Every finding on record at Center at Lowry, LLC

Based on observations and interviews the facility failed to distribute food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure employees performed hand hygiene appropriately during meal service. Findings include:I. Professional referenceThe Colorado Retail Food Regulations, (3/16/24), retrieved on 4/6/26, read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)II. ObservationsDuring a continuous observation on 3/31/26, beginning at 5:08 p.m. and ending at 5:30 p.m., the following was observed during meal service in the main kitchen:At 5:10 p.m. cook (CK) #1 had gloves on and was touching several high traffic surface areas (counter tops, the refrigerator handle and using utensils to plate the meal). Without changing gloves, CK #1 used the same gloved hands to retrieve clean plates and clean bowls for service. He placed gloved hands on the eating surfaces of the clean dishware. Without performing hand hygiene, CK #1 used the same gloved hands to place bread on the plates. At 5:20 p.m. CK #1 had not changed his gloves and touched the counter top of the serving table, wiped the sneeze guard top with his gloved hand and used utensils for plating food. CK #1 took carrots to a cutting station with the same gloved hands. He used a knife and scooped up carrots to plate the carrots with the same gloved hands. CK #1 continued to plate bread without utensils wearing the same gloves. -During the observation time, CK #1 had not changed his gloves during service, although he had left the service area, touched the refrigerator handle, picked up utensils and touched counter tops prior to handling plates and food. During a continuous observation on 4/1/26, beginning at 11:27 a.m. and ending at 12:17 p.m. the following was observed during meal service in the main kitchen:At 11:31 a.m. the dietary manager (DM) put on gloves and took plates from the clean dish rack for service. With the same gloved hands, he scooped up lettuce and plated the lettuce for a salad. He then used utensils to put the toppings on the salad. He continued to use the same gloved hands for scooping the lettuce. Without changing gloves, the DM placed rolls on the plates with his gloved hands. He left the service area to retrieve more plates, touching the eating surface of the plates, and scooped the lettuce without changing his gloves.At 11:36 a.m. CK #2 washed his hands and put on gloves. He then left the service area to retrieve wrapped sandwiches from the reach-in refrigerator with the same gloves. With the same gloved hands, he unwrapped the sandwiches and used his gloved hands to steady the sandwiches while he cut them in half. He then plated the sandwiches with the same gloved hands.At 11:41 a.m., with the same gloved hands, CK #2 went to the grill and removed cooked chicken with a utensil, cut the chicken on the cutting board and then scooped up the chicken with his gloved hands and plated the chicken for a resident. At 11:45 CK #2 removed his gloves, washed his hands and donned (put on) another pair of gloves. He then returned to the refrigerator with the gloves on, removed more sandwiches, unwrapped the sandwiches, placed them on the cutting board and placed his hands on the sandwiches to stabilize them while he cut them in half, then plated each sandwich. -During the continuous observation, CK #2 had not removed his gloves after touching high surface areas, such as the refrigerator handle, counter tops, the top of the sneeze guard and leaving the service area before handling food. With gloved hands he touched his personal clothing and went back to touching food without changing gloves.At 11:50 a.m. the DM put on gloves, touched several surfaces and scooped the lettuce with his gloved hands. He used utensils for salad toppings and without changing gloves placed bread on each plate. -During this time, without changing gloves, the DM retrieved a bag of sliced bread, removed the bread from the bag and made sandwiches after touching several surfaces. III. Staff interviewsCK #2 was interviewed on 4/1/26 at 12:18 a.m. CK #2 said hands should be washed before handling food. He said gloves should be changed when they were dirty or greasy. CK #2 said hands should be washed in between changing gloves. He said he changed gloves often, especially when moving to spots such as the serving line to the grill. The DM was interviewed on 4/2/26 at approximately 10:00 a.m. The DM said gloves should be changed when surfaces were touched and before handling food. He said if a staff member stepped away from the service area, they should remove gloves, wash hands and put on new gloves before starting food service. The DM said the staff should use utensils when plating food and not their hands. The DM said he was in the process of starting to have his staff go through an online food safety course.

Based on observations, record review, and interviews, the facility failed to ensure one (#8) of nine residents out of 30 sample residents was provided services that met professional standards of quality. Specifically, the facility failed to ensure Resident #8's medications were administered in a timely manner and not left at the resident's bedside.Findings include: I. Professional referenceAccording to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 4/6/26 from https://www.ncbi.nlm.nih.gov/books/NBK560654, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Incorrect time is a prevalent modality of medication administration error. This error type stems from nurses giving a patient medication at an incorrect time, even if it is the correct medication and the patient's identity is verified, without first checking to ensure it is the correct time for the medication to be administered to the patient.II. Facility policy and procedure The Medication Administration policy and procedure, revised 4/2/24, was provided by the director of nursing (DON) on 4/2/26 at 3:15 p.m. It read in pertinent part, It is the policy of this facility that medications are to be administered as prescribed by the attending physician. Medications must be administered in accordance with the attending physician's written orders. Medications may not be set up in advance and must be administered one hour before or one hour after their prescribed time. III. Resident #8A. Resident statusResident #8, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included surgical after care following surgery to the nervous system (lumbar surgery), radiculopathy to the lumbar region (pinched nerve resulting in sciatica), multiple sclerosis, difficulty walking, pulmonary embolism (sudden blockage in a lung artery), hypertension, long-term use of anticoagulant medications and major depressive disorder. The 3/30/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required partial assistance with activities of daily living (ADL) and moderate assistance for ambulation. He used a walker and a wheelchair.B. ObservationsOn 3/30/26 at 2:15 p.m. a medication cup with two tablets in it was sitting on the cover of Resident #8's lunch tray. On 3/30/26 at 2:43 p.m. the same medication cup with two tablets in it was still sitting on Resident #8's lunch tray.On 3/30/26 at 2:45 p.m., upon prompting, LPN #3 entered Resident #8's room and administered the two tablets in the medication cup on the resident's lunch tray cover to Resident #8.-However, the medications were administered over an hour after the allowed medication administration time (see record review below). C. Resident interviewResident #8 was interviewed on 4/1/26 at 11:12 a.m. Resident #8 said that he did not know if the medication cup with the two tablets in it that was left on his bedside table the day prior (3/31/26) was his medication. D. Record reviewReview of Resident #8's March 2026 medication administration records (MAR) revealed the following medications were to be administered to Resident #8 at 12:00 p.m.: Gabapentin (anticonvulsant medication primarily used to treat neuropathic pain and partial seizures). Give one 600 milligram (mg) tablet by mouth three times a day, ordered 3/30/26.Cyclobenzaprine HCl (muscle relaxant used for muscle spasms). Give one 10 mg tablet by mouth three times a day, ordered 3/24/26. -However, the medications were observed sitting in a medication cup over one hour after the allowed medication administration time (see observations above). IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 3/30/26 at 2:45 p.m. LPN #3 entered Resident #8's room and said the resident had been in the bathroom when he (LPN #3) came to administer the resident's medications. LPN #3 said he left the resident's medications on the bedside table and exited the room. LPN #3 said it was inappropriate to leave medication on the resident's bedside table and not observe the resident taking the medication. LPN #3 said one tablet in the medication cup was Neurontin (gabapentin) and the other was cyclobenzaprine.The director of nursing (DON) was interviewed on 4/1/26 at 10:50 a.m. The DON said that LPN #3 had told her that Resident #8 was on the phone when he went to administer the medications to the resident. The DON said LPN #3 said he left the resident's medication on the bedside table and exited the resident's room. The DON said it was not appropriate to leave medications with a resident and not observe the resident taking the medication.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of five medication carts. Specifically, the facility failed to:-Ensure medications, such as inhalers, eye drops and tuberculin purified protein derivative (PPD - a skin test antigen used to detect infection with tuberculosis) were dated when opened;-Ensure medications were not stored in a medication cup instead of a labeled medication bottle in the medication cart; and,-Ensure loose pills were not in the bottom of the medication cart drawers.Findings include:I. Professional referenceAccording to Drugs.com (1/23/25) Can You Use An Expired Albuterol Inhaler?, retrieved on 4/6/26 from https://www.drugs.com/medical-answers/you-expired-albuterol-inhaler-3556003/, An albuterol inhaler should be discarded after it passes its expiration date. It should be thrown out even sooner if it has been 13 months since it was removed from its foil packaging.According to the Spiriva Respimat (tiotropium bromide) inhaler package insert, retrieved on 4/6/26 from https://pro.boehringer-ingelheim.com/us/products/spiriva/copd/, After assembly, the Spiriva Respimat inhaler should be discarded, at the latest, three months after first use or when the locking mechanism is engaged, whichever comes first.According to Drugs.com (10/27/25), Arnuity Ellipta: Package Insert/Prescribing Info, retrieved on 4/9/26 from https://www.drugs.com/pro/arnuity-ellipta.html. Discard Arnuity Ellipta six weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first.According to Drugs.com (12/29/25) Xalatan Package Insert/Prescribing Information, retrieved on 4/9/26 from https://www.drugs.com/pro/xalatan.html Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees celsius (C) (77 degrees Fahrenheit (F) for six weeks.According to Drugs.com (10/10/24), Tuberculin Purified Protein Derivative (Interdermal) (monograph), retrieved on 4/8/26https://www.drugs.com/monograph/tuberculin-purified-protein-derivative-interdermal.html#:~:text=for%20intradermal%20injection.-,Administration,Mantoux%20Test Tuberculin PPD, diluted (Aplisol), is supplied as multi-dose vials containing 5 Tuberculin Units (TU) per 0.1 milliliters (ml) for intradermal injection. Store vials at 2 to 8 degrees C (36-46 degrees F); do not freeze; protect from light. Vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.II. Facility policy and procedureThe Storage of Medications policy, revised 2/9/26, was provided by the director of nursing (DON) on 4/1/26 at 3:34 p.m. It read in pertinent part, Medications are stored properly, following pharmacy or provider instructions to maintain their integrity and support safe, effective medication administration. The pharmacy dispenses the medication in containers with labels. Medications are to remain in the containers until dispensing. Medications requiring refrigeration are kept refrigerated. Outdated, discontinued, and expired medications should be removed from stock. Medication storage should be kept clean, organized, and free of clutter. Medication storage conditions are monitored randomly as a quality assurance program.III. ObservationsOn 3/30/26 at 8:20 a.m. the second floor medication cart A was observed with registered nurse (RN) #3. The following items were found: One bottle of Xalatan (latanaprost 0.005%) eye drops (used to reduce high eye pressure) was not dated when opened.One vial of tuberculin (PPD) was not dated when opened and was being stored in the medication cart and not the refrigerator.One Spiriva inhaler (medication used to help open airways to improve breathing) was not dated when opened. One loose pill was in the bottom of the second drawer of the medication cart.There was a medication cup sitting in the top drawer of the medication cart. The medication cup contained seven burgundy colored softgel tablets. The medication cup was not labeled with a resident's name or the medication name of the softgel tablets.On 3/30/26 at 8:40 a.m. the third floor medication cart C was observed with RN #4. The following items were found:Two Albuterol inhalers were not dated when opened. One Spiriva inhaler was not dated when opened.One Arnuity Ellipta inhaler (inhaled medication used to treat asthma) was not dated when opened.Seven loose pills were in the bottom of the second drawer of the medication cart.IV. Staff interviewsRN #3 was interviewed on 3/30/26 at 8:20 a.m. RN #3 said the nurses cleaned the medication carts on each shift. RN #3 said the one loose medication at the bottom of the second drawer of the second floor medication cart A was a Senna Plus (medication used to treat constipation). RN #3 said the risk of not putting an open date on the medication was giving an expired medication. RN #3 said expired medications may not be effective. She said the burgundy colored softgel tablets sitting in the medication cup in the top drawer of the medication cart were Preservision Eye Supplement tablets. She said she ran out of the medication in her cart and went to another medication cart to get some. She said she poured seven softgel tablets from the over the counter medication bottle in the other cart into a medication cup and brought them back to her medication cart.RN #4 was interviewed on 3/30/26 at 8:40 a.m. RN #4 said every nurse was responsible for cleaning the medication carts on each shift that they worked. RN #4 said she knew that two of the loose medications in the bottom of the second drawer of the third floor medication cart C were acetaminophen (medication used to treat pain and fever) and one loose medication was omeprazole (medication that reduces stomach acid). She said she was not sure what the other four loose medications were. RN #4 said the risk of loose medications was that a medication could drop to the floor and be taken by a resident. RN #4 said nurses should always put an open date label on medications so they knew when the medication expired. She said expired medications might no longer be potent.The DON was interviewed on 4/1/26 at 10:50 a.m. The DON said it was the nurses' responsibility to clean the medication carts on their shifts. The DON said there should not be any medications in a medicine cup without a label in the medication cart. The DON said it was important for the nurses to mark medications with an open date to prevent giving an expired medication because the medication might then be ineffective.

