician orders (CPO), diagnoses included chronic systolic congestive heart failure (when the left ventricle weakens and cannot contract properly, reducing blood flow to the body and backing up fluids to the lungs), hypertensive heart disease with heart failure, dementia and chronic respiratory failure with hypoxia (low levels of oxygen in the blood). The 12/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The assessment revealed she was dependent on staff for most of her activities of daily living (ADL) and mobility. The assessment indicated the resident was receiving hospice care services. B. Record reviewThe February 2026 CPO documented Resident #3 was admitted to hospice care services on 9/2/25. -A review of the comprehensive care plan, initiated 9/12/25, revealed Resident #3 was receiving hospice care services, however it failed to include delineation of care responsibilities between the facility and hospice care services. A review of Resident #3’s electronic medical record (EMR) revealed documentation of hospice recertifications for the resident and a hospice plan of care. -However, review of the resident’s EMR failed to reveal documentation of routine hospice care visits provided to the resident. III. Resident #58A. Resident status Resident #58, age 85, was admitted on 2/8/26. According to the February 2026 CPO, diagnoses included chronic respiratory failure, pulmonary hypertension and anxiety disorder. The 2/13/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The assessment f revealed that Resident #58 needed substantial to maximal assistance with most of her ADLs. The MDS assessment did not indicate Resident #58 was receiving hospice care services. -However, the resident was admitted to the facility for respite care and was receiving hospice care services at home and at the facility (see record review below). B. Record reviewReview of Resident #58’s EMR revealed she was receiving hospice care services upon her admission to the facility on 2/8/26. Review of her EMR revealed she was at the facility for respite care. A review of Resident #58’s comprehensive care plan, initiated 2/9/26, revealed her hospice care plan was initiated on 2/24/26 (during the survey process), 16 days after her admission to the facility. Resident #58’s hospice care plan failed to include a delineation of care responsibilities between the facility and hospice care services. V. Staff interviewsThe hospice nurse practitioner (NP) was interviewed on 2/26/26 at 9:00 a.m. The hospice NP said hospice care staff would document in a binder when they visited a resident. She said the hospice staff would chart clinical documentation in their own electronic system, not the facility’s. She said the hospice staff would document the physician’s order changes in the facility binder, but they would additionally fax over the physician’s orders to the facility. The hospice NP said from her understanding, the hospice company would fax over their clinical documentation weekly to the facility. Licensed practical nurse (LPN) #2 was interviewed on 2/26/26 at 9:51 a.m. LPN #2 said the facility had a binder that hospice staff would write in when they came to visit a resident. She said the hospice certified nurse aides (CNA) would document if they gave the resident a shower. She said most of the communication with hospice was done verbally. The social services director (SSD) was interviewed on 2/26/26 at 6:14 p.m. The SSD said she would create the hospice baseline care plan if a resident was admitted to the facility on hospice. She said she would also create the care plan for hospice care services when a resident was already a resident in the facility. She said a baseline care plan should be completed within 48 hours of admission. She said Resident #58’s baseline care plan was not completed timely. She said it was important to have the baseline care plan completed timely because if something were to happen or change, staff would know who to inform for care coordination. The medical records director was interviewed on 2/26/26 at 6:58 p.m. The medical records director said he started working for the facility at the end of June 2025 or beginning of July 2025. He said his first priority when a resident was receiving hospice care services was getting records uploaded and making sure the documents were signed and completed before they were scanned into the EMR. He said the hospice care services companies would email him residents’ records or the records that he requested from the hospice care services companies. He said the hospice care services companies would email him the residents’ clinical documentation from their visits every week. He said if the hospice care services company did not email him residents’ records, he would request the records from them. He said the records that they sent to him were the residents’ progress notes, physicians’ orders, care plans and anything that hospice might find important for the facility to know.-However, there was no clinical documentation found in the resident’s EMRs during the survey (see record review above). The medical records director said he had recently found out that Resident #3 was receiving hospice care services. He said he found out about a week and a half prior to the survey. He said he had no knowledge or contact with Resident #3’s hospice care services contact prior to a week and a half ago. He said he had to ask the admissions staff for all the residents receiving hospice care services. He said he was unsure of who was responsible for informing him if a resident was admitted to hospice care services. He said from a medical records standpoint, Resident #3’s EMR was incomplete due to none of her hospice progress notes being uploaded. He said it was important to have her hospice notes uploaded because any hole in the record could cause delay in care or a lack of care for the resident. The director of nursing (DON) and the regional clinical resource were interviewed together on 2/26/26 at 7:25 p.m. The DON and the regional clinical resource said the facility and the hospice care services team communicated using the binder that was at the nurses’ station. The DON and the regional clinical resource said that hospice staff would write in the binder describing what services were provided during a visit for each resident. The DON and the regional clinical resource said that the hospice care services companies would send the facility the resident’s clinical documentation, and the medical records director would upload the documentation into the EMR. The regional clinical resource said the residents’ hospice care plans should have a delineation of responsibilities between the facility and hospice. She said it was important to have a delineation of responsibilities so both the facility and the hospice care team would know who was providing what service for residents in order to provide the best care for the residents. The regional clinical resource said there should be clinical documentation from hospice in the residents’ EMRs so facility staff knew what was being provided at each hospice and so the facility staff and the hospice care staff were on the same page.

