Every finding on record at Center at Northridge, LLC, The

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease on two of two units. Specifically, the facility failed to:-Ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing care to Resident #31, who was on enhanced barrier precautions (EBP); -Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' rooms; and, -Ensure Resident #50's respiratory equipment was properly cleaned and stored.Findings include: I. Failed to ensure staff donned the appropriate PPE when providing care to Resident #31, who was on EBPA. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (updated 4/2/24), retrieved on 7/8/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of a gown and gloves for high-contact resident care activities was indicated when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), or wound care (any skin opening requiring a dressing). In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.B. Facility policy and procedureThe Enhanced Barrier Precautions (EBP) policy, dated 3/27/24 and revised 1/29/25, was received from the nursing home administrator (NHA) on 7/8/26 at 12:44 p.m. The policy read in pertinent part, To reduce transmission of multidrug-resistant organisms by employing targeted gown and glove use during high-contact resident care activities. Per the CDC, EBPs are recommended (whencontact precautions do not otherwise apply during high-contact care activities with residents who are at higher risk of acquiring or spreading an MDRO. Enhanced barrier precautions include the use of a gown and gloves during the high-contact patient care activities: changing briefs or assisting with toileting.C. ObservationOn 7/8/26 at 8:42 a.m. physical therapist #1 was assisting Resident #31, who was on EBP, with toileting assistance in the bathroom. The door to the bathroom was ajar. PT #1 was verbalizing his actions to the resident while wiping the resident's backside. The toilet was flushed and PT #1 emerged from the bathroom, only wearing gloves. -PT #1 failed to wear a protective gown while assisting Resident #31 with toileting hygiene.D. Resident interviewResident #31 was interviewed on 7/8/26 at 10:45 a.m. Resident #31 said he was on EBP due to a wound on his foot. E. Staff interviewPT #1 was interviewed on 7/8/26 at 8:49 a.m. PT #1 said Resident #31 was on EBP. He said when assisting a resident with EBP, he should be wearing a gown and gloves. PT #1 said it was important to wear EBP to reduce the risk of transmission of germs from resident to resident. II. Failed to ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' roomsA. Facility policy and procedureThe Cleaning Room policy, dated 11/1/17 and reviewed on 3/8/24, was received from the NHA on 7/8/26 at 12:44 p.m. The policy read in pertinent part, Our team can control the spread of infection by performing daily disinfection and adhering to all hand hygiene protocols. Always work from the cleanest to the dirtiest. Daily routine needs to include high-touch areas, which can include: door knobs, light switch, sharps box, table and tray, call light and phone when not being held by the resident, call box and pull cord, commode seat, rim, and flusher. If you have to leave the room after you have started a room clean, remove your gloves and perform hand hygiene. Put a new pair of gloves on to resume cleaning. Always use a fresh towel when cleaning a toilet:- Wipe the toilet paper dispenser;- Wipe the flusher;- Wipe the toilet seat;- Wipe under the bowl;- Wipe the toilet rim; and,- Clean the inside of the bowl using disinfectant cleaner and a toilet brush.The Hand Hygiene policy, dated 12/5/2020 and reviewed 1/7/24, was received from the NHA on 7/8/26 at 12:44 p.m. The policy read in pertinent part, Soap and water: Use when hands become dirty or soiled. Hand sanitizer: Use an alcohol-based hand sanitizer that contains at least 60% alcohol. Put enough sanitizer on your hands to cover all surfaces. Rub your hands together until they feel dry. Do not rinse or wipe off.B. ObservationOn 7/7/26 at 2:35 p.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. HK #1 donned clean gloves and removed the trash bags from the trash cans and disposed of them. HK #1 then made the bed and folded extra blankets. She donned clean gloves. She got a cleaning rag and germicidal ultra bleach spray from her cart. HK #1 then sprayed the sink and wiped it down with a clean rag. She grabbed the toilet cleaner, dispensed some in the toilet, and used the toilet brush in the bowl, on the rim, and on the bottom of the seat. HK #1 then changed her gloves and got a clean rag to wipe the handrails in the bathroom. -HK #1 failed to perform hand hygiene throughout the entire process of cleaning resident room [ROOM NUMBER]. -HK #1 failed to clean the high-touch areas, such as the door knobs in room [ROOM NUMBER].-HK #1 failed to clean the toilet from the cleanest area to the dirtiest area. C. Staff interviewsHK #1 was interviewed on 7/7/26 at 2:55 p.m. HK #1 said she forgot to wash her hands when she was cleaning room [ROOM NUMBER]. She said it was important to wash her hands to prevent the spread of germs. HK #1 said that she used the toilet brush to scrub the lid of the toilet. She said she understood that the brush should stay in the toilet bowl and that by bringing the brush out of the toilet bowl and cleaning the toilet seat, bacteria could be transferred. The housekeeping supervisor was interviewed on 7/9/26 at 8:40 a.m. The housekeeping supervisor said she instructed the housekeeping staff to change gloves and sanitize their hands when disposing of a dirty rag. The housekeeping supervisor said that the housekeepers were required to clean the high-touch areas in residents' rooms on a daily basis. The housekeeping supervisor said the toilet brush should only be used in the toilet bowl and the housekeeping staff should follow this rule in order to avoid cross contamination.III. Failed to ensure Resident #50's respiratory equipment was properly cleaned and storedA. Facility policy and procedureThe Respiratory Equipment policy, dated 9/14/17 and revised on 11/18/25, was received from the NHA on 7/9/26 at 9:07 a.m. The policy read in pertinent part, Residents will have an order that includes settings when indicated for CPAP (continuous positive airway pressure)/BiPAP (bilevel positive airway pressure). Respiratory equipment will be cleaned and stored per the manufacturer's guidelines.B. ObservationOn 7/8/26 at 10:43 a.m. Resident #50 had her nebulizer mask lying on the bedside table without a paper towel underneath it. The resident's noninvasive portable ventilator was at the bedside with the mask in the basket, not in a bag. On 7/9/26 at 10:55 a.m. Resident #50 was receiving a nebulizer treatment with a new mask; however, there was still a nebulizer mask on the bedside table, not on a paper towel. The resident's noninvasive portable ventilator was at the bedside, with the mask on top of the machine, not in a plastic bag. C. Resident interviewResident #50 was interviewed on 7/9/26 at 10:14 a.m. Resident #50 said she was on contact precautions due to clostridium difficile (C. diff - a highly contagious bacterium that causes severe inflammation of the colon and watery diarrhea). She said that the nurse did not wash her noninvasive portable ventilator mask yesterday or today after use. Resident #50 said that her other nebulizer mask had also not been washed.D. Staff interviewLicensed practical nurse (LPN) #3 interviewed on 7/9/26 at 11:20 a.m. LPN #3 said she was going to enter Resident #50's room and remove the old nebulizer mask and wash the new mask she had given to the resident today (7/9/26). LPN #3 said she would wash the resident's noninvasive ventilator mask and place it in a plastic bag. She said the importance of cleaning and placing the resident's respiratory equipment in a clean bag was because the resident had respiratory issues and was on precautions due to C. diff. IV. Additional staff interviewsThe infection preventionist (IP) and the director of nursing (DON) were interviewed together on 7/9/26 at 11:30 a.m. The IP said she conducted re-education with the therapy department about EBP and the importance of adhering to the use of a gown and gloves when performing care with residents on EBP. The DON said that it was the nurses' responsibility to remind the staff when they forgot to use proper PPE when working with residents on EBP. The IP said the housekeeping department was re-educated about the importance of good hand hygiene when removing soiled gloves and donning clean gloves. The DON said nebulizer masks should be rinsed and then air-dried on a paper towel. The DON said there was a plastic bag that the mask would go in until the next use. She said the mask for Resident #50's portable noninvasive ventilator should be cleaned as the physician's order indicated and placed in a clean plastic bag. The IP said there was a holder that Resident #50's portable noninvasive ventilator mask should go on after drying. The IP said that it was important to clean the mask to prevent the growth of microorganisms.

Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process focussing on the resident's discharge goals for three (#76, #47 and #64) of five residents reviewed for discharge planning out of 38 sample residents. Specifically, the facility failed to for Resident #76, Resident #47 and Resident #64: -Involve the resident and the resident's representative in the discharge plan; and, -Develop discharge care plan with appropriate goals and approaches. Findings include: I. Facility policy and procedure The Admission, Discharge and Transfer policy, revised 2/9/23, was provided by the nursing home administrator (NHA) on 4/2/24 at 12:31 p.m. It read in pertinent part: Regardless of payment method, all residents have access to: Care that is timely and meets the needs of the resident; access to their physician; Staff, including administrative staff; and Care-planning and discharge-planning processes. Staff involved in the move in, transfer and move out process will ensure that the focus is the resident and their family and their needs and concerns. Facility staff will assist the resident and/or representative in making appropriate arrangements for the discharge of the resident when it is determined that the facility can no longer meet the needs of the resident, the resident is a danger to themselves or others, or has not paid for their stay after receiving notice meeting the above-mentioned criteria. When the physician and resident determine that moving to another facility or home is appropriate, facility staff will assist the resident and/or surrogate decision- maker and family to plan for the care and services to ensure continuity of care. II. Resident #76 A. Resident status Resident #76, age 73, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), the diagnoses included acute osteomyelitis of left foot and ankle, type two diabetes and muscle weakness. The 3/12/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She was independent or required supervision with activities of daily living (ADL). B. Resident interview Resident #76 was interviewed on 3/27/24 at 4:27 p.m. Resident #76 said she was told she had to move out of the current facility because she had exceeded her benefits and she was moving to an assisted living while home repairs were being completed. Resident #76 said there was a broken sewer line at her house that had caused a lot of damage and was more than she could manage. The resident said she was at the current facility for help managing her insulin and an infection needing antibiotics administered through her arm (intravenously). Resident #76 said a placement agent had helped her find assisted living and she knew her before she was admitted to the current facility. Resident #76 said the placement agent and her two friends were the only people helping here with discharge planning. Resident #76 said she was signing admission paperwork for assisted living on 3/28/24 and would only be staying there until her home renovation was complete. C. Record review The discharge care plan, initiated on 3/6/24, revealed Resident #76 wanted to establish goals for herself and be involved in her discharge planning. It indicated the resident would discharge to the highest optimal level of care over the next 90 days. Pertinent interventions included Resident #76 wanted to go home when she was discharged , communicating with the patient and/or family as needed related to progress, goals and plans and encouraging the patient to make an effort toward achieving their goals. -The care plan failed to identify Resident #76 would discharge to assisted living, was working with a placement agency to achieve this goal and if returning home was attainable. The 3/8/24 progress note revealed a care conference occurred discussing discharge, therapy and plan of care, in attendance was Resident #76, case manager (CM) #1, two friends of Resident #76, a member of the therapy department and the primary care physician. It indicated Resident #76 was living at home alone and staying at an extended stay hotel due to home renovations and Resident #76 was working with a company for discharge options. Resident #76 was advised by CM #1 to take all valuables home as they would not be needed in the facility and the facility would not be financially liable for any lost or missing property. Resident #76 was educated by CM #1 the typical length of stay was three weeks. CM #1 informed those present to bring in clothing for the resident and provided contact information for any further questions or concerns. The 4/1/24 progress note (during survey process) indicated Resident #76 had been issued a notice of medicare non-coverage (NOMNC) and the last coverage day (LCD) was 4/3/24 and Resident #76 would discharge to an assisted living on 4/4/24. Resident #76 was educated on her right to appeal and waived this right. III. Resident #47 A. Resident status Resident #47, age 88, was admitted on [DATE]. According to the April 2024 CPO, the diagnoses included fracture of the neck and right femur. The 3/3/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She required moderate assistance of one staff member for transferring, toileting and personal hygiene. B. Resident and resident representative interview Resident #47 and the resident representative were interviewed on 3/27/24 at 3:07 p.m. The resident representative said Resident #47 spent time living between her and her sister's home. She said there was a lack of communication happening with the discharge plan for Resident #47. She said she and her sister had been informed CM #1 would be the contact person for discussing discharge planning during a care conference at admission. She said she and her sister were leaving town for a family event and had left messages for CM #1 but had not heard back. Resident #47's representative said not having communication was stressful. Resident #47 said she was planning to return to her prior living arrangements between both homes. Resident #47 said she did not know who her CM was at the facility or if she had one. C. Record review The discharge care plan, initiated on 2/27/24, revealed Resident #47 wanted to establish goals for herself and be involved in the discharge planning process. It indicated the resident would discharge to the highest optimal level of care over the next 90 days. Pertinent interventions included Resident #47 wanted to go home, to an assisted living or to a long term care community when she was discharged and communicating with the patient and/or her family as needed related to progress, goals and plans. The 2/28/24 progress note revealed a care conference occurred discussing discharge, therapy and plan of care, Resident #47, CM #1, Resident #47's resident representative, a member of therapy and the primary care physician were in attendance. It indicated Resident #47 lived between the home of two daughters and the plan for discharge was to return to the prior living arrangement. CM #1 advised Resident #47 and family to take home all valuables as they were not needed in the facility and the facility would not be financially liable for any lost or missing property. CM #1 informed the Resident a typical length of stay was three weeks. CM #1 informed those present to bring in clothing for the resident and provided contact information for any further questions or concerns. The 4/1/24 progress note revealed (during the survey) CM #1 had spoken to Resident #47's resident representative to discuss a 4/6/24 discharge date and a care conference had been scheduled for 4/2/24 at 2:00 p.m. including therapy and the progression Resident #47 had made. -The care plan failed to identify returning home as the resident and the preferred discharge location. 50315 IV. Resident #64 A. Resident status Resident #64, age over 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included acquired absence of the right leg below the knee, type two diabetes (insulin resistance), muscle weakness and chronic heart failure. The minimum data set (MDS) assessment from 3/7/24 documented this resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. This resident was dependent on assistance for activities of daily living (ADL) and transfers. B. Resident and representative interview Resident #64 and her representative were interviewed on 3/28/24 at 12:50 p.m. The resident said she received paperwork about her discharge. She said she was not sure where she was going and was scared they were going to send her back home, where she did not have the support to take care of herself. The resident's representative was assisting her in the discharge process. He said he had a senior blue book and was looking for options for Residents #64's discharge because her home was not equipped for a wheelchair and he did not have adequate support for her to excel at home. He knew she needed more care and he said the case managers only gave him resources for him to find on his own. He said he was stressed and worried about the resident getting sent back home and not having the assistance she required at home. C. Record review The progress note from 3/7/24 documented there was a care conference held to discuss discharge planning and therapy goals. The discharge plan was to return home at this time. The progress note on 3/20/24 documented case management met with the resident's husband regarding discharge plans. The husband had started looking for a long term care facility for his wife and he had a Senior Blue Book (resources for aging population). V. Staff interviews Occupational therapist #1 was interviewed on 3/28/24 at 3:41 p.m. She said it was not safe for Resident #64 to go home. She said the therapy department knew right away from the initial evaluation she would not be able to go home. She said Resident #64 was being discharged because she had plateaued on her therapy goals and it was unlikely she would progress. Social services assistant (SSA) #1 and SSA #2 were interviewed on 4/1/24 at 12:05 p.m. SSA #1 said care conferences typically happened on the second day of admission and involved discussing the primary discharge plan and discussing alternatives if the primary discharge plan was not attainable. SSA #1 said residents, families, resident representatives, therapy staff and primary care physicians were in attendance. SSA #1 said discharge discussions were held weekly with residents, families and resident representatives and conversations were documented in the electronic medical record. SSA #1 said nursing initiated the baseline care plans to include the discharge planning focus, goals and interventions. SSA #1 and SSA #2 said it was the responsibility of the social services department to coordinate discharge planning. SSA #2 said care plans were reviewed and revised every 21 days and more if needed. SSA #2 said changes with discharge location were considered a reason for revising a discharge care plan. SSA #1 said she was assigned to Resident #76 and Resident #47. SSA #1 said she had spoken to Resident #76 a couple of times since her admission and the discharge plan had always been to admit to assisted living. SSA #1 said a placement agent who worked for the company the resident was utilizing had been assisting Resident #76 with discharge planning. SSA #1 said the discharge plan for Resident #47 had always been to return to her prior living arrangements between each daughter's home. SSA #1 said she had spoken with Resident #76's power of attorney (POA) weekly. SSA #1 was unable to provide documentation of conversation or topics discussed. SSA #1 said she could not recall the last time she had spoken to Resident #47 or daughter's about the discharge plan. SSA #3 was interviewed on 4/2/24 at 9:18 a.m. She said Resident #64's discharge planning began at her initial care conference on 3/7/24. She said the resident's medical power of attorney (MDPOA) was hopeful the resident would return home at the time of the initial care conference. She said immediately when the resident began working with therapy, the care team knew she would not progress to return home. She said the plan to return home was not realistic so there was nothing done to plan for that discharge route. She said more conversations with residents and representatives should be occurring. The minimal data set coordinator (MDSC) was interviewed on 4/2/24 at 10:17 a.m. She said the baseline care plan should be completed within seven days but no longer than 21 days after an admission and the social services department was responsible for completing the discharge care plan and ensuring accuracy.

