Every finding on record at Beth Israel at Shalom Park

Based on observations, interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety. Observations in the kitchen/dry storage area revealed food items in the refrigerators, freezers, and dry storage were not dated nor labeled with an expiration date. This failed practice had the potential to affect 121 residents who received food from the main kitchen. Findings included: A review of the facility policy titled, Food and Supply Storage, revised ,d+[DATE], revealed, Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Foods past the 'use by', 'sell-by', 'best-by' or 'enjoy by' date should be discarded. Cover, label and date unused portions and open packages. Products are good through the close of business on the date noted on the label. Date and rotate items; first in, first out. Discard food past the use-by or expiration date. On [DATE] from 10:43 AM to 11:03 AM, the surveyor observed the following in the kitchen, in the presence of the Director of Dining Services (DDS) and Executive Sous Chef (ESC): - In the dry storage area, an opened 32-ounce (oz.) box of raisins had no opened date. An opened 56-oz. box of cornbread stuffing mix had no opened date. An opened 160-oz. bag of durum wheat pasta had no opened date. An opened bag of multi-colored cereal had no label, nor opened date. - In the reach-in freezer, four 14-oz. marble cakes had expiration dates of [DATE]. - In the walk-in kosher refrigerator, an opened bag of hash brown patties had an approximately three-inch hole in the bag, which was open to air. There was no opened date or label on the bag. An opened bag of meatballs had no label or opened date. A bag of red meat had no label or date. - In walk-in refrigerator C, two yellow peppers contained brown and white runny substances. - In walk-in refrigerator E, an opened bag of yellow shredded cheese had no label or date. An opened bag of approximately five cookies had no label or date. - In walk-in refrigerator H, an opened 32-oz. carton of liquid eggs was unsealed, with the contents exposed to air. During an interview on [DATE] at 9:31 AM, the DDS said he expected all dietary employees to label/date opened foods to be stored in the freezers, refrigerators, and dry storage and to discard food items past their expiration date. He revealed it was his and the ESC's ultimate responsibility to check behind other dietary employees to ensure foods were labeled, dated, and discarded if expired. In an interview on [DATE] at 9:36 AM, the ESC said he expected foods to be labeled/dated after opening and discarded by the expiration date or if spoiled. He revealed he was aware that all opened food items required a label/date to be placed on it before storing it. He indicated he and the DDS were responsible for monitoring for proper food storage in the refrigerators, freezers, and dry storage. The ESC indicated some dietary staff were out and on vacation, so they were a little behind on labeling/dating food items. In an interview on [DATE] at 12:19 PM, the Director of Nursing (DON) said he held the elders in the highest esteem and expected all opened foods to be labeled and dated and for expired foods to be disposed of. The DON stated the DDS was ultimately responsible for checking to ensure foods were labeled/dated, within expiration dates, and not spoiled. In an interview on [DATE] at 12:37 PM, the Administrator said the DDS was ultimately responsible for checking the refrigerators, freezers, and dry storage daily to ensure proper storage and labeling of food items. The Administrator stated she expected all opened foods in the refrigerators, freezers, and dry storage to be labeled/dated and stored properly and for expired/spoiled food to be discarded when or before they expired.

Based on observations, interviews, record review, and facility policy review, the facility failed to maintain a medication error rate of 5% or less. There were two errors out of 31 opportunities for error, which resulted in a 6.45% medication error rate for 1 (Resident #73) of 4 residents observed during medication pass. Findings included: A review of the facility policy titled, Medication Administration, dated 11/20/2020, revealed, Policy Explanation and Compliance Guidelines: 10. Review MAR [Medication Administration Record] to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc. [et cetera]) with MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy also indicated, 14. Administer medication as ordered in accordance with manufacturer specifications. An observation of the medication administration pass on 07/12/2022 at 7:24 AM for Resident #73 revealed Licensed Practical Nurse (LPN) #1 administered [MEDICATION(S)] nasal spray, two sprays in each nostril; B-12 1000 microgram (mcg) tablet; Senna 8.6 milligram (mg) two tablets; and Famotidine 40 mg one tablet. A review of the Physician's Orders revealed the following orders: - An order dated 06/07/2019 indicated the resident was to receive [MEDICATION(S)] Allergy Relief nasal spray, 50 mcg. The directions were to administer one spray in each nostril daily for allergies. - An order dated 08/16/2019 indicated the resident was to receive [MEDICATION(S)] (Vitamin B-12) 500 mcg daily for B12 deficiency. During an interview on 07/12/2022 at 7:36 AM, LPN #1 said he administered two sprays of the [MEDICATION(S)] in each nostril to Resident #73. During an interview on 07/12/2022 at 10:16 AM, LPN #1 said a 1000 mcg tablet of Vitamin B12 was administered to Resident #73 during the medication pass. LPN #1 reviewed the physician's orders and stated the orders were for Vitamin B12 500 mcg and [MEDICATION(S)] one spray in each nostril. During an interview on 07/13/2022 at 10:48 AM, the Director of Nursing (DON) said it was expected for staff to observe the six rights of medication administration, including the right dosage. The nurse was responsible to ensure medications were given correctly. (The six rights of medication administration, referenced by the DON are an accepted standard of nursing practice. The six rights include: 1. Right patient. 2. Right drug. 3. Right dose. 4. Right route. 5. Right time. 6. Right documentation). During an interview on 07/13/2022 at 11:57 AM, the Administrator said the expectations for the nursing staff included being accurate, always reading the orders before administering the medications.

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of three sample residents. Specifically, the facility failed to ensure a registered nurse (RN) #1 administered the pain medication, [MEDICATION(S)], to Resident #1 according to the physician order. RN #1 administered [MEDICATION(S)] to the resident at four times the ordered dose in error due to misinterpreting the order. Resident #1 passed away an hour and a half after the administration of the [MEDICATION(S)]. Resident #1 was a hospice patient, actively dying at the time of the medication error, the error caused a medication overdose which hastened his death. Resident #1's manner of death was an accident and the cause of death was acute [MEDICATION(S)] toxicity due to administration of incorrect dose of [MEDICATION(S)] (refer to 8/25/21 death certificate, under section C). Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/7/21 to 9/9/21, resulting in the deficiency being cited as past noncompliance with a correction date of 6/25/21. I. Facility policy and procedure The Medication Administration policy, revised 6/9/21, was provided by the nursing home administrator (NHA) on 9/7/21 at 11:00 a.m. It read, in pertinent part: Medications will be administered only by nurses licensed in the state of Colorado, medical, pharmacy, or other personnel authorized to administer medications. Medications will be administered in accordance with written orders authorized by the attending physician or designee. Medications will not be pre-poured or administered by anyone other than the person who prepared the dose. Medications supplied for one resident will not be administered to another resident. If there are any questions about dosage, diagnosis, frequency, route, or length of administration, nursing will notify the provider pharmacy and/or physician for clarification. This clarification will be documented as a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The 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 expiration date -Medications will be administered based on the resident's schedule and preferences as well as specific medication and physician requirements. If resident preferences conflict with medication and physician recommendations for administration, the resident will be educated and physician notified for further evaluation. -Narcotics (including refrigerated and unrefrigerated medications) will be double locked, and counted by the incoming and outgoing nurse. -Medications are documented as given at the time of administration. Residents will be observed after medication administration to ensure the dose was completely swallowed. If only a partial dose is taken, this is noted on the MAR (medication administration record) with additional interventions taken as appropriate. -Liquid medication orders will contain both the milligram and milliliter to be administered in the body of the order. II. Resident #1 A. Resident status Resident #1, age 77, was admitted on [DATE] and passed away in the facility on 6/6/21. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/27/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of eight out of 15. He required extensive assistance of two staff members with mobility and ADLs. He received scheduled and as needed pain medication and had a chronic disease that may result in a life expectancy of less than six months. He received hospice care in the facility. B. Record review Resident #1 was admitted with hospice services in place. Review of nursing notes from 5/21/21 to 6/4/21 revealed the resident experienced a steady decline in both physical and cognitive condition which the facility and hospice managed. On 6/3/21 an order was written for the resident to receive: [MEDICATION(S)] 4 mg(milligram)/ml (milliliter) oral liquid-sublingual (SL). Give 8mg SL every four hours for increased pain. A hospice note from 6/4/21 revealed the resident was in the active dying process, had signs of mottling in his knees and was experiencing increased anxiety and pain. He received as needed doses of pain medication in between scheduled doses. Review of the resident's nursing notes from 6/4/21 to 6/6/21 revealed the resident continued to decline with medications and nursing services provided to keep him comfortable. On 6/6/21 an incident note revealed a medication error had occurred and the resident had passed away an hour and half after the incorrect dose was administered. The incident note read, This nurse pulled out bottle of [MEDICATION(S)] and the syringe used for administering medication from narc (narcotic) box. Prepared other medications that were to be administered as well and brought them to the elder's (resident's) room. Nurse then used a 3ml syringe to pull up 3mls of [MEDICATION(S)] and gave to elder. Then pulled another 3mls and gave to elder. Then pulled 2 more mls of [MEDICATION(S)] and also gave that to elder. Staff Actions at the time of incident: Nurse went to return [MEDICATION(S)] to narc box and sign the [MEDICATION(S)] dosage on the narc book and saw that previous administrations were for 2 mls. This nurse called on-call nurse immediately, then called (hospice company) and talked with hospice nurse and MD (medical doctor). Nurse told elder's partner, who was at the elder's bedside about the dosage he was given. Nurse talked to on-call to call and update son about dosage and elder's condition. Report done with LPN (licensed practical nurse) to take over cart and other elders and RN to follow-up with elder's condition. C. Facility investigation On 6/6/21 the facility began an investigation of the incident immediately upon learning of the medication error. The facility self-reported the incident to appropriate agencies as required. The investigation revealed RN #1 misinterpreted the order as it was written due to a combination of how the order was written and the strength of the medication delivered from the hospice pharmacy. The order as written read: [MEDICATION(S)] 4 mg/ml oral liquid-sublingual (SL). Give 8 mg SL every four hours. The facility investigation determined the written order did not include the milliliter amount to be administered to the resident, which could have prevented the error. Additionally, the facility pharmacy delivers medications at a strength of 1 mg/ml, though the resident's medication from the hospice pharmacy was delivered at 4 mg/ml. The resident's death certificate was received on 8/25/21 and revealed the resident's manner of death was an accident and the cause of death was acute [MEDICATION(S)] toxicity due to administration of incorrect dose of [MEDICATION(S)] under hospice care. Other significant conditions were metastatic [CONDITION(S)]. III. Facility actions The facility took action immediately after the medication error to identify any other potential areas of concern and prevent any recurrence. On 6/6/21 upon identification of the error, RN #1 was removed from the medication cart and sent for a drug screen which was negative. RN #1 was suspended from working in the facility during the course of the investigation and did not return to work until 6/21/21. The facility reported the incident to the board of nursing and the investigation remains ongoing. In addition to the suspension, RN #1 remains under counselling and coaching with the facility staff development coordinator (SDC). Each nurse working in the facility on 6/6/21 received immediate education related to medication administration and the rights of medication administration. An audit of all liquid medication orders was conducted on 6/8/21 and a follow up audit was conducted on 6/10/21 to ensure any needed modifications had been made. The facility policy and procedure for medication administration was revised on 6/9/21 to include: 13. Liquid medication orders will contain both the milligram and milliliter to be administered in the body of the order. An additional facility education titled Learning from Mistakes: What medication errors teach us June 2021 was completed by all facility nurses (43) by 6/19/21. At least one medication pass observation was completed on each facility nurse by 6/25/21. The medication pass observations continued at random of at least five per quarter to ensure ongoing compliance. -There were no issues with these medication pass audits upon review during the survey 9/7/21 to 9/9/21. The facility created a medication management committee which met every other week and discussed medication errors, how to prevent them, and any challenges. The committee consisted of the SDC, the director of nursing (DON), RN #1 and various other nurses in the facility. III. Interviews The SDC was interviewed on 9/9/21 at 12:05 p.m. She stated RN #1 had worked in the facility since April 2018 and had never had any disciplinary action or issues prior to the error on 6/6/21. She stated RN #1 was working as a resource nurse manager in the facility and had been the interim infection preventionist in the past. She stated after the incident, the nurse was suspended from working in the facility and had been receiving coaching and counseling since the incident. She was no longer working as a nurse manager and was given a consistent assignment and schedule rather than moving around the facility and filling in shifts. She stated the facility also now required all medications to come from their pharmacy for more consistent and streamlined orders, concentrations, packaging, and equipment. She stated the medication management committee had been very helpful for the nurses and the administrative staff to communicate about challenges, possible issues, near misses, and solutions to prevent any other medication errors in the future. The DON was interviewed on 9/9/21 at 12:15 p.m. He stated immediately following the incident RN #1 was interviewed and stated the morning was quiet and calm. He said, she obtained the medications for Resident #1 and administered them. He stated narcotic medications come in different strengths from different pharmacies and the resident's [MEDICATION(S)] came from the hospice pharmacy and was four mg/ml instead of the traditional one mg/ml. He stated that did not excuse the error as the strength was written on the bottle and in the order. He stated the facility immediately educated the nurses who were in the facility at the time and each nurse before their next shift in the facility. He stated the facility also arranged with all hospice providers to obtain medications from the facility pharmacy to prevent any further errors. He stated every nurse had at least one medication pass observation and most had more than one. The NHA was interviewed on 9/9/21 at 12:30 p.m. She stated the nurse who made the error was immediately removed from the floor and was suspended from the facility for two weeks. She stated the facility took immediate action to prevent any further errors and had ongoing programs and ongoing monitoring to ensure there was no recurrence. Licensed practical nurse (LPN) #1 was interviewed on 9/9/21 at 1:20 p.m. She stated she received medication administration education two days ago. She stated she had also received the education two or three months prior when there was a medication error in the facility. She stated she had a random medication pass observation conducted by the SDC about two weeks ago. She stated a medication order should state the medication, the strength, the dose, the route of administration and when the medication should be given. She stated she signed out medications when she poured them. RN #2 was interviewed on 9/9/21 at 1:30 p.m. She stated she had last received medication administration education last week. She stated all of the nurses had a big training after a medication error a few months ago, though they continuously train the staff in the facility. She stated the SDC completed a medication pass observation on her within the last couple weeks and the pharmacist did an observation on all the nurses in the facility a while ago after the medication error. She stated medication orders should have the medication, the milligrams and the milliliters if it is a liquid. She stated the facility now received all of the medications from the same pharmacy so there was no confusion on how the orders were written or different concentrations of medications. She stated if a medication order looked wrong or was missing information, she would not give the medication and would call the physician for clarification. LPN #2 was interviewed on 9/9/21 at 1:35 p.m. She stated she started working in the facility in June 2021 after the incident. She stated she received all of the medication administration education prior to working on the floor and she stated she had been observed for medication passes three times since she started. She stated if a medication order did not include all of the required information, she would call the physician for clarification before administering the medication to a resident. She stated all of the medications in the facility come from the facility pharmacy, even the hospice medications.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards in one of three medication rooms, and two of six medication carts. Specifically, the facility failed to: -Date two vials of [MEDICATION(S)] when opened on the first skilled floor; -Date a Wixela inhaler when opened on the third floor west medication cart; and, -Date a Breo inhaler when opened on the third floor east medication cart. I. Professional references According to the [MEDICATION(S)] package insert, retrieved on 5/3/21 from: https://www.fda.gov/media/ /download, A vial of [MEDICATION(S)] which has been entered and in use for 30 days should be discarded. According to the Wixela prescribing information, retrieved on 5/3/21 from: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=3beef422-8a07-4a45-9ba6- 1e4b7e2, Wixela should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard Wixela one month after opening the foil pouch or when the counter reads 0, whichever comes first. According to the Breo prescribing information, retrieved on 5/3/21 from: https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Breo_Ellipta/pdf/BREO-ELLIPTA-PI-PIL-IFU.PDF, Discard Breo Ellipta six weeks after opening the foil tray or when the counter reads 0, whichever comes first. II. Observations and interviews On 4/28/21 at 8:57 a.m. the first floor medication storage room was found to have two opened vials of [MEDICATION(S)] with no date of opening on the vial. Assistant director of nursing (ADON) #1 said the night shift should have noticed the undated vials. She said the vials were good 28 days after opening. She said with no open date she did not know when they were opened and would discard them right away. On 4/28/21 at 9:24 a.m. the third floor west medication cart had a Wixela inhaler with no date of opening. The storage instructions on the side of the box was shared with registered nurse (RN) #3. She said she did not know the inhaler had a limited time to be used after opening and would discard the inhaler right away. On 4/28/21 at 9:40 a.m. the third floor east medication cart had a Breo inhaler with no date of opening. The storage instructions on the side of the box was shared with RN #1. She said she did not know about the expiration time and would discard the inhaler right away. III. Management interview The director of nursing (DON) was interviewed on 4/28/21 at 2:15 p.m. He said the two [MEDICATION(S)] vials should have been dated to know if the preservative is still good to ensure the efficacy of the medication. He said the inhalers should have been dated for the same reasons. He said education would be provided to the staff.

