WESTLAKE CARE COMMUNITY

INITIAL COMMENTS (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). The facility is one story, Type V(111), wood framed structure with a partial lower level used for support services. The residents have routine access to the lower level; however, resident rooms are not located in the lower level. The lower level has two exits at grade to the exterior. The facility is protected throughout by an automatic fire sprinkler system and is classified as Fully Sprinklered. The facility was constructed in 1972. The 70 bed facility was surveyed on Sep 24, 2025 using the National Fire Protection Association, (NFPA)101 Life Safety Code (2012) chapter 19, Existing Health Care Occupancies. The deficiencies cited were discussed with the Administrator and Regional Director of Facility Maintenance during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 62 residents. The facility is licensed for 69 residents.

Exit sign directional arrow is pointing towards the wall. It needs to be pointing the opposite direction (To the left). By the double doors in the main corridor. Based on observation, record review and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Section 101, Ch 7Exit sign directional arrow is pointing towards the wall. It needs to be pointing the opposite direction (To the left). By the double doors in the main corridor. 7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2.7.10.1.2.2 * Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious. This deficiency has the potential to affect occupants, including residents, staff, and visitors throughout the smoke compartment The deficiencies were addressed with the administrator and maintenance director during the exit conference.

Decommission residential stove in dining area. Based on observation, record review and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Section 101, CH 19.3. Decommission residential stove in dining area. 19.3.2.5.3* Within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that all of the following conditions are met:(1)The portion of the health care facility served by the cooking facility is limited to 30 beds and is separated from other portions of the health care facility by a smoke barrier constructed in accordance with 19.3.7.3, 19.3.7.6, and 19.3.7.8. This deficiency has the potential to affect occupants, including residents, staff, and visitors throughout the smoke compartment The deficiencies were addressed with the administrator and maintenance director during the exit conference.

Based on observation, record review and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Section NFPA 72, Annex A, 17.7.4.1Vents/Diffusers are within 3 feet of the smoke detector in Peaceful Hall. Smoke detector is within 3 feet the of vent/diffuser in the kitchen. (X2)A.17.7.4.1 Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies. This deficiency has the potential to affect occupants, including residents, staff, and visitors throughout the smoke compartment The deficiencies were addressed with the administrator and maintenance director during the exit conference. Based on observation, record review and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Section NFPA 72, Annex A, 17.7.4.1Vents/Diffusers are within 3 feet of the smoke detector in Peaceful Hall. Smoke detector is within 3 feet the of vent/diffuser in the kitchen. (X2)A.17.7.4.1 Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies. This deficiency has the potential to affect occupants, including residents, staff, and visitors throughout the smoke compartment The deficiencies were addressed with the administrator and maintenance director during the exit conference.

Based on observation, it was determined the facility failed to maintain corridor doors in accordance with NFPA 101. Peaceful neighborhood, soiled utility door not latching properly. 19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. This deficiency has the potential to affect occupants, including residents, staff, and visitors throughout the smoke compartment The deficiencies were addressed with the administrator and maintenance director during the exit conference. Based on observation, record review and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Section 19.2 Peaceful neighborhood, soiled utility door not latching properly. 19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. This deficiency has the potential to affect occupants, including residents, staff, and visitors throughout the smoke compartment The deficiencies were addressed with the administrator and maintenance director during the exit conference.

Remove door stops 2. Remove STOP signs on exit doors CDS3. A clear hallway width of 44 inches needs to be maintained at all times.

A recertification survey with complaint #CO2594458 and #CO2594843 was completed on 8/24/25 to 8/27/25. Six deficiencies were cited.

An Emergency preparedness survey was conducted from 8/24/25 to 8/27/25. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for one (#13) of five residents reviewed for personal funds accounts out of 34 sample residents. Specifically, the facility failed to notify Resident #13, who was Medicaid funded, or her legal representative, when the resident’s personal funds account reached $200.00 less than the eligibility resource limit. Findings include:I. Record reviewA review of Resident #13’s current trust account balance revealed the resident had $2,631.92 in her account, which was $631.92 over the allotted limit of $2,000.00 for Medicaid-funded residents. II. Staff interviewsThe financial coordinator and the nursing home administrator (NHA) were interviewed together on 8/27/25 at 9:30 a.m. The financial coordinator said she notified residents or residents’ representatives when the residents’ personal funds accounts reached $2,000. The financial coordinator said she was unaware that the residents or their representatives needed to be notified when their personal funds account reached $200.00 less than the eligibility resource limit. The financial coordinator said residents were at risk of losing their Medicaid-funded benefits when their personal funds account reached $2,000. The NHA said the facility had been in contact with Resident #13’s representative to spend down the resident’s personal funds account once the account reached the allotted limit. -However, the facility was unable to provide documentation to indicate communication with Resident #13’s representative had taken place in regards to the account balance of the resident’s personal funds account.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#10) of one resident out of 34 sample residents. Specifically, the facility failed to:-Obtain a physician's order that addressed Resident #10’s medical symptoms; -Ensure ongoing safety risk assessments were completed for the use of restraints for Resident #10; and,-Ensure that the least restrictive measures attempted and proven unsuccessful for Resident #10 were documented. Findings include:I. Facility policy and procedureThe Restraint Assessment and Consent policy and procedure, revised October 2024, was provided by the director of nursing (DON) on 8/27/25 at 9:55 a.m. It read in pertinent part, “A physical restraint free or least restrictive environment will be the standard for resident care. If restraints are present, the interdisciplinary team will make every effort to reduce and then eliminate restraints. Purposes for restraint use include resident safety, injury prevention and protection of a medical device. When evaluating restraints, a risk benefit of device use will be completed.“The following will be documented on the evaluation/consent form:-Alternative measures tried prior to device use, with trial results;-Evaluation of self-release ability and potential movement or access to body restriction;-Observations of device effect on resident;-Identification of potential risks and benefits of device; and,-Medical symptoms. “A physician’s order will be obtained for restraints. This order will include the type and purpose of the restraint and duration of application, as well as a diagnosis for the restraint.“If the restraint is determined to be appropriate, a long term care plan will be implemented, including a plan for interdisciplinary team restraint reduction.“Restraints will be evaluated and reported on a monthly basis as part of the quality assurance process and with any potential change of condition. This evaluation is located on the back of the consent form. If a significant change of condition is identified, the restraint evaluation will be re-done.”II. Resident #10A. Resident statusResident #10, age less than 65, was admitted on 8/1/24. According to the August 2025 computerized physician orders (CPO), diagnoses included cerebral palsy (a congenital disorder of movement and muscle mass) and depression. The 7/31/25 minimum data set (MDS) assessment revealed Resident #10 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated a trunk restraint and limb restraints were used daily. B. ObservationsOn 8/24/25 at 9:00 a.m. Resident #10 was observed wearing a seatbelt and foot straps while seated in her wheelchair. On 8/25/25 at 10:30 a.m. Resident #10 was observed wearing a seatbelt and foot straps while seated in her wheelchair. On 8/26/25 at 1:18 p.m. Resident #10 was observed wearing a seatbelt and foot straps while seated in her wheelchair. C. Record reviewOn 10/14/24, a physical restraint evaluation and consent were completed. The evaluation documented Resident #10 was trialed without the use of foot straps, however both feet were not able to be positioned independently and the resident needed the staff to place both feet back on the foot pedals. It documented Resident #10 had an increased risk for injury without the foot straps. On 11/19/24, a physical restraint evaluation and consent were completed. The evaluation documented Resident #10 was trialed without the use of the wheelchair seatbelt however it was not successful. The evaluation documented the resident benefited and required a seatbelt for midline, upright positioning in her custom power wheelchair.-Review of Resident #10’s electronic medical record (EMR) did not reveal the facility completed ongoing evaluations (after 11/19/24) to ensure the resident’s use of the seatbelt and foot straps were still appropriate for use, including a trial without the straps and the seatbelt. -Review of Resident #10’s EMR did not reveal documentation indicating less restrictive interventions were attempted prior to the use of the seatbelt and foot straps. Review of Resident #10’s August 2025 CPO revealed the following physician’s order:Apply a wheelchair seatbelt and foot straps when the resident is seated in her wheelchair. Staff need to release the straps every shift, as needed and at the request of the resident, ordered 11/20/24.-However, the physician’s order failed to identify the medical symptom the seatbelt and foot straps were used for. Resident #10’s activities of daily living (ADL) care plan, revised 8/7/25, revealed the resident had impaired ADL function due to cerebral palsy. The care plan documented the resident used a motorized wheelchair with a seatbelt and foot straps, which she was unable to release. The seatbelt and foot straps were being used for positioning due to a diagnosis of cerebral palsy. Interventions included applying the seatbelt and foot straps when she was seated in her wheelchair and releasing the seatbelt and foot straps every shift, as needed and at the resident’s request. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/26/25 at 1:15 p.m. LPN #1 said Resident #10 liked to stretch backwards and the seatbelt helped with positioning Resident #10 in her wheelchair correctly. LPN #1 said Resident #10 was unable to undo the straps herself. He said the staff only released the straps when she was getting out of her chair. The DON was interviewed on 8/27/25 at 9:32 a.m. The DON said per policy, the staff were supposed to release Resident #10 from her seatbelt and foot straps every two hours. She said Resident #10 requested the seatbelt and foot straps and the resident knew it was a restraint because Resident #10 was unable to release them herself. She said assessments needed to be completed every quarter for the restraints and that therapy usually completed the assessments. The DON said the restraints and the resident not being able to release the restraints had been documented in Resident #10’s care plan.