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 possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure housekeeping staff cleaned and disinfected residents’ rooms in a hygienic manner; -Ensure housekeeping staff performed appropriate hand hygiene while cleaning residents’ rooms; -Ensure a urine spill in the dining room was cleaned and disinfected in an appropriate manner; and,-Ensure urinary catheter bags were stored in a sanitary manner in residents’ rooms. Findings include:I. Failed to ensure housekeeping staff cleaned and disinfected residents’ rooms in a hygienic manner and performed appropriate hand hygiene while cleaning residents’ roomsA. Professional referenceThe Centers for Disease Control and Prevention’s (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 3/2/26 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."The CDC/ Environment Cleaning Procedures (revised 3/19/24) was retrieved on 3/2/26 from https://www.cdc.gove/healthcare-associated-infections/hcp/cleaning-global/supplies-and-equipment.html#cdc_generic_section_6-3-4-personal-protective-equipment-for-environmental-cleaning. It read in pertinent part, "Best practices for glove usage for cleaning: perform hand hygiene immediately before putting on gloves and directly after taking them off. When use of gloves is indicated, always change them between each cleaning session (routine cleaning of a patient zone under contact precautions, terminal cleaning of a general patient area)."B. Facility policy and procedureThe Hand Hygiene policy, revised 10/28/25, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, “Staff must perform hand hygiene (even if gloves are used) in the following situations: before and after contact with the resident; after contact with blood, body fluids, or visibly contaminated surfaces and. after contact with objects and surfaces in the resident’s environment." C. Room cleaning observationsOn 2/25/26 at 8:54 a.m. housekeeper (HK) #1 was observed cleaning resident room #102, a double occupancy room. HK #1 performed hand hygiene with alcohol based hand rub (ABHR) and applied clean gloves. HK #1 collected a disinfectant spray bottle labeled from the housekeeping cart, entered the resident’s room, went to the residents’ bathroom and sprayed the toilet (both inside and out) and the wall grab bars. HK #1 began dusting in the residents’ room. HK #1 started above the main entry door and worked counterclockwise through the room, dusting the dresser, the light fixtures above the sink area, the bathroom ceiling areas, the top of the inside and outside of the bathroom door, the window blinds, over the second resident’s bed area, including the light fixtures and art work on the wall, over the curtain pull area, then over the first resident’s bed, including her light fixtures and decor that was hanging. HK #1 finished her dustingabove the oxygen concentrator by the main entry door to the room. HK #1 then proceeded to perform hand hygiene with ABHR, don a new pair of gloves and take a premoistened washcloth to wipe down the areas in the residents' room. She used the same cloth for both sides of the room.-HK #1 failed to use a different dusting device or cloth for each side of the residents’ room. -Additionally, HK #1 continued to dust in the residents’ living space after using the dusting device to dust in the residents’ bathroom. At 9:13 a.m., HK #1 went to the housekeeping cart, performed hand hygiene, applied clean gloves and took the toilet brush and container from the cart. HK #1 went to the residents’ bathroom and used the toilet brush to clean in and around the toilet bowl and toilet tank, including the surface of the toilet tank that was housed on the floor. Approximately one minute after cleaning all the toilet surfaces, she put the brush back into the toilet bowl, flushed the toilet and then tapped the toilet brush against the toilet seat. Droplets spread from the toilet brush onto the bathroom walls and floor. She shook the toilet brush five times and then put the brush back into the container. She took a rag and wiped down the surfaces of the toilet seat, the toilet tank and handrails and flushed the toilet again. -HK #1 failed to clean the toilet from cleanest to dirtiest areas when she used the toilet brush on the surfaces outside of the toilet bowl. -Additionally, when HK #1 hit the brush against the toilet seat to clear the excess solution and contaminated water from the brush, the droplets from the brush spread onto the bathroom walls resulting in cross contamination and the spread of germs. HK #1 went back to the housekeeping cart, put the toilet brush container into the cart and placed the used rag into a soiled bucket. She then removed her gloves, performed hand hygiene, and applied a new pair of gloves. She went back into the residents’ room to mop. HK #1 completed cleaning the residents' room at 9:24 a.m. On 2/25/26 at 9:58 a.m. HK #2 placed her housekeeping cart outside room #222 and performed hand hygiene at the cart with ABHB. She applied a clean pair of gloves prior to entering the resident room. She collected a disinfectant spray bottle from the housekeeping cart and went into the resident’s bathroom to spray down the toilet area including the toilet bowl, the toilet tank and under the toilet seat. She then closed the bathroom door, set a timer for ten minutes on a cellular phone and took the bottle of disinfectant back to the housekeeping cart.-HK #2 failed to change her gloves and perform hand hygiene after spraying the toilet with disinfectant and touching the lid of the toilet. Using the same gloves she used when touching the toilet lid, HK #2 took a dusting device out of her cart and proceeded to dust the top of the lighting fixture over the sink, the top of the bathroom door, the blinds and the radiator vents on the floor. She dusted the resident’s doorway last before putting the dusting device back on the cart. -HK #2 did not change her gloves or perform hand hygiene after returning the dusting device to her cart. Using her same soiled gloves, HK #2 took a cleaning rag out of a container that was premoistened with a disinfectant solution. She went back into the resident’s room and wiped the mirror and sink area, moving any personal items out of the way and then returning them when finished.-HK #2 did not change her gloves or perform hand hygiene prior to obtaining a cleaning rag out of the disinfectant solution and touching the resident’s personal items. Without changing her gloves and using the same cleaning rag, HK #2 proceeded to wipe down the resident’s bedside tray table surface, the bottom of the tray table area, the nightstand, again moving the resident’s personal items out of the way to wipe underneath and then replacing them in their original spot, and finished with using the rag to clean the resident’s dresser top. When she finished with the surface cleaning, HK #2 took the trash bag out of the trash container, disposed of it in the housekeeping cart and replaced the bag in the container. Without changing her gloves, HK #2 proceeded to sweep the resident’s room, including the bathroom area, and gathered all the debris into her dust bin. The timer went off on the phone.-HK #2 failed to change her gloves or perform hand hygiene after removing the trash from the resident’s room and prior to using the broom to sweep the resident’s room and bathroom. HK#2 returned the broom and dustbin to the cart and took another premoistened rag from the cart and the toilet brush container. -HK #2 again failed to change her gloves or perform hand hygiene prior to obtaining another cleaning rag from the container of disinfectant solution. HK #2 returned to the resident’s bathroom where she cleaned the toilet from top to bottom with the rag, including the top of the toilet tank, the toilet tank, the sides of the toilet tank, the flush handle, the underside of the toilet bowl and then the bottom area on the floor surface. She used the toilet brush to scrub under the toilet bowl rim and the toilet bowl. She flushed the toilet and squeezed the excess water from the scrub brush into the toilet tank. She then put the brush back into the container and took the rag and the container back to the cart.-HK #2 failed to change her gloves and perform hand hygiene after cleaning the toilet, which included squeezing the excess water from the soiled toilet scrub brush with her gloved hands. Wearing the same soiled gloves she had been wearing for the entire room cleaning observation, HK#2 took another premoistened rag from the disinfectant solution and went back into the resident’s room. She began cleaning all the high contact areas, starting in the room first and then in the bathroom. She wiped the light switch, the bed remote, the call light, the mirror light switch, then the doorknobs to the bathroom, the hand rails in the bathroom, the emergency call light cord in the bathroom and then lastly the inside door knob of the bathroom door. She returned the rag to the dirty container and then took the mop handle from her cart. She opened a black storage container that was filled with a solution and had mop heads inside. Using her same soiled gloves, she picked up a mop pad, squeezed the excess water solution mix back into the container of solution where she retrieved it from and then attached the mop pad to her mop. -HK #2 failed to change her gloves and perform hand hygiene after cleaning the high contact surfaces in the resident’s room and prior to obtaining the mop pad from the cleaning solution and squeezing the excess water from the mop pad back into the cleaning solution with her soiled gloves. HK#2 went to the resident’s bathroom and mopped all areas behind and around the toilet bowl and then the floor, stopping at the bathroom/bedroom line. She took the used mop head pad to the cart, placed it in the dirty container and took out another clean mop head with her same soiled gloves. She followed the aforementioned procedure of squeezing the excess water back into the clean container. HK #2 finished mopping the resident’s room, getting underneath the bed, underneath the night stand, under the sink area, and all along the floor surface of the area. She mopped backwards towards the resident’s room door, where the last task she did was take another premoistened rag and wiped the doorknobs for the main door. She put the dirty rag into the dirty container, removed the dirty mop head, placed it in the same dirty container and then took off her gloves and performed hand hygiene. HK #2 completed cleaning the resident's room at 10:15 a.m.-HK #2 failed to change her gloves and perform hand hygiene throughout the entire room cleaning observation, cleaning the resident’s entire room and bathroom with the same pair of soiled gloves throughout the process. HK #2 was observed a second time on 2/25/26 at 11:10 a.m., cleaning room #220. HK #2 rolled the housekeeping cart to outside room #220 and performed hand hygiene at the cart with ABHR and applied a clean pair of gloves prior to entering the resident’s room. HK #2 followed the same aforementioned process when cleaning room #220.-HK #2 failed to perform hand hygiene and change gloves after spraying down and touching the toilet seat, before and after cleaning high contact areas, before and after dusting, before and after taking the trash from the resident’s room, before and after taking a new rag from the clean container, before taking a new mop head out of the solution container, before and after mopping and before cleaning high contact areas. -Additionally, HK #2 contaminated the clean mop bucket solution when excess water was squeezed from the mop pad with her soiled gloves. -HK #2 again failed to change her gloves and perform hand hygiene throughout the entire room cleaning observation, cleaning the resident’s entire room and bathroom with the same pair of soiled gloves throughout the process..D. Staff interviewsHK #1 was interviewed on 2/25/26 at 9:25 a.m. HK #1 said every resident room was cleaned daily in the same manner as she did during the observation (see observations above). The housekeeping supervisor (HKS) was interviewed on 2/26/26 at 1:45 p.m. The HKS said when new housekeeping staff were hired, he trained them personally on room cleaning. He said he created a housekeeping process sheet that was kept on each housekeeping cart, with one side written in Spanish and the other side written in English. He said it was his expectation that housekeepers followed that written cleaning process. The HKS said the dusting devices the facility used were not able to be disinfected, therefore housekeepers should not use them in residents’ bathrooms. The HKS said he had specifically told staff the dusting devices were only to be used for room light fixtures and the window blinds. The HKS said he would set up a time to meet with management to discuss the purchase of disposable dusting devices. The HKS said housekeeping staff should be changing gloves at a minimum of three times during a room cleaning. The HKS said staff did not practice good infection control procedures when HK #1 hit the toilet brush against the toilet bowl and when HK #2 cleaned and completed an entire room cleaning with only one pair of gloves being used. He said staff would be trained specifically in infection control measures. II. Failed to ensure a urine spill in the dining room was cleaned and disinfected in an appropriate manner A. Professional referenceThe CDC's Environment Cleaning Procedures (revised 3/19/24) was retrieved on 3/2/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html#cdc_generic_section_6-4-5-spills-of-blood-or-body-fluids. It ready in pertinent part, "For spills of blood or body fluids, wear appropriate personal protective equipment (PPE). Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules (if available) that are spread over the spill to solidify the blood or body fluid (all should then be disposed as infectious waste). Clean thoroughly, using neutral detergent and warm water solution. Disinfect by using a facility-approved intermediate-level disinfectant."B. Facility policy and procedureThe Housekeeping Services policy, revised 1/6/226 was received from the NHA on 2/27/26 at 3:54 p.m. It read in pertinent part, "Blood/Body Fluid Spills: If there is a blood or body fluid spill or contamination, clean and disinfect the area immediately in a two-step process. Mark off the spill area to prevent contact, as well as accidental slips and falls. Clean and disinfect the spill as soon as possible. Confine the spill and wipe it up immediately with absorbent paper towels, cloths or absorbent granules and dispose of it as infectious waste. Clean the area with a facility-approved cleanser. 1:10 dilution of bleach may be used. Disinfect using a facility-approved intermediate-level disinfectant."C. Dining room observation and staff interviewA continuous observation of the dining room on the second floor to the left of the nurses’ station was conducted on 2/24/26, beginning at 4:00 p.m. and ending at 6:55 p.m..At 5:25 p.m. Resident #23 was seated at the first table of the dining room with two other residents. At 5:40 p.m. a puddle was observed underneath Resident #23’s wheelchair. A strong urine odor was noted and additional urine was trickling out from the back of the resident's wheelchair. At 5:51 p.m. more urine was observed puddling under Resident #23’s wheelchair. At 6:30 p.m. an unidentified male certified nurse aide (CNA) came into the dining room pushing a different resident in a wheelchair. He wheeled the other resident’s wheelchair right through the puddle of urine, causing urine wheel marks on the floor. At 6:31 p.m. an unidentified nurse came into the dining room with a soiled linen bag and put Resident #23's sweater and towels that she had been sitting on in her soiled wheelchair into the bag. A male CNA then wheeled Resident #23 through the puddle of urine again, leaving urine wheel marks down the hallway to Resident #23’s room. At 6:41 p.m. a laundry assistant entered the dining room with a broom and a dust pan and started sweeping the dining room. At 6:48 p.m. the laundry assistant began mopping the far end of the dining room. He then proceeded to mop up the urine from the floor before he finished mopping the rest of the dining room with the same mop. The laundry assistant was interviewed on 2/24/26 at 6:55 p.m. The laundry assistant said he changed the mop water but did not change the mop head. He said he only cleaned the dining rooms with that specific mop head and did not clean bathrooms with it, so he did not have to change the mop head.-However, the laundry assistant did not change the mop head after mopping up Resident #23’s urine from the floor and prior to finishing mopping the rest of the dining room. D. Additional staff interviewThe HKS was interviewed on 2/26/26 at 5:00 p.m. The HKS said he was not aware staff did not properly mop up Resident #23’s urine in the dining room. He said the expectation was the laundry assistant would sweep and then mop. He said he could not confirm if the laundry assistant used a disinfectant solution on the floor. He said by the time dinner was over, he and the housekeeping staff were already gone for the day. The HKS acknowledged the use of disinfectant was pertinent to infection control and prevention. He said moving forward, he would ensure the laundry assistant had access to disinfectant floor solution and he would have his staff use a different mop head for each dining room. III. Failed to ensure urinary catheter bags were stored in a sanitary manner in residents’ roomsA. Facility policy and procedureThe Indwelling Urinary Catheter (Foley) Management policy, revised 6/27/23, was received from the NHA on 2/27/26 at 3:54 p.m. It read in pertinent part, "Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor." B. Urinary catheter observationOn 2/24/26 at 4:30 p.m. an interview was conducted in Resident #2's room. Observation during the interview revealed Resident #2 had her urinary catheter drainage bag hanging from the lower rail of the bed. The urinary catheter drainage bag was resting on the floor. On 2/25/26 at 8:17 a.m. a walk through observation revealed Resident #2's urinary catheter drainage bag hanging from the lower rail of the bed. The urinary catheter drainage bag was resting on the floor. C. Staff interviews CNA #1 was interviewed on 2/25/26 at 10:00 a.m. CNA #1 said urinary catheter drainage bags were emptied at least one time each shift, more if needed. She acknowledged urinary catheter drainage bags should never be touching the floor. At 10:14 a.m. CNA #1 observed Resident #2’s urinary catheter drainage bag resting on the floor. CNA #1 immediately raised the resident's bed and adjusted the clip to bring the urinary catheter drainage bag off the floor. CNA #1 said the resident tended to lower her bed to the lowest position and that caused the urinary catheter drainage bag to hit the floor. CNA #1 said moving forward, the clip would be tighter so there wouldn't be any ability for the urinary catheter drainage bag to touch the floor. The director of nursing (DON) was interviewed on 2/25/26 at 6:15 p.m. The DON said her expectation was that all staff followed proper infection control policies and procedures. The DON said urinary catheter drainage bags should never touch the floor because of the high potential of contamination of germs. The DON said she was not aware that urinary catheter drainage bags were not being stored properly and she would use this as a learning experience and a good opportunity to provide staff with additional training related to urinary catheter drainage bags.