Based on observation, record review and interviews the facility failed to ensure food safety and sanitation of personal resident refrigerators on three of three floors. Specifically, the facility failed to ensure personal resident refrigerators were maintained, monitored, and cleaned. Findings include: I. Facility policy and procedure The Resident Room Refrigerator policy, updated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:32 p.m. It read in pertinent part, Refrigerators and freezers will be cleaned, (and) contents properly stored. Housekeeping will check refrigerators to verify appropriate storage and cleanliness as part of routine cleaning of resident rooms. Refrigerators will be cleaned a minimum of weekly and as needed for spills and spoiled food. If any care partner sees food or beverages that is spoiled or has safety issues please discuss the questionable item with the resident. Food and beverages will be discarded on a regular schedule or every 2 (two) days and/or when the food/beverage is past the printed expiration date. II. Observations and resident interviews Personal refrigerators in 12 rooms (305, 323, 336, 200, 204, 228, 230, 232, 234, 236, 223, and 102) did not have a temperature or cleaning log accompanying the refrigerator. Personal refrigerators in eight rooms (305, 336, 208, 228, 230, 234, 223, and 102) did not have thermometers in them. An observation on [DATE] at 11:06 a.m. revealed opened juices in the room of Resident #73. The resident had opened 46 oz. Sysco thickened orange juice, with an expiration date of [DATE], on his bedside table. There was no open date documented on the carton. It was room temperature to the touch. A second identical carton was found opened, with an expiration date of [DATE], on the resident's television stand. There was no opened date documented on the second carton, and it was also at room temperature to the touch. Once the second container lid was opened, mold was observed inside the opening. The cartons' instructions stated After opening, may be kept up to 7 days under refrigeration. Certified nurse aide (CNA #10) entered Resident #73's room on [DATE] at 11:10 a.m. She said the CNAs and the nurses would often bring the resident thickened drinks for his room, since the resident did not always like to leave his room. She said the two cartons in his room may have been brought to him recently. She was not sure when they had come to his room, but that they would have been left for him. The CNA observed the mold inside one of the cartons, and she said that perhaps staff should date when they were opened. She discarded the cartons. Resident personal refrigerators from all three floors were observed on [DATE] between 2:40 p.m. and 4:05 p.m. and revealed the following: In Room 305, at 2:40 p.m., the refrigerator had visible food residue on the inside surfaces and the freezer compartment was frosted shut. The resident said no one checks or cleans out the refrigerator. She said something had started to smell in the refrigerator, and she did not know the source. In Room 323 at 2:45 p.m., there was an unopened yogurt dated [DATE] and un-dated food inside of a plastic bag inside the refrigerator. The resident said no one came to clean the refrigerator. He said the refrigerator was left in his room by the former occupant. In Room 336, at 2:50 p.m., the freezer was dirty with food residue stuck on the freezer surfaces and needed to be defrosted. The contents of the resident's refrigerator included: Guacamole in freezer expired [DATE] on package and facility label dated ,d+[DATE], Two expired unopened guacamole containers in fridge expired [DATE], one opened brown guacamole in container expired [DATE], no open date was indicated on the packaging, one mold-covered guacamole expired [DATE], no open date was included on the open package, multiple expired Sargento Snack packs containing cheese, nuts, and dried fruit, three packages of six individual snack containers expired on [DATE]. -Three packages of six individual snack containers expired [DATE], [DATE], and [DATE], an undated plastic bag contained half of a large cookie that was hard as a rock, an undated apple pie from a fast-food restaurant was stuck to the back of the fridge by a sticky substance, an undated, open container of instant mashed potatoes was completely covered in mold. -Two open, un-dated bottles of nutritional supplement (Ensure) expired [DATE] and [DATE]. The cheese in the container was dried out and moldy. -The resident said her refrigerator had not been cleaned or gone through since visits stopped because of COVID-19. She said her family cleaned and maintained the refrigerator for her. She said she was not able to access the refrigerator herself and needed staff assistance to get her snacks out of the fridge. She said staff would sometimes clean it. She said some of the food had been in there for over a year. In Room 200, at 3:00 p.m., the inside of the fridge was clean. The leftover food in a facility container in the refrigerator was un-dated and there was a small carton of milk that expired on [DATE]. -The resident said no one comes to clean their refrigerator or to check the temperature. She said she and her husband kept it clean and needed to throw out the old food in the fridge. In Room 228 was observed at 3:10 p.m., The food in the fridge was un-dated. In Room 230, at 3:20 p.m. the refrigerator had a smell emanating from it after being opened, the open packages of food were un-dated and some unlabeled. The freezer compartment was frosted shut. Room 232, at 3:22 p.m., the thermometer in the refrigerator read 30 degrees Fahrenheit (F). The freezer compartment was frosted shut. Room 234, at 3:30 p.m., there were no dates on the open containers and leftover food. -The resident said no one cleans or checks the temperature of my refrigerator for me. She said she has to clean the refrigerator herself. Room 236, at 3:35 p.m., the thermometer inside the refrigerator ready 35 degrees F. The freezer compartment was frosted shut. -The resident said she completed the cleaning of her refrigerator. She said she needed to defrost the refrigerator but did not know what to do and when she asked the staff, they said they did not know either. Room 223, at 3:40 p.m., no dates on opened food packages in the refrigerator. Room 102, at 4:05 p.m., there was food residue on the inside of the refrigerator and freezer compartment. An open bottle of chocolate sauce expired [DATE] and an open bottle of supplemental nutrition (Ensure) expired [DATE]. III. Record review The facility director (FD) provided temperature logs on [DATE] at 12:21 p.m. The temperature logs revealed the last temperature taken for an unspecified floor was in [DATE]. The temperatures were taken and recorded weekly. The last temperature logs for the other two unspecified floors were dated [DATE] and were blank. IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on [DATE] at 3:25 p.m. She said it was the night shift's responsibility to clean and check the temperature of resident refrigerators. Housekeeper #1 was interviewed on [DATE] at 3:42 p.m. He said the CNA and nurses usually check the temperatures and were responsible for cleaning the resident refrigerators. Dietary aide (DA) #1 was interviewed on [DATE] at 3:50 p.m. She said she was not sure if nursing staff or dietary staff were responsible for cleaning the resident refrigerators. She said all food should be labeled with a date before being put into any refrigerator. CNA #4 was interviewed on [DATE] at 3:55 p.m. She said the housekeeping staff was responsible for cleaning the resident refrigerators. She said if she was asked or noticed a resident refrigerator needed cleaning she would clean it. CNA #5 was interviewed on [DATE] at 3:57 p.m. She said nursing staff could clean the resident refrigerators but did not know who was responsible for cleaning and monitoring them. Registered nurse (RN) #5 was interviewed on [DATE] at 3:58 p.m. She said she thought housekeeping was supposed to clean and monitor the resident refrigerators. She said some CNAs will clean out the refrigerators if they notice the refrigerators need attention. Assistant director of nursing (ADON) #1 was interviewed on [DATE] at 4:00 p.m. She said nursing staff and dietary staff had to clean and monitor resident refrigerators. She said temperatures should be checked every 24 hours. She said the temperatures in the resident refrigerators were not being checked. She said open food in residents' refrigerators, from the facility or family members, should be cleaned out after 72 hours. She said the inside of resident refrigerators should be cleaned regularly. She said not all fridges in resident rooms had thermometers. She said there should not be one-year-old food in resident fridges. She said if there was no date on open food it should be thrown away because staff would not know how old it was and if it was safe for resident consumption. CNA #6 was interviewed on [DATE] at 4:10 p.m. She said she did not know who was responsible for cleaning and monitoring resident refrigerators. The dietary manager (DM) was interviewed on [DATE] at 11:20 a.m. He said housekeeping was responsible for cleaning personal resident refrigerators. He said he was not sure who should check temperatures. He said leftovers from meals should not be in the fridge past 72 hours of the date on the container. He said packaged foods should be thrown out according to the date on the package. He said any spoiled/moldy food should be thrown out. The FD was interviewed on [DATE] at 11:53 a.m. He said he started as FD three months ago and was still compiling a working list of things he needed to do in the facility. He said housekeeping staff should be checking temperatures, cleaning, and monitoring the personal resident refrigerators. He said he did a walk-through of the facility to find out who had personal refrigerators, temperature sheets, and thermometers. He said refrigerator temperatures should be checked and documented weekly. He said all personal resident refrigerators should have thermometers. He said food in resident refrigerators should be thrown out two days after it was put into the refrigerator. He said he was working on equipping all personal refrigerators with temperature sheets, thermometers, and educating his staff. -The previous observations and interviews indicate a clear systemic breakdown regarding who is to monitor the resident refrigerators.

Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident ' s goals and preferences for two (#33, and #96) of three residents reviewed for oxygen therapy out of 40 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy The oxygen policy, provided by the director of nursing (DON) on 4/29/21 at 8:40 a.m., revised on 3/5/2020, included, Oxygen will be administered per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] II. Resident #33 A. Resident status Resident #33, [AGE] years old, was admitted to the facility on [DATE]. According to the April 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/1/21 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) of seven out of 15. The MDS identified the resident utilized oxygen. B. Record review The long term story care plan, updated 11/15/2020, identified the resident wore oxygen because of [CONDITION(S)] and encouraged staff to check the oxygen level if the resident felt short of breath or more weak than usual. -The care plan did not identify the resident would remove the oxygen nasal cannula. The April 2021 CPO included: -Oxygen (O2) at one liter per minute (lpm) by (via) nasal cannula continuous ordered 2/2/21. C. Observations and interviews On 4/27/21 at 10:27 a.m. Resident #33 was laying down in his bed. He had his nasal cannula on, but the concentrator was not on. Registered nurse (RN) #1 was asked about Resident #33 and his oxygen. She said he was ordered 1 LPM continuously. She said he took off his oxygen often and the facility could make him wear it, but the facility did monitor him for low oxygen levels. After she was informed his concentrator was off, she went into his room and turned on the concentrator. She said the aides could turn on the concentrator. She said they were not allowed to adjust it. She checked and the concentrator setting was at 1 LPM. She said the concentrator should have been on. On 4/27/21 at 2:30 p.m. Resident #33 was in his room in bed with his nasal cannula on, and the concentrator was off. Certified nurse aide (CNA) #2 said the concentrator should be on. She turned on the concentrator. The concentrator was set to 2 LPM. She said the concentration should be set at 2 LPM. She said she was told by the nurse of the LPM setting the concentrator should be set at. She said he often would take off his nasal cannula. On 4/27/21 at 2:57 p.m. RN #2 said Resident #33 often would take off his oxygen. She said he was non-compliant about wearing the nasal cannula. She said his order was for 1 LPM. She checked the setting on the concentrator and adjusted it to 1 LPM. She said it should be at the ordered setting to make sure he was receiving the correct dose prescribed. She said too much oxygen could increase the [MEDICATION(S)] and be more harmful. She said oxygen was a medication. She said aides were not allowed to adjust the concentrator. D. Interview The DON was interviewed on 4/28/21 at 2:05 p.m. He said oxygen was a medication. He said Resident #33 was ordered 1 LPM continuously. He said the resident often refused to wear the oxygen. He said if the resident refused to wear the oxygen, he would expect the nurse to write a note. He said the long term story care plan should have identified he would remove the nasal cannula. He said if Resident #33 was in his room and in bed, the concentrator should be on and at the correct setting. He said if the resident received too much oxygen he could develop high [MEDICATION(S)] levels which are dangerous. He said education would be provided to the staff. II. Resident #96 A. Resident status Resident #96, age 85, was admitted [DATE]. According to the April 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/29/21 MDS assessment revealed the resident had significant cognitive impairment. The resident was totally dependent on two people for transferring. She had impairment on both sides, with limited range of motion for upper and lower extremities. She required oxygen therapy. She did not reject care. B. Record review A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Keep oxygen saturation 88% and above. Inhalation every shift. For [CONDITION(S)]. Review of the daily vital signs from 2/1/21 through 4/28/21 revealed the resident was charted to be on 3 LPM, 14 times out of 134 opportunities. All other documented opportunities indicated the resident was on 2 LPM. The resident ' s care plan narrative, last revised 4/13/21, identified that because of her chronic respiratory failure with [CONDITION(S)], she required supplemental oxygen. C. Resident observations On 4/26/21 at 11:17 a.m. Resident #96 was observed resting in the hallway common area, near the kitchenette, in her tilted high back wheelchair. She was using her portable oxygen concentrator. It was set at 2 ½ LPM . -At 11:25 a.m. certified nurse aide (CNA #10) took the portable oxygen concentrator to be refilled. She returned, placed the full portable oxygen concentrator back on the resident ' s wheelchair, and placed it for the resident to use. The CNA set the concentrator back on 2 ½ LPM. On 4/27/21 at 10:05 a.m. the resident was observed in her room, in her wheelchair. Her room oxygen concentrator was on and in use. It was set at 2 LPM. On 4/28/21 at 7:46 a.m. Resident #96 was observed in the hallway common area, seated in her wheelchair. Her portable oxygen concentrator was missing. A minute later CNA #10 was observed placing the full portable oxygen concentrator on the resident ' s wheelchair, and put in place for the resident to use. The CNA set the concentrator on 2 ½ LPM. D. Staff interviews On 4/28/21 at 7:48 a.m. CNA #10 said that the night staff usually refilled the oxygen tanks before the end of their shift, but she always checked anyway, to make sure they were all filled. She said someone must have forgotten to double check Resident #96 ' s. She said the resident was on 2 ½ LPM. She said she would not adjust the liters. She said she knew what to put the liter flow on by looking at what the room concentrator was set on. She went to the resident ' s room, turned the room oxygen concentrator on, and said that it also read 2 ½ LPM. She said that was how she knew it was supposed to be set at 2 ½ LPM. She said each morning she received a piece of paper from the nurse to take resident vitals. She said she then turned the paper back into the nurse, so they could put the information into the resident ' s chart. Registered nurse (RN #7) was interviewed on 4/28/21 at 7:55 a.m. He said that the CNAs filled out the vital forms each morning, and then gave them to him. He said he then put the information into the residents ' records, and also verified the orders when he did it. He said he thought Resident #96 was on oxygen at 2 LPM. He went to the resident, and looked at her portable oxygen concentrator, and said it was currently set at 2 ½ LPM. He said he would check the resident ' s oxygen physician order. After the RN reviewed the resident ' s order, he said the resident had an order to be on oxygen at 3 LPM. He said that the CNAs had to turn the portable oxygen concentrators off to refill them, but they should place the oxygen back onto the liters they were already on. He said that the white boards in the residents ' rooms was where they would write what the oxygen order was, for reference. He went to the resident ' s room, and pointed out that 3 LPM was written in the top corner of the white board for Resident #96.