Based on observations, record review, and interviews, the facility failed to ensure one (#69) of four residents reviewed for activities of daily living (ADLs) out of 34 sample residents received the necessary services to maintain good nutrition and personal care. Specifically, the facility failed to provide meal assistance for Resident #69. Findings include:I. Resident #69A. Resident statusResident #69, age 77, was admitted on 6/27/25. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer’s disease, type 2 diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD) , essential hypertension (high blood pressure), and hypothyroidism (low thyroid function). The 8/13/25 minimum data set (MDS) assessment revealed Resident #69 had a memory problem and and was moderately impaired cognitive skills for daily decision making per staff assessment. She required maximum assistance of one staff member with meals and one-person assistance with transfers and personal hygiene. B. ObservationsDuring a continuous observation on 8/24/25, beginning at 11:30 a.m. and ending at 12:25 p.m., the following was observed: At 11:30 a.m. Resident #69 received her meal, which consisted of a pureed diet. The food was placed on the table, within her reach. Two unidentified certified nurse aides (CNA) were next to the resident and the other two residents who were at the same table. The unidentified CNAs assisted the other residents, but Resident #69 was not assisted. The staff encouraged the resident to eat, but they did not provide any physical assistance. Resident #69 had a third of a glass of milk and her plate remained full when she left the dining room at 12:25 p.m. During a continuous observation on 8/25/25, beginning at 11:25 a.m. and ending at 12:00 p.m., the following was observed: At 11:30 a.m. Resident #69 received her meal, which consisted of a pureed diet. The food was placed on the table, within her reach. An unidentified CNA was next to the resident and fed another resident who was at the table, but Resident #69 was not assisted. Resident #69 had three-quarters of a glass of milk and her plate remained full when she left. At 11:58 a.m. the unidentified CNA assisted Resident #69 out of the dining room and to a common area. C. Record reviewThe nutrition care plan, revised 7/4/25, revealed Resident #69 required a modified texture diet consisting of pureed foods with thin liquids, fortified foods, one-on-one assistance during meals and verbal cues to encourage swallowing after taking bites or sips to prevent pocketed food. The care plan indicated staff were to offer the resident one food item at a time. D. Staff interviewsCNA #4 was interviewed on 8/27/25 at 9:51 a.m. CNA #4 said Resident #69 was usually able to communicate with others during meals. CNA #4 said the staff set Resident #69 up at the table and prepared the resident’s food. CNA #4 said when the resident was unable to eat, the staff provided some cueing assistance with reminders and occasionally physically helped her with her food. CNA #4 said Resident #69 did not eat well and often had a snack between meals. CNA #4 said if the resident refused to eat her meals, the staff could not force her to eat. Registered nurse (RN) #3 was interviewed on 8/27/25 at 11:01 a.m. RN #3 said Resident #69 had cognitive impairments, but was able to communicate at times. RN #3 said Resident #69 lost some weight lately, so the staff continued to try to assist her, but she repeatedly refused help.-However, observations revealed staff did not attempt to physically assist the resident with eating (see observations above). The medical director (MD) was interviewed on 8/27/2025 at 12:21 p.m. The MD said Resident #69 had impaired cognition and needed one-on-one assistance during her meals.

Based on observations, record review and interviews, the facility failed to ensure one (#56) of two residents out of 34 sample residents received proper respiratory care and services in accordance with professional standards of practice, the resident's care plan and the resident’s choice. Specifically, the facility failed to:-Ensure Resident #56’s continuous oxygen setting was set at the prescribed flow rate; and,-Ensure Resident #56 was provided with continuous oxygen supplementation per physician’s orders. Findings include:I. Facility policy and procedureThe Oxygen Titration policy and procedure, reviewed 1/14/25, was provided by the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. via email. It read in pertinent part, “Oxygen will be administered per physician orders and nursing evaluation. Evaluation of thecontinued need for oxygen will be based on diagnoses, history and clinical presentation,including titration results. Continuous oxygen orders will include the liter flow, route andfrequency for oxygen use, frequency of pulse oximetry, titration parameters and diagnosis. Oxygen titration orders will consist of the frequency of pulse oximetry and parameters for titration.”II. Resident #56A. Resident statusResident #56, age greater than 65, was admitted on 10/4/22. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbances, respiratory failure with hypoxia, chronic obstructive pulmonary disease and cognitive communication deficit. The 5/7/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The resident required maximum assistance with activities of daily living (ADL). The MDS assessment revealed that the resident required continuous oxygen at 2 liters per minute (LPM) with a nasal cannula. B. ObservationsOn 8/24/25 at 9:30 a.m. Resident #56 was observed sitting in her room. The resident’s oxygen concentrator was set to 4.5 LPM.-However, Resident #56 oxygen flow rate was supposed to be 2 LPM, per physician’s orders (see record review below). At 2:45 p.m. Resident #56 was observed sitting in her room. The resident’s oxygen concentrator remained set at 4.5 LPM.On 8/25/25 at 9:55 a.m. Resident #56 was observed sitting in her room with her oxygen concentrator set at 4.5 LPM.At 1:20 p.m. the Resident #56’s oxygen concentrator remained set at 4.5 liters LPM.At 3:01 p.m. Resident #36 was observed sitting in her wheelchair in the activity room. She was not wearing any supplemental oxygen. At 4:00 p.m. Resident #56 was taken to the dining room for dinner. She was not provided with any supplemental oxygen. On 8/26/25 at 9:00 a.m. Resident #56 was observed asleep in her room. The resident was not using any supplemental oxygen. At 11:24 am, the resident remained asleep in her room without supplemental oxygen. C. Record reviewThe respiratory care plan, dated 4/19/24, documented that the resident had a diagnosis of acute respiratory failure and was at risk for hypoxia. The interventions included the use of supplemental oxygen at 2 LPM continuously. Review of Resident #56’s August 2025 CPO revealed the following physician’s order:Oxygen at 2 LPM continuously via nasal cannula, ordered 4/19/24. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/26/25 at 11:25 a.m. LPN #1 said Resident #56 was prescribed 2 LPM of oxygen continuously via nasal cannula, per the physician's order. LPN #1 entered Resident #56’s room and confirmed the resident was not wearing her nasal cannula and therefore was not receiving oxygen. LPN #1 checked Resident #56’s oxygen saturation (level of oxygen in the blood), which read 91% (percent) on room air LPN #1 placed the oxygen on the resident via nasal cannula at 2 LPM.LPN #1 said it was the nurse's responsibility to ensure residents were on their appropriate oxygen liter flow rates. LPN #1 said he did not realizeResident #56 was not wearing the oxygen when he administered her morning medications. The director of nursing (DON) was interviewed on 8/26/25 at 12:50 p.m. The DON said each resident’s oxygen should be checked three times per day to ensure the resident was receiving the correct amount of oxygen. She said it should be documented in the treatment administration records (TAR), along with the resident’s oxygen saturation. The medical director (MD) was interviewed on 8/27/25 at 12:30 p.m. The MD said it was appropriate for Resident #56 to receive oxygen at 2 LPM via nasal cannula continuously. He said he would continue to monitor the resident to determine if her oxygen flow rate needed to be adjusted.