Based on observations, record review and interviews, the facility failed to ensure four (#1, #3, #2 and #4) of five residents out of 12 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure staff followed the physician's orders for Resident #1's anti-fungal medication;-Ensure staff followed the physician's orders for Resident #3's skin treatment; and, -Ensure staff obtained a physician's order before providing skin treatment for Resident #2 and Resident #4.Findings include: I. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 11/17/25 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Incorrect dosage is a prevalent modality of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct medication and the patient's identity is verified, without first checking to ensure it is the correct strength for the patient. According to the Institute of Medicine (IOM) Committee on Quality of Healthcare in the United States (January 2025), retrieved on 11/17/25 from https://pubmed.ncbi.nlm.nih.gov/30085607/, An error is the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. The IOM identifies medical errors as a leading cause of death and injury. II. Facility policy and procedure The Medication Administration policy and procedure, revised 4/2/24, was provided by the director of operations on 11/5/25 at 1:55 p.m. It read in pertinent part, It is the policy of this facility that medications are to be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (an artery is blocked by a clot leading to brain tissue death from a lack of oxygen) due to unspecified occlusion or stenosis of right carotid arteries, type 2 diabetes mellitus and essential hypertension (high blood pressure). According to the 10/18/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She used a walker and a wheelchair. She required set up assistance with eating and supervision with oral and personal hygiene. She required moderate assistance with toileting. B. Record review Review of the October 2025 CPO revealed Resident #1 had the following physician's order: Miconazole external powder 2%. Apply to the groin topically every day shift related to weakness until 10/30/25, ordered 10/16/25. -Review of Resident #1's October 2025 treatment administration record (TAR) revealed the miconazole was not documented as administered from 10/16/25 to 10/21/25. -Review of Resident #1's electronic medical record (EMR) revealed there was no documentation as to why the miconazole medication was not administered. IV. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included cellulitis of the left lower limb, open wound of the right hand, osteoarthritis, osteoporosis, hypertension and altered mental status. According to the 10/23/25 MDS assessment, the resident was cognitively intact with a BIMS score of 14 out of 15. She used a walker and wheelchair. She required moderate assistance with eating and was dependent with toileting. She required substantial assistance with oral hygiene and lower body dressing. The assessment revealed applications of non-surgical dressings, ointments and medications were used for skin treatments. B. Resident interview Resident #3 was interviewed on 11/4/25 at 10:31 a.m. in her room. Resident #3 was sitting in her wheelchair on the left side of her bed. She said she did not have any skin conditions. However, two small abrasions were observed on her right hand that appeared to be healing. Resident #3 said she did not know what the abrasions were from. C. Resident observation On 11/4/25 at 12:14 p.m. Resident #3 was observed in her room with registered nurse (RN) #2. On the outer aspect of the resident's right hand there were two abrasions/scabs that appeared to be healing. There was no drainage and no dressing on the abrasions. RN #2 said Resident #3 did not need wound care for the two abrasions on her right hand. -However, the resident had an active physician's order for a daily treatment and dressing to the abrasions on her right hand (see physician's orders below). D. Record review Resident #3's skin breakdown care plan, initiated 10/18/25 and revised 11/4/25, revealed the resident had potential for skin breakdown related to impaired mobility secondary to weakness and debility. Resident #3 was admitted with a wound to her right hand. Interventions included dressing changes per physician's orders and skin treatment per physician's orders. Review of Resident #3's November 2025 CPO revealed the following physician's orders: Cleanse the right hand with wound cleanser or normal saline, pat dry, apply hydrogel (a type of wound treatment) and cover with bordered foam. Monitor and change daily every day shift, ordered 10/18/25. Monitor the small open area to right lateral hand every shift. Assess for any signs and symptoms, complications and or signs of infection. Report to the physician as noted. Leave the site open to air and discontinue the every shift monitoring once the open area has fully resolved, ordered 11/4/25. -The above physician's order was obtained during the survey, after the issue was brought to the facility's attention. -Review of Resident #3's October 2025 TAR revealed the treatment to the resident's right hand was not documented as being provided on 10/20/25 and 10/30/25. The 11/4/25 nurse note revealed, per hospital documentation, Resident #3 sustained a fairly large wound to the lateral portion of her right hand as the result of a mechanical fall. The resident was admitted with corresponding treatment orders. Upon assessing the site on 11/4/25 the area had almost entirely resolved. There was a very small and superficial opening currently measuring approximately 0.2 centimeters (cm) in width by 0.2 cm in length and less than 0.1 cm deep still being appreciated. The nurse was informed the resident had a scab covering the area earlier today and thought the resident scratched the scab off as faint scratch marks were noted to the surrounding tissue. There was no drainage or active bleeding and no signs or symptoms of infection present. The condition of the hand was discussed with the physician and an order to discontinue the hydrogel treatment was received. The physician believed the best thing to do was to just keep it open to air and let it heal up. The hydrogel order was discontinued and a new order was entered to keep the area open to air, asking the nurses to monitor the site every shift, looking for any signs and symptoms of complication and signs of infection and reporting any concerns to the physician if noted. The order was to be discontinued once the open area resolved. Resident #3 was updated to the plan and voiced no related questions or concerns during the conversation. -The progress note was documented during the survey. V. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included atherosclerosis, heart disease of native coronary artery, type 2 diabetes mellitus, pneumonia and sepsis. According to the 10/24/25 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He required set up assistance with eating and personal hygiene. He required substantial assistance with oral hygiene and upper body dressing. The assessment revealed he had a pressure ulcer, a formal assessment tool was used and a clinical assessment was used. He had a stage 2 pressure ulcer and a diabetic foot ulcer. Treatments included applications of ointments and medications. B. Observation On 11/4/25 at 11:42 a.m., Resident #2 was observed in his room with RN #1. There were dressings present on both of the resident's right and left great toes, dated 11/3/25. The dressings were dry and intact. RN #1 said he could not find the wound care orders in the resident's electronic medical record (EMR) for dressings to the right and left great toes. C. Record review The 10/21/25 admission skin evaluation revealed Resident #2 had a wound to the right great toe with a dressing in place. The 10/22/25 wound skin evaluation revealed there was a diabetic ulcer on the resident's right greater toe measuring 0.5 cm in length by 0.5 cm in width and 0.1 cm deep. The note revealed the area presented with 80% granulated tissue (red, bumpy tissue in a wound bed) and 20% epithelial tissue (tissue in a wound that appears pink or white and wrinkles when touched) and scant serous drainage (thin, watery, clear to pale yellow fluid that leaks from wounds). The area would continue to be treated with medihoney (wound treatment) and hydrocolloid (wound dressing) every other day and as needed and left open to air. The 10/29/25 wound skin evaluation revealed there was a diabetic ulcer on Resident #2's right greater toe measuring 0.5 cm in length by 0.5 cm in width and 0.1 cm deep. The note revealed the area was improving and presented with 80% granulation tissue and 20% epithelial tissue with scant serous drainage. The area would continue to be treated with medihoney and hydrocolloid every other day and as needed and left open to air. The 11/3/25 skin evaluation revealed the wound to the resident's right great toe. The wound had a scabbed area. The wound was to be patted dry and medihoney applied then covered with a dry dressing. There was a wound to the resident's left toe. The left toe wound was to be cleaned with normal saline, patted dry and medihoney applied and covered with a dry dressing. The 11/4/25 skin evaluation revealed Resident #2's right great toe ulcer was relatively smaller in size, 0.4 cm in length by 0.3 cm in width and 0.1 cm in depth. The resident's left great toe ulcer had 100% epithelial tissue. Review of Resident #2's October 2025 CPO revealed no physician's orders for the resident's right great toe diabetic wound. Review of Resident #2's November 2025 CPO revealed the following physician's orders: Wound care, right foot great toe. Cleanse with normal saline, pat dry, apply medihoney to wound bed, cover with border dressing every other day and as needed related to difficulty in walking, ordered 11/4/25 (added during the survey). Wound care, left foot great toe. Cleanse with normal saline, pat dry, apply povidone iodine, cover with border gauze daily, ordered 11/4/25 (added during the survey). -However, wound treatment was provided to Resident #2's right great toe from 10/22/25 to 11/4/25 without a physician's order and wound treatment was provided to the resident's left right great toe on 11/3/25 without a physician's order (see staff interviews below). VI. Resident #4 A. Resident status Resident #4, age [AGE], was admitted to the facility on [DATE]. According to the November 2025 CPO, diagnoses included cellulitis (skin infection caused when germs enter through a crack in the skin) of left lower limb, edema and difficulty in walking. The 11/4/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The functional and mobility assessment had not been completed at the time of the survey. B. Resident interview Resident #4 was interviewed on 11/4/25 at 9:40 a.m. Resident #4 said he was not aware of his wound care treatment schedule. He said WCN #1 provided wound care treatment to both legs on 10/31/25. Resident #4 said licensed practical nurse (LPN) #1 provided wound care to his left leg on 11/3/25 but did not complete the treatment for his right leg. He said he asked LPN #1 about the treatment for the right leg, and LPN #1 told him she could not complete it at that time. Resident #4 said LPN #1 left the room and did not come back. C. Record review The skin care plan, initiated 10/30/25 and revised 11/4/25, documented Resident #4 had a potential for skin breakdown related to impaired mobility secondary to weakness and debility. Interventions included completing dressing changes per physician's order, notifying the physician of any signs and symptoms of infections and completing skin evaluations as ordered and as needed. The wound care evaluation, dated 10/31/25, documented a vascular wound on the front of Resident #4's left lower leg. The wound measured 19 cm in length by 15 cm in width with 0.1 cm in depth. The evaluation documented another vascular wound on the rear of Resident #4's right lower leg. The wound measured 15 cm in length by 15 cm in width with 0.1 cm in depth. The 10/31/25 progress note revealed WCN #1 cleansed, dried, and placed silver antimicrobial gel (wound care treatment) on the wounds. WCN #1 overlaid the wounds with an adaptec dressing, covered with an abdominal (ABD) pad, wrapped with kerlix, and secured with an ace wrap. -However, there was no documentation in the resident's October 2025 CPO indicating an active physician's order for the wound treatment provided on 10/31/25. Review of Resident #4's November 2025 CPO revealed the following physician's orders: Normal saline with instructions to cleanse and pat dry every other day for the left lower extremity wound, ordered 11/2/25. Silver antimicrobial gel with instructions to apply to open areas every other day for the left lower extremity wound, ordered 11/2/25. Adaptec dressing and abdominal pad with instructions to cover the left lower extremity wound, ordered 11/2/25. Kerlix and Ace wrap with instructions to wrap the lower left lower extremity wound, ordered 11/2/25. -Review of the November 2025 CPO revealed the resident did not have physician's orders for the right lower extremity wound until 11/4/25, during the survey (see physician's orders below). The November 2025 CPO revealed the following physician's orders: Normal saline with instructions to cleanse and pat dry every other day for the right lower extremity wound, ordered 11/4/25. Silver antimicrobial gel with instructions to apply to open areas every other day for the right lower extremity wound, ordered 11/4/25. Adaptec dressing and abdominal pad with instructions to cover the right lower extremity wound, ordered 11/4/25. Kerlix and Ace wrap with instructions to wrap the lower right lower extremity wound, ordered 11/4/25. VII. Staff interviews The director of nursing (DON) was interviewed on 11/4/25 at 12:20 p.m. The DON said residents' skin was assessed at admission by the floor nurse, by the WCN within 24 hours, weekly and as needed. The DON said if a resident came with discharge orders for wound treatment, the floor nurse who admitted the resident did not obtain wound treatment orders, the ADON or another nurse entered the wound treatment orders. Wound care nurse (WCN) #1 was interviewed on 11/4/25 at 2:53 p.m. WCN #1 said she had worked at the facility for one month and was the wound care nurse for all residents. WCN #1 said residents' skin was assessed at admission by the floor nurse, by the wound care nurse within 24 hours, weekly and as needed. WCN #1 said she documented her skin assessments on a paper log and then transcribed the paper log notes into the residents' EMRs, either as a skin assessment or a wound assessment, depending on what she saw during her skin assessment. WCN #1 said she documented the wound treatment orders on the wound assessment. WCN #1 said she was familiar with Resident #1. WCN #1 said when she saw Resident #1, she documented her findings on the paper log. WCN #1 said she updated Resident #1's EMR on 10/23/25. WCN #1 said she obtained physician's orders for miconazole on 10/16/25 and she did not enter the orders into Resident #1's EMR until 10/23/25. WCN #1 said since she did not enter the physician's orders into the EMR timely, the floor nurses were unable to administer the medication to Resident #1 as ordered. WCN #1 said she completed wound care to Resident #4's both legs on 10/31/25 even though there were no active physician's orders at that time. She said wound care physician's orders for Resident #4 were entered on 11/2/25 for the resident's left leg only. LPN #1 was interviewed on 11/5/25 at 12:26 p.m. LPN #1 said she completed wound care on 11/3/25 for Resident #4's left leg only as it was the only treatment order listed on the resident's TAR at that time. LPN #1 said she did not know who completed the wound care for the right leg, noting the bandage was clean, without drainage, and not soiled. LPN #1 said she thought there might have been a physician's order for the right leg wound scheduled for a different day but she could not find any documentation. LPN #1 said she did not ask WCN #1 about the resident's right leg wound treatment nor document it. The DON was interviewed a second time on 11/5/25 at 1:10 p.m. The DON said all physician's orders should be entered into the residents' EMRs as a physician's order, not in a skin evaluation assessment or wound evaluation assessment. The DON was familiar with Resident #1. The DON said she talked to WCN #1 after Resident #1 was discharged to the hospital and that was when the DON found out WCN #1 did not enter the skin assessment and the physician's order for miconazole in Resident #1's EMR until 10/23/25. The DON said WCN #1 should have entered the physician's order for the miconazole as soon as it was obtained so the floor nurses could administer the medication timely. The DON was familiar with Resident #2. The DON said the resident's toe wound treatment orders should have been in Resident #2's EMR as a physician's order so the floor nurses were aware of the treatment orders and when to provide care. The DON was familiar with Resident #3. The DON said the nursing staff needed to notify the physician when the physician's order was not followed so the physician could provide further orders if needed. The DON said there were no physician's orders in place for Resident #4's wounds when WCN #1 provided treatment on 10/31/25. However, she said WCN #1 documented the treatment in the resident's progress notes. The DON said as of 11/4/25 (during the survey), the facility had entered physician's orders into Resident #4's November 2025 CPO for wound treatment of both legs.

Based on record review and interviews, the facility failed to notify the resident's physician when there was a significant change in the resident's condition for one (#1) of two residents out of 12 sample residents. Specifically, the facility failed to notify the physician for Resident #1 when she had slurred speech.Findings include: I. Professional referenceAccording to Nursing Skills (2023), retrieved on 11/17/25 from https://www.ncbi.nlm.nih.gov/books/NBK596735/, Document and notify physician if new unexpected findings including slurred words or inability to speak. Critical findings to report immediately and or obtain emergency assistance include slurred speech or inability to speak.II. Facility policy and procedureThe Change in Condition policy, revised 4/2/24, was provided by the director of operations on 11/5/25 at 1:55 p.m. It read in pertinent part, As part of the evaluation, the nurse will help identify individuals for having any changes of condition during their stay. In addition, the nurse shall evaluate and document/report difficulty speaking. The nursing staff will notify the physician if any of the above signs and symptoms are identified. The physician will indicate if the patient requires additional evaluation/ treatment at the facility or if the resident needs to be sent out to the hospital.III. Resident #1A. Resident status Resident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (an artery is blocked by a clot leading to brain tissue death from a lack of oxygen) due to unspecified occlusion or stenosis of right carotid arteries, type 2 diabetes mellitus and essential hypertension (high blood pressure). According to the 10/18/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She used a walker and a wheelchair. She required set up assistance with eating and supervision with oral and personal hygiene. She required moderate assistance with toileting. B. Record reviewThe 10/18/25 nurse progress note revealed the resident experienced a brief episode of slurred speech during assessment in the morning. The slurred speech resolved and the resident appeared back to baseline. Her vital signs were within normal limits. There was no facial droop observed. Her extremities were equal and strong. The resident was alert and responsive. The facility would continue to monitor for any recurrence. -However, there was no documentation to indicate the resident's physician was notified of the resident's episode of slurred speech. The 10/22/25 nurse progress note revealed Resident #1 was again found in her room with slurred speech. At the initial assessment, the resident was alert and at baseline with bilateral upper and lower extremity strength equal. Her vital signs were within normal limits. The physician was notified and assessed the resident at the bedside. The physician ordered a transfer of the resident to the hospital. 911 was called and emergency medical services (EMS) arrived fifteen minutes later. Upon EMS arrival, the resident was noted with mild confusion and generalized weakness. The resident was transferred to the hospital. Resident #1 has a history of a recent stroke and had a remote cardiac monitor attached to her upper chest during the event. The resident's family was updated. The 10/22/25 hospital history and physical physician note revealed Resident #1 had nonsensical speech upon exam. The nursing facility was called by the hospital and the facility reported the resident was normally sociable with intermittent slurred speech. When the facility noted the resident's speech was slurred again, a neurological exam was completed that was okay. The nursing facility's physician was notified and recommended calling 911. The facility reported this happened last Saturday (10/18/25) but was worse today (10/22/25) with weakness and confusion. The episode on 10/18/25 was brief.-However, the facility's physician was not notified that the resident was exhibiting slurred speech until the resident's second episode of slurred speech on 10/22/25, despite the fact that she had initially demonstrated slurred speech on 10/18/25, four days prior to being transferred to the hospital (see progress notes above).IV. Staff interviews Registered nurse (RN) #1 was interviewed on 11/5/25 at 12:07 p.m. RN #1 said he was the nurse who assessed Resident #1 on 10/18/25. RN #1 said Resident #1 had slurred speech so he completed an assessment and notified his assistant director of nursing (ADON) because it was a change in condition for the resident. RN #1 said the ADON completed an assessment. RN #1 was interviewed a second time on 11/5/25 at 12:30 p.m. RN #1 said the ADON did not tell him to notify the physician about Resident #1's slurred speech on 10/18/25. RN#1 said he notified the ADON because he did not know the resident's baseline due to the fact that 10/18/25 was the first full shift he had cared for the resident. The ADON was interviewed on 11/5/25 at 12:15 p.m. The ADON said she worked on 10/18/25 and was notified by RN #1 about Resident #1's slurred speech. The ADON said she completed vital signs and an assessment on the resident together with RN #1 and she told RN #1 to document the findings. The ADON said the physician should have been notified and she said she told RN #1 to notify the physician on 10/18/25. The ADON was interviewed a second time on 11/5/25 at 12:30 p.m. The ADON said if a resident had slurred speech, an assessment should be completed because it could indicate a change in condition. She said she documented the assessment in a progress note. She said the physician, the director of nursing (DON) and the resident's representative should be notified.The director of nursing (DON) was interviewed on 11/5/25 at 1:10 p.m. The DON said a change of condition included an episode of slurred speech. She said if a nurse observed slurred speech with a resident, the physician should be contacted. The DON said the nurse should also notify the unit manager and the ADON or the DON. The DON said she was familiar with Resident #1. She said if a nurse observed slurred speech with the resident on 10/18/25, she hoped the nurse would have contacted the physician. She said if the nurse had notified the ADON, the nurse should have also notified the physician. She said she thought the facility had discussed Resident #1's slurred speech in morning rounds, but she was not sure and she would check. She said RN #1 or the ADON may have notified the physician but they did not document that the physician was notified. The DON said based on Resident #1's insurance, the physician was notified electronically, not by phone, and she would check to see if there was documentation on the back end. V. Facility follow-up The nursing home administrator (NHA) provided the following typed document on 11/6/25 at 2:16 p.m.: The nurse very appropriately performed a thorough evaluation, documenting his findings and plan moving forward. The nurse was clear, indicating the event was brief and had fully resolved. Resident #1's vital signs were stable. The resident was back to baseline. The nurse would continue to monitor for any recurrence. The facility believed it was important to note the identification of transient changes in speech had been a common historical finding. Documentation reflects the anomalies tended to come and go and were thought to be the result of past neurological events. The documented treatment plan simply focused on working on compensatory strategies. The 10/11/25 hospital speech language pathology evaluation revealed a recommendation for home speech language pathology due to the resident reporting intermittent word finding difficulties since the previous transient ischemic attack (TIA) which she described as frustrating at times. -However, RN #1, the ADON and the DON said if a resident had slurred speech, the physician should be notified. The facility did not document transient changes during the resident's stay at the facility to determine slurred speech was the resident's baseline.

Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents.Resident #1 was admitted on [DATE] with diagnoses of metabolic encephalopathy (a change in how the brain works), weakness, difficulty in walking, heart failure and unspecified dementia.On 6/18/25 a nursing staff member documented Resident #1 was wandering, angry and saying he wanted to leave. The facility initiated a care plan for wandering on 6/19/25, however, the care plan did not identify the resident was at risk for elopement, despite the resident indicating he wanted to leave. The facility did not implement any interventions to prevent a potential elopement from the facility for Resident #1. On 6/22/25 Resident #1 was on the phone with a family member and said he was going home. When the family member called the facility to check on the resident, the facility was unable to locate the resident. Resident #1 was found by the police in a soccer field an hour and a half later and transported to the hospital. Resident #1 suffered a laceration (a deep cut) to his head, extensive bruising to his upper extremities, left temple and face, and abrasions (scrapes) to both knees. The resident was transported to the hospital for treatment prior to returning to the facility.Specifically, the facility failed to:- Identify Resident #1 was at risk for elopement; and,-Ensure Resident #1 was provided with the supervision necessary to prevent an elopement. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/15/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/26/25. I. Elopement incident on 6/22/25On 6/22/25 the facility staff received a phone call from Resident#1's family member who said she was on the phone with the resident and he said he was going home. The facility was unaware the resident had exited the facility. The police found the resident an hour and a half after he was noted as missing. He was found in a soccer field and had extensive bruising and a laceration to his head. Police transported the resident to the hospital. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #1's elopement incident on 6/22/25 was provided by the nursing home administrator (NHA) on 7/15/25 at 2:05 p.m. The plan documented the following:A. Immediate action On 6/22/25 all staff was educated on the facility's policy and procedure for elopement. The NHA and the regional director of operations completed a facility audit on 6/24/25 and reviewed the wander risk assessment to determine which residents were high risk for elopement. Once identified, residents' care plans were updated to prevent residents from eloping. The binder at the front desk was updated to include pictures and information of residents who were high risk for elopement.Signs were placed at the front exit, on visitor elevators and displayed at the reception desk to alert visitors not to assist residents outside, unless approved by a staff member.B. Identification of other residentsCurrent residents in the facility were reviewed and residents who were high risk for elopement were identified. Effective immediately, new admissions to the facility would be assessed for elopement risk and interventions would be initiated to prevent elopement.C. Systemic changesOn 6/22/25 to 6/26/25 the NHA completed in-services to all staff on the facility's elopement policy to include an elopement assessment, updating the care plan and the basics on conducting a search. All new admissions were assessed and care planned for elopement risk if the assessment indicated moderate to high risk elopement. An elopement drill would be conducted once a month to ensure all staff members were aware of what to do when there was an elopement, per the facility policy.D. MonitoringThe NHA or designee would review random residents' elopement risk assessments to ensure they were completed and that residents who identified as high risk had interventions in place. Monitoring would continue for two weeks and then one time a month for three months. The NHA or designee would monitor that elopement drills were completed monthly for the following three months. III. Facility policy and procedureThe Elopement policy and procedure, revised 3/28/24, was provided by the NHA on 7/14/25 at 1:30 p.m. It read in pertinent part, It is the policy of the facility that staff shall investigate and report all cases of missing residents.If an employee discovers that a resident is missing from the facility, he/she should determine if the resident was out on an authorized leave or pass. If the resident was not authorized to leave, initiate a search of the facility and premises. If the resident was not located, notify the NHA and the director of nursing (DON), the resident's legal representative, the attending physician and law enforcement officials.IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 7/12/25. According to the July 2025 computerized physician orders (CPO), diagnosis included metabolic encephalopathy, weakness, difficulty in walking, heart failure and unspecified dementia. The 5/20/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The assessment indicated the resident used a wheelchair and a walker. He was dependent on staff for transfers. B. Resident #1's representative's interviewResident #1's representative was interviewed on 7/15/25 at 10:16 a.m. via phone. The resident's representative said she was on the phone with Resident #1 when he said he was going home. She said she heard a visitor speaking to the resident asking if he was able to get back in. She said she immediately called the facility to check on his status. She said the facility was unable to locate Resident #1 and a search was conducted. She said the police found Resident #1 at a soccer field behind the facility and transported him to the hospital for treatment of his injuries. C. Record reviewThe wandering care plan, initiated 6/19/25 and revised 7/4/25, revealed Resident #1 had an acute history of wandering outside of the facility grounds. The interventions included checking the resident for physical comfort needs/pain (initiated 6/19/25), offering emotional and psychological support as needed (initiated 6/19/25), providing and involving the resident in activities directed at the resident's specific interests (initiated 6/19/25), reorienting and redirecting the resident as needed (initiated 6/19/25), providing one-to-one staff as needed (initiated 6/26/25) and posting a picture/photo of the resident at the front desk to identify elopement risk (initiated 6/27/25).The elopement care plan, initiated 6/23/25 and revised 7/1/25, revealed Resident #1 left the facility unescorted on 6/22/25 and was at risk for further elopement. Interventions included documenting any attempts at elopement, encouraging visits from friends and family, monitoring the resident's whereabouts regularly, offering emotional support, orienting the resident to the environment, placing a photo of Resident #1 at the front desk to identify the elopement risk and providing a one-to-one staff member for safety. The wandering risk assessment, dated 5/13/25, revealed Resident #1 was a low risk for wandering.-However, the facility failed to complete another wander risk assessment on 6/18/25 when Resident #1 was noted to be upset, wandering in the facility and saying he wanted to leave (see progress note below). A nursing progress note, dated 6/18/25 at 3:46 p.m. (four days before the elopement), revealed Resident #1 was wandering, angry and saying he wanted to leave. The nurse and certified nurse aide (CNA) walked with the resident around the nurses station for 40 minutes. The resident was having a hard time maneuvering his walker. The nurse spoke to Resident #1's representative who was also unable to redirect him. -The facility failed to identify Resident #1's exit seeking behavior prior to his elopement and implement effective interventions to prevent a potential elopement.A nursing progress note, dated 6/22/25 at 9:10 p.m., revealed Resident #1 was last seen at 8:49 p.m. when he was administered medication. He was calm, sitting in a chair in front of the nurses' station and talking on the phone. At 9:10 p.m. Resident #1's representative called the facility to check in and the resident was noted to be missing. The representative said she was speaking to him on the phone and he told her he was coming home. She said she heard a man asking Resident #1 if he knew how to go back into the facility. The entire facility was searched, including outside areas, by the staff. All other residents were accounted for. The assistant director of nursing (ADON), the DON and the police were notified.A nursing progress note, dated 6/23/25 at 5:56 p.m., revealed Resident #1 had returned from the hospital with extensive bruising to both upper extremities, left temple and face. Abrasions were noted to both knees. Resident #1 was highly confused and a wanderer. Staff was unable to easily redirect him. He was a high fall and elopement risk. He had poor balance and resisted most of his cares and treatments. V. Staff interviewsThe facility's receptionist was interviewed on 7/15/25 at 12:10 p.m. The receptionist said the facility's front doors automatically locked at 6:30 p.m. She said a visitor needed to ring the door bell at the front entrance after 6:00 p.m. However, she said anyone was able to exit the facility at any time. She said a receptionist was on duty everyday from 7:00 a.m. to 7:00 p.m. She said at the time of the survey, the facility did not have any wandering residents. She said if a resident was identified as a wander or an elopement risk, their photo and information was posted at the front desk. She said all the staff attended an in-service on the elopement policy following Resident #1's elopement. She said all staff must know where a resident was going or the resident must have a staff member with them when leaving the facility. She said there was a sign out binder for the residents to sign out on pass. CNA #1 was interviewed on 7/15/25 at 12:58 p.m. CNA #1 said Resident #1 always wandered and was exit seeking. She said a CNA was assigned as one-to-one supervision for Resident #1, but she said he did not have one-to-one supervision prior to his elopement. She said he was in an observation room in front of the nurses' station because he was a high fall risk. She said Resident #1 was very fast and he would be sitting in the common area by the elevators and the next moment he would be gone. She said she was not working the day of the elopement. Registered nurse (RN) #1 was interviewed on 7/15/25 at 1:02 p.m. RN #1 said Resident #1 did not have any wandering or exit seeking behavior that he was aware of. He said Resident #1 was admitted as a high fall risk and always had a low blood pressure. He said Resident #1 was admitted to an observation room across from the nurses' station because he was very forgetful and was always trying to get out of bed. He said after Resident #1's elopement, an in-service was provided for all staff. The DON was interviewed on 7/15/25 at 3:40 p.m. The DON said she was not aware of the 6/18/25 nurse progress note that indicated Resident #1 was wandering and wanted to leave. She said the staff did not identify Resident #1's exit seeking behavior and no interventions were put into place as far as she knew. She said she did not know Resident #1 was capable of leaving the second floor. She said she was aware that Resident #1 had a lot of behaviors and was a high fall risk, but she did not know he was a wandering risk. She said the staff had a morning huddle but it was not communicated to her that Resident #1 was exit seeking prior to his elopement from the facility on 6/22/25. She said she was not aware that the MDS coordinator had initiated a wandering care plan on 6/19/25. She said there must have been a lack of communication. The NHA was interviewed on 7/15/25 at 4:18 p.m. The NHA said the staff failed to identify Resident #1's behavior on 6/18/25 as exit seeking. She said the staff were more focused on his fall risk and behaviors. She said she did not think Resident #1 knew where the elevator was or how to get outside. She said following his elopement, a plan of correction was put into place to prevent residents from eloping. She said she believed the facility completed a thorough investigation and put measures in place to safeguard residents from elopements. RN #2 was interviewed via phone on 7/15/25 at 4:43 p.m. RN #2 said Resident #1 was sitting in the lobby next to the elevators and he seemed fine (on 6/22/25). She said she had other residents to care for and continued to provide care for the other residents. She said Resident #1's representative called the facility and asked for Resident #1 to be checked on because she was on the phone with him and she thought he may be outside. RN #2 said she did not think Resident #1 was outside but she said she looked for him anyway. She said the staff was unable to locate the resident and the ADON was notified and she notified the DON and the police. RN #2 said Resident #1 was found by the police and transported to the hospital. She said she was not aware of the 6/18/25 nurse progress note regarding the resident wandering and wanting to leave and was not aware Resident #1 was exit seeking. She said there were only interventions for his fall risk prior to the resident's elopement. She said following the elopement, all staff received an in-service training on the elopement policy, as well as completing risk assessments.