Based on observation, interview and record review the facility failed to implement an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) communicable diseases and infections for two out of six wings. Specifically, the facility failed to: - Have alcohol based hand rub readily available. - Change gloves and perform hand hygiene after cleaning the bathroom, a dirty surface prior to cleaning clean surfaces. - Perform hand hygiene before and after resident care. Findings include: I. Status of COVID-19 in the facility The nursing home administrator (NHA), the director of nursing (DON), the infection preventionist (IP), and executive director (ED) were interviewed on 5/7/2020 at 10:00 a.m. regarding COVID-19 status at the facility. The NHA said they received 50 cloth gowns recently which they were in need of since they were in critical capacity with gowns. She said more were ordered and on the way. The NHA said that there were no test positive for COVID-19 residents in the building. She said they had a resident test positive on March 31, 2020 and recovered by April 21, 2020. She said that one staff member who had not worked in the building since April 2, 2020, still testing positive. She said that staff member was shared with another facility, however as she said before the staff member had not been at the facility since April 2nd. The NHA and the DON said that they were in phone contact with Colorado Department of Public Health and Environment (CDPHE) and TriCounty Health Department (TCHD). The NHA said that they started the communication with CDPHE on March 5, 2020. She said that the reason for starting the communication with CDPHE and TCHD was because a resident ' s family had visited and soon after tested positive for COVID-19. They treated the resident as presumptive and implemented isolation precautions. She said the facility implemented strict visitation, hand hygiene, cleaning protocols and the universal wearing of a mask on March 11, 2020 after two local hospitals had positive COVID-19 cases. The ED said that the facility had closed entrance to visitors/vendors before March 8, 2020 when the Governor ' s mandate was to close nursing homes to visitors. The IP said she sent the facility's COVID-19 tracking and monitoring information to CDPHE TCHD weekly but would increase communication if the facility had positive COVID-19 cases. The IP said that the resident that had possible exposure from family visit had two negative COVID-19 tests completed. She said that currently they had one presumptive test pending for a resident with a symptom of runny nose. The IP and NHA said that there were television screens on units that showed the Centers for Disease Control's (CDC) guidance on how to don and doff personal protective equipment (PPE). The DON, NHA and IP said that they had enough disposable gowns at this time and did not need to use the cloth gowns, however they had cloth gowns for when it would be necessary to use them. They said that they were reusing goggles. The staff were instructed to clean them between use with bleach wipes. In the isolation rooms the staff were to use the face shields along with the N95 mask which was disposed of after use and before leaving the room. The IP said she provided training to all department personnel about COVID-19 management in the building. She said that included the housekeeping department. She said that the housekeeping department manager did training with the staff as well. She said that they did constant education on the cleaning of high touch surfaces. She said the training included discussion on the appropriate chemical to use during the pandemic. She said the company was able to obtain a chemical that can be sprayed on the surface that required no surface contact time. She said the education included what to do for a resident with a multidrug resistant organism (MDRO) and influenza regarding the type of precautions to take and type of PPE to be used. She said that she provided training every week on hand hygiene which included observing the staff and providing on the spot training. II. Housekeeping A. Professional standard According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html. It read in pertinent part, Multiple opportunities for hand hygiene may occur during a single care episode. Following were the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer (ABHR), put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. B. Observations On 5/7/2020 at 11:45 a.m. observed a CNA exiting a room, after performing resident care, and walked three rooms away to perform hand hygiene. The ABHR was not readily available to the CNA; the locations of the ABHR dispensers were in the cubbies located in the middle of the six hallways and medication carts. Housekeeper (HSK) #1 was observed on 5/7/2020 at 10:34 a.m., cleaning rooms on the second floor East wing. - She donned gloves and removed the cleaning tote from the housekeeping cart. She attempted to clean a room, but the resident in that room needed to use the bathroom. HK #1 exited the room, returned the tote to the cart, and removed her gloves. She threw the gloves away in the trash but did not perform hand hygiene after removing her gloves. - She pushed the cart down the hall in front of room [ROOM NUMBER]. She donned clean gloves and collected supplies in her plastic tote. - She entered the room and removed a spray bottle of disinfectant from the tote. The tote was on the floor in front of the bathroom. - After cleaning and vacuuming the room she removed her gloves. She donned new gloves, however, she did not perform hand hygiene. - She removed the toilet brush from her tote and scrubbed the inside of the toilet. She placed the toilet brush back into its holder, in the tote, which also held the disinfectant spray bottle and glass cleaner bottle. - She did not change her gloves after cleaning the toilet and began to clean the rest of the bathroom. - She emptied the bathroom trash and disposed of it on her cart. She sprayed the bathroom floor with disinfectant and let it set for two minutes and mopped the floor. She removed the mop pad, from the mop head, placed it in the dirty rag bag, tied the bag shut and placed it on the cart. - She walked back to the room and sprayed the vacuum and the mop handle with the disinfectant spray. She was still wearing the same dirty gloves she cleaned the bathroom. - She removed a white rag, from the rag bag, and wiped down the mop handle. She placed the mop handle back on the cart and put a wet floor sign at the bathroom entrance. She wiped down the vacuum handle, the cord and the base. She cleaned those items with the gloves she used to clean the toilet. - She reached into the clean rag bag and removed the last white rag with the same dirty gloves. She then wiped down everything that was stored in the tote. She failed to clean the outside of the tote which she took from room to room. C. Interviews HSK #1 was interviewed on 5/7/2020 at 11:01 a.m. She said she recently attended hand hygiene training. She said she did not know she had to perform hand hygiene every time she removed her gloves or after cleaning the bathroom. She said she had ABHR in her cleaning cart. The housekeeping manager (HSKM) was interviewed on 5/7/2020 at 11:28 a.m. He said he did hand hygiene training a couple weeks prior, to his housekeeping staff. He said ABHR was to be rubbed into the hands for 20 seconds. He said hand hygiene should be performed after removing gloves, after cleaning the bedroom and after cleaning the bathroom. He said he would provide training to his staff immediately on proper hand hygiene. III. Shared equipment A. Observations On 5/7/2020 at 10:40 a.m. observed CNA #1 obtaining vital signs from two different residents sitting in the common area. The CNA did not perform hand hygiene between physical contact with each resident. At 10:58 a.m. observed CNA #2 obtaining vital signs for a resident in their room in hallway 200 West side. She then assisted that resident by handing the resident the television remote and their personal water pitcher. The CNA left the room and went into the room next door and obtained vital signs on that resident without performing hand hygiene after physical contact with the residents. B. Interviews CNA #1 was interviewed on 5/7/2020 at 10:45 a.m. She stated she used hand sanitizer or washed her hands with soap and water before providing care to residents. The DON and the IP were interviewed on 4/7/2020 at 11:45 a.m. They stated that all staff were educated on hand washing or use of hand sanitizer before and after all resident care. They said to ensure staff compliance they would provide more ABHR dispensers throughout the building. They said that they would provide staff with personal containers of hand sanitizer.

Based on observations, record review and interviews; the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced the dignity and respect, affecting one of three dining rooms. Specifically, the facility failed to ensure residents in the assisted area of the dining room did not wait for extended periods of time after the stated meal times to receive their meals. Findings include: I. Facility policy The Quality of Life Dignity policy, revised 8/09 was provided by the nursing home administrator (NHA) on 5/2/19 at 10:37 a.m. It read in pertinent part, Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The dining room was open at all times; however, dining room service start times were as listed below: -Breakfast served at 8:00 a.m. -Lunch served at 12:00 p.m. -Dinner served at 5:00 p.m. II. Group interview A group interview was conducted on 4/30/19 at 1:30 p.m. There were eight residents in attendance. Four of the eight residents said at times it took a long time to be served their meal in the dining room. One resident said sometimes they would not get served any water to drink and the residents at her table could not pour the water themselves One resident said after they were served their meal no one ever came back to check to see if they needed anything else. Two residents said they were always served their meal last. III. Meal observations Observation of the Terrace dining room 1.Tuesday 4/30/19 -At 8:03 a.m. Resident #6 was in the dining room being assisted with her breakfast by a family member. -At 8:13 a.m. several residents were being assisted to the dining room by staff. There were water carafe's observed on the dining tables. Resident #75 had a breakfast meal in front of her, (bowels with saran wrap around them and two drinks with saran wrap). The nursing home administrator (NHA) was in the dining room greeting residents serving coffee and Danish's. The server was observed behind the steam table and not assisting the residents with eating . -At 8:15 a.m. certified nurse aide (CNA) #1 was pouring drinks to independent residents throughout the dining room and taking orders. There were two assist tables with residents present who had not been served any drinks or offered any breakfast. -At 8:25 a.m. Resident #100 was assisted to the dining table. The staff member who assisted her to the table did not take her breakfast order or offer to bring her anything to drink. -At 8:30 a.m. Resident #75 was sitting in her wheelchair with her eyes closed with her meal in front of her no one had offered her any assistance with her meal or her liquids. The NHA was still rounding in the dining room serving coffee and Danish's to independent residents, other staff were starting to take residents breakfast orders. -At 8:34 a.m. the NHA was observed at Resident #100's table. She poured Resident #100's table mate coffee and milk. She said good morning to Resident #100 and walked away, she did not offer her anything to drink. -At 8:37 a.m. RN #1 entered the dining room and gathered a clothing protector for Resident #100 then she walked away, she did not offer Resident #100 anything to drink. -At 8:27 a.m. Resident #28 began yelling for apple juice. -At 8:30 a.m. Resident #28 was served some apple juice. -At 8:32 a.m. The restorative CNA sat down to assist Resident #129 with his breakfast meal. -At 8:39 a.m. Resident #28 began yelling he wanted to leave CNA #1 offered the resident something more to eat and drink; however, the resident insisted on leaving so the CNA assisted him out of the dining room. -At 8:44 a.m. RN #1 offered Resident #100 toast and orange juice for breakfast, Resident #100 agreed. Resident #100 sat for 19 minutes without being offered anything to drink. -At 8:43 a.m. Resident #31 was assisted to Resident #75, Resident #78 and Resident #11's table. CNA #1 brought Resident #11 a cup of coffee and piece of coffee cake, he did not offer any of the other residents at the table anything to eat or drink. Resident #75 sat with her eyes closed and her meal and drinks in front of her without any assistance for the past 30 minutes. -At 8:48 a.m. Resident #31 was observed rummaging through the creamer and sugar bowl. She took one of the liquid coffee creamers and bit into it and started to drink the creamer. -At 8:51 a.m. CNA #11 served Resident #98 juice and oatmeal and the resident began to eat independently. Residents #2 and #68 were not offered anything to eat or drink. -At 8:52 a.m. Resident #31 continued to rummage through the cream and sugar bowel, and she bit into another coffee creamer. Several staff observed in front of the steam table and prepping room trays. CNA #1 left the dining room with a room tray. -At 8:56 a.m. CNA #3 continued to set up room trays while CNA #2 and CNA #11 were just standing in front of the steam table -At 8:58 a.m. CNA #1 came back in the dining room and sat at Resident #6's table to assist a male resident with his breakfast. -At 9:01 a.m. there were four staff standing in front of the steam table waiting to deliver the last of the room trays. -At 9:03 a.m. several breakfast trays were being delivered into the dining room. -At 9:04 a.m. Resident #31 was sitting with a paper cup in front of her she continued to pick up the cup, bring it to her mouth to take a drink but there was nothing in her cup. She repeated this action for a few minutes. -At 9:07 a.m. RN #5 came in the dining room and administered medication to an alert an oriented resident. He asked the residents at the table if they needed anything else to drink, they said no and then he walked out of the dining room. -At 9:08 a.m. CNAs #2 and #4 were observed delivering meals to the residents. -At 9:10 a.m. CNA #11 sat at Resident #6's table to assist a female resident her with her breakfast. -At 9:11 a.m. Resident #98 spilt her juice. Resident #2 and Resident #68 were sitting at the table with Resident #98 when she was served juice; and they had not been offered any food or drinks. -At 9:12 a.m. Resident #11 was finished with her cake and coffee, while the other three residents at her table had not been offered anything to eat and drink. -At 9:13 Residents #2 and #11 were served their meal and drinks. -At 9:14 CNA #3 brought a cup of hot water and set it down on the table in front of Resident #75. -At 9:15 CNA #4 sat down to assist Resident #68 -At 9:16 a.m. CNA #2 poured Resident #2 and Resident #78 thickened water. -At 09:20 CNA #3 sat down to assist Resident #75 with her breakfast. She removed the saran wrap from the resident's bowls and poured the cup of hot water into one of the bowls. She said she poured the hot water into the resident's cream of wheat and that she had pudding in one of her other bowls and cranberry juice to drink. It had been over one-hour Resident #75 sat with her meal in front of her before she received any assistance. All of the residents in the dining room had been served and the residents had received assistance. 2. Wednesday 5/1/19 -At 5:04 p.m. The NHA in the dining room talking with residents. There were nine residents at the three assist tables. There were no water Carafe's on the dining table. Eight of the nine residents at the assist tables did not have any drinks in front of them. Resident #11 had a cup of coffee. Nursing staff were assisting residents into the dining room and the server was behind the steam table. Resident #75 had a puree kosher diet sitting in front of her. There was a meal at the table were Resident #6 sat for her meals. -At 5:08 p.m. The NHA started passing out bread and butter rolls to independent residents. Assist tables they had three residents at each table. Resident #6 was assisted into the dining room by family and the family began to assist her with her meal. CNA #6 began taking residents orders. -At 5:13 p.m. The NHA began offering soup to independent residents. Resident #31 was assisted to the assist table by CNA #8. -At 5:15 p.m. CNAs #8 and #10 began to set up room trays to be delivered, and CNA #9 began taking residents orders. -At 5:19 p.m. CNA #8 delivered a room tray down the hall. -At 5:23 p.m. The NHA began passing water to independent residents. -At 5:27 p.m. Resident #28 served his meal. -At 5:28 p.m. The NHA began pouring coffee to independent residents. -At 5:30 p.m. Resident #129 was served his meal along with several other independent residents. -At 5:34 p.m. CNA #8 poured Resident #31 some cranberry juice, and then she poured Resident #2 and Resident ##78 thickened water. -At 5:37 p.m. CNA #10 began pouring drinks to the residents at the three assist tables, she did not offer or pour Resident #68 anything to drink. Resident #31, Resident #78, and Resident #98 were able to drink their liquids after queuing was provided. -At 5:41 p.m. CNA #8 assisted Resident #75 with a clothing protector and she sat down next to her. She removed the saran wrap from her food, dessert, and soup in bowls. Then she started assisting Resident #75 with her soup. -At 5:45 p.m. The NHA left the dining room. -At 5:46 CNA #8 assisted Resident #75 with her main puree meal. She did not offer to heat the resident's food. -At 5:49 p.m. The last meal tray delivered. IV. Staff interviews The NHA, director of nursing (DON), director of dining services (DDS), and the executive chef were interviewed on 5/2/19 at 2:30 p.m. The DDS said there one server on each floor. He said the server would set up meal, water, glasses at the table and they would compete an initial round to any residents that are in the dining room and offer drinks. He said the nursing staff were responsible to help assist residents into the dining room, take orders and would serve the residents. He said they did have a food committee to discuss any concerns. The DON said there was a time that the dining room doors were not opened until a certain time and recently they have made it open at all times. She said the residents could go in at any time and would be served coffee if they wanted it; however, the meal service did not start until its designated times. She said they were in the process of making the dining service as an open dining room. The NHA said she implemented the Danish program, and would pass them every morning. She said she was in the dining room Monday through Friday to help the staff with service. They said acknowledged there was a problem with meal service. The NHA said she was in the dining room Monday through Friday for breakfast. She said she had been individually working on the breakfast meal, and believed that the breakfast service had improved. They said it was not okay that residents sat without fluids and did not receive assistance during meal service for over 40 minutes and longer. The NHA said they finally had the right team at the facility to provide oversight, and she recognized they needed more management presence in the dining room and they need to document what they had implemented to review for effectiveness. She said the problems would be addressed.

Based on interviews and record review, the facility failed to provide adequate training and assess competencies for adequate provision of care and services. Specifically, the facility failed to provide the ongoing required 12 hour inservice training, dementia and abuse training for certified nurse aides (CNA) yearly. Findings include: I. Facility policy and procedure The CNA Education and Competencies policy, effective 5/1/19 (during survey), was provided by the staff development coordinator (SDC) on 5/2/19 at 1:31 p.m. It read, in pertinent part, In-service training is offered throughout the year. CNAs will be required to attend a minimum of 12 number of hours training annually. The SDC will manage the content, scheduling and tracking of CNA in-services and competencies. II. Record review The facility assessment revised on 3/27/19, was provided by the nursing home administrator (NHA) on 4/29/19 at 11:00 a.m. It revealed 39% (percent) of the facility's population (out of a census listed as 128 residents) had Non-Alzheimer ' s dementia and 10% had Alzheimer ' s diagnosis. The facility identified the following areas of training required for cognitive, mental and behavioral status as sufficient for staffing companies and services with ongoing education provided internally. The resident census and conditions of resident's form was provided by the director of nursing (DON) on 4/30/19 at 2:00 p.m. The form revealed the facility had a census of 131 residents, 80 residents (61%) had dementia, 25 residents (19%) had documented psychiatric diagnosis (excluding dementia and depression), and 88 residents (67%) had documented signs and symptoms of depression. Review of the facility training spreadsheet of CNA staff revealed: -Fourteen out of 47 total CNAs (30%) of staff for more than one year had not had 12 hour inservice training. -Twelve out of 47 total CNAs (26%) of staff for more than one year had not had abuse prevention training after their initial training when hired. -Forty out of 47 total CNAs (85%) of staff for more than one year had not had additional dementia training since their initial training when hired. III. Staff interviews The SDC was interviewed on 5/1/19 at 11:43 a.m. She said she kept track of the training in-service education for the CNAs via a spreadsheet that included their name and which training they attended for the year. She said when a CNA is hired abuse and dementia training were completed by the human resources department and she kept track after their initial trainings. She said for the CNAs that did not attend mandatory all staff meetings, where dementia and abuse training are covered, they were required to complete the training with a post test and turn it in to be tracked. She said the CNA staff that did not attend the all staff meetings or turn in the make up training were not held responsible by the management staff to ensure compliance with the ongoing training requirements. She said the required 12 hour inservice education, abuse and dementia training among the CNA staff was inconsistent so she implemented a computer based training to help track and in order to provide the required training. The DON was interviewed on 5/2/19 at 10:11 a.m. She said the CNA staff had been provided abuse and dementia training when they were hired but could not say it had been completed yearly. She said she was aware that the CNA training provided was not consistently attended and the lack of follow through with those that did not make the required training. She said CNA staff training and competency training were going to be a focus as a part of their monthly quality assurance meetings.