Based on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure kitchen staff appropriately cleaned thermometers before and after use. Findings include:I. Improper cleaning of food thermometerA. Professional referenceAccording to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved 9/2/25 from:, revealed in pertinent part, “Equipment food-contact surfaces and utensils shall be clean to sight and touch. Equipment, food-contact surfaces and utensils shall be cleaned before using or storing food temperature measuring devices.” (4-602.11)B. Facility policy and procedureThe Food Temperatures policy, undated, was provided by the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. It read in pertinent part,“To take temperatures, a clean, rinsed, sanitized and air-dried thermometer that is metal stem type.“To take hot food temperatures, insert the thermometer at a 45-degree angle to the middle of the food item, taking care not to touch the container or bone if it has one. Wait for the thermometer to rise to the maximum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clean and sanitize.”C. ObservationsDuring a continuous observation of the lunch meal on 8/26/25, beginning at 11:30 a.m. and ending at 12:10 p.m., the following was observed:At 11:30 a.m. the cook (CK) was cleaning a thermometer to take a temperature before serving. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe square and the packaging. He then ran the alcohol wipe and the packaging up and down the thermometer probe. He obtained the temperature of the beans and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe. At 11:32 a.m. the CK took the temperature of pureed quesadillas. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe square. He then ran the alcohol wipe and the packaging up and down the thermometer probe. He obtained the temperature of the quesadillas and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe. At 11:35 a.m. the CK took he temperature of pureed beans. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe square. He then ran the alcohol wipe and the packaging up and down the thermometer probe. He obtained the temperature of the beans and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe. At 11:37 a.m. the CK took the temperature of sour cream. He took an alcohol wipe out to clean the thermometer and he poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. He then ran the alcohol wipe and its packaging up and down the thermometer probe. He obtained the temperature of the sour cream and cleaned the thermometer probe by poking a hole through the middle of another alcohol wipe and moving it up and down the thermometer probe.-The CK failed to open the alcohol wipe diagonally, inserting the thermometer probe into the opening and cleaning the probe without the packaging touching the probe. D. Staff interviewsThe CK was interviewed on 8/26/25 at 11:40 a.m. The CK said he was taught to poke the thermometer through the alcohol wipe packaging to disinfect the thermometer. The dietary manager (DM) and the NHA were interviewed together on 8/27/25 at 9:30 a.m. The DM showed how she was taught to clean a thermometer. She took an alcohol wipe out to clean the thermometer and she poked the thermometer through the middle of the alcohol wipe square. She then ran the alcohol wipe and its packaging up and down the thermometer probe. -The DM failed to open the alcohol wipe diagonally, inserting the thermometer probe into the opening and cleaning the probe without the packaging touching the probe.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of two units. Specifically, the facility failed to:-Ensure housekeeping staff performed appropriate hand hygiene when cleaning residents’ rooms,-Ensure staff performed appropriate hand hygiene when performing incontinence care for Resident #23; and,-Ensure staff wore appropriate personal protective equipment (PPE) during high contact resident care for Resident #23 and Resident #4, who were on enhanced barrier precautions (EBP). Findings include: I. Failed to ensure housekeeping staff performed appropriate hand hygiene when cleaning residents’ roomsA. Professional reference According to The Centers for Disease Control And Prevention’s (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers (February 2024), retrieved on 9/2/25 from: https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html,“Recommendations to clean your hands include immediately before touching a patient, before performing an aseptic technique, before moving from work on a soiled body site to a clean body site, after touching a patient or patient’s surroundings, after contact with body fluids and immediately after glove removal.”B. ObservationsDuring a continuous observation on 8/26/25, beginning at 1:30 p.m. and ending at 1:50 p.m., the following was observed: Housekeeper (HK) #1 was cleaning resident room #34. HK #1 began by putting gloves on her hands. She retrieved bottles of chemicals out of a housekeeping cart and set them inside the room. She removed her gloves and donned (put on) clean gloves without performing hand hygiene. HK #1 removed a dust pan from the housekeeping cart and set it up inside the room. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 removed a broom and mop from the housekeeping cart and set them up inside the room. She removed her gloves and donned clean gloves without performing hand hygiene. . HK #1 sprayed a chemical solution onto a rag and wiped down the television remote on side A of the room and disposed of the rag in the cart. She removed her gloves and donned clean gloves without performing hand hygiene. She then sprayed the chemical onto a clean rag and wiped down the bedside table on side A before disposing of the rag in the cart. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 next sprayed a glass cleaner chemical onto a rag and wiped the mirror in the bathroom before disposing of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 then scrubbed the toilet with a brush and put it back into the cart. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 next sprayed the toilet with a chemical. She removed her gloves and donned clean gloves without performing hand hygiene. She swept the room and disposed of the contents in the dust pan. She removed her gloves and donned clean gloves without performing hand hygiene. She removed the fall mat on side A of the room and swept where the mat was. She removed her gloves and donned clean gloves without performing hand hygiene. . She wiped down the toilet with a rag and disposed of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. She got a clean rag and wiped the inside of the toilet and disposed of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. She wiped the mirror with a clean rag and disposed of the rag. She removed her gloves and donned clean gloves without performing hand hygiene. HK #1 put away the glass cleaner. She removed her gloves and donned clean gloves without performing hand hygiene. She attached a clean mop head to the mop and mopped the bedroom. She disposed of the mop head. She removed her gloves and donned clean gloves without performing hand hygiene. She attached a clean mop head to the mop and mopped the bathroom. She disposed of the mop head. She removed her gloves and donned clean gloves without performing hand hygiene. She attached a new mop head to the mop and mopped the entryway of the room. She removed her gloves and donned clean gloves without performing hand hygiene. She swept the entryway of the room. She removed her gloves. HK #1 said she was finished cleaning the resident’s room. -HK #1 changed her gloves 18 times throughout the course of cleaning resident room #34, however, she failed to perform hand hygiene with each glove change, including after cleaning the toilet and prior to cleaning other areas of the room. II. Failed to ensure staff performed appropriate hand hygiene when performing incontinence care for Resident #23 A. Observation During a continuous observation on 8/26/25, beginning at 12:40 p.m. and ending at 1:30 p.m., the following was observed: At 1:15 p.m. the call light in Resident #23’s room was turned on. . At 1:18 p.m. certified nurse aide (CNA) #1 went into the room. CNA #1 donned clean gloves and began to check Resident #23’s brief. She removed the soiled brief and performed perineal (area between the genitals) care on Resident #23. She put a clean brief on Resident #23. Without changing gloves and performing hand hygiene, CNA #1 pulled Resident #23’s skirt over her legs and assisted her to sit up in bed. CNA #1 put shoes on Resident #23 and put a gait belt around her waist. CNA #1 transferred Resident #23 to her wheelchair. CNA #1 put Resident #23’s oxygen cannula in her nose and secured the oxygen tubing behind her ears. CNA #1 then removed her gloves and, without performing hand hygiene, removed the bag of trash from the trashcan. CNA #1 put Resident #23’s sweater on her and proceeded to wheel Resident #23 out of the room. CNA #1 stopped to throw away the trash and perform hand hygiene and then wheeled Resident #23 into the living room. -CNA #1 failed to change her gloves and perform hand hygiene after changing the resident’s soiled brief and prior to touching the resident’s clothing, shoes, a gait belt, the resident’s oxygen nasal cannula and tubing and the handles of the resident’s wheelchair.-Additionally, CNA #1 failed to don a gown prior to performing high-contact resident care for Resident #23, who had a wound on her left shin (see additional EBP failures below). III. Failed to ensure staff wore appropriate PPE during high-contact resident care for Resident #23 and Resident #4, who were on EBPA. Professional reference According to the Centers for Disease Control and Prevention’s (CDC) Frequently Asked Questions about EBP in Nursing Homes (6/28/24), retrieved on 9/2/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html,“EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally-inserted central catheters (PICCs), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. The presence of an indwelling device is a major risk factor for being colonized with or acquiring a MDRO. Therefore, the safest practice would be to wear a gown and gloves for any care (such as dressing changes) or use (injecting or infusing medications or tube feeds) of the indwelling medical device.”B. Facility policy and procedure The Enhanced Barrier Precautions policy and procedure, revised June 2024, was received from the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. It documented in pertinent part, “EBP should be used during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their multi-drug resistant organism (MDRO) status. Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care.”C. ObservationsDuring a continuous observation on 8/25/25, beginning at 12:15 p.m. and ending at 4:05 p.m., the following was observed: At 12:49 p.m. Resident #23 was sitting in her wheelchair in the living room. CNA #1 went up to Resident #23 and wheeled her into her room. There was a sign for EBP precautions on the door of Resident #23’s room. CNA #1 put gloves on, took Resident #23’s sweater off and assisted Resident #23 into bed. Resident #23 had a large bandage on her left shin. CNA #1 took Resident #23’s shoes off and covered her up with a blanket. -CNA #1 failed to don a gown prior to transferring Resident #23 into bed. At 3:04 p.m. CNA #2 and CNA #3 went into Resident #23’s room. CNA #3 put gloves on but no gown. CNA #2 did not put a gown or gloves on. CNA #2 sat Resident #23 up in bed and put socks on her feet. CNA #3 put a gait belt around Resident #23’s waist. CNA #2 and CNA #3 transferred Resident #23 into her wheelchair. CNA #2 put on Resident #23’s sweater and shoes and wheeled her into the living room. -CNA #2 and CNA #3 failed to wear appropriate PPE during high-contact resident care for Resident #23. On 8/26/25 at 11:30 a.m. registered nurse (RN) #1 was providing tube feeding for Resident #4. RN #1 gathered supplies and went into Resident #4’s room. There was an EBP sign outside of Resident #4’s room. RN #1 donned clean gloves and explained the procedure to Resident #4. RN #1 unclamped the feeding tube, administered warm water into the feeding tube, administered the feeding tube formula and administered more warm water to flush the tube. RN #1 clamped the tube closed and threw the supplies away. She cleaned out the syringe and removed her gloves. RN #1 washed her hands.-RN #1 failed to don a gown prior to performing Resident #4’s tube feeding. IV. Staff interviews The environmental services director was interviewed on 8/26/25 at 2:00 p.m. The environmental services director said housekeepers should change their gloves when they were soiled while cleaning residents’ rooms. She said gloves should be changed a minimum of five times during cleaning one room. She said hand hygiene should be performed after each glove removal. RN #1 was interviewed on 8/27/25 at 9:25 a.m. RN #1 said residents with bacteria in their urine, foley catheters, feeding tubes and wounds required EBP. She said EBP required wearing a gown and gloves when performing high-contact care. She said she was not sure if she should wear a gown when administering tube feeding formula to a resident’s feeding tube and said she had not received any education about that. The infection preventionist (IP) was interviewed on 8/27/25 at 11:00 a.m. The IP said hand hygiene should be completed when entering the dining room, removing gloves, coming out of a resident’s room and between handling room trays. She said gloves should be changed when moving from a dirty to clean area during care. She said this included after performing perineal care on a resident. She said the importance of hand hygiene was for infection control. The IP said residents with indwelling medical devices, including a gastric feeding tube, residents with wounds and residents with MDROs were placed on EBP. She said this meant staff should wear a gown and gloves during high contact resident cares such as showers, transfers and perineal care. She said Resident #23 was on EBP because of a wound. She said EBP included the administration of tube feedings and medications through a gastric feeding tube. She said the importance of following EBP was for infection control. She said RN #1 should have put on a gown before working with Resident #4’s tube feeding. The director of nursing (DON) was interviewed on 8/27/25 at 11:20 a.m. The DON said hand hygiene should be completed after moving from a dirty task to a clean task during resident care and after glove removal. She said the importance of this was to prevent the spread of infection. She said wounds, foley catheters, intravenous catheters (IVs) and gastric feeding tubes qualified a resident to be placed on EBP. She said staff should wear a gown and gloves when providing care to these residents. She said the importance of this was to prevent infection.