Based on record review and interviews, the facility failed to ensure the safety and supervision to prevent accidents for one (#66) of three residents reviewed for falls of 38 sample residents. Specifically, the facility failed to ensure Resident #66 was safe while ambulating with therapy. Findings include: I. Facility policy and procedure The Fall Prevention policy, revised October 2017, was received from the nursing home administrator (NHA) on 4/2/24 at 12:31 p.m. The policy documented in pertinent part, The post fall procedure includes nursing to assess the patient and determine the most appropriate course of action. Notification of the following must take place: physician, responsible party, and director of nursing (DON). Risk management was to be completed. Determine what interventions needed to be implemented to prevent further falls, and complete orders and/or tasks for fall prevention and for further skin injuries if indicated. II. Resident #66 status Resident #66, age under 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included peritoneal abscess (infection in the lining of the abdominal cavity), Crohn's disease (swollen and irritated digestive tract), muscle weakness and difficulty in walking. According to the 2/27/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. It was documented that this resident was a substantial/maximal assistance for chair to bed transfers, toilet transfers, and lying to sitting on the side of the bed. III. Resident interview Resident #66 was interviewed on 4/1/24 at 12:30 p.m. She said she fell while working on the stairs in the therapy gym on 3/26/24. She said she got tired and her knees buckled under her body and she fell down, scraping her right knee on the stairs. She said two days later, on 3/28/24, she was working with the same therapist. She was walking to the elevator with the therapist following behind with her wheelchair. She said when they got to the elevator, the wheelchair was no longer behind her and the therapist went to press the elevator button. The resident said she fell backward and did not remember the fall. She said nursing staff came over to assess her and she was sent to the hospital. She said she sustained a bruise and gash on the back of her head. She said she was taking pain medication for it. IV. Record review The nursing note from 3/26/24 documented therapy reported to the nurse the resident had fallen to her knees while doing the stairs in the therapy gym. The resident was witnessed and assisted into a wheelchair. There was a small abrasion to the resident's right knee. The resident was assessed by the nursing staff and assisted back to her room. The post fall assessment documented on 3/26/24 recommendations from the interdisciplinary review team included therapy to assess resident's need for a support device to the right knee. The nursing note from 3/28/24 documented a therapist was walking the resident to the elevator. The resident lost balance and fell backwards on the floor, hit the back of her head, and sustained a laceration and was bleeding. The resident was on anticoagulant (blood thinner) medication and she was sent to the hospital for further evaluation. The post fall assessment documented on 3/28/24 recommendations from the review team included educating physical therapy on transitioning into the elevator and holding the gait belt while getting on the elevator. -However, education was not provided until 4/2/24 after brought to the facility's attention (see below). According to the hospital record from 3/28/24, it was documented the fall was most likely attributed to resident debility/deconditioning. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/1/24 at 12:40 p.m. She said Resident #66 required one assist for transfers. She said this meant one person would be there to assist this resident using a gait belt and holding onto the belt. She said she only assisted with transferring from the bed to the wheelchair and the therapy department were the only staff who walked with her. Registered nurse (RN) #1 was interviewed on 4/1/24 at 12:50 p.m. He said Resident #66 required one person to assist with transfers. He said this meant one person used a gait belt and would hold onto the belt during the transfer. He said she used a front wheeled walker and a wheelchair. Physical therapy assistant (PTA) #1 was interviewed on 4/1/24 at 3:08 p.m. PTA #1 said Resident #66 was a contact guard on the stairs, meaning the PTA had her hands on the resident at all times. PTA #1 said Resident #66 was working on the stairs on 3/26/28 in the therapy gym and fell on to the stairs. The resident was wearing a gait belt and the PTA was holding onto it. PTA #1 said Resident #66 was a stand by assist for walking, which meant the therapist had to be within arm's reach to prevent a fall. PTA #1 said she was working with Resident #66 two days later and they walked to the elevators together. PTA #1 was following behind the resident with a wheelchair and the resident was walking with a walker. The resident was wearing a gait belt. They got to the elevator and PTA #1 set the wheelchair beside the resident. PTA #1 walked over to press the elevator button and when she looked back at the resident, the resident was falling backward. She said the resident fell straight back and hit her head on the ground. She said the nursing staff came to assess the resident and the resident was sent to the hospital. VI. Facility follow-up PTA #1 was provided education on 4/2/24 regarding downgrading Resident #66 to contact guard (placing one or two hands on the resident's body to help with balance) during walking and transitioning to the elevator.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Ensure residents were served the correct diets; and, -Follow correct portion sizes to ensure adequate nutrition was provided to the residents. Findings include: I. Professional reference According to The Nutrition Care Manual website, Diet Liberalization, https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=33&lv1=273627&ncm_toc_id=273627&ncm_heading=Diet%20Manual(Retrieved 1/17/23), Therapeutic diets controlling carbohydrates or restricting specific nutrients such as protein, sodium, or potassium may be indicated for patients with impaired metabolic capacity for specific nutrients or to prevent the progression of certain diseases. II. Failure to ensure residents were served the correct diets A. Observation and record review During a continuous observation during the lunch meal on 1/9/22 beginning at 11:14 a.m. and ending at 12:37 p.m, cook #1 used the following scoop sizes: A four ounce spoodle for the whipped sweet potatoes, A four ounce spoodle for the roasted brussel sprouts; and, Tongs for the brown sugar pork cutlet with garlic and herbs. -Residents who were on a consistent carbohydrate diet and a renal diet received the same portion and food items as the regular diet. -The menu revealed the residents on a renal diet should have received a two ounce low sodium pork cutlet, four low sodium crackers and a four ounce spoodle of low sodium green beans. However, the residents on a renal diet received a brown sugar pork cutlet with garlic and herbs, a green spoodle of whipped sweet potatoes and a green spoodle of brussel sprouts. -The menu revealed the residents on a consistent carbohydrate diet should have received a three ounce unbreaded baked pork cutlet and a three ounce portion of the whipped sweet potatoes. However, the residents who were prescribed a carbohydrate controlled diet received the same pork chop as the residents on a regular diet and a four ounce spoodle of whipped sweet potatoes. III. Failure to follow correct portion sizes to ensure adequate nutrition was provided to residents A. Observation and record review During the lunch meal on 1/9/22 beginning at 11:14 a.m. and ending at 12:37 p.m., the following was observed making the mined and moist diet: -At 11:32 a.m. cook #1 scooped green beans out of a pot on the stove and placed in the food processor. She turned the food processor on to grind up the green beans. She put the green beans in a metal pan and put the pan in a hot box. -At 11:40 a.m. cook #1 placed several pork cutlets into the food processor and ground the meat. -At 11:43 a.m. cook #1 began preparing plates for residents who were on a minced and moist diet. She then used a plastic spoon to place green beans on the plate. She did not use a measuring device. She then used a #10 scoop (3.25 ounces) to place the mashed potatoes on the plate. -Cook #1 did not use a measuring device to ensure she provided the residents on the minced and moist diet the correct portion size. -The menu revealed residents who were prescribed a minced and moist diet should have received a four ounce portion of the whipped sweet potatoes and a four ounce portion of green beans. IV. Staff interviews The registered dietitian (RD) was interviewed on 1/9/23 at 3:10 p.m. She said the facility offered renal diets and carbohydrate controlled diets. She said the diets were liberalized, so the kitchen did not need to follow the menus for therapeutic diets. The RD said the physician ordered the resident's diet, but she was able to change it if it was necessary. The RD said there were residents on a renal diet and a carbohydrate controlled diet. The RD said portion sizes should be followed to ensure residents were receiving the correct amount. The director of dining (DOD) was not available for an interview during the survey process. The nursing home administrator (NHA) was interviewed on 1/9/23 at 7:28 p.m. He said upon hire the dietary staff members were trained on how to follow the menus for therapeutic diets. The NHA said when the DOD returned he would have him train the staff again to ensure they knew how to follow the menu correctly.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically the facility failed to: -Ensure food was served at proper temperatures; -Store equipment in a sanitary manner; -Sanitize equipment properly and hygienically; and, -Have a thermometer internally for the walk in refrigerator and walk in freezer. Findings include: I. Food temperatures A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view . It read in pertinent part; The food shall have an initial temperature of 41 degree Fahrenheit (ºF) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. Accessed on 10/7/21. B. Observations Lunch tray line was observed on 9/29/21 at 11:16 a.m. The meal served consisted of spaghetti, roasted vegetables, and cornbread. Hamburgers were observed being cooked on the grill. Dietary worker (DW) #1 took the burgers off the grill and placed them in a pan, covered with plastic wrap, and placed them in a warming cabinet. The temperature of the burgers was not taken. Mechanical soft spaghetti had been plated and placed in a warming cabinet to be served. The temperature of the mechanical soft spaghetti was 111 degrees fahrenheit. The dietary manager (DM) asked DW #1 to heat the mechanical soft spaghetti in the microwave, take the temperature, and then place it back in the warmer. DW #1 heated the spaghetti in the microwave and then placed it back in the warmer. The temperature was not taken once it was taken out of the microwave. The mechanical soft spaghetti was served at 106 degrees fahrenheit and the hamburger was served at 115 degrees fahrenheit. C. Recipes The DM provided recipes for the hamburger and spaghetti on 9/30/21 at 4:32 p.m. The hamburger recipe read, in pertinent part: Final internal temperature greater than 155 degrees fahrenheit and maintain 135 degrees fahrenheit or above. The spaghetti recipe read, in pertinent part: Maintain 135 degrees fahrenheit or above and reheat (one time only) to greater than 165 degrees fahrenheit. D. Interview The DM was interviewed on 9/30/21 at 3:43 p.m. She said if food was going to be served and it dropped in temperature, staff could microwave and bring it back to 160 degrees. She said staff should take the temperature prior to putting the food in the heated cabinet. She said food should be at 135 degrees fahrenheit when served. II. Storage of equipment A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view. It read in pertinent part; After cleaning and sanitizing, equipment and utensils: Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food; and may not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. B. Observations On 9/27/21 at 8:40 a.m. the kitchen was observed following breakfast service. Three cake pans were observed moist and stacked onto other cake pans on shelf. C. Interview The DM was interviewed on 9/30/21 at 1:00 p.m. She went to the shelf and found two cake pans moist stacked onto other pans. She acknowledged the moisture that was present on the pans. She said pans should be air dried prior to stacking. III. Sanitation of equipment A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view . It read in, .The food-contact surfaces of all equipment and utensils shall be sanitized by: a) Immersion for at least ½ minute in clean, hot water of a temperature of at least 170°F (77°C); or b) Immersion for at least 1 minute in a clean solution containing a minimum of 50 parts per million (mg/L) and no more than 200 parts per million (mg/L) of available chlorine as a hypochlorite and having a temperature of at least 75°F (24°C); or c) Immersion for at least 1 minute in a clean solution containing at least 12.5 parts per million (mg/L) of available iodine, having a pH range not higher than 5.0, unless otherwise certified to be effective by the manufacturer, and at a temperature of at least 75°F (24°C); or d) Immersion in a clean solution containing a quaternary [MEDICATION(S)] product or any other chemical sanitizing agent allowed . B. Observation On 9/30/21 at 1:15 p.m. an ice chest was observed on the second floor hallway. Upon inspection, the ice was inside the ice chest with no plastic wrap between the ice and the walls of the chest. C. Interviews The DM was interviewed on 9/30/21 at 1:00 p.m. She said the ice chests that were used on the halls were cleaned weekly. She said they were run through the dishwasher in the kitchen. The infection preventionist was interviewed on 9/30/21 at 4:13 p.m. She said the ice chests that were used on the halls were cleaned daily with bleach wipes. She said the night shift handled this task. She said the ice chests along with the scoop should be run through the dishwasher and bleach wipes should not be used. IV. Temperature gauges on equipment A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 10/12/21 https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view . It read in, In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. B. Observations On 9/27/21 at 8:40 a.m. the kitchen was observed. The walk in freezer and walk in refrigerator did not have thermometers inside in order to check temperatures. There was only a thermometer gauge on the outside. On 9/30/21 at 3:30 p.m., with the DM present, the walk-in freezer and the walk-in refrigerator continued to not have an internal thermometer to ensure the accuracy of the temperature. C. Interview The DM was interviewed on 9/30/21 at 1:00 p.m. She said a thermometer should be inside of each walk in even though there was a thermometer on the outside. She said if the outside gauge broke or was not calibrated, the staff would not have a way to know the temperature.