Based on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for one (#36) of five residents reviewed for immunizations out of 41 sample residents. Specifically, the facility failed to ensure Resident #36 received pneumococcal immunization when consent was given. Findings include:I. Professional Reference According to the Centers for Disease Control and Prevention’s (CDC) Pneumococcal Vaccination, revised 2/25/26, retrieved on 3/2/26 from https://www.cdc.gov/pneumococcal/vaccines/index.html, "CDC recommends pneumococcal vaccination for all adults 50 years or older."II. Facility policy and procedureThe Vaccination of Older Adults policy, revised 1/28/25, was received from the nursing home administrator (NHA) on 2/27/26 at 3:54 p.m. It read in pertinent part, "Consents and declinations should be captured using an informed consent form for the vaccine."Education, assessment findings, administration, refusal or did not receive due to medical contraindications, and monitoring are documented in the resident’s medical record. Update immunization record in the electronic health record." III. Resident #36 A. Resident statusResident #36, age greater than 65, was admitted to the facility on 9/9/25. According to the February 2026 computerized physician orders (CPO), diagnoses including acute kidney failure (sudden loss of kidney function), unspecified atrial fibrillation (rapid and quivering heartbeat) and chronic venous hypertension (elevated blood pressure in the leg veins). The 2/5/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMs) score of 14 out of 15. The MDS assessment indicated the resident was not up-to-date with pneumococcal vaccination due to the vaccine not being offered by the facility. B. Record reviewReview of Resident #36’s electronic medical record (EMR) revealed Resident #36 consented to receive the pneumococcal vaccine on 9/9/25, during her admission to the facility.-However, there was no documentation in the resident’s EMR to indicate the pneumococcal vaccine had been administered to the resident. The facility obtained a second consent for the pneumococcal vaccine from Resident #36 on 12/28/25, however, the resident declined the pneumococcal vaccine at that time. IV. Staff interviewThe infection preventionalist (IP) was interviewed on 2/26/26 at 5:45 p.m. The IP said Resident #36 had consented to receive the pneumococcal vaccination on 9/9/25. The IP did not know why Resident #36 did not receive her pneumococcal vaccination from the date of initial consent 9/9/25 upon her admission to the facility. The IP said a second consent for the pneumococcal vaccine was obtained from the resident on 12/28/25, however, she said the resident declined at that time and she did not know why the resident declined the vaccination on 12/28/25. The IP confirmed Resident #36’s EMR failed to provide documentation of attempts to administer the pneumococcal vaccination to the resident, education provided to the resident at time of the attempts and/or a reason why the resident chose to decline consent for the vaccination in December 2025.

A survey for Incident #39770 was conducted on 5/5/25. No deficiencies were cited.

A survey prompted by #CO35452, #CO36031, #CO36549, #CO38532 and #CO38897 was conducted on 1/13/25 to 1/14/25. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required. An onsite revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A revisit survey was completed on 1/26/24 to 1/29/24 for all previous deficiencies cited on 11/30/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 1/26/24 and 1/29/24 for all previous deficiencies cited on 11/30/23. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey conducted on December 14, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies." This structure is a one (2) story, Type II (111) construction. This original facility was constructed in 1973. There is a partial basement that is used for support services only and there is no resident access. The facility is licensed for 118 beds. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe sprinkler system. There is also an anti-freeze loop that protects the main entrance canopy. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Regional Vice President and the Physical Plant Manager during the exit conference conducted on December, 14 2023

STANDARD is not met as evidenced by: Based on testing and observation of the delayed egress door , it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2.2.2.4 and Chapter 7. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit discharge to the public way is not provided. 1. Egress doors located on the first floor contained delayed egress hardware on both exit doors. Only one delayed egress door allowed per exit. 2. No delayed egress signage posted on the lobby exit door NFPA Life Safety Code 20127.2.1.6.1.1 Delayed-Egress Locking Systems.(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10under all of the following conditions:(a) The force shall not be required to exceed 15 lbf (67 N).(b) The force shall not be required to be continuously applied for more than 3 seconds.(c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening.(d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. The exit discharge deficiency was discussed with the Director of Maintenance during the survey and again during the exit conference with the Administrator.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the exit access doors so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 7.16.2. This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. During the walk through of the facility, with the Maintenance Supervisor, the rear means of egress sidewalk has large pieces of concrete missing creating an uneven surface. 7.1.6.2 Changes in Elevation. Abrupt changes in elevation of walking surfaces shall not exceed 1?4 in. (6.3 mm). Changes in elevation exceeding 1?4 in. (6.3 mm), but not exceeding 1?2 in. (13 mm), shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1?2 in. (13 mm) shall be considered a change in level and shall be subject to the requirements of 7.1.7. The Maintenance Director acknowledged the condition of the door during the time of the tour.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provided for building egress. This was evidence by the following. 1. Facility failed to provide proper exit signage next to room 215, directional arrows were pointing in the wrong direction. 2. Missing exit sign at first floor Nurses Station. Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. The Director of Maintenance acknowledge the lack of exit signage condition during the tour of the facility.

STANDARD is not met as evidenced by: During the review of the facility records, with staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system cleaning schedule as required by NFPA 96, (Chapter 8, Section 8-3). This deficient practice could affect all residents, and staff should a fire occur due to grease build-up in the exhaust system and fail to operate effectively due to non-code compliant cleaning and maintenance. This was evidence by the following;1. No documentation was available to confirm that the facility had the kitchen-hood-exhaust-system cleaned, or schedule as required by NFPA 96. 2. The facility was unable to provide further documentation indicating the inspection and servicing of the Kitchen-suppression-system every six months. NFPA 96, Chapter 8, Section 8-3.1 Hoods, grease removal devices, fans, ducts and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surface becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire system shall be inspected by a properly trained, qualified and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1. The Maintenance Director acknowledge the lack of documentation for the cleaning of the Kitchen Hood System.

STANDARD not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following. 1)One (1) painted sprinkler head in Beauty Salon2)One (1) Painted sprinkler head in the Maintenance Shop3)Pendent sprinkler heads located in the walk-in cooler and freeze observed to be older than 5 years. 4)No way to conduct a flow test at elevator pit. 5)Main drain test cannot be conducted due to flooding dinning area. NFPA 101 2012 editionLife Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are installed, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors. Door opening in the cross-corridor of the second floor would not latch and close completely into the door frames creating a 20- minute smoke barrier. The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the door frame. Section 19.3.6.3.1, Exception #2 requires that corridor doors installed within sprinklered protected smoke compartments be constructed to resist the passage of smoke. The Director of Maintenance acknowledge the corridor door condition during the facility tour.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the fire resistance rating of smoke barrier walls were not maintained in accordance with Life Safety Code Section 19.3.2.1 This deficient practice could affect all residents in all smoke compartment by allowing the spread of fire and smoke to the adjoining compartments. Unsealed 1ft by 1ft penetrations in the fire rated ceiling in the oxygen transfer rooms first and second floors are not sealed to maintain the 1-hour fire resistance rating of the fire barrier, as required. Life Safety Code Section 19.3.2.1 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ½ hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces. Section 8-3.1.1 requires, in part, that the space between piping penetrations. The Maintenance Director acknowledge the penetrations during a tour of the facility.