A complaint survey, prompted by #CO37861, Incident #CO37660, and Incident #CO38416 was completed from 12/18/24 to 12/19/24. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A revisit survey was completed on 4/23/24 for all previous deficiencies cited on 2/14/24. The facility was in compliance with all regulations surveyed.

A revisit survey was completed on 4/23/24 or all previous deficiencies cited on 2/14/24. The facility is in compliance with all regulations surveyed.

INITIAL COMMENTS (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). The facility is one story, Type V(111), wood framed structure with a partial lower level used for support services. The residents have routine access to the lower level; however, resident rooms are not located in the lower level. The lower level has two exits at grade to the exterior. The facility is protected throughout by an automatic fire sprinkler system and is classified as Fully Sprinklered. The facility was constructed in 1972. The 70 bed facility was surveyed on March 5, 2024 using the National Fire Protection Association, (NFPA)101 Life Safety Code (2012) chapter 19, Existing Health Care Occupancies. The deficiencies cited were discussed with the Administrator and Regional Director of Facility Maintenance during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 62 residents. The facility is licensed for 69 residents.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101 and NFPA 80. Kitchen fire door does not shut. When the door closer is released. NFPA 80 5.2.14.1 Self-closing devices shall be kept in working conditionat all times. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 and NFPA 72. Fire panel in trouble heat detector in boiler room. 2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling CodeThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011) Rm 14 corroded sprinkler head2) Missing escutcheon Room 13, hole in drywall around head 3) Missing escutcheon in room 124)Storage needs to be 18" below sprinkler heads In Maintenance room, maintenance storage and kitchen. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. NFPA 13 8.5.5.3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3. NFPA 101 (2012) 8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. This was evidenced by the following:Gas orifice on dryer rated for 0-2000 feet in elevation in the laundry room. NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer ' s installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference.

A recertification survey with Incident #30757 was completed on 2/12/24 to 2/14/24. Four deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/12/24 to 2/14/24. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent the development of pressure injuries for one (#31) of two residents out of 26 sample residents reviewed for pressure injuries. Resident #31, who was receiving hospice services related to his diagnosis of senile dementia, was known to be at risk for developing pressure injuries. The resident was admitted to the facility on 5/13/22 without any pressure injuries. On 10/6/23, a weekly skin assessment was conducted for Resident #31 and documented the resident had no new skin issues. The facility failed to conduct a skin assessment between the dates of 10/6/23 and 10/18/23. On 10/18/23, multiple pressure wounds were noted to Resident #31's left foot. The wounds included an unstageable left lateral malleolus (outside ankle) wound which later evolved to reveal a stage 3 pressure injury, an unstageable lateral (outside) left heel wound, an unstageable lateral left foot wound which later evolved to reveal a stage 4 pressure injury, and an unstageable left fifth metatarsal head (joint between the foot and the small toe) deep tissue injury (DTI). The left fifth metatarsal wound resolved on 11/28/23 and reemerged as a DTI on 1/8/24. On 1/18/24, the left fifth metatarsal wound evolved into an unstageable pressure wound. On 10/22/23, the resident developed an unstageable pressure injury to his left hip. The facility had initiated a skin integrity care plan for the resident on 5/27/22, however, interventions, such as implementing a specialty air mattress and repositioning the resident, were not implemented until after Resident #31 developed the pressure injuries to his left hip and left foot. As a result of the facility's failures to implement timely pressure injury interventions, Resident #31 developed multiple advanced pressure injuries to his left foot and left hip. 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 2/15/24, "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 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 policy and procedureThe Pressure Wound Prevention and Skin Management policy and procedure was provided by the nursing home administrator (NHA) on 2/14/24 at 10:52 a.m. It read in pertinent part,"Based on the resident's history, clinical status, head to toe skin assessment, and Braden scale, an acute temporary care plan should be initiated per definition and policy."Interventions to promote healing and/or prevent breakdown may include incontinence management, a turning and repositioning plan, initial treatment(s), off loading devices and any other pressure relieving strategies and resident goals for treatment."All residents are provided with pressure reducing mattresses. Special support surfaces (such as pressure relieving specialty mattresses or cushions) will be utilized as part of the treatment plan when residents are identified to be at higher risk for skin breakdown or having existing breakdown."Weight shifts may be implemented as part of both prevention and treatment for pressure wounds. When possible, weight shifting and off loading, which allows sufficient capillary refill and tissue perfusion may be implemented."III. Resident #31A. Resident statusResident #31, age 90, was admitted on 5/13/22. According to the February 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic kidney disease and peripheral vascular disease. The 12/29/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He was dependent with toileting, personal hygiene, bed mobility, required substantial/maximal assistance with transfers and supervision with eating. The assessment indicated the resident had one unhealed stage 3 pressure ulcer and four unhealed unstageable pressure ulcers not present on admission and was at risk for developing pressure ulcers. B. ObservationsOn 2/13/24 at 12:30 p.m. licensed practical nurse (LPN) #1 was observed removing the dressing on Resident #31's left hip. A small amount of serosanguinous (yellowish with a small amount of blood) drainage was observed on the dressing. The wound bed was difficult to visualize due to the depth of the wound. There was no redness noted around the wound site. Resident #31 was observed on an air mattress. On 2/13/24 at 12:40 p.m. LPN #1 was observed removing soft heel boots from Resident #31's left foot for wound care. The left lateral malleolus (outside ankle bone) wound bed appeared pink without drainage or redness noted around the wound site. The left lateral heel wound bed appeared pink with a small amount of yellowish material and a small amount of brown black material. The left lateral foot wound bed appeared red with a small amount of red material. The left fifth metatarsal wound bed had brown black material. C. Record reviewThe skin integrity care plan, initiated 5/27/22 and revised 12/20/23, indicated Resident #31 had actual and the potential for skin breakdown due to dementia, decreased mobility, fluctuating nutritional intake and incontinence. Interventions included air mattress, toileting regularly, encourage optimal nutrition and hydration, float heels, heel protectors to bilateral heels when in bed and wheelchair, keep skin clean and dry, outside wound care to follow for weekly wound management, nutritional supplements, reposition frequently in bed and wheelchair and weekly skin checks. The hospice care plan, initiated 5/27/22 and revised on 12/21/23, indicated the resident was receiving hospice services due to senile dementia. Interventions included work cooperatively with the hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. Further review of the comprehensive care plan revealed turn and reposition frequently was initiated on 5/27/22 and reinitiated on 10/23/23, the air mattress was initiated on 9/13/22 and reinitiated on 10/25/23 and floating bilateral heels was initiated on 11/17/23. The February 2024 CPO documented physician orders:-An order for hospice services, ordered 3/15/23;-Float heels while in bed, ordered 5/13/22 and reordered 10/19/23 (after the wounds developed);-Left heel protector, ordered 6/14/22 and discontinued 7/6/22;-Left heel protection boot, ordered 7/6/22;-Air mattress, ordered 10/18/23 (after the wounds developed);-Bilateral heel protectors, ordered 10/19/23 (after the wounds developed);-Turn and reposition resident frequently in bed and in wheelchair, ordered 10/23/23 (after the wounds developed);-Left lateral malleolus, cleanse wound with wound cleanser or normal saline, pat dry and apply skin prep around the wound and leave open to the air every day and as necessary, ordered 1/31/24;-Left lateral heel, cleanse wound with wound cleanser and apply liquid medihoney and cover with bordered gauze. Change dressing every other day and as necessary, ordered 1/31/24;-Left lateral foot, cleanse wound with wound cleanser and apply wound with liquid medihoney and bordered gauze. Do not cover other wounds with this dressing, ordered 1/31/24;-Left hip, cleanse wound with wound cleanser, express drainage from wound and pack loosely with Dakins moistened 1/4 inch packing strips and cover with ABD (thick abdominal type dressing) and secure with medipore tape. Change dressing twice a day and as necessary, ordered 1/31/24; and,-Left lateral metatarsal, cleanse wound with wound cleanser. Apply skin prep around the wound and leave it open to air, ordered.