Based on observation, record review and interview, the facility failed to ensure the resident environment remained as free of accident hazards are possible, and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility failed to assess a residents wandering risk as a potential safety hazard for one (#31) of one out of 46 sample residents. Findings include: I. Facility policy The Elopement, Missing, at risk policy, dated [DATE] was provided by the nursing home administrator (NHA) on [DATE] at 12:00 p.m. It read in pertinent part, Residents will be evaluated for elopement risk on admission, quarterly if risk identified, and with changes of condition. It the potential for elopement is identified, this will be addressed in their long-term or (if a current, acute issue) the acute-temporary care plan. Interventions will be individualized, based on the resident unmet needs and personal history. Elopement drills will be completed annually and PRN (as needed). II. Resident status Resident #31, age 95, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment, revealed the resident was severely impaired. She required extensive one-person assistance with bed mobility, dressing, personal hygiene and toileting and required two-person assistance with transfers. Wandering presence was four to six times but less than daily. It was not documented if the wandering placed Resident #31 at risk for getting into a potentially dangerous place or if her wandering intruded the privacy of activities of others. III. Observation On [DATE] at 4:02 p.m. Resident #31 was observed pacing the hallway. She went to the patio door and touched the door. Licensed practical nurse (LPN) #1 went up to the door and placed a key in the door to ensure it was locked then she walked down the hallway. -At 4:03 p.m. The resident walked up to Resident #25 who was sitting at a table in the common area on the west wing. Resident #25 put her arm up as to shoo Resident #31 away and began speaking loudly in her native language. Then the CNA #5 came and took Resident #31 by the hand and started to walk with her in the hallway. -At 4:14 p.m. Resident #31 was observed ambulating in the hallway, she entered room [ROOM NUMBER]. CNA #5 followed Resident #31 and escorted her out of the room and assisted her into a recliner in the common area. -At 4:17 p.m. Resident #31 stood up from the recliner and began to wander in the common area. -At 4:17 p.m. CNA #5 assisted the resident to sit in a black metal chair. -At 4:25 p.m. Resident #31 wandered into room [ROOM NUMBER]. Someone in room [ROOM NUMBER] started yelling, CNA #5 came walking in the hallway, and assisted Resident #31 out of room [ROOM NUMBER] and began to walk with her in the hallway. IV. Resident interview Resident #49 was interviewed on [DATE] at 3:10 p.m. He said the reason he had the stop sign on his door was to keep Resident #31 out of his room. He said for the most part it did keep her out. He said that he and his wife shared a room on the opposite side of the hallway and she used to come in their room uninvited all the time. He said they had a stop sign when they shared that room but he didn't really get mad if Resident #31 came in the room because his wife didn't mind her visiting, but since his wife died and he moved he did not want her in his room. He said she had been in his room and knocked over several pictures of him and his wife, and tried to get into his wife's ashes and the staff had to place them higher in the room where she could not reach them. He said once she was in his room and he had a small empty water bottle and I just threw it at her. He said he did not think it hit her but she left my room, he said I know that sounds mean but I just wasn't feeling good and I wanted her out. He said he did not tell anyone because she left the room. He said just last week she was in his room again. He said he and other residents would be happy if the facility could find a way to keep her from going into their rooms. He said he knew Resident #31 was not well so he just learned to deal with her coming in his room uninvited. V. Record review The care plan story, initiated [DATE] and revised on [DATE] revealed in the past she was at risk for elopement, entered others personal space, and entered others rooms, but now that her mobility and activity level fluctuated she was at lower risk, intervention included close supervision so that she did not intrude on the privacy of others. Resident #31's daily charting (for wandering) was reviewed for February, March, and (MONTH) 2019. During the month of February, Resident #31 wandered 13 out of the 28 days, all were on evening shift. During the month of March, Resident #31 wandered 19 times out of the 31 days, all days except one was on the evening shift. During the month of March, Resident #31 wandered 17 times out of the 30 days, all were on the evening shift. Review of Resident #31's progress notes revealed staff spoke with Resident #31's medical power of attorney (MPOA) frequently, however, there was no discussion of Resident #31's wandering. The progress note dated [DATE] at 2:42 p.m. revealed Resident #31 wandered during the evening on four occasions but did not put herself in danger or impede on other resident's privacy. -The progress note did not indicate a time frame in which the four occasions of wandering occurred only that they occurred on evening shift. The progress note dated [DATE] at 2:50 p.m. revealed facility staff spoke with MPOA about seating arrangements in the dining room. No mention to the MDPOA regarding wandering. The progress note dated [DATE] at 2:36 p.m. revealed facility staff left a message for the MPOA with an update about seating arrangements in the dining room. No mention to the MDPOA regarding wandering. VI. Staff interviews CNA #7 was interviewed on [DATE] at 11:11 a.m. She said Resident #31 was able to ambulate by herself. CNA #3 was interviewed on [DATE] at 11:29 a.m. She said she worked at the facility for over three years and she worked the day shift. She said Resident #31 wandered daily at least once a shift. She said staff would have to redirect her out of a resident's rooms. She said most of the time the CNAs sat near the charting area to keep Resident #31 in line of sight. She said Resident's #47 and #49 did not like it when Resident #31 wandered into their room. CNA #1 was interviewed on [DATE] at 11:35 a.m. He said he had worked at the facility for close to two years. He said he usually worked day shift on the Terrace unit and once in a while the evening shift. He said Resident #31 could get up and walk on her own. He said she would wander daily unless she was tired. He said she would often go into Resident #49's room. He said as soon as staff saw Resident #31 wandering they would try to redirect her. He said all the staff know to redirect her. He said Resident's #47, #49, and #83 would get upset if she went in their room. He said Resident #49 had a stop sign outside his room to keep her out but the other residents would just have to put their call light on to get Resident #31 out of their room. The nursing home administrator (NHA) was interviewed on [DATE] at 12:04 p.m. She said they were unaware of Resident #49 throwing an empty plastic water bottle at Resident #31 to get her out of his room. She said there had been no resident to resident altercations reported but she would check and interview Resident #49. She said the facility ensured all residents safety. The NHA was interviewed a second time on [DATE] at 12:30 p.m. She said the assistant director of nursing (ADON), activities directors, and the social worker were reviewing current interventions and would provide and review all the new interventions which had been put in to place to ensure Resident #31's safety with her wandering. Registered nurse RN #1 was interviewed on [DATE] at 1:50 p.m. She said Resident #31 wandered often and it often depended on how restless she was. She said there were a few residents who would get irritated if Resident #31 wandered in their room. She said, if the staff found her wandering, they would assist her out of resident rooms and would attempt to walk with her as an intervention for her restlessness. The ADON, activities director, and the social worker were interviewed on [DATE] at 1:55 p.m. The ADON said they had multiple interventions to keep the resident safe when she was wandering. She said they were only aware of Resident #31 wandering into Resident #49 ' s room, but no other resident ' s rooms. She said there was a basket made by activities to keep her busy. She said they had discussions with Resident #31's MDPOA about her wandering and placement elsewhere in the past: the family wanted to keep the resident at the facility. -The activities director said they worked with Resident #31's family closely with interventions to help with her wandering and restlessness because the family preferred the resident stay at the facility. She said they were aware Resident #31 was a nurse so they obtained videos she could watch about nursing. They had memorabilia and pictures that she could view to keep her busy. -They said she had mechanical cat that purr's and responded to touch which they utilized, and she was seen by musical therapy weekly. They said as an interdisciplinary approach they would review residents for wandering to ensure if they were appropriate for the facility. They had no response to several residents being upset that Resident #31 wandered into their rooms or if Resident #31's wandering risk was a potential safety hazard. -The ADON said they felt if Resident #31 was transferred to another facility she would decline rapidly. She said the most recent intervention they implemented that day was physical therapy to assess mobility and possible pain intervention. VII. Follow-up The facility updated Resident #31's care plan to include additional interventions such as a restorative aide to assist with ambulation at 2:30 p.m., music therapy to visit weekly after 4:00 p.m., social worker to reeducate staff on Resident #31's care, and staff to offer meaningful leisure activities such as folding washcloths, pet visits, and looking through magazines. The goal was to keep Resident #31 engaged when she started to wander. They also said they would start interviewing residents on the unit about Resident #31 ' s wandering and if she were entering other rooms uninvited and if it bothered them.

Based on multiple observations, interviews, and review of facility policy, it was determined the facility failed to demonstrate proper hand sanitation practices while handling food during meal service. The findings include: 1. Observation of the 1st floor (Terrace) lunch meal service on 2/20/18 at 12 noon revealed a male Certified Nursing Assistant FF (CNA) assisting R#9 at 12:25 p.m. with her meal. During the observation CNA FF touched the resident's pink pants, and then touched her black shoes, and Geri chair footrests. CNA FF then scratched his head and nose, and covered his mouth with his hand while yawning, and then proceeded to feed R#9. He then paused assisting the resident and put his right hand on top of his black pants. At 12:31 p.m. CAN FF was noted stopping from feeding R#9 and passing his left hand touching while his skin over his right elbow and then continue to feed R#9. CNA FF again stopped and scratched his head with his left hand and then passing it over his face. He then grabbed R#9's soup bowl and continued to feed the resident. At 12:45 p.m. CNA FF was observed rubbing his eyes with his right hand and then proceed to feed R#9 her meal. An interview conducted with the CNA FF on 2/20/18 at 12:57 p.m. revealed when asked what the policy was for feeding residents and touching other surfaces such as pants, face, etc. He reported they were to wash their hands in between assisting residents and touching other surfaces such as clothing, face, etc. 2. Observation on 2/20/18 at 12:15 p.m. in the dining room on the second floor during the noon meal revealed residents were being assisted by four staff members. The Staffing Coordinator (SC) was at the counter setting up trays and reading tickets to the person serving the tray line. The SC would then take the plate and place it on a meal tray and hand it to another staff member. That staff member would then serve the meal to the resident it had been prepared for. The SC would also deliver trays to the table if no other staff member had returned to the counter to retrieve another tray to serve. This process happened repeatedly. The staff serving trays included CNA AA, CNA BB and the MDS Co-Ordinator (MDSC). All staff were observed touching residents, touching chairs, touching their own clothes and hair and continuing to serve the meals without washing their hands or using hand sanitizer. Observation also revealed CNA AA sitting a table with two residents. She was feeding both residents with her right hand, touching her back, touching residents to assist them in cleaning their face with a napkin and did not wash her hands or use hand sanitizer while assisting these two residents at the same time. 3. Penthouse Unit dining observation on 2/20/18 at 11:59 a.m. to 12:30 p.m. revealed CNA MM served four residents bowls of soup as she returned to the serving counter, CNA MM touched the arm of the resident and the back of the resident's chair. CNA MM failed to use the hand sanitizer at the serving counter before obtaining another four plates of food to serve residents. After serving these residents CNA MM was observed rubbing her nose as she returned to the serving counter. CNA MM again failed to utilize the hand sanitizer located on the serving counter. Also, during this observation CNA LL was observed touching her face and repositioning her eyeglasses. CNA LL returned to the serving counter without washing her hands or using the hand sanitizer. On 2/20/18 at 12:31 p.m. the surveyor attempted to use the hand sanitizer pump located at the entrance to kitchen area and was unable to obtain any hand sanitizer gel. At 12:36 p.m. a maintenance/housekeeping person was observed attempting to use the same hand sanitizer pump unsuccessfully. At this time the maintenance/housekeeping person stated the hand sanitizer pump required need batteries to work. Review of the facility's document titled Sanitation and Infection Prevention/Control with a revision date of 1/2016 revealed Avoid touching hair, face, mouth, and clothing, rubbing the skin, or scratching, while working. Always cover the mouth and nose with a disposable when coughing, or sneezing, or cough or sneeze into your sleeve. Always wash your hands thoroughly before handling food if these situations occur. A review of the facility's training log dated 11/16/17 revealed CNA LL and CNA MM attended training for this policy. Interview 02/20/18 12:43 pm in the dining room with CNA LL revealed the CNAs are supposed to wash hands at the start of service. If they stop to cut up food or rearrange items for resident then they must use the hand sanitizer. CNA LL admitted that she had adjusted her eye glasses and did not use the hand sanitizer afterwards. Interview on 2/20/18 12:58 p.m. with CNA MM in the dining room revealed the staff are supposed to wash hands before services and use hand sanitizer. admitted that she did touch the back of resident chair and rubbed her nose without using hand sanitizer or washing her hands before serving the next resident.

Based on observation, record review, interview, and review of facility policies, it was determined the facility failed to provide the appropriate care and services for one resident (Resident #86) with a suprapubic catheter from a sampled 25 residents. This affected one of three residents reviewed with indwelling catheters. The findings include: Observations: During a tour of the unit on 2/20/18 at 10:30 a.m. Resident #86 was observed dressed laying in her bed. The resident had a suprapubic catheter connected to a bedside drainage bag. Resident #86 stated there was a problem with the catheter leaking around the insertion site and she felt the staff was not fully inflating the catheter balloon. Observation on 2/20/18 at 3:30 p.m. revealed two Certified Nursing Assistants (CNAs) transferring Resident #86 from the wheel chair to her bed using a Hoyer lift. The CNAs placed the resident's urinary drainage bag in the resident's lap with urine in the tubing draining back towards the resident's bladder. After the resident was placed in her bed the CNAs then placed drainage bag on the bed level with the residents' bladder; yellow urine was observed in the tubing backing into the resident bladder. Both CNAs were preparing to perform incontinent care. Both CNAs washed their hands. The CNA GG donned a pair of gloves and assisted the resident in removing her removing her wet clothing. CNA GG removed her gloves and used the hand sanitizer and donned a new pair of gloves. CNA GG positioned the resident on her left side facing the wall. CNA HH wiped the resident's right buttocks and part of the left buttocks with wipes without changing gloves. CNA HH put clean incontinence brief on the resident without changing gloves. CNA HH had on two pairs of gloves removed top pair gloves and went into the resident's bathroom wearing the second pair of gloves came out and applied incontinence cream to resident buttocks. CNA GG then removed her/his gloves and donned new gloves without handwashing or use of the hand sanitizer. CNA HH proceeded to clean the resident's vaginal area and did not change gloves then applied barrier cream without washing hands or hand sanitizer or changing gloves. The CNAs failed to turn the resident to the opposite side and complete cleaning the remaining portion of the resident's left buttocks. Continued observation on 2/20/18 at 3:55p.m. revealed RN CC and RN EE entered the resident's room to change the Resident #86's suprapubic catheter. The RN CC and RN EE washed their hands and applied clean gloves. RN CC created a clean field at foot of the resident's bed between the resident's feet. RN CC then picked up trash can and placed at the bedside next to RN EE. The clear plastic bag inside the trash can became loose from the edge of the can. RN CC reached inside the trash can repositioned the clear plastic bag and placed an orange plastic bag in the trash can also. RN CC did not change gloves and proceeded to assist RN EE in setting up equipment. RN CC held the anchored suprapubic catheter being replaced and the resident's abdomen while RN EE opened a package of [MEDICATION NAME] swabs and cleaned the area of the catheter insertion site in the abdomen. RN removed the old gloves, used the hand sanitizer and donned a sterile pair of gloves from the catheter insertion kit and continued to setup for the catheter insertion. However, RN EE did not test the catheter balloon to ensure it would inflate after inserted in the resident's bladder. RN EE placed tip of catheter in the package of lubricating gel, deflated the balloon of old catheter and removed the catheter. RN EE placed the old catheter in the trash can. RN EE removed her gloves, used hand sanitizer and donned new pair of sterile gloves and cleaned the insertion site again with a [MEDICATION NAME] swab. RN EE proceeded to insert catheter into the insertion site; the catheter not connected to drainage bag. RN CC, yet to have changed gloves during this procedure, uncapped the tubing tip of the drainage bag, touched the tubing tip with his unchanged gloved hand and handed it to RN EE whom was holding the sterile supra pubic catheter. RN EE allowed the sterile supra pubic tip of the catheter to touch the uncleaned area of the Residents right upper thigh during this transfer of the drainage bag from RN CC. RN EE proceeded to insert the sterile suprapubic catheter into the insertion site. RN EE inflated the balloon with 10cc of normal saline to which the Resident #373 stated she felt pressure. When pulling back on the placed supra pubic catheter after insertion, the catheter came completely out and the anchoring balloon on the catheter was not inflated. Rn CC and RN EE stated they planned a second attempt to anchor a sterile supra pubic catheter. RN EE had not tested the balloon prior to inserting the catheter. Record review: Review of Resident #86's Minimum Data Set ((MDS) dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The resident required extensive to total assistance with activities of daily living. Medical record review revealed a Urology consult dated 8/8/17 documenting The resident had a catheter change; doing well resident . can have suprapubic tube (SPT) change at facility if so desires. An additional review of the medical records revealed a physician's orders [REDACTED]. Review of facility's document titled Incontinent Care with an effective date of 6/15/15 documents the following: Wash the genital area moving front to back using a clean area of the washcloth or peri-wipe for each stroke. After washing the genital area turn to side to wash and rinse rectal area moving from front to back. Use a clean area of the washcloth or per-wipe for each stroke. Dry with towel Apply incontinence barrier cream according to MD orders or protocol Review of facility's document titled Catheter Insertion with a revision date of 2/22/18 documents the following: Place the clean equipment on the bedside stand or overbed table. Arrange supplies so that they can be easily reached. Organize the items on sterile field. Attached prefilled syringe to the balloon lumen of the catheter and instill the fluid to ensure that the balloon inflates properly. Then aspirate all the fluid back into the syringe and leave attached to the catheter. Insert the catheter until urine begins to flow from the bladder, advance the catheter another two to three inches and inflate the balloon with five milliliters of normal saline and remove the syringe. Pull gently on the catheter to check placement. Secure drainage tubing to bottom sheet with clip from drainage set. Attach catheter to drainage tubing. Tape catheter to inner thigh or secure with leg band. Review of the facility document titled Indwelling Bladder Catheter Management with a revision date 1/10/18 documents the following: A closed gravity drainage system will be maintained as much as possible. Catheter bags will be positioned lower than the bladder. Every effort will be made to maintain dignity and decrease the potential for infection by covering the catheter bag and keeping it off the floor. Interviews: During an interview with RN CC on 2/22/18 at 1:40 p.m. outside the dining room the surveyor described the scenario with the CNAs providing incontinent care. RN CC stated this was not how the CNAs were trained to perform incontinent care or placement of the urinary drainage bag. Also during the interview RN CC reviewed the procedure for the place of the suprapubic catheter and agreed RN EE did not test the catheter balloon prior to insertion and confirmed that he/she touch the inside of the trash can and did not change gloves or use hand sanitizer. RN CC also stated the resident has history of urinary tract infections, but currently had been asymptomatic. Interview with RN EE on 2/23/18 at 8:33 a.m. revealed she had received training on insertion of Foley and Suprapubic catheters but did not realize that she should have set-up her clean field on the overbed table; and did not realize that the catheter did touch the resident's thigh. RN EE acknowledged that she should have check for the balloon inflated properly prepare inserting the catheter and was not familiar with facility's policy on catheter insertion. On 2/23/18 at 12:15 p.m. during an interview with the Administrator in the conference room, she stated hand washing in-services are conducted a minimum of four times a year on a quarterly basis. She stated the most recent in-service the facility had was in (MONTH) (YEAR) during the annual infection control fair. She provided for review an undated facility document titled Hand Washing Monitoring Tool. She stated the hand washing tool is a form they use to make sure employees are washing their hands correctly. She confirmed, as a part of completing this form, employees are to do a return demonstration to indicate they know how to properly wash their hands.