STANDARD is not met as evidenced by: During observation of the kitchen gas fired cooking equipment it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents, and staff should a fire occur due to failure to operate safely due to non-code compliant. This was evidence by the following. Gas fired cooking equipment with casters where not limited by a restraining device and wheel chocks. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliance with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufactures installation instructions. The Maintenance Director acknowledge lack of a restraining on the gas fired cooking appliances

STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire drill on the first and second shift in the first quarter. Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. The Director of Maintenance acknowledge the conditions of fire drills deficiency during record review of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview it was determined that the facility failed to maintain fire safe environment within the facility. This deficient practice could affect all patients, staff and visitors should a fire occur by the non-rated space heaters. This was evidence by the following. A non- documented portable baseboard space heater used for heat at main lobby desk. Life Safety Code, Section 19.7.8. Portable space-heating devices shall be prohibited in all heath care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee's areas where the heating elements of such devices do not exceed 212? F (100? C). The Maintenance Director acknowledge the deficiency of the prohibited space heaters during the facility tour.

STANDARD not met: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain electrical equipment in accordance with National Fire Protection Association 70, National Electrical Code. This deficient practice could affect all residents on the sixth floor smoke compartments due to increased potential hazards of electrical fire. This was evidence by the following:The facility failed to maintain electrical equipment. Electrical light switch is not rated for 110 volts in the front lobby. NFPA 70, National Electrical Code. The Director of Maintenance acknowledged the electrical hazard during a tour of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights for 1-1/2-hour duration at the transfer switches. accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:The battery-powered emergency lighting system did not function at the transfer switch. Life Safety 101 section 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The Maintenance Director acknowledge the required testing and maintenance of the emergency lighting during the tour of the facility.

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.8 Maintenance and Operational Testing. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. 1. Diesel annual fuel quality test not conducted as annually using applicable STM Standards 2. No annual service and maintenance on generator. 3. At the time of the survey, no records were available to verify testing and recording of battery conductance testing in connection with the emergency power supply system (emergency generator) monthly. The emergency power supply system deficiency item was discussed with the Director of Maintenance during the survey. NFPA 110, Section 8.3.8 a fuel quality test shall be performed at least annually using approved ASTM standards.

A recertification survey with complaint #CO34039, #CO34250 and #CO34292 was completed on 11/27/23 to 11/30/23. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 11/27/23 to 11/30/23. No deficiencies were cited.