-Review of the February 2024 CPO revealed the float heels while in bed, air mattress, bilateral heel protectors and repositioning orders were not implemented until after the identification of the pressure wounds. The 10/20/23 Braden Scale Assessment (a tool used to predict the risk of pressure ulcers) indicated Resident #31 was at a severe risk for developing pressure ulcers. The 10/6/23 weekly comprehensive nursing skin observation documented Resident #31 had no new skin issues and a boot for heels for heel redness.-There was no documentation to indicate a weekly skin assessment had been conducted between 10/6/23 and 10/18/23 (a period of 12 days). A 10/18/23 nursing progress note documented a hospice certified nurse aide (CNA) alerted a registered nurse (RN) to new wounds on Resident #31's left foot. The measurements to the wounds were 1.5 centimeters (cm) by 0.5 cm, 1.5 cm by 0.9 cm and 2.0 cm by 1.0 cm. The wounds were cleansed with a wound cleanser and bandages were applied. The director of nursing (DON), power of attorney (POA), physician and the hospice provider were notified. -The nursing progress note failed to document a detailed description regarding the location of each wound on Resident #31's left foot and which measurements pertained to each wound identified. The stage of the wound was not identified. A 10/18/23 change of condition note documented the identification of new foot wounds for Resident #31. The 10/22/23 nursing progress incident note documented a certified nurse aide reported a skin breakdown on the left hip. The measurements were 3.5 cm by 2 cm by 0.2 cm by 0.5 cm by 1 cm. It documented the hospice provider, the DON and the power of attorney (POA) were notified.-The incident note did not identify the stage of the wound. The 10/24/23 interdisciplinary team (IDT) progress note documented a referral to a wound physician for weekly wound management and wound treatment orders.-A comprehensive review of Resident #31's electronic medical record (EMR) failed to reveal documentation of turning and repositioning prior to the identification of the resident's woundsReview of the wound care physician assistant's (WCPA) notes revealed the PA initially evaluated Resident #31's wounds on 10/23/23 and continued to provide weekly wound care visits. The WCPA's initial visit note on 10/23/23 documented the following wounds:The left hip wound was documented as a shearing friction wound. The measurements were 6 centimeters (cm) by 3.5 cm by 0.1 cm. The wound bed had 50% slough (yellow/white material in the wound bed) and 50% eschar (black brown collection of dead tissue in the wound bed). The left lateral malleolus wound was documented as an unstageable pressure wound. The wound measurements were 2 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 1.8 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral foot pressure wound was documented as an unstageable pressure wound. The measurements were 1.1 cm by 1.4 cm by 0 cm. The wound bed had 100% slough. The left fifth metatarsal pressure wound was documented as a DTI. The measurements were 0.4 cm by 1.1 cm. The wound was a non blanchable deep red, maroon or purple discoloration. The 10/31/23 IDT progress note documented interventions for frequent turning and positioning, air mattress and floating heels. -However, the interventions were implemented after the wounds were identified and assessed by the wound care PA.According to the most recent wound care notes dated 2/5/24, the WCPA documented the resident still currently had the five wounds with the following changes:The left hip wound was documented as an unstageable pressure wound. The measurements were 0.7 cm by 0.7 cm by 0.7 cm. The wound was documented as undermining. The wound bed had 100% granulation. The left lateral malleolus wound was documented as a stage 3 pressure wound (evolved from the initial unstageable classification). The measurements were 1.1 cm by 0.5 cm by 0 cm. The wound bed had 100% epithelialization. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 0.5 cm by 0.7 cm by 0.1 cm. The wound bed had 80% slough and 20% eschar. The left lateral foot pressure wound was documented as a stage 4 pressure wound (evolved from the initial unstageable classification). The measurements were 1.7 cm by 1.7 cm by 0.1 cm. The wound bed had 70% granulation, 15% slough and 14% epithelialization. The left fifth metatarsal head wound was documented as an unstageable pressure injury. The measurements were 1.1 cm by 2.0 cm. The left fifth metatarsal wound healed on 11/28/23 and reemerged on 1/8/24 as a DTI which evolved into an unstageable pressure wound on 1/18/24. -Although the WCPA had followed the wounds weekly since 10/23/23, after the wounds were identified, the facility failed to prevent them from occurring initially, despite knowing the resident was at risk of developing pressure injuries and there were not enough preventative measures put in place to prevent them from developing. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/14/24 at 1:35 p.m. She said Resident #31 had multiple pressure wounds on his left hip and bilateral feet. She said she did not remember if he was on a pressure mattress before the identification of his wounds. She said he did have his heel protector boots on because of previous issues with wounds on his feet. She said since he was a dependent resident, was stiff and had previous skin issues, he should have had preventative measures in place and be frequently repositioned at least every two hours. The primary care physician (PCP) was interviewed on 2/14/24 at 10:23 a.m. He said he had been taking care of Resident #31 and the resident had previous issues with wounds about one year ago. He said Resident #31 was bed and wheelchair bound, on hospice and was at risk for developing pressure wounds. He said there was no guarantee he would not have developed the wounds, however, he said there was an "absolute guarantee" the wounds would develop if preventative measures were not in place. He said preventative measures should include an air mattress, special cushions, heel protectors, weekly skin assessments, nutritional interventions and frequent repositioning. The WCPA was interviewed on 2/14/24 at 10:52 a.m. She said she saw Resident #31 in October 2023, after he developed multiple pressure wounds. She said when she saw him an air mattress was in place and he was wearing heel boots. She said, with his comorbidities, he was at a high risk of developing pressure wounds and preventative measures would have helped decrease the risk of developing the wounds. She said preventative measures included air mattresses, heel boots, frequent repositioning and nutritional interventions. She said the resident's pressure wounds were improving. The director of nursing (DON) was interviewed on 2/14/24 at 3:45 p.m. He said he was the wound care coordinator who rounded with the wound care consultants. He said a full nursing assessment with a skin assessment was completed on all residents upon admission. He said skin assessments were done on a weekly basis and scheduled for each resident. He said if a new skin issue was identified it was reported to the physician, hospice and the DON. He said a risk report, such as a change of condition or situation, background, assessment, response (SBAR) was completed. The skin issue was discussed with the IDT, a root cause analysis completed and interventions to prevent further deterioration were implemented. He said the Braden Scale Assessment score acted as a guide for preventative measures. The DON said residents who were dependent and at risk should be put on an air mattress, special cushions for wheelchairs, heels should be floated and frequent repositioning should be done. He said Resident #31's wounds developed in October 2023 and the majority of interventions were put into place after the wounds were identified. He said Resident #31 was not on an air mattress before the wounds were identified. He said at risk residents should be frequently repositioned. He said there was no set frequency of how often residents were repositioned. He said the facility did not have a repositioning program and did not document how often or when a resident was repositioned.