Based on observations, interviews, and record review, the facility failed to have an effective infection control program. Specifically, the facility failed to: -Ensure staff offered hand sanitation prior to resident meals; -Perform appropriate screening, restrictions and education of visitors; and, -Ensure housekeeping staff completed proper handwashing, and disinfected appropriately during cleaning of resident rooms. Findings include: I. Staff not offering hand sanitation prior to serving residents their meals A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 5/17/2020, retrieved on 10/8/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate [CONDITION(S)]-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% [MEDICATION(S)] or 70% [MEDICATION(S)] in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy The infection prevention, control and immunization policy was provided by the nursing home administrator (NHA) on 9/29/21 at 9:49 a.m. It read , in pertinent part: Staff will implement appropriate transmission based precautions, staff will follow appropriate hand hygiene practice, and the facility will follow the CDC guidelines and recommendations. C. Observations On 9/27/21 at 12:21 p.m. lunch cart arrived on 300 hall Continuous observations from 12:21 p.m. to 1:00 p.m revealed three staff delivered trays to each resident in the hall and did not offer hand hygiene to the residents before the meal. Certified nursing aide (CNA) #2 was observed delivering lunch trays to room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] and did not offer or encourage proper hand hygiene to the residents. Two other unidentified staff members were observed delivering lunch trays to room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] and did not offer or encourage proper hand hygiene to the residents. On 9/27/21 at 12:10 p.m., CNA #4 was observed to not offer hand washing to the resident in room [ROOM NUMBER]. D. Interviews The infection preventionist (IP)/assistant director of nursing (ADON) was interviewed on 9/30/21 at 4:13 p.m. She said all staff are provided infection control training at time of hire and certain competencies are done monthly thereafter. She said additional training was completed periodically based on care concerns. She said staff should be offering and encouraging the residents to use proper hand hygiene before meals to include the sanitizer wipes that are placed on each room tray. She said the wipes are on the tray for the residents to use before each meal. The dietary manager (DM) was interviewed on 9/30/21 at 3:43 p.m. The DM said the dietary staff put the sanitizer wipes on every tray for meal service and most of the wipes come back to the kitchen unopened. She said she is not aware of any training for staff to remind or encourage the residents to use the wipes before each meal. II. Visitation screening, restrictions and education A. Professional reference According to the CDC, Interim infection prevention control recommendations for healthcare personal during COVID-19 retrieved on 10/12/21, read in pertinent parts https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control-after-vaccination.html Implement Source Control Measures Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Indoor visitation (in single-person rooms; in multi-person rooms, when roommates are not present; or in designated visitation areas when others are not present): The safest practice is for patients and visitors to wear source control and physically distance, particularly if either of them are at risk for severe disease or are unvaccinated. If the patient and all their visitor(s) are fully vaccinated, they can choose not to wear source control and to have physical contact. Visitors should wear source control when around other residents or HCP, regardless of vaccination status. Unvaccinated HCP, patients and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. B. Facility policy The facility visitation policy was requested and not provided. The receptionist #1 provided on 9/30/21 at 7:45 a.m. a copy of two different COVID 19 screening forms for outdoor/indoor visitations. Each form covered similar questions and read in pertinent part; -full name of visitor or employee -temperature -signs or symptoms -exposure to someone with COVID 19. One screening form reminded staff, visitors and vendors to wash their hands and use hand sanitizer frequently while the other form did not mention hand hygiene. Neither form provides guidance on mask wearing or distinguishes between vaccinated or unvaccinated visitation requirements or regulations. C. Observations 9/27/21 -At 11:10 a.m. Resident #76's daughter was in the resident's room vising. The resident's daughter was observed to have her mask down, under her chin. The daughter was sitting in a chair next to the resident approximately two feet away. - At 11:20 a.m. her son was escorted to her room and joined the daughter in the room. The staff escorted the son to the room and the son entered and shut the door. The staff placed a sign on the outside of the room that read visitation from 11:20 a.m. to 12:05 p.m. The 45 minute visit with the unvaccinated visitor was not supervised. 9/29/21 -At 12:19 p.m. Resident #16 had a visitor. Staff were observed to escort the visitor to her room. Staff placed a visitation sign on the outside of her door that read visitation from 12:20 p.m. to 1:05 p.m. The visitor wore a mask in the hall until she entered the resident's room. The daughter sat down at the table next to the resident and removed her mask. The resident was also not wearing a mask. The daughter brought in a shake and the resident was observed eating with the daughter who was unvaccinated and not wearing a mask during the visit. The visitation was scheduled for 45 minutes. On 9/30/21 at 11:29 a.m. front desk staff member #1 checked in a visitor with a dog. Front desk #1 read the COVID 19 screening questionnaire but did not ask the visitor about vaccine status and did not remind the visitor to use hand sanitizer or to wear a mask during the entire visit. D. Interviews The activity director (AD) was interviewed on 9/28/21 at 2:07 p.m. The AD said she and the front desk staff scheduled the outside visits for the residents. She said the visitors who were unvaccinated were scheduled for 45 minutes and there was a sign placed on the outside of the residents room to notify staff there was a scheduled visit. The AD said the visitors were screened at the front desk. The front desk staff member #1 was interviewed on 9/29/21 at 5:11 p.m. She said the front desk and activity department scheduled the outside visits for the residents. She said the visitors were screened for covid 19 before they are allowed to enter the residents room. She said when a visitor was vaccinated they were given a wristband that they can bring back each time they visited to help identify they were vaccinated. She said if they were vaccinated they do not have a limit to the visit and can stay as long as they wish. She said they do not need to be escorted. She said not all visitors show a vaccine card and they do not ask for a card. She said they take the word of the visitor and if they visitor did offer a vaccine card then they take a photocopy of the card and keep it on file for thirty days. She said she has access to look up the visitor's name in a vaccine database. She said she did not feel comfortable asking the visitor to see a copy of the vaccine card. She said there was not a current visitation policy for visitors to review prior to visitation. She said the policy was updated on july 19, 2021 so she does not use the policy. She said she tells the unvaccinated visitors to wear a mask during the visit and provides an escort to the room. She said the infection preventionist (IP) and the nursing home administrator (NHA) are responsible for writing and updating the visitation policy. The infection preventionist (IP) was interviewed on9/30/21 at 4:13 p.m. She said she started two weeks ago and needs to review the current visitation policy. She said her understanding is that visitations are allowed indoors for vaccinated visitors and unvaccinated visitors need to have outside visits. She said all visitors regardless of vaccination status need to wear a mask during indoor and outdoor visits. She said the covid screening, hand hygiene and mask wearing is a requirement. She said she was not aware of unvaccinated visitation conducted in resident rooms and will need to review the policy. III. Housekeeping staff disinfected appropriately during cleaning of resident rooms A. Facility policy and training The cleaning rooms policy, dated 11/1/2017 was provided by the housekeeping supervisor on 9/30/21 at 8:32 a.m. It read in pertinent part, Housekeeping employees are a part of a very vital team that helps keep our patients and staff safe, preventing infections every day. The policy read: -disinfecting kills germs, allowing adequate time for disinfectant to sit on a surface assures 100% disinfection, this is called kill time; -we currently use 1:10 bleach solution that has a 3 minute kill time and 730 [MEDICATION(S)] disinfectant cleaner that has a kill time of 10 minutes; -always work cleanest to dirtiest and highest to lowest; -minimize moving patient's personal belongings and wipe or mop around them. The housekeeping supervisor provided an inservice and training conducted on 9/30/21 to the housekeeping staff working on that day. The training covered in pertinent part; -how many towels to use when cleaning the residents room -when to discard soiled towels and use clean towels -proper hand hygiene and use or gloves -proper cleaning chemicals and dwell time for each chemical -cleaning from cleanest to dirtiest and highest to lowest B. Record review Review of the germicidal ultra-bleach bottle showed the surface needed to stay wet for a total of three minutes. C. Observations and interviews On 9/29/21 at 9:09 a.m., housekeeper #1 was observed entering room [ROOM NUMBER] to clean. She used hand sanitizer and put on new gloves. She did not complete hand rubbing properly, as she only did the palm of her hands and not for 20 seconds. She removed a wet cloth which was soaking in a bucket of water and clorox mix and started to clean the residents room. She sprayed the bathroom sink with and wiped the sink and counters immediately after spraying and did not allow a dwell time. She sprayed the toilet and seat and allowed 30 seconds of dwell time. She placed her chemical cleaning bottles back on her cleaning cart and organized them before she removed the soiled gloves she had on to clean the bathroom. Housekeeper #1 was interviewed on 9/29/21 at approximately 9:20 a.m. She said she filled the bucket with the water/clorox mixture from the premixed dispenser in the chemical room. She demonstrated how she pushed the button to access the germicidal ultra bleach and water mixture for her cleaning bucket. She said she changed the water two to three times a day. She said she had training from her supervisor on the room cleaning process. On 9/29/21 at 9:36 a.m., housekeeper #2 was observed entering room [ROOM NUMBER] to clean. She removed a cloth which was soaking in the bleach and water mixture to clean the residents bedroom. She was observed to remove all of the resident's personal items from the bathroom counter and placed them in the soiled bathroom sink including her hair brush and toothbrush which touched the soiled sink. She proceeded to spray the counter top around the sink and allowed the chemicals to dwell for three minutes. She sprayed the shower, toilet and raised toilet seat before she removed the trash. She returned to wipe down the countertop around the sink and placed the soiled personal hygiene items she had sitting in the dirty sink and placed them on the clean counter top. She used the same cloth to clean the dirty sink, the towel dispenser, door handle, shower, raised toilet seat, toilet and toilet paper holder. She did not change out the cloth during the cleaning process. Housekeeper #2 said she cleaned 24 rooms a day including one or two deep cleaning rooms for new admissions. She said she allowed three minutes for dwell time when spraying her cleaning chemicals. She said she was not trained to place the personal hygiene items in the sink but it was easier to clean the countertop when there was nothing on there. She said she then organized the personal toiletry items on the counter. She said she had received training from her supervisor on how to clean the room and chemical usage. The facilities director who oversaw the housekeeping department was interviewed on 9/29/21 and 10:37 a.m. She said all the rooms were cleaned once a day. The isolation rooms, if they have any are cleaned at the end of the day. She said all of the residents are vaccinated. She said the housekeeping staff were trained at time of hire and demonstrated proper room cleaning procedures before they clean a room on their own. She said the chemical company came out three to four months ago and tested the chemicals. She said she did not test the chemicals and currently did not have the test strips required to test the chemicals. She said Housekeeper #2 should not have placed the residents personal items in the dirty sink and should clean around the personal toiletry items. She said cleaning the bathroom is not a one cloth job and there were multiple times the cloth should be changed. She said there was a flow pattern the housekeepers should follow, cleaning from cleanest to dirtiest and from high to low surfaces. She said Housekeeper #1 should have removed her soiled gloves from the bathroom before she placed her cleaning bottles back on her clean cart. She said housekeeper #1 contaminated her cart by using her dirty gloved hands to organize her cart. She said housekeeper #1 did not follow the proper hand hygiene procedure when she did not sanitizer her whole hand and did not allow dry time. IV. Facility COVID-19 status The director of nurses (DON) was interviewed on 9/27/21 at approximately 11:00 a.m. She said they had no COVID-19 positive residents and no COVID-19 positive staff. She said there were no presumptive positive COVID-19 residents and no pending COVID-19 tests for staff.

Based on observations, interviews and record review,, the facility failed to provide a meaningful program of activities for three (#285, #32 and #133) of four residents reviewed for activities out of 38 sample residents. Specifically, the facility failed to: -Ensure the facility provided consistent activity programming after 3:00 p.m. seven days a week; -Ensure Resident #285 was offered preferred activity programs in the evening and more than one program a day; -Ensure Resident #32 was offered a resident centered activity program including one-to-one social activities in her room; and, -Ensure Resident #133 was offered a resident centered activity program including independent leisure activities in her room. Findings include: I. Facility-wide activities The July 2021 activity calendar offered one group activity a day at 2:00 p.m. Twenty-six out of 31 days, no evening activities were offered and no group activity five out of 31 days. The August 2021 activity calendar offered one group activity a day at 2:00 p.m. Twenty-seven out of 31 days, no evening activities were offered and no group activity four out of 31 days. The facility was observed during scheduled group activity times between 9/27/21 and 9/30/21. The September 2021 activity calendar offered one group activity a day at 2:00 p.m. Nineteen out of 30 days, no evening activities and no group activities 11 out of 30 days. The resident council meeting was posted on the July 2021 activity calendar but was not posted on the August 2021 and September 2021 activity calendar. B. Staff interview The activity director (AD) was interviewed on 9/30/21 at 12:14 p.m. She said since the pandemic she scheduled one group activity a day at 2:00 p.m. but did not have a group activity every day. She said before the pandemic she would try to schedule two group activities a day. She said most of the residents were at the facility for rehabilitation and were not interested in group activities. She said many of the residents had visitations from family or they preferred individual activities like watching television in their room. She said she had not offered evening activities in the past but would start. She said she forgot to post the resident council meeting on the August and September 2021 calendar and said she picked three to five residents a month to interview with the facility customer satisfaction survey instead of offering a group meeting. She said she was the only activity staff currently and the department was hiring an activity assistant. II. Resident #285 A. Resident status Resident #285, age 92, was admitted on [DATE]. According to the September 2021 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. The resident required extensive assistance with bed mobility and transfers. She required assistance with activities of daily (ADLs). The MDS revealed it was very important to have reading materials, listen to music,and pet visits. The MDS showed it was somewhat important to go outside, keep up with the news and participate in her favorite activities. B. Resident observation Resident #285 was observed on 9/27/21 at 10:35 a.m. She was sitting in her chair facing the doorway with her head down and hand on her forehead. Her nasal cannula was on her forehead. She stated she was so tired and was having a terrible time. She stated she did not know what to do. She had the television on to a daily talk show and her bedside table was in front of her with her television remote and call light. She was not watching television. Resident #285 was observed on 9/28/21 for continuous observation from 8:58 a.m. to 11:00 a.m she was sitting in her chair facing the doorway. Her television was on a talk show. She repetitively stated help me three times and dozed off in her chair. Resident #285 was observed in her room alone for two hours repeatedly stating help me and I want to lay down. Staff did not visit or assist her during the observation period. The resident was not offered social visits or activities of interest during the observation period. From 2:02 p.m to 3:53 p.m. she was observed lying in bed with her door closed. During the observation period, Resident #285 was not offered activities of interest or room visits. The resident stated she needed help and needed to use the bathroom. At 3:36 p.m. an unidentified certified nursing aide assisted her with personal care needs and closed her door when she exited the room. At 3:53 p.m. therapy staff entered her room. C. Record review The 9/24/21 admission activity assessment reported the resident was interested in individual activities of interest to include watching television, listening to music, reading, pet visits and in room visits. The September 2021 comprehensive care plan revealed the resident expressed an interest in talking on the phone, watching television, reading, pet visits and in room visits. The resident will participate in both individual and group activities of interest. Staff will encourage participation, offer transportation to activities of interest and activity staff will provide supplies such as books, newspaper, magazines, batteries, craft supplies and work games. Review of the resident's activity participation log dated on 9/28/21 revealed the resident participated in a social interaction three times in six days. The log revealed no other activity participation or one-to-one visits were documented. D. Staff interview The activity director (AD) was interviewed on 9/30/21 at 12:14 p.m. She said Resident #285 had a daughter who visits daily and did activities in her room. Resident #285 had a husband who visited twice during the observation. -However, the resident's daughter did not visit during observation (see above). The AD said Resident #285 was not offered one-to-one visits. She said she did offer her a word search but was not offered music or pet visits. She said Resident #285 preferred to spend time in her room and sleep. III. Resident # 32 A. Resident status Resident # 32, age 67, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/24/21 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 MDS revealed the resident was independent to supervision for mobility and activities of daily living (ADLs). The MDS coded the resident as very important to have music, pet visits, outside time and participate in his favorite activities. B. Resident observation and interview Resident #32 was observed on 9//27/21 at 9:00 a.m. He was observed in his room on his bed watching television. At 10:45 a.m. he was observed in his room on his bed watching television. At 11:20 a.m. Resident #32 was observed walking on the hall talking with staff. Resident #32 was interviewed on 9/27/21 at 11:20 a.m. He said he gets bored sitting in his room so he walks around the facility to visit with staff and other residents. He stopped in hall and talked. He said he joined the 2:00 p.m. activity daily unless he has an appointment. He said there was usually only one group activity on the calendar daily. He said he wished there were more activities offered during the day in case he missed the one activity offered. He said the other day there was bingo for the daily activity but he missed it because he was on the phone. He said he wished there were evening activities because he gets bored at night. At 3:00 p.m. resident was observed in his room on his bed watching television. Resident #32 was observed on 9/28/21 at 8:58 a.m. in his room on his bed watching television. On 9/28/21 at 10:47 a.m. he was observed in his room on the telephone. At 2:02 p.m. he was observed sitting on his bed watching television. At 4:00 p.m. Resident #32 was observed sitting on his bed watching television. On. 9/29/21 at 11:21 a.m. Resident #32 was observed visiting on the unit with a certified nursing aide (CNA) #4 who said she needed to get back to work and walked away from the resident. The resident said he liked to talk and was bored in his room. At 12:07 p.m. he was observed walking up and down the hall. On 9/30/21 at 8:00 a.m. the resident was observed in his room watching television. At 10:47 a.m. he was observed in his room watching television. At 11:28 a.m he was observed in his room watching television. C. Record review The 8/24/21 admission activity assessment reported music, pet visits, outside time and participation in his favorite activities was very important to him. The August 2021 comprehensive care plan revealed the resident expressed interest in watching television, listening to music, going outside, cooking, pet visits and room visits. The resident will participate in both individual and group activities of interest. Staff will encourage participation, offer transportation to activities of interest and activity staff will provide supplies such as books, newspaper, magazines, batteries, craft supplies and work games. The 8/29/21 activity participation note revealed the resident will be offered reminders, encouragement, assistance and supplies as needed to meet his leisure needs. D. Staff interviews The activity director (AD) was interviewed on 9/30/21 at 12:14 p.m. She said she completed Resident #32's and that he did participate in the group activities and did like to visit with others. IV. Resident #133 A. Resident status Resident #133, age 59, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/25/21 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a score of six out of 15. The resident required extensive assistance with activities of daily living. The MDS was coded that it was very important to be outside, to participate in favorite activities, keeping up with the news, listen to music and to be around animals. B. Observations On 9/27/21 at 10:30 a.m., the resident had nothing to do in her room. She was sitting up in bed. She did not have anything to do, no music, or television on in her room. There was no reading material on her bedside table. At approximately 3:00 p.m., the resident continued to sit in her wheelchair in her room at the end of her bed. The television was not on, and no music was playing, there was no meaningful activity. On 9/28/21 at 9:08 a.m., the resident was sitting in her room. She was sitting at the end of the bed in her wheelchair. The television was not on, and no music was playing, there was no meaningful activity. C. Resident interview The resident was interviewed on 9/28/21 at 9:10 a.m. The resident said she did not have much to do and would like more to keep her busy. She said she liked to listen to music. D. Record review The care plan dated 9/19/21 identified the resident was interested in talking with loved ones on the phone, watching TV (television), having in room visits, being physically active, pet visits, painting and going outside. Interventions included, to provide an activity calendar, encourage participation in the expressed activities of interest. The activity assessment dated [DATE] showed the resident enjoyed watching TV, listening to music, painting, physical walking/exercise and visiting with family and friends. The activity participation log showed the following: -9/20/21 leisure cart; -9/23/21 visitation; and, -9/27/21 leisure cart. E. Interview The activity director (AD) was interviewed on 9/30/21 at 12:24 p.m. The AD reviewed the care plan and said the resident liked to paint, pet visits, and to go outside. She said that the participation records showed the resident received the activity (leisure) cart which had books on it. The AD said the assessment showed she enjoyed music, so music should be played in the resident room. The AD said she was not aware the resident wanted more to do.