Based on observation, record review, interview, and review of facility policy, it was determined the facility failed to ensure that one resident (Resident #373 (diagnosed with [REDACTED]. The sample size was 25 residents. The findings include: Observation 2/22/18 10:40 a.m. revealed Resident #373 observed sitting in a wheelchair (w/c) with left leg elevated in lounge area wearing nasal oxygen cannula. The Medication Nurse was observed to give the resident a small glass of liquid, the resident drank without any difficulty. Resident #373 drank all of the liquid and requested additional liquid. The Nurse brought large size drinking cup with thickened liquid. Observation of the resident's room revealed on night stand by resident's bed was one drinking glass with thickened liquid with a spoon in it; water pitcher with ice and water and a straw; and another small cup with approximately 120 cc. un-thickened clear liquid. Observation on 2/22/18 at 12:10 -12:30 p.m. Resident #373 brought to dining room by family member and the family member left. A staff member was observed taking the resident's lunch order. CNA NN brought the resident a glass of dark brown [MEDICATION NAME] un-thickened liquid with ice to drink. Resident started taking a few sips after a couple minutes started coughing. Resident received egg salad sandwich taking small bites chewing and swallowing without difficulty and continued taking small sips of dark brown [MEDICATION NAME] un-thickened liquid. An additional observation on 2/22/18 at 12:41 p.m. of the resident's room revealed a water pitcher with water and ice and straw, half glass of thickened liquid, and glass with approx. 120 ccs of water. Review of resident's care Kardex located in the resident's room revealed the resident was on a mechanical soft diet with nectar thick liquids. Observation on 2/22/18 1:30 p.m. in the dining revealed the resident ate most of the egg salad sandwich and drank all of dark brown [MEDICATION NAME] thin liquid only ice chips remain. Review of resident's lunch diet slip revealed the resident is to receive a regular diet mechanical soft texture and nectar thick liquids. Observation on 2/22/18 at 2:35p.m revealed the resident was in bed receiving incontinent care. The Speech Therapist was in room writing on communication board the following directions: Resident on nectar thick liquids and reg diet mechanical soft texture Encourage small bites with small sips of liquid Eat slowly Alternated solid and liquids Tongue sweeps to the left side No straws Observation of the resident's room on 2/23/18 at 8:05 a.m. revealed the resident's water pitcher half full of un-thickened clear liquid with straw and glass filled halfway thickened liquid and spoon Observation of breakfast service at 8:10 a.m. in the dining room revealed the resident received a cup of un-thickened coffee, glass of thin water with ice chips, box of cold cereal with un-thickened milk. CNA NN opened the milk carton for the resident and poured milk over cereal. Resident #373 began eating the cereal and drinking the coffee with an occasional cough. There was no staff present at the table to monitor the resident. CNA MM offered the resident a choice of cranberry juice or orange juice (OJ) to drink. (both liquids were un-thickened.) CNA MM poured the resident un-thickened OJ to drink. Still no staff supervision while the resident was eating. Closer observation revealed there was no diet slip at the resident's place to indicate the resident dietary restrictions. Record review: Review of the resident's baseline care plan with an initiation date of 2/20/18 revealed the resident's initial goal was dietary instructions, resident is on a regular diet mechanical soft texture and nectar thick liquids. Review of a facility document titled Thickened Liquids with a revision date of 1/2017 documents: Nursing - Communicates order via the communication process. Dining Services - Serves commercial pre-thickened liquids as available. Supplies thickener to the Nursing Unit for other liquids that the resident needs thickened such as soup, coffee or thickened by Food and Nutrition Services. The policy lacked direction for ensuring the residents receive the consistency of thickened liquids and supervision of those residents identified with swallowing difficulty receiving thickened liquids. The facility was unable to provide another policy regarding residents on thickened liquids. Interviews: Interview on 2/23/18 at 8:20 AM with CNA MM in the dining room revealed the CNA the resident was a new resident but did not know his dietary restrictions. Interview on 2/2/18 at 8:35 a.m. with CNA NN in the dining room revealed she knew the resident thought the resident was on a regular diet and thinks maybe thicken liquids. When asked about the liquids on the resident's table, the CNA confirmed the liquids were un-thickened consistency but would verify the resident's meal order. Resident had already drunk all the OJ, half of coffee and ate all the cold cereal. On 2/23/18 at 8:40 a.m. observation and interview with the RN CC in the resident's room revealed the liquid in the water pitcher was water. The ADON removed the water pitcher and read the communication board in the residents' room. The surveyor explained the observations in the dining room; RN CC stated the staff should have printed a diet slip and placed it in the dining room so the servers are aware of the resident's dietary restrictions. The RN also stated the resident should be placed at a table were staff could monitor the resident while he eats. An additional observation and interview was conducted on 2/23/18 at 8:45a.m., the resident was drinking a glass of thickened OJ. CNA NN verified the resident was to be on a mechanical soft diet with nectar thick liquids. During an interview on 2/23/18 at 1:55 p.m. in the administrative offices the Director of Dining Services stated a regular diet with mechanical soft texture consisted of chopped or ground meats and soft vegetables. For breakfast if the resident received cold cereal it should be with thickened milk and let the cereal get soggy or crushed before serving it to the resident, but the staff should offer the resident warm cereal instead of crispy cold cereal. The surveyor described the dining observations for Resident #373 and the Director of Dining Services stated it sounded like the more training was needed with the staff and she would work on retraining the staff.

Based on observation, record review, and interview, it was determined the facility failed to provide correct texture of foods and liquids as identified in the care plan interventions for one (1) Resident #373 from a sampled 25 residents. Cross reference to F805 The findings include: Observation on 2/22/18 at 10:40 a.m. of Resident #373's room revealed on night stand by resident's bed was one drinking glass with thickened liquid with a spoon in it, a water pitcher with ice and water and a straw; and another small cup with approximately 120 cc. of un-thickened clear liquid. Observation on 02/22/18 at 12:10 to 12:30 p.m. revealed the resident in the Penthouse unit dining room sitting at lunch table. The Certified Nursing Assistant (CNA) NN brought the resident a glass of dark brown [MEDICATION NAME] un-thickened liquid with ice to drink. The resident began taking a few sips after a couple minutes the resident started coughing. The resident then received an egg salad sandwich taking small bites chewing and swallowing without difficulty. The resident continued taking small sips of dark brown [MEDICATION NAME] thin liquid. A review of the resident's meal ticket slip reviewed the resident was to receive a regular diet mechanical soft texture and nectar thick liquids. Observation on 02/23/18 at 8:10 a.m. of the Penthouse unit's dining room revealed the resident sitting at the table with a cup of un-thickened coffee, glass of un-thickened water with ice chips, box of cold cereal with un-thickened milk. CNA NN opened carton of milk poured it over the resident's cereal. Resident #373 immediately began eating the cold cereal and drinking coffee with occasional cough. Another CNA MM offered the resident a choice of cranberry juice or orange juice to drink (both liquids were un-thickened.) The CNA poured the resident un-thickened orange juice to drink. The resident began to drink the un-thickened orange juice and continued to eat the cold cereal with occasional coughing. Review of Resident #373's physician order [REDACTED]. Review of the resident's baseline care plan with an initial start date of 2/20/18 documents the facility established the following goals for the resident: Dietary instructions - the resident was on a regular diet mechanical soft diet and nectar thick liquids. Interview on 2/23/18 at 8:20 a.m. with CNA MM in the dining room revealed the CNA knew Resident 373 was a new resident but did not know the resident's dietary restrictions. Interview on 2/23/18 at 8:35 a.m. with CNA NN in the dining room revealed she knew the resident and thought he was on a regular diet and maybe the resident was on thicken liquids but was unsure. Interview on 2/23/18 at 8:40 a.m. with the Assistant Director of Nursing (ADON) in the Resident #373's room revealed the resident was on a regular diet mechanical soft texture with nectar thickened liquids. The ADON confirmed the staff failed to provide the prescribed diet and liquids according to the care plan interventions.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and the spread of food-borne illness in two of three satellite kitchens and one of three areas of the main kitchen. Specifically, the facility failed to follow proper hand washing practices and refrain from eating on the second floor pantry during meal service. The findings included: I. Improper hand washing and glove use practices A. Policy and procedure On 11/3/16 the administrator's assistant provided a copy of the hand hygiene policy, revised 1/14. It documented the following information, in pertinent part, Hand wash sinks, including restroom sinks, should be clean and stocked with soap, paper towels and a covered waste receptacle. Hot water should reach 100 degrees Fahrenheit. -Wet hands with warm water and apply a disinfectant soap, lathering up to mid-arm. -Work lather into hands for 20 seconds, including areas under fingernails, between fingers, on the inside and outside of hands. -Keep hands away for sides of sink. -Rinse thoroughly under warm running water, allowing the water to flow from the arms, down to the fingertips. -Use a paper towel to turn off the faucet to avoid contact with faucet germs. -Dry hands with a single use, disposable towel. Do not use common towels for drying or wiping hands . B. Observations 1. Penthouse/3rd floor/top level dining room On 11/1/16 at 12:42 p.m., 12:46 p.m. and 12:28 p.m. dietary server (DS) #3 was serving on the line and proceeded to the hand washing area where she turned on the faucet and washed her hands with soap and then turned off the faucet with her clean hands. She then dried them with a paper towel which she discarded in the trash receptacle. At 12:43 p.m., 12:45 p.m., and 12:48 p.m. DS #4 helping in the back kitchen proceeded to the hand washing area where she turned on the faucet and washed her hands with soap and then turned off the faucet with her clean hands. She then dried her hands with a paper towel which she discarded in the trash receptacle. At 12:45 p.m. and 12:29 p.m. she continued the practice of washing her hands as mentioned above. On 11/2/16 at 8:24 a.m., DS #4 continued the same practice of handwashing by turning off the faucet with her bare hands. At 8:29 a.m. and 8:31 a.m. DS #3 continued the same practice of handwashing by turning off the faucet with her bare hands. On 11/3/16 at 12:36 a.m. and 12:37 a.m. DS #4 continued the dame practice of handwashing by turning off the faucet with her bare hands. 2. Mountain View/2nd floor/main level dining room On 11/3/16 at 8:19 a.m. certified nurse aide #1 (CNA) showed improper handwashing by turning off the faucet with her bare hands after washing them, shook her hands in the air and continued assisting in the dining room. No paper towels were observed at this sink. On 11/3/16 at 8:12 a.m. and 8:15 a.m. licensed practical nurse #3 (LPN) showed improper handwashing by turning off the faucet with her bare hands after washing them and left the dining room to get a paper towel to dry her hands with. On 11/4/16 at 8:40 a.m., the registered dietician (RD) #2 was observed assisting with second floor meal service. She washed her hands at the designated sink. She obtained soap, lathered, rinsed, and turned off the water faucet with wet hands before she obtained a paper towel to dry her hands. 3. Main Dairy Kitchen On 11/3/16 at 7:46 a.m., and 7:58 a.m. DS#1 was serving on the line and proceeded to the hand washing area where she turned on the faucet and washed her hands with soap and then turned off the faucet with her clean hands. She then dried them with a paper towel which she discarded in the trash receptacle of the dairy kitchen. On 11/4/16 at 7:26 a.m., cook #1 removed her gloves, opened the trash can lid with her right hand and placed the two egg crates in the trash. She lowered the trashcan lid with her hand and placed her hand firmly on the lid with soiled elements to secure the lid to the trashcan. The cook then proceeded to the dry goods area of the kitchen. She did not wash her hands after touching the trashcan in the dairy kitchen. -At 7:35 a.m., the cook began to setup meal prep for the next meal in the dairy kitchen. She took the rolling cart out of the kitchen prep area and returned to the kitchen without washing her hands. The meal inspector (MI) reminded the cook she needed to wash her hands. -At 7:36 a.m., the MI and cook were at the designated hand washing sink in the dairy kitchen. The MI was observed turning off the faucet with his wet hands and then reaching for a paper towel to dry his hands. The cook washed her hands after the MI and obtained soap, lathered, rinsed, and turned off the water faucet with her wet hands before she located a paper towel. C. Staff Interviews The CNA #1 was interviewed on 11/3/16 at 2:00 p.m. She said when asked about proper handwashing she would open the water, wash her hands with soap and water, grab a paper towel, dry her hands with the paper towel and then turn of the water with the paper towel and throw it away. Registered nurse #4 (RN) was interviewed on 11/3/16 at 12:57 p.m. When asked about what the proper steps were for washing her hands, she said she would turn on the faucet, wash her hands by washing in between her fingers, rinse her hands. Do not shake your hands but get a paper towel and dry them. She said she would get another paper towel to turn off the faucet with. She said the purpose of the paper towel to turn off the faucet would be so that you do not re-contaminate your hands after washing them. The LPN #1 was interviewed on 11/3/16 at 1:15 p.m. When asked when she would wash her hands she said before and after care, when visibly soiled. When asked what the steps were for washing her hands she said she would turn on the faucet, put soap on her hands, rub her hands, leave the water on and dry her hands with a paper towel, throw that paper towel away and get another paper towel to turn off the faucet. The director of nursing (DON) was interviewed on 11/4/16 at 5:05 p.m. She said when asked about proper hand washing the staff place their hands in the water, wash them using soap and friction between the fingers for 20 seconds, clean under their finger nails and rinse their hands with their fingers down. She said they should leave the water running while drying their hands and use a different paper towel to turn off the faucet. She said the purpose is to not re-contaminate their hands. The director of dining services (DDS) and registered dietician (RD) #1 were interviewed on 11/4/16 at 2:13 p.m. The DDS and RD said hands should be washed after using the restroom, touching or wiping hair or nose. The DDS stated gloves should be single use and not reduce or prevent staff from proper handwashing practices or give a false sense of security when handling foods. The DDS and RD confirmed when staff are at the sink they have been trained to wash hands for twenty seconds with soap, lather, scrub nail, and rinse with water, and obtain paper towels to dry hands. The DDS and RD said if staff turned off the faucet with wet hands instead of a paper towel, the potential to re-contaminate their hands with bacteria was possible and there was a potential to spread a food borne illness. They expected their staff to following proper hand washing practices to prevent the spread of infections. II. Eating during meal service A. Observations On 11/2/16 at approximately 12:45 p.m., two dietary servers were observed in the meat pantry consuming hamburgers on the second floor satellite kitchen. They were both standing in the pantry as residents ate in the dining room. There were no visible plates or silverware as the staff ate with the use of their fingers. -At 12:46 p.m., the female dietary server (DS) #1, plated two test trays as the male dietary server continued to eat in the meat pantry room while residents ate in the second floor dining room. B. Staff Interviews The DDS and RD #1 were interviewed on 11/4/16 at 2:13 p.m. The DDS stated staff were encouraged to eat with residents to offer a more homelike environment. She said staff should be seated with the residents or they could eat in the employee breakroom. The DDS stated the dietary servers should not be eating food in the meat pantry while meal service was still taking place. The DDS and RD confirmed potential kitchen sanitation concerns by eating food in the pantry and going from hand to mouth.

Based on observation, record review and staff interview, the facility failed to ensure it was free of a medication error rate of five percent or greater. Specifically, there was an error rate of 8.6%, with three errors out of 35 opportunities for error. These errors by three different nurses affected three (#119, #5, and #35) of the six residents observed during medication pass of 40 sample residents. The findings included: A. Professional Reference Perry, Potter & Ostendorf, Clinical Nursing Skills & Techniques, 8th ed., Safe Medication Administration, Philadelphia PA, 2014, pp 480-489, read in part: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation -Read the label on the medication container and compare it with the MAR (medication administration record) at least three times: before removing the container from the supply drawer, when placing the medication in an administration cup/syringe, and just before administering the medication to the patient . -Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication . -When an error occurs, the patient's safety and well-being become the top priority . B. Facility Policy On 11/4/16 the facility provided the policy and procedure titled Medication Administration General Guidelines last revised 6/8/16, which included in pertinent part: -The six rights of medication administration will be followed; -If there are any questions about dosage, diagnosis, frequency, route or length of administration, nursing will notify the provider pharmacy and /or physician for clarification. This clarification will be documented as a physician's orders [REDACTED]. C. [MEDICATION NAME] 1. Observations Registered nurse (RN) #4 was observed preparing and administering medication to resident #119 on 11/4/16 at 9:25 a.m. According to the 9/16 computerized physicians order (CPO) the resident's order was for [MEDICATION NAME] eight hour tablets 650 milligram (mg) two tablets by mouth twice daily which was ordered on [DATE]. The RN was observed to administer two tablets of [MEDICATION NAME] 325mg. 2. Interview RN #4 was interviewed on 11/4/16 at 11:31 a.m. The RN said the facility did not have 650 mg tablets so she gave two tabs of 325mg to equal 650mg. After reviewing the order, she agreed the order was unclear as to total dosage to be given. She said she would clarify the order with the physician. 3. Follow up The facility provided a telephone order to clarify the [MEDICATION NAME] order for resident #119. The physician's telephone order read, [MEDICATION NAME] 325mg two tabs by mouth every 12 hours. It was transcribed onto the MAR indicated [REDACTED]. The director of nurses (DON) was interviewed on 11/4/16 at 5:51 p.m. She said after reviewing the order it was determined it was transcribed incorrectly as there is a difference between BID and every 12 hour when scheduling medication times. D. [MEDICATION NAME] 1. Observations RN #2 was observed to prepare and administer medication to resident #5 on 11/4/16 at 8:25 a.m. The resident's order was for [MEDICATION NAME] tablet 20mg one tab by mouth daily ordered 3/14/16. The RN was unable to find the medication on the medication cart so she omitted the medication. She was observed to circle her initials on the MAR indicated [REDACTED]. However, did not document on the back of the MAR indicated [REDACTED]. 2. Follow up On 11/4/16 at 2:05 p.m., the DON showed the card of [MEDICATION NAME] tablets for resident #5. She said it had been in the facility in a box from the pharmacy. It had not been checked in. She said the medication would be administered. E. Senna 1. Observations Licensed practical nurse (LPN) #2 was observed to prepare and administer medication to resident #35 on 11/4/16 at 8:50 a.m. According to the 11/16 MAR indicated [REDACTED]. For loose stools, decrease to one tab by mouth daily or hold, ordered 10/25/16. The LPN was observed administering Senna 8.6mg three tabs. The LPN failed to clarify the order before administering the medication. 2. Interviews LPN #2 was interviewed 11/4/16 at 9:40 a.m. She said if a medication was not available the physician was notified then the pharmacy was contacted. The LPN #2 was interviewed a second time on 11/4/16 at 1:02 p.m. She said the total dose on the Senna order for resident # 35 was unclear and she would call the physician to get clarification. 3. Follow-up A physician telephone order to clarify the Senna order was received on 11/4/16. The director of nursing (DON) was interviewed on 11/4/16 at 1:55 p.m. She said they have a bowel protocol that gives a titrating dose but there should be a specific order as to what the resident was receiving routinely at that time. She said if a medication was not available on the medication cart the nurse should look on the computer to see the status of the medication. The nurse should contact the pharmacy if needed. The physician should be notified if a medication was delayed or omitted. She further stated, the nurses were responsible to call the physician to clarify any order that was unclear.