Based on observation, interviews, and record review, the facility failed to assess and monitor an existing pressure injury for one (#50) of seven residents reviewed for wounds out of 32 sample residents and failed to take steps to prevent the resident's development of pressure injuries. Resident #50 who required hands on assisance from staff to complete activities of daily living such as toileting, bed mobility, dressing and personal hygiene and who was at high risk for developing pressure injuries developed facility acquired pressure injury. The resident's pressure injury was first discovered on 4/27/23 and started as a redness spread over the bony part of the resident's left hip. The wound care physician classified the wound as a "trauma wound." There was no documentation in the resident's chart to identify what type of trauma caused the wound to develop other than the resident lying on the hip creating skin damage for pressure to the wound site. A note written by the facility's occupational therapist (OT) documented that the pressure injury was discovered on 4/27/23 after the resident had been sitting up in her wheelchair for an extended period. The injury was linked to the resident seating system and position in the wheelchair from the wheelchair components and the cushion putting pressure on the resident's left hip. Following the observation, the OT adjusted the resident's wheelchair seating system and the wound improved by 5/24/23 but emerged again a month later. On 6/28/23 the resident medical record revealed the wound to the resident left hip emerged again as an open wound measuring 1.3 centimeters (cm) in length by 2 cm in width by 2 cm in depth. The wound bed was covered with 100% slough (stringy yellowish dead skin). The facility physical therapist (PT) assessed the resident and recommended the resident lay off of her left side to facilitate wound healing to the left hip. Following this recommendation, the resident developed a pressure injury to the right hip (on 9/4/23). The wound was assessed as an unstageable pressure injury on the resident's right posterior (back) hip with full-thickness of the skin (extending beyond two layers of skin tissue) and tissue loss. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The PT reassessed the resident's seating system following the progression of the facility acquired pressure injuries and documented that the resident had had an inappropriate wheelchair and positioning program causing poor posture and skin related issues. The assessment documented that the resident required more frequent repositioning assistance to offload pressure from the left him with added side and back laying positions. The assessment documented that the resident had been tolerating the recommended repositioning; however, observations revealed the resident was not being respositioned as recommended (see observations below). The wound care physician (WCP) assessment of the pressure injuries reviewed the WCP believed the wounds were avoidable (see the WCP interview below). Interventions were not implemented consistently and observation of the resident's care revealed a lack of timely repositioning and staff not following the PT's recommendations to assist resident to offload pressure alternating from side to side and back lying on a frequent basis in order to promote healing the left hip wound and improved skin integrity. The facility failed to promote full healing of the wound and failed to prevent the formation of a second wound from worsening. The facility's failure to develop and implement timely and effective interventions led to the development of two unhealed pressure injury wounds one of which caused the resident severe pain. On 11/22/23, the pressure injury to the resident's left hip while healing persisted and measured 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. However, the pressure injury wound to the right rear hip, first observed 9/4/23, worsened from intact skin to an unstageable pressure injury measuring 1.2 cm in length by 1.2 cm in width by 0.1cm depth with a build-up of dead tissue and severe pain at the wound site. The wound required surgical debridement to remove dead tissue and progressed to a stage 4 pressure ulcer measured 1.2 cm in length by 1.2 cm that began to spread under the surface of the skin at the wound edges. Findings include: I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 12/7/23, "Pressure ulcer classification is as follows: "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). "Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. "Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dark dead skin) may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable "Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thinblister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment." II. Facility policyThe Skin Integrity and Pressure Ulcer/Injury Prevention and Skin Management policy, reviewed 3/31/23, was provided by the nursing home administrator (NHA) on 11/30/23 at 1:26 p.m. It revealed in pertinent part, "Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure, ulcer injury, complete, wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury, Advisory Panel) and WOCN (Wound, Ostomy, Continent, Nurse Society)."A comprehensive skin inspection/assessment on admission and readmission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas, surrounded by edema; profound, redness, or induration; bogginess; and or discoloration. These signs possibly indicate an unavoidable stage three or four with slough, drainage, or even eschar within a few days."A risk assessment to Braden Scale, or Norton scale determines the resident's. Risk of pressure injury development. The score is documented on the tool and placed in the resident's medical record using the appropriate form."Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include, but are not limited to; impaired/decreased mobility and decreased functional ability. Morbid conditions, such as end-stage, renal disease, thyroid disease, diabetes mellitus, or other end-of-life concerns. Drugs such as steroids that may affect wound healing. Impaired diffuse, or localized blood flow. A patient's refusal of some aspects of care treatment especially in multi-system organ failure, or end-of-life conditions. Exposure of skin to urinary and fecal incontinence. Under nutrition, malnutrition, and hydration deficit, edema and history of a healed injury. "Measures to maintain and improve resident's tissue tolerance to pressure and implemented in the plan of care. All residents upon admission are considered to be at risk of pressure injury development due to medical issues requiring nursing care and related disease processes and illness or need for rehabilitation services. Upon admission and throughout stay at minimum distribution surface is in use with her and repositioning as needed with ADL care/assistance in care, if needed to include skin barriers, application as needed, preventative, wheelchair cushions, if indicated, etc. Skin inspections with particular attention to bony prominences. Skin cleansing with appropriate cleanser at the time of swelling and at routine intervals. Minimize skin exposure to incontinence using devices and skin barriers. Minimize injury due to shear friction through proper positioning, transfers, and turning schedules. Encourage PO food and fluid intake and improve residence, mobility and activity when potential exists."Measures to protect the resident against the adverse effect of external mechanical forces, such as pressure friction, and are implemented in the plan of care; reposition, at least every 2 to 4 hours, as consistent with overall patient goal and medical condition. Utilize positioning devices to keep prominences from direct contact and ensure proper body alignment protection/suspension if indicated. A distribution mattress surface is placed under the resident. When positioned in the wheelchair, the resident is to be placed on a pressure reduction device and repositioned. When positioned in a wheelchair consideration is given to postural alignment, distribution, weight, balance, and stability. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident."III. Resident #50A. Resident status Resident #50, age 75, was admitted on 8/10/2020. According to the November 2023 computerized physician orders (CPO), the diagnoses included Parkinson's, dementia with behavioral disturbances and major depressive disorder. According to the 11/10/23 minimum data set (MDS) assessment, the resident was cognitively severely impaired and was unable to complete a brief interview for mental status (BIMS). She was dependent on one person with transferring and dressing. She required substantial assistance from one person with toileting, bed mobility, dressing, personal hygiene and eating. The resident was dependent on a wheelchair and needed moderate assistance with locomotion. The resident was at risk for developing pressure ulcers. The resident had unhealed pressure ulcers. The resident had one unstageable pressure ulcer. The pressure ulcers were not present at admission. B. ObservationsOn n 11/27/23 Resident #50 was observed and revealed: -At 9:00 a.m. the resident was in her bed lying on her right side.-At 10:00 a.m. the resident was in her bed lying on her right side.-At 11:58 a.m. the resident was in her bed lying on her right side. On 11/28/23 Resident #50 was observed and revealed:-At 10:26 a.m. the resident was in her bed lying on her right side.-At 10:40 a.m. an unknown CNA went into the Resident #50's room but did not reposition her and the resident remained lying on her right side. -At 12:30 a.m. a unknown CNA went into Resident #50's room to help her roommate, but did not assist Resident #50 with any care. Resident #50 remained on her right side.-At 1:30 p.m. the Resident #50 remained on her right side. On 11/30/23 Resident #50 was observed and revealed:-At 9:00 a.m. the resident was in her wheelchair in the hallway.-At 12:00 p.m. an unknown staff member transported the resident, who was still up in her wheelchair to the dining room for lunch. -At 12:45 p.m. after the resident finished lunch, an unknown staff member transported the resident to her room and transferred her to bed using a hoyer (mechanical) lift. The staff laid her down on her right side. C. Record review According to the Braden scale (a scale to measure risk of developing pressure ulcers) dated 5/11/23 Resident #50 was at mild risk of developing pressure ulcers. According to the health status note dated 5/1/23 at 11 a.m., the resident had a new skin issue discovered on 4/27/23. The resident had redness spread over her left hip. The registered nurse (RN) on duty cleansed the skin and placed prophylactic (preventative) foam dressing on the left hip. A seating cushion that was previously placed for positioning the resident in the wheelchair was removed and OT had been working with the resident on positioning. OT removed a rigid lateral support (lateral trunk support) and adjusted lateral support so it would not rest on the bony prominence of her hip. According to a care management note dated 5/4/23 OT was discontinued due to the resident meeting all her wheelchair goals. According to the OT discharge summary dated 5/6/23 the resident received therapy between 3/15/23 and 5/6/23. The resident had been assessed by OT due to the resident being at risk for falling out of her wheelchair due to inability to sit up in the chair without leading to the left. The initial intervention for positioning was causing additional rubbing and pressure on the residents left hip. As a part of the assessment and treatment the OT made adjustments to preventing the support from rubbing against the resident's hip. According to an event note dated 6/28/23 the resident had an open area to her left hip on the bony prominence. The affected area had been padded with mepilex dressing for the past four weeks due to non blanchable redness (when the skin is unable to return to a normal pigment when pressed) that developed from using equipment to help her sit upright in her wheelchair. The resident was evaluated by the wound team. According to the wound observation tool dated 6/28/23 the resident acquired a new skin impairment on 6/28/23, on her left hip. The first observation revealed the resident's skin had epithelial tissue (normal healthy skin) present and granulation tissue (beefy red tissue an indicator that skin was healing) the wound had a small amount of serous drainage (normal clear yellow fluid an indicator of a healing wound). The wound measured 1.3 cm in length, 2.2 cm in width and 0.2 cm in depth. According to the wound note dated 7/5/23 the resident's left hip was identified as a trauma wound with a status of not healed. The wound measurements were 1.3 cm in length by 1.9 cm in width with no measurable depth with 100% slough. There was a small amount of serous drainage noted. The physician performed surgical debridement (procedure to remove dead tissue). Post debridement measurements were 1.3 cm in length by 1.9 cm in width by 0.1 cm in depth. According to the wound note dated 7/12/23 the resident had an unhealed left hip trauma wound. The wound measurements were 1.3 cm in length by 2.2 cm in width with no measurable depth. There was a small amount of sero-sanguineous (watery bloody) drainage noted. The wound bed had 95% eschar and 5% slough. There was no change noted in the wound progression. The left hip wound was still developing but not enough to allow for debridement. According to wound notes dated 7/19/23 the resident's left hip trauma wound and had received a status of not healed. The wound measured 1.5 cm length by 2.5 cm in width with no measurable depth. There was a small amount of serous drainage noted. Wound bed had 100% slough. There was no change noted in the wound progression. The wound was surgically debridement; post debridement measurements were 1.5 cm in length by 2.5 cm in width by 0.3 cm in depth. According to the PT evaluation and treatment plan dated 7/19/23 the resident had a pressure wound. The resident had poor posture, adverse effects to skin integrity and there was inconsistent use of hoyer lift. The resident's goal was to be able to sit in an upright position and transfer safely in the hoyer lift to decrease further risk of skin trauma. The PT assessment recommended making changes to the resident's wheelchair cushion. According to the wound note dated 8/2/23 the resident's left hip wound measured 1.7 cm in length by 2.4 cm in width with no measurable depth, muscle was exposed. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided with post debridement measurements of 1.7 cm length by 2.4 cm width by 0.3 cm. According to the August 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition resident every two hours and ensure offload of the left hip at all times every shift for wound on left hip, ensuring the resident was not laying on left hip until wound was resolved. Order dated 8/2/23 and discontinued 9/24/23. According to the wound note dated 8/9/23 the resident's left hip wound measurements were 2.5 cm in length by 1.3 cm in width with no measurable depth. Muscle was exposed and tunneling (occurs when a chronic wound has progressed to form an opening underneath the surface of the wound's edge) was present at a distance of 1.4 cm. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided. The post debridement measurements were 2.5 cm in length by 1.3 in cm width by 0.1 cm in depth. According to the PT evaluation and treatment plan dated 8/30/23 the resident's wheelchair was modified but continued to require monitoring for adverse effects. The assessment recommended that the resident be encouraged to lay on her side while in bed to alleviate pressure to aid with left wound healing but this resulted in a non-blanchable redness on the resident's right hip. The resident continued to require education on participants in a rotating program reposition and promote overall skin integrity. According to the comprehensive care plan focus for impaired skin integrity dated 8/24/23 the resident had a trauma injury wound. Interventions included providing treatment as ordered. Weekly skin checks in wound rounds. Air pressure mattress. Clean and dry skin after each incontinent episode. Encourage the residents to wear geri-gloves (non-compression, seamless knit material that contours to the body to protect thin, sensitive skin from tears, abrasions, and light bruising) as tolerated, to avoid skin tears on hands. Staff should make certain nails are trimmed. Added padding to the resident's wheelchair arms. Ensure the resident's hands on her lap when assisting her with ambulation. According to the altered skin integrity care focus dated 9/11/23 interventions included assisting the resident to reposition when in bed off of her back with the use of wedges, as tolerated, to prevent skin breakdown. According to an event note dated 9/4/23, the resident had a non-blanchable wound to the right hip bony prominence. The affected area was maroon in color. The resident had been laying mostly on her right side due to the wound on her left hip. The resident did not like to lay on her back to relieve pressure from both bony prominences. Affected area was cleansed with normal saline, skin prep and covered with mepilex dressing. According to wound notes dated 9/6/23, the resident developed an unstageable pressure injury on her right posterior hip with full-thickness skin and tissue loss. The pressure ulcer had received a status of not healed. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The wound bed had 100% epithelialization with obscured full-thickness skin and tissue loss. According to wound note dated 9/6/23 the resident's left hip wound measured 1.2 cm in length by1.5 in cm width by 1 cm in depth with undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) with a maximum distance of 2.3 cm. According to event note dated on 9/11/23,the resident had a non blanchable wound. The resident was sleeping and resting on an air mattress with order for staff to provide repositioning assistance and wound care treatment and dressing changes. According to the wound observation tool dated 9/13/23 the resident had an unstageable pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had slough tissue. The wound measurements were 3.0 cm in length and 5.0 cm in width According to the PT evaluation and treatment plan dated 9/20/23 the resident tolerated the position throughout the day with no adverse effects to the left hip wound. The resident tolerated a rotating positioning program in supine (on back) to promote overall skin integrity. The resident currently had an inappropriate wheelchair and positioning program. The resident needed a smaller wheelchair and to be repositioned more frequently. According to the September 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition the resident and offload bilateral hip as allowed every shift for skin management order dated 9/24/23 and discontinued 10/19/23. According to the PT discharge summary dated 10/2/23 the resident was discharged with a good seated and supine positioning with no worsening wounds. According to the pressure ulcer care focus dated 11/13/23 the resident had an unstageable pressure ulcer on her right hip. Interventions included administer medications and treatments, as ordered. Provide enhanced barrier precautions. Inform the resident and family of any new skin breakdown. Perform lab and other diagnostic work as ordered, report the results to the medical doctor and follow up as indicated. Observe and report changes in skin status; appearance, color, wound healing, sign of infection, wound size and stage of wound. Serve diet as ordered and monitor intake and record. According to the wound notedated 11/15/23 The resident had an unstageable pressure injury on her right, posterior hip with obscured full-thickness skin and tissue loss and had received a status of not healed. The wound measured 1.2 cm in length by 1.2 cm in width with no measurable depth, with undermining at a distance of 2.6 cm. There was a large amount of serous drainage noted. The patient reports a wound pain of level 0/10. The wound bed had 80%, granulation, 20% slough. The wound was surgically debrided, post debridement measurements were 1.2 cm in length by 1.2 cm in width by 0.1cm depth. According to the wound observation tool dated 11/22/23 the resident acquired a skin impairment on her left hip, due to trauma of equipment use on 6/28/23 (seating and transferring devices, see above). The left pressure wound was assessed to have been healing with granulation tissue (beefy red) the wound had serous and scan drainage. measurements were 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. According to the wound observation tool dated 11/22/23 the resident had a stage 4 pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had granulation and slough tissue . The wound measurements were, 1.2 cm in length and 1.2 cm in width with tunneling. IV. Staff interviewsThe wound care physician (WCP) was interviewed and observed on 11/29/23 at 1:20 p.m. while performing wound care on Resident #50's left hip. The WCP said the resident was admitted to the facility on 6/26/23, with a left hip trauma injury. The wound had been unstable. The wound had worsened and was now classified as a stage 4 pressure injury with tunneling and had a large amount of drainage. The WCP said the wound likely had severe colonization and was possibly an infection but he was unable to determine the severity of the infection because he was unable to see the bottom of the wound. The WCP said if the resident acquired the left hip wound at the facility then the wound on her right hip was avoidable. The wound doctor said the resident would not have acquired the right hip wound if she did not have the left wound. The WCP said the resident was positioned on the right hip because it was painful to lay on her left hip. The WCP said the resident should be repositioned supine (on her back) to avoid the wound's progression. The WCP said both wounds were stage 4. Registered nurse (RN) #1 was interviewed on 11/29/23 at 2:20 p.m. RN #1 said the resident's left hip trauma wound developed because the resident would propel herself in her wheelchair and would lean to the left side. RN #1 said the pressure ulcer on the right side developed because the resident was in pain and preferred to only lay on her right side. RN #1 said the resident should be positioned on her back to relieve pressure on both hips. RN #1 said the resident had wedge cushions on her bed to help the resident stay positioned on her back. Certified nursing aide (CNA) #1 was interviewed on 11/30/23 at 8:59 a.m. CNA #1 said if there was a change in skin condition the CNAs would report to the nurse and the nurses would report it to the resident's physician. CNA #1 said residents should be repositioned every two hours. CNA #1 said the residents in the facility should not have pressure ulcers if they were repositioned. CNA #1 said Resident #50 acquired pressure ulcers because she was not repositioned properly. CNA #1 said the resident initially had skin issues due to poor positioning in the wheelchair and because the resident was consistently laying on her left side due to not wanting to face the wall while in bed it made her wounds worse. CNA #1 said the resident's bed was facing the other way so now the resident was willing to lay on her right side. CNA #1 said the resident had bed wedges to keep her laying on her back and off her hips. CNA #1 said the other staff did not reposition the resident correctly; she knew this because she observed the other CNAs position the resident consistently on to her rightside because the resident moved around when she was on her back. The director of nursing (DON) was interviewed on 11/30/23 at 12:06 p.m. The DON said if a change in the resident's skin was found the CNAs were to notify a nurse and the nurse would notify DON and start the risk management assessment documentation. The DON said residents who could not reposition themselves should be repositioned every two hours. The DON said Resident #50 had first developed a skin tear because she was not seated properly in her wheelchair and was leaning to the left causing friction. The DON said therapy staff put a wedge positioning cushion in place to prevent further skin issues but the resident did not tolerate laying on her back to offload pressure on her hips. The DON said the resident was not eating enough so she was at high risk of pressure ulcers. V. Facility follow-up On 12/1/23, the nursing home administrator (NHA) provided an addendum to the physician's 11/17/23. The addendum note dated 12/1/23 (after exit), documented the wound progress note demonstrates that the wound was unavoidable. The resident was combative during care and repositioning. -The note provided no other rationale about why the wound development was now determined to be unavoidable. Additionally, the WCP said during the interview that the resident's right hip wound was avoidable and would not be there if not for the left wound causing the resident pain and making her reluctant to off load pressure from the right hip and lay on her back.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in one of two medication storage rooms. Specifically, the facility failed to ensure vaccines and insulins (medications used to regulate blood glucose levels) were not stored in a dormitory style fridge. Findings include:I. Professional referenceAccording to the Vaccine storage and Handling Toolkit retrieved on 11/30/23 from: https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf it revealed in pertinent part "Do not store any vaccines in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units pose a significant risk of freezing vaccines, even when used for temporary storage."II. Facility policy and procedureThe Storage and Expiration Dating of Medication, Biologicals policy, revised 7/21/22, was received from the nursing home administrator (NHA) on 11/30/23 at 12:50 p.m. It revealed in pertinent part, "facility should ensure that medications and biologicals were stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges."III. ObservationOn 11/30/23 at 9:19 a.m. the first floor medication room was observed to have a dormitory style refrigerator used to store vaccines and insulins. -The following insulin medications were stored in the refrigerator: three Trulicity pens, five Lantus pens, one Novolog pen, one insulin emergency kit containing one vial of each Lispro, Humalog, Humulin R and Lantus. -The following vaccines were stored in the refrigerator: eight Influenza quadrivalent 2023-2024 formula vials and 18 Prevnar 20 (vaccine for pneumonia) vials. -The freezer was observed with ice built up in and around the freezer compartment affecting the first shelf of the refrigerator. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 11/29/23 at 9:19 a.m. She said the freezer had a lot of ice built up around it and needed to be cleaned out. RN #1 said she did not believe the medications or vaccines in the refrigerator were compromised by the freezer or the ice build up. RN #1 said it was the responsibility of the night shift nurse to log temperatures and clean the medication refrigerators. The director of nursing (DON) was interviewed on 11/30/23 at 12:27 p.m. She said medication refrigerators were to be cleaned by nursing staff. The DON said medications and vaccines were not to be stored in a dormitory style refrigerator as they could freeze medication. The DON was not aware the first floor medication refrigerator was a dormitory style refrigerator and that it had a large amount of ice built up around the freezer. The infection preventionist (IP) was interviewed on 11/30/23 at 2:03 p.m. He said medications and vaccines should be stored at the manufacturer's recommendations. The IP was unaware there was a dormitory style refrigerator in use for medication/vaccine storage and said it should not be used as it was not good at regulating temperature within the compartment.