Based on observations, interviews and record review, the facility failed to provide needed care and services that meet professional standards of practice for of six (#187, #384, #189, #78, #40, #61) of nine residents reviewed for quality of care of 38 sample residents. Specifically, the facility failed to: -Provide wound care treatments as ordered for Resident #384, #78, #187; -Follow blood pressure medication parameters for Resident #40, #189; -Administer an antibiotic as ordered for Resident 189; and, -Have pain medication parameters for Resident #61. Findings include: I. Failure to provide wound care as ordered A. Resident #384 1. Resident status Resident #384, age 88, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/20/21 minimum data set (MDS) assessment revealed Resident #384 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had one or more stage one or higher pressure ulcers or wounds, and was occasionally incontinent with urine and bowels. 2. Resident Interview Resident #384 was interviewed on 9/27/21 at 3:25 p.m. The resident stated that she had a wound on her leg which was caused by hitting an open drawer before entering the facility. The resident was not sure how long the wound had been there for. The resident stated that she was not sure if the bandage had been changed since being in the facility. 3. Observations On 9/27/21 at 3:25 p.m. Resident #384 was observed with a bandage on her left lower leg which was dated in permanent marker with the date of 9/23/21. 4. Record review A baseline care plan initiated 9/22/21 and revised on 9/26/21 read in pertinent part: The resident had potential for skin breakdown with wounds present on admission. The residents' goal was for skin to show signs of healing and remain free from further breakdown and infection for 90 days, with interventions of weekly Braden scale, floating heels while in bed, repositioning frequently, pressure reducing devices, and skin and wound treatments as ordered. A Braden scale dated 9/29/21 documented the resident's Braden scale as a 22 out of 23 which meant she had a low risk of skin breakdown. The September 2021 CPO revealed an order dated 9/25/21 documented wound care to the left medial shin was to be done every other day during the day shift. A nursing progress note dated 9/25/21 documented bruising to bilateral upper and lower extremities. -It did not mention the skin tear wound to the left shin. The September 2021 treatment administration record (TAR) documented that wound care of the left shin was performed on 9/25/21, 9/27/21 and 9/29/21. -However, the observation (see above) revealed the bandage was dated 9/23/21. 5. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/27/21 at 4:55 p.m. She stated she did notice that Resident #384's bandage on left leg was dated for 9/23/21 when she went to perform wound care for the resident on 9/27/21. Verifying the orders she stated that the wound care should have been done every other day and it appeared that bandage dated 9/23/21 indicated that wound care was not performed on 9/25/21. B. Resident #78 1. Resident status Resident #78, age 85, was admitted on [DATE] and discharged [DATE]. According to the September 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/12/21 MDS assessment revealed Resident #78 had moderate cognitive impairment with a BIMS score of eight out of 15. The resident was at risk of developing pressure ulcers and had surgical wounds and skin tears present. 2. Resident interview Resident #78 was interviewed on 9/27/21 at 3:32 p.m. He stated that there were wounds on his right lower leg, but was uncertain as to what caused them. The resident said the nurses had put bandages on his leg because they were bleeding. He was unaware of any further instructions on wound care that was to be received. 3. Observations On 9/27/21 at 3:32 p.m. Resident #78 was observed to have two separate bandages on his right lower leg. One bandage was dated 9/24/21 and one was dated 9/25/21 written in permanent marker on the bandages. D. Record review A baseline care plan dated 9/27/21 and not since revised read in pertinent part: Resident #78 had potential for skin breakdown with wounds present on admission. The residents' goal was for skin to show signs of healing and remain free from further breakdown and infection for 90 days, with interventions of weekly Braden scale, floating heels while in bed, repositioning frequently, pressure reducing devices, and skin treatments as ordered. A Braden scale dated 9/25/21 documented the resident's Braden scale as a 20/23 which meant the resident had a low risk of skin breakdown. The September 2021 CPO revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other orders for wound care after 9/23/21. After a staff interview with the wound nurse (see below), an order was placed on 9/27/21 for additional wound care to the right lower leg. A daily skilled nurse's note dated 9/24/21 documented: Bruising to BUE (bilateral upper extremities) and RLE (right lower extremity). Dressing to bilateral knees. Scabs to bilateral ankles. A daily skilled nurse's note dated 9/25/21 documented: Bruising to BUE (bilateral upper extremities) and RLE (right lower extremity). Dressing to bilateral knees. Scabs to bilateral ankles. A skin evaluation dated 9/25/21 documented: Scattered bruises to bilateral upper extremities in various stages of healing. Bruising to the right lower extremity, skin assessment was limited to areas that were easily accessed; the resident did not want to get undressed completely. 4. Staff interviews The wound nurse (WN) and LPN #1 were interviewed on 9/27/21 at 4:55 p.m. The WN stated that Resident #78 did not have any open wounds and only protection cream was to be applied. WN and LPN #1 went to Resident #78's room and verified that Resident #78 did have two bandages on his right leg that were not ordered. The WN stated that if a new wound was observed by a nurse, the nurse should have documented a progress note of the wound, a change of condition form, if indicated an incident report, and then WN should have been contacted to assess. The director of nursing (DON) was interviewed on 9/30/21 at 1:45 p.m. The DON said that the WN was responsible for assessing residents with wounds once a week and as needed to determine appropriate wound care orders. The DON stated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There should also have been a progress note, change of condition documentation, and a possible incident report. The DON said if wound care was not performed the doctor should have been notified. C. Resident #187 1. Resident status Resident #187, age 81, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not have a minimum data set assessment completed yet. The 9/19/21 baseline care plan assessment revealed the resident was alert and cognitively intact. She required extensive assistance with two persons for bed mobility and transfers. One person assistance for toileting, locomotion in wheelchair, grooming, and bathing. Eating required set up. Vision was impaired and hearing was adequate. The baseline care plan documented the resident receiving intravenous (IV) therapy. 2. Resident interview Resident #187 was interviewed on 9/27/21 at 2:54 p.m. She said the facility missed her right foot dressing changes which was supposed to be done one time per day. She said, they did not begin doing the daily wound care dressing change until 9/23/21. She said she was admitted to the facility on [DATE]. She said when she saw the doctor on 9/22/21 he was not happy that the facility was not following the orders and wrote a letter to the facility reminding them that the dressing change was to be done daily. She said the missed foot wound care dressing changes affected her health. 3. Record review The hospital discharge orders dated 9/19/21 read, Wound Care: Change dressing daily. Pack with packing strip, piece of silver alginate added over packing. Several layers of 4x4 gauze placed on top of alginate, then wrapped with loose gauze wrap and Coban. -The facility did not begin daily wound care until 9/23/21 according to the facility medication administration record and treatment administration record (MAR/TAR). Review of facility September 2021 medication administration record and treatment administration record (MAR/TAR) revealed the following orders. Wound care right foot posterior incision and drainage (I & D). Remove dressing irrigate wound with 20cc of normal saline (NS) pack with 1/4 inch AMD gauze impregnated with Iodosorb. Cover with 4 x4 gauze wrap with kerlix and coban every day shift-Order Date-9/22/2021 5:27 p.m Documentation of the first right foot dressing change was 9/23/21. -However, the resident was admitted [DATE]. Resident #187 saw her physician (MD #2) on 9/22/21. MD #2 sent a communication letter back to the facility reminding them of the wound care for right foot, to be changed daily, and highlighted with yellow and signed by the physician. 4. Staff interviews Licensed practical nurse (LPN) #3, who was a unit manager, was interviewed on 9/29/21 at 4:30 p.m. She said if there was a missed wound care dressing change, the physician should be notified. LPN #3 looked into the electronic medical record and acknowledged the missed wound care dressing changes and that the physician was not notified. She said it was just overlooked. The nursing home administrator (NHA) was interviewed on 9/30/21 at 8:36 a.m. He said if there was a missed wound care dressing change it should be discussed with the team at the morning clinical meeting. He said he did not know about the missed wound care dressing change but he would have liked to know. He reviewed the physician communication letter to the facility which he was not aware of. The director of nursing (DON) was interviewed on 9/30/21 at 1:45 p.m. She said she was aware of the missed wound care for Resident #187 that was not performed per physician order. She said she already did education. -Documentation of the education was requested, however it was not provided by the time of exit on 9/30/21. II. Failure to follow blood pressure medication parameters A. Resident #40 1. Resident status Resident #40, age 66, was admitted on [DATE]. According to the September 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/1/21 MDS assessment revealed Resident #40 had no cognitive deficit with a BIMS score of 14 out of 15. The resident had received diuretic medications seven out of seven days. Resident #40 had an indwelling catheter and an ostomy for bladder and bowel administration. 2. Resident interview Resident #40 was interviewed on 9/28/21 at 2:09 p.m. He stated that vitals are taken by staff sometimes, however he did not believe that they always checked blood pressure and pulse rate before giving him medications. 3. Record review A baseline care plan initiated on 8/25/21 and revised on 9/28/21 documented that Resident #40 was at risk for falls related to medication side effects. It read that the resident was at risk for complications related to cardiac diseases. Interventions documented; administer medications per physician orders, monitor the resident's blood pressure as indicated, and observe the resident for signs or symptoms of adverse drug effects and report to the physician. According to the September 2021 CPO, an order dated 8/25/21 the following medications were ordered with parameters for blood pressure monitoring: [MEDICATION(S)] 12.5mg twice daily for hypertension. Hold for systolic blood pressure less than 100 or heart rate less than 60 [MEDICATION(S)] 25mg in morning for hypertension. Hold for systolic blood pressure less than 100 or heart rate less than 60 [MEDICATION(S)] 40mg in the morning for [CONDITION(S)]. Hold for systolic blood pressure less than 100 or heart rate less than 60 According to the September 2021 medication administration record (MAR)/TAR the medications listed above were given to Resident #40 either when the systolic blood pressure was under 100 or the heart rate was below 60 on the following dates: -9/15/21 systolic blood pressure 93 -9/19/21 systolic blood pressure 98 -9/26/21 systolic blood pressure 99 4. Staff interviews On 9/30/21 at 1:48 p.m. The director of nursing (DON) and NHA were interviewed on 9/30/21 at 1:48 p.m. The DON acknowledged that according to the MAR, Resident #40's blood pressure parameters were not followed for [MEDICATION(S)] (diuretic) or [MEDICATION(S)] (antihypertensive). The DON stated that they do perform education on the following parameters for medication administration periodically, however they were not able to give a definite time frame of training that was completed. The DON stated that if a medication had been given outside of the parameters then the doctor should have been contacted. The DON stated it is important to follow parameters for medications that reduce blood pressure to avoid a resident's blood pressure bottoming out (becoming too low). B. Resident #189 1. Resident status Resident #189, age 80, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/10/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance with one person for bed mobility and transfers. 2. Record review The computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] tablet extended release 24 hour. Give 25 mg by mouth in the morning for hypertension ([CONDITION(S)]). Hold for systolic blood pressure (SBP) less than 100 or Pulse less than 60. The medication administration record (MAR) revealed a systolic blood pressure: -of 95/55 on 9/4/21; -of 86/37 on 9/19/21; and, -of 59 on 9/25/21. -The blood pressure medication was given in these instances when the systolic blood pressure and pulse was out of parameters of the order. 3. Staff interview The director of nursing (DON) was interviewed on 9/30/21 at 1:45 p.m. She read the [MEDICATION(S)] medication parameters for Resident #189, hold for systolic blood pressure (SBP) less than 100 or pulse less than 60. The DON acknowledged that the medication had been given outside of the physician ordered parameters on multiple occasions (9/4/21, 9/19/21, and 9/25/21). III. Failure to administer antibiotic medication as ordered A. Resident #189 1. Record review The computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 125 mg by mouth four times a day for Clostridioides difficile (C. diff) for 10 days, start date 9/14/21 9:00 am, end date 9/24/21. The September 2021 MAR reviewed, [MEDICATION(S)] dose was missed on 9/22/21 at 9:00 p.m. -Resident #189's progress notes were reviewed and no documentation found of notice to the physician regarding missed antibiotic dose. 2. Staff interview LPN #4, who was a charge nurse, was interviewed on 9/30/21 at 10:33 a.m. She reviewed the electronic medical record and acknowledged the missed antibiotic dose for Resident #189 and that the physician was not notified of the missed antibiotic dose. She said notifying the physician was the correct process if a medication was missed, and should have been documented in the progress notes. She said it was important to notify the physician so the physician could tell something else to give or make that decision of what to do. The DON was interviewed on 9/30/21 at 1:45 p.m. She reviewed the MAR and acknowledged that the [MEDICATION(S)] antibiotic dose was missed for Resident #189 on 9/22/21 at 9:00 p.m. She said the nurse should have called the physician if missed. IV. Failure to have pain medication parameters A. Resident #61 1. Facility policies and procedures The [MEDICATION(S)] policy and procedure, revised on 2/8/21, was provided by the nursing home administrator (NHA) on 9/29/21 at 9:49 a.m. The document read in pertinent part: Upon admission, all patients will be evaluated for pain. Pain level will also be evaluated every shift. Once a patient expresses the perception of pain or makes a request for pain medication, patient will be provided with a dose of [MEDICATION(S)] pain medication or nonpharmacological intervention will be initiated. -It did not address needing parameters for administering as needed pain medications based on pain levels the resident was experiencing. 2. Resident status Resident #61, age 91, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/3/21 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive one personal physical assistance for activities of daily living. It indicated she was not a scheduled pain medication regimen but received as needed (PRN) pain medication. 3. Record review A pain assessment was completed on 9/19/21. It indicated Resident #61 was able to verbalize pain. It indicated her pain was located at her left hip and lower back, occurred daily, and she was at a level 4 of 10 (with 10 being the most severe pain). It indicated her pain increased with movement and decreased with rest and repositioning. The assessment indicated her acceptable pain level was 4 out of 10. The September 2021 CPO included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The following order were on the September 2021 CPO: -Tylenol tablet 650 mg (milligrams) every six hours as needed for pain with a start date of 7/29/21; and, -Oxycodone tablet 5 mg two tablets at bedtime and one tablet every 24 hours as needed for pain with a start date of 9/20/21. -There were no parameters included in the pain medication orders to determine when to administer each pain medication according to the resident's pain level. 4. Interview The director of nursing (DON) was interviewed on 9/30/21 at 2:03 p.m. She said orders for pain medication typically had the parameters included so the nurse knew which pain medication to administer based on the resident's pain level. She said Oxycodone would be for moderate pain and Tylenol of mild pain. She said the pain medication orders in Resident #61's chart did not have parameters.

Based on interviews and observations, the facility failed to store drugs and biologicals under proper temperature controls in one of two medication storage rooms reviewed. Specifically, the facility failed to ensure: -Vaccine refrigerators maintained temperature parameters for vaccine storage; and, -Vaccine refrigerators with digital data logger thermometer. Findings include: I. Professional reference Centers for Disease Control and Prevention (August 18, 2021), Epidemiology and Prevention of Vaccine Preventable Diseases; Chapter 5: Storage and Handling, retrieved from https://www.cdc.gov/vaccines/pubs/pinkbook/vac-storage.html (retrieved on 9/30/21). The professional reference read in pertinent part: Every vaccine storage unit must have a reliable temperature monitoring device (TMD) which provides continuous monitoring and recording of temperatures via a digital data logger (DDL). The DDL provides recording of temperatures every 30 minutes, alarms for out-of-range temperatures, and provides details on how long a unit has been operating outside of the recommended temperature range (36-46 degrees fahrenheit). Any temperature reading out of ranges requires immediate action as follows: 1. Notify the vaccine coordinator immediately or report the problem to a supervisor. 2. Label exposed vaccine DO NOT USE, and place them in a separate container apart from other vaccines in the storage unit. 3. The vaccine coordinator or supervisor should document details of the event. Standard operating procedures should be followed for out-of-range temperatures. 4. Coordinate with the immunization program director and/or the vaccine manufacturer(s) for guidance. 5. Complete documentation of the event, including actions taken and results. II. Facility policy and procedure Policy and procedure of storage and handling of vaccines was requested from the director of nursing (DON) on 9/30/21 at 1:48 p.m., however it was not provided. III. Observations One of two medication storage rooms was observed on 9/30/21 at 11:45 a.m. The vaccine refrigerator log documented that parameters for the refrigerator temperature were 36-46 degrees fahrenheit. An analog thermometer was observed to show a temperature of 45 degrees fahrenheit. There were no digital thermometers observed. IV. Record review The September log sheet of temperatures revealed the refrigerator temperature was at 50 degrees fahrenheit on 9/10/21. There was a handwritten note next to the recording that read adjusted 40 after adjusting. Records for actions taken by the facility when vaccine storage refrigerator temperature was out of range, on 9/10/21, were requested from the DON on 9/30/21 at 1:48 p.m., however were not provided. V. Staff interviews Licensed practical nurse (LPN) #5, who was the unit manager, was interviewed on 9/30/21 at 11:49 a.m. She stated she did not know the process of how medications were handled, or what to do if the refrigerators were out of range. She said she was not aware of any other thermometers other than the analog thermometers present. The DON and nursing home administrator (NHA) were interviewed on 9/30/21 at 1:48 p.m. The DON said that medication storage was maintained by the pharmacist, the unit manager, and the infection control nurse. She said if the refrigerator was out of range it was to be adjusted. She said she was not sure how to tell how long the refrigerator temperature had been out of range on 9/10/21 or what action was taken for the vaccines in the refrigerator at that time. The DON stated that they did not have digital data logger thermometers for medication refrigerators. The DON and NHA said they were unaware that digital data logger thermometers were required, but would look into ordering some.