Based on observations, record review and staff interviews, the facility failed to store, dispose of, and label medications according to regulations for five of six medication carts, four of six treatment carts, one of three medication rooms, and one (#134) of 40 sample residents. Specifically, the facility failed to: -Store medications separately according to the route administered; -Dispose of medications from the medication cart according to the expiration date; -Monitor treatment/medications carts to make sure they locked and secure; -Provide accurate labeling of medications with residents' names when received in the building; and -Ensure eye drops were properly labeled, stored and not left at the bedside of resident #134. The findings included: I. Policy and procedure On 11/3/16 at 6:00 9.m. the Care Plan Coordinator (CPC) provided a copy of the medication storage and labeling policy with a revision date of 10/23/15. It documented the following information, in pertinent part . Carts must be locked at all times when not in use. All internal and external use drugs, whether in liquid, tablet, capsule, ointment, or powder form, must be kept separate from each other in medicine cabinet, medicine room or mobile medication cart. The manufacturer's expiration date on the bottle for over the counter (OTC) medications will be used. All insulin must be kept refrigerated until opened . II. Observations of the Penthouse/3rd floor/top level A. Medication carts for East and West hallways West cart- On 11/4/16 at 8:10 a.m. the narcotic drawer held one expired blister pack for a current resident in the building of 11/2/16. -8:18 a.m. the third drawer down had mixed medications in it without being separated according the route being administered. It had suppositories, powders, OTC tablets, and inhalate solutions. East cart -On 11/4/16 at 8:21 a.m. the 4th drawer on the right side of the medication cart had medications mixed together without being separated according to the route being administered. All the medications were in one bin oral medications (OTC), suppositories and liquids. -Two Lantus pens were in the top cart without and open date on them. This meant the unrefrigerated count starts when the pen was no longer refrigerated. LPN #4 could not confirm when the pen was opened so the 28 day after opening could not be confirmed. -The narcotic drawer revealed three narcotic carts rubber band together. LPN #5 said one of the medications had expired, confirmed with the expiration of 10/26/16 on the blister pack and the other two medication blister packs were discontinued for a different resident. B. Security of the medication/treatment carts On 11/1/16 at 8:23 a.m. the treatment cart for the east hallway was open with no staff insight and residents in close proximity to the treatment cart. The drawers were easily opened to reveal the 2nd and 3rd drawer had medicated items in them (including but not limited to butt paste, nystop powder, pain relief cream which should all be kept out of reach of children). On 11/4/16 at 8:41 a.m. the medication cart was unlocked and LPN # 2 came from the other side of the dining room where she was assisting residents, out to the hallway where her cart was stationed and locked her cart at 8:46 when she realized she left it unlocked. -At 10 :45 a.m. LPN #2 cart was unlocked again she was not around the cart. -At 11:00 a.m. the attention of the CPC was obtained and he noticed the cart was unlocked. He locked it immediately and said Oh my god as he looked around for the nurse (LPN#2) who was assigned to the cart. On 11/4/16 at 6:22 a.m., eye drops prescribed to a resident #4 of the facility were not properly secure and accessible to others. The eye drops were left on the top of the medication cart on the third floor and not stored in a locked cart. There were no staff present or in line of sight of the unsecure medication. -At 6:24 a.m., the overnight registered nurse (RN) #1 was observed exiting a resident's room down the hallway to the right of the south of the nurse's station. She returned to her cart and confirmed she had left the resident's eye drop medication out on the cart instead of securely placing the medication in her cart. III. Observations of the Mountain View/2nd floor/ main level A. Medication cart West cart- On 11/3/16 at 1:01 p.m. in the bottom drawer were two Lantus pens and 2 Novolog pens with insulin in the chamber. No open date was on any of the pens in the cart. - At 1:07 p.m. an Advair disk for a resident was at a count of 40 without having an open date on the disk or the box it came in. East cart- On 11/3/16 at 1:20 p.m. revealed eye drops were mixed with nasal gels in multiple sections of the top drawer. -Third drawer down had tablets, OTC medications, mixed with suppositories in the same bin/basket. B. Treatment cart East cart- On 11/3/16 at 7:20 a.m. had three bottles of hydrogel without the caps on them. IV. Observations of the Terrace/1st floor/basement level A. Medication cart West cart -On 11/3/16 at 8:32 a.m. revealed liquid medications were mixed with powder medications in the same drawer without a divider. B. Treatment cart East- On 11/3/16 at 8:33 a.m. revealed ammonium lactate for a resident was expired, along with a tube of psoriasis cream which was unlabeled and expired as of 8/30/16. The floor nurse was asked by ADON #3 to label the tube with the resident's name and it was placed back into the treatment cart. LPN #6 stated the resident brought the psoriasis cream in with her when she was admitted . West- On 11/03/16 at 8:39 a.m. revealed in the top drawer a tube of Hydrocerin plus cream had expired 9/16. C. Medication room On 11/3/16 at 12:34 p.m. the medication room revealed a drawer by the sink in the lower counter space stored oral, rectal, topical, eye and nose medications all in one drawer. V. Staff interviews A. Interviews for expired medications RN #2 was interviewed on 11/2/16 at 9:18 am. When asked about expired medications she said they are put in a bin for the pharmacy to pick up but they need to be removed from the cart immediately. The ADON #3 was interviewed on 11/3/16 at 8:27 a.m. she said the nurses on the floor would take the expired medications and put them in the medication storage bin in the medication room and the pharmacy would pick them up for disposal. She said the medications creams, powders are also to be removed from the treatment carts and placed in the expired bin in the medication room for the pharmacy to pick up as well. She said the nurses along with herself check the carts weekly. LPN #1 was interviewed on 11/3/16 at 1:10 p.m. she said the expired medications are put in the medication storage room or the nurse on the floor can give the medication to the ADON #1. RN #4 was interviewed on 11/3/16 at 1:30 p.m. she said expired medications should have an open date put on them or do not use after date on them. She said if the medications expire they are pulled from the cart and are given to the ADON on the floor. LPN #2 was interviewed on 11/4/16 at 8:14 a.m. she said she works on an as needed basis and the nurse that had the cart would normally give the expired medication to the unit manager to lock up for disposal. The medication should not remain in the cart. LPN #5 was interviewed on 11/4/16 at 8:27 a.m. when asked about the three narcotics still in the cart in the narcotic drawer that were rubber band together with the count sheet, she said one medication was expired and two were discontinued. She was unsure of the time line on when to give the medications to the ADON on the floor. The ADON #2 was interviewed on 11/4/16 at 8:28 a.m. he said the expired narcotics are kept in the medication room on 2nd floor. The DON was interviewed on 11/4/16 at 5:00 p.m. she said the removal of expired medications from the cart would be according the expiration date. She said if the medication had a month and a year only the staff could utilize this medication to the end of the month listed on the medication. When asked if the medication expired on a specific date would it need to be removed from the cart, she said yes it would. B. Safety and security of the medication and treatment carts. RN #2 was interviewed on 11/2/16 at 9:15 a.m. she said the treatment and medication carts are to stay locked at all times when not in use. She said the narcotics are double locked. The ADON #3 was interviewed on 11/3/16 at 8:28 a.m. she said all carts should be locked when not being used by staff or if the staff leave the cart. LPN #1 was interviewed on 11/3/16 at 1:12 p.m. she said the medication and treatment carts should be absolutely locked when not in use for safety reasons. RN #1 was interviewed on 11/4/16 at 6:26 a.m. said she felt rushed to meet the needs of the residents when she was the only RN on overnight shifts and knew she had left the medications out. She said medications should be stored and locked on the medication cart and not be left out unsecured. The DON was interviewed on 11/4/16 at 4:58 p.m. she said the carts have lock on them and they should be locked at all times when the cart is not in sight. C. Storage of biologicals and medications according to the route administered LPN #1 was interviewed on 11/3/16 at 1:14 p.m. she said when asked about the proper way to store medications of different routes she said the medications have to be separated. She said they should all be separated by the specific routes. The ADON #2 was interviewed on 11/4/16 8:32 a.m. he said the medications needed to be kept separated according to the route. The DON was interviewed on 11/4/16 at 5:02 p.m. she said if the Lantus was being used the nurses need to put a use by date on it and it would be administered based on this used by date or open date. She said the Lantus needed to be used within 28 days from the open date. She said all the nurses have this information in a book that is kept on their carts. She said the storage of biologicals would need to be refrigerated or kept according to manufactures recommendations. She said the storage of medications with different routes should be stored separately. This would include medications stored in the medication carts, the treatment carts, and the medication rooms. 4. Labeling of medications 11/3/16 8:35 a.m. It was confirmed but the Luz the medication belonged to a specific resident and should have been labeled with the resident's name. Additional interviews: The pharmacist was interviewed on 11/4/16 at 8:36 a.m. He said he just started at this building in May of this year. He said he came to the building every month or every other month. He said he would medication rooms probably once a quarter. He said the management and the floor staff go the carts and are doing it more frequently to get the staff and the carts to where they need to be. He said he did an in service a few months ago with the management team but not the floor staff. When he was asked how medications should be stored according to route he said he would expect the medications to be separated with dividers in the medication carts, treatment carts and the medication storage room. When asked about the storage of biologicals such as a Lantus pen he said the Lantus pens come in a package of two, one is opened and the date is put on it and that opened pen can be kept in the medication cart out of the refrigerator. He said the unopened pen needs to stay in the refrigerator until it is opened and once the pen is opened the count starts against the medications and its effectiveness. VI. Failure to ensure proper labeling and storage of resident #134's Systane Ultra eye drops A. Resident Status Resident #134, age 95, was admitted on [DATE]. According to the 11/16 computerized physician orders [REDACTED]. According to the 10/31/16 quarterly minimum data set (MDS) interdisciplinary assessment, the resident had severe cognitive impairment as evidenced by a brief interview for mental status score of five of 15. The resident did not reject cares. A review of the resident's care plans (certified nurse aide care plan, acute temporary care plans and story care plan) revealed no plan of care related to self-administration of any medications for the resident. B. Observations and Resident Interview The resident's room was observed on 11/2/16 at 9:46 a.m. The resident was seated in her recliner with a small table next to her. There was a vial of Systane Ultra eye drops out in the open on the table. The resident was in a shared room. The resident said the product in the vial was for her eyes. The resident was not able to elaborate the reason she used the eye drops, but stated she used the eye drops at times. The vial of Systane Ultra eye drops was observed out on the table next to the recliner on 11/3/16 at 11:23 a.m. C. Record Review A review of the 11/16 CPO demonstrated the resident did not have an order for [REDACTED].>A review of the telephone orders from 10/25/16 through 11/4/16 demonstrated no order for Systane Ultra. A review of the 11/16 medication and treatment administration record revealed no order or documentation of administration of Systane Ultra. A review of the clinical record revealed the resident did not have an assessment from the interdisciplinary team evidencing the resident had been determined to be able to safely self-administer medications. D. Staff Interviews Assistant director of nursing (ADON) #1 was interviewed on 11/3/16 at 12:13 p.m. The director of nursing (DON) joined the interview at 12:21 p.m. The ADON viewed the resident's room and agreed the resident had an open, mostly used vial of Systane Ultra eye drops out on the table by her recliner. The ADON removed the eye drops from the resident's table. The ADON said residents who self-medicate are required to store their medicine in a secure location, and not out in the open. The ADON agreed the resident had a roommate who could access the resident's eyed drops when they were left out on the table by the recliner. The ADON reviewed the resident's clinical record and stated the resident did not have an order for [REDACTED]. The DON said the resident had not been evaluated by the interdisciplinary team for self-administration of medication. The DON said the resident would be evaluated for self-administration of medication later that day.

Based on observations and interviews, the facility failed to ensure that infection control procedures were followed for storage of resident personal use items in six of six shared rooms and for handling of linens in one of one laundry room. Specifically, the facility failed to ensure: -Resident personal use items were labeled and stored in a manner that minimized the potential for cross contamination; -Laundry staff had a system for storing reusable personal protective equipment (PPE) in a way that minimized cross contamination; -The laundry room had a cleanable surface between the clean and soiled processing areas, and the fan above the folding table was free from fuzzy dust. The findings included: 1. Resident Personal Use Items Observations and Staff Interviews: Observations of the shared resident rooms revealed personal use items like combs, bar soap, and toothbrushes were not labeled. Observations of shared rooms revealed reusable items like urinals and basins were stored unlabeled and unbagged on the floor and toilet backs. -room [ROOM NUMBER] room [ROOM NUMBER] was observed on 11/1/16 at 3:44 p.m. There was a gray, plastic wash basin (for bed baths) stored unlabeled and unbagged on the floor beside the toilet of this shared room. room [ROOM NUMBER] was observed with assistant director of nursing (ADON) #1 on 11/4/16 at 11:11 a.m. The ADON said the basin on the floor should be labeled and stored in a clean plastic bag, ready for use. The ADON said the observed method of storing the basin presented a risk for cross contamination due to use by the wrong resident. The ADON agreed the basin, if clean, was not stored in a way to maintained cleanliness because it was on the floor under behind the toilet. -room [ROOM NUMBER] room [ROOM NUMBER], a shared room, was observed on 11/2/16 at 9:54 a.m. In the bathroom there were two gray, plastic washbasins stored on the floor behind the toilet. An unlabeled bar of soap that was white, with debris/discoloration collected in the cracks was at the sink. room [ROOM NUMBER] was observed with assistant director of nursing (ADON) #1 on 11/4/16 at 11:08 a.m. The ADON said the soap should be stored in container labeled with the resident ' s name. The ADON said the method of storage the soap presented a risk for cross contamination due to use by the wrong resident. -room [ROOM NUMBER] room [ROOM NUMBER] was observed on 11/1/16 at 3:30 p.m. A gray, plastic basin was stored, unbagged, on the floor of the bathroom under the sink. A toothbrush was out at the sink of this shared room. The toothbrush was not labeled with its owner ' s name or identifier. ADON #1 was interviewed about personal item storage in room [ROOM NUMBER] on room [ROOM NUMBER] 11/4/16 at 11:14 a.m. The ADON said the basin should be labeled and stored in a plastic bag. The ADON said that because the room was shared, the toothbrush should be labeled with the name of the resident that owned it to reduce the risk of staff or residents using the wrong toothbrush. The ADON said correct labeling of resident toothbrushes was an infection control practice. -room [ROOM NUMBER] room [ROOM NUMBER] was observed on 11/2/16 at 9:26 a.m. There was a black comb, a white hairbrush and two toothbrushes out at the sink of this shared room. None of these personal use items were labeled. The items were observed out at the sink, unlabeled on 11/3/16 at 8:15 a.m. Service coordinator (SC) #2 was interviewed on 11/4/16 at 11:31 a.m. The SC said she was a certified nurse aide (CNA) and that she was familiar with infection control procedures in the facility. The SC observed room [ROOM NUMBER]. The SC said there was a white hairbrush, a black comb, and a black comb/hair pick unlabeled at the sink. The SC said the hair grooming implements should be labeled to minimize misuse on on/by the wrong resident. The SC said the two toothbrushes at the sink were not labeled, but should be labeled because the room was shared. -room [ROOM NUMBER] room [ROOM NUMBER] was observed on 11/2/16 at 10:00 a.m. There was an unbagged, unlabeled urinal stored on the back of the toilet in this shared room. room [ROOM NUMBER] was observed with the housekeeping supervisor (HS) and the maintenance assistant (MA) on 11/4/16 at 12:28 p.m. The HS agreed that the urinal was not bagged or labeled. The HS said the urinals were usually stored in clean bags in order to prevent contamination of other surfaces by the urinal. -room [ROOM NUMBER] room [ROOM NUMBER] was observed on 11/1/16 at 2:44 p.m. There was an unlabeled, unbagged, plastic basin and graduate (for measuring fluids) stored on the floor by the toilet of this shared room. room [ROOM NUMBER] was observed with the HS and the MA on 11/4/16 at 12:48 p.m. The HS agreed the basin and urinal were not labeled or bagged and were stored on the floor by the toilet. Facility Follow-up/Additional Interview: The director of nursing (DON) was interviewed on 11/4/16 at 4:25 p.m. The DON stated that the facility staff had observed rooms to ensure that resident personal use items were labeled and properly stored in order to remedy the infection control concerns observed on survey. 2. Laundry Room/Personal Protective Equipment (PPE) Observations: The laundry room was observed on 11/3/16 at 7:46 a.m. The black rubber apron was observed handing on a hook in such a way that the inside of the apron contacted the long, yellow reusable gloves and the dustpan and hand broom stored on the adjoining hooks. The threshold between the clean and soiled linen areas had multiple missing tiles, creating an area of exposed cement and crevices that were not cleanable. The fan above, and pointed directly at the folding table in the clean linen area was coated with fuzzy dust. Laundry attendant (LA) #1 was observed folding laundry on 11/3/16 at 7:47 a.m. The LA was folding clothing protectors. As the clothing protectors were folded, the linens were observed to brush against the LA ' s shirt. The LA said she would be loading linens for was in about 30 to 45 minutes. LA #1 was observed with janitor #1 on 11/3/16 at 8:35 a.m. The LA donned the black rubber apron, the long yellow gloves and mask. The LA wheeled the tall gray 55-gallon bin to the washer and loaded soiled sheets into the washing machines. As the soiled linens were loaded, the whole surfaces of the yellow gloves were immersed in the bin of soiled linens. The front of the apron frequently contacted the soiled linens and the soiled linen bin as the LA leaned into the bin to reach items near the bottom of the bin. The LA loaded each machine and started the wash cycles. The LA then returned to the sorting area where she sprayed a couple of squirts of peroxide solution on each glove and the front of the apron. The LA used an insufficient amount of chemical to contact each surface of the gloves and apron. The LA waited one minute and then wiped the sprayed area of the gloves and the apron with a paper towel. The LA returned the gloves and the apron to the adjoining hooks where they had been previously observed. Additional folding of linens was observed on 11/3/16 at 8:50 a.m. The LA and janitor were feeding table linens into the pressing machine. As the linens were removed from the press and folded, the linens were observed to contact the shirts of both the LA and the janitor. The laundry room was observed on 11/3/16 at 4:24 p.m. The inside of the apron (which would contact the LA ' s shirt) was touching the yellow reusable yellow gloves and the dustpan. The fan above the table used for folding clean linens remained coated with fuzzy debris. The threshold between the clean and soiled linen processing areas continued to have missing tiles. The HS was interviewed on 11/3/16 at 4:42 p.m. The HS acknowledged the inside of the apron was touching the dustpan and the exterior of the yellow sorting gloves. The HS agreed that gloves touching the inside of the apron meant whatever contaminants and microorganisms were on the soiled laundry contact surface of the gloves were now also on the inside of the apron, where they would contact the LA ' s shirt and the clean linens that touched the LA ' s shirt. The HS stated he had not considered or identified how the PPE was stored as being a source for cross-contamination. The HS said the missing tiles at the threshold between the clean and soiled linen areas had been there since he began his tenure at the facility eight months earlier. The HS said he was not aware of a plan to repair the missing tiles. The HS agreed the fan above the folding table was coated with fuzzy gray dust. The HS said it was not acceptable to have dust being blown at the clean linens. The HS said he would add cleaning the fan to the routine housekeeping tasks in the laundry room. The DON was interviewed on 11/4/16 at 4:25 p.m. The DON said the LA ' s shirt was a source of possible cross contamination because of how the reusable rubber apron was stored. The DON agreed that missing tile at the threshold between the clean and dirty linen areas presented a non-cleanable surface due to the crevices and the exposed cement. The DON said it was an infection control problem to have a dirty fan blowing on clean linens. Facility Follow-up: The HS provided an in-service on the new PPE procedure. The HS had switched from a reusable apron to disposable aprons to eliminate the storage concerns presented by the reusable apron.