Based on observation, record review and interviews, the facility failed to ensure that residents were kept free from significant medication errors for two (#54 and #47) of six residents out of 26 sample residents. Specifically, the facility failed to:-Ensure an antipsychotic medication for Resident #54 was obtained and administered according to physician's orders;-Notify resident #54's physician that the resident's antipsychotic medication was not refilled which resulted in the resident missing administration of the medication three days;-Ensure Resident #47 received all ordered doses of her prescribed antibiotic medication; and,-Notify Resident #47's physician when the resident did not receive the antibiotic medication. Findings include:I. Professional referenceAccording to Potter, P.A. and Perry, A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 599 - 609. "Nurses play an important role in patient safety, especially in the area of medication administration. The safe administration of medications is also an important topic for current nursing researchers. As a nurse you need to know how to calculate medication doses accurately and understand the different roles that members of the health care team play in prescribing and administering medications. "The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. -Preventing medication errors is essential.-Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. "Professional standards such as scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors follow the seven rights of medication administration consistently every time you administer medication. -The right medication; the right dose; the right patient; the right route; the right time; the right documentation; and right indication."The Food and Drug Administration (FDA) Combating Antibiotic Resistance (10/29/19), https://www.fda.gov/consumers/consumer-updates/combating-antibiotic-resistance#:, retrieved on 2/15/24 at 1:59 p.m., documented in pertinent part,"Take the antibiotics as prescribed. It is important to take the medication as prescribed by your doctor. If treatment stops too soon, the remaining bacteria may become resistant to the antibiotics that you have taken."Do not skip doses. Antibiotics are most effective when they are taken as prescribed."II. Facility policy and procedureThe Medication Administration Guidelines policy and procedure was provided by the nursing home administrator (NHA) on 2/14/24 at 10:52 a.m. It read in pertinent part,"The 6 (six) rights of medication administration will be followed to include: the right resident, the right drug, the right dosage, the right time, the right route, the right documentation."III. Resident #54 A. Resident statusResident #54, under age 65, was admitted on 8/28/23. According to the February 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder, depression and bilateral below knee amputation. The 12/1/23 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. He was independent with eating, oral hygiene, toileting hygiene, upper and lower body dressing and personal hygiene. He needed moderate assistance with bathing. The MDS assessment documented Resident #54 received antipsychotic medication on a regular basis. B. Resident interviewResident #54 was interviewed on 2/14/24 at 2:00 p.m. Resident #54 said he did not receive Clozapine (an antipsychotic medication) for a few days. Resident #54 said facility staff told him the laboratory did not communicate his lab work results to the pharmacy on time for his medication to be refilled. Resident #54 said he was stressed about not having his medication and he felt like he was sweating more, experienced cold sweats and started to cough without the medication. C. Record reviewA review of Resident #54's February 2024 CPO revealed the following physician orders: -Clozapine 200 milligrams (mg) to be administered by mouth daily at bedtime for schizoaffective depressive disorder, ordered 11/20/23;-Complete blood count (CBC) with differential (specific blood cell type count) draw every two weeks for Clozapine use. Ensure requisition is completed and placed in the laboratory book, ordered 12/5/23; and,-Fax the results of the CBC with differential to the pharmacy every 14 days to reorder Clozapine, ordered 12/5/23. A review of Resident #54's January 2024 medication administration record (MAR) revealed the following:A CBC with differential blood draw and results sent to the pharmacy was documented as completed on 1/22/24. Resident #54 did not receive Clozapine on 1/23/24, 1/24/24 and 1/25/24. The chart code used all three days to document the reason Resident #54 did not receive his medication was "Other/See progress notes."A progress note written on 1/23/24 at 9:10 p.m. documented the Clozapine was reordered from the pharmacy. -There was no further documentation to indicate Resident #54's physician was notified the resident's medication was unavailable.-There was no documentation to indicate further attempts were made by facility staff to call the pharmacy to follow up on Resident #54's Clozapine medication status on 1/24/24 or 1/25/25. A review of the submission record from Resident #54's electronic medication record documented Resident #54's Clozapine was reordered at 9:10 p.m. on 1/23/24. D. Staff interviewsThe director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 2/13/24 at 2:30 p.m. The DON said the Resident #54 had a physician's order for a blood draw every two weeks for Clozapine use and said Resident #54's Clozapine was ordered on 1/23/24. The DON said laboratory blood work results were sent to the pharmacy from the facility each time the blood work was completed. He said the resident's bloodwork results were sent to the pharmacy on 1/22/24. The ADON said staff should have notified notified the physician when Resident #54 was without his antipsychotic medication. The ADON said the pharmacy would not refill a medication order if lab work results were not received prior to the medication order. She said if that occurred, the medication order would have to be resent again to the pharmacy once the lab work results were received. The consulting pharmacist (CP) was interviewed on 2/14/24 at 2:38 p.m.. The CP said the pharmacy received the order to refill Resident #54's antipsychotic medication order on 1/23/24. She said the order was processed on the 24th and the medication arrived at the facility on 1/25/24. The CP said from what she could see in the pharmacy system, the pharmacy did not receive Resident #54's lab work results on 1/22/24. The CP said if the facility forgot to reorder a medication, the facility could call the pharmacy. The CP said if the facility would have called the pharmacy it would have facilitated the process to refill Resident #54's medication timely. The DON and ADON were interviewed again on 2/14/24 at 3:31 p.m. The DON said he should be notified when a resident was out of antipsychotic medication for three days. The ADON said the facility was going to adjust Resident #54's laboratory blood work schedule to give the facility more time to get the medication refilled. The ADON said the facility staff should notify the physician that a resident was without medication in case the resident had an adverse reaction from not receiving the medication as prescribed. IV. Resident #47A. Resident statusResident #47, age 71, was admitted on 1/20/24 readmitted on 2/6/24. According to the February 2024 CPO, diagnoses included parainfluenza virus pneumonia and metabolic encephalopathy. The 1/27/24 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required supervision with personal hygiene, bed mobility, transfers, toileting and was independent with eating. B. Record reviewThe February 2024 CPO revealed an order for Cefuroxime (an antibiotic medication) 500 milligrams (mg) twice a day for pneumonia for three days. The February 2024 medication administration record (MAR) revealed the following:-A dose of Cefuroxime was given on 2/7/24 at 5:00 p.m.-A dose of Cefuroxime was held on 2/8/24 at 8:00 a.m. and 5:00 p.m.-A dose of Cefuroxime was given on 2/9/24 at 8:00 a.m. and 5:00 p.m.-A dose of Cefuroxime was given 2/10/24 at 8:00 a.m.-Resident #47 received only four of the six doses of the prescribed antibiotic medication. -There was no documentation to indicate the resident's physician had been notified the resident did not receive both scheduled doses of the antibiotic medication on 2/8/24. C. Staff interviewsThe assistant director of nursing (ADON) was interviewed on 2/13/24 at 4:30 p.m. She said Resident #47's antibiotic was not given for two doses due to a delay in receiving the medication from the pharmacy. She said the administering nurse notified the provider of the delay in receiving the antibiotic from the pharmacy, however, she said there was no documentation the provider was aware the resident did not receive two doses of the antibiotic. The ADON said she did not know why the resident was able to receive the first dose and not the next two doses. The director of nursing (DON) was interviewed on 2/13/24 at 4:40 p.m. He said there was a back up supply of the Cefuroxime in the automated dispensing system. He said he did not know why Resident #47 received the first dose but did not receive the next two doses since the facility had the medication in the dispensing system. He said it was important to receive antibiotics as they were ordered to effectively treat an infection. The DON said the physician or provider should be notified if a medication was not given because it was not available.