Based on observations, record review and interviews, the facility failed to ensure the resident had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for one (#186) of five out of 38 sample residents. Specifically, the facility failed to: -Have an accurate Colorado medical orders for scope of treatment (MOST) form uploaded in the electronic medical record (EMR) for Resident #186, the MOST form uploaded was dated [DATE] for Full cardiopulmonary resuscitation (CPR), however the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Obtain the medical durable power of attorney (MDPOA) signature timely for a new MOST form; and, -Date the new MOST form accurately when the MDPOA signature was obtained. Findings include: I. Facility policy and procedure The Advance Directives policy and procedure, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:49 a.m. It read in pertinent part, All patients at the centers have the right to formulate an advance directive. Advance directive is a ' written instruction, such as a living will or durable power of attorney for health care, recognized under State Law, whether statutory or as recognized by the courts of the State ' , relating to the provision of health care when the individual is incapapcitated. If the patient or the patient ' s representative has executed one or more advance(s), or executes one upon admission, copies of these documents will be obtained and maintained in the patient ' s medical record. The facility staff will communicate the patient ' s wishes to the patient ' s direct care staff and physician. II. Resident #186 A. Resident status Resident #186, age 90, was admitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not have a minimum data set assessment completed yet. The [DATE] baseline care plan assessment revealed the resident was confused. Her code status was marked as DNR-Do not resuscitate. She required extensive assistance with two persons for bed mobility, and toileting. Transfers required a mechanical lift. Eating, grooming, and bathing required one person assistance. Vision and hearing were adequate. Initial goal: Get stronger and return home. B. Resident representative interview Resident #186 ' s representative was interviewed on [DATE] at 9:11 a.m. She said she was the POA for Resident #186 She said when her mom first admitted on [DATE] the facility had her fill out all the financial information but made no other indication of the need for filling out another MOST form (the MOST form from [DATE] was still active). She said she signed the new MOST form yesterday [DATE], she was not sure why the facility had back dated the date signed box to [DATE] when that was not the date she signed it. She said she had attempted to sign the new MOST form earlier last week but when she came to the nurse station they did not know where the paperwork was. She said the new MOST form was discussed with her over the phone on [DATE]. She said the whole process of updating to a new MOST form with new designations was unorganized and if an emergent situation had occurred it could have been a problem. C. Record review The [DATE] baseline care plan assessment revealed the resident code status was marked as DNR-Do not resuscitate, however there was a high risk alert trigger marked next to What is my code status. Upon opening the trigger it reveals that the baseline care plan triggers for response, Full code. The MOST form (viewed on [DATE]) was found in the EMR under the miscellaneous section. It was dated and signed by Resident #186 on [DATE]. It was marked as Yes cardiopulmonary resuscitation (CPR): Attempt resuscitation. -There was no other MOST form found in the electronic medical record. Resident #186 ' s MOST form was not found in the MOST book at the nurses station (viewed on [DATE]), which is a facility policy to keep the MOST form in the binder (see director of nursing interview). The computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Which conflicted with the MOST form in the EMR (dated [DATE]) which designated full code. Progress notes revealed physician discussion with MDPOA on [DATE] code status, indicated DNR status. The physician signed the new MOST form on [DATE]. The form was set aside waiting for the MDPOA signature. The care plan was updated to, DNR status, date initiated [DATE]. Interventions included: nursing to ensure that DNR orders are clearly documented, reviewed, and updated periodically to reflect changes in the patient's condition. Patient wishes not to be a full code, will maintain DNR and allow natural death per pt wishes. Review the code status form, explain the scope of treatment clearly, and complete and place in the chart as needed. D. Staff interview The director of nursing (DON) was interviewed on [DATE] at 4:57 p.m. She was notified of the MOST form discrepancies. She said the MOST form was the advanced directive that the facility uses. She said the MOST form comes in the admission packet, and the nurse helps fill out a new one, with POA help if indicated. She said the MOST form went into the MOST binder at the nurses station and was uploaded into the EMR miscellaneous tab. The DON reviewed the MOST binder and a new MOST form had been added that day but was dated [DATE] (day of admission). The new MOST form was designated as No CPR. The DON said the new MOST form had been in another folder waiting for the MDPOA ' s signature (for two weeks). The DON said the facility wanted the MOST forms uploaded within 48 hours of admission. Licensed practical nurse (LPN) #4 was interviewed on [DATE] at 2:37 p.m. She said all residents had a hard chart folder with papers to be signed and then all the papers signed were uploaded to EMR. She said the admission nurse went over the admission paperwork and MOST form with the resident and if there was a MDPOA the nurse called them to review She said the nurses can get authorization to treat from the MDPOA. She said a resident would be considered full code/CPR until the MDPOA comes in to sign DNR paperwork. She said the MOST form paperwork was kept with the charge nurse until the MDPOA signs and it was usually completed by the next day. The social services director (SSD) and social worker (SW) #1 were interviewed on [DATE] at 3:19 p.m. They said the social services department were not part of the process for developing a MOST form for residents. They said it would be the admitting nurse who developed the MOST form and it went into a binder for the physician to sign.

Based on record review and interviews, the facility failed to ensure one (#187) out of three residents reviewed out of 38 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed timely follow-up with grievances from Resident #187. Findings include: I. Facility policy and procedure The Grievance policy and procedure, revised 2/8/21, was provided by the executive director (ED) on 9/29/21 at 6:35 p.m. It read in pertinent part, Each patient ., have the right to voice complaints and/or grievances without discrimination or the fear of reprisal. Such grievances include those with respect to care, treatment, or any other matters related to quality of care or quality of life. II. Resident #187 A. Resident status Resident #187, age 81, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not have a minimum data set assessment completed yet. The 9/19/21 baseline care plan assessment revealed the resident was alert and cognitively intact. She required extensive assistance with two persons for bed mobility and transfers. One person assistance for toileting, locomotion in a wheelchair, grooming, and bathing. Eating required set up. Vision was impaired and hearing was adequate. The baseline care plan documented the resident receiving intravenous (IV) therapy. B. Resident interview Resident #187 was interviewed on 9/27/21 at 2:54 p.m. She said she told registered nurse (RN) #1 that she wanted to file a grievance in the morning of 9/20/21 but the social worker did not come. She said the first day she was admitted at about 5:00 p.m. She told RN #1 she needed her IV antibiotic treatment through her peripherally inserted central catheter (PICC) line and RN #1 said the medication had not arrived yet. She said she yelled at RN #1 that she needed her antibiotics. Resident #187 said she was blind so she used her voice. She said she did not get her antibiotics started until the early morning of 9/20/21 at 12:15 a.m. She said her admission to the facility was very chaotic. She said she called a friend and said get her out. She said she had not file a grievance but she told RN #1. Resident #187 said missing her antibiotic on 9/19/21 affected her health. C. Record review Progress note 9/20/21 late entry, time 10:30 p.m. 9/19/21, revealed in pertinent part, Resident #187 informed nursing staff that she was not pleased based on her medications being due at bedtime had not arrived. Registered nurse (RN) #1 attempted to explain the four to six hour time gap for new admission medication delivery. RN #1 explained there was no pharmacy in the building but medication was brought in. The resident was not pleased. The patient informed that she was to receive her abx (antibiotic) IV every 4 hours. RN #1 explained the new order was for every 8 hours. The patient, not pleased, states ' I know what the doctor told me to do. ' RN #1 read the order to the patient. She does not agree with IV medication nor time. RN #1 administered the resident's bedtime medication at 12:30 a.m. The patient informs ' I am upset. What kinda place was this? ' RN #1 assured the patient in the morning she would be able to speak with a medical doctor (MD) regarding her medication concerns . -There were no grievances filed by Resident #187 when requested from the facility. D. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 9/29/21 at 2:37 p.m. She said if a nurse received a complaint they should tell the unit manager or the charge nurse. She said the charge nurse or unit manager would fill out the grievance form and give it to the director of nursing (DON) and she would follow up. The nursing home administrator (NHA) was interviewed on 9/30/21 at 8:36 a.m. He said he did not have a grievance for Resident #187. He said in morning clinical the staff should go over any concerns and discuss with the team.

Based on interviews and record review, the facility failed to assure that services being provided met professional standards of quality for three (#2, #71, #384) of nine residents reviewed for medication administration out of 38 sample residents. Specifically, the facility failed to document administration for Resident #2, #71 and #384 medications that were documented as being administered on the narcotic log sheets. Findings include: I. Facility policy and procedure The Narcotic Waste and Disposal policy and procedure, dated 3/5/21, was provided by the director of nursing (DON) on 10/5/21 and read in pertinent part: Narcotic medications were to be disposed of properly. Narcotic medications that were refused by a resident or those that needed to be wasted were to be disposed of in the appropriate drug buster solution container. Wasted narcotics were to be signed off/witnessed by two nurses and documented by both on the narcotics sheet. One of the two nurses was required to be a registered nurse (RN). II. Resident #2 A. Resident status Resident #2, age 97, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/13/2021 MDS assessment was not completed. B. Record review Resident #2 was on the following pain medications according to the September 2021 CPO: -Tylenol 1,000mg every eight hours; -[MEDICATION(S)] cream 4% topically every eight hours as needed; and, -[MEDICATION(S)] 25mg every eight hours as needed. On 9/30/21 at 10:40 a.m. Resident #2's narcotic log was reviewed. It documented [MEDICATION(S)] 50mg tablet was removed on 9/29/21 at 2:00 a.m. There was no documentation of this being administered in the MAR, and no documentation of medication being discarded since it was not indicated as administered on the resident's MAR. III. Resident #71 A. Resident status Resident #71, age 65, was admitted on [DATE]. According to the September 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/12/21 MDS assessment revealed Resident #71 had no cognitive impairment with a BIMS score of 14 out of 15. The resident was on scheduled and as needed pain medications. He experienced moderate pain occasionally that did not affect sleep or day-to-day activities. B. Record review Resident #71 was on the following pain medications according to the September 2021 CPO: -[MEDICATION(S)] 400mg one time on 9/23/21; -[MEDICATION(S)] 300mg twice daily from 9/23/21-9/24/21; -[MEDICATION(S)] 300mg three times per day from 9/7/21- 9/23/21; -[MEDICATION(S)] gel 1% four times a day; -Tylenol 500mg every six hours as needed; -[MEDICATION(S)]-Acetaminophen 5-325mg every six hours as needed; and, -[MEDICATION(S)] patch 4% topically every 24 hours as needed (remove after 12 hours) On 9/30/21 at 12:04 p.m. Resident #17's narcotic log was reviewed. It documented [MEDICATION(S)]-Acetaminophen 5-325mg tablets were removed from narcotics bin on the following dates: -9/24/21 at 9:10 a.m. -9/23/21 at 3:41 p.m. -9/22/21 at 8:14 p.m. -9/17/21 at 12:30 p.m. -9/14/21 at 3:10 p.m. -9/9/21 at 11:46 a.m. -9/7/21 at 4:14 p.m. -There was no documentation on those dates of the medication being administered in the MAR, and no documentation of medication being disposed of since it was not indicated in the resident's MAR. On 9/14/21 and 9/17/21 there were daily skilled nursing notes that documented as needed pain medication for Resident #17 was effective, but no medication was documented as being administered in the MAR. IV. Resident #384 Resident #384, age 88, was admitted on [DATE]. According to the September 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/20/21 minimum data set (MDS) assessment revealed Resident #384 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was on scheduled and as needed pain medications. The resident had moderate pain occasionally that did not interfere with sleep or day-to-day activities. Resident #384 was on the following pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Tylenol 1,000mg every 12 hours as needed; -[MEDICATION(S)]-acetaminophen 5-325mg every eight hours as needed; and, -[MEDICATION(S)] 15 mg every 24 hours as needed. On 9/30/21 at 12:00 p.m. Resident #384's narcotic log was reviewed. It documented [MEDICATION(S)] 15mg capsule was removed on 9/28/21 at 10:50 p.m. There was no documentation of this being administered in the MAR, and no documentation of medication being disposed of since it was not administered on the resident's MAR. III. Staff interviews Registered nurse (RN) #5 was interviewed on 9/30/21 at 10:40 am. She stated that when a resident was given a narcotic medication that the nurse would pull the medication, write the medication given and amount in the narcotics log, and document in the resident's MAR. She said if the nurse disposed of the medication, they would dispose of it in the medication destroyer bottle and make a note in the narcotics log. She acknowledged that Resident #2 had [MEDICATION(S)] 50mg tablet documented as being removed on 9/29/21 at 2:00 a.m. She was unable to see that this medication was administered according to the MAR. She said that there should have been a note in the narcotics log as to why the medication was not given. The DON and nursing home administrator (NHA) were interviewed on 9/30/21 at 1:48 p.m. The DON said the process of administering narcotics to residents was: the nurses should have evaluated pain and their need for medication, review orders, and determine appropriate medication to be administered. The medication was to be signed out for each resident on their narcotics sheet in the narcotics log. Once the medication was given to the resident it should have been recorded in the MAR. She said if a medication had to be wasted due to circumstances, such as the resident refusing or a medication being dropped on the floor, then the medication should be disposed of in the drug buster solution and witnessed by two nurses and signed by both nurses in the narcotic log. The DON said the facility performed narcotic administration audits periodically, but was not able to give a definitive timeline. The DON said they do provide training to nursing staff on two person narcotic wasting during orientation. -However, the DON did not provide any nursing training on narcotic wasting before survey exit on 9/30/21. The NHA stated the facility had an incident of drug diversion a while ago and had since changed the cubex medication administration system to be a two person signoff. He said he wondered if the facility had a pattern and would investigate it. -However, the NHA did not provide any documentation on why medications were not identified as being administered in the resident's MAR and signed off on the narcotic logs for Resident #2, #71 and #384 before exit on 9/30/21.

Based on observations, interviews, and record review, the facility failed to provide an environment free of accidents and hazards for two (#61 and #382) of two of 38 sample residents. Specifically, the facility failed to: -Protect Resident #61's feeding tube site resulting in the tube dislodging and requiring hospitalization on two occasions; and, -Transfer Resident #382 with two staff members as recommended by the therapy department. Findings include: I. Resident #61 A. Resident #61 status Resident #61, age 91, was admitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included dementia, dysphagia (swallowing problem), and gastrostomy (opening in the stomach). The 9/3/21 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. It indicated the resident did not have behaviors including refusal of care. She required extensive one personal physical assistance for activities of daily living. It indicated the resident had difficulty swallowing and received 25% or less of total calories through tube feeding. B. Resident interview Resident #61 was interviewed on 9/27/21 at 3:12 p.m. The resident's power of attorney (POA) was present during the interview. Resident #61 said her feeding tube was pulled out during transfers with certified nurse aides (CNAs) on two occasions. She said it was very painful. She said the site still hurts and bothers her. She said she cannot sleep and has been exhausted and that it affects everything including her appetite. She said she was hurt that none of the staff apologized to her after either incident. Resident #61 said the shock of the incidents did something to her and it made her angry that she had to go through the ordeal twice. C. Record review The tube feedings care plan was last updated on 8/9/21. It indicated the resident required tube feedings in order to maintain or improve nutritional status. It indicated the placement should be checked prior to feedings and as needed. The September 2021 CPO indicated an abdominal binder was ordered to be worn at all times for PEG tube protection on 9/15/21. -However, this was ordered after the percutaneous endoscopic gastronomy (PEG) tube was displaced twice. A nurse progress note was completed on 8/20/21. It indicated Resident #61 accidentally pulled her PEG tube out and the on call physician was notified as well as the resident's emergency contact. The note indicated the resident's power of attorney (POA) would come to the facility in the morning to further discuss options. It indicated the resident was resting with no signs or symptoms of discomfort. A nurse progress note was completed on 8/21/21. It indicated Resident #61's POA requested the PEG tube to be replaced. It indicated the resident would have to be sent out to the hospital for the procedure. A nurse progress note was completed on 9/12/21. It indicated CNA #1 observed Resident #61 had blood near PEG site and transferred the resident to bed. CNA #1 then observed the PEG tube was out and notified the nurse. The nurse notified the physician and the resident's daughter. It indicated the resident had no signs or symptoms of distress. The risk management assessments for the incident on 8/20/21 and 9/12/21 were provided by the DON on 9/29/21 at 3:45 p.m. The 8/20/21 assessment indicated a CNA went to answer Resident #61's call light. The resident said she wanted to show something to the nurse. The nurse came in and looked at the resident's stomach and saw the PEG tube had been pulled out. The assessment did not indicate any injuries and indicated the resident's POA had been notified. The 9/12/21 assessment indicated a nurse and CNA went to transfer the resident. The staff noticed blood near the PEG site prior to the transfer and upon inspection identified that the PEG tube had been pulled out. The nurse attempted to insert foley to keep the PEG site open but the resident refused. The assessment did not indicate any injuries. It indicated the physician and resident's POA were notified. D. Staff interviews CNA #1 was interviewed on 9/28/21 at 4:01 p.m. She said she was transferring Resident #61 from her wheelchair to her bed when the PEG tube came out the second time. She said the resident felt weak and began to fall so she grabbed her pants to catch her. She said the resident had a gait belt on near her chest but since she panicked she was only able to grab the resident's pants. She said she has received training on transfers with residents who have PEG tubes. Licenced practical nurse (LPN) #3 was interviewed on 9/29/21 at 3:49 p.m. She said the incident on 8/20/21 was handled according to the physician and family preferences. She said for the incident on 9/12/21, the staff had to go off the information provided in the risk management assessment so she was unsure if the PEG tube came out during transfer with CNA #1. The DON was interviewed on 9/30/21 at 1:49 p.m. She said on 8/20/21, the night nurse reported the CNA called him into Resident #61's room prior to a transfer. The nurse observed the PEG tube was out and notified the physician and the resident's POA. She said the POA was understanding of the situation. The DON said on 9/12/21 CNA #1 entered the room and noticed the resident's pants were wet. The CNA initiated a transfer to the bed and felt the resident became weak, so the CNA lifted the resident from her waist band and realized the PEG tube was out. The DON said after the event an abdominal binder was ordered in order to keep the PEG tube in place but the resident refused to wear it. She said she was unsure if the physician was notified of the resident's refusals. The DON said after two incidents, no additional training was provided to staff members regarding transfers and how to protect residents with PEG tubes. The DON said the facility did not often have incidents where residents with PEG tubes were removed. II. Resident #382 A. Resident status Resident #382, age 76, was admitted on [DATE]. According to the September 2021 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), spinal stenosis, type 2 diabetes mellitus, [CONDITION(S)], and muscle weakness. The minimum data set (MDS) assessment was not completed due to the resident's recent admission to the facility. B. Record review The resident had a baseline care plan initiated 9/22/21 and not since revised that read in pertinent part: Resident #382 needed assistance with transfers related to impaired mobility due to decreased ability to transfer, decreased balance, decreased range of motion (ROM), decreased strength, and post operative precautions of no bending, lifting, or twisting. The Physical Therapy (PT) Evaluation and Plan of Treatment form dated 9/23/21 documented Resident #382 was inconsistently able to follow one step directions at times. The resident needed two person assistance for all mobility. Resident #382 was documented to be at risk for falls. A PT progress note dated 9/28/21 documented Resident #382 required maximum assistance from two staff members to stand, and moderate assistance of two staff members to go from sitting at the edge of the bed to lying down. C. Observations On 9/27/21 at 3:22 p.m. licensed practical nurse (LPN) #1 was observed entering Resident #382's room where the resident was noted sitting in her wheelchair. LPN #1 closed the door and when she came out of the residents room the resident was observed lying in bed. No other staff members were observed going into the room during that time. On 9/29/21 at 9:20 a.m. LPN #2 was observed transferring Resident #382 using a gait belt and stand pivot transfer from the residents wheelchair to their bed independently without assistance from a second staff member. On 9/29/21 at 2:36 p.m. the white board in Resident #382's room was observed and read: - Fall risk leans to left side - Two moderate assist with belt to toilet or wheelchair (indicating two staff for assistance) - Do not leave alone in bathroom or at edge of bed D. Staff interviews Registered nurse (RN) #3 was interviewed on 9/28/21 at 4:14 p.m. RN #3 stated that the staff move residents based on what was written by the PT on the white board in the resident's room. RN #3 said that Resident #382 was a two person assist with a sara stedy (manual stand aid). Occupational therapist (OT) #1 was interviewed on 9/29/21 at 1:53 p.m. OT #1 said that the therapists evaluated the residents' transfer status after admission and throughout therapy. She stated they communicate this to the nurses and certified nurse aides by writing the transfer status and requirements on the white board in the resident's room. OT #1 said they also did interdisciplinary verbal communication with the nursing staff. The rehab director (RD) was interviewed on 9/29/21 at 3:17 p.m. The RD stated the therapists update the whiteboard in the residents room each day and that was how the nurses and certified nurse aides would know how a resident transferred. She stated that whatever was on the board was to be followed even if the transfer was just from a wheelchair to the bed. The RD stated that Resident #382 required the assistance of two staff because the resident had a push lean where she used her strong side to push herself towards her weak side, which would have made it unsafe for just one staff member to assist the resident during transfers. She stated that PT was using a sara stedy when working with Resident #382, however nursing staff was not to use sara stedy and they were instructed to only perform two person assist stand pivot transfers with the resident.