Based on record review and interviews, the facility failed to provide the necessary care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (#34) of five residents evaluated for unnecessary medications and one (#35) of five residents observed for non-pressure related skin condition, of 40 sample residents. Specifically, the facility failed to consistently notify resident #34's physician after fasting blood sugars were observed out of the recommended parameters. -The facility also failed to ensure care and services were followed up timely after skin pathology findings for resident #35. The findings included: I. Diabetic management A. Resident status Resident #434, age 93, was admitted on [DATE]. The 11/16 computerized physician orders [REDACTED]. The 8/17/16 minimum data set (MDS) assessment showed the resident's cognition was intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with bed mobility, transfers, dressing, and toilet use. There were no behavioral concerns reported during the review period and no refusals of care. The resident received insulin injections seven of seven days throughout the review period. B. Record Review 1. Physician Orders A review of the 11/16 CPO revealed the following: -A 2/26/16 order to notify physician for finger stick blood sugar (FSBS) less than 100 or greater than 400. All FSBS were to be obtained before meals and all insulin administered after meals due to [DIAGNOSES REDACTED]. -A 2/28/15 order to follow diabetic protocol for signs/symptoms of [DIAGNOSES REDACTED]. The 9/28/16 diabetic protocol was to treat [DIAGNOSES REDACTED] with either four to six ounces of orange juice or glucose gel for blood sugar of less than 70 or symptoms of [DIAGNOSES REDACTED]. The facility was to recheck in no less than 15 minutes; reconstituted [MEDICATION NAME] one milliliter (ml) intramuscular per nurse discretion for severe [DIAGNOSES REDACTED] or decreased consciousness. The facility was to recheck blood sugars in no less than 15 minutes, 911 may be contacted; call provider and on call nurse to evaluate diabetic regime. The diabetic protocol further revealed facility provider notification was to: -Call all episodes of [DIAGNOSES REDACTED] (below 70 and/or symptomatic) to the provider. -If fasting blood glucose less than 100 or greater than 200, call the provider for possible treatment adjustment. -Treat isolated instances of elevated blood sugars with water or non-sweetened beverage. -A 3/17/16 order for Humalog 100 units/ml (u/ml), insulin medication, inject 18 units (u) subcutaneously every morning after breakfast. -A 4/20/16 order for Humalog 100u/ml, inject 10u subcutaneously at noon (after lunch). -A 12/21/15 order for [MEDICATION NAME] 100u/ml, insulin medication, inject 23u subcutaneously every morning. -A 12/21/15 order for [MEDICATION NAME] 100u/ml, 7u subcutaneously at bedtime. 2. Care Plan A review of the resident's individualized care plan revealed he had managed his blood sugars ever since his doctor told him he had diabetes mellitus. The resident thought his blood sugars were too high and he worried about his vision. His blood sugar levels were brittle and sometimes he did not eat, so insulin was to be administered after meals. 3. Medication Administration Records (MAR)/ Treatment Administration Records (TAR) A review of the 9/16 MAR indicated [REDACTED] -9/4/16, FSBS 92 before lunch -9/15/16, FSBS 79 before lunch -9/15/16, FSBS 95 before dinner -9/18/16, FSBS 97 before breakfast -9/19/16, FSBS 74 before breakfast -9/19/16, FSBS 99 before lunch -9/21/16, FSBS 79 before breakfast -9/21/16, FSBS 97 before lunch -9/23/16, FSBS 93 before breakfast -9/26/16, FSBS 413 before breakfast There was no evidence to show the resident's physician was notified when blood sugars fell outside the recommended parameters. Subsequently, the 9/16 MAR indicated [REDACTED]. Furthermore, the 11/16 CPO reflected a signed order to administer 10u of Humalog 100u/ml after lunch. Additionally, there were two signatures on the 9/16 MAR indicated [REDACTED]. In the instances listed above, there was no documentation that either the primary signee or co-signee made attempts to contact the resident's physician when the resident's blood sugars fell outside the recommended parameters. A review of the 10/16 MAR indicated [REDACTED] -10/4/16, FSBS 90 before breakfast -10/7/16, FSBS 93 before lunch -10/14/16, FSBS 97 before breakfast -10/16/16, FSBS 98 before breakfast -10/17/16, FSBS 98 before breakfast -10/18/16, FSBS 89 before breakfast -10/19/16, FSBS 88 before breakfast -10/25/16, FSBS 94 before breakfast There was no evidence to show the resident's physician was notified when blood sugars fell outside the recommended parameters. Subsequently, the 10/16 MAR indicated [REDACTED]. Furthermore, the 11/16 CPO reflected a signed order to administer 10u of Humalog 100u/ml after lunch. Additionally, there were two signatures on the 10/16 MAR indicated [REDACTED]. In the instances listed above, there was no mention of either the primary signee or co-signee making attempts to contact the resident's physician when blood sugars fell outside the recommended parameters. 4. Interdisciplinary Notes A review of the resident's 9/1/16 through 11/3/16 interdisciplinary notes revealed no evidence to show the facility notified the resident's physician when the resident's FSBS fell outside the individualized parameters for the dates listed above. C. Interviews The registered nurse (RN) #3 was interviewed on 11/3/16 at 11:19 a.m. She stated she provided care to diabetic residents. She said before the administration of insulin, orders should be checked. She said the facility utilized a system where if insulin was given, two nurses had to sign off on the administration. She said each resident had patient specific parameters to monitor around blood sugar. She also said there was a diabetic protocol in case blood sugars became too high or too low. She said it was important to follow physician orders [REDACTED]. The RN reviewed the 11/16 CPO and confirmed the order to notify the physician if the resident's blood sugars were less than 100 and greater than 400. She said if the physician was notified, it would be on the back of the MAR indicated [REDACTED] The assistant director of nursing (ADON) #1 was interviewed on 11/3/16 at 12:28 p.m. She said the resident was alert and oriented and able to make his needs known. She confirmed the resident was diabetic. She described him as having both type I and type II diabetes mellitus. The ADON said the resident's blood sugar was checked before each meal. She said he received injections of [MEDICATION NAME] and Humalog. The ADON reviewed the resident's 11/16 CPO and confirmed the parameters was to notify the physician when his blood sugars were less than 100 and greater than 400. She said the parameters were set for him to make sure he did not experience [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. The ADON stated if the physician was contacted when the parameters were out of the recommended levels, staff would document on the back of the MAR indicated [REDACTED]. She said if the physician was notified, it should have been documented and any adjusts should be reflected on the MAR. The ADON #1 and director of nursing (DON) were interviewed on 11/3/16 at 5:27 p.m. The ADON and DON confirmed the resident's parameters were not clear and the resident's nurse practitioner (NP) was contacted and his parameters were changed from less than 100 to less than 85. The DON said the parameter to notify when greater 400 remained unchanged. The DON stated the resident was unstable and had mixed type I and type II DM. The DON said the resident's individual parameters should have been followed and physician notified to determine if an adjustment to his treatment was needed when his blood sugars fell outside the recommended parameters. Facility Follow-up: On 11/3/16 at 5:27 p.m., the ADON provided a training with the nursing staff to discuss gaps observed in the MARs and TARs of resident records. Although the facility provided an in-service to staff, it did not address the failure to notify the physician when the resident's blood sugar fell outside of the recommended parameters. II. Failure to follow up timely on dermatologist and pathologist findings after a biopsy report that diagnosed [MEDICAL CONDITION] and recommended excision, delaying care for resident #35. A. Facility policy and procedure On 11/4/16 at 4:28 p.m., the lab, X-ray and other diagnostic testing policy, revised 9/28/15, was provided by the care plan coordinator. The policy documented the following information, in pertinent part,If lab results are not received in a timely manner, the physician will be informed. In addition, the director of nursing (DON)/designee will be notified. The assistant director of nursing (ADON) on each neighborhood is responsible for coordination of laboratory and diagnostic testing, including obtaining timely results and appropriate follow-up. B. Resident status Resident #35 was admitted on [DATE]. According to the computerized physician orders, [DIAGNOSES REDACTED]. According to the 10/16 minimum data set (MDS) assessment, the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. She had very little mood or behaviors with a depression score of three out of 27. The resident's care plan, initiated on 7/22/15, included the following information regarding skin condition: -I often complain of itching. I will scratch my arms, midsection, and legs to the point that I cause superficial abrasions and wounds. I have tried various creams, ointments, daily cleansings and preparations, and even an antidepressant that might help with the compulsive scratching. -I have had biopsies and am followed by the dermatologist . C. Observations On 11/1/16 at 10:41 a.m. scratches and red scabbed areas were observed to the resident's bilateral lower extremities. She said she had had a rash for a while that didn't seem to get any better, and was all over her body now. On 11/2/16 at 1:30 p.m. the resident was observed in her room with her head down on her table. She said she wished this skin stuff would go away. She said she probably got too much sun on her skin. On 11/4/16 at 8:05 a.m. the resident was in her room waiting to go and eat breakfast. She said the nurses were putting on cream for her because she had been itchy and her skin was dry with patches . some are white and some are red. D. Record review Medical record review revealed the resident saw the dermatologist on 5/10/16 and had a biopsy which was diagnosed on [DATE] as squamous cell [MEDICAL CONDITIONS]. Dermatologist Consultation Report The 5/10/16 dermatologist office visit report included: Lesion to check on right lower lateral leg, and rash to check on bilateral legs and arms. Lesion on right lateral lower leg . Sun exposed areas . -Problem 1. Neoplasm of uncertain behavior located on her right superior lateral posterior tibial. It's been present for an unknown amount of time. She states that it is painful. The severity of this concern is mild to moderate. The timing is constant. Patient doesn't know how long sore has been there, states it's itchy and sore . -Problem 1. Assessment: Neoplasm of uncertain. Procedure: Biopsy today -A shave biopsy was performed . -Final comments: Discussion of [DIAGNOSES REDACTED]. Patient was instructed to follow up as needed with physician assistant (PA) for excision if positive [MEDICAL CONDITION] . Pathology Report The 5/11/16 pathology report documented the following information: Final pathologic Diagnosis: [REDACTED]. Extending to the deep margin (electronically verified by the dermatopathologist on 5/12/16). Facility delay in response to recommendation for excision There was no evidence in the resident's medical record that her physician was notified of the results of the dermatologist visit or the pathologist diagnosis, or that an appointment was scheduled for excision of the area. According to the doctor's progress notes on 10/5/16 the resident had itchy pain resulting in obsessive scratching of the skin on the resident's arms and legs, causing abrasions and open areas. There was no mention of the dermatologist visit on 5/10 or the resulting pathologist [DIAGNOSES REDACTED]. According to the skin evaluation dated 10/20/16, the resident had left lateral leg, scattered superficial open areas, left lateral lower leg, shin, [MEDICAL CONDITION] evaluation. [MEDICATION NAME] 10 milligrams by mouth twice a day. Pharmacy request for generic Prudoxin cream for itching. Review of interdisciplinary notes revealed no evidence of other follow-up by the facility after the above dermatology visit. There was no evidence the results of the dermatologist visit and pathology [DIAGNOSES REDACTED]. record. Further, there was no evidence the resident, her physician or family were notified of the results until 10/28/16, according a note documented by the ADON. The ADON documented on 10/28/16 that the nurse practitioner (NP) was in to review the dermatology biopsy results. The NP notified the resident and her daughter of the results. The NP requested a follow up appointment with the dermatologist, which was scheduled for 11/17/16 at 2:15 p.m. The resident's daughter was notified of the appointment and said she would meet the resident at the appointment. E. Staff interview The director of nursing (DON) was interviewed on 11/4/16 at 10:43 a.m. When asked about the delay in care for this resident, the DON said she had been missed. She said they had discovered on 10/19/16 that the consult visit information was missing, and requested and received the consult documentation on 10/21/16. She said the facility service coordinators were educated that if they did not receive the information from a consult visit in a timely manner, they were to call and request the information. She said the family and resident should have been notified if the facility did not have the results. When asked about the notation on 10/28/16 in the resident's chart, she said the daughter was notified of the results then, and would like to proceed with treatment of [REDACTED]. Facility follow up The DON was interviewed a second time on 11/4/16 at 5:50 p.m. She said there had been two educational meetings provided for staff, on 10/19/16 and 10/26/16, to identify the problem of missing ancillary/consult orders, inconsistent follow-up, e.g. appointments, medications, treatments and labs. Three residents had been identified, including resident #35. Although the facility identified the omissions on 10/19/16, the resident's treatment was further delayed when the facility failed to notify the physician, resident and family until 10/28/16; and failed to acquire a follow-up appointment until 11/17/16.