Based on observations, record reviews, and interviews, the facility failed to ensure food was prepared, distributed, and served under sanitary conditions in the kitchen to prevent the spread of foodborne pathogens. I. Observations, interviews, and record review revealed the facility failed to ensure for the last several months, that cookware, drinkware, dishware, and flatware were sufficiently sanitized over the last several months. The dietary manager (DM) reported the fuse to the electrical breaker was insufficient and shorted out in the facility's high-temperature dishwashing machine on three occasions. The facility changed from a high-temperature process to a low-temperature process by making makeshift modifications to the dishwashing machine. Once converted, the machine's sprayer jets clogged on at least three additional occasions, preventing the sanitizing solution from dispensing. Additionally, the temperature gauge on the dishwashing machine had not been working for an undetermined length of time. The facility, aware of the intermittent problems with the sprayer jets, failed to monitor the sanitation level and water temperature of the dishwashing machine consistently to ensure the cookware, dishware, drinkware, and flatware would be properly sanitized throughout the dishwashing process. Temperature and sanitizing logs for November 2023 could not be located. Log entries were missing for 15 days between December 2023 and February 1, 2024, including on four occasions for multiple, consecutive days. The facility reported using paper products on only one occasion during this time. The dietary manager (DM) said staff were aware they needed to use the three-compartment sink to wash and sanitize dishes when the dishwashing machine was not working but staff interview revealed the facility failed to ensure the water temperature and sanitation levels in the three-compartment sink were at the proper level. The facility's lack of consistent sanitization of cookware, drinkware, dishware, and flatware made the transmission of foodborne pathogens likely to contribute to serious harm to all residents. II. Observation, interview, and record review also revealed several other failures in the facility's preparation, distribution, and service of food. Specifically, the facility failed to ensure: -Staff practiced appropriate hand hygiene and glove use during food preparation activities. -The proper temperature of refrigerated, frozen foods and cooked food. -Kitchen staff wore hair restraints to prevent hair from contacting food; -The kitchen ice machine and filter were clean; -Disposable cups were not immersed and stored in containers holding cooking ingredients; Findings include: I. Immediate Jeopardy for serious harm A. Situation of Immediate Jeopardy The facility failed to ensure cookware, drinkware, dishware, and flatware were sufficiently sanitized; the dishwashing machine had not been working consistently for the last several months. The dietary manager (DM) reported the fuse to the electrical breaker was insufficient and shorted out in the high-temperature dishwashing machine on three occasions. The facility changed from a high-temperature process to a low-temperature process by making makeshift modifications to the dishwashing machine. Once converted, the machine's sprayer jets clogged on at least three additional occasions, preventing the sanitizing solution from dispensing. Additionally, the temperature gauge on the dish machine had not been working for an undetermined length of time. The facility, aware of the intermittent problems with the sprayer jets, failed to monitor the sanitization levels and water temperature consistently to ensure the cookware, dishware, drinkware, and flatware would be sufficiently sanitized throughout the dishwashing process. Temperature and sanitizing logs for November 2023 could not be located, and log entries were missing for 15 days between December 2023 and February 1, 2024, including on four occasions for multiple, consecutive days. The facility reported using paper products on only one occasion during this time. According to staff, thermometers to check the water temperature in the three-compartment sink were not always available which the DM said staff was instructed to use to wash and sanitize dishes when the dishwashing machine was not working. Staff interviews with dietary staff revealed they were unaware of the temperature and sanitizing requirements for manual washing of cookware, drinkware, dishware, and flatware and had not received correct training on manual sanitizing using the three-compartment sink. The facility's lack of consistent sanitization of cookware, drinkware, dishware, and flatware made the transmission of foodborne pathogens likely to contribute to serious harm to all residents. B. Imposition of immediate jeopardy On 2/23/24 at 12:21 p.m., the nursing home administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure food was prepared, distributed, and served under sanitary conditions. C. Facility plan to remove immediate jeopardy On 2/23/24 at 3:14 p.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: The facility purchased and installed a low-temp dishwasher that was operable February 8, 2024. 1. Staff were in-serviced 02/23/2024 by Ecolab representative on the process of how to use the new dish machine and successfully returned the demonstration. 2. Staff were in-serviced on the process of how to use 3 compartment sinks in the event that the dishwashing machine is not operable. All staff were able to verbalize understanding of the process. 3. If for any reason neither of the two methods are functional then dietary staff will use disposable paper products. 4. Return demonstration competencies would be completed with each staff prior to starting their next shift. 5. The dishwasher machine will be monitored for proper water temperature and sanitization after each meal. The dietary manager will monitor the temperature and ppm of the dishwasher machine one time a day. The Dietary Manager will receive additional training from the Registered Dietitian on how to monitor dietary staff for compliance. All dietary staff members will be educated on policy and procedure before their next scheduled shift and will provide return demonstration to ensure competency. Furthermore, new dietary staff members will be completing the same process. This education will be completed by the Ecolab representative by 02/23/2024. All patients have the potential to be affected by this alleged deficiency. There is no evidence that any patients were adversely affected. The Administrator or designee will monitor for compliance of the dishwashing process to include temperature, sanitation ppm, and three compartment sinks are being followed per facility policy. Monitoring will be as follows. Daily x1 week, then weekly x4 weeks, then monthly x 2 months for at least 3 months monitoring or until substantial compliance is obtained. Results of audits will be reviewed in the QA monthly meeting to ensure the plan has been implemented, sustained and evaluated for its effectiveness. D. Removal of the immediate jeopardy The above plan was accepted on 2/23/24 at 3:35 p.m., and the immediate jeopardy was removed based on the actions taken and monitoring planned by the facility to remove the immediate jeopardy situation. However, deficient practice remained at a level F, with widespread potential for more than minimal harm. II. Facility failure to ensure for the last several months, that cookware, drinkware, dishware, and flatware were sanitized sufficiently. A. Dishwashing machine Professional Reference: The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 2/8/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, ]The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 degrees F. When used for warewashing, the wash compartment of a sink, mechanical warewasher, or wash receptacle of alternative manual warewashing equipment, shall contain a wash solution of soap, detergent, acid cleaner, alkaline cleaner, degreaser, abrasive cleaner, or other cleaning agent according to the cleaning agent manufacturer's label instructions. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified under sanitizers, criteria, shall be used in accordance with the EPA- registered label use instructions, and shall be used as follows: a chlorine solution shall have a minimum temperature based on the concentration and ph of the solution as listed in the following chart concentration range (mg/l). Mg/L means milligrams per liter, which is the metric equivalent of parts per million (ppm). For a minimum temperature of pH 10 or less at 120 degrees F the concentration range should be between or at 25-49 (mg/l). Facility policy and procedure: The Kitchen Sanitation and Infection Control policy and procedure revised 2021, was provided by the NHA on 2/5/24 at 3:33 p.m. It revealed in pertinent part, All local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. -The director of food and nutrition services will be responsible for providing safe foods to all individuals. Dishwashing guidelines and techniques will be understood by staff and carried out in compliance with the state and local health codes. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes. -Low Temperature Dishwasher and Spray Type Dish Machines Using Chemicals to Sanitize should reach a temperature of 120 degrees F and 50 PPM Hypochlorite for final rinse temperature and sanitation. Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The director of food and nutrition services will post a log near the dish machine for the staff to document temperatures. Staff will monitor dish machine temperatures throughout the dishwashing process. -Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. Staff will be trained to report any problems with the dish machine to the director of food and nutrition services as soon as they occur. -The director of food and nutrition services will promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. 1. Observations and record review Observations and record reviews revealed the facility failed to meet facility expectations to ensure monitoring, reporting, and taking action to ensure proper sanitation of cookware, dishware, drinkware, and flatware. On 1/31/24 at 9:05 a.m., the low-temperature dishwasher temperature gauge was not functional, as the temperature did not change when the machine was not operating and when it was running. The dishwasher machine's chemical sanitizer (hypochlorite) solution was tested and indicated that the testing strip measured between 5 to 10 PPM. The test was repeated three times by the dietary manager (DM) and the hypochlorite PPM solution was between 5 to 10 PPM. On 2/1/24 at 9:00 a.m., a review of the low-temperature dishwasher logs from November to January 2024 for recording temperature and sanitation levels revealed a log for November 2023 could not be located. Further, the dishwasher logs had over 100 missing entries for the dishwashing machine's temperature and PPM during these months. As on 1/31/24, the low-temperature dishwashing machine's temperature gauge was observed to not be functional, as the temperature did not change when the machine was not operating and when it was running. On 2/1/24 at 12:05 p.m., the dishwasher machine's chemical sanitizer (hypochlorite) solution was tested and the testing strip measured 0 PPM. The test was repeated three times by the DM and a contracted kitchen vendor who was present to repair the dishwashing machine. All tests revealed the hypochlorite PPM solution was at 0 PPM. 2. Interviews Staff interviews revealed the expectation that the temperature and PPM should be taken at intervals throughout the dishwashing process to ensure the dishwashing machine functioned properly but that this was not done, even though staff was aware the dishwashing machine had been broken intermittently for the past year. Dietary aide (DA) #1 was interviewed on 2/1/24 at 10:12 a.m. She said the dishwashing machine had been broken for a few months and there was always something wrong with it. She said the temperature gauge was not functional, so she washed dishes manually using the three-compartment sink. The contracted kitchen repair vendor was interviewed on 2/1/24 at 12:05 p.m. He said the sanitizer line that ran to the dishwashing machine was completely clogged and looked like there had been buildup occurring over the past few weeks which decreased the concentration of the hypochlorite solution over time. He said the clog had been removed today and the dishwashing machine was retested . The hypochlorite solution PPM was now 50. The DM (the director of food and nutrition services) was interviewed on 2/1/24 at 2:50 p.m. The DM said he was able to test the dishwashing machine temperature to ensure it reached at least 125 degrees F utilizing a portable thermometer; however, he said other dietary staff did not have access to the thermometer. He said he measured the PPM for the dishwashing machine earlier today, but said he did not document it on the dishwashing machine log along with the machine temperature because he had a reading of 0 PPM and he did not want to indicate a low reading on the log. The DM said a new dishwashing machine was going to be installed on 2/8/24. The registered dietitian (RD) was interviewed on 2/5/24 at 3:40 p.m. He said the dishwashing machine has been broken intermittently throughout the last year and therefore the facility had resorted to using disposable silverware at times. The RD said the temperature and PPM should be taken at intervals before each meal service to ensure the dishwashing machine functioned properly and the dishes were clean and disinfected before serving residents. The infection preventionist (IP) was interviewed on 2/5/24 at 4:11 p.m. She said it was important to ensure the PPM and correct temperature readings were logged for the dishwashing machine to ensure the facility disinfected all eating utensils because the facility had residents with active infectious diseases such as COVID-19, flu, and clostridium difficile. Therefore, the dishes needed to be washed correctly to kill any pathogens. The director of nursing (DON) was interviewed on 2/5/24 at 4:30 p.m. She said it was important to document the PPM and temperature of the dishwashing machine to ensure the machine functioned properly and any plates, mugs, cups, and silverware were disinfected properly. The DON said if proper disinfecting did not occur, it would pose a health risk for the residents due to contamination and the development of infection. The NHA was interviewed on 2/5/24 at 4:46 p.m. She said it was best practice to test the PPM of the dishwashing machine or log entries to ensure the dishwashing machine functioned properly. The DM was interviewed again on 2/23/24 at 8:35 a.m. -He said the fuse to the electrical breaker was insufficient and shorted out on three occasions. The facility then made makeshift modifications to the dishwashing machine, changing it from a high-temperature process to a low-temperature process. He said that once converted, the dishwashing machine's sprayer jets clogged on at least three additional occasions, preventing the sanitizing solution from dispensing. He said the facility used paper products on only one occasion during this time. -He confirmed the temperature and sanitizing logs for November 2023 could not be located. Log entries were missing for 15 days between December 2023 and February 1, 2024, including on four occasions involving multiple, consecutive days (12/13 - 12/14, 12/22 - 12/25, 12/28 -12/30/23, 1/19 -1/21, and 1/26 -1/28/24). -He said a new dishwashing machine was purchased and staff were educated on the current dishwashing machine on 2/6/24 and the new dishwashing machine on 2/12/24. However, interviews with DA #4 and DA #5 on 2/23/24 at 9:00 a.m. revealed staff were not clear about the instructions for operating the new dishwashing machine. DA #4 said he took the PPM but did not log it. DA #5 said she was never trained due to the language barrier she had, she did not understand the training provided. B. Three-compartment sink Observations and interviews revealed the facility failed to ensure the manual sanitation of dishes in the three-compartment sink was properly completed. Professional Reference: The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 2/8/24 from https://cdphe.colorado.gov/environment/food-regulations. it revealed in pertinent part, in manual warewashing operations, a temperature measuring device shall be provided and readily accessible for frequently measuring the washing and sanitizing temperatures in hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the utensil surface temperature. The temperature of the wash solution in manual warewashing equipment shall be maintained at not less than 110 degrees F and the temperature specified on the cleaning agent manufacturer's label instructions. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified under sanitizers, criteria, shall be used in accordance with the EPA-registered label use instructions. Facility policy and procedure: The Kitchen Sanitation and Infection Control policy and procedure revised 2021, was provided by NHA on 2/5/24 at 3:33 p.m. It revealed in pertinent part, All local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. The director of food and nutrition services will be responsible for providing safe foods to all individuals. The director of food and nutrition services will promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. Staff will follow these procedures for washing dishes using the three sink method: -Wash dishes in detergent and warm water to remove all soil. -Prepare the clean sink by measuring the appropriate amount of water into the sink and marking the sink with a water line. -Determine the appropriate amount of detergent to be used, and follow the manufacturer's directions for use. Water should be at 110 F. -Change water frequently to assure effective cleaning of dishes. -Rinse dishes in clean, warm water: Prepare the clean sink with hot water and rinse the dishes thoroughly before placing [them] in the sanitizing sink. Sanitize dishes: -Measure the appropriate amount of sanitizing chemical into the appropriate amount of water (following the manufacturer's guidelines). Water should be 75 to 100 Ft. -Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure [the] appropriate level. -Place the dishes in the sanitizing sink. Allow to stand according to the manufacturer's guidelines for sanitizer. - Allow dishes to air dry. Invert dishes in a single layer to air dry. Check all dishes to be sure they are clean and dry prior to storing. Sanitize all dishes by immersion in one of the following: -Chlorine 50 to 100 PPM 75 F 10 seconds -Quaternary Ammonium 150 to 200 PPM 75 F Per manufacturer -Iodine 12.5 PPM 75 F 30 seconds. 1. Observations and record review On 2/1/24 at 10:05 a.m., the three-step manual wash and rinse sinks were observed. The wash sink was full of water. The water was tested with a thermometer. The temperature reading was 93.7 degrees F. DA #1 submerged plates and cups into the sink for 19 seconds and then removed the plates and cups and placed them on a drying rack. The sanitizing solution was labeled as Sentinel. Posted directly above the three-step manual wash sink was a display with the procedure for kitchen staff to follow for the three-step manual wash method using a different sanitizing product (Dawn). The Sentinel sanitizer product label recommended a dip time of a minimum of two minutes to be effective. 2. Staff interviews DA #1 was interviewed on 2/1/24 at 10:12 a.m. -She said she used the three-sink manual method because of issues with the dishwashing machine. She said she was told that when using the three-sink method, she needed to first scrape off any food. Second, she placed the dishes in the soapy water. Third, she transferred them to the rinse sink with only water, however, she said she was not instructed to take the water temperature. Lastly, she would take the dishes out of the water and dunk the items into the sanitizing sink for 15 seconds. After this, she pulls the dishes out to air dry. -She said she never timed herself but just waited a few seconds. DA #1 said the instructions posted for the kitchen staff to use the three-compartment sink were wrong and they were for an old sanitation product they no longer use. She said she was trained by the DM to dunk items for 15 seconds in the sanitizing sink. DA #2 was interviewed on 2/1/24 at 2:40 p.m. -He said he oversaw the dinner-time meal service. He said the dishwashing machine had been broken for several months and he never knew when to use it. Due to this uncertainty, he washed all the dishes using the three-step sink. He said he needed to first scrape off any food and then place the dishes in the soapy water and then transfer them to the rinse sink with only water. He said he does not take the temperature of the water. After the rinse, he would dunk the dishes into the sanitizing sink for 15 seconds then pull them out to air dry. -He said he never timed himself but he just had a feeling that 15 seconds had passed. He said he wished there was more clarity with kitchen day-to-day operations, cleaning, and oversight from the DM. The DM was interviewed on 2/1/24 at 2:50 p.m. He said the manual three-sink cleaning method was being used due to issues with the dishwashing machine and that the dunk time for sanitization was 15 seconds. The DM then contacted the manufacturer of the Sentinel sanitizer product and reported he was told the Sentinel sanitizer product would take two minutes to disinfect dishes. Therefore, dishes needed to be dunked for a minimum of two minutes. The DM said the correct procedure should be posted in front of the three-step sink since the posted one was outdated. The RD was interviewed on 2/5/24 at 3:40 p.m. He said the manual three-sink method should have the dunk time posted and the DM should know the correct dunk time. The IP was interviewed on 2/5/24 at 4:11 p.m. She said kitchen staff should have followed manufacturer recommendations when sanitizing dishes using the three-sink manual method to ensure the facility disinfected all eating utensils because the facility had residents with active infectious diseases such as COVID, flu, and clostridium difficile. Therefore, dishes needed to be washed correctly to kill any pathogens. The NHA was interviewed on 2/5/24 at 4:46 p.m. She said it was best practice for kitchen staff to use the correct procedure for the three-sink manual method wash. III. Other failures in the facility's preparation, distribution, and service of food. A. Hand hygiene and glove use Professional Reference: The Colorado retail food regulations, effective 1/1/19, were retrieved 2/8/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, employees are preventing cross-contamination of ready-to-eat food with bare hands by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning gloves to initiate a task that involves working with food; after engaging in other activities that contaminate the hands. Food employees shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: rinse under clean, running warm water; apply an amount of cleaning compound recommended by the cleaning compound manufacturer; rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails during the cleaning procedure and creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms, finger tips, and areas between the fingers. Thoroughly rinse under clean, running warm water. Immediately follow the cleaning procedure with thorough drying using a method to avoid re-contaminating hands or surrogate prosthetic devices. Food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a handwashing sink. Equipment food-contact surfaces and utensils shall be cleaned: -Before each use with a different type of raw animal food such as beef, fish, lamb, pork, or poultry. -Each time there is a change from working with raw foods to working with ready-to-eat foods. -Employees are preventing cross-contamination of ready-to-eat food with bare hands by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Facility policy and procedure: The Kitchen Sanitation and Infection Control policy and procedure revised 2021, was provided by the NHA on 2/5/24 at 3:33 p.m. It revealed in pertinent part, All local, state, and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. The director of food and nutrition services will be responsible for providing safe foods to all individuals. Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination. Staff will use good hygienic practices and techniques with access to proper hand washing facilities (available soap, hot water, and disposable towels and/or heat/air drying methods). Antimicrobial or antiseptic gel will not be used in place of proper hand washing techniques. Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food. Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 1. Observations On 2/1/24 between 11:45 a.m. and 12:17 p.m., the cook prepared the residents' plates by stacking plates with warmers on top of one another before putting food on the residents' plates. The cook wore the same gloves throughout the lunch plating and service. Throughout the lunch service, the cook touched other non-disinfected areas within the kitchen such as the freezer and reach-in refrigerator handles, fryer handles, steamer handles, frozen raw chicken, his face, and clothing garments with the same soiled gloves 32 times. The cook also touched a soiled kitchen cleaning cloth seven times with his soiled gloves and proceeded to plate and cut foods with his soiled gloves. During the lunch service, the cook touched both cooked pork and chicken directly with his soiled gloves to stabilize them on the resident plate 11 times as he cut them with a knife and then served the meat to the residents. The knife was not disinfected between cutting ready-to-eat chicken and pork. -During the meal service, the cook requested DA #3, who wore gloves while cleaning dirty dishes and cleaning the surface top of the sink with a chemical sanitizer, to heat two bread rolls. DA #3 did not remove his gloves after cleaning dirty dishes and submerging his hands into the sanitizer solution. He used the soiled gloves to reach into the reach-in refrigerator and touched two bread rolls with his soiled hands, placed them on a plate, and heated them in the toaster. DA #3 put plastic wrap on the rolls when they were out of the toaster; however, he made some contact with the ready-to-eat rolls after being cooked. 2. Staff interviews DA #3 was interviewed on 2/1/24 at 2:45 p.m. He said he forgot to change his gloves before grabbing the bread rolls with his soiled gloves. He said he should have taken his gloves off and sanitized or washed his hands before touching and warming the bread rolls. He said it was important to change or remove gloves to prevent chemical contamination of food. The cook was interviewed on 2/1/24 at 2:46 p.m. He said he was in a hurry and tried to be efficient during the lunch meal service hour and therefore, he forgot to change his gloves throughout the entire meal. However, he said he should have changed them between surfaces, handling meats, and touching areas of the kitchen. He said he should wash his hands and/or use sanitizer before putting on new gloves. The DM was interviewed on 2/1/24 at 2:50 p.m. The DM said staff should always wash their hands and or change gloves and wash hands between different work areas, after touching their garments and or cleaning cloths, after handling different uncooked meats, and especially after handling chemicals or dirty dishes to prevent cross-contamination. The DM said they do have residents who have a religious belief that pork was restricted and therefore, kitchen staff could not touch both ready-to-serve meats in that case. The RD was interviewed on 2/5/24 at 3:40 p.m. He said kitchen staff should wear gloves or wash their hands before touching ready-to-eat food or any surface and re-wash their hands or replace gloves when there is any cross-contamination, especially with raw foods and/or switching gloves in between an allergen. Kitchen staff should never touch chemicals and any ready-to-eat food without washing their hands or changing gloves and engaging in hand

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for one of two units. Specifically, the facility failed to: -Ensure insulin (medication used for blood sugar control) pens were cleaned prior to administration of insulin to a resident; -Ensure staff donned personal protective equipment (PPE) properly; -Ensure staff did not cause cross contamination from COVID-19 positive resident rooms; and, -Ensure visitors donned PPE prior to entering a COVID-19 positive resident room. Findings include: I. Medication administration failures A. Professional reference According to the Instructions for use Insulin Lispro Kwik pen, retrieved on 2/6/24 from: https://uspl.lilly.com/lispro/lispro.html#ug1, it read in pertinent part, Step one pull pen cap straight off. Wipe the Rubber seal with an alcohol swab. B. Facility policy and procedure The Insulin Pen Injection policy and procedure, revised on 6/14/22, was received from the nursing home administrator (NHA) on 2/5/24 at 2:18 p.m. It revealed in pertinent part, an insulin pen was an injection device with a needle that delivers insulin into the subcutaneous tissue (the tissue between the skin and the muscle). Wipe the rubber stopper with an alcohol wipe. C. Observations Licensed practical nurse (LPN) #2 was observed on 2/1/24 at 12:38 p.m. administering insulin to Resident #227. LPN #2 collected a Lispro insulin pen from the medication cart, applied a new needle to the pen, primed the pen with two units of insulin and dialed two units to administer to the resident. -LPN #2 failed to clean the rubber seal of the insulin pen prior to applying the needle. LPN # 2 was observed at 12:42 p.m. administering insulin to Resident #223. LPN #2 collected the Lispro insulin pen from the medication cart, applied a new needle to the pen, primed the pen with two units, dialed six units and administered insulin. -LPN #2 failed to clean the rubber seal of the insulin pen prior to applying the needle. LPN #2 was observed at 12:47 p.m. administering insulin to Resident #218. LPN #2 collected the Lispro insulin pen from the medication cart, applied a new needle to the pen, primed the pen with two units, dialed the pen to six units and administered insulin. -LPN #2 failed to clean the rubber seal of the insulin pen prior to applying the needle. D. Staff interviews LPN #2 was interviewed on 2/1/24 at 12:54 p.m. She said was not aware that the insulin pens rubber seal needed to be cleaned prior to applying a new needle. The assistant director of nursing (ADON) was interviewed on 2/1/24 at 4:07 p.m. She said the rubber seal on insulin pens should be cleaned with an alcohol swab prior to applying a new needle to prevent infection. The infection preventionist (IP) was interviewed on 2/1/24 at 4:09 p.m. She said an alcohol swab should be used to clean the top of the pen before applying a needle to prevent infection. The director of nursing (DON) was interviewed on 2/6/24 at 9:48 a.m. She said insulin pens should be cleaned prior to applying the needle to prevent bacteria from being introduced into the resident. 47024 II. Failures with COVID-19 positive resident rooms A. Facility policy and procedure The Infection prevention policy, revised 8/19/22, was provided by the NHA on 1/31/24 at 2:57 p.m. It read in pertinent part: The staff, employees, consultants, contractors, volunteers, and others who provide services and care to the patients on behalf of the patients. PPE equipment to be worn for contact with blood, bodily fluids, mucus membranes, or non-intact skin. Appropriate PPE to be worn for infection/illnesses and in quarantine rooms. Staff will implement appropriate transmission-based precautions. The Transmission based precaution policy, revised 2/8/21, was provided by the DON on 2/6/24 at 11:15 a.m. it read in pertinent part: Transmission-based precautions are to be used in addition to Standard precautions for patients with documented or suspected infection or colonization with highly transmissible (spreadable) pathogens (germs) for which additional precautions are needed to prevent transmission. Transmission-based precautions include: droplet and airborne precautions. Gowns shall be worn whenever it is anticipated that clothing will have direct contact with the patient, or potentially contaminated environmental surfaces. Droplet precautions shall be used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing or talking. A face mask shall be donned upon entry into the patient room. B. Observations During continuous observation on 1/31/24 between 12:10 p.m. and 12:56 p.m. The infection preventionist (IP) failed to close the gown in the back while donning (put on) PPE for a COVID-19 positive room [ROOM NUMBER]. During continuous observation on 2/1/24 between approximately 2:40 p.m. and 3:10 p.m. Certified nurse aide (CNA) #1 exited a COVID-19 positive resident room [ROOM NUMBER], with the resident's large plastic water cup, set it on the counter while washing his hands, took the cup to the nourishment room for ice, returned and placed the cup on the PPE cart, donned new PPE and re-entered the resident room. At 2:58 p.m. a visitor entered the room, without stopping at the nurse station or donning PPE. The visitor was not wearing a mask. CNA #1 was present when the visitor entered the room. CNA #1 failed to offer PPE to the visitor. At 3:05 p.m. CNA #2 prepared to enter the room, she failed to don the mask (N95) correctly by failing to place the second strap over the head and around the neck to secure the seal of the mask. The CNA failed to put on a face shield or goggles before entering the room. C. Staff interviews Registered nurse (RN) #2 was interviewed on 2/6/24 at 9:55 a.m. RN #2 said when staff was donning PPE, for COVID-19 positive residents, the back of the gown should be closed and resident personal items should not be brought out of the room because it could be a source for contamination. She said family members of COVID-19 positive residents should wear a surgical mask when entering a COVID-19 positive room. She said family members should be educated on the need to wear PPE. CNA #3 was interviewed on 2/6/24 at 10:22 a.m. She said the back of the PPE gown should be closed before entering the room. She said COVID-19 positive residents' personal items should not be taken out of the room. She said family members of COVID-19 positive residents should wear PPE in the resident room and the staff should educate them. LPN #4 was interviewed on 2/6/24 at 10:24 a.m. She said the PPE gown should be closed in the back before entering the resident room. She said items from isolation rooms should not be brought into the hall. She said the staff educated family members about isolation and the need for PPE. The DON was interviewed on 2/6/24 at 10:54 a.m. The DON said COVID-19 positive residents' personal items should not be brought out of the room. She said the staff should encourage family members of COVID-19 positive residents to wear PPE while in the resident room. She said the floor nurses educated the family members, however, any staff member could educate on using PPE. The IP was interviewed on 2/6/24 at 11:01 a.m. The IP said N95 masks needed to have both straps put on to have the proper seal around the face. If the N95 was not on correctly the person could be compromised. She said the gown should be closed in the back when entering an isolation room even for a short time. She said staff should not bring COVID-19 positive residents' personal items into the hall. She said family members should wear PPE into COVID-19 positive residents' rooms because they could be contagious and the disease could be transmitted to others. She said staff should encourage and educate family members to wear PPE into COVID-19 positive resident rooms.