Based on record review, and observations, the facility failed to ensure six of seven residents out of 36 sample residents received food and fluids prepared in a form designed to meet their needs per speech therapy recommendation, physician orders, and the resident's care plan. Specifically, the facility failed to ensure the puree textures produced were consistent with the International Dysphagia Diet Standard Initiative (IDDSI) level four puree texture (PU4) for residents prescribed a puree diet. Findings include:I. Professional standardThe International Dysphagia Diet Standard Initiative (IDDSI) effective July 2019 and retrieved 2/15/24 from https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf revealed in pertinent part, "A level four puree texture (PU4): is usually eaten with a spoon (a fork is possible); should not require chewing if presented in this form; falls off the spoon in a single spoonful when tilted and continues to hold shape on a plate; and has no lumps. No biting or chewing is required and the food is smooth with no lumps."II. Facility policy and procedureThe Diet Textures policy and procedure, reviewed December 2021, was provided by the nursing home administrator (NHA) on 2/13/24 at 3:43 p.m. It revealed in pertinent part, "The puree texture diet: all food is puree consistency."III. Menus and puree recipesA review of the lunch menu on 2/13/24 revealed it included barbecue pork loin, mashed potatoes, mixed vegetable blend and banana parfait. The recipe instructions for puree menu items read in pertinent part:"Mashed potatoes for a level four puree diet ingredients included 28 ounces (oz) dehydrated mashed potatoes and one gallon of water. Prepare according to the manufacturer packaging. Level four puree diet: serve smooth texture with no lumps. Mixed vegetable blend for a level four puree diet ingredients included two and a half quarts of the mixed vegetable blend and a half cup of food thickener. Prepare the mixed vegetable blend recipe as directed. Place the portions needed in the food processor and process until fine in consistency. Slowly add reserve liquid and thickener as needed and process until smooth."IV. ObservationsThe following observations were made on 2/13/24 during lunch service. The temperatures of the menu items served for lunch on 2/13/24 were taken at 11:18 a.m. Cook (CK) #1 inserted his thermometer into a pan of food and said the food was pureed vegetables. The puree vegetables were green in color with small pieces of orange chunks visible inside the puree vegetables. The vegetable blend for the regular diet included green beans and sliced round carrots. Lunch service started for the dining room at 11:33 a.m. At 11:38 a.m. CK #1 placed a plate of pureed food in the serving window. Small pieces of carrot were visible in the pureed green vegetable. The meal card placed under the plate revealed the resident had a puree texture diet. The dietary manager (DM) picked up the plate and meal card and delivered the plate to a resident seated at a dining room table. The DM was notified after serving the resident that the puree vegetables on the plate had visible pieces of carrot in the puree vegetable. The DM said the blender used to puree food was an issue and he was unsure what guidelines were included in the menu program the facility used for puree diets. Five more plates with puree foods were served to residents during the lunch shift at 11:45 a.m., 11:46 a.m., 11:47 a.m., 11:51 a.m. and 11:52 a.m. CK #1 placed each of the plates containing puree food in the serving window with their corresponding meal cards. All five meal cards indicated a puree diet on the card and all five plates had puree green vegetables with visible pieces of orange carrot inside the puree vegetable. A four ounce portion of mashed potatoes was sampled at 12:27 p.m. after residents had been served lunch. The mashed potatoes were portioned from the mashed potatoes that were served to the residents on apuree texture diet for lunch. -The mashed potatoes were not smooth and had lumps of potatoes in each bite sampled. V. Staff interviewsThe DM was interviewed on 2/14/24 at 9:00 a.m. The DM said the instant dry potato mix should be used for puree diet potatoes and fresh potatoes were used for mashed potatoes served to residents on a regular diet. The DM said fresh potatoes were used for the mashed potatoes served for lunch on 2/13/24 instead of instant dry potatoes. The DM said puree recipes were on the kitchen counter for use prior to meal service. The DM said the staff did check puree items before meal service and taste the puree items for texture variances. The DM said he had not checked the puree items served at breakfast that morning (2/14/24) to see if the puree items were the appropriate texture. The DM and (CK) #1 were interviewed together on 2/14/24 at 1:00 p.m. CK#1 said he used the blender to puree the food items for the lunch meal service on 2/13/24. He said the blender had stopped working and he had used the food processor to finish the puree items, however, he said the food processor blade was not sharp enough to make the puree smooth. CK #1 said he did not see the carrot pieces in the puree vegetable during meal service. The DM said the new blender was smaller then the previous one so the staff were not able to put the same amount of puree food into the blender as the previous one. The DM said he did not see pieces of carrot in the puree green beans prior to lunch because he was busy. The DM said the puree foods with lumps were a choking hazard for residents on a puree diet. He said puree foods could be run through a sieve if needed to remove the lumps in puree food.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment refrigerators. Specifically, the facility failed to:-Ensure thawed nutritional supplements and thickened liquids were dated appropriately;-Ensure food was labeled and dated in the nourishment refrigerators; and,-Ensure expired food was discarded in the nourishment refrigerators. Findings include:I. Professional referenceThe (2019) Colorado Retail Food Establishment Rules and Regulations, retrieved from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 2/15/24, read in pertinent part, "A date marking system that meets the criteria may include: Using a method approved by the department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified; or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request."The Hormel Health Labs Thick & Easy® Thickeners, Tea, and Coffee date information sheet, dated January 2022 and retrieved from https://www.hormelhealthlabs.com/wp-content/uploads/2022-HHL-Code-Date-Information.pdf on 2/15/24, read in pertinent part, "Thick and easy 46 oz hydrolyte clear thickened water had a shelf life of up to 10 days refrigerated. The shelf life of a refrigerated hormel mighty shake is 14 days thawed."II. Facility policy and procedureThe Food from Outside policy and procedure, reviewed 12/2/22, was provided by the nursing home administrator (NHA) on 2/12/24 at 1:59 p.m. It revealed in pertinent part, "The purpose of this policy is to establish a guideline that allows patients to adhere to usual food practices and ensure that safe food handling procedures are observed. The food shall remain in the original container, labeled with the name, room number and date and stored in the resident neighborhood refrigerator located on their respective floor. The food should be consumed in 48-72 hours or it will be discarded by designated staff."III. Observations and interviewsOn 2/13/24 at 9:15 a.m., the Bronco unit nourishment refrigerator was observed with the director of nursing. The following item was found:, A 32 ounce (oz) container of oat based creamer with an expiration date of September 2023. At 9:18 a.m., an unidentified staff member placed approximately 12 four ounce Hormel health shakes in the Bronco unit nourishment refrigerator. Printed on each health shake carton was "store frozen." -There were no pull dates or expiration dates written on the health shake cartons that indicated when the shakes were pulled from the freezer or the shelf life of the thawed product. On 2/13/24 at 9:20 a.m., the Peaceful unit nourishment refrigerator was observed with the director of nursing (DON). The following items were found:Two 46 oz containers of commercially produced hormel thickened water, both approximately half full. One bottle of the thickened water had a date of 12/3/23 written in black marker on the bottle. The other bottle of thickened water had no written open date or expiration date on the bottle. Four four vanilla and one strawberry four ounce Hormel health shakes. Printed on each health shake carton was "store frozen." -There were no pull dates or expiration dates written on the health shake cartons that indicated when the shakes were pulled from the freezer or the shelf life of the thawed product. A container of whipped cream cheese with an expiration date of 11/26/23 and a name written on the lid in black marker. The DON discarded the two containers of thickened water from the nourishment refrigerator on the Peaceful unit. The DON was interviewed on 2/13/24 at 9:23 a.m. The DON said the expired container of cream cheese belonged to a resident at the facility and the resident's name was written on the container. The DON said he was unsure of the shelf life of an opened 46 oz container of thickened liquids. The DON said the nurses used the health shakes in the nourishment refrigerator as needed for residents who had a supplement ordered. On 2/14/24 at 8:15 a.m., the Bronco unit nourishment refrigerator was observed again. The following items were found:32 vanilla and strawberry Hormel health shakes with the words "store frozen" printed on each health shake carton. -There were no pull dates or expiration dates written on the health shake cartons that indicated when the shakes were pulled from the freezer or the shelf life of the thawed product. On 2/14/24 at 2:30 p.m., the Peaceful unit nourishment freezer was observed. The following items were found: Two individually wrapped ice cream sandwiches wrapped together in foil.-There was no resident name written on the ice cream sandwiches and no date indicating when the food was placed in the freezer or an expiration date. A clear ziploc bag of unidentifiable food items.-There was no resident name written on the ziploc bag and no date indicating when the food was placed in the freezer or an expiration date. A beef and broccoli commercially prepared stir fry.-There was no resident name written on the ice cream sandwiches and no date indicating when the food was placed in the freezer or an expiration date. A Therapearl back wrap (ice gel pack) with a velcro strap was in the freezer with the food items with a resident's name written on the gel pack in black marker. License practical nurse (LPN) #1 was interviewed on 2/14/24 at 2:35 p.m. LPN#1 said ice gel packs used on a resident's body part should not be in a freezer stored with resident food. LPN #1 discarded the gel pack. IV. Additional staff interviewsRegistered nurse (RN) #2 was interviewed on 2/14/24 at 8:15 a.m. RN #2 said nurses went to the kitchen to get more health shakes from the dining team and put the health shakes in the nourishment refrigerators. RN #2 said she thought dietary staff and nursing staff checked the refrigerators for expired products. She said the task of checking for expired foods was not assigned to a specific position and all nursing staff could check the product. The dietary manager (DM) was interviewed on 2/14/24 at 9:00 a.m. The DM said the dietary staff checked the nourishment refrigerators. The DM said he knew there was a 10 day shelf life for 46 oz bottles of opened thickened drinks. Certified nurse aide (CNA) #1 and LPN #1 were interviewed together on 2/14/24 at 2:30 p.m. CNA #1 said the residents' food stored in nourishment refrigerators should have the resident's name and a date the food items were put in the refrigerator or freezer. CNA #1 said she was not sure who was responsible for removing the expired food from the nourishment refrigerators. LPN #1 said the residents' food stored in nourishment refrigerators should have the resident's name and a date the food items were put in the refrigerator or freezer. The DON and assistant director of nursing (ADON) were interviewed together on 2/14/2 at 3:31 p.m. The DON said staff should label the foods in the nourishment refrigerators with the residents' name and date. The DON said ice gel packs used on the body should not be stored with the food in the nourishment freezers. The ADON said ice gel packs used on the body should not be stored in the nourishment freezers with food.