Based on resident interviews, staff interviews and record review, the facility to ensure two (#61 and #6) of three sample residents reviewed, of seven residents who said they were not included in care planning decisions of 40 sample residents, were invited and encouraged to participate in planning or changes in care and treatment. Specifically, the facility failed to have an effective system to ensure residents were invited and included in care planning conferences. The findings included: 1. Resident #6 A. Resident status Resident #6 was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 11/1/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Some mood and behaviors were noted, and a depression score of six out of 27. He required setup with his activities of daily living. B. Resident interview Resident #6 was interviewed on 11/1/16 at 11:31 a.m. He said the staff did not involve him in his care. When asked if he participated in his care conferences, he said, No, no. C. Record review On 11/3/16 at 7:30 a.m. the last four care conference summaries were requested from the facility. On 11/3/16 at 5:30 p.m. the facility provided one interdisciplinary note, two elder of the day meetings, and one care conference/team huddle note. According to the interdisciplinary note dated 11/18/15, Contacted family on this day to follow-up about scheduling a care conference. His son had no issues/concerns of note, and declined at this time. Staff huddle with (resident #6) will be scheduled. According to the elder of the day, held on 7/16 and 8/16/16, there was no documentation on the signature page the resident/family representative was in attendance, or whether the resident was invited to the elder of the day meeting. According to the care conference/team huddle note on 9/2/16, the resident was invited and declined to attended the meeting. His family representative was invited and attended. There was no evidence of an attempt to reschedule for a date and time that was more convenient for the resident. D. Staff interview regarding the elder of the day The assistant director of nursing #2 (ADON) was interviewed on 11/4/16 at 9:20 a.m. He said the elder of the day meeting was a way to make the elder known in the community and for the staff to discuss the resident's needs. He said the elder of the day meeting doesn't take the place of the care conference. Social worker #1 (SW) was interviewed on 11/14/16 at 2:42 p.m. She said the elder of the day meeting was not the same as the care conference. During the elder of the day meeting, typically the team comes together to communicate for the care plan story. E. Staff interviews ADON #2 was interviewed on 11/4/16 at 9:22 p.m. When asked about the care conference process, he said the care conference had its own agenda and it was done quarterly or more frequently if needed. He said you would expect to see care conference summaries along with the elder of the day meeting summaries within a resident's chart. He said the least amount of care conferences that would be annually would be four given the resident is in the community for that length of time. He said they are generally at the same time as the MDS but they are not the same thing. The director of nursing (DON) was interviewed on 11/4/16 at 5:30 p.m. She said the care conferences were held quarterly or more frequently, depending on the resident's needs. She said the minimum would be four for the year that the resident and or the family representative would be invited to. SW #1 was interviewed on 11/4/16 at 2:38 p.m. She said she had been with the community for about one year and she was still learning the process. When asked about care conferences she said the conferences were held as needed and in conjunction usually with the MDS. She said ideally there are at least four care conference meetings a year but sometimes more. She said, It didn't always happen but certainly it is what we would like to do, four. 2. Resident #61 A. Resident Status Resident #61, age 95-plus, was admitted on [DATE]. According to the 11/16 computerized physician orders [REDACTED]. The 10/10/16 quarterly minimum data set (MDS) assessment demonstrated the resident was cognitively impaired as evidenced by a brief interview for mental status (BIMS) of seven of 15. The resident required extensive assistance with locomotion on the unit and only left the unit once or twice during the MDS observation period. B. Resident Interview The resident was interviewed on 11/1/16 at 4:45 p.m. The resident stated she was not included in decisions about her medicine, therapies or treatments. The resident stated she could not recall attending a care conference with staff from the building where she was provided the opportunity to give input on her care. C. Record Review A review of the clinical record showed the resident's most recent care planning conference note was in 12/15. No additional care plan conference documentation was present in the resident's clinical record. A review of social service notes from 5/1/16 through 11/4/16 revealed no documentation of a care plan conference held with the resident. A review of interdisciplinary documentation showed the resident was reviewed as an elder of the day in 4/22/16 and 9/1/16. The elder of the day documentation showed that staff reviewed the resident; however, the resident was not included in the review per the documentation. D. Staff Interviews The care plan coordinator (CPC) was interviewed on 11/4/16 at 8:28 a.m. The CPC said he was not responsible for inviting either the residents or their family to care planning conferences. The CPC said he did not always attend care planning meetings. The CPC suggested speaking with the social worker for the unit where the resident resided. Social worker (SW) #3 was interviewed on 11/4/16 at 8:42 a.m. and 9:35 a.m. The SW said she was new to the facility and had been working as the social worker on the unit where the resident resided for about one month. The SW said she was familiar with the resident. According to the SW, the resident was active in the community and liked to give input as evidenced by her attendance and participation in resident council. The SW said when a conference is initiated, the care conference attendee and invitees were documented on a care conference form in the electronic record. The SW reviewed the resident's clinical record and said she could not find evidence that the resident was invited to or attended the 10/16 care conference. According to the SW, the clinical record showed the most recent care planning conference where the resident was invited to participate was conducted on 12/15. The MDS coordinator (MDSC) was interviewed on 11/4/16 at 8:51 a.m. The MDSC said the resident was reviewed as an elder of the day on 4/22/16 and 9/1/16. Per the MDSC, the elder of the day was a plan of care meeting attended by direct care staff, like nurses and certified nurse aides. The MDSC said residents were not included in elder of the day reviews.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for four of seven residents (#103, #104, #2, and #75) of 48 sample residents, received adequate supervision to prevent accidents. Specifically: The facility failed to put adequate and effective measures in place to protect residents from the potential of burns from use of the hot/cold gel packs which created a situation of immediate jeopardy with the potential for serious harm for residents #103, #104 and #2 and other residents in the facility. --Failed to monitor resident #75 safety after an elopement. Findings included: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Observations: The Terrace floor was observed on 9/24/15 at 11:00 a.m. to use a promotional gel bead hot/cold pack. The packs had the name of the facility on the front and had blue beads. The packs were cold to the touch and were used to keep the supplements cold. The back of the gel pack had on the backside printed to heat for 30 seconds in the microwave. The packs did not have an internal thermometer. Interviews were conducted throughout the facility and it was determined the inconsistencies of the use of the heated hot/cold gel packs and also no monitoring of temperature was in place to ensure the resident ' s safety. Terrace Floor (1st floor) Staff Interviews: --Registered nurse (RN #8) was interviewed on 9/24/15 at approximately 3:30 p.m. The RN stated that resident #103 used the hot/cold gel pack. The RN confirmed it was the same packs as used cold to keep the supplements cold. The RN #8 stated that the beaded pack would be heated for one minute. The resident liked it hot, the RN stated. RN #8 stated that the resident kept it for longer than 20 minutes as he liked to have it until it cooled. The RN was unaware of the temperature of the beaded gel pack. --RN #9 was interviewed on 9/24/15 at approximately 3:30 p.m. The RN stated that the gel packs were used to help with the pain for resident #103. The RN stated that the resident liked it hot, it was heated then placed into a cloth sleeve and placed on the resident ' s back. The resident kept the pack until it cooled. The RN stated that the resident had an order to use the gel packs and that he used them. The RN was unaware of the temperature of the beaded gel pack. Penthouse (3rd floor) --The RN #3 was interviewed on 9/24/2015 11:51 a.m. The RN #3 on the 3rd floor reported that if a resident had pain and they offered pharmacological approaches, they would offer repositioning, music and activities as a distraction, medications. The resident may also have an order for [REDACTED].#3 stated that hot/cold gel pads were available and could be applied. They gel pad was a heating device that could be wrapped in a wet washcloth and regular towel to apply to affected area. The assistant director of nurses for the 3rd floor was interviewed on 9/24/15 at approximately 4:45 p.m. The ADON stated that he recently became the ADON for the third floor. He stated that the beaded packs were removed from the 2nd floor as he took the initiative to remove them as the packs became too hot. He stated that when it was heated at 30 seconds and then it was not warm enough, another five seconds and it became too hot, however he was not aware of the temperature. He stated that the medical director instructed to stay with the resident constantly to monitor. He stated that the pack was to stay on for no longer than 20 minutes. He stated that only one resident used it on the third floor. He had not had a chance to remove it, but she had not used it. The director of nurses (DON) and the director of rehabilitation (DOR) were interviewed on 9/24/15 at approximately 4:00 p.m. The DON stated that the hot/cold gel packs with the blue beads were used as alternatives for pain management. She stated that the gel packs were used in a sleeve, to help prevent a burn. She stated the blue gel packs the temperature cannot be obtained. The policy for the hot/cold gel packs was provided. Policy: The policy for Warm and Cold Packs effective date 8/12/15 read in pertinent parts, .Heating pads will not be used at (name of facility). As an alternative, beaded warm packs may be used with supervision. Depending on preference, a cold or warm pack may be used. An MD (medical doctor) order will be required. Use of the pack will be supervised by a direct care nurse Procedure Warm Pack 1. Wrap the pack in a damp washcloth. Microwave for 30 seconds. 2. Apply to area no more than 20 minutes 3. Check for redness following removal The facility failed to put adequate and effective measures in place to protect residents from the potential of burns from use of the hot/cold gel packs which created a situation of immediate jeopardy with the potential for serious harm for residents #103, 104 and #2 and other residents in the facility. B. Notification of Immediate Jeopardy (IJ) On 9/24/15 at 5:35 p.m. the nursing home administrator (NHA), DON, and the administrator in training (AIT) were notified of the IJ situation which had been called by CMS at 5:30 p.m. The NHA confirmed there was not a system for an alternative treatment for [REDACTED]. The immediate plan was to remove the gel packs from the building and begin educating staff. C. FACILITY ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY The NHA was interviewed on 9/24/15 at 6:00 p.m. The NHA stated in order to keep the residents safe for the night he removed all of the hot/cold gel packs from the building and they were thrown out. He stated five packs were located on both the first and third floor. The NHA was interviewed and on 9/24/15 at 6:00 p.m. The NHA stated the staff were being in serviced that the hot/cold gel packs were not to be used. The DON was interviewed at approximately 6:00 p.m. The DON stated that the heated shoulder wrap which was used for resident #104 was not going to be used, as the pack needed to be warmed in the microwave. The Nursing Home Administrator (NHA) and Company Consultant (CC) was interviewed on 9/25/15 at 11:51 a.m. about the abatement plan. The NHA stated that all staff who worked the previous night was educated. He further stated the oncoming staff was educated prior to their shift. The facility's proposed plan to remove immediate jeopardy, submitted 9/25/15 at 11:55 a.m. and again on 9/25/15 at 2:48p.m., were rejected by HFEMSD as incomplete. The facility submitted another plan on 9/25/15 at 4:15 p.m. The facility abatement plan read: Microwavable heating products may be used as a non-pharmacological alternative for pain management when the following have been completed: --A risk benefit assessment is completed by a nurse --A physician order [REDACTED]. --Only a nurse will apply the product --Temperature of the product after heating in the microwave is determined to be between 100- 105 degrees. --All products will be tested with a thermometer prior to administering to a resident to ensure the temperature is between 100-105 degrees. --A thermometer will be kept in the treatment caret and calibrated weekly --A temperature log will be maintained. --On initial use, the effect of the product on the resident will be checked five minutes intervals for 20 minutes after application and removed not longer than 20 minutes after application. --On subsequent use, the effect of the product on the resident will be checked within the first ten minutes after application and removed not longer than twenty minutes after application. --If any adverse effects are observed, the product will be removed and resident will be evaluated for any needed treatment or follow up. --If any adverse effects occur, use of the product will be immediately discontinued and the physician and the family notified. --If any adverse effects occur, use of the product will be immediately discontinued pending further evaluation. All nurses will be educated to these guidelines and DON or designee will monitor: --During initial application and once again during the first week. --Weekly thereafter for the first month --Based on reporting to QA (quality assurance), additional frequency of monitoring will be determined. --Education will begin immediately --Staff will not work until educated. Alternatives will be identified with resident ' s physician and other disciplines in an attempt to accommodate a resident ' s preference to avoid medication for pain management. If alternatives are not successful, we will continue to offer medication as ordered by the physician . D. Removal of Immediate Jeopardy On 9/25/15 at 4:30 p.m. the NHA was informed of their plans for abatement had been accepted and the immediate jeopardy removed. However, deficient practice remained at an E level (potential for more than minimal harm at a pattern) based on the facility's systematic failures identified during survey 9/24/15 - 9/30/15, including the lack of safety precautions in place for use of micro-wave gel packs. The medical director (MD) was interviewed on 9/28/15 at approximately 6:00 p.m. The MD stated he was aware that the gel packs were being used as an alternative for pain management. He stated that he wanted to ensure that the gel packs were micro-waved with specific time frames and also that the temperature checked and monitored. E. Residents 1. Resident # 103, age 95, was admitted to the facility on [DATE]. According to the 9/15 computerized physician orders [REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE] documented the resident had a nine out of 15 for the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairments. The resident required extensive assistance with activities of living. Record Review: The 9/15 CPO documented an order with a start date of 7/28/15 , May use gel pack for heat use white wash cloth pouch- make damp with water and place gel pack inside. Microwave for 30 second. May place warm wash cloth with gel pack against back to relive pain as requested. The treatment administration record for 8/15 and 9/15 showed the resident received the hot gel pack three times. The care plan story dated 5/29/15 and updated on 8/10/15 failed to identify the gel packs were used to help relieve his lower back pain. 2. Resident #2, age 95, was admitted to the facility on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE] revealed the following information: -The brief interview for mental status (BIMS) exam revealed a score of 10 out of a possible 15 points which indicated that the resident had moderately impaired cognition. (Section C) -The mood interview revealed a score of four out of a possible 27 points. This scored indicated minimal depression. (Section D) Record review: --The 9/15 CPO documented a physician order [REDACTED]. Don ' t apply over thermal ointment. The resident had not used the moist heat for the past 60 days. The care plan story dated 6/1/15 failed to identify one of the approaches to relieve pain was the moist heat applied to her left shoulder. 3. Resident #104, age 91, was admitted to the facility on [DATE]. According to the 6/15/15 MDS [DIAGNOSES REDACTED]. According to the most recent MDS dated [DATE] documented the residnet had minimal cognitive impairments. The MDS coded the resident as requiring supervison with activities of daily living. Record Review: The nurses note dated 8/14/15 documented the resident had pain in her shoulder. The resident had a shoulder wrap (micro-wave heated) purchased. The heat pack was used three times that night and the resident stated it helped. The note further documented after 20 minutes it was removed and skin was red and warm to touch. The note documented that an order would be obtained for further applications. The care plan dated 8/14/15 identified the resident pain issues. The approaches included Evaluate skin for redness and pain relief, DON/ADON to apply pack 1-2 /(times) day. heat shoulder wrap in micro wave X (for) 90 apply over shirt or night gown per res (resident) preference . II. Elopement A. Facility policy The facility Elopement of Resident Policy and Procedure (P&P) revised 7/13/11 revealed, in pertinent part: - .effort will be made to minimize the risk of a resident leaving the facility without authorization when departure presents a threat to the safety of the resident or others; and - any episode involving a resident that is unauthorized, leaving the building unattended requires the completion of an incident report . B. Resident #75 1. Resident Status The resident, age 86, was admitted on [DATE] to the facility. According to the face sheet, the resident had [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] documented the resident had a four out of 15 on the brief interview for mental status (BIMS) which indicated the resident had severe cognitive impairment. He required supervision with transfers and ambulation. He required extensive assistance with dressing and personal hygiene. He was independent with eating. He had wandered one to three days throughout the facility during the MDS look back period. 2. Observations On 9/28/15 at 2:30 p.m. the resident was observed walking in and out of the courtyard door. The doors were propped open by large rocks. On 9/28/15 at 5:10 p.m. the resident was observed wandering up and down halls. The nurse was observed at 5:15 p.m. searching the area. She was observed checking courtyard doors to ensure they were closed and locked. The nurse stated where is the resident She located the resident near the nurse station. 3. Record review The social services noted dated 6/11/15 documented, in pertinent part, .care conference held with daughter, mentioned need to begin finding secure unit as wandering is increasing, we are not able to ensure his safety . The social services note dated 6/12/15 documented, in pertinent part Resident (was) seen wandering outside attempting to open outside gate, eventually redirected back indoors. The care plan dated 8/3/15 documented the resident had increased wandering and was entering resident rooms. The interventions included documentation due to increased wandering and redirection due to becoming more difficult to redirect. Additionally the care plan documented the resident was on a waiting list for a secure unit. The care plan did not address the elopement attempt made. The physician ' s progress note dated 8/3/15, documented, in pertinent part .He has a wander guard on .facility working on finding a secure dementia unit . The nurses ' note dated 8/23/15 documented, in pertinent part . restless as evidenced by wandering, opening doors to other residents rooms and entering, entering shower rooms and other private areas . The physician ' s progress note dated 8/24/15 documented, in pertinent part .social work still pursuing transfer to a secure dementia unit. The social services ' note dated 9/10/15 documented, in pertinent part .resident continues to wander off the unit as well as into other residents ' rooms .discharge plan to transfer to secure unit . The elopement assessment, dated 9/30/15 and completed during the survey, documented the resident was fully ambulatory and disoriented. The resident had made one or more attempts to elope from the facility. The resident had dementia. The resident had less than 30 days without an elopement attempt. On 9/20/15, during the survey, the nursing home administrator (NHA) provided a memo. The memo documented, All doors with access to the subject courtyard have been manually locked by the NHA preventing all access to said courtyard from the inside of the building until the resident of concern has been transferred to another facility. 4. Staff interviews The director of nursing (DON) was interviewed on 9/30/15 at approximately 3:15 p.m. She reported she did not complete an investigation on 6/12/15 when the resident went into the courtyard. She reported she considered the courtyard was part of the building and was not concerned. The social worker (SW) was interviewed on 9/30/15 at 4:30 p.m. She reported the staff struggled with his attention in activities. She reported staff had not received any formal education for redirecting the resident. She reported she and other staff would keep the resident out of rooms, offer him snacks and walk with him outside. She reported other residents were annoyed with him because he will enter their rooms. She reported his exit seeking had increased since admission to the facility. 5. Staff interview/observation The DON and the NHA were interviewed on 9/30/15 at 3:20 p.m. They walked to the exit where the courtyard was located and walked into the courtyard. They pointed to the gate, which was accessed in the courtyard, where the resident was discovered after exiting the building into the courtyard. The NHA reported the resident was found pushing on the releasing handle of the gate. He reported the gate could be pushed for 15 seconds. He reported after 15 seconds the gate would open. The opening was observed to have a three foot sidewalk then a drop off of approximately six feet to a road below.