Based on interviews and observations, the facility failed to provide adequate maintenance and prevention of infection at a peripherally inserted central catheter (PICC) line insertion site for one (#15) of two residents reviewed for PICC care services of 38 sample residents. Specifically, the facility failed to maintain a sterile field while performing a PICC line dressing change. Findings include: I. Facility policy and procedure The Central Venous Catheter Dressing Changes policy and procedure, revised April 2016, was provided by the nursing home administrator (NHA) on 9/29/21 at 6:35 p.m. The policy read in pertinent part: The purpose of the procedure was to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. The procedure was documented as follows: Procedure to remove old dressing: 1. Clean the over bed table with soap and water, or alcohol. 2. Place equipment on the table. 3. Perform hand hygiene. Wear non sterile gloves. 4. The resident should be laying in bed, with their head facing the opposite direction from the dressing site. If the resident is coughing or has a [CONDITION(S)], apply a mask to the resident if he or she can tolerate it. 5. Ask the resident to keep arms at the side of their body or have someone help to do this. 6. The dressing can be rubbed with alcohol wipes to help dissolve the adhesive and loosen the dressing. 7. Remove any tape on the dressing. 8. While stabilizing the catheter, remove the dressing in the direction of the catheter insertion to avoid dislodging the catheter. Procedure to apply sterile dressing: 1. Open sterile dressing kit 2. Apply a mask. 3. Apply sterile gloves. Once the gloves are on, only the contents of the kit can be touched. Do not pick up the catheter with sterile gloves. The outside of the catheter is not sterile. Use sterile gauze to pick up the catheter when cleaning underneath the catheter to preserve sterile gloves. 4. Clean catheter insertion site with approved antiseptic solution. 5. Allow antiseptic solution to air dry on skin. Do not blow or wave over site. 6. Apply sterile transparent dressing to the area, making sure to center the dressing over the insertion site. Starting at the catheter, smooth dressing outward toward the edges to remove air. While removing the paper around edges of dressing, press down on the edges of the dressing. 7.Label with initials, date and time. The PICC Line Maintenance and Sterility procedure form, not dated, was provided by the director of nursing (DON) on 9/29/21 at 2:01 p.m. and documented in pertinent part the following procedure steps: 1. Gather supplies (central line dressing tray, [MEDICATION(S)] patch). 2. Perform hand hygiene and don clean gloves. 3. Remove old transparent dressing by gently pulling in upward direction 4. Open plastic wings to separate the line from the stabilizing device, and gently remove the stabilizing device. 5. Remove [MEDICATION(S)] patch and observe for any signs of infection or bleeding. 6. Discard old dressing, stabilizing device, and gloves. Perform hand hygiene. 7. Prepare sterile supplies 8. Don sterile gloves 9. Clean exit site and catheter with antimicrobial swabs using back and forth motion. Allow to air dry. 10. Place [MEDICATION(S)] pad on client's arm under catheter wings and slide holes of catheter wings into the [MEDICATION(S)] post, close hinged clamps over posts to secure PICC. Peel paper liner from [MEDICATION(S)] device and press onto skin. 11. Apply [MEDICATION(S)] patch to insertion site 12. Cover exit site with transparent semipermeable dressing. Press down on dressing to seal the catheter site. II. Resident status Resident #15, age 90, was admitted on [DATE]. According to the September 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/15/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. III. Record Review The resident had a baseline care plan initiated 9/14/21, and not since revised, that read in pertinent part: Resident #15 was receiving IV therapy via the PICC line. The goal was for the IV line to remain patent and show no signs or symptoms of infection at the insertion site. Dressing was to be changed as ordered by the physician and as needed. The September 2021 CPO documented that PICC line dressing change was to be performed once a week on Wednesdays. The medication ordered was [MEDICATION(S)] 1 gram intravenously one time a day for [CONDITION(S)]. IV. Observations Licensed practical nurse (LPN) #2 was observed performing a PICC dressing change on 9/29/21 at 10:41 a.m. After the old dressing was removed, the resident was not instructed to keep the exposed insertion site away from clothing and the catheter insertion site on the inner right arm was rubbing against the resident's clothing (which contaminated the catheter insertion site. During the procedure, LPN #2 was observed emptying the contents of sterile dressing change kit with unsterile gloves contaminating sterile products. LPN #2 donned sterile gloves and then opened unsterile products, resulting in gloves becoming unsterile. LPN #2 then touched the resident's arm several times for repositioning and cleaning. There was no [MEDICATION(S)] (catheter securing device) applied. Throughout the procedure, there were several incidences of sterile and non sterile actions performed in conjunction with one another, resulting in failure to maintain a sterile environment. V. Staff interviews LPN #2 was interviewed on 9/29/21 at 10:25 a.m. after the dressing change was performed. LPN #2 acknowledged that the sterile field was broken when unsterile gloves were used to touch sterile items, and again when sterile gloves were contaminated with unsterile items. The DON was interviewed on 9/29/21 at 2:01 p.m. She stated that PICC dressing changes were to be performed every seven days and as needed. The DON referred to the procedure guidelines and read aloud through and acknowledged each step of the procedure. She acknowledged that a [MEDICATION(S)] should have been applied during the procedure performed by LPN #2, and stated the procedure should have been restarted if the sterile field was broken. The DON stated that education for PICC line care was provided quarterly during the skills fair for nursing staff. The DON stated that the facility's infection preventionist provided competency checks for staff providing IV care. The DON said the staff that provides IV care would be provided additional education on completing the procedure appropriately. -Documentation of this training was requested during the interview, however PICC care was not included in the training material provided and no additional education pertaining to PICC care and management was provided by the time of exit on 9/30/21.

Based on observations, record review and interviews, the facility failed to ensure each resident received necessary respiratory care and services that is in accordance with professional standards of practice for one (#285) of four residents reviewed for oxygen therapy out of 38 sample residents. Specifically, the facility failed to ensure: -Resident #285 had oxygen turned on while laying in bed to follow current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy The Oxygen Administration policy, revised February 2021, was provided by the nursing home administrator (NHA) on 9/30/21 at 5:32 p.m., it read in pertinent part: the patient's record should include when to administer, the equipment settings for prescribed flow rates and monitoring of the O2 (oxygen) levels as ordered. II Resident #285 A. Resident status Resident #285, age 92, was admitted on [DATE]. According to the September 2021 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/20/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. The resident required extensive assistance with bed mobility and transfers. The resident was coded for the use of oxygen. B. Observations and interview On 9/29/21 at 2:50 p.m. Resident #285 entered her room from an outside appointment and had two unidentified certified nursing aides assist her to lay down in bed. The CNAs closed the door when they left the room. The resident was observed in her room in bed from 2:50 p.m. until 3:53 p.m. -At 3:53 p.m. physical therapist (PT) #1 opened the door and checked the oxygen liter flow for resident #285. She stated the oxygen was not turned on and the resident was not receiving oxygen. The resident was observed lying in bed wearing a nasal cannula. The tubing was connected to the central wall oxygen outlet. PT #1 turned on the oxygen and set the litter flow to two liters per minute (LPM). PT #1 checked Resident #285 ' s oxygen levels and place a pulse oximeter on her finger. PT #1 said her oxygen levels read between 86 and 88%. PT #1 said the CNAs who helped the resident lay down after her appointment were responsible for turning on her oxygen before leaving the room. PT #1 said the resident did not receive oxygen from the time she returned from her appointment to the time she turned on the oxygen for the resident. C. Record review The comprehensive September 2021 care plan was reviewed. It read the oxygen to be on at (1-5) liters per minute continuously delivered through a nasal cannula. The September 2021 CPO revealed the current oxygen order read on at (1-5) liters per minute continuously delivered through a nasal cannula. The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -9/24/21 6 liters per minute (LPM) -9/25/21 6 liters per minute -9/26/21 6 liters per minute -9/27/21 6 liters per minute -9/29/21 6 liters per minute D. Administrative interviews The director of nursing (DON) was interviewed on 9/30/21 at 1:52 p.m. She said vital signs were checked three times a day and as needed for oxygen levels. She said it was the responsibility of the staff who put the resident to bed to make sure the oxygen was turned on and placed on the resident. She said the nurse should follow the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was interviewed again on 9/30/21 at 5:30 p.m. She said the medication record review (MAR) for Resident #285 did show the resident was placed on six liters for multiple days outside the current order perimeters of one to five liters per minute. She said the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interviews, the facility failed to ensure behavior monitoring was conducted for target behaviors related to the use of [CONDITION(S)] medications of one (#133) of five residents reviewed for [CONDITION(S)] medications of 38 sample residents. Specifically, the facility failed to track and monitor target behaviors and have a personalized care plan for Resident #133, who was ordered a [CONDITION(S)] medication. Findings include: I. Facility policy The Pharmacy Services policy, revised on 2/8/21, was provided by the nursing home administrator (NHA) on 9/29/21 at 6:35 p.m. It read in pertinent part: The pharmacist will report irregularities; excessive dose or duration, without adequate monitoring or indication for use in the presence of adverse outcome to the Medical Director as well as the attending physician and Director of Nursing. II. Resident status Resident #133, age 59, was admitted on [DATE]. According to the September 2021 computerized physician orders (CPO) diagnoses included, [MEDICATION(S)] toxicity, weakness and falls. The 9/25/21 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a score of six out of 15. The resident required extensive assistance with activities of daily living. The MDS coded the resident as not having any behavior exhibited or [CONDITION(S)]. III. Resident interview and NHA interview The resident was interviewed on 9/27/21 at 10:00 a.m. The resident said there were three residents who were arguing outside her room. She said that one male resident had told her she had called another resident a name. She said the police were called to help with the fight. The NHA was notified of the interview with the resident on 9/27/21 at approximately 11:00 a m. The NHA was interviewed on 9/27/21 at approximately 4:00 p.m. The NHA said he spoke with the resident and the resident told him the same statement. The NHA investigated by speaking with the neighboring residents, and staff, and found the resident's statement was not true. IV. Record review 1. Medications The September 2021 CPO showed a physician order for: [MEDICATION(S)] [MEDICATION(S)] 600 mg one time a day with the associated diagnosis of [CONDITION(S)] and a start date of 9/18/21. 2. Behavior tracking The medical record failed to show that the target behaviors for the administration of [MEDICATION(S)] [MEDICATION(S)] were being tracked. 3. Care plan The resident's comprehensive care plan dated 9/18/21 failed to show the resident had a diagnosis of [CONDITION(S)] and the reasons for the use of the [MEDICATION(S)] [MEDICATION(S)]. -Review of the resident's medical record failed to show the facility was tracking targeted behaviors like hallucinations. V. Interview The director of nurses (DON) was interviewed on 9/30/21 at 2:53 p.m. The DON reviewed the record and confirmed the resident was receiving [MEDICATION(S)]. She confirmed that there were no target behaviors and behavior tracking for Resident #133. She said the social service department was responsible for ensuring the target behaviors were developed and specific behaviors tracked. The social service director (SSD) was interviewed on 9/30/21 at 3:15 p.m. The SSD confirmed that Resident #133 had a diagnosis of [CONDITION(S)] and she was prescribed [MEDICATION(S)]. She said the target behaviors were determined and tracked by the nursing department. The SSD agreed the resident needed to have specific behaviors which were tracked. She said a day ago, she did initiate a hallucinations care plan in regards to the above interview (see above).

Based on record review and interviews, the facility failed to develop and implement a comprehensive person centered care plan that included the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being for one (#1) of three sample residents. Specifically, the facility failed to include the use and care of a continuous positive airway pressure ([MEDICAL CONDITION]) machine in the resident's respiratory care plan. Cross-reference F695 failed to have orders for respiratory care Findings include I. Facility policies and procedures A.The Quality of Care Policy, was provided by the DON on 8/20/2020 at 3:00 p.m. It read, in pertinent part: The center will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan, and the patient's choices. Respiratory care O2, [MEDICAL CONDITION]/[MEDICAL CONDITION]: -Services need to be provided in accordance to standards of practice, comprehensive care, person centered care plan to include goals and preferences. II. Resident status Resident #1, younger than 85, was admitted on [DATE] and discharged on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 7/28/2020 minimum data set (MDS) assessment revealed the resident was slightly cognitively impaired with a brief interview for mental status score of 13 out of 15. He required limited assistance of one staff member for mobility and activities of daily living (ADLs). He required oxygen and [MEDICAL CONDITION] treatment while not a resident and required oxygen treatment while a resident, though the assessment read the resident did not require [MEDICAL CONDITION] treatment while he was a resident. III. Record review A. Progress notes Review of the resident's progress notes from 7/21/2020 to 8/4/2020 revealed the resident received oxygen therapy continuously and received treatment through a [MEDICAL CONDITION] machine at night. B. Care plans Review of the resident's respiratory care plan initiated 7/22/2020 read: The resident is at respiratory risk related to [MEDICAL CONDITION], obstructive sleep apnea, oxygen delivery, pulse oximetry, respiratory infection, and shortness of breath. The goal of the care plan read: the resident's respiratory risks will be minimized with preventive interventions over the next 90 days. Interventions included: Administer medications per physician's orders [REDACTED]. There was no intervention for the use or care of a [MEDICAL CONDITION] machine. Review of additional care plans revealed there was no mention of the resident's use of a [MEDICAL CONDITION] machine. IV. Interviews The DON was interviewed on 8/20/2020 at 3:00 p.m. She stated the resident's use of the [MEDICAL CONDITION] machine should have been added to his respiratory care plan as it was used through his entire stay in the facility.