Based on record review and interviews, the facility failed to ensure two (#41 and #114) residents out of three residents received treatment and care in accordance with professional standards of practice out of 43 sample residents. Specifically, the facility failed to administer insulin timely per the physician orders. Findings include: I. Facility policy The Medication Administration policy and procedure, revised 8/22/22, was provided by the nursing home administrator (NHA) on 2/1/24 at 6:25 p.m. It read in pertinent part, It is the policy of this facility that medications are to be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. II. Resident #41 A. Resident status Resident #41, age below 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus (too much sugar in the blood), fracture off the neck of the femur (thigh bone), viral hepatitis and cirrhosis of the liver. The 9/13/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He had impairment to one side of his lower extremities. He required touching assistance with toilet hygiene, rolling side to side, sitting to lying, lying to sitting, sitting to stand, chair to bed transfers and walking 10 feet. He received insulin. B. Resident interview Resident #41 was interviewed on 2/1/24 at 10:08 a.m. He said his evening insulin was given late on many occasions. C. Record review The blood glucose care plan, initiated 9/8/23, revealed the resident had the potential for fluctuating blood glucose levels, diabetic complications and/or poor wound healing. The interventions included: -Monitor blood sugars per the physician orders and as needed; -Monitor for signs and symptoms of hyperglycemia (high blood sugar) and /or hypoglycemia (low blood sugar) and report to the physician; -Monitor guidelines set by the physician for low or high blood sugars that exceed or meet the parameters and follow up with the physician as needed; and -Provide medications per physician orders. Review of the December 2023 and January 2024 CPO revealed the following orders related to diabetes mellitus (DM) reviewed from 12/1/23 to 1/22/24: -Humalog injection solution (insulin Lispro) inject as per sliding scale: if 200-249=1 unit; 250-299=2 unit; 300-349=3 unit and contact MD (medical doctor); 350-399=4 unit and contact MD, subcutaneously at bedtime for DM. Call MD if BS is >300 and above. Order Date 10/7/23. -Humalog injection solution (insulin Lispro) inject subcutaneously at bedtime for DM (diabetes mellitus). Call the physician if blood sugar is above 300. Order dated 10/7/23. Review of the December 2023 and January 2024 medication and treatment administration record (MAR/TAR) revealed the resident did not receive his humalog sliding scale insulin timely at 7:00 p.m. on the following days: -12/1/23 insulin was administered at 9:05 p.m. -12/6/23 insulin was administered at 10:29 p.m. -12/12/23 insulin was administered at 10:32 p.m. -12/18/2 insulin was administered at 8:53 p.m. -12/19/23 insulin was administered at 9:51 p.m. -12/20/23 insulin was administered at 9:07 p.m. -1/8/24 insulin was administered at 8:35 p.m. -1/9/24 insulin was administered at 8:38 p.m. -1/10/24 insulin was administered at 10:08 p.m. -1/17/24 insulin was administered at 10:08 p.m. -1/19/24 insulin was administered at 10:13 p.m. -1/22/24 insulin was administered at 10:33 p.m. III. Resident #114 A. Resident status Resident #114, age below 65, was admitted [DATE] and discharged [DATE]. According to the October 2023 CPO, diagnoses included type 2 diabetes mellitus, anemia (not enough healthy red blood cells to carry oxygen in the blood) in chronic kidney disease, major depressive disorder, anxiety disorder and muscle spasm. The 9/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. He required limited assistance with dressing, He required supervision with bed mobility, transfers, locomotion on and off the unit, toilet use, and personal hygiene. He received insulin. B. Record review The blood glucose care plan, revised on 10/31/23, revealed the resident had the potential for fluctuating blood glucose levels, diabetic complications and/or poor wound healing related to a diabetic diagnosis. The interventions included: -Monitor blood sugars per the physician orders and as needed; -Monitor for signs and symptoms of hyperglycemia and /or hypoglycemia and report to the physician; and -Provide medications per physician orders. Review of the August to October 2023 CPO revealed the following order related to diabetes mellitus reviewed from 8/8/23 to 10/7/23: -HumaLOG Solution (Insulin Lispro) inject as per sliding scale: if 0-70=0 give high protein/carb and recheck blood glucose and call physician; 71-149=0 no intervention; 150-200=2 units give subcutaneously; 201-250=4 units give subcutaneously; 251-300=6 units give subcutaneously; 301-350=8 units give subcutaneously; 351-400=10 units give subcutaneously; 401-405=call physician if greater than 400, subcutaneously three times a day for DM II. Order date 6/5/23. Review of the August, September and October 2023 MAR/TAR revealed the resident did not receive his humalog sliding scale insulin timely on the following days: -8/8/23 insulin was administered at 9:47 a.m. due at 8:00 a.m. -8/10/23 insulin was administered at 9:56 a.m. due at 8:00 a.m. -8/12/23 insulin was administered at 7:21 p.m. due at 5:00 p.m. -8/13/23 insulin was administered at 11:40 a.m. due at 8:00 a.m. -8/28/23 insulin was administered at 9:35 a.m. due at 8:00 a.m. -8/30/23 insulin was administered at 9:51 a.m. due at 8:00 a.m. -9/16/23 insulin was administered at 9:21 a.m. due at 8:00 a.m. -9/20/23 insulin was administered at 11:20 a.m. due at 8:00 a.m. -9/27/23 insulin was administered at 11:41 a.m. due at 8:00 a.m. -9/29/23 insulin was administered at 10:24 a.m. due at 8:00 a.m. -10/4/23 insulin was administered at 12:38 p.m. due at 8:00 a.m. -10/7/23 insulin was administered at 10:59 a.m. due at 8:00 a.m. -The facility failed to follow the physician orders when administering sliding scale insulin. III. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 2/5/24 at 2:23 p.m. She said insulin should be administered before the meal because when the resident ate a meal it increased their blood sugar. She said the blood sugar should be kept in the normal range as much as possible to keep the blood sugar regulated. She said the residents' blood sugar could elevate way too high if the insulin was not given timely and put them into hyperglycemia (high blood sugar). Registered nurse (RN) #1 was interviewed on 2/5/24 at 2:29 p.m. He said insulin should be given at the scheduled time. He said if a resident was not given their insulin timely it could increase their blood sugar. He said high blood sugars could affect the resident's eyes and kidneys if not regulated and controlled. The director of nursing (DON) was interviewed on 2/5/24 at 2:59 p.m. She said insulin should be given within the hour either before or after the scheduled time. She said sliding scale short acting insulin should be administered on time. She said long acting insulin works throughout the day. She said the short acting insulin has less effect if not given on time. She said administering insulin should be a priority to be given on time. She said if the resident's blood sugar was too high and the insulin was administered late, the blood sugar would go even higher before the insulin could take effect.

Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of three medication carts reviewed. Specifically, the facility failed to ensure nursing staff did not store medications in their pocket. Findings include: I. Facility policy and procedure The Storage of Medication policy and procedure, revised 1/13/22, was received from the nursing home administrator (NHA) on 2/6/24 at 1:30 p.m. It revealed in pertinent part, purpose of this policy was to ensure medications and biologics were stored properly, following all applicable manufacturer and legal requirements, to maintain integrity and support safe effective drug administration. Medication storage should be kept clean. Outdated, contaminated, discontinued or deteriorated medications and those in containers that were cracked soiled or without secure closure should be removed and disposed of. II. Observations and staff interviews Medication cart 2 B was reviewed on 2/5/24 at 4:45 p.m. with licensed practical nurse (LPN) # 4. LPN #4 unlocked the medication cart and removed two medication cups from the top drawer and placed them into her left pant pocket. LPN #4 pulled out the medication cups from her pants when asked about the medication. LPN #4 identified the first medication cup to belong to Resident #69. LPN #4 identified the medication as Lasix (medication used to remove excess fluids from the body). LPN #4 identified the second medication cup to belong to Resident #30. LPN #4 identified the medications in the cup were gabapentin (medication used for neurological pain) and potassium chloride (medication used to increase potassium levels in the body). LPN #4 said she placed the medication cups in her pocket to hide them. LPN #4 said medications should never be stored in a pocket because they could be lost, contaminated or given to the wrong resident. The director of nursing (DON) was interviewed on 2/5/24 at 4:57 p.m. She said medications should not be stored in a pocket because it could lead to infection and was not an acceptable way to store medications.

Based on observations, interview and record review, the facility failed to ensure residents and representatives had full access to the facility's most recent survey findings including the survey results, certifications, complaint investigations and plans of correction. Specifically, the facility failed to: -Ensure the survey finding binder was available; -Ensure staff members were aware of where the binder was located; and, -Ensure survey documents were updated. Findings include: I. Resident group interview During the resident council meeting on 1/31/24 at approximately 1:30 p.m. Residents, #166 and #59, who were cognitively intact. The residents stated they were not aware of how to access the survey findings binder. II. Observation During observation upon request of the survey findings binder at the front desk on 1/31/24 at 2:00 p.m. The receptionist (RCP) attempted to look for the binder. The nursing home administrator (NHA) came to the front desk and looked in the drawers and cabinets and the admissions coordinator (AC) came from her office to assist. The NHA found the binder in the storage closet behind the front desk. The last survey in the binder was dated 1/15/21. -The recertification survey from 10/27/22 was not included in the binder. III. Staff interview The RCP was interviewed on 1/31/24 at 2:01 p.m. The RCP said she did not know where the survey binder was located. The NHA was interviewed on 1/31/24 at 2:07 p.m. She said the binder was in the storage closet. She said the facility had not had a recertification survey since 2021. The social services director (SSD) was interviewed on 2/6/24 at 9:48 a.m. The SSD said the NHA should keep the survey finding binder up to date. The NHA was interviewed on 2/6/24 at 10:33 a.m. The NHA said she was responsible for keeping the survey binder up to date with the most recent surveys.

Based on record review and interviews, the facility failed to ensure one (#15) of three residents out of 12 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure that Resident #15: -Received all doses of his prescribed diuretic medication; and, -Received the correct dose of the diuretic medication. Findings include: I. Professional reference According to [NAME], P.A. and [NAME], A.G. et.al., (2017), Fundamentals of Nursing, ninth edition, pp 624 - 626, Medication errors can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval. Administering extra doses, and/or failing to administer medications. Preventing medication errors is essential. Professional standards such as scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medication: the right medication, the right dose, the right patient, the right route, the right time and the right documentation. II. Facility policy and procedure The Medication Administration policy, revised 3/31/21, was provided by the nursing home administrator (NHA) on 9/8/23 at 6:17 p.m. It read in pertinent part, It is the policy of this facility that medications are to be administered as prescribed by the attending physician. Medications should be administered in accordance with the written orders of the attending physician. -The policy did not address the six rights of medication administration. -The policy did not address medication errors. III. Resident status Resident #15, age greater than 70, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included heart failure, acute respiratory failure with hypoxia (low levels of oxygen in the body tissues) and pneumonia. The 8/19/23 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required one-person limited assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. He had a diagnosis of heart failure and had received a diuretic medication for six days during the seven day assessment look back period. Per the 8/19/23 MDS assessment, no clinically significant medication issues were identified during a complete drug regimen review. IV. Record review Review of Resident #15's discharge orders from the hospital revealed the following physician's order: Torsemide (diuretic medication which acts to increase urine passing from the body) 20 milligram (mg) tablet. Take one tablet by mouth every other day for fluid retention. The medication was documented as last being given on 8/11/23 at 8:33 a.m. Review of Resident #15's September 2023 CPO revealed the following physician's order: Torsemide oral tablet. Give 20 mg by mouth in the morning for edema. Hold medication for systolic blood pressure (SBP) less than 100. The order was dated 8/14/23. -The physician's order was obtained two days after the resident's admission to the facility. -The physician's order did not match the physician's order on Resident #15's discharge orders from the hospital which indicated the resident was to receive Torsemide 20 mg every other day (not daily). -Review of Resident #15's August 2023 CPO revealed the admitting nurse had incorrectly transcribed the physician's order for Torsemide 20 mg every other day as Toremifene Citrate (a medication used to treat metastatic breast cancer) oral tablet 20 mg by mouth every other day for fluid retention. -The medication error was not identified until 8/14/23 during a post admission medication review conducted by the pharmacist. Review of Resident #15's August 2023 medication administration record (MAR) revealed the resident did not receive a dose of Torsemide until 8/15/23. -The resident missed a dose of Torsemide on 8/13/23. Review of Resident #15's MARS from 8/15/23 to 9/6/23 revealed the resident was receiving Torsemide 20 mg daily (not every other day as the hospital discharge orders had specified - see discharge orders above). -The resident was receiving two times the dose of Torsemide he was initially ordered to receive. Review of physician's assistant (PA) notes revealed the PA documented on 8/15/23 that Resident #15 was receiving Torsemide 40 mg every other day. -The physician's order did not match the physician's order on Resident #15's discharge orders from the hospital which indicated the resident was to receive Torsemide 20 mg every other day (not daily). -The PA additionally documented the resident was on Torsemide 40 mg every other day on 8/17/23, 8/21/23, 8/23/23, 8/28/23, 8/30/23, 9/1/23 and 9/5/23. -The documentation error was not identified until 9/7/23, during the survey. Review of Resident #15's care plan revealed the resident was at risk for cardiac complications related to cardiac/heart disease, hypertension (high blood pressure) and congestive heart failure. Pertinent interventions included administering medications per physician's orders. -The care plan was not initiated until 8/22/23 (10 days after the resident was admitted to the facility). V. Director of nursing (DON) interview The DON was interviewed on 9/7/23 at 2:45 p.m. The DON said the pharmacist identified the initial transcription medication error of Resident #15's Torsemide medication on 8/14/23 during the pharmacist's post admission medication review. She said the admitting nurse had transcribed the medication incorrectly as another medication and the resident missed one dose of the Torsemide. She said the facility educated the admitting nurse regarding ensuring orders were transcribed accurately. She said the medication error was corrected and the resident began receiving Torsemide on 8/15/23. The DON said she was unaware the resident was to be receiving the medication every other day. She confirmed the hospital discharge orders indicated the resident should have been receiving Torsemide 20 mg every other day instead of daily. She said this was another medication error. The DON confirmed the PA's documentation indicated the resident was receiving 40 mg of Torsemide every other day instead of 20 mg every other day. She said she would need to clarify the order with the PA. The DON was interviewed again on 9/7/23 at 3:30 p.m. She said she had spoken with the PA. She said the PA thought the resident was taking 40 mg of Torsemide daily and was unaware that the resident had been receiving 20 mg of the medication daily instead. She said the PA determined Resident #15 was stable and wanted the resident to continue receiving Torsemide 20 mg daily. The DON said she would do another education with the nurses regarding the second medication error.

Based on interviews, record review, facility policy review, and facility document review, the facility failed to ensure residents were allowed to choose whether to perform services for which the facility was responsible for 3 (Resident #44, Resident #102, and Resident #35) of 3 sampled residents who were interviewed about the facility's services during a Resident Council meeting. Specifically, the facility required residents (or their families) perform laundry services for which the facility was responsible. Findings included: Review of a facility policy titled, Resident Use of Laundry Facility Infection Control Policy and Procedure, revised 02/08/2021, revealed, The centers are dedicated to promoting all resident's functional independence with activities of daily living. As such, patients are allowed to utilize the therapy laundry room to wash and dry clothing under the supervision of facility staff. The following policy will be utilized to minimize the risk of infectious disease transmission during the laundering process. Review of the facility's undated Financial Arrangement Agreement revealed, Laundry policy: family members are encouraged to launder the patient's clothing at home. Because of government regulations, the following policies are adopted: clothing must be taken home weekly (or more often for soiled clothing); and if an odor problem is identified with the laundry, clothing will be sent to an outside vendor at the patient's expense. The Federal regulation at 42 CFR 483.10(f)(11)(i)-(iii), tag F571, indicated routine personal hygiene items and services, as required to meet the needs of residents, were among the services included in Medicare or Medicaid payment. The listed items and services included basic personal laundry. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #44 scored 13 on a Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The MDS indicated the resident was at the facility for a Medicare-covered stay that began on 10/11/2022. During an interview on 10/24/2022 at 4:02 PM, Resident #44 reported that, upon admission, the facility stated the resident's family must launder the resident's personal clothing. Resident #44 expressed worry that if they had an accident or if their family could not launder their clothing often enough, they would not have clean clothes to wear. The resident stated, I don't know what to do. Review of an MDS Entry Tracking Record revealed the facility admitted Resident #102 on 10/17/2022 and that the resident had not had a Medicare-covered stay since the most recent entry to the facility. The resident's cognitive status was not assessed on the entry-tracking record; however, review of the electronic medical record revealed a Brief Interview for Mental Status (BIMS) assessment, dated 10/20/2022, which indicated Resident #102 scored 15 on the BIMS, indicating the resident was cognitively intact. Review of an admission MDS dated [DATE] revealed Resident #35 scored 15 on a BIMS, indicating the resident was cognitively intact. The MDS indicated the resident was at the facility for a Medicare-covered stay that began on 10/07/2022. During a Resident Council interview on 10/26/2022 at 11:06 AM, Resident #44 again mentioned that they were told on admission that their family must do their laundry, and if they had no clean clothes, their only option was to wear a gown. Resident #102 stated they wished the facility offered laundry services, because not everyone had family to do their laundry. Resident #35 stated they had been wearing a gown since 10/07/2022 because their family member was not available until 11/01/2022 to do their laundry, and Resident #35 had no clean clothes. During an interview on 10/25/2022 at 1:01 PM, Certified Nursing Assistant (CNA) #1 stated families did the residents' laundry. CNA #1 indicated if a resident had soiled clothes, they placed them in a bag in the resident's room for the family to pick up, because the facility did not wash personal laundry. CNA #1 further stated the facility provided gowns if a resident had no clean clothes of their own. During an interview on 10/25/2022 at 1:08 PM, CNA #2 stated the facility had no in-house laundry and that most residents had their families take their clothing home to wash them. CNA #2 indicated staff bagged up soiled clothing for the families and offered a gown if a resident had no clean clothes of their own. During an interview on 10/25/2022 at 1:17 PM, Registered Nurse (RN) #1 stated since COVID-19 started, the facility stopped doing residents' laundry. RN #1 noted most families picked up dirty clothes and laundered them at home, because there were no on-site laundry services. RN #1 further stated she did not know why the facility had not started doing residents' laundry again . During an interview on 10/25/2022 at 2:25 PM, CNA #4 stated the facility sent out linens to be laundered at an off-site location but did not wash resident clothes. CNA #4 indicated there was a washer and dryer in the therapy department that a resident could use if they were on occupational therapy (OT) services; otherwise, the family had to do a resident's personal laundry. During an interview on 10/26/2022 at 1:27 PM, the Business Office Manager (BOM) stated residents were responsible for doing their own personal laundry, but the facility sent the linens, towels, blankets, socks, and gowns out to be laundered. The BOM further stated families had to help with laundry, and if a resident had no family, staff helped them use the washer and dryer in the therapy department. The BOM then stated the facility did not charge for personal laundry services, even though the financial agreement reflected that personal laundry would be done at the residents' expense. During an interview on 10/26/2022 at 3:15 PM, the Director of Nursing (DON) stated families had to pick up residents' laundry and wash it at home, because the facility only laundered linens, towels, cloth napkins, and gowns at an outside site. Per the DON, if a resident had no clean clothing, the facility offered gowns to wear. The DON then stated there was a washer and dryer in the therapy department but thought they were only for the use of residents on OT services who were transitioning home. During an interview on 10/26/2022 at 3:50 PM, the Executive Director (ED) stated residents and families were notified upon admission that there were no laundry services available, so most families washed residents' laundry.