Based on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation. Specifically, the facility failed to ensure the soiled linen laundry room exhaust fan was functional. Findings include: I. Observations An observation of the soiled linen laundry room was completed on 11/30/23 at 10:45 a.m. An exhaust fan was installed in the ceiling of the soiled linen laundry room. The fan was not audible and did not create air movement with the switch turned on. The fan was covered with thick gray and black debris. As a measure of checking the function of the fan, a small square of single ply toilet paper was placed against the vent. The exhaust fan was unable to hold the toilet tissue in place which indicated the fan did not function properly. -Soiled linen odors such as urine were observed during multiple observations in the soiled linen laundry room. The soiled linen laundry room exhaust fan was not functional. II. Staff Interview The environmental tour was conducted with the director of maintenance (DM) and the housekeeping director (HKD) on 11/30/23 at 10:46 a.m. The HKD said the exhaust fan had not worked in the soiled linen laundry room for the past 10 years. The DM confirmed the exhaust fan was not functional because he had shut it off from the main breaker three months prior to the survey because it was too loud and therefore he had to turn it back on to demonstrate it was functional during the survey. He said the fan had been serviced recently to ensure it was functional. -The DM attempted to turn on the fan from the main breaker, however, the fan did not turn on. -The DM was unable to provide documentation that the exhaust fan had been previously serviced. The DM said the ventilation fan should be in good working condition to protect staff from foul odors and ensure there was adequate airflow within the room.

A licensure survey was completed on 11/27/23 to 11/30/23. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure compliance with the Colorado Adult Protective Services Data System (CAPS) check requirement for four of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to provide documents that a CAPS background check was completed for four of five CNAs reviewed. I. Professional referenceThe Colorado Adult Protective Services Caps Check Unit, Statute and Rule Requirements 1/21/22, retrieved from https://ccu.colorado.gov/statute-and-rule-requirements on 12/1/23 revealed in pertinent part: "Employers who are required to request a CAPS Check prior to hiring an employee, including a contractor, who will be providing direct care to at-risk adults include the following agency types. "Agencies licensed by the Colorado Department of Public Health and Environment under Title 25 and listed below are required to request CAPS Checks: "Any licensed health facility (Section 25-1.5-103, C.R.S.), including those wholly owned and operated by any governmental unit. "More specifically, these agencies include...nursing homes."II. Record reviewThe nursing home administrator (NHA) provided requested employee records on 11/29/23 at 10:05 a.m. Review of the employee files revealed CNA #1, CNA #2, CNA #3 and CNA #4 did not have CAPS background checks. III. Staff interviewsThe human resource director (HRD) was interviewed on 11/30/23 at 2:44 p.m. She said she started the HRD position in 2022. She said she was not aware that she needed to get CAPs checks on the new employees. She said going forward she would print the results of the CAPS checks and place them in the employee files. The NHA was interviewed on 11/30/23 at 2:50 p.m. He said all employees must have a CAPS check prior to working. He said he would immediately conduct an audit to ensure all staff had a CAPS check in place.

Based on observation, interviews, and record review, the facility failed to assess and monitor an existing pressure injury for one (#50) of seven residents reviewed for wounds out of 32 sampled residents and failed to take steps to prevent the resident's development of pressure injuries. Resident #50 who required hands on assisance from staff to complete activities of daily living such as toileting, bed mobility, dressing and personal hygiene and who was at high risk for developing pressure injuries developed facility acquired pressure injury. The resident's pressure injury was first discovered on 4/27/23 and started as a redness spread over the bony part of the resident's left hip. The wound care physician classified the wound as a "trauma wound." There was no documentation in the resident's chart to identify what type of trauma caused the wound to develop other than the resident lying on the hip creating skin damage for pressure to the wound site. A note written by the facility's occupational therapist (OT) documented that the pressure injury was discovered on 4/27/23 after the resident had been sitting up in her wheelchair for an extended period. The injury was linked to the resident seating system and position in the wheelchair from the wheelchair components and the cushion putting pressure on the resident's left hip. Following the observation, the OT adjusted the resident's wheelchair seating system and the wound improved by 5/24/23 but emerged again a month later. On 6/28/23 the resident medical record revealed the wound to the resident left hip emerged again as an open wound measuring 1.3 centimeters (cm) in length by 2 cm in width by 2 cm in depth. The wound bed was covered with 100% slough (stringy yellowish dead skin). The facility physical therapist (PT) assessed the resident and recommended the resident lay off of her left side to facilitate wound healing to the left hip. Following this recommendation, the resident developed a pressure injury to the right hip (on 9/4/23). The wound was assessed as an unstageable pressure injury on the resident's right posterior (back) hip with full-thickness of the skin (extending beyond two layers of skin tissue) and tissue loss. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The PT reassessed the resident's seating system following the progression of the facility acquired pressure injuries and documented that the resident had had an inappropriate wheelchair and positioning program causing poor posture and skin related issues. The assessment documented that the resident required more frequent repositioning assistance to offload pressure from the left him with added side and back laying positions. The assessment documented that the resident had been tolerating the recommended repositioning; however, observations revealed the resident was not being respositioned as recommended (see observations below). The wound care physician (WCP) assessment of the pressure injuries reviewed the WCP believed the wounds were avoidable (see the WCP interview below). Interventions were not implemented consistently and observation of the resident's care revealed a lack of timely repositioning and staff not following the PT's recommendations to assist resident to offload pressure alternating from side to side and back lying on a frequent basis in order to promote healing the left hip wound and improved skin integrity. The facility failed to promote full healing of the wound and failed to prevent the formation of a second wound from worsening. The facility's failure to develop and implement timely and effective interventions led to the development of two unhealed pressure injury wounds one of which caused the resident severe pain. On 11/22/23, the pressure injury to the resident's left hip while healing persisted and measured 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. However, the pressure injury wound to the right rear hip, first observed 9/4/23, worsened from intact skin to an unstageable pressure injury measuring 1.2 cm in length by 1.2 cm in width by 0.1cm depth with a build-up of dead tissue and severe pain at the wound site. The wound required surgical debridement to remove dead tissue and progressed to a stage 4 pressure ulcer measured 1.2 cm in length by 1.2 cm that began to spread under the surface of the skin at the wound edges. Findings include: I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 12/7/23, "Pressure ulcer classification is as follows: "Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). "Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. "Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dark dead skin) may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable "Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. "Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment." II. Facility policyThe Skin Integrity and Pressure Ulcer/Injury Prevention and Skin Management policy, reviewed 3/31/23, was provided by the nursing home administrator (NHA) on 11/30/23 at 1:26 p.m. It revealed in pertinent part, "Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure, ulcer injury, complete, wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury, Advisory Panel) and WOCN (Wound, Ostomy, Continent, Nurse Society)."A comprehensive skin inspection/assessment on admission and readmission to the center may identify pre-existing signs of possible deep tissue damage already present. These signs include purple or very dark areas, surrounded by edema; profound, redness, or induration; bogginess; and or discoloration. These signs possibly indicate an unavoidable stage three or four with slough, drainage, or even eschar within a few days."A risk assessment to Braden Scale, or Norton scale determines the resident's. Risk of pressure injury development. The score is documented on the tool and placed in the resident's medical record using the appropriate form."Certain risk factors have been identified that increase a resident's susceptibility to develop or impair healing of pressure injuries. Examples include, but are not limited to; impaired/decreased mobility and decreased functional ability. Morbid conditions, such as end-stage, renal disease, thyroid disease, diabetes mellitus, or other end-of-life concerns. Drugs such as steroids that may affect wound healing. Impaired diffuse, or localized blood flow. A patient's refusal of some aspects of care treatment especially in multi-system organ failure, or end-of-life conditions. Exposure of skin to urinary and fecal incontinence. Under nutrition, malnutrition, and hydration deficit, edema and history of a healed injury. "Measures to maintain and improve resident's tissue tolerance to pressure and implemented in the plan of care. All residents upon admission are considered to be at risk of pressure injury development due to medical issues requiring nursing care and related disease processes and illness or need for rehabilitation services. Upon admission and throughout stay at minimum distribution surface is in use with her and repositioning as needed with ADL care/assistance in care, if needed to include skin barriers, application as needed, preventative, wheelchair cushions, if indicated, etc. Skin inspections with particular attention to bony prominences. Skin cleansing with appropriate cleanser at the time of swelling and at routine intervals. Minimize skin exposure to incontinence using devices and skin barriers. Minimize injury due to shear friction through proper positioning, transfers, and turning schedules. Encourage PO food and fluid intake and improve residence, mobility and activity when potential exists."Measures to protect the resident against the adverse effect of external mechanical forces, such as pressure friction, and are implemented in the plan of care; reposition, at least every 2 to 4 hours, as consistent with overall patient goal and medical condition. Utilize positioning devices to keep prominences from direct contact and ensure proper body alignment protection/suspension if indicated. A distribution mattress surface is placed under the resident. When positioned in the wheelchair, the resident is to be placed on a pressure reduction device and repositioned. When positioned in a wheelchair consideration is given to postural alignment, distribution, weight, balance, and stability. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident."III. Resident #50A. Resident status Resident #50, age 75, was admitted on 8/10/2020. According to the November 2023 computerized physician orders (CPO), the diagnoses included Parkinson's, dementia with behavioral disturbances and major depressive disorder. According to the 11/10/23 facility assessment, the resident was cognitively severely impaired and was unable to complete a brief interview for mental status (BIMS). She was dependent on one person with transferring and dressing. She required substantial assistance from one person with toileting, bed mobility, dressing, personal hygiene and eating. The resident was dependent on a wheelchair and needed moderate assistance with locomotion. The resident was at risk for developing pressure ulcers. The resident had unhealed pressure ulcers. The resident had one unstageable pressure ulcer. The pressure ulcers were not present at admission. B. ObservationsOn n 11/27/23 Resident #50 was observed and revealed: -At 9:00 a.m. the resident was in her bed lying on her right side.-At 10:00 a.m. the resident was in her bed lying on her right side.-At 11:58 a.m. the resident was in her bed lying on her right side. On 11/28/23 Resident #50 was observed and revealed:-At 10:26 a.m. the resident was in her bed lying on her right side.-At 10:40 a.m. an unknown CNA went into the Resident #50's room but did not reposition her and the resident remained lying on her right side. -At 12:30 a.m. a unknown CNA went into Resident #50's room to help her roommate, but did not assist Resident #50 with any care. Resident #50 remained on her right side.-At 1:30 p.m. the Resident #50 remained on her right side. On 11/30/23 Resident #50 was observed and revealed:-At 9:00 a.m. the resident was in her wheelchair in the hallway.-At 12:00 p.m. an unknown staff member transported the resident, who was still up in her wheelchair to the dining room for lunch. -At 12:45 p.m. after the resident finished lunch, an unknown staff member transported the resident to her room and transferred her to bed using a hoyer (mechanical) lift. The staff laid her down on her right side. C. Record review According to the Braden scale (a scale to measure risk of developing pressure ulcers) dated 5/11/23 Resident #50 was at mild risk of developing pressure ulcers. According to the health status note dated 5/1/23 at 11 a.m., the resident had a new skin issue discovered on 4/27/23. The resident had redness spread over her left hip. The registered nurse (RN) on duty cleansed the skin and placed prophylactic (preventative) foam dressing on the left hip. A seating cushion that was previously placed for positioning the resident in the wheelchair was removed and OT had been working with the resident on positioning. OT removed a rigid lateral support (lateral trunk support) and adjusted lateral support so it would not rest on the bony prominence of her hip. According to a care management note dated 5/4/23 OT was discontinued due to the resident meeting all her wheelchair goals. According to the OT discharge summary dated 5/6/23 the resident received therapy between 3/15/23 and 5/6/23. The resident had been assessed by OT due to the resident being at risk for falling out of her wheelchair due to inability to sit up in the chair without leading to the left. The initial intervention for positioning was causing additional rubbing and pressure on the residents left hip. As a part of the assessment and treatment the OT made adjustments to preventing the support from rubbing against the resident's hip. According to an event note dated 6/28/23 the resident had an open area to her left hip on the bony prominence. The affected area had been padded with mepilex dressing for the past four weeks due to non blanchable redness (when the skin is unable to return to a normal pigment when pressed) that developed from using equipment to help her sit upright in her wheelchair. The resident was evaluated by the wound team. According to the wound observation tool dated 6/28/23 the resident acquired a new skin impairment on 6/28/23, on her left hip. The first observation revealed the resident's skin had epithelial tissue (normal healthy skin) present and granulation tissue (beefy red tissue an indicator that skin was healing) the wound had a small amount of serous drainage (normal clear yellow fluid an indicator of a healing wound). The wound measured 1.3 cm in length, 2.2 cm in width and 0.2 cm in depth. According to the wound note dated 7/5/23 the resident's left hip was identified as a trauma wound with a status of not healed. The wound measurements were 1.3 cm in length by 1.9 cm in width with no measurable depth with 100% slough. There was a small amount of serous drainage noted. The physician performed surgical debridement (procedure to remove dead tissue). Post debridement measurements were 1.3 cm in length by 1.9 cm in width by 0.1 cm in depth. According to the wound note dated 7/12/23 the resident had an unhealed left hip trauma wound. The wound measurements were 1.3 cm in length by 2.2 cm in width with no measurable depth. There was a small amount of sero-sanguineous (watery bloody) drainage noted. The wound bed had 95% eschar and 5% slough. There was no change noted in the wound progression. The left hip wound was still developing but not enough to allow for debridement. According to wound notes dated 7/19/23 the resident's left hip trauma wound and had received a status of not healed. The wound measured 1.5 cm length by 2.5 cm in width with no measurable depth. There was a small amount of serous drainage noted. Wound bed had 100% slough. There was no change noted in the wound progression. The wound was surgically debridement; post debridement measurements were 1.5 cm in length by 2.5 cm in width by 0.3 cm in depth. According to the PT evaluation and treatment plan dated 7/19/23 the resident had a pressure wound. The resident had poor posture, adverse effects to skin integrity and there was inconsistent use of hoyer lift. The resident's goal was to be able to sit in an upright position and transfer safely in the hoyer lift to decrease further risk of skin trauma. The PT assessment recommended making changes to the resident's wheelchair cushion. According to the wound note dated 8/2/23 the resident's left hip wound measured 1.7 cm in length by 2.4 cm in width with no measurable depth, muscle was exposed. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided with post debridement measurements of 1.7 cm length by 2.4 cm width by 0.3 cm. According to the August 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition resident every two hours and ensure offload of the left hip at all times every shift for wound on left hip, ensuring the resident was not laying on left hip until wound was resolved. Order dated 8/2/23 and discontinued 9/24/23. According to the wound note dated 8/9/23 the resident's left hip wound measurements were 2.5 cm in length by 1.3 cm in width with no measurable depth. Muscle was exposed and tunneling (occurs when a chronic wound has progressed to form an opening underneath the surface of the wound's edge) was present at a distance of 1.4 cm. There was a moderate amount of serous drainage noted. Wound bed had 100% slough. The wound was surgically debrided. The post debridement measurements were 2.5 cm in length by 1.3 in cm width by 0.1 cm in depth. According to the PT evaluation and treatment plan dated 8/30/23 the resident's wheelchair was modified but continued to require monitoring for adverse effects. The assessment recommended that the resident be encouraged to lay on her side while in bed to alleviate pressure to aid with left wound healing but this resulted in a non-blanchable redness on the resident's right hip. The resident continued to require education on participants in a rotating program reposition and promote overall skin integrity. According to the comprehensive care plan focus for impaired skin integrity dated 8/24/23 the resident had a trauma injury wound. Interventions included providing treatment as ordered. Weekly skin checks in wound rounds. Air pressure mattress. Clean and dry skin after each incontinent episode. Encourage the residents to wear geri-gloves (non-compression, seamless knit material that contours to the body to protect thin, sensitive skin from tears, abrasions, and light bruising) as tolerated, to avoid skin tears on hands. Staff should make certain nails are trimmed. Added padding to the resident's wheelchair arms. Ensure the resident's hands on her lap when assisting her with ambulation. According to the altered skin integrity care focus dated 9/11/23 interventions included assisting the resident to reposition when in bed off of her back with the use of wedges, as tolerated, to prevent skin breakdown. According to an event note dated 9/4/23, the resident had a non-blanchable wound to the right hip bony prominence. The affected area was maroon in color. The resident had been laying mostly on her right side due to the wound on her left hip. The resident did not like to lay on her back to relieve pressure from both bony prominences. Affected area was cleansed with normal saline, skin prep and covered with mepilex dressing. According to wound notes dated 9/6/23, the resident developed an unstageable pressure injury on her right posterior hip with full-thickness skin and tissue loss. The pressure ulcer had received a status of not healed. The wound measured 0.5 cm in length by 0.7 cm in width with no measurable depth. The wound bed had 100% epithelialization with obscured full-thickness skin and tissue loss. According to wound note dated 9/6/23 the resident's left hip wound measured 1.2 cm in length by1.5 in cm width by 1 cm in depth with undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) with a maximum distance of 2.3 cm. According to event note dated on 9/11/23,the resident had a non blanchable wound. The resident was sleeping and resting on an air mattress with order for staff to provide repositioning assistance and wound care treatment and dressing changes. According to the wound observation tool dated 9/13/23 the resident had an unstageable pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had slough tissue. The wound measurements were 3.0 cm in length and 5.0 cm in width According to the PT evaluation and treatment plan dated 9/20/23 the resident tolerated the position throughout the day with no adverse effects to the left hip wound. The resident tolerated a rotating positioning program in supine (on back) to promote overall skin integrity. The resident currently had an inappropriate wheelchair and positioning program. The resident needed a smaller wheelchair and to be repositioned more frequently. According to the September 2023 treatment administration record (TAR) treatment orders included instructions for staff to reposition the resident and offload bilateral hip as allowed every shift for skin management order dated 9/24/23 and discontinued 10/19/23. According to the PT discharge summary dated 10/2/23 the resident was discharged with a good seated and supine positioning with no worsening wounds. According to the pressure ulcer care focus dated 11/13/23 the resident had an unstageable pressure ulcer on her right hip. Interventions included administer medications and treatments, as ordered. Provide enhanced barrier precautions. Inform the resident and family of any new skin breakdown. Perform lab and other diagnostic work as ordered, report the results to the medical doctor and follow up as indicated. Observe and report changes in skin status; appearance, color, wound healing, sign of infection, wound size and stage of wound. Serve diet as ordered and monitor intake and record. According to the wound note dated 11/15/23 The resident had an unstageable pressure injury on her right, posterior hip with obscured full-thickness skin and tissue loss and had received a status of not healed. The wound measured 1.2 cm in length by 1.2 cm in width with no measurable depth, with undermining at a distance of 2.6 cm. There was a large amount of serous drainage noted. The patient reports a wound pain of level 0/10. The wound bed had 80%, granulation, 20% slough. The wound was surgically debrided, post debridement measurements were 1.2 cm in length by 1.2 cm in width by 0.1cm depth. According to the wound observation tool dated 11/22/23 the resident acquired a skin impairment on her left hip, due to trauma of equipment use on 6/28/23 (seating and transferring devices, see above). The left pressure wound was assessed to have been healing with granulation tissue (beefy red) the wound had serous and scan drainage. measurements were 0.7 cm, in length by 0.7 cm in width by 0.1 cm in depth. According to the wound observation tool dated 11/22/23 the resident had a stage 4 pressure ulcer facility acquired on 9/4/23, on her right hip. The wound was worsening and had granulation and slough tissue . The wound measurements were, 1.2 cm in length and 1.2 cm in width with tunneling. IV. Staff interviewsThe wound care physician (WCP) was interviewed and observed on 11/29/23 at 1:20 p.m. while performing wound care on Resident #50's left hip. The WCP said the resident was admitted to the facility on 6/26/23, with a left hip trauma injury. The wound had been unstable. The wound had worsened and was now classified as a stage 4 pressure injury with tunneling and had a large amount of drainage. The WCP said the wound likely had severe colonization and was possibly an infection but he was unable to determine the severity of the infection because he was unable to see the bottom of the wound. The WCP said if the resident acquired the left hip wound at the facility then the wound on her right hip was avoidable. The wound doctor said the resident would not have acquired the right hip wound if she did not have the left wound. The WCP said the resident was positioned on the right hip because it was painful to lay on her left hip. The WCP said the resident should be repositioned supine (on her back) to avoid the wound's progression. The WCP said both wounds were stage 4. Registered nurse (RN) #1 was interviewed on 11/29/23 at 2:20 p.m. RN #1 said the resident's left hip trauma wound developed because the resident would propel herself in her wheelchair and would lean to the left side. RN #1 said the pressure ulcer on the right side developed because the resident was in pain and preferred to only lay on her right side. RN #1 said the resident should be positioned on her back to relieve pressure on both hips. RN #1 said the resident had wedge cushions on her bed to help the resident stay positioned on her back. Certified nursing aide (CNA) #1 was interviewed on 11/30/23 at 8:59 a.m. CNA #1 said if there was a change in skin condition the CNAs would report to the nurse and the nurses would report it to the resident's physician. CNA #1 said residents should be repositioned every two hours. CNA #1 said the residents in the facility should not have pressure ulcers if they were repositioned. CNA #1 said Resident #50 acquired pressure ulcers because she was not repositioned properly. CNA #1 said the resident initially had skin issues due to poor positioning in the wheelchair and because the resident was consistently laying on her left side due to not wanting to face the wall while in bed it made her wounds worse. CNA #1 said the resident's bed was facing the other way so now the resident was willing to lay on her right side. CNA #1 said the resident had bed wedges to keep her laying on her back and off her hips. CNA #1 said the other staff did not reposition the resident correctly; she knew this because she observed the other CNAs position the resident consistently on to her right side becausethe resident moved around when she was on her back. The director of nursing (DON) was interviewed on 11/30/23 at 12:06 p.m. The DON said if a change in the resident's skin was found the CNAs were to notify a nurse and the nurse would notify DON and start the risk management assessment documentation. The DON said residents who could not reposition themselves should be repositioned every two hours. The DON said Resident #50 had first developed a skin tear because she was not seated properly in her wheelchair and was leaning to the left causing friction. The DON said therapy staff put a wedge positioning cushion in place to prevent further skin issues but the resident did not tolerate laying on her back to offload pressure on her hips. The DON said the resident was not eating enough so she was at high risk of pressure ulcers. V. Facility follow-up On 12/1/23, the nursing home administrator (NHA) provided an addendum to the physician's 11/17/23. The addendum note dated 12/1/23 (after exit), documented the wound progress note demonstrates that the wound was unavoidable. The resident was combative during care and repositioning. -The note provided no other rationale about why the wound development was now determined to be unavoidable. Additionally, the WCP said during the interview that the resident's right hip wound was avoidable and would not be there if not for the left wound causing the resident pain and making her reluctant to off load pressure from the right hip and lay on her back.