Based on record review and interviews, the facility failed to ensure one (#1) resident out of three sample residents who needed respiratory care, received the care consistent with professional standards of practice, the comprehensive person centered care plan, the residents' goals and preferences. Specifically, the facility failed to obtain and ensure the resident had orders for the use and care of a continuous positive airway pressure ([MEDICAL CONDITION]) machine. Cross-reference F656 failed to have a [MEDICAL CONDITION] comprehensive care plan Findings include I. Facility policies and procedures A.The Oxygen Policy, was provided by the director of nursing (DON) on 8/20/2020 at 3:00 p.m. It read, in pertinent part: Oxygen therapy may be provided through various types of supply and delivery systems. For a patient receiving oxygen therapy, the patient's record must reflect ongoing evaluation of the patient's respiratory status, response to oxygen therapy and include, at a minimum, the attending practitioner's orders and indication for use. In addition, the record should include: -The type of oxygen delivery system; -When to administer, such as continuous or intermittent and/or when to discontinue; and -Equipment settings for the prescribed flow rates. B.The Quality of Care Policy, was provided by the DON on 8/20/2020 at 3:00 p.m. It read, in pertinent part: The center will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan, and the patient's choices. Respiratory care O2, [MEDICAL CONDITION]/[MEDICAL CONDITION]: -Services need to be provided in accordance to standards of practice, comprehensive care, person centered care plan to include goals and preferences. II. Resident status Resident #1, age 68, was admitted on [DATE] and discharged on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 7/28/2020 minimum data set (MDS) assessment revealed the resident was slightly cognitively impaired with a brief interview for mental status score of 13 out of 15. He required limited assistance of one staff member for mobility and activities of daily living (ADLs). He required oxygen and [MEDICAL CONDITION] treatment while not a resident and required oxygen treatment while a resident, though the assessment read the resident did not require [MEDICAL CONDITION] treatment while he was a resident. III. Record review A. Progress notes Review of the resident's progress notes from 7/21/2020 to 8/4/2020 revealed the resident received oxygen therapy continuously and received treatment through a [MEDICAL CONDITION] machine at night. B. Care plans Review of the resident's respiratory care plan initiated 7/22/2020 read: The resident is at respiratory risk related to [MEDICAL CONDITION], obstructive sleep apnea, oxygen delivery, pulse oximetry, respiratory infection, and shortness of breath. The goal of the care plan read: the resident's respiratory risks will be minimized with preventive interventions over the next 90 days. Interventions included: Administer medications per physician's orders [REDACTED]. There was no intervention for the use of a [MEDICAL CONDITION] machine. Review of additional care plans revealed there was no mention of the resident's use of a [MEDICAL CONDITION] machine. (cross-reference F656) C. Physician orders An order dated 7/21/2020 read: oxygen to be on at (1-5) liters per minute (continuously), delivered through nasal cannula, may titrate to greater than or equal to 88% every shift and as needed. An order dated 8/3/2020 read: OK to titrate with high flow oxygen to maintain O2 saturation above 88%. Review of the resident's physician orders [REDACTED]. IV. Interviews A registered nurse (RN) #1 was interviewed on 8/19/2020 at 2:17 p.m. She stated Resident #1 required oxygen therapy as well as a [MEDICAL CONDITION] at night. She stated the [MEDICAL CONDITION] machine was worn at night and was switched to oxygen through a nasal cannula in the morning during the day shift. She stated there should have been an order for [REDACTED].>RN #2 was interviewed on 8/19/2020 at 3:10 p.m. She stated every treatment or medication a resident receives in the facility should have an order. She stated over the two weeks Resident #1 was in the facility, someone should have noticed there was no order for the use of [REDACTED] The DON was interviewed on 8/20/2020 at 3:00 p.m. She stated Resident #1 did require and receive [MEDICAL CONDITION] treatment while he was in the facility. She stated the facility did not have orders for the resident to receive the treatment, even though he needed and received the treatment. She stated [MEDICAL CONDITION] orders were required and would state what kind of machine was used, how it should be used, what the settings should be, and how to care for the machine. She stated without orders with the above information, it would be unknown if the machine was used correctly. She stated the lack of orders for the use of the [MEDICAL CONDITION] machine should have been discovered.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as COVID-19 on one of two units. Specifically, the facility failed to ensure housekeeping staff practiced proper hand hygiene and cleaning procedures. I. Professional reference The Center for Disease Control and Prevention (4/21/2020) Environmental Cleaning Procedures-Best Practices for Environmental Cleaning in Healthcare Facilities, retrieved from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html. It read in pertinent part; These are the best practices for environmental cleaning in transmission-based precaution areas: -Clean these areas after non-isolation areas. -Change environmental cleaning supplies and equipment, including PPE, directly after cleaning these areas. If resources permit, dedicate supplies and equipment for these areas -Post the type of precaution and required procedures, including required PPE, on visible signage outside the isolation area, ensuring that these indications are understood by cleaning staff. -Do not bring cleaning carts into the area-keep them at the door and only bring the equipment and supplies needed for the cleaning process. Clean patient areas and patient zones before patient toilets. Follow proper procedures for effective uses of mops, clothes and solutions. Accessed on 8/17/2020. II. Facility policy and procedure The Facility Housekeeping Information, undated, was provided by the housekeeping supervisor (HKS) on 8/11/2020 at 10:30 a.m. It read in pertinent part; -Hand hygiene/sanitizer: Rub hands together for 20 seconds. Must be completed before wearing gloves, between glove changes. Change gloves and perform hand hygiene with every new towel. -You should use 4-5 rags per patient room. III. Observations On 8/10/2020 at 10:57 a.m. a housekeeper (HK) #1 was observed prepared to clean a resident room on isolation precautions for a 14 day quarantine. She donned a hospital gown, snapping it behind her neck, and gloves prior to entering the room. She removed the trash and discarded it on the housekeeping cart and replaced a new bag in the trash can. -At 11:03 a.m., she obtained a dry cloth from the cart and a spray bottle of bleach solution from the cart. She sprayed the bleach solution on the cloth and wiped the door frame and the door handle. She sprayed the cloth again and proceeded to wipe the open spots of the desk area around the resident's belongings, she wiped the chair at the desk, the door handles of the closet, the resident's wheelchair, the resident's walker, the bed frame and the resident's over bed table. She did not re-spray the cloth or change the cloth between cleaning any of the above surfaces which did not allow for proper disinfection. -At 11:05 a.m., she disposed of the cloth she used for the surfaces in the resident's room. She obtained a wet rag from a bucket of cleaning solution and entered the bathroom. She flushed the toilet and exited the bathroom after cleaning to discard the cloth from the bathroom. She did not perform hand hygiene after cleaning the bathroom. She returned to the cart for the broom, she swept the room, obtained the dustpan, and discarded the dustpan contents in the trash bag on the cart. -At 11:10 a.m., she obtained a mop head from a bucket of cleaning solution and mopped the bathroom. She removed the mop head, discarded it, and obtained a new mop head to mop the bedroom. -At 11:12 a.m., she removed and discarded the mop head. She removed her gown and gloves. She proceeded to roll the housekeeping cart down the hallway. She stopped and obtained some ABHR from a wall dispenser. She rubbed the sanitizer on her hands for 10 seconds and dried her hands on the front of her scrubs. IV. Staff interviews HK #1 was interviewed on 8/10/2020 at 11:13 a.m. She stated she had been employed at the facility for two months. She stated she had received all of the training related to COVID-19 and housekeeping procedures. She stated she had not changed her gloves or performed hand hygiene during the cleaning of the room. She stated she was supposed to change her gloves and perform hand hygiene in between each task when her gloves became contaminated. She stated she was supposed to spray beach solution directly on the surface, not on a cloth, to ensure proper disinfection, though she stated residents complain about the bleach smell, so she sprayed it on the cloth to decrease the smell. She stated she had not received approval from her supervisor to clean that way. The HKS was interviewed on 8/10/2020 at 11:17 a.m. She stated the housekeepers were supposed to change their gloves between each task and perform hand hygiene in between each glove change. She stated the housekeepers were supposed to and had been trained to use at least four clothes per room and to use saturated towels or to spray the cleaning solution directly on the surface to ensure proper disinfection of the surface. She stated if a resident complained about any of the cleaning solutions or the housekeeping procedure, the housekeeper should tell her in order to come up with a solution so the resident would be comfortable. She stated she was not aware of any residents who were complaining. The nursing home administrator (NHA) was interviewed on 8/11/2020 at 10:00 a.m. He stated the housekeeper identified was relatively new to the facility and had received all of the training related to her job responsibilities, COVID-19 and requirements for the facility. He stated after the observations, the housekeeper was removed from the floor to go through the facility orientation and training again and she would not return to the floor until additional training was completed. V. Facility COVID-19 status The NHA was interviewed on 8/10/2020 at 9:30 a.m. He stated they had eight positive residents and five positive staff. He stated there were no presumptive positive or tests pending for residents or staff.

Based on observations, record review and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19. Specifically, the facility: -Failed to ensure necessary personal protective equipment (PPE) was used by staff when care was provided to residents admitted in the last 14 days; -Failed to ensure hand hygiene was completed by housekeeping when cleaning resident rooms; -Failed to ensure housekeeping staff were knowledgeable regarding the dwell times of disinfectant chemicals in order to be effective, and ensure chemicals were labeled; and -Failed to follow return to work guidelines for employees with symptoms of COVID-19. The above failures to conform to infection prevention and control measures related to COVID-19 created a situation of immediate jeopardy due to the presence of a resident that was presumptive positive for COVID-19, newly admitted residents on 14-day observation for signs and symptoms of COVID-19, and staff that returned to work from reported illness before being symptom-free as specified by guidelines. Findings include: I. Failed to ensure necessary PPE (gowns and masks) were used by staff when care was provided to residents admitted in the last 14 days A. Professional reference According to the Centers for Disease Control and Prevention (CDC), (4/14/2020) Preparing for COVID-19: Long-term Care Facilities, Nursing Homesretrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html: Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Residents could be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission). All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn by HCP when PPE is indicated. B. Policy and procedure The policy titled Quarantine Protocol During the COVID-19, dated 4/8/2020, revised 5/8/2020, was received from the nursing home administrator (NHA) on 5/12/2020 at 4:59 p.m. The policy documented, All new admissions who enter the facility will be placed on quarantine with full PPE in room for 14 days. PPE required for new admission includes: surgical masks, gloves, gowns, and eye protection. C. Observations and interviews The NHA was interviewed on 5/11/2020 at 8:58 a.m. He said new admissions are quarantined for 14 days in their room, but the staff do not wear a gown or gloves when caring for them. He said he had a call with his corporate office last week and was waiting to hear if they had to wear full PPE or not. However the policy he provided, dated 4/8/2020, revised 5/8/2020, documented full PPE, including gowns, masks and gloves were to be worn for all new admissions for 14 days. He said the residents admitted in the last 14 days are not on droplet or contact precautions at this time. Housekeeper (HSK) #1 was interviewed on 5/11/2020 at 9:56 a.m. She said she uses the same precautions for all residents. She said there were no special precautions for new admissions. HSK #1 said she did not use a gown or a new mask when cleaning rooms for new admissions. She could not say which rooms on her assignment were new admissions. She said she could look up new admissions at the nurses station. She went to the nurses station and said the book of new admissions was not there. HSK #2 was interviewed on 5/11/2020 at 10:06 a.m. She said she did not know which residents were new admissions in the last 14 days, she said it is usually a surprise. She said there were no different precautions used for a new admission. She said she wears her mask that she keeps on all days and wears gloves for all rooms. Licensed practical nurse (LPN) #1 was interviewed on 5/11/2020 at 10:10 a.m. She said she wears a gown when she cares for new residents. She said she wears the same mask that she keeps on all day. LPN #1 said the resident in the room next to where we were standing came in yesterday. One gown was observed in the room. LPN #1 said she wears the gown but she did not know what the certified nurse aides (CNAs) wore when they went on. She said they should be doing the same thing. CNA #1 was interviewed on 5/11/2020 at 10:16 a.m. She said she did not know if they were any new admissions and pointed to a resident room maybe him. The room she pointed to did not have any signage on the door indicating isolation, or an isolation cart outside the door. The inside of the room was observed with the CNA; there were no gowns inside the room. She said they wear a mask for new admissions. She said they do not gown or use a new mask for new admissions. She said, We try to keep them in their rooms for 14 days. LPN #2 was interviewed on 5/11/2020 at 10:25 a.m. She said she did not know which residents were new admissions in the last 14 days. She said she had been off for a week. She said today, the facility is starting a new program and marking the doors of new admissions with a seedling picture. She said today they were just told to start using gowns for new admissions. She said they were supposed to have one per staff member per resident and dispose of them at the end of their shift. Registered nurse (RN) #1 was interviewed on 5/11/2020 at 10:31 a.m. She said she did not know who the new admissions were in the last 14 days. She said the facility started putting up pictures of seedlings on the doorways this morning to indicate who the new admissions were. She said they were told today to wear a gown for new admissions for 14 days. She said before today we were only told to keep them in their rooms for 14 days. The facilities director (FD) was interviewed on 5/11/2020 at 10:46 a.m. She said the facility began a new program today, putting a picture of a seedling on the door of new admissions. She said the housekeepers have not been educated regarding the need to wear a gown and new mask for new admissions on quarantine/isolation for 14 days. She said the plan was for the housekeepers to have a gown per room with their name on it. The director of nursing (DON) was interviewed on 5/11/2020 at 11:00 a.m. She said an email was sent out from the corporate office last Friday documenting the facility needed to use full PPE for new admissions including gowns. She said they were told to use strict isolation with gowns, masks and gloves. The DON said the staff do not change masks for the new admission quarantine rooms. She said the staff should wear a face shield over the mask they have on. She said the facility had started educating their staff on Saturday through their homepage. She did not know which staff had read it and been educated as of today. She said the housekeeper would not be assigned their own gown and would have to ask the nurse for one for each room. II. Failed to ensure hand hygiene was completed by housekeeping when cleaning resident rooms A. Professional reference According to the Centers for Disease Control and Prevention (CDC),(1/31/2020), Hand Hygiene in Healthcare setting, Glove Use retrieved from https://www.cdc.gov/handhygiene/providers/index.html: Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. B. Observations and interviews On 5/11/2020 at 9:56 a.m., HSK #1 was observed cleaning a resident's room. She left the room and went to the housekeeping cart at the doorway of the room. She removed her gloves and donned new gloves. She did not perform hand hygiene. She went back into the resident room. On 5/11/2020 at 10:06 a.m., HSK #2 was cleaning a resident's room.She left the room and went to the housekeeping cart at the doorway of the room. She removed her gloves and donned new gloves. She did not perform hand hygiene. She went back into the resident room. On 5/11/2020 at 10:35 a.m., HSK #3 was observed cleaning a resident's bathroom. She was observed to change her gloves twice but did not perform hand hygiene. HSK #3 said she only washes her hands or uses hand sanitizer with about every two glove changes. The FD was interviewed on 5/11/2020 at 10:46 a.m. She said the housekeepers should change gloves and perform hand hygiene each time they put on new gloves. She said they are expected to perform hand hygiene two to three times per room with each glove change. III. Failed to ensure housekeeping staff were knowledgeable regarding the dwell times of disinfectant chemicals in order to be effective and label chemicals A. Professional reference According to the Colorado Department of Public Health and Environment COVID-19 Preparation and Rapid Response Checklist for Long Term Care Facilities (LTCF's), revised 4/24/2020, retrieved from:https://COVID19.colorado.gov/ltcf on 4/30/2020. Environmental Cleaning and Disinfection, Validate environmental services staff members processes (1) Follow label instructions on the hospital grade disinfectant; (2) Validate disinfection procedures. According to manufacturer's information regarding Clorox Pro, germicidal bleach, (2020) retrieved from:https://www.cloroxpro.com/products/clorox/germicidal-bleach/ Causes severe [MEDICAL CONDITION] serious eye damage. Dwell times ranged from 30 seconds to five minutes. B. Observations and interviews On 5/11/2020 at 9:56 a.m. two unlabeled spray bottles of fluid were noted on the housekeeper's cart at the doorway of a resident room. One bottle had yellow fluid, one half full, and one bottle had blue fluid, one half full. HSK #1 came to the cart. She said the bottle with yellow fluid was bleach and the bottle with blue fluid was deodorizer. She said her supervisor did not have the box of labels available this morning for her to put a label on the bottles. She said the bleach comes premixed from a company and she was not sure of the dwell time (time the product must remain wet on surfaces to be effective) but thought it was two minutes. She could not recall the product' s specific name. She said the chemicals should be labeled with the name and product information. HSK #2 was interviewed on 5/11/2020 at 10:06 a.m. She said she used Clorox to clean. She had a bottle of Germicidal Ultra Bleach on her cart. She said she thought the dwell time was around 10 minutes. HSK #3 was observed in a resident room on 5/11/2020 at 10:35. She said she was using bleach to clean the high touch surfaces in the resident's room. However, the bottle she had in her hand said Hydrogen Peroxide. She said she must have grabbed the wrong bottle. She could not locate a bottle of bleach spray on her cart. She said the hydrogen peroxide spray was for the floors. She said the bleach spray was a five minute dwell time, but she was unsure of the hydrogen peroxide dwell time. She said, Maybe five or eight minutes. The FD was interviewed on 5/11/2020 at 10:46 a.m. She said the chemicals had to be labeled. She said she just spoke with HSK #1 and labeled the chemicals on her cart. She said there is a risk of accidental exposure, and it can be dangerous or could be mixed with the wrong chemicals. She said the bleach was a three minute dwell time and used for high touch surfaces. She said the peroxide was a 10 minute dwell time and used for floors. She said only bleach was to be used on the high touch surfaces. VI. Failed to follow return to work guidelines for employees with symptoms of COVID-19 A. Facility policy and procedure The policy titled Testing for COVID-19 for Patients and Staff-Colorado was received from the NHA on 5/11/2020 at 10:50 a.m. The policy documented in pertinent part, Health care staff professionals confirmed or suspected of COVID-19 may return to work based on guidance of test based criteria and cleared by a physician. Symptom based strategy, at least 72 hours have passed since recovery defined as resolution of fever without use of fever reducing medications and improvement in respiratory symptoms and at least 10 days have passed since symptoms first appeared. B. Professional reference According to the Colorado Department of Public Health and Environment (CDPHE), COVID-19 Preparation and Rapid Response Checklist for Long-Term Care Facilities, revised 4/24/2020, All staff should be screened at the beginning of their shift for fever, symptoms (cough, shortness of breath, difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new smell or taste disorders, rhinorrhea, diarrhea, nausea or vomiting. Any staff member with identified illness (as defined above) .should be excluded from work based on return to work criteria. Test-based criteria, resolution of fever without fever reducing medications, and improvement in respiratory symptoms and negative results of an FDA emergency use authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected greater or equal to 24 hours apart (total of two negative specimens). Non test criteria, at least 3 days (72 hours) after recovery defined as resolution of fever without use of fever reducing medications and improvement in respiratory symptoms and at least 10 days have passed since symptoms first appeared. Remind staff not to work when ill with even mild symptoms. C. Record review The Employee Illness Log was reviewed for the last 30 days and documented the following: Certified nurse aide (CNA) #2 called off of their shift on 4/11/2020 with stomach ache and temperature of 99.5 degrees fahrenheit. The line listing documented date employee can return to work 4/13/2020. This would have been 48 hours after symptoms started. There was no documentation of a COVID-19 test. HSK #4 called off of their shift on 4/13/2020 with fever and diarrhea. There was no documented temperature. The line listing documented date employee can return to work, 4/15/2020. This would have been 48 hours after symptoms started. There was no documentation of a COVID-19 test. Dietary aide (DA) #1 called off of their shift on 4/21/2020 with fever of 101.2 degrees fahrenheit. The line listing documented date employee can return to work, 4/23/2020. This would have been 48 hours after symptoms started. There was no documentation of a COVID-19 test. DA #2 called off of their shift on 4/26/2020 with diarrhea. The line listing documented date employee can return to work, 4/28/2020. This would have been 48 hours after symptoms started. There was no documentation of a COVID-19 test. DA # 3 called off of their shift on 4/28/2020 with stomach pain and diarrhea. The line listing documented date employee can return to work, 4/29/2020. This would have been 24 hours after symptoms started. There was no documentation of a COVID-19 test. HSK #5 called off of their shift on 5/7/2020 with temperature of 100.9 degrees fahrenheit. The line listing documented date employee can return to work, 5/9/2020. This would have been 48 hours after symptoms started. There was no documentation of a COVID-19 test. D. Interview The NHA was interviewed on 5/11/2020 at 11:52 a.m. He said HSK #5 had been having trouble with their diabetes and working with her physician. He did not feel her symptoms of a temperature of 100.9 were related to COVID but to diabetes. He said the facility had also had a Norovirus outbreak in the last few weeks. He reviewed the Employee Illness Log and the return to work dates set on the log. He said the log was not correct. Employees could not return to work until 72 hours after the last symptoms had resolved. However, the facility policy said at least 72 hours have passed since recovery defined as resolution of fever without use of fever reducing medications and improvement in respiratory symptoms and at least 10 days have passed since symptoms first appeared. The NHA said the infection preventionist (IP) was the person responsible for setting the return to work date. He could not say what date each of the employees actually returned to work. The IP was not available at the facility on 5/11/2020 for an interview. The IP was unable to be reached by phone on 5/13/2020 and 5/15/2020 for an interview. VII. Facility notification of Immediate Jeopardy On 5/26/2020 at 5:00 p.m., the NHA was notified of the Immediate Jeopardy under F880, infection prevention and control. A. Facility plan to remove Immediate Jeopardy On 5/26/2020 6:30 p.m., the NHA provided a plan to remove the Immediate Jeopardy. The plan read: 1. Staff not wearing full PPE in quarantine rooms of new admissions. Staff unaware of the rooms under quarantine and what PPE they should be wearing. -The immediate remedy was all rooms of patients admitted within 14 days were labeled and appropriate signet was placed on each room showing the date of admission, quarantine, and date of discontinuation of quarantine. (5/9/20) -Staff educated on 5/9/20 regarding use of quarantine signage and the appropriate use of full PPE including gowns, gloves, face shield and mask. Education included: 'All new admissions will be placed on a 14 day strict isolation quarantine. This will require PPE to be used for all cares provided. Staff are to wear gloves, mask, cloth hospital gown and eye protection when indicated. Supplies are located at the charge desk/nurse's station.' -On 5/22/20 the system was updated to reflect the newer signage and process. All staff were educated on the new signage process and any remaining must complete the education prior to working (15 total remaining out of 220). -On 5/26/20 at 6:13 p.m., the Regional Clinical Director audited all rooms of new admissions <14 days for appropriate signage and PPE availability. All rooms were signed appropriately and PPE was available and in use. This was completed as of 5/9/20; however, the audit was completed to demonstrate continued compliance. 2. Housekeeping not using cleaning products correctly, and did not know dwell times for leaving bleach on surfaces, one housekeeper using peroxide on surfaces instead of bleach. -On 5/18/20 the NHA did an in-person in-service with all members (100%) of housekeeping regarding dwell times, glove use and quarantine. 3. Housekeeping not performing hand hygiene between rooms and using same gloves from room to room. -On 5/18/20 the NHA inserviced 100% of housekeeping staff on dwell times, hand hygiene and quarantine. They all signed that they attested to understanding how to don and doff all appropriate PPE while performing any tasks in isolation rooms. 4. Not following guidance for staff with symptoms to return to work. -An education was completed for 100% of department heads on 5/13/20 regarding employee screening and return to work including, Employee will not be able to return to work until they are symptom free (without medication) for 72 hours and 10 days have passed since their first symptom unless they have a clear alternative [DIAGNOSES REDACTED]. Or they have 2 current negative COVID-19 test results. -All staff were educated starting on 5/13/20 regarding the same policy on return to work noted above. (22 remaining out of 220.) All staff are required to complete the education prior to working. B. Removal of Immediate Jeopardy On 5/26/2020 at 9:30 p.m. the ANHA was notified the Immediate Jeopardy situation was removed. However, deficient practice remained at an E level.