Based on observations, interviews, and record review, the facility failed to ensure that before a resident was allowed the opportunity to self-administer medications, the interdisciplinary team (IDT) conducted an assessment to determine if the resident could safely and accurately do so and a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of a facility policy titled, Self-Administration of Medications, dated 07/01/2018, revealed, Patients have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the nursing staff will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Observation and interview on 10/24/2022 at 2:45 PM revealed Resident #14 sitting in a wheelchair in their room. On the bedside table in front of the resident, there was a medication cup that contained four pills. Resident #14 stated the nurse left the pills on the bedside table about 15 minutes prior. Resident #14 stated they were not going to take the pills because they wanted to ask the nurse a question. Review of an October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's medical record revealed no physician's order or assessment for medication self-administration since the resident's admission to the facility on [DATE]. During an interview on 10/25/2022 at 1:12 PM, Registered Nurse (RN) #1 stated that when administering medications, the nurse should remain with the resident to ensure the resident took all medications as ordered. RN #1 further stated Resident #14 was not safe to self-administer medications and that the only time a resident could self-administer medications was if the physician had assessed the resident as safe to do so and the resident had an order written [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/25/2022 at 3:50 PM, RN #3 stated she left the pills on Resident #14's bedside table the day before because she had to leave Resident #14's room to do something else. RN #3 asserted she did not normally leave pills in a resident's room and acknowledged she should have stayed to ensure Resident #14 took the medications. RN #3 indicated when she returned to Resident #14's room, the pills were still in the cup on the bedside table, and RN #3 did not know how long Resident #14 was left alone with the medications. During an interview on 10/26/2022 at 10:54 AM, the Physician's Assistant (PA) stated Resident #14 needed to be assessed for safety and trained on how to self-administer medications if determined safe to do so. The PA further stated nursing should not leave pills in a resident's room if the resident had not been properly assessed to self-administer medications. During an interview on 10/26/2022 at 3:10 PM, the Director of Nursing (DON) stated she expected the nurse to stay in a resident's room when the resident was taking medications and indicated the nurse should not leave pills at a resident's bedside. The DON further stated that for a resident to self-administer medications, an assessment needed to be completed with a physician's order to self-administer. The DON then stated Resident #14 was not safe to self-administer medications because there was no order and no assessment done. During an interview on 10/26/2022 at 3:48 PM, the Executive Director (ED) stated he expected a nurse to stay in the room when administering a resident's medications. He indicated the nurse should only leave medications with a resident if the resident had been properly assessed to safely administer their own medications.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure a resident was free from misappropriation of personal belongings for 1 (Resident #105) of 3 sampled residents reviewed for misappropriation. Specifically, the facility's Social Worker (SW) gave Resident #105's personal belongings to an unidentified visitor without confirming the person's identity or obtaining the resident's permission. Findings included: Review of the facility's undated policy titled, Abuse and Neglect Prohibition revealed, misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Review of an Admission Record revealed Resident #105 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #105 was listed as their own primary contact; the secondary contact indicated, NO contact. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #105 was independent in cognitive skills for daily decision making per a staff assessment of mental status. Review of a Resident Belonging Inventory Sheet, dated 07/07/2022, revealed Resident #105 had eyeglasses, a wallet, shirts, dresses, shoes, skirts, slippers, stockings, undershirts, underpants, money, and credit cards upon admission. The inventory sheet was signed by Resident #105 on 07/07/2022. Review of Progress Notes, dated 07/23/2022, revealed Resident #105 was discharged to the hospital. During an interview on 10/26/2022 at 12:14 PM, the Executive Director (ED) stated he started employment at the facility after Resident #105 was discharged to the hospital and did not know Resident #105. The ED indicated he received a phone call from Resident #105's family member on 08/12/2022, and the family member wanted to pick up Resident #105's personal belongings. The ED spoke with the SW, who stated someone had already picked up Resident #105's personal belongings. The ED stated the SW gave Resident #105's personal belongings to a person who stated Resident #105 was in the hospital and wanted their wallet. The ED indicated he asked the SW if she contacted Resident #105's family member, and she had not. The ED reached out to the hospital and the assisted living facility where Resident #105 lived prior to admission, and neither had possession of Resident #105's personal belongings. The ED stated he then contacted the police, but it was unknown where Resident #105's personal belongings were upon filing the report. During an interview on 10/26/2022 at 12:48 PM, the SW stated she gave Resident #105's personal belongings to someone, but she could not remember the person's name. When asked how she knew it was permissible to give Resident #105's personal belongings to this person, the SW stated she thought it was alright because this person knew Resident #105 by name and knew the contents of Resident #105's bag. The SW acknowledged she did not confirm with Resident #105 that it was okay to give the belongings to this person. During an interview on 10/26/2022 at 3:19 PM, the Director of Nursing (DON) stated that to prevent misappropriation of personal belongings, facility staff completed an inventory sheet upon admission and verified it with the resident and family member. If a resident went out to the hospital and there was no power of attorney (POA) listed on the face sheet, the SW should reach out to the hospital to get a resident's personal belongings back to them. The DON stated the SW should not have given Resident #105's personal belongings to the person who came to the facility claiming to know Resident #105. During an interview on 10/26/2022 at 3:53 PM, the ED stated that when a resident went out to the hospital and was not coming back, staff typically placed their personal belongings in a bag and labeled it with the resident's name. The facility held onto resident belongings until a family member picked them up. The ED further stated the SW should not have given Resident #105's personal belongings to the person who came to the facility claiming to know Resident #105; she should have verified the person's identity and confirmed with Resident #105 that she had permission to release their personal belongings.

Based on interviews, record review, and facility policy review, it was determined the facility failed to notify the resident and the resident's representative in writing and provide a copy of the written notice to the long-term care ombudsman when a resident was transferred to the hospital for 1 (Resident #21) of 3 sampled residents reviewed for hospitalization . Findings included: Review of a facility policy titled, Admissions, Transfers, and Discharge Process, updated on 02/12/2021, indicated, Upon admission, if/when a resident is transferred to another health care facility, transferred within this facility, or discharged from this facility, the resident or his/her representative will be informed about the Facility Admission/Transfer/Discharge policies. The policy did not indicate that the resident or their representative would be informed in writing. Review of Progress Notes, revealed Resident #21 was transferred to the hospital on 09/20/2022 at 12:34 PM, on 10/05/2022 at 1:58 PM, and on 10/11/2022 at 2:09 PM. Review of Resident #21's electronic health record (EHR) revealed no documentation to indicate written notice was provided to Resident #21 or the resident's representative of the resident's transfer to the hospital. An Admission Record in the EHR included a name and home phone number for Emergency Contact #1. In an interview on 10/25/2022 at 1:45 PM, Registered Nurse (RN) #2 stated she was present on one of the days when Resident #21 was transferred to a hospital but could not remember the date. RN #2 stated the facility did not provide the resident or the resident's representative with notification in writing of the resident's transfer to the hospital. In an interview on 10/25/2022 at 1:52 PM, Licensed Practical Nurse (LPN) #2 stated that when a resident was transferred to the hospital, the facility staff notified the resident's family by phone of the transfer but did not provide the resident or the resident's representative with written notification. In an interview on 10/25/2022 at 1:56 PM, LPN #1 stated she was present on one of the days when Resident #21 was transferred to the hospital but could not remember the date. LPN #1 stated that when a resident was transferred to the hospital, the facility staff notified the resident's family by phone of the transfer but did not provide a written notification. In an interview on 10/25/2022 at 3:46 PM, RN #3 stated that when a resident was transferred to the hospital, the facility staff notified the resident's family by phone of the transfer and documented the notification in the resident's chart but did not provide written notification. An interview was attempted on 10/26/2022 at 2:28 PM with the local Ombudsman, and a voicemail was left. The Ombudsman did not return the surveyor's call during the survey. In an interview on 10/26/2022 at 3:02 PM, the Director of Nursing (DON) stated that when a resident was transferred to the hospital, facility staff notified the resident's family by phone of the transfer but did not provide written notification. The DON stated the facility did not notify the Ombudsman if a resident was transferred or discharged , and the only time they contacted the Ombudsman was if there were a resident rights concern. In an interview on 10/26/2022 at 3:42 PM, the Administrator (ADM) stated that when a resident was transferred to the hospital, the facility staff notified the resident's family by phone of the transfer but did not provide written notification. The ADM stated he was unaware of whether the facility notified the Ombudsman of a resident transfers.