A licensure survey was completed on 2/12/24 to 2/14/24. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent the development of pressure injuries for one (#31) of two residents out of 26 sample residents reviewed for pressure injuries. Resident #31, who was receiving hospice services related to his diagnosis of senile dementia, was known to be at risk for developing pressure injuries. The resident was admitted to the facility on 5/13/22 without any pressure injuries. On 10/6/23, a weekly skin assessment was conducted for Resident #31 and documented the resident had no new skin issues. The facility failed to conduct a skin assessment between the dates of 10/6/23 and 10/18/23. On 10/18/23, multiple pressure wounds were noted to Resident #31's left foot. The wounds included an unstageable left lateral malleolus (outside ankle) wound which later evolved to reveal a stage 3 pressure injury, an unstageable lateral (outside) left heel wound, an unstageable lateral left foot wound which later evolved to reveal a stage 4 pressure injury, and an unstageable left fifth metatarsal head (joint between the foot and the small toe) deep tissue injury (DTI). The left fifth metatarsal wound resolved on 11/28/23 and reemerged as a DTI on 1/8/24. On 1/18/24, the left fifth metatarsal wound evolved into an unstageable pressure wound. On 10/22/23, the resident developed an unstageable pressure injury to his left hip. The facility had initiated a skin integrity care plan for the resident on 5/27/22, however, interventions, such as implementing a specialty air mattress and repositioning the resident, were not implemented until after Resident #31 developed the pressure injuries to his left hip and left foot. As a result of the facility's failures to implement timely pressure injury interventions, Resident #31 developed multiple advanced pressure injuries to his left foot and left hip. 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 2/15/24, "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 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 policy and procedureThe Pressure Wound Prevention and Skin Management policy and procedure was provided by the nursing home administrator (NHA) on 2/14/24 at 10:52 a.m. It read in pertinent part,"Based on the resident's history, clinical status, head to toe skin assessment, and Braden scale, an acute temporary care plan should be initiated per definition and policy."Interventions to promote healing and/or prevent breakdown may include incontinence management, a turning and repositioning plan, initial treatment(s), off loading devices and any other pressure relieving strategies and resident goals for treatment."All residents are provided with pressure reducing mattresses. Special support surfaces (such as pressure relieving specialty mattresses or cushions) will be utilized as part of the treatment plan when residents are identified to be at higher risk for skin breakdown or having existing breakdown."Weight shifts may be implemented as part of both prevention and treatment for pressure wounds. When possible, weight shifting and off loading, which allows sufficient capillary refill and tissue perfusion may be implemented."III. Resident #31A. Resident statusResident #31, age 90, was admitted on 5/13/22. According to the February 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic kidney disease and peripheral vascular disease. The 12/29/23 facility assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He was dependent with toileting, personal hygiene, bed mobility, required substantial/maximal assistance with transfers and supervision with eating. The assessment indicated the resident had one unhealed stage 3 pressure ulcer and four unhealed unstageable pressure ulcers not present on admission and was at risk for developing pressure ulcers. B. ObservationsOn 2/13/24 at 12:30 p.m. licensed practical nurse (LPN) #1 was observed removing the dressing on Resident #31's left hip. A small amount of serosanguinous (yellowish with a small amount of blood) drainage was observed on the dressing. The wound bed was difficult to visualize due to the depth of the wound. There was no redness noted around the wound site. Resident #31 was observed on an air mattress. On 2/13/24 at 12:40 p.m. LPN #1 was observed removing soft heel boots from Resident #31's left foot for wound care. The left lateral malleolus (outside ankle bone) wound bed appeared pink without drainage or redness noted around the wound site. The left lateral heel wound bed appeared pink with a small amount of yellowish material and a small amount of brown black material. The left lateral foot wound bed appeared red with a small amount of red material. The left fifth metatarsal wound bed had brown black material. C. Record reviewThe skin integrity care plan, initiated 5/27/22 and revised 12/20/23, indicated Resident #31 had actual and the potential for skin breakdown due to dementia, decreased mobility, fluctuating nutritional intake and incontinence. Interventions included air mattress, toileting regularly, encourage optimal nutrition and hydration, float heels, heel protectors to bilateral heels when in bed and wheelchair, keep skin clean and dry, outside wound care to follow for weekly wound management, nutritional supplements, reposition frequently in bed and wheelchair and weekly skin checks. The hospice care plan, initiated 5/27/22 and revised on 12/21/23, indicated the resident was receiving hospice services due to senile dementia. Interventions included work cooperatively with the hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. Further review of the comprehensive care plan revealed turn and reposition frequently was initiated on 5/27/22 and reinitiated on 10/23/23, the air mattress was initiated on 9/13/22 and reinitiated on 10/25/23 and floating bilateral heels was initiated on 11/17/23. The February 2024 CPO documented physician orders:-An order for hospice services, ordered 3/15/23;-Float heels while in bed, ordered 5/13/22 and reordered 10/19/23 (after the wounds developed);-Left heel protector, ordered 6/14/22 and discontinued 7/6/22;-Left heel protection boot, ordered 7/6/22;-Air mattress, ordered 10/18/23 (after the wounds developed);-Bilateral heel protectors, ordered 10/19/23 (after the wounds developed);-Turn and reposition resident frequently in bed and in wheelchair, ordered 10/23/23 (after the wounds developed);-Left lateral malleolus, cleanse wound with wound cleanser or normal saline, pat dry and apply skin prep around the wound and leave open to the air every day and as necessary, ordered 1/31/24;-Left lateral heel, cleanse wound with wound cleanser and apply liquid medihoney and cover with bordered gauze. Change dressing every other day and as necessary, ordered 1/31/24;-Left lateral foot, cleanse wound with wound cleanser and apply wound with liquid medihoney and bordered gauze. Do not cover other wounds with this dressing, ordered 1/31/24;-Left hip, cleanse wound with wound cleanser, express drainage from wound and pack loosely with Dakins moistened 1/4 inch packing strips and cover with ABD (thick abdominal type dressing) and secure with medipore tape. Change dressing twice a day and as necessary, ordered 1/31/24; and,-Left lateral metatarsal, cleanse wound with wound cleanser. Apply skin prep around the wound and leave it open to air, ordered.-Review of the February 2024 CPO revealed the float heels while in bed, air mattress, bilateral heel protectors and repositioning orders were not implemented until after the identification of the pressure wounds. The 10/20/23 Braden Scale Assessment (a tool used to predict the risk of pressure ulcers) indicated Resident #31 was at a severe risk for developing pressure ulcers. The 10/6/23 weekly comprehensive nursing skin observation documented Resident #31 had no new skin issues and a boot for heels for heel redness.-There was no documentation to indicate a weekly skin assessment had been conducted between 10/6/23 and 10/18/23 (a period of 12 days). A 10/18/23 nursing progress note documented a hospice certified nurse aide (CNA) alerted a registered nurse (RN) to new wounds on Resident #31's left foot. The measurements to the wounds were 1.5 centimeters (cm) by 0.5 cm, 1.5 cm by 0.9 cm and 2.0 cm by 1.0 cm. The wounds were cleansed with a wound cleanser and bandages were applied. The director of nursing (DON), power of attorney (POA), physician and the hospice provider were notified. -The nursing progress note failed to document a detailed description regarding the location of each wound on Resident #31's left foot and which measurements pertained to each wound identified. The stage of the wound was not identified. A 10/18/23 change of condition note documented the identification of new foot wounds for Resident #31. The 10/22/23 nursing progress incident note documented a certified nurse aide reported a skin breakdown on the left hip. The measurements were 3.5 cm by 2 cm by 0.2 cm by 0.5 cm by 1 cm. It documented the hospice provider, the DON and the power of attorney (POA) were notified.-The incident note did not identify the stage of the wound. The 10/24/23 interdisciplinary team (IDT) progress note documented a referral to a wound physician for weekly wound management and wound treatment orders.-A comprehensive review of Resident #31's electronic medical record (EMR) failed to reveal documentation of turning and repositioning prior to the identification of the resident's woundsReview of the wound care physician assistant's (PA) notes revealed the PA initially evaluated Resident #31's wounds on 10/23/23 and continued to provide weekly wound care visits. The PA's initial visit note on 10/23/23 documented the following wounds:The left hip wound was documented as a shearing friction wound. The measurements were 6 centimeters (cm) by 3.5 cm by 0.1 cm. The wound bed had 50% slough (yellow/white material in the wound bed) and 50% eschar (black brown collection of dead tissue in the wound bed). The left lateral malleolus wound was documented as an unstageable pressure wound. The wound measurements were 2 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 1.8 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral foot pressure wound was documented as an unstageable pressure wound. The measurements were 1.1 cm by 1.4 cm by 0 cm. The wound bed had 100% slough. The left fifth metatarsal pressure wound was documented as a DTI. The measurements were 0.4 cm by 1.1 cm. The wound was a non blanchable deep red, maroon or purple discoloration. The 10/31/23 IDT progress note documented interventions for frequent turning and positioning, air mattress and floating heels. -However, the interventions were implemented after the wounds were identified and assessed by the wound care PA.According to the most recent wound care notes dated 2/5/24, the PA documented the resident still currently had the five wounds with the following changes:The left hip wound was documented as an unstageable pressure wound. The measurements were 0.7 cm by 0.7 cm by 0.7 cm. The wound was documented as undermining. The wound bed had 100% granulation. The left lateral malleolus wound was documented as a stage 3 pressure wound (evolved from the initial unstageable classification). The measurements were 1.1 cm by 0.5 cm by 0 cm. The wound bed had 100% epithelialization. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 0.5 cm by 0.7 cm by 0.1 cm. The wound bed had 80% slough and 20% eschar. The left lateral foot pressure wound was documented as a stage 4 pressure wound (evolved from the initial unstageable classification). The measurements were 1.7 cm by 1.7 cm by 0.1 cm. The wound bed had 70% granulation, 15% slough and 14% epithelialization. The left fifth metatarsal head wound was documented as an unstageable pressure injury. The measurements were 1.1 cm by 2.0 cm. The left fifth metatarsal wound healed on 11/28/23 and reemerged on 1/8/24 as a DTI which evolved into an unstageable pressure wound on 1/18/24. -Although the wound PA had followed the wounds weekly since 10/23/23, after the wounds were identified, the facility failed to prevent them from occurring initially, despite knowing the resident was at risk of developing pressure injuries and there were not enough preventative measures put in place to prevent them from developing. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/14/24 at 1:35 p.m. She said Resident #31 had multiple pressure wounds on his left hip and bilateral feet. She said she did not remember if he was on a pressure mattress before the identification of his wounds. She said he did have his heel protector boots on because of previous issues with wounds on his feet. She said since he was a dependent resident, was stiff and had previous skin issues, he should have had preventative measures in place and be frequently repositioned at least every two hours. The primary care physician (PCP) was interviewed on 2/14/24 at 10:23 a.m. He said he had been taking care of Resident #31 and the resident had previous issues with wounds about one year ago. He said Resident #31 was bed and wheelchair bound, on hospice and was at risk for developing pressure wounds. He said there was no guarantee he would not have developed the wounds, however, he said there was an "absolute guarantee" the wounds would develop if preventative measures were not in place. He said preventative measures should include an air mattress, special cushions, heel protectors, weekly skin assessments, nutritional interventions and frequent repositioning. The wound care PA was interviewed on 2/14/24 at 10:52 a.m. She said she saw Resident #31 in October 2023, after he developed multiple pressure wounds. She said when she saw him an air mattress was in place and he was wearing heel boots. She said, with his comorbidities, he was at a high risk of developing pressure wounds and preventative measures would have helped decrease the risk of developing the wounds. She said preventative measures included air mattresses, heel boots, frequent repositioning and nutritional interventions. She said the resident's pressure wounds were improving. The director of nursing (DON) was interviewed on 2/14/24 at 3:45 p.m. He said he was the wound care coordinator who rounded with the wound care consultants. He said a full nursing assessment with a skin assessment was completed on all residents upon admission. He said skin assessments were done on a weekly basis and scheduled for each resident. He said if a new skin issue was identified it was reported to the physician, hospice and the DON. He said a risk report, such as a change of condition or situation, background, assessment, response (SBAR) was completed. The skin issue was discussed with the IDT, a root cause analysis completed and interventions to prevent further deterioration were implemented. He said the Braden Scale Assessment score acted as a guide for preventative measures. The DON said residents who were dependent and at risk should be put on an air mattress, special cushions for wheelchairs, heels should be floated and frequent repositioning should be done. He said Resident #31's wounds developed in October 2023 and the majority of interventions were put into place after the wounds were identified. He said Resident #31 was not on an air mattress before the wounds were identified. He said at risk residents should be frequently repositioned. He said there was no set frequency of how often residents were repositioned. He said the facility did not have a repositioning program and did not document how often or when a resident was repositioned.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.