Based on resident interview, record review, and staff interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#18) of five residents reviewed for mood and behavior of 41 sampled residents. Specifically, the facility failed to develop a person-centered care plan to address the resident's behavioral needs, adequately and comprehensively address the resident's psychosocial needs and provide psychological services to help manage Resident #18's anxiety. Findings include: I. Facility policy and procedure The Behavioral Health Services policy, dated 7/1/18, was provided by the director of nursing (DON) on 11/21/19 at 11:40 p.m. It documented in pertinent part, -The facility will provide necessary behavioral care and services by ensuring necessary care and services are person-centered and reflect the patient's goals for care, while maximizing dignity, autonomy, privacy, socialization, independence, choice and safety. - If a patient is assessed or requests behavioral services the interdisciplinary team (IDT) will contact the medical doctor for order and staff will contact behavioral health service profession or consult with the patient. - Staff will provide and ensure patient's highest practicable physical and mental wellbeing. The facility has referrals and group of specialists to see referrals to see patients. II. Resident #18 [NAME] Resident status Resident #18, age 71, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/18/19 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment according to the brief interview for mental status (BIMS) score of 11 out of 15. She did not exhibit any behaviors and required extensive assistance from staff for most activities of daily living. The resident had symptoms of little interest or pleasure in doing things, feeling down, depressed or hopeless, trouble falling asleep, feeling tired or having little energy and poor appetite. B. Resident interview The resident was interviewed on 11/19/19 at 2:35 p.m. She said she had been at the facility for over a month. She said for about three weeks she had daily panic attacks from her anxiety. She said the physician had ordered her [MEDICATION NAME] (anti-anxiety medication) as needed that she could be administered at night but she was having these attacks throughout the day as well. She said the physician had told her during a visit that due to her insurance, a psychologist would not be able to see her at the facility. She said her depression and anxiety had been worse lately because she used to be living independently and was a retired nurse with no medical problems. She said since her hospitalization in (MONTH) 2019 she had a medical decline and she required long term care to take care of her medical needs. She said due to her medical decline it had been life changing to her and wanted to have some support to help her mentally with all the changes. She said the nurses were aware of her anxiety and panic attacks because they often had to calm her down during the day by talking it out with her. She said if the nurse was busy helping other residents she felt like she had no one to talk to and her anxiety was worse. She said the facility was discharging her to a long term care facility soon and she was hoping she would get the psychological services she needed when she moved since she was not offered any by the current facility. C. Record review Mood and behavior documentation 1. Care plan The 10/16/19 [MEDICAL CONDITION] medication care plan documented the resident was receiving an antidepressant for the [DIAGNOSES REDACTED]. Pertinent interventions were administered medications per physician orders, monitor for [MEDICAL CONDITION] or weight changes, non-pharmacological interventions and monitor for side effects of the medication. 2. Nursing documentation a.) Medication Administration Record [REDACTED] The 11/5/19 physician order [REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED]. The target behaviors documented on the (MONTH) 2019 MAR indicated [REDACTED] Despite the [MEDICATION NAME] ordered for anxiety and panic attacks, the facility monitored restlessness and the resident had eight episodes from 11/1/19 to 11/19/19. The mood disturbances for her antidepressant medication documented on the (MONTH) 2019 MAR indicated [REDACTED]. According to the record, the resident had four episodes documented from 11/1/19 to 11/19/19. b.) Progress notes The 11/5/19 nursing progress note documented the resident was having increased episodes of anxiety and the physician was aware. The nurse provided one-to-one conversation with the resident when her anxiety occurred. The 11/10/19 note documented the resident was having extreme anxiety regarding discharging home and how she cannot take care of her [MEDICAL CONDITION]. The 11/12/19 at 5:35 p.m., a nurse documented the resident was getting overwhelmed and anxious about [MEDICAL CONDITION] dressing change. The nurse encourage resident and spent 30 minutes with her. The 11/12/19 at 9:37 p.m., a nurse documented the resident refused to try to take care of her [MEDICAL CONDITION] independently and the nurse had to change it for her. The resident cried in bed and expressed frustration the whole time while nurse was providing care. The 11/14/19 note documented the resident was tearful and anxious about changing her [MEDICAL CONDITION] bag. The 11/18/19 note documented the resident continued to have anxiety and panic attacks frequently. The 11/20/19 nursing notes documented therapy reported the resident had stated she wanted to kill herself. The resident had told the nurse that her feelings had slowly been building up and she had tried to keep them hidden. The resident said she was tired of feeling that way and would cry. The physician had ordered the resident be sent out to the hospital for psychiatric evaluation due to her suicidal ideation and administer a one time dose of [MEDICATION NAME] 0.5miligram (mg). 3. Physician documentation The 10/12/19 history and physical documented the resident had generalized anxiety disorder and [MEDICAL CONDITION] disorder with psychiatry following and to continue [MEDICATION NAME] (antidepressant) 40 milligrams (mg). The resident's mood, affect and behavior were normal. The 10/16/19 physician progress notes [REDACTED]. The 11/5/19 physician progress notes [REDACTED]. The resident was followed by psychiatry. The 11/13/19 physician progress notes [REDACTED]. The resident had a lot of anxiety over uncertainty of what was to come and discussed looking into long term care. The 11/19/19 physician progress notes [REDACTED]. Reports of the resident crying often and being seen by a contracted therapist. 4. Social service documentation The 10/15/19 patient health questionnaire (PHQ-9) documented the resident had a score of 15 out of 27, which indicated she had moderate depression with symptoms of little interest or pleasure in doing things, feeling down, depressed or hopeless, trouble falling asleep, feeling tired or having little energy and poor appetite. The 10/15/19 social history documented the resident appeared to be depressed, decreased energy and lethargy, appetite changes. The resident was able to make simple thing knows and had no behavior issues. The 10/17/19, 10/24/19 and 10/30/19 social service progress notes documented discharge plans discussed for resident to return to her independent living or may require assisted living care with her mood being pleasant and in good spirits on each occasion. The 11/7/19 social service progress note documented discharge plans were discussed with the resident and family with barriers to her discharge. The resident felt she needed more training on how to take care of her colorstomy before returning to her home the following week. The 11/14/19 social service progress note documented a discharge meeting was held with resident and family since the resident felt she could not go home since she could not take care of the [MEDICAL CONDITION] on her own. The social services assessments and progress notes failed to document the resident's mood and behavior relating to her depressed mood and anxiety with panic attacks that started on 11/5/19. The 11/19/19 social service progress note documented the resident wanted to speak with a psychologist regarding her change in health status and recent panic attacks. A referral was sent to a psychologist. 5. Palliative care documentation The 10/17/19 supportive care social worker visit documented the resident was experiencing sadness and frustration due to her medical issues and dependence on others for her activities of daily living. The resident stated she had depression and wondered if her medications could be readjusted. A message was sent to the physician. The 10/24/19 supportive care social worker visit documented the resident mood was better since starting an additional antidepressant medication. Coping strategies were discussed when the resident had frustration or fear. It documented, (The resident) is aware she can meet with a private pay psychologist while at SNF (skilled nursing facility), however declines this service at this time, stating the conversation has been helpful and does not feel she needs ongoing counseling. The supportive care social worker did not meet with the resident after her anxiety and panic attacks start increasing after 11/5/19. 6. Hospital documentation The resident was transferred to the hospital on [DATE] due to having suicidal thoughts and anxiety. She was transferred for behavioral health evaluation. It documented the resident still felt anxious but was not suicidal after behavioral health evaluated. The 11/20/19 behavioral health consultation documented the resident had suicidal ideation with a number of medical issues. Resident #18 had increased anxiety due to being discharged to a long term care and caring for her [MEDICAL CONDITION]. The resident was provided coping skills and methods to help her with her sleep and anxiety. The recommendation provided was to increase her [MEDICATION NAME] to 0.5 mg twice a day as needed with her psychiatry team to continue to manage her medications. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 11/19/19 at 2:57 p.m. She said Resident #18 had anxiety related to her [MEDICAL CONDITION]. She said other than that the resident was not anxious during her interactions with her. She said she had worked with the resident on her [MEDICAL CONDITION] training and she showed her the steps slowly and answered any questions she had. She said she was not aware of resident ' s increased anxiety or panic attacks. The case manager (CM) was interviewed on 11/19/19 at 3:11 a.m. She said she managed the psychosocial needs for residents at the facility. She said she was a part of the social services department and completed social history, PHQ-9 and BIMS assessments when the resident was admitted . She coordinated discharge planning and referrals to specialists like the mental health providers. She said the managed care insurance that Resident #18 had, provided their own psychology services determined by the physician and the supportive care social worker that came to facility. She said if there was a need for psychological services identified by the facility if a resident was having an increase in behaviors, depressed or psychosocial need then the facility had a psychologist that came to the facility to see residents once a week. She said staff reported to her if a resident had a need for services whether it was the nurses taking care of the resident, therapy department or any other supportive staff. She said she reviewed the 24 hour shift reports completed by the nursing department to know if there was a change of condition that included any changes in their mood or behavior. She said that it was her responsibility to make a referral to the psychologist if the resident required services no matter their payment source. She said for Resident #18, the supportive care social worker had seen her a couple times in (MONTH) 2019. She said Resident #18 was getting ready to discharge from the facility and transition to a long term care facility that week. She said she was aware she was anxious over managing the [MEDICAL CONDITION] and the facility had found her long term care placement since she was not able to take care of it independently. She said she had thought that the supportive care social worker and physician were addressing her psychological needs so she had not offered her services to see the psychologist. She said she was in contact with the family of the resident about her discharge and ensuring that she transited to her long term care facility soon. She said Resident #18 had trouble sleeping and was depressed when she arrived at the facility and had some [MEDICAL CONDITION] but she was able to make her own decisions. She said the nursing staff had been monitoring her behaviors of restlessness due to her trouble sleeping and crying and tearfulness from her depression. She said since her [MEDICATION NAME] was started 11/5/19, she said the facility had not been tracking her behaviors of anxiety and panic attacks. She said she had not offered any psychological services or checked with the resident about her anxiety since she had started the [MEDICATION NAME]. She said she would speak to the resident to see if she wanted to see the psychologist regarding her depression, anxiety and panic attacks. The CM was interviewed again on 11/19/19 at 4:26 p.m. She said after speaking with Resident #18, she wanted to see the psychologist regarding the change in her health status and her increased feeling of anxiety. She said she sent the referral to the psychologist and she was coming to see her on 11/21/19. LPN #6 was interviewed on 11/19/19 at 4:53 p.m. She said Resident #18 had behaviors of anxiousness which led to her having panic attacks for a few weeks. She said her anxiety esteemed from her not knowing how to manage her [MEDICAL CONDITION]. She said she had reported it to the nursing management, the case manager and the physician many times about resident's anxiety. She said she was not aware if a psychologist had been involved with her care because the case manager arranged those services. She said it took a long time to console the resident multiple times daily with her increasing anxiety and talking with her seemed to calm her down in the moment and help her cope. The DON was interviewed on 11/21/19 at 9:03 a.m. She said she was aware that Resident #18 was anxious and had panic attacks. She said from what she could recall that the staff were providing non-pharmacological interventions like redirection to help alleviate her anxiety but the interventions had failed so the physician ordered [MEDICATION NAME]. She said the resident was administered an antidepressant medication to help with her depression and anxiety. She said she relied on the physician to tell the case manager or nursing management if the resident needed to see a psychologist so the services could be arranged. She said if the staff had known prior to 11/19/19 that she needed psychological services, the case manager would have arranged it. She said the staff should have been more proactive in monitoring her behavior and offering her the required services to prevent the resident from going to the hospital on [DATE] for a psychiatric evaluation and suicidal ideation. The nursing home administrator was interviewed on 11/21/19 at 10:53 p.m. He said the facility had an outside psychologist to provide services once a week to residents that needed services. He said regardless of what the resident's payor status, the services for those that need it should be offered without the stipulation of cost. He said he was unaware that the supportive care social worker had offered Resident #18 psychological services but informed the resident she would have to pay. He said he was going to work with case management, nursing management and the managed care insurance to ensure the residents behavioral health needs were met.