Based on interviews, record review, and facility policy review, it was determined the facility failed to provide written information regarding the facility's bed-hold policy to a resident and their representative when the resident was transferred to the hospital for 1 (Resident #21) of 3 sampled residents reviewed for hospitalization . Findings included: Review of a facility policy titled, Admissions, Transfers, and Discharge Process, updated on 02/12/2021, indicated, At the time of move in, transfer to another health care facility or overnight visits outside the facility, the resident and/or representative will be provided with information on how to hold the resident's current bedroom during their absence. The policy did not indicate that the resident or their representative would be informed in writing. Review of Progress Notes revealed Resident #21 was transferred to the hospital on 09/20/2022 at 12:34 PM, on 10/05/2022 at 1:58 PM, and on 10/11/2022 at 2:09 PM. Review of Resident #21's electronic health record (EHR) revealed no documentation to indicate that Resident #21 and their representative was provided with written information regarding the facility's bed-hold policy before or at the time of Resident #21's transfer to the hospital. An Admission Record in the EHR listed a name and home phone number for Emergency Contact #1. In an interview on 10/25/2022 at 1:45 PM, Registered Nurse (RN) #2 stated she was present on one of the days when the resident was transferred to the hospital but could not remember the date. RN #2 stated that upon admission, residents sign a bed-hold policy notice. RN #2 indicated when a resident was sent to the hospital, they were verbally told about the policy, but the facility did not provide the resident with anything in writing. In an interview on 10/25/2022 at 1:52 PM, Licensed Practical Nurse (LPN) #2 stated a resident was provided with the bed-hold policy upon admission. LPN #2 said facility staff did not go over the bed-hold policy when a resident was transferred to a hospital. LPN #2 stated the facility did not provide a resident or their representative with anything in writing about the bed-hold policy. In an interview on 10/25/2022 at 3:46 PM, RN #3 stated the facility provided a resident a copy of the bed-hold policy upon admission, but facility staff did not go over the policy when the resident was transferred to a hospital. In an interview on 10/26/2022 at 3:02 PM, the Director of Nursing (DON) stated a resident was given the bed-hold policy when the resident was admitted to the facility, and the facility staff went over the bed-hold policy when the resident was transferred to the hospital. The DON stated the information provided was verbal only, and the facility did not provide the resident or resident representative with a written copy of the bed-hold policy upon transfer. In an interview on 10/26/2022 at 3:42 PM, the Administrator (ADM) stated the bed-hold policy was signed upon admission by a resident and was only verbally discussed before the resident was transferred to the hospital.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident who required extensive assistance with personal hygiene was regularly offered trimming or shaving of facial hair to maintain good grooming and hygiene for 1 (Resident #38) of 2 sampled residents reviewed for activities of daily living (ADLs). Findings included: Review of a facility policy titled, ADL Services, revised 02/08/2021, revealed, Patients shall receive assistance with activities of daily living (ADLs) every shift, as appropriate. ADLs include: - Bathing - Grooming - Dressing - Eating - Oral Hygiene - Ambulation - Toilet Activities. Review of an Admission Record revealed Resident #38 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance for personal hygiene. Review of a Care Plan, dated as initiated 10/08/2022, revealed Resident #38 had an actual/potential decline in the ability to perform ADLs. Interventions included providing assistance as needed with grooming, bathing, and personal hygiene according to the resident's preferences. During an observation and interview on 10/24/2022 at 2:37 PM, Resident #38 was lying in bed, with the head of the bed elevated. The resident had facial hair on both sides of their chin that was approximately one inch long. The resident stated they would like to have their facial hair trimmed but did not have a razor at the facility. Review of Bathing Daily per preference task documentation revealed that from 10/08/2022 through 10/24/2022, for the question: Did you shave patient? the staff responded, Resident Refused on six occasions; Not Applicable on one occasion; and No on seven occasions. During an interview on 10/25/2022 at 1:56 PM, Licensed Practical Nurse (LPN) #1 stated the Certified Nursing Assistants (CNAs) were responsible for trimming the resident's facial hair. LPN #1 acknowledged she had never offered to shave the resident's facial hair. During an interview and observation on 10/25/2022 at 2:00 PM, CNA #3 stated the CNAs were responsible for trimming the resident's facial hair. CNA #3 stated she thought she offered to shave the resident last week but acknowledged she did not offer to shave the resident today, when she combed the resident's hair. At this time, CNA #3 and the surveyor went into Resident #38's room. CNA #3 indicated Resident #38's facial hair was approximately one inch long and stated she should have offered to shave Resident #38 earlier in the day when she brushed the resident's hair. Resident #38 stated, Oh, I would love to be shaved. I normally use a regular razor but an electric one will be okay. During an interview on 10/25/2022 at 2:09 PM, LPN #1 entered Resident #38's room to observe the resident's facial hair with the surveyor. After exiting the resident's room, LPN #1 described Resident #38's facial hair was pretty long, and estimated it was approximately one inch long. LPN #1 stated she did not notice Resident 38's facial hair that morning when she provided the resident's morning medications. LPN #1 stated staff should have offered to shave Resident #38. During an observation on 10/25/2022 at 2:12 PM, CNA #3 was in the resident's room, preparing to shave the resident. CNA #3 stated, I offered last week, and you didn't want it. Resident #38 replied, No, you didn't. CNA #3 then shaved Resident #38's facial hair. During an interview on 10/26/2022 at 12:38 PM, the Assistant Director of Nursing (ADON) stated if staff saw a resident with visible facial hair, they should immediately ask the resident if they want to be shaved. She stated if the resident refused, this should be care planned and, if the resident wanted to be shaved, it should be done right then. In an interview on 10/26/2022 at 3:02 PM, the Director of Nursing (DON) stated CNAs were responsible for shaving the residents. The DON stated staff should ask residents if they wanted any assistance with shaving, and it was not appropriate for Resident #38 to have facial hair that was one inch long. In an interview on 10/26/2022 at 3:42 PM, the Administrator (ADM) stated CNAs, and sometimes nurses, were responsible for trimming residents' facial hair. The ADM stated he expected staff to assist the residents to remove the hair or provide the tools to enable the residents to perform the task themselves.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for one out of four units. Specifically, the facility failed to: -Ensure staff followed proper hand hygiene practices with glove changes; -Ensure housekeeping cleaning steps included starting from clean to dirty; and, -Clean and disinfect shared equipment/products. Findings include: I . Facility policies and procedures The Hand Hygiene policy and procedure, dated 5/23/2020, was provided by the nursing home administrator on 7/14/21 via email. It read in pertinent part, Every time you enter a patient room hand sanitizer should be applied. You should sanitize your hands after removing gloves. The Medical Devices/Equipment-Disinfection policy and procedure, dated 3/27/2020, was provided by the nursing home administrator on 7/14/21 via email. It read in pertinent part, The (facility name) will follow CDC (Centers for Disease Control) guidelines for disinfection of medical devices/equipment. All non-dedicated, non-disposable medical equipment used for patient care is cleaned and disinfected with EPA (Environmental Protection Agency) approved product/CDC guidelines & recommendations. Infection rounds are conducted to ensure medical devices/equipment are cleaned and disinfected consistently and correctly. II. Observations of breaks in infection control practices and staff interviews On 7/7/21 at 9:40 am. Entered the labeled red zone, also called the COVID-19 recovery unit, located on the third floor with two newly admitted residents with a positive test result of COVID-19 for recovery. The unit was separated from the rest of the facility with a separate entrance and exit for the staff. The end of the hallway had a draped section that the staff used as a staging area to prepare residents and items for entering the unit per interview with the NHA on 7/7/21 at 2:22 p.m. At 9:55 a.m. housekeeping services director (HSS) who had worked at the facility for the past five years. He was the housekeeping supervisor and his supervisor was the maintenance service director (MSD). He said he received training and instructions on the infections on the unit via a meeting that took place every morning before he got to his assigned unit with the nursing home administrator (NHA) and MSD. He said he was instructed on the appropriate Environmental Protection Agency (EPA) approved product to use for cleaning and disinfecting. At 10:27 a.m. HSS cleaned room [ROOM NUMBER] and at 11:00 a.m. room [ROOM NUMBER], the below described practices were observed in each room. HSS said that his system for cleaning a resident room was to start at the door and work around the room, wiping down the horizontal surfaces. He said the last area he cleaned was the bathroom. He sprayed the clean rag with a peroxide based disinfectant and said the surface contact time was a minute. He said he did extra sprays on the toilet and sink and let them sit longer to make sure he was killing the bacteria and not taking it home to his family. HSS sprayed the rag and wiped off the door handles and set the bottle on the floor and continued to wipe off other surfaces. He went to the cart for a clean rag and set the bottle on the side panel of the cart. He sprayed the clean rag and placed the bottle on the dresser counter. He sprayed a clean rag and moved the bottle to the chair seat next to the window. He went to the cart for a clean rag and set the bottle on the side panel of the cart. He sprayed a rag and moved the bottle to the bedside table and wiped off the remotes and call light. He sprayed the sink and toilet in the bathroom and set the bottle on the floor and then later moved to the top of the sink after wiping it off. After he was finished, he put the bottles on the cart, put other items away on the cart then pulled the bottles out to wipe off, however the cart surface was not cleaned. After spraying twice and waiting a few minutes between each spray to the toilet, sink and shower he then wiped off the surfaces with a clean rag. He used the rag to wipe off the rim of the toilet bowl and under the toilet seat to the top of the toilet seat down the side of the bowl and across the guardrail. HSS used a green and yellow sponge to scrub the sink bowl and the shower stall walls and the seat built into the shower stall. The sponge was stored in the cabinet on the cart and used in each resident room. HSS said that he used the sponge to get a better clean on the surfaces and stored the sponge on the cart. He said he was careful to use extra disinfectant on the sponge to help clean it between use. At 11:14 a.m. certified nurse aide (CNA) #1 used the alcohol based hand sanitizer (ABHS) in room [ROOM NUMBER] while HSS was cleaning. The dispenser was empty so she got a refill. HSS attempted to refill the dispenser, however it broke so he removed it from the resident's room and placed it on the sink counter in the hallway outside of the resident's room in the common area where staff washed their hands. HSS said he would call the maintenance services director (MSD) to replace the ABHS dispenser. At 11:30 a.m. the MSD arrived at the unit carrying a handheld drill and a new ABHS dispenser for which he placed both items on the sink counter next to the broken dispenser. He washed his hands then moved the broken dispenser to the side and opened the new dispenser on the sink counter. He used something on a key ring to open the dispenser, set it on the sink counter then put on his pants belt loop. He put the new dispenser parts together then carried the handheld drill and new dispenser into the resident's room. He placed the drill on the floor and placed the ABHS bottle on the top of the puncture resistant container hanging on the wall, inserted the drip plate for the dispenser into the opening to deposit needles. When completed he picked up the drill from the floor and went to the sink and set the drill on the counter. He then threw away the broken dispenser and washed his hands. He left the unit with the drill but did not clean/disinfect prior to leaving or entering. He did not clean/disinfect before and after setting it on the floor. The MSD said that he managed the housekeeping department; however, the HSS was the supervisor. He said he provided the training to the three employees he had in the housekeeping department. He said that he did not have dedicated equipment for the COVID-19 unit. At 11:42 a.m. licensed practical nurse (LPN) #1 reached into her pockets past the gown she was wearing to get keys to the medication cart. She had the clipboard and pen that was sitting on the makeshift certified nurse aide (CNA) charting area, bedside table in the hallway next to the makeshift nurses station alcove. CNA #1 used the pen and documented resident vital signs on the clipboard then LPN #1 moved the clipboard and pen to the top of the medication cart. LPN #1 said she needed to verify the vital signs before administering medications. LPN #1 placed the bag of medications from the pharmacy on top of the medication cart then threw the bag away once the medications were secured in the medication cart. At 11:54 a.m. an over the counter medication bottle was brought to the nurse and set on top of the medication cart so she could date the container. She checked her pockets moving the gown out of the way but did not find the marker. She asked CNA #1 for a marker for which she pulled out of her pocket past the gown and gave to the nurse to use. As she was reaching across the top of the medication cart to put items away and label them, the gown sleeves were touching the surface. The marker was left on top of the medication cart then moved later to the makeshift nurses station. At 12:06 p.m. after verifying the vital signs she documented the results on the clipboard that was set on top of the medication cart. She then proceeded to draw up the medications for Resident #100 without cleaning/disinfecting the top of the medication cart. At 12:41 p.m. CNA #1 delivered meal tray to Resident #101. She entered the room and performed hand hygiene and donned gloves. She adjusted his legs and then his seat. She moved the catheter tube and bag. He said he dropped the mask she picked up and threw away. She leaned him forward to prepare him to be adjusted by her and the nurse. LPN #1 delivered the mask to CNA #1 who put the mask on his face. But the same gloves that touched the catheter tubing. CNA #1 changed gloves but did not perform hand hygiene and moved the bedside table next to him. She opened a hand wipe from the meal tray and helped him clean hands. She moved the meal next to him on the table. She opened packets of condiments and plasticware. On 7/8/21 at 2:48 p.m. LPN #3 was drawing up medications at the medication cart. On top of the cart surface were medications she had drawn up ready to administer. She was reviewing the clipboard of resident vital signs with the pen which were set on top of the medication cart. She said she had reviewed the vital signs because they were low so she wanted to recheck using a manual cuff. She pulled a purple bag from the bottom of the medication cart and placed it on top of the cart. She had a stethoscope around her neck that she said she cleaned with the sanitation wipes. After she completed taking the blood pressure, she removed gloves and put ABHS in her hand and carried the cuff to the cart and set it on top. She applied the ABHS then donned gloves and used sanitizing wipes on the stethoscope which was then placed on top of the medication cart. The blood pressure cuff was wiped as well and placed back on top of the cart then finally moved to the bottom drawer of the medication cart. The pulse oximeter (POX) probe was set on top of the cart. She wiped the POX probe with sanitizing wipes and replaced on top of the cart. At 3:03 p.m. CNA #1 trying to change Resident #102 who was pulling the sheet over herself every step of the way so CNA #1 kept talking to the resident to get the resident to not resist care. She cleaned the bowel movement (BM) while holding the resident with one arm. She disposed of dirty gloves and put on new gloves then donned a new brief and under pad without hand hygiene. She wiped the skin on buttock with new gloves then assisted with transferring the resident with the same gloved hands. On 7/12/21 at 11:26 a.m. CNA #2 assisted Resident #101 with oral care and repositioning. She removed a pillow from his wheelchair and replaced it with a supportive cushion. She set the pillow on the floor outside the bathroom door. While collecting the dirty linen, she picked up the pillow that did not have a pillow case and set it on the top of the resident's bed/comforter that was contaminated after being on the floor. III. Staff interviews The nursing home administrator (NHA) was interviewed on 7/12/21 at 8:09 a.m. He said that training was provided last week to the housekeeper regarding the moving of bottles from dirty to clean surfaces. He said he would provide the training topics, see facility follow-up below. He said the toilet brushes were supplied to each room and when the resident discharges then the brush will be replaced for the next resident to inhabit the room. He said the sponges were thrown away and would not be used in the future. He said the sponges were discarded and staff trained to not use them during cleaning of rooms. Interviewed the minimum data set (MDS) coordinator (MDSC) who assists with collecting data for the infection preventionist (IP), the IP, and the director of nursing (DON) on 7/13/21 at 1:18 p.m. The surveillance gathering consisted of the MDSC, IP and DON's input. They met daily and more often upon identification of infections in the building. Upon notification of the above mentioned breaks in infection control, the IP said that they conducted frequent monitoring of staff practices and have provided ongoing training to all staff. She said she did not work directly with the housekeeping supervisor, however she did provide some of the all staff training that the housekeeping staff would have attended. The IP said the hand hygiene training consisted of the staff showing her how they wash their hands in the sink. She said she had not in the past included the when to wash hands in the observations but would implement it into the monitoring strategies currently being used. IV Facility follow-up The NHA provided a copy via email on 7/14/21 the training provided to staff regarding infection control practices. -7/8/21 to all staff, the topic of the training was cleaning shared equipment between rooms. -7/10/21 to housekeeping and maintenance director, the topic of the training included cleaning procedures, donning and doffing PPE and surface contact times. -7/10/21 to all staff, the topic of training was hand hygiene. V. Infection and vaccination status of residents and staff in building The facility was not in outbreak status with COVID-19, however they directly admitted residents to the third floor COVID unit for treatment and recovery. Other highly contagious infections included Clostridioides difficile (CDiff) and extended spectrum beta-lactamase (ESBL) that were present in the facility. The NHA was interviewed on 7/7/21 at 8:43 a.m. He reported that 66% of staff were vaccinated for COVID-19 and 71% of residents. He said due to the high rate of admissions and discharges, the resident vaccination rate changed daily. He was seeing an upward trend of residents being admitted and already vaccinated.

Based on observations, record review and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of the novel Coronavirus (COVID-19) in one of one units. Specifically, the facility: -Failed to ensure staff properly and consistently used personal protective equipment (PPE) when entering residents' rooms who were on 14-day quarantine; -Staff changed gloves and performed hand hygiene when cleaning resident rooms. Findings include: I. Personal protective equipment A. Professional References Centers for Disease Control and Prevention Personal Protective Equipment: Questions and Answers, (updated 8/8/2020) retrieved on 11/16/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html read, in pertinent part, N95 respirators reduce the wearer ' s exposure to airborne particles, from small particle aerosols to large droplets. N95 respirators are tight-fitting respirators that filter out at least 95% of particles in the air, including large and small particles. -Not everyone is able to wear a respirator due to medical conditions that may be made worse when breathing through a respirator. Before using a respirator or getting fit-tested , workers must have a medical evaluation to make sure that they are able to wear a respirator safely. -Achieving an adequate seal to the face is essential. United States regulations require that workers undergo an annual fit test and conduct a user seal check each time the respirator is used. Workers must pass a fit test to confirm a proper seal before using a respirator in the workplace. -When properly fitted and worn, minimal leakage occurs around edges of the respirator when the user inhales. This means almost all of the air is directed through the filter media. -Unlike NIOSH-approved N95s, facemasks are loose-fitting and provide only barrier protection against droplets, including large respiratory particles. No fit testing or seal check is necessary with facemasks. Most facemasks do not effectively filter small particles from the air and do not prevent leakage around the edge of the mask when the user inhales. B. Facility policy The Coronavirus - COVID-19 policy, last updated 10/1/2020, was received from the executive director on 11/12/2020. It read in pertinent part, Any patients that are COVID-19 positive or pending results will be on strict droplet isolation. -Gloves: Perform hand hygiene and put on clean gloves. Remove and discard gloves when leaving the patient room or care area and immediately perform hand hygiene. -Gowns: Put on a clean isolation gown upon entry in the patient room. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room. -Respiratory protection: Apply disposable mask. Disposable masks should be removed and discarded before exiting the patient's room. Perform hand hygiene after discarding the mask. -Eye protection: Put on eye protection (e.g., goggles, a disposable face shield that covers the front and sides of the face) upon entry to the patient room. Remove eye protection before leaving the patient room. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. C. Observations On 11/11/2020 at 9:40 a.m., physical therapist (PT) #1 and occupational therapist (OT) #1 donned gloves and an isolation gown to enter room [ROOM NUMBER], which was a resident on quarantine as a new admission. Both PT #1 and OT #1 wore facemasks and eye protection prior to donning their gowns and gloves. The PT #1 exited the room at 10:02 a.m. and the OT #1 exited the room at 10:19 a.m. -PT #1 and OT #1 failed to remove their facemasks and failed to clean or disinfect their eye protection when leaving the room. At 9:53 a.m., registered nurse (RN) #1 donned gloves and an isolation gown to enter room [ROOM NUMBER], which was a resident on quarantine as a new admission. She already wore a facemask and eye protection. She administered an injection, doffed her gloves and gown then performed hand hygiene with alcohol based hand rub (ABHR). -RN #1 failed to remove her facemask and failed to clean or disinfect her eye protection when leaving the room. At 10:09 a.m., a new resident was admitted to room [ROOM NUMBER]. RN #1 donned gloves and an isolation gown to enter the room. She wore the same facemask and eye protection she wore while providing care to the resident on quarantine in room [ROOM NUMBER]. -RN #1 failed to remove her facemask and failed to clean or disinfect her eye protection. D. Staff interviews RN #1 was interviewed on 11/11/20 at 9:30 a.m. She said newly admitted residents were placed in quarantine for 14 days. RN #1 said staff were expected to wear eye protection, to include either safety glasses or a face shield, and a facemask at all times. She said they wore an isolation gown and gloves before entering the rooms of the residents in quarantine. II. Environmental cleaning A. Professional references Centers for Disease Control (CDC), Best Practices for Environmental Cleaning in Healthcare Facilities: in Resource-Limited Settings, (updated 2019) retrieved on 11/16/2020 from: https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-RLS-H.pdf read, in pertinent part, Contact with contaminated environmental surfaces and contaminated hands or gloves will continue to spread microorganisms around the environment. Proper hand hygiene and environmental cleaning can prevent transfer of microorganisms to healthcare personnel, caretakers and visitors and to susceptible patients. B. Observations and interview On 11/11/2020 at 9:07 a.m., the housekeeper (HSK) #1 was observed cleaning an occupied resident room. With gloved hands the HSK #1 took a cloth from a bucket of solution and wiped several surfaces then wiped the bathroom door and handles. The HSK #1 discarded the soiled cloth into a receptacle. He retrieved a container with disinfecting solution and a toilet wand, swabbed the toilet bowl then placed the container back in the housekeeping cart. The HSK #1 retrieved a clean cloth and wiped the bathroom sink. He sprayed the shower chair, shower walls and floor with a disinfectant. Continuing with the same gloves he applied upon entering the room, he attached a clean microfiber mophead to a mop handle and swept the floor of the resident ' s room. With gloved hands, he removed the used mophead with one hand on the mop handle and one hand on the soiled surface of the mophead. He returned to the shower area, which he sprayed earlier with disinfectant, and used a scrubbing wand to scrub the shower chair, walls then shower floor. With the gloved hands, he used the removable shower wand to spray down the shower area. -He failed to change his gloves after handling the soiled mophead and failed to perform hand hygiene prior to touching the removable shower wand. The HSK wiped down the toilet seat then the base of the toilet. He put a clean microfiber mophead on the mop handle and mopped the bathroom floor. With the gloved hands, he removed the used mophead with one hand on the mop handle and one hand on the soiled surface of the mophead. Still wearing the same gloves, he placed a clean microfiber head on the mop handle. With the gloved hands, he moved the over-the-bed table, mopped in that location and returned the table to its original location and finished mopping the rest of the resident's room. -He failed to change the soiled gloves and perform hand hygiene prior to touching the over-the-bed table. The HSK #1 removed the used mophead and put it in the receptacle with the other soiled mopheads, then removed the gloves and performed hand hygiene. The HSK #1 was interviewed on 11/11/2020 at 9:20 a.m. He said before entering the room he had on eye protection and a facemask, then he donned gloves. He cleaned the high-touch areas first, then the bathroom and finished by mopping. He stated that gloves should be changed before going to the next resident's room or when they are soiled. He stated he should have changed gloves each time he disposed of the used cloths and mopheads. C. Staff interviews The housekeeping supervisor (HSK) was interviewed on 11/11/20 at 4:00 p.m. He said gloves should be removed and hand hygiene performed after touching soiled mopheads. III. Additional staff interviews The DON was interviewed on 11/11/2020 at 5:23 p.m. The DON said staff were expected to wear a facemask, eye protection, an isolation gown and gloves before entering a room with a resident in quarantine. The DON failed to state the mask should be discarded and the eye protection should be cleaned or disinfected upon exiting a quarantine room. The nursing home administrator (NHA) was interviewed on 11/11/20 at 5:23 p.m. The NHA said staff were expected to change gloves when soiled or contaminated. The medical director (MD) was interviewed on 11/12/2020 at 2:07 p.m. He said he was aware of the facility resident COVID-19 outbreak. He said the facility had policy and procedures in place to prevent the spread of COVID-19. He said he was in the facility frequently assessing residents and for quality assurance performance improvement review. He said during review they review the COVID-19 pandemic, policy and procedures. He said he planned to review the facility's policies related to the pandemic in their next QAPI.

Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The failure affected 12 residents (including #177) who shared four blood glucose meters, one on each of four medication carts. Blood glucose meter The facility had four blood glucose meters, which were shared among 12 residents who required routine blood sugar checks. The facility's policy and procedure for cleaning and sanitizing the blood glucose meters documented to disinfect prior to use per manufacturer's guidelines. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized, and stored properly in between each residents' use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. Handwashing The facility failed to perform hand hygiene when administering oral medications, tube feeding, and injections. Personal protective equipment The facility failed to follow contact isolation precautions, including wearing and disposing of appropriate personal protective equipment (PPE) when entering and exiting a room where one resident (#165) was on contact precautions for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) to an abdominal wound. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Resident #177, age 64, was admitted on [DATE]. The (MONTH) 2019 CPO included a [DIAGNOSES REDACTED]. On 6/17/19 at 4:55 p.m. Licensed practical nurse (LPN) # 4 was observed checking the blood glucose of Resident #177 prior to administering insulin. She entered the resident's room with a black pouch which contained the blood glucose meter and a syringe of insulin She applied gloves, and cleaned the right index finger of the resident. She lanced the resident ' s index finger to draw blood, and applied the blood to the test strip located in the Evencare G2 blood glucose meter. The blood glucose level was 171. She then administered 12 units of Humalog insulin to the resident. She then wiped the front of blood glucose meter once with an alcohol prep pad and immediately placed the machine back in a black cloth pouch and zipped it shut. The LPN said this was the blood glucose meter she used to check two of her residents blood glucose levels earlier that afternoon. She further said she usually cleaned the blood glucose meters with alcohol prep pads. LPN # 6 was interviewed on 6/17/19 at 5:08 p.m. She pulled a blood glucose meter out of her uniform pocket and said she cleaned the blood glucose meter by wrapping a bleach wipe around it and leaving it for one minute. LPN # 5 was interviewed on 6/17/19 at 5:11 p.m. He said he usually cleaned the blood glucose meter with alcohol prep pads or disinfectant wipes. He said tonight he had cleaned it with alcohol prep pads between residents because he could not find any bleach or disinfectant wipes. He opened his cart and could not find any, and then looked around the nurse's station and could not find any bleach or disinfectant wipes. The DON was interviewed on 6/17/19 at 5:45 p.m. She stated most diabetic residents get a blood glucose check and each cart had one machine used for multiple residents. The DON said residents did not have their own blood glucose meters. She said there were twelve residents who currently shared the use of the blood glucose meters. The nursing home administrator (NHA) was interviewed on 6/17/19 at 5:45 p.m. with the DON. She said the nurse should clean the blood glucose meters between residents with sanitizer wipes but she did not know which ones were used. The NHA said she thought the dwell time (time the surface must remain visibly wet with the cleaning agent in order to be effective), was two minutes. She said the staff should not be using alcohol pads to clean the machines because they are not effective against blood borne pathogens. The NHA said that because the residents are short stay, the residents do not each have their own blood glucose meters. She did not know if insurance would cover the cost of a blood glucose meter for each resident. She further said she thought they had done education around blood glucose meters in (MONTH) 2019, but was unable to provide any documentation. On 6/17/19 at 6:00 p.m., manufacturer ' s instructions for the use and cleaning of the Evencare G2 blood glucose meter were not located on any of the floors. The DON stated she could not find them in any of the medication carts or with the blood glucose meters and she would have to look them up online. B. Facility notice of Immediate Jeopardy On 6/17/19 at 5:36 p.m. the NHA was notified of the Immediate Jeopardy under F880, infection prevention and control. On 6/17/19 at 7:45 p.m. the facility submitted documentation indicating the assistant director of nursing (ADON) was to ensure each resident had their own blood glucose meter for single patient use and all licensed nurses scheduled that night, and day shift for the next day had been trained on the proper cleaning of the blood glucose meters per the manufacturer's instructions. C. Facility plan to remove Immediate Jeopardy On 6/18/19 at 2:38 p.m , the NHA provided a plan to remove the Immediate Jeopardy. The plan read: The facility uses the Evencare G2 blood glucose meter. Per the manufacturer's recommendations, the cleaning process is as follows: 1. To clean the meter, you must use Medline Micro-kill germicidal bleach wipes. If Medline Micro-kill germicidal bleach wipes are not available, Medline micro kill+ disinfecting, deodorizing, cleaning wipes with alcohol. 2. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter to remain WET at room temperature for THREE MINUTES. ADON demonstrated/tested on [DATE], that when cleansed with wipes, surface area cleaned, did remain wet for 3 minutes. 3. Allow meter to air dry-do not wipe dry. Per our policy, all blood glucose meters used will be Evencare G2 blood glucose meter brand. DON identified all residents who are currently are receiving blood glucose monitoring beginning on 6/17/19. All blood glucose meters in-house were disinfected and assigned to individual residents. More blood glucose meters (8) were purchased on the evening of 6/17/19 at approximately 8:00 p.m The ADON began In-servicing nursing staff promptly on evening of 6/17/19 at 6:50 p.m. on proper use of single use blood glucose meter and cleansing of blood glucose meter. All licensed nursing staff members will be educated on the policy and procedure before their next scheduled shift until all licensed nursing staff have been educated. Education will include that this process must be followed after each use of a blood glucose meter. All nurses will provide return demonstration immediately after training on how to clean the blood glucose meter demonstrating competency. Further, current staff, upon hire and prior to working the floor, all licensed nursing staff will receive education and complete return demonstration of the appropriate cleaning methods as described above. This education will be completed by the DON or designee and a copy of the manufacturer's guideline is available in each narcotic book located on each nurse's cart. Education/training to all current staff will be completed by 6/29/19. All residents who receive blood glucose monitoring through a finger stick mechanism have the potential to be affected. All physicians, residents, and resident representatives of these residents will be notified about potential exposure to blood borne pathogens due to appropriate cleaning procedures potentially not being followed. The physician will then dictate what monitoring or further testing should be done. Notification will be made by 6/29/2019. As an added measure, all residents who receive blood glucose monitoring will have a blood glucose meter issued to them that is for single patient use. These blood glucose meters are kept in pouches. The pouch will be labeled with the patient's name. The actual blood glucose meter will be labeled with either a permanent marker or label maker with the patient's name. These blood glucose meters will be stored in their designated medication cart when not in use. Blood glucose meters must be stored appropriately as listed above and should never be placed in staff pockets or on staff in between cares. D. Removal of Immediate Jeopardy The facility's plan to remove Immediate Jeopardy was accepted and the Immediate Jeopardy was lifted on 6/18/19 at 2:38 p.m. Record review and observations revealed the facility had implemented their policy and procedure for blood glucose meter cleaning. They purchased new blood glucose meters, labeled them with each resident's name, stored them in their own containers labeled with each resident's name, and educated the nursing staff on the proper cleaning and storage of the meters. However, deficient practice remained at an [NAME] level, pattern with the potential for more than minimal harm. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice. A. Blood glucose meters care and facility expectations. 1.Professional standards According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (6/2019): The CDC has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Fingerstick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.Meters requiring preloading of the test strip may come in direct or close contact with the resident's fingerstick wound. Subsequent residents can be exposed when the meter is used on them.Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure. According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_ on 6/20/19, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions to prevent carry-over of blood and infectious agents. 2. Facility policy and procedure The Obtaining a Finger Stick Glucose Level policy, undated, was received from the director of nursing (DON) on 6/18/19 at 10:58 a.m. It documented in pertinent part, disinfect the blood glucose meter prior to use per manufacturer's guidelines (see Evencare insert). Clean and disinfect reusable equipment between uses per manufacturer ' s guidelines. 3. Manufacturer instructions Manualslib, Medline Evencare G2 user manual, retrieved from: https://www.manualslib.com/products/Medline-Evencare-G2- 72.html.Cleaning allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter. Cleaning and Disinfecting Your Meter: To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipes directions for use. Wipe meter dry or allow to air dry. Dispatch®( EPA Registration Number: -8) Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: -10- ) Clorox Healthcare (EPA Registration Number: -12) Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: -1) Wipe meter dry or allow to air dry. Wash hands with soap and water and dry thoroughly. C. Observations and interviews after Immediate Jeopardy removal LPN # 3 was interviewed on 6/18/19 at 9:19 a.m. She said each resident had a new blood glucose meter machine now. The brand was (name of machine). She said she did not know where the manufacturer directions where to clean the machine. She could not verbalize the cleaning instructions for the new machine. She said she had cleaned it with a bleach wipe this morning and let it sit for four minutes. LPN #3 found the manufacturer instructions in the blood glucose meter pouch, but stated the print was too small to read. The NHA and DON were interviewed on 6/18/19 at 9:35 a.m. The NHA said each resident had a blood glucose meter labeled with their name. She said the instructions for cleaning the new blood glucose meter were the same as the Evencare G2 blood glucose meter, use bleach wipes, according to what the pharmacist told her at the store. She said the assistant director of nursing (ADON) educated the nurses on cleaning the blood glucose meters and had them do return demonstrations. She said they were told to have a two minute dwell time (time the surface must remain visibly wet with the cleaning agent in order to be effective). The DON was interviewed on 6/18/19 at 9:43 a.m. She said she would obtain the (name of machine) blood glucose meter manufacturer ' s instructions with larger print. She said each resident now has their own blood glucose meter. She said the facility had an extra supply of blood glucose meters now, and each new admission would be assigned their own blood glucose meter and would take it with them at discharge. The DON was interviewed on 6/18/19 at 10:58 a.m. She said the new (name of machine) blood glucose meters were not supposed to be cleaned with bleach. She said they would be changing back to Evencare G2 blood glucose meter, and assign each resident an Evencare G2 blood glucose meter. Registered nurse (RN) # 3 was interviewed on 6/18/19 at 4:53 p.m. She said she had been in serviced on how to clean the blood glucose meter today. However, she said she was unsure of the contact time and if the blood glucose meter needed to stay wet for three minutes with the disinfectant product. On 6/18/19 at 5:18 p.m. Two blood glucose meters were noted in the medication cart on the third floor. The blood glucose meters were not labeled with each resident ' s name. The DON said she would have them labeled, and that all the other blood glucose meters were labeled with the resident ' s name. III. Hand hygiene and medication administration A. Professional reference The World Health Organization (WHO) Retrieved from:https://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf Thousands of people die every day around the world from infections acquired while receiving health care. Hands are the main pathways of germ transmission during health care. Hand hygiene is therefore the most important measure to prevent the transmission of harmful germs and prevent health care-associated. Hand hygiene should be performed before preparing food, medications, pharmaceutical products, and sterile material. B. Facility policy and procedure The Infection control precautions policy and procedure, dated 2/1/16, was received from the NHA on 6/25/19 at 3:00 p.m. The policy documented routine hand washing, using soap and running water and friction must be strictly adhered to. In certain circumstances hands may be cleaned with an alcohol based waterless hand cleaner between washing hands with soap and water. C. Observations On 6/17/19 at 5:44 p.m., LPN # 4, looked up orders with her computer keyboard, unlocked the mediation cart and picked up an insulin pen. She proceeded to the resident room, administered insulin and sanitized her hands. However, she did not sanitize her hands at any point prior to administering the medication. On 6/18/19 at 3:32 p.m., LPN # 4, looked up orders with her computer keyboard, unlocked the medication cart, picked up a bottle of medication, poured the mediation into a cup, locked the cart, went to the resident ' s room, and administered the medication. Hand hygiene was not completed before or after medication administration. LPN # 4 returned to the medication cart, looked up orders on her computer, and walked to the medication room. She unlocked the door, opened the refrigerator, retrieved an IV medication and proceeded to a resident ' s room. Once in the room she put gloves on, she then proceed to flush the IV port with a syringe and connect the IV tubing with medication. She removed her gloves and sanitized her hands. However, she had not sanitized her hands prior to the IV administration or before putting on her gloves. On 6/20/19 at 11:11 a.m., RN # 4 was observed looking up orders on her computer with the keyboard. She then put on gloves, opened the cart and poured four pills and one liquid medication. She put the pills in a pouch and crushed them with a medication crusher. She then took them to the resident ' s room along with a syringe of medication. She poured the crushed pills and liquid medication in a cup together. She then used a syringe to withdraw stomach contents from the resident ' s gastric tube. She then administered the mediation and flushed the tube with water. She did not clean the port before or after using it. She then administered an injection of blood thinning medication into the resident ' s abdomen, removed the gloves and washed her hands. However, RN #4 never sanitized her hands prior to the preparation or administration of medication into the gastric tube or before giving the resident an injection. D. Interviews The DON was interviewed on 6/20/19 at approximately 12:00 p.m. She stated hand hygiene should have occurred before and after medication administration. The infection control preventionist was interviewed on 6/25/19 at 3:20 p.m. She stated hand hygiene should be completed before and after medication administration. IV. The facility failed to follow contact precautions according to professional standards A. Facility policy The Infection Control Precautions Policy and Procedures, dated 2/1/16, was provided by the nursing home administrator (NHA) on 6/25/19 at approximately 3:00 p.m. It read, in pertinent part: .All employees must do everything to keep infection down .these infection control precautions must be used by all staff for all residents, regardless of [DIAGNOSES REDACTED].routine hand washing, using soap, running water, and friction must be strictly adhered to. In certain circumstances, hands may be cleansed with an alcohol-based waterless hand cleaner (containing at least 60% alcohol) between washing with soap and water .single use, disposable gloves must be used when touching blood and all body fluids, non intact skin, and mucous membranes . B. Professional reference According to the Center for Disease Control (CDC) Hand Hygiene in Healthcare Setting, (4/29/19) https://www.cdc.gov/handhygiene/providers/index.html, (6/24/19): -Hand hygiene includes washing hands with soap and water, or using alcohol based hand rub (ABHR). -Hand hygiene reduces the spread of potentially deadly germs to the patient. -Multiple opportunities for hand hygiene could occur in a single care episode. -Hand hygiene should be performed: before touching a patient, before moving from work on a soiled body site to work on a clean body site on the same patient, after touching a patient or their immediate environment, after contact with contaminated surfaces and body fluids, and immediately after removal of gloves. According to the CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html (5/24/19): -Implement contact precautions routinely for all patients colonized or infected with a target multidrug resistant organism (MDRO). -Because environmental surfaces and medical equipment, especially those in close proximity to the patient, may be contaminated, don gowns and gloves before or upon entry to the patient ' s room or cubicle. Personal Protective Equipment (PPE) for Healthcare Personnel: -Designated containers for used disposable or reusable PPE should be placed in a location that is convenient to the site of removal to facilitate disposal and containment of contaminated materials. -Hand hygiene is always the final step after removing and disposing of PPE. Gloves are used to prevent contamination of healthcare personnel hands when anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route e.g., VRE,[MEDICAL CONDITION]; or handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces. -Isolation gowns are used as specified by standard and transmission-based precautions, to protect the healthcare workers (HCW ' s) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material. -The wearing of isolation gowns and other protective apparel is mandated by the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. -When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. C. Resident status Resident #165, age 62, was admitted on [DATE]. The (MONTH) 2019 computerized physician orders [REDACTED]. The 6/13/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive two-person assistance with bed mobility, transfers, dressing, and toileting, limited one-person assistance for personal hygiene and supervision one-person assistance for eating. D. Record review The (MONTH) 2019 CPO revealed the resident was on contact precautions for [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) in the abdominal wound. The care plan initiated on 6/7/19 documented the resident had an infection related to intra abdominal VRE. Interventions included resident and family education related to transmission based precautions policy and procedure and infection prevention, notify therapy, activities, and dietary when initiating transmission based precautions, and resident was to be on contact isolation for wound only. E. Observations During these following observations no staff members were observed to use the hand sanitizer station that was outside the residents room to the right of the door. On 6/19/19 at 9:01 a.m., physical therapist (PT #1) was observed to don gloves and a gown, and without performing hand hygiene, entered the residents room. The PT left the residents room shortly after entering, without PPE donned and holding the residents water jug by the handle. The PT walked to the ice and water machine, located in the lobby area across from the nurses station and proceeded to fill the water jug. He returned to the residents room, held the water jug with his right hand, retrieved gloves and gown from the isolation cart outside the residents room with his left hand and entered the residents room without performing hand hygiene or donning the PPE prior to entering. On 6/19/19 at 9:10 a.m., housekeeping was observed to don gloves, gown, and mask, and without performing hand hygiene, entered the residents room. Housekeeping took a couple of steps into the residents room, saw the resident was with therapy and said would return later. The housekeeper backed out of the room, closed the door and with gloves still on, removed the mask and gown in the hallway, outside the residents room. The gloves were the last item to be removed. The housekeeper disposed of the PPE in the cleaning cart. The wet floor sign, placed in front of the residents room prior to entering, was placed back on the cart. The housekeeper used ABHR as she walked to the next room. On 6/19/19 at 9:40 a.m., certified nursing aide (CNA) #3 was observed to open the residents door and stood just inside the doorway while donning the gown. She walked into the room and closed the door. The CNA reopened the door with her contaminated hands and reached out and retrieved a pair of gloves from the isolation cart without performing hand hygiene being performed. The gloves were not donned as she closed the door to the residents room. On 6/19/19 at 10:07 a.m., a therapist was observed to retrieve a pair of gloves from the isolation cart, and without performing hand hygiene, entered the residents room with gloves not fully donned. On 6/19/19 at 10:15 a.m., Case manager (CM) #2 was observed to don a mask, and without performing hand hygiene, entered the residents room, but left the residents room shortly afterwards. CM #2 returned to the residents room to answer the call light, no PPE was used or hand hygiene performed before the CM entered the residents room. The CM exited the residents room with gloves in hand, walked across the hall and disposed of the used PPE in a trash can at the nurses station. -At 10:19 a.m., CM #2 returned to the residents room, donned a mask and gloves, and without hand hygiene performed, entered the residents room. The CM exited the residents room with PPE in hand, walked across the hall and disposed of the used PPE in the trash can in the nutrition room. F. Staff interviews CNA #3 was interviewed on 6/19/19 at 11:34 a.m. The CNA said the resident was on contact precautions for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) or something like that. The CNA said it was very important to wash your hands with soap and water or use ABHR both before and after resident care was provided. Registered nurse (RN) #2 was interviewed on 6/19/19 at 12:02 p.m. The RN said the resident [MEDICAL CONDITION] in the abdominal wound and was on contact precautions. The RN said contact precautions required the use of a gown and gloves upon entering the room. -The RN failed to mention washing hands before and/or after care and when entering and exiting the residents room. CNA #2 was interviewed on 6/19/19 at 12:22 p.m. She said gloves and gown were to be donned before entering the residents room and removed before exiting the room. The CNA said you should wash your hands both before and after resident care. The assistant director of nursing (ADON) and the nursing home administrator (NHA) were interviewed on 6/19/19 at 2:53 p.m. They said contact precautions were in place to protect the community from the contaminate and so it would not be spread to other residents, as other residents may be immune compromised. If precautions were not followed, it could spread to other residents. They said standard, universal precautions did not exclude anyone, they were to be used by all staff to protect all residents. The ADON said it was not just for direct resident care, but essentially any type of care, as all of the residents personal items could be contaminated. The ADON said in some cases, contact precautions were only needed for wound care. Hand washing should be done before and after resident care. The ADON added only hand hygiene needed to be performed if a resident just wanted water in their glass. Staff did not need to glove or gown if they did not touch other personal items in the residents room. Both the ADON and NHA confirmed the resident was on contact precautions for wound care related to VRE in the abdominal incision. The individual who provided wound care would need to wash hands both before and after care and don the proper PPE of gloves and gown. The ADON and NHA confirmed the PPE should have been disposed of in the residents room and not in a trash can outside the room. The NHA said the sequence for removal of PPE was mask then gown, with gloves removed as the gown was removed from the arms. Reviewed information provided by CDC that showed the proper sequence for removal of PPE was gloves, gown inside out, and then mask or gown inside out, gloves as sleeves came down the arms and then mask. Hand hygiene was to be performed after both examples. G. Follow-up An in-service related to infection control was initiated by the ADON on 6/20/19 and a copy was provided. It consisted of knowledge of contact precautions and organisms, proper use of PPE to include donning, sequential doffing, and disposal of PPE, and proper hand